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   Table of Contents - Current issue
January-March 2023
Volume 61 | Issue 1
Page Nos. 1-150

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Bioprinting in ophthalmology – Is it a fad or the future? Highly accessed article p. 1
Jeyanthan Soundarapandian
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The 'Negative' impact p. 4
Shruti Nishanth
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Diagnosis and treatment of ophthalmology related cerebral arterial circulation diseases with 3D images - A review p. 6
Prasanna Venkatesh Ramesh, Shruthy Vaishali Ramesh, Prajnya Ray, Aji Kunnath Devadas, Meena Kumari Ramesh, Ramesh Rajasekaran
Vascular brain damage can manifest as various ophthalmic pathologies. It is important to understand cerebral circulation to understand the aetiopathogenesis of the disease. It can manifest as various ocular pathologies with visual field defects, cranial nerve palsies, orbital diseases, etc. In this review, with the help of three-dimensional (3D) images, various ophthalmology-related cerebrovascular diseases, their diagnostic methods and their treatment modalities are explained in detail for neophytes.
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A review of istent inject: A novel MIGS device in India p. 26
Sahebaan Sethi
Minimally invasive glaucoma surgery (MIGS) is a new ab-interno surgical procedure that aims to effectively and safely lower intraocular pressure (IOP) in open angle glaucoma (OAG). It has far less complications and recovery time compared to the traditional filtration surgeries. iStent inject is a second-generation device that allows placement of two stents in the trabecular meshwork through a single injector, thereby facilitating the reduction in IOP compared to first generation iStent that was a single stent. It works by bypassing the trabecular meshwork, which is the commonest site of outflow obstruction, to re-establish communication of aqueous humor directly with the Schlemm's canal. It is the smallest stent approved to be placed inside the human body. This review compiles publications about iStent inject highlighting its clinical efficacy as standalone procedure and with phacoemulsification, safety and cost effectiveness. This device was found to be effective and safe in the management of OAG.
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Aberrometry in ophthalmology and its applications in cataract surgery p. 32
Josephine S Christy, Aditi Parab
We live in a world of exponentially increasing technology advancements and improving patient care has become a priority for all health care providers. In the field of ophthalmology, quality of vision has taken an edge over the need for regular visual acuity. Aberrometry is a newer non-invasive technique to accurately measure the imperfections of the eye and largely aid in achieving the best post-operative visual outcome. This article aims in reviewing the basics of optical aberrations and how to make the best of this technique in our clinical practice.
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Traboulsi syndrome: A rare eye disease and its genetic association p. 41
Prakash Chermakani, Periasamy Sundaresan
Traboulsi syndrome is a multi-organ disorder typically characterized by pleiotropic manifestations including facial dysmorphism, lens dislocation, anterior segment abnormalities, and spontaneous filtering blebs (FDLAB). It is caused by mutations in the candidate gene ASPH, which encodes an enzyme aspartyl/asparaginyl beta-hydroxylase involved in the hydroxylation of the epidermal growth factor domain (EGFD). It is a rare monogenic disorder, inherited in an autosomal recessive manner. In recent years, many rare genetic disorders have been identified without established registries, which poses a major public health challenge. Consequently, diagnosing and treating rare disorders requires a thorough understanding of their predisposition factors. This review provides an in-depth understanding of genetic aetiology, pathophysiology, and possible disease management approaches contributing to Traboulsi syndrome.
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Patterns of paediatric ocular trauma in a tertiary care hospital in Southern Tamil Nadu, India p. 46
Savithiri Visvanathan, LS Mathivadhani, Thendral Velmurugan, D Sujitha, Heber Anandhan
Though it accounts for 8 to 14% of total injuries in children,[2] it can be prevented in 90% of the cases.[1],[2] The major anticipated problems in pediatric ocular trauma even with good healing response are amblyopia, dense fibrous reaction, cataract, and also the lower success rate of keratoplasty due to excessive fibrin formation.[2],[6] This study aims to determine the patterns of ocular trauma and analyze the mode of injury, its complications, and the visual prognosis after injury. Methods: This study was a prospective observational case study conducted in the Department of Ophthalmology, in a tertiary care center for 1 year from January 2020 to January 2021, which included all children below the age of 12 years with a history of ocular trauma. Data were collected on the demographic characteristics, mode of injury, place of injury, intervention done, the course in the hospital, its complications, and final visual outcome. The eye injuries were also classified using the international classification of ocular trauma, the Birmingham Eye Trauma Terminology System (BETTS), and Ocular Trauma Score have been given to each patient. The data were entered in an Excel sheet, and Snellen's visual acuity was converted to a Log MAR unit for statistical analysis. Mean and standard deviation were used to describe the continuous variables, whereas frequencies were used to describe the categorical and binary variables. Results: A total of 50 children presented to the Department of Ophthalmology with a history of ocular trauma during the study period. Out of 50 children, the mean age of presentation was 7.434. Children aged 9 to 12 years (48%) were most commonly affected followed by the age group 0 to 4 years and 5 to 8 were equally involved (26% each). Thirty-five (70%) of the children were male and 15 were female (30%). Forty-five (90%) children were from rural areas and 5 (10%) were from urban areas. The most common mode of injury was road traffic accidents and accidental falls which were about 24% (n = 12 each). Ocular trauma has been classified as closed or open injury based on BETTS, which showed only 6% (3 patients) had open globe injury and 84% (42 patients) had closed globe injury, 10% (5 patients) had an adnexal injury. 40 children were managed medically, and 10 children required surgical intervention. Discussion: Eye injuries are an important cause of ocular morbidity in children, being a leading cause of unilateral blindness in this age group. Timely referral and prompt management can help prevent blindness from ocular trauma. Follow-up plays a vital role in identifying the secondary complications earlier. It is a prerequisite to educate the children, parents and teachers concerning ocular health and hygiene to minimize eye injuries. Introduction: Pediatric ocular trauma is an important cause of eye morbidity. Epidemiology varies in different regions of the world.
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A clinico-virological study on identification of viral aetiological agents in conjunctivitis p. 51
Nirmal Fredrick, Sunitha Nirmal, Kaveri Krishnasamy, Thendral Karthik, Niranjan Karthik Senthil Kumar, Santhi Senthilvelan
Purpose: To identify and isolate various viral aetiological agents that cause conjunctivitis among patients with suspected viral conjunctivitis or keratoconjunctivitis who attended the outpatient department (OPD) at a tertiary eye care hospital in Chennai during June 2018 to October 2019 and to correlate the clinical symptomatology with the respective isolated virus. Methods: The study population consisted of 75 patients (age ranging from 6 to 82 years; mean age: 37.3 years) with conjunctivitis of suspected viral aetiology. Samples were obtained using a swab from the inferior palpebral conjunctiva of the affected individual using Dacron swabs placed immediately in a viral transport medium (VTM) and transported to a tertiary virology lab in Chennai, Tamil Nadu in cold chain for screening. All of the above samples were subjected to virus isolation using virus-susceptible cell lines as well as by molecular diagnosis of viruses such as herpes simplex virus, adenovirus, and enterovirus by real-time polymerase chain reaction (PCR). Results: Among the samples obtained, viral aetiology was identified in 58.67% of conjunctivitis samples either by PCR or virus isolation. Among the virus-positive samples, adenovirus, enterovirus, and herpes simplex virus accounted for 40.91%, 31.81%, and 27.27%, respectively. Coexistence of viruses was observed in 18.18% of virus-positive patients. Conclusion: This study identifies adenovirus as the most common viral pathogen that caused conjunctivitis among the study patients followed by enterovirus and herpes simplex virus. More than one viral pathogen was identified in some of the conjunctivitis patients and this showed that the conjunctivitis in the study group was caused by coexistence of various viruses.
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Customised artificial intelligence toolbox for detecting diabetic retinopathy with confocal truecolor fundus images using object detection methods p. 57
Prasanna Venkatesh Ramesh, Shruthy Vaishali Ramesh, Tamilselvan Subramanian, Prajnya Ray, Aji Kunnath Devadas, Sheik Mohamed Ansar, Ramesh Rajasekaran, Sathyan Parthasarathi
Purpose: A novel convolutional neural network approach in detecting diabetic retinopathy (DR) was employed to overcome the black box dilemma in artificial intelligence (AI). In addition to identification and classification, this tool is intended to identify signs such as microaneurysms, hard exudates, dot-blot haemorrhages and flame-shaped haemorrhages, and neovascularisation with the help of customised human annotations. Design: This is a prospective cross-sectional study. Subjects: Eight thousand confocal high-resolution fundus images of 5,174 patients were included in this study. Methods: Dataset involved 8,000 fundus images of DR with 5,200 images for training, 1,400 images for validation and 1,400 images for the held-out test. The 1,400 images used for the held-out test were non-annotated fundus images. You Only Look Once (YOLO) 5 algorithms were used for detection. Main Outcome Measures: The AI tool was evaluated with mean average precision, objectness loss, classification loss, precision and recall. The number of images in which all the clinical signs of DR were correctly predicted, wrongly predicted and missed were also calculated. Results: Tests showed consistent increments from 79.5% to 91% accuracy in predicting the diagnosis, severity, and clinical fundus signs pertaining to DR. The overall sensitivity was 81.6% and the specificity was 100%. Conclusion: To our knowledge, this is the first paper to train fundus images with high-resolution confocal images and annotate every clinical sign of the DR fundus along with diagnosis and severity for accurate predictions with their various fundus signs, thus overcoming the black box dilemma. With constant training via a feedback mechanism, there was a continuous upsurge in prediction accuracy.
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Conjunctival impression cytology in chronic cement exposure: A comparative study p. 67
Jayashree P Menashinkai, Shilpa Umarani, Shruthi Mrityunjaya Agadi, Salman S Gathinavar
Context: The Bagalkot region of Karnataka in specific is known for its hot and dry climate and also the presence of cement factory. Very few studies have been conducted in this region, and there is a need for this study to know the ocular symptoms and conjunctival cell changes among the population residing in the vicinity of Bagalkot cement factory. Settings and Design: This is a comparative cross-sectional study between70 participants residing within 2 km radius (Group 1) and 70 participants residing outside 2 km radius (Group 2) of Bagalkot cement factory. Patients were evaluated for ocular discomfort using OSDI questionnaire and tear film changes using Schirmer's-1 test and sample was collected for conjunctival impression cytology. Results: As this study was age and gender matched, the age distribution and gender distribution among two groups were same. Schirmer's-1 test values were significantly low (<10 mm) in group 1 subjects (71.4%) than in group 2 subjects (32.9%) (P = <0.001). Majority of group 1 subjects were graded 2 and 3 in Nelson's grading for conjunctival impression cytology (55.8%), but this was 22.9% in group 2 (P < 0.001). OSDI score showed that 57.2% of group 1 had moderate-to-severe dry eye and this was 12.9% in group 2 (P < 0.001). Gender, occupation, location of stay and duration of stay showed significant association with Schirmer's test, OSDI score and Nelson's grading (P < 0.05). Conclusions: Cement dust poses high risk to eye health. More plans should be carried out to reduce dust exposure in the high-risk areas of the factory.
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Effectiveness of live interactive vs. pre-recorded surgical video demonstration as a teaching methodology for cataract surgery among undergraduates p. 71
Jisha Kamalakshy, Natasha P Krishnankutty, Gino Abraham, Saritha J Shenoy
Purpose: Cataract surgery, being a microsurgical procedure can be taught in an operation theatre with a live display of surgery on a monitor. Recorded videos of surgeries can also be utilized for teaching even in a classroom. The present study compared these two methods of teaching in the acquisition of knowledge by the students and their perception towards the teaching methods. Materials and Methods: Seventy MBBS students attending ophthalmology postings were included in the study. They were randomly allocated into two groups and each group was exposed to one type of teaching method. The knowledge acquired was assessed by using a multiple-choice question paper containing 20 questions. Cross-over exposure to the teaching method was given. Their perception of both teaching methods was assessed by using a validated questionnaire with answers on a 5-point Likert score scale. Results: The mean marks obtained were 16.26 ± 2.174 after attending the teaching method in the operation theatre and 17.03 ± 1.740 after the classroom session (p = 0.106). The total perception score obtained for the teaching method in operation theatre had a median value of 44 in comparison to the median score of 40 in classroom teaching (p = 0.001). Conclusion: The knowledge achieved from the teaching method of live interactive display of cataract surgery undertaken in operation theatre was comparable to the teaching method using pre-recorded video display in the classroom. Students had a better perception towards the teaching method in the operation theatre.
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Ocular findings in patients with chronic kidney disease p. 75
Divya Jayaraman, M Shivakumar, Prathibha Shanthaveerappa
Introduction: Chronic kidney disease (CKD) affects every organ system including the eye. Aim: To conduct a thorough ocular examination in the patients of CKD and to analyse the findings. Materials and Methods: A total of 100 cases were collected from the nephrology unit of our tertiary centre. This was a cross-sectional, hospital-based study. Results: The commonest causes for visual impairment were maculopathy followed by cataracts. The other ocular findings were progressive pterygium, keratitis, central retinal vein occlusion (CRVO), retinal detachments (RDs), vitreous haemorrhage (VH) and disc-related changes. Hypertensive retinopathy (HR) was more prevalent and tended to be more severe as the renal disease progressed. More severe grades of diabetic retinopathy (DR) were detected with increasing severity of the renal disease. Conclusion: This study shows the importance of ocular evaluation of patients with CKD.
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Questionnaire-Based evaluation of patient's awareness on proper eye drop opening and usage among the outpatients visiting a tertiary eye care center in South India: A pilot survey p. 80
Anitha Venugopal, Meenakshi Ravindran, Ramakrishnan Rangappa, Mohammed Sithiq Uduman
Purpose: The purpose of this study is to study the patient's awareness of the proper method of eye drop (ED) opening and usage among patients attending the outpatient and specialty clinics of a tertiary eye care center in South India. Methods: A questionnaire-based cross-sectional survey was conducted among 514 patients attending outpatient departments of general units and specialty clinics by seven study coordinators. The questionnaire consists of 10 simple questions to assess the awareness of these patients on ED opening, usage methods, and from whom they received the information. Immediately, at the end of the questionnaire, all the patients participating in the survey were properly instructed on the right method of ED usage. In addition, they were inquired about the right mode of communication on the topic of interest. Results: Total number of participants included was 514. Mean age was (standard deviation) 50.58 (20.8) years; only 3.3% (17) were not informed about the proper usage of ED method by any of the staff or the counselors or doctors from the hospital, and 96.7% (497) were counseled for the proper method of ED usage. Among them, the information was properly explained to 82.7% (412) of the respondents by the counselors in each department; only 7.4% (37) were explained by the doctors. Most of them, 80.2% (412), preferred direct oral conversation methods of counseling on ED usage, 9.9% (51) preferred through posters, 7% (36) through video displays, and only 9% (10) through public address systems. Conclusion: A separate, precise ED counseling system is necessary for delivering proper instructions on ED usage and opening. The patient's education with eye-to-eye contact from the counselors is the patient's preferred route of obtaining information on ED usage.
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Perception of Knowledge, Attitude and Practice Towards COVID - 19 among Patients Visiting Ophthalmology OPD for Admissions and Surgery during COVID - 19 in a Tertiary Care Centre p. 85
H Mohan Kumar, N Apoorva, B Rachana, J Anitha, M Manasa, Sahana S Shankar
Introduction: On 11 March, 2020, World Health Organisation (WHO) declared coronavirus disease 2019 (COVID- 19) a pandemic disease, and by 26 March, 2020, COVID-19 had spread to nearly 199 countries and homes worldwide. Cases substantially present with fever, dry cough and breathing difficulty. As a result of the pandemic, a number of cases visiting the hospital for non-COVID-19 diseases was drastically reduced and only emergencies were seen in our hospital. Inpatient admissions were also reduced and surgical procedures were reduced. The cost of ocular surgeries was escalated to adhere to the guidelines issued by authorities, for the safety of patients and staff. Majority of ocular surgeries are elective, and national programmes conducting cataract camps were completely stopped since cataract surgeries are elective. Objectives: To assess the knowledge, attitude and practice (KAP) of the patients visiting ophthalmology OPD towards COVID-19 and ocular surgery. Materials and Methods: A cross-sectional non-interventional questionnaire-based study was conducted among patients visiting ophthalmology OPD. Results: The study included 100 patients of which 54% were males and 46% were females. A total of 38% were above the age of 50 years and literates consisted of 60%. The main ocular symptom was defective vision (43%). Furthermore, 98% were aware of COVID-19. Internet/media (48%) was the major source of knowledge. In addition, 80% were aware of the cause and mode of spread, 40% were willing to undergo eye surgery and 75% agreed with government lockdown measures and were ready to take the vaccine to prevent COVID-19 infection. Conclusion: The study suggests that the population demonstrated decent knowledge, appropriate practice and a positive attitude towards COVID-19 at the time of its outbreak.
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Study of retinal nerve fiber layer in patients with type 2 diabetes mellitus p. 90
Rohan Kapoor, Gurvinder Kaur, Nitin Batra
Purpose: (1) To assess the Retinal nerve fiber layer (RNFL) thickness in patients with type 2 diabetes mellitus (DM). (2) To assess the correlation of RNFL thickness with duration of DM and HbA1c levels. Methods: The study included 200 patients divided into three groups. Group A included 50 patients with type 2 DM without diabetic retinopathy (DR), group B included 50 patients with type 2 DM with mild to moderate NPDR, and group C included 100 age- and gender-matched controls. The duration of DM and HbA1c values were recorded. Optical coherence tomography scanning was performed, and the RNFL thickness was obtained. Results: The thickness of RNFL was less among diabetics than non-diabetics for the whole of the optic disc as well as for every quadrant except nasal quadrant. This difference was statistically significant only in the inferior quadrant (p = 0.035). The correlation coefficient between RNFL thickness of the whole of the optic disc and duration of DM and HbA1c level was -0.139 and 0.114, respectively. Conclusion: We conclude that the RNFL thickness is reduced in diabetic patients as compared to non-diabetic subjects. This may be beneficial for diabetic patients for early diagnosis of diabetic retinopathy irrespective of duration of DM or HbA1c levels.
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A comparative study on peek (Smartphone based) Visual acuity test and LogMAR visual acuity test p. 94
J Anitha, M Manasa, N Sindhu Khanna, N Apoorva, Aathira Paul
Context: The use of smartphone-based peek acuity application to test the visual acuity will improve the time efficacy, availability, and utility of subjective results collections for the healthcare providers. Aims: To assess and compare the VA by Smartphone visual acuity chart and LogMAR visual acuity chart and to determine the significance of the peek acuity chart over the LogMAR chart. Settings and Design: Prospective study. Methods and Material: We analysed 50 subjects with their approval and informed consent, evaluated their visual acuity using a LogMAR chart at three metres, and performed subjective refraction, silt lamp examination, and fundus examination. VA measures were taken with a smartphone software called Peek acuity and subjective refraction was done with a smartphone-based visual acuity program. The results were then compared between the two techniques. Sample Size: Convenient sampling. Statistical Analysis Used: The data were entered in MS excel and the results were calculated using statistical software SPSS, version 20. The results were expressed in the form of descriptive statistics like mean, standard deviation, graphs, frequency, and percentage was performed and inferential statistics like corelation and paired t-test were performed wherever necessary to compare unaided visual acuity, visual acuity with pinhole, and with glasses in both the eyes using smartphone-based PEEK visual acuity app and LogMAR visual acuity chart. If P <.05, said to be statistically significant. Normality was checked using Kolmogorov-Smirnov test. Results: The visual acuity measurement using LogMAR and the peek acuity chart had a P value.0001 significant positive connection with correlative data with and without pinhole. In addition, when comparing the Peek acuity app and the LogMAR chart, it shows that the mean unaided visual acuity difference with pinhole in OD is 0.0200 and OS is 0.0100 and with full correction they read out all optotypes clearly and without lag or failure. Conclusion: We discovered a significant statistical association between visual acuity measurement using a standard logMAR chart and a smartphone-based visual acuity application in this study (peek acuity app). As a result, a smartphone visual acuity application can be used to assess vision instead of the logMAR chart.
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Pattern of uveitis in a tertiary eye care hospital in hilly area of North India p. 98
Sushil Ojha, Reena Sharma, Nitin K Jain, Vaibhav K Jain
Aim: Pattern of uveitis in a tertiary eye care centre in Hilly area of North India. Materials and Methods: All new cases of uveitis seen in Out Patient Department (OPD) and In Patient Department (IPD) of department of Ophthalmology from June 2017 to May 2019 were consecutively enrolled in the study. After taking a complete history of systemic and ocular diseases, all patients underwent a thorough ophthalmic examination including determination of Snellen visual acuity, slit lamp biomicroscopy, applanation tonometry and dilated posterior segment examination. Patients were classified according to International Uveitis Study Group (IUSG) definitions. Results: A total of 89 patients diagnosed with uveitis with mean age of onset 35 ± 15.16 years. Male patients were 47 (52.80%) with mean age of 32 ± 15.56, and female patients were 42 (47.19%) with mean age of 38 ± 15.05. Follow-up duration varied from 4 months to 18 months. Uveitis was unilateral in 78 patients (87.64%) and bilateral in 11 patients (12.36%). The clinical course acute in 42 patients (47.19%) and chronic in 47 patients (52.81%). The uveitis was granulomatous in 12 patients (13.48%) and non-granulomatous in 77 patients (86.51%) . Anterior uveitis (iritis and iridocyclitis) was most common type of inflammation (41 patients, 46.07%), followed by (Retinitis or Retinochoroiditis) posterior uveitis (23 patients, 25.84%), panuveitis (13 patients, 14.61%) and least common intermediate uveitis (12 patients, 13.48%). HLA-B27 negative was most common type of anterior uveitis (20 patients, 22.47%) . In cases of posterior uveitis, panuveitis and intermediate uveitis (Cyclitis), idiopathic uveitis was most common. Uveitis was infectious in 10 patients (11.24%), non-infectious in 78 patients (87.64%). Hence, non-granulomatous and non-infectious uveitis was most common. In intermediate uveitis, all cases were idiopathic. Uveitis with diagnosis was herpetic (five cases), toxoplasma (two cases), tuberculosis (two cases) and HIV-associated uveitis in one case. Uveitis with specific ocular disease most common was serpiginous choroiditis (four cases), Fuchs' heterochromatic uveitis (FHU) (three cases), VKH (two cases) and sympathetic ophthalmitis (two cases). Uveitis with systemic disease non-specific arthropathy (six cases) is followed by ankylosing spondylitis (two cases), juvenile idiopathic arthritis (one case), inflammatory bowel disease (one case), sarcoidosis (one case) and systemic lupus erythromatosus (SLE one case). Conclusion: The most common uveitis in hilly area of North India is anterior uveitis. The most common aetiology is idiopathic in all types of uveitis.
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Reminiscing the past - A dive into the history of ophthalmology p. 103
Shruthy Vaishali Ramesh
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MII retcam assisted documentation of unilateral angiopathia retinae traumatica in a three year old p. 105
Taranpreet K Chitkara, Shubhneek K D. Utaal, Mandeep Kaur, Shakeen Singh
Purtscher's retinopathy is characterized by sudden vision loss following severe head trauma. Signs of ischemia are visible at the posterior pole with edema and hemorrhages concentrated around the optic disc. Digital imaging with retcam is more precise in diagnosing but is not easily available or affordable. Smartphones have thus, emerged as an alternative and reliable imaging tool. The aim of this study is to illustrate the utility of MII RetCam assisted smartphone based fundus imaging in registering and monitoring Purtscher's retinopathy. Good documentation helps in better communication with the patient and relatives and improves their compliance with treatment.
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Paediatric injury- A case report p. 108
Velu Maneksha, Kavya Setty, Naveena Saseendran
Ocular trauma is the leading cause of monocular blindness among children.Paediatric ocular trauma has a significant impact on the future quality of life of children. Here, we report a case of a 3 year old child who presented with swelling in upper lid following fall from bed. The symptoms got worse the next day. On repeated probing, grandmother gave a history of child holding pen when the fall occurred. Computerized tomography of orbit was done and it showed an intra orbital foreign body. Anterior orbitotomy was done under general anesthesia and foreign body was removed. Patient recovered with excellent visual prognosis. This report highlights importance of history taking, high suspicion of intra orbital foreign body, and need for imaging whenever indicated.
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Ocular injuries due to shuttlecock: A case series p. 111
Debolina Deb, Lily Daniel
For decades badminton has been a leisure sport, with a majority of players being non-professional players and playing without protective eyewear. We report a retrospective case series of three patients who presented at a suburban eye clinic in south India with various ocular signs post injury while playing with shuttlecock. On a detailed slit-lamp examination, anterior uveitis, bilateral angle recession, commotio retinae, and retinal hole were the varied presentations. Early diagnosis, prompt treatment and long-term follow-up is important in these patients especially in the event of angle recession and retinal pathologies post shuttlecock injury. We recommend strict sports regulations to implement wearing of protective eyewear while playing the sport.
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Acute anterior non-granulomatous uveitis in COVID-19—A case series p. 115
Priyadarshini Parthasarathi, Sarala Sankar, Suriya Djeamoorthy, Hannah Ranjee Prasanth
We present a series of three covid positive cases of ages 7, 31, and 53 years, respectively. Among them, one patient had active symptoms of COVID-19, and two patients were in a recovery phase. All three cases presented to ophthalmology out patient department (OPD) with complaints of redness and pain. One of the cases had bilateral involvement, while the other two had unilateral involvement. On ocular examination, all three patients had BCVA 6/6 in both eyes. The anterior segment revealed circumcorneal congestion with moderate anterior chamber reaction. The rest of the anterior segment and fundus were within normal limits. Patients were started on topical steroids and improved symptomatically. Ophthalmic manifestations can develop at any stage of COVID-19 disease, conjunctivitis being the most common feature. Uveitis is a rarely documented manifestation, and ophthalmologists should be aware of this manifestation.
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Migraine presenting as recurrent ophthalmoplegia: The wolf in sheep's clothing p. 117
Prabrisha Banerjee, Bipasha Mukherjee
Ophthalmoplegic migraine or recurrent painful ophthalmoplegic neuropathy is a rare condition with childhood onset. Adult onset is extremely rare. A 43-year-old hypothyroid lady presented with right-sided ptosis and diplopia. She had right ocular motility restriction in elevation and adduction with pupillary involvement. Initially, neuroimaging was suggestive of dysthyroid optic neuropathy for which she received oral steroids with incomplete recovery. She underwent strabismus surgery in the right eye for diplopia. After 2 years, she presented with a recurrence of third nerve palsy with ptosis. Neuroimaging and systemic investigations were inconclusive. Based on clinical presentation, diagnosis of ophthalmoplegic migraine was made by the neurologist, and prophylactic treatment was started to abort further attacks. Ophthalmoplegic migraine, although rare, should be considered a differential for painful ophthalmoplegia after excluding the presence of intracranial lesion, infectious, inflammatory and vascular pathology.
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Third cranial nerve palsy: An unusual presentation of cytarabine toxicity p. 120
Suchismita Mishra, Pradeep K Panigrahi, Yamijala N Srija, Priyanka Samal
A 62-year-old male presented with pupil-sparing third cranial nerve palsy. He was not a known case of diabetes mellitus or hypertension. The patient was on cytarabine as a part of treatment for acute lymphoblastic leukaemia (ALL). There was no other neurological finding. Magnetic resonance imaging with contrast and magnetic resonance angiogram was normal. The major side effects of cytarabine are limited to the gastrointestinal system and bone marrow. While with high doses, cerebellar neurotoxicity is seen, peripheral neurotoxicity is relatively uncommon. This case report describes a unique case of peripheral neuropathy in the form of third cranial nerve palsy due to cytarabine toxicity and its management.
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Complete clinical spectrum of melkersson–Rosenthal syndrome with bilateral temporal optic disc pallor – A case report p. 123
Henal Javeri, Dipankar Das, Shahinur Tayab, Gayatri Bharali, Harsha Bhattacharjee, Suklengmung Buragohain
Melkersson Rosenthal syndrome (MRS) is a very rare neuro-mucocutaneous disease, the aetiology of which is not well defined. It is classically characterised by recurring facial paralysis, swelling of face, lips and presence of a furrowed tongue. The presentation is usually oligosymtomatic, with only about one-fourth of cases showing the classical triad. Here, we present a 32-year-old female with MRS, showing the complete clinical triad of symptoms. We report for the first time, an association of MRS with bilateral optic nerve involvement. A standard criterion for diagnosis and management is lacking. It is important to increase awareness of such a rare syndrome with various associated manifestations, so that it can be accurately identified and treated.
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The momentary deposits behind the phakic intraocular lens: The rationale! p. 126
Venugopal Anitha, Meenakshi Ravindran, Aditya Ghorpade
To report a unique case of spontaneous resolution of momentary, non-inflammatory phakic intraocular lens implantation (pIOL) deposits, in a 24-year-old female underwent phakic IOL implantation in both eyes for high myopia. Surprisingly, multiple, whitish, refractile, non-inflammatory deposits were noted in the immediate postoperative period on the posterior surface of the pIOL in the right eye. A quick recap of surgical steps identified the rationale for the lens deposits, circumventing similar incident in the fellow eye.
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Third nerve palsy as a presenting feature of neurofibromatosis 2 – A case report p. 129
Hennaav K Dhillon, Muthumeena Muthumalai, Durga Priyadarshini
Neurofibromatosis 2 is an inheritable disorder characterized by bilateral vestibular nerve schwannomas. The usual presentation of such patients is hearing loss and difficulties with balancing. However, we report a case of a 20-year-old female presenting with a long-standing 3rd nerve palsy without any hearing disturbances. Although it is a rare presentation, neuroimaging must be performed in all cases of nerve palsies to rule out any CNS manifestations. Management in such conditions should be multidisciplinary especially under the leadership of a neurologist as the cardinal complications are central.
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Escitalopram induced bilateral angle closure secondary to ciliochoroidal effusion – An interesting case report p. 132
Vijayalakshmi A Senthilkumar, Sujitha Ramesh
Escitalopram, a selective serotonin reuptake inhibitor is widely used for the treatment of depression in psychiatric and primary care practices. We report a rare instance of escitalopram-induced bilateral secondary angle closure and acute onset myopic shift in a young male treated for depression. Ultrasound biomicroscopy obtained after the onset of his symptoms revealed bilateral ciliochoroidal effusion. His signs and symptoms stabilized completely within two weeks of stopping the drug. The presentation of escitalopram-induced idiosyncratic reaction with bilateral angle closure and ciliochoroidal effusion was rarely reported in Indian ethnic eyes. A detailed history taking and meticulous clinical evaluation helped us differentiate from acute primary angle closure glaucoma.
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Conjunctival rhinosporidiosis mimicking pyogenic granuloma—A case report p. 135
S Sreevibya, S Manavalan, M Nithya, B Krishnaswamy, K Sathish
Rhinosporidiosis is a chronic granulomatous infection caused by Rhinosporidium seeberi endemic in India, commonly in Tamil Nadu, Karnataka, Pondicherry, Chhattisgarh, etc. Ocular rhinosporidiosis though uncommon can affect the conjunctiva, lacrimal sac, sclera, and eyelids. In the conjunctiva, the palpebral conjunctiva is affected the most. Here, we discuss a case of a 14-year-old male who presented with a polypoidal mass in the bulbar conjunctiva mimicking a pyogenic granuloma, which on excision biopsy was confirmed as rhinosporidiosis. Diagnosis is based mainly on strong clinical suspicion and can be confirmed on excision biopsy.
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Bilateral crowning of lens equator with secondary angle closure glaucoma in a middle-aged female with microspherophakia p. 138
Vijayalakshmi A Senthilkumar, Niyati Gandhi
Microspherophakia is a rare congenital anomaly characterised by an increased anteroposterior thickness of the lens associated with a reduced equatorial diameter. The primary pathology lies in the development of zonules. Glaucoma is a serious complication associated with this disorder. We report a rare instance of bilateral crowning of the lens equator with secondary angle closure glaucoma in a middle-aged female with microspherophakia.
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Primary aqueous drainage implant in secondary childhood glaucoma associated with aniridia p. 140
Sapna Sinha, Indira Durai, George Varghese Puthuran
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Vanishing PCO- Recurrent posterior capsular opacification p. 141
Bala Saraswathy, Kalpana Narendran
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Optic Disc Melanocytoma – A Perfect Image p. 142
Shivraj Tagare, Basitali Lakhani
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Multi-Modal imaging of torpedo maculopathy p. 143
Arthi Mohankumar, Roshni Mohan
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Copper coined eyes p. 144
Seema Yadav, Sameer Chaudhary
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Retina crossword and OSCE Highly accessed article p. 145
Sashwanthi Mohan, Arthi Mohankumar, Mohan Rajan
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New age cost-effective teleophthalmology with innovative frugal ophthalmic imaging - Anterior segment photography with intraocular lens (ASPI) and trash to treasure retcam (T3R) p. 147
Prasanna Venkatesh Ramesh, Prithvi Chandrakanth, Shruthy Vaishali Ramesh, Aji Kunnath Devadas, Prajnya Ray, KS Chandrakanth, Meena Kumari Ramesh, Ramesh Rajasekaran
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Pattern of uveitis in a rural eye care hospital in Tamil p. 150
Mahmood D Al-Mendalawi
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