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   2017| October-December  | Volume 55 | Issue 4  
    Online since April 25, 2018

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Accommodative spasm: Case series
Anjali Kavthekar, N Shruti, M Nivean, M Nishanth
October-December 2017, 55(4):301-303
This study highlights importance of cycloplegic refraction to detect accommodative spasm(AS) patients and role of atropinisation for its management.This retrospective case series study was done at a tertiary care eye hospital in Chennai, India. Four patients, presented with complaints of sudden onset blurring of vision and asthenopic symptoms with history of aggravation of symptoms with prolonged near work and under stressful conditions.Refraction was initially showing myopic refractive error.After cycloplegia,there was hypermetropic shift and VA was 20/20 for distance in all patients with their hyperopic correction,and N6 with upto +3.00 dioptres for near.Diagnosis of AS was made.Bifocal glasses were prescribed and atropinisation(1%) with avoidance of aggravating factors was started . Patients were tapered gradually to prevent recurrence over three months and were observed for six months in which none had reccurence.Post cycloplegia,the condition resolved and asthenopic symptoms were improved.
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Kayser fleischer ring: A strong clinical indicator of neuro-wilson's
Rajalakshmi Selvaraj, Subashini Kaliaperumal, Pooja Kumari
October-December 2017, 55(4):307-309
A female child presenting with features of lupus nephritis was referred for ophthalmic evaluation related to autoimmune diseases. It turned out to be a dense yellow-brown deposit of Kayser Fleischer (KF) Ring and sunflower cataract following which diagnostic tests for Wilson disease (WD) were carried out and treated for the same. However, the child died in a month due to hepatic encephalopathy and sepsis. The dense KF ring conveys that it has been long-standing and a definite indicator of Neuro WD. In this brief report, the authors would like to insist on the significance of early identification of KF ring and its neurological relevance.
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Scleral buckling: Principles, utility, and relevance today
VG Madanagopalan
October-December 2017, 55(4):286-292
With time, any surgical specialty or procedure invariably undergoes change. New techniques and technologies become available and the next generations of surgeons innovate to modify established methods. The surgical management of retinal detachment has come a long way from the days of Custodis and Schepens. Scleral buckling (SB), which was once the “gold standard” when reattachment of the retina was desired, no longer enjoys the coveted standing of yore. Despite being in use for more than six decades, the many “modifications” of this surgical procedure are rather superficial - although some may argue that the procedure itself is superficial - and the original surgical principles described have remained constant. In this article, we focus on the utility of buckling, the dynamic physical forces at work when a buckle attempts to reattach the retina and the role of SB in this era of microincision surgeries.
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Posterior iris-claw intraocular lens implantation as an effective option in aphakia
M Periyanayagi, Nithiya Selvaraj, M Sivakami
October-December 2017, 55(4):282-285
Aim: This study aims to evaluate the safety, effectiveness, and complications of posterior iris-claw intraocular lens (IOL) in aphakic patients with inadequate capsular support. Patients and Methods: This prospective interventional study was conducted in 100 eyes of 99 patients between July 2013 and June 2017. Surgical aphakia with inadequate capsular support, large zonular dialysis, subluxated lens, dislocated lens, dislocated IOL, and aphakia following congenital cataract surgery were included. Preoperative and postoperative best-corrected visual acuity (BCVA) and the occurrence of various vision-threatening complications such as iridocyclitis, decentration, vitritis, cystoid macular edema, and retinal detachment were considered during the follow-up period. Results: One hundred eyes of 99 patients who fulfilled the criteria were included. The mean follow-up period was 13.5 months (4–24 months). About 90% of patients had improvement in vision with postoperative BCVA of 6/12–6/6, 7% had visual improvement with postoperative BCVA of 6/18–6/36, and 3% had a drop in visual acuity with BCVA < 6/60. About 15% developed iridocyclitis in the immediate postoperative period and responded well to topical steroids. Nearly 2% developed vitritis during the follow-up period and 1% developed rhegmatogenous retinal detachment. None had decentration or cystoid macular edema during the follow-up period. Conclusion: Posterior iris-claw IOL implantation is a safe, effective, and timely procedure in aphakia with inadequate capsular support in the hands of a skilled experienced surgeon.
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Management of isolated subconjunctival hemangioma masquerading as ocular surface squamous neoplasia
Shreesha Kumar Kodavoor, Nikit Sarvate
October-December 2017, 55(4):310-312
The purpose of this article is to report a case of isolated subconjunctival cavernous hemangioma, masquerading as ocular surface squamous neoplasia (OSSN) in a young male. A 40-year-old male presented with complaints of elevated vascular nodular lesions with feeder vessels in both eyes (right eye > left eye), in temporal limbus for the right eye, and in temporal bulbar conjunctiva for the left eye. Provisional diagnosis of both eyes' OSSN was made. Wide excisional biopsy with cryotherapy was performed for the right eye, and bare sclera was covered with conjunctival autograft. Histopathology report of the lesion showed subconjunctival cavernous hemangioma with no malignancy. The patient did not show any recurrence of lesion in the right eye at 1-year follow-up. Isolated conjunctival hemangioma is rare, but it can be considered as a differential diagnosis of vascular limbal nodules.
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Coats' disease diagnosed in adults: A rare case report
Mohan Sivakami, M Periyanayagi, B Chandrasekar
October-December 2017, 55(4):304-306
Coats' disease is a form of exudative retinal vasculopathy, commonly diagnosed in the first to second decades. In adults, it usually exhibits a benign course. We report the case of a 33-year-old male who presented with defective vision in the left eye for 2 weeks. He was diagnosed to have Coats' disease by fundus examination and fundus fluorescein angiography. He was treated with intravitreal antivascular endothelial growth factor and sectoral retinal photocoagulation.
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Outcome of combined cataract extraction and trabeculectomy with mitomycin c performed by fellows
Archana Singaram, Premanand Chandran, Varsha Ramachandra, Vinoth Arunaachalam, Vishwaraj Ramaswamy, Ganesh V Raman
October-December 2017, 55(4):273-277
Aim: This study was aimed to report the outcome of combined cataract extraction and trabeculectomy with mitomycin C performed by fellows at a tertiary eye care center in South India. Materials and Methods: A retrospective review of patients who underwent combined cataract extraction, intraocular lens implantation, and trabeculectomy with mitomycin C performed by fellows between January and December 2015. Patients diagnosed with primary open-angle glaucoma, primary angle-closure glaucoma, and pseudoexfoliation glaucoma were included and those with normal tension, lens-induced, neovascular glaucoma and previous failed glaucoma-filtering surgery were excluded. Results: The study included 280 patients (282 eyes) with a mean age ± standard deviation of 67.9 ± 7.9 years. Mean intraocular pressure (IOP) reduced from a preoperative value of 21.1 ± 6.7 mmHg to 14.2 ± 3.6 and 15.3 ± 4.8 mmHg (P < 0.001) at 6 months and 1 year, respectively. Mean number of antiglaucoma medications reduced from 1.4 ± 0.7 to 0.1 ± 0.1 and 0.1 ± 0.3 (P < 0.001) at 6 months and 1 year, respectively. Mean best-corrected visual acuity improved from 6/60 to 6/12 (P < 0.001) postoperatively. Complete success was 97% at 6 months and 92% at 1 year and qualified success was 100% at 6 months and 1 year. Three patients failed during the follow-up period. The intraoperative complication rate was 7% and reoperation rate was 4.6%. Conclusion: Combined cataract extraction and trabeculectomy performed by fellows is safe and effective to restore vision and control IOP in patients with coexisting cataract and glaucoma.
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Lacrimal sac infections and microbial analysis
Dhivya Ashok Kumar
October-December 2017, 55(4):293-297
Lacrimal sac infection is one of the common pathologies in a routine ophthalmic practice. Dacryocystitis often present as epiphora with or without discharge. Regurgitation of mucopurulent discharge from punctum is a specific indicator of sac infection. In this article, we have reviewed the literature on the microbial spectrum in lacrimal duct obstruction with sac infection. The common microbial organism and the antibiotic sensitivity status of the same have also been reviewed. More than 90% culture positivity is noted in all the studies as noted in the literature. Gram-positive organism is the commonest source of infection. Staphylococcal species, namely, Staphylococcus aureus have been noted to be the most common among the Gram-positive organisms. The other Gram-positive organisms include Streptococcus pneumonia and Staphylococcus epidermidis. The Gram-negative organisms predominantly seen are Pseudomonas aeruginosa, Hemophilus influenza, and Klebsiella. Very rarely anaerobic organism such as Propionibacterium, fungi like Candida, other Gram-negative microbes such as Enterobacter, and occasionally, Mycobacterium are also cultured. Gram-positive organisms are sensitive to Vancomycin, Ofloxacin, Gatifloxacin, and Chloramphenicol. Gram-negative organisms showed sensitivity to Tobramycin. Resistant to topical quinolones has also been reported in some studies. The overall antibiotic sensitivity has been good and encouraging in the management of lacrimal sac infections.
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Cerebral visual impairment
Manjula Jayakumar
October-December 2017, 55(4):298-300
This article highlights the importance of the evaluation of children with cerebral visual impairment and addressing their visual needs.
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Correlation of impression cytology with histopathology in the diagnosis of ocular surface squamous neoplasia
Sharmiladevi Vinod, R Radha Priyadharshni, M Anandababu, B Meenakshi, Jiz Mary Santhosh
October-December 2017, 55(4):267-272
Background: Ocular surface squamous neoplasia (OSSN) includes a wide spectrum of conjunctival and corneal intraepithelial neoplasia which can manifest as dysplasia, carcinoma in situ, and invasive squamous cell carcinoma. OSSN can be diagnosed by certain noninvasive techniques as well as invasive histopathological examination. One of such noninvasive techniques is impression cytology which refers to the histological study of superficial layers of ocular surface epithelium. Aim: The aim of this study was to assess the accuracy of impression cytology in the diagnosis of OSSN using cellulose acetate paper by correlating with histopathology. Materials and Methods: This is a prospective observational and interventional study conducted at a tertiary referral center in Chennai. This study was conducted from January 2016 to July 2017 and included 43 eyes of 42 patients presenting with conjunctival mass at the limbus or over the conjunctiva. Hospital ethics committee approval was obtained. Results: A total of 43 excision biopsies of 42 patients suspected for OSSN were performed. There was correlation in 36 eyes (83.72%), and in 7 eyes, there was no correlation (16.27%). The cases having hyperkeratotic lesions were missed by the impression cytology. Conclusion: Impression cytology can be used as a screening tool in the diagnosis of OSSN and in the follow-up of patients with recurrence. However, histopathology always remains the gold standard in diagnosing OSSN.
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Lobular capillary hemangioma of caruncle: A rare presentation
Anjali Kavthekar, Pratheeba Devi Nivean, M Nivean, Murali Ariga
October-December 2017, 55(4):313-314
Lobular capillary haemangioma also called as pyogenic granuloma is a hyperplastic vascular lesion generally found in mucus membranes of head and neck region especially the nasal and oral mucosae. It is rapidly growing and more common in paediatric age group, pregnancy and after surgery or trauma. Its occurrence involving caruncle is uncommon. Here we report a case of a 46 year old male who presented to us with caruncular nodular mass which on excision biopsy was diagnosed as lobular capillary hemangioma. The purpose of this case report is to make readers aware of its rare site of presentation and management. Pyogenic granuloma should be borne in mind as one of the differentials in cases like this and complete excision should be done to prevent recurrence and to rule out malignant entities.
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Spotlight on dry eye disease management
Srinivas Rao, R Revathi, Ramesh Durairajan, Suresh Palanisamy, Sudhir Rachapalli Reddy, Malathi Nainappan, D Chandrasekhar
October-December 2017, 55(4):321-324
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Ocular surface squamous neoplasia presenting as subconjunctival hemorrhage
Srikanth Krishnagopal, Rekha Sankar
October-December 2017, 55(4):315-317
Ocular surface squamous neoplasia (OSSN) presents as a spectrum from simple dysplasia to carcinoma in situ to invasive squamous cell carcinoma involving the conjunctiva as well as the cornea. It is a distinct clinical entity although it has been known by a variety of different names throughout the literature. Most commonly, it arises in the limbal area, occurring particularly in elderly males who have lived in geographic areas exposed to high levels of ultraviolet-B radiations. Symptoms of OSSN range from none to severe pain and visual loss. The development of preoperative diagnostic techniques, such as impression cytology, is of value in clinical decision-making and for follow-up. Simple excision with adequate margins is currently the best-established form of treatment, despite other modalities. The course of this treatment is evanescent but is more frequently slowly progressive and may require exenteration and occasionally may lead to death. In this article, we report a case of OSSN in a 76-year-old male farmer, who presented with complaints of subconjunctival hemorrhage of the left eye. Excisional biopsy was done. Histopathological examination revealed a well-differentiated squamous cell carcinoma.
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Optical coherence tomography-based assessment of central macular thickness after penetrating keratoplasty
Mamta Singh, Bibhuti P Sinha
October-December 2017, 55(4):278-281
Purpose: To assess the pattern of change in central macular thickness (CMT) after penetrating keratoplasty (PKP) with the help of optical coherence tomography (OCT) and to know the prevalence and prognosis of cystoid macular edema (CME) in these patients. Materials and Methods: A hospital-based prospective study of 13 eyes of 13 patients of PKP was conducted. Eleven of them underwent PKP and two of them underwent triple procedure. Postoperative CMT analysis was done with OCT at the end of 1st, 2nd, and 3rd month. CME has been defined as CMT >250 μ, loss of normal foveal contour, and cystoid changes in the central macula. Patients with macular edema were continued with the routine postoperative regimen of PKP. Results: The CMT at the end of 1, 2, and 3 months were 253.46 ± 37.50 μ, 230 ± 34.89 μ, and 214.53 ± 33.84 μ, respectively. The statistical difference between 1st and 2nd month and between 2nd and 3rd month was very significant. The prevalence of CME at the end of 1st, 2nd, and 3rd month was 30.7%, 23.07%, and 7.69% respectively. At month 1, 42.85% cases of pseudophakic bullous keratopathy and 16.66% cases of corneal opacity patients had CME. Triple procedure is associated with higher CMT in comparison to simple keratoplasty, but this difference was not significant statistically. Conclusion: There is a gradual decline in CMT and prevalence of macular edema with time. Hence, not every case of diagnosed macular edema after PKP needs to be treated very aggressively. Triple procedure without vitreous manipulations has no separate implication on incidence of CME, than a routine PKP.
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Invasive ocular surface squamous neoplasia in congenital ichthyosiform erythroderma
Dhivya Ashok Kumar, Sasikala Nindra Krishna
October-December 2017, 55(4):318-320
We report an invasive type of ocular surface squamous neoplasia (OSSN) in a patient with congenital ichthyosiform erythroderma. A male patient aged 44 years, with ichthyosis presented with progressively growing right corneal mass, with decreasing vision. He was clinically diagnosed as OSSN and treated with local excision, conjunctival cryotherapy, and ocular surface reconstruction with amniotic membrane graft. Histopathological examination of the excised specimen confirmed the mass as a well-differentiated squamous cell carcinoma with invasion into the corneal stroma. Postoperatively, ocular surface reconstruction was achieved, and visual acuity improved from only perception of light to counting fingers one meter due to dense corneal scar. Postoperative central corneal scar with thinning was noted. Early age of onset and progression of OSSN in such patient with ichthyosis, recommend the need for screening in patients with congenital ichthyosis. Early treatment can prevent visual disability and permanent sequelae due to corneal scar.
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From the editor's desk
T Nirmal Fredrick
October-December 2017, 55(4):265-266
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Minimally invasive glaucoma surgery: A practical guide
Pratheeba Devi Nivean, Murali Ariga
October-December 2017, 55(4):325-325
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Photo quiz/image
Atheek Shaik, Lalit Kumar, Jeyanthan Soundarapandian, Antony Arockiadass
October-December 2017, 55(4):330-332
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Answers to previous issue photo quiz
Devi Radhakrishnan, Padmaja Jagadeesan
October-December 2017, 55(4):333-335
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Journal scan
R Vasumathi
October-December 2017, 55(4):326-329
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Congratulations to the editorial team
Sivakami Karthikeyan
October-December 2017, 55(4):336-336
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