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   Table of Contents - Current issue
Coverpage
July-September 2021
Volume 59 | Issue 3
Page Nos. 231-325

Online since Thursday, September 9, 2021

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EDITORIAL  

It is time to embrace artificial intelligence Highly accessed article p. 231
Sharmila Devi
DOI:10.4103/tjosr.tjosr_130_21  
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REVIEW ARTICLES Top

Navigation-guided surgery in orbital trauma Highly accessed article p. 233
Priti Udhay
DOI:10.4103/tjosr.tjosr_104_21  
There are times in an orbital surgeon's life when experience and instincts seem inadequate and there is a need for some extra guidance and technical support. High-velocity injuries with shattered orbits are one such instance. In these cases, the entire orbit is disrupted and there are no bony landmarks to guide placement of implants and restoration of volume. Orbital walls have complex curvatures and it is extremely difficult to reestablish and symmetrize this complex three-dimensional (3D) anatomy. Inadequate reductions and poor implant placements are common causes of postoperative persistent enophthalmos. Intraoperative navigation guidance has greatly aided in accurate localization of bony landmarks, in planning complex reconstructions and verifying adequate reconstruction and symmetry, and in planning patient-specific or customized 3D-printed implants. It has brought in a revolution in the treatment of orbital trauma in current times.
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Current approach in surgical management of dry eyes – Dry eye review II Highly accessed article p. 241
Bharat Gurnani, Kirandeep Kaur
DOI:10.4103/tjosr.tjosr_56_21  
Dry eye is a multifactorial disease of the tear film and ocular surface that manifests with symptoms of irritation, heaviness, visual acuity disturbance, and tear film instability with substantial damage to the ocular surface. It is characterized by inflammation of the ocular surface and increased osmolarity of the tear film. Due to the multifactorial and wide spectrum of etiology, it is often challenging to treat dry eyes. Comprehensive knowledge of pathophysiology, factors contributing to the disease process, and etiology of dry eye disease leads to more efficient management and treatment of the disease process. However, the treatment is marked by regional variation and differs among clinicians and ocular societies in terms of treatment options and diagnostic modalities available. Our previous review article was an intricate review of dry eye definition, epidemiology, classification, causes, diagnostic tests, management, and future trends of dry eye disease. This article will detail all the surgical management options available for dry eyes and recent upcoming modalities. This review aims to enlist all the surgical management options in a nutshell so that all the treating ophthalmologists, clinicians, cornea specialists, and dry eye experts have a detailed idea of the same and this article serves as a reference for better patient care.
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EXPEDITED PUBLICATION - REVIEW BRIEF Top

Indications for exenteration and role of imaging in rhino-orbital-cerebral mucormycosis: An ophthalmologist's perspective p. 250
Jayashree Bakthavatchalam, Viji Rangarajan, Veena Noronha
DOI:10.4103/tjosr.tjosr_126_21  
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ORIGINAL ARTICLES Top

Phacoemulsification without manual hydrodissection: “Passive-Hydro Phaco” p. 254
Mithun Thulasidas, Keya Barman
DOI:10.4103/tjosr.tjosr_40_21  
Purpose: The aim of this study was to describe a technique, “Passive-Hydro Phaco” and to evaluate the outcomes of this technique in eyes with visually significant cataract. Design: This was a retrospective interventional study. Materials and Methods: We conducted a single-center study including eyes with visually significant cataract that had undergone the technique of phacoemulsification without manual hydrodissection during a period of 3 months. The functional outcomes were assessed based on postoperative corrected distance visual acuity (CDVA) at 3 weeks and 3 months, intraoperative complications, and endothelial cell count (ECC) at 3 months of follow-up. Results: The study included 112 patients (112 eyes) with a mean age of 69.2 ± 8.8 years. The mean preoperative logarithm of the minimal angle of resolution (logMAR) CDVA improved from 0.60 ± 0.20 to 0.08 ± 0.12 at 3 weeks of follow-up (P < 0.001) and remained the same till 3 months. One hundred and six eyes (94.6%) had a CDVA of logMAR <0.3 and six eyes (5.4%) had a CDVA of logMAR 0.3–0.6 at 3 weeks postoperatively. The mean difference between pre- and post-operative ECC at 3 months was 5.46 ± 26.72 cells/mm2 (P = 0.928). No posterior capsule rupture or significant intraoperative complications occurred in any of the cases. Conclusion: Passive-Hydro Phaco technique is an effective solution to avoid hydrodissection-related complications in high-risk cases.
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Triaging of patients and their management during the lockdown period due to COVID-19 pandemic at a tertiary eye center in India p. 259
Suraj Mistry, Arshad Iqbal, Md Shahid Alam, Sudipta Das, Suchetna Mukherjee, Amitabh Kumar, Girish Shiva Rao
DOI:10.4103/tjosr.tjosr_85_21  
Aim: The aim of the study is to describe the triaging of patients based on their clinical profile and the management offered during the lockdown period due to the COVID-19 pandemic at a tertiary eye center. Methods: A cross-sectional study of patients who visited the emergency department during the lockdown (Phase 1 and Phase 2) from March 3,2020 to May 5, 2020 at a tertiary eye care center and their management was carried out. All the data were collected from the Electronic Medical Record of the hospital. Results: A total of 453 patients presented to the hospital during this period. The mean age of the patients was 42.12 ± 18.12 years (Median 46 and Range 31–54). Maximum numbers of patients were in the adult age group (73.95%) and were male (63.35%). On triaging, 42.83% needed emergency care, 20.75% needed urgent care, and 36.42% of patients were manageable with routine care. The majority of the emergency cases were of trauma (46.91%) followed by vitreoretinal (17.01%) and corneal (11.86%) complaints. Most of the patients were managed medically (94.26%) while few needed surgeries (5.74%). The patients being attended during the lockdown period was 1.9% of the total patients (23,121) seen during the same time period in the year 2019. Conclusion: There was a drastic fall in the number of patients visiting the hospital during the lockdown period. The majority of the visiting patients needed emergency care and a handful of patients were managed surgically. Rearranging the clinical and surgical activity with triaging helped us to achieve safe and methodological practice during this pandemic period.
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A clinical study of anterior uveitis at India p. 265
Pawan Jarwal
DOI:10.4103/tjosr.tjosr_89_20  
Purpose: To evaluate the etiological pattern, treatment, and its outcome and complications of anterior uveitis. Uveitis, a complex intraocular inflammatory disease, results from several etiological entities. The cause of inflammation might be an infectious agent or trauma, but in most cases, the underlying mechanism appears to be autoimmune in nature.[1] Methods: A prospective clinical study was done in the department of ophthalmology at a general hospital in Jaipur, during July 2017 to June 2018. All patients between 20 and 80 years of age clinically presenting with anterior uveitis were studied. A thorough clinical evaluation followed by investigations was done to determine etiology. Patients were put on specific and nonspecific treatment and were followed up for a period of 6 months. Complications were noted. Results: The etiology of uveitis remained unknown in most cases (42%). The most common cause was observed to be blunt trauma (20%) followed by phacolytic (12%). Most cases responded well to treatment. The most common complication was posterior persistent synechiae (23.64%), and cataract was the second common (14.54%). Conclusion: Etiological diagnosis remains undetermined in majority of cases. A thorough examination and investigation is required in each case to facilitate a final diagnosis. Prompt treatment ensures good visual outcome. Ocular morbidity is common in chronic and recurrent cases.
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CASE REPORTS Top

Malady of lattice p. 270
Shobita Nair, Venugopal Anitha, Meenakshi Ravindran, Vinit J Shah
DOI:10.4103/tjosr.tjosr_20_21  
Lattice corneal dystrophy (LCD) is rare, bilateral, slowly progressive, inherited condition characterized by amyloid deposition in the corneal stroma. Recurrent corneal erosions most commonly occur with LCD due to abnormal basement membrane complexes incapable of providing normal structural integrity to the epithelial layer predisposing the cornea to microbial infections such as bacterial and fungal keratitis. Amyloid fibrils have also been postulated to cause tissue damage by stimulating local and nonlocal immune cell infiltration into the tissues and producing pro-inflammatory cytokines leading to sterile inflammation. This case is one of the few rare case reports of sterile infiltrates in LCD Type 1, patients identified after multiple treatment failures to the best of our knowledge.
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Radius maumenee syndrome - Idiopathic elevated episcleral venous pressure p. 273
Vijayalakshmi A Senthilkumar, Sharmila Rajendrababu, R Krishnadas
DOI:10.4103/tjosr.tjosr_53_20  
A 42-year-old female patient has been referred for high intraocular pressure (IOP) in both eyes (BE). Examination revealed dilated, tortuous conjunctival, and episcleral vessels in BE with no apparent cause, also the patient had advanced glaucomatous damage in the left eye (LE). A diagnosis of bilateral idiopathic elevated episcleral venous pressure with secondary open-angle glaucoma (Radius Maumenee syndrome) was made. She was treated with aqueous suppressants in BE and underwent Partial diode cyclophotocoagulation in LE for control of high IOP. Nearly 50–55 cases have been reported till now. We publish here as this is a rare entity; also we discuss certain management controversies and provide literature review about this entity.
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Triple trouble: Congenital nasolacrimal duct obstruction, cleft palate, and sensorineural hearing loss - A rare association of blepharophimosis-ptosis-epicanthus inversus syndrome p. 277
Reshma Ramakrishnan, Sayali Santosh Amberkar, Priyanka Gandhi
DOI:10.4103/tjosr.tjosr_8_21  
Blepharophimosis-ptosis-epicanthus inversus syndrome (BPES) is autosomal dominant disorder affecting 200 families worldwide. It is marked by bilateral ptosis with poor levator function, shortened horizontal palpebral fissures, and epicanthus inversus. We report a case of 7-month-old female child who presented to us with watering of both eyes since birth and failure to thrive. Examination revealed peculiarities of BPES with bilateral congenital nasolacrimal duct obstruction (CNLDO) and associated findings of bilateral sensorineural hearing loss (SNHL) and cleft palate. Initially, conservative management followed by probing, cleft palate correction, and V-Y plasty was advised and ptosis correction planned at later age. There are several ocular and nonocular associations with BPES, but CNLDO, cleft palate, and SNHL together have never been reported to the best of our knowledge.
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Management of post glaucoma drainage device-related endophthalmitis: To retain or to remove? p. 280
S Usha Tejaswini, Srinivasan Kavitha
DOI:10.4103/tjosr.tjosr_80_20  
Glaucoma drainage devices (GDD) play important role in the management of intractable glaucoma. Endophthalmitis in such cases though is a rare occurrence, could still be a vision threatening complication. We report a case of patient with refractory glaucoma who was managed with GDD implantation presenting with delayed endophthalmitis. Here, we discuss the approach to the diagnosis and modalities of intervention keeping the GDD in situ as removing the GDD can jeopardize the intraocular pressure control in such a case of advanced glaucoma.
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Diagnostic and therapeutic dilemmas in alacrima, achalasia, and addisonism syndrome p. 283
Laavanayaa Somasundaram, Suhas Prabhakar
DOI:10.4103/tjosr.tjosr_187_20  
Allgrove's syndrome is a rare genetic disorder characterized by alacrima, achalasia, and addisonism (AAA syndrome). The rarity of the disease and the requirement of genetic analysis to confirm the disease cause diagnostic issues. The variable nature of presentation of the classical triad is known. Requirement of education among the clinician and parents is essential to avoid severe or fatal complications. We present a case of male child who presented with near-fatal hypoglycemia and on evaluation found to have early-onset complete manifestation of AAA syndrome. The case also highlights the need of periodical assessment, awareness among clinicians about disease, and parental education to avoid severe complications.
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Case report of rhino-orbital-cerebral mucormycosis secondary to periodontal abscess presenting as exudative retinal detachment p. 286
Elango Vidhya
DOI:10.4103/tjosr.tjosr_36_21  
A 31-year-old Type 1 diabetes mellitus presented with exudative retinal detachment due to rhino-orbital-cerebral mucormycosis secondary to a periodontal abscess developed following a tooth extraction. He received liposomal amphotericin B due to diabetic nephropathy. We report this case for the rarity in the combination of exudative retinal detachment in a case of orbital cellulitis as well for its rarest origin following a dental extraction.
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A mysterious case of transient proptosis p. 289
Debolina Deb, Chaitanya Aravind Ankem, Suhas Prabhakar, M Radhakrishnan
DOI:10.4103/tjosr.tjosr_18_21  
A 42-year-old Indian woman presented with a slowly progressive and painless swelling in the superomedial aspect of right orbit over past 5 years. She succumbed to homeopathic treatment which controlled the swelling for some time, but eventually recurred. The swelling led to protrusion of her right eye down and out. The patient's vision in her right eye was reduced, with restricted movement on elevation and adduction. The right eye pupil was sluggishly reacting to light. The fundus examination of the right eye revealed hyperemic disc with disc edema and retinal folds. Whereas, left ocular examination was normal. The computed tomography and magnetic resonance imaging scans of the right orbit revealed an intraconal, multiloculated lesion in the superomedial aspect of the orbit, adhering to the optic nerve, giving us an array of differential diagnosis. She underwent right anterolateral orbitotomy under general anesthesia; the masses excised were sent for histopathological examination, which gave the definitive diagnosis of a schwannoma.
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Thinking beyond chalazion!!! p. 292
Harikrishnan Marappan, P Deepika Makam, Dhatri Himanshu Karanam
DOI:10.4103/tjosr.tjosr_158_20  
A 57-year-old male complained of painless swelling in the left eye upper lid for 5 months and increasing in size for 2 months. On examination, a round well-defined, firm swelling, nontender measuring 5 mm horizontally and 7 mm vertically above the lid margin in lateral part of the upper eyelid with small yellowish pustule at the lid margin corresponding to the site of lesion. The architecture of the lid and lid margin was maintained, no telangiectasia and there were no loss of eyelashes. A provisional diagnosis of marginal chalazion was made. Then incision and curettage were done. Biopsy showed invasive meibomian gland carcinoma with malignant sebocytes, numerous mitoses, and necrosis. Later, wide excision with reconstruction by tenzels flap done after edge clearance. Sebaceous gland carcinoma though rare is an aggressive tumor, and is a great mimicker of many benign conditions leading to diagnostic difficulty. Hence thinking beyond chalazion is necessary in old age, recurrent chalazion, unilateral blepharitis, keratoconjunctivitis should arise suspicion to decease the morbidity and mortality associated with the tumor.
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Experience with manual small incision cataract surgery in the management of isolated bilateral microspherophakia p. 295
R Sankarananthan, Mulasthanam Sai Dheera, Madhu Shekhar, Sagnik Sen
DOI:10.4103/tjosr.tjosr_15_21  
Introduction: We report a case of isolated microspherophakia,managed by an anterior segment surgeon with good visual recovery. Case Description: A 36-year-old female who presented with complaints of defective vision was diagnosed with bilateral isolated microspherophakic lens with cataractous changes. She underwent manual small incision cataract surgery (SICS) uneventful, utilizing capsular tension ring within the bag placement of lens in one eye, whereas in the other eye, an iris fixation of the intraocular lens using sutures was done. Conclusion: In cases of MSP, clear lens extraction, phacoemulsification, and pars plana lensectomy have been described for lenticular myopia and cataract. However, we reiterate the use of simpler techniques like SICS, especially when challenged by advanced cataract or a resource-poor setting. We report a good visual recovery in our patient, substantiating that such complicated cases can be handled by an anterior segment surgeon even in such a challenging context.
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Congenital aniridia- there's more than meets the eye p. 298
GN Subathra, Indira Durai, Sahithya Bhaskaran
DOI:10.4103/tjosr.tjosr_19_21  
Congenital aniridia is a rare panocular disorder, leading to significant visual impairment which may present as an isolated ocular phenotype or in association with a systemic syndrome. We report the case of a 20-year-old female with congenital aniridia associated with ectopia lentis, horizontal pendular nystagmus, and foveal hypoplasia, leading to low vision subsequently limiting her social life. This case report highlights the importance of early intervention with low vision aids and focused rehabilitation to enhance the quality of life in individuals with congenital aniridia, thus preventing progression to permanent disability.
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Fungal scleritis following evisceration p. 301
Aalia Rasool Sufi, Namrata Gaikwad, Aamina Shah, Junaid Wani
DOI:10.4103/tjosr.tjosr_43_21  
Infection of the sclera poses a therapeutic challenge due to its poor vascularity. Herein, we describe a case of fungal scleritis following evisceration in an immunocompetent man. Aggressive multidrug medical treatment was combined with enucleation to eliminate the infection. Thus, a multipronged approach is to be adopted for successful outcome and the prevention of complications.
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A case of unilateral presentation of peters' anomaly with fundus involvement p. 304
Mamta Agrawal, Reshma Ramakrishnan, Ayushi Choudhary, Aishwarya Singh Raghuvanshi, Purva Deore
DOI:10.4103/tjosr.tjosr_172_20  
Peters' anomaly is a rare congenital malformation of anterior segment dysgenesis, in which abnormal cleavage of anterior chamber occurs. A 22-month-old male was brought by his parents with a history of whitish discoloration in the right eye since birth. The child was born by full-term lower segment cesarean section, with breech presentation. His birth weight was 3 kg and he did not cry immediately. The patient was the first child of nonconsanguineous marriage. The child was diagnosed with hypoxic–ischemic encephalopathy at birth. On TORCH profile, he was found to be cytomegalovirus (CMV) immunoglobulin G positive. The mother gave a history of neonatal intensive care unit admission on the 3rd day of birth for seizures. On ophthalmic examination, the child followed torchlight and had nystagmus in horizontal gaze in both eyes and exophoria in the right eye. Slit-lamp examination of the right eye revealed microcornea, leucomatous corneal opacity measuring 2.5 mm × 3.5 mm involving the central cornea, and iridocorneal touch, however, peripheral cornea was clear. On fundus examination, a large coloboma involving the optic nerve head was noted in the right eye. Left eye anterior segment and fundus was normal. Intraocular pressure in both eyes was 14 mmHg using Perkins tonometer. Electroencephalography suggested right occipital lobe dysfunction. Diagnosis of unilateral Peters' anomaly type I with optic disc coloboma in the right eye with CMV was made. The parents were counseled about the condition, and 6-monthly ophthalmic checkup was advised.
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Overlapping visual fields – A “diagnostic” conundrum p. 307
Sophia Louisraj, CA Nelson Jesudasan
DOI:10.4103/tjosr.tjosr_42_20  
A 55-year old male, a patient with established glaucoma, presented with worsening of visual complaints. Field analysis revealed an apparent progression of the pre-existing field changes. A possible overlap of a neurological field defect was however suspected. Computerised tomogram (CT) revealed an acute vascular event in the territory of the middle cerebral artery. Mistaking the new field defect as a sign of glaucoma progression, would have resulted in missing the cerebrovascular accident, with a possible ominous outcome. Careful interpretation of visual fields (especially in those with pre-existing field defects), is therefore, a must in every given clinical scenario.
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Isolated alacrimia associated with microblepharon p. 310
Venugopal Anitha, Meenakshi Ravindran, Venkatachalam Karthikeyan
DOI:10.4103/tjosr.tjosr_70_20  
Isolated alacrimia is a rare condition often reported with salivary gland agenesis in the literature. Children with the isolated absence of the lacrimal gland can have normal tear film but not during emotional stimuli. Microblepharon is a congenital anomaly with abnormally small eyelids due to vertical shortening, which leads to incomplete blink, exposure keratopathy, and corneal ulceration. The combined occurrence of both the conditions in our case led to ocular surface keratinization and visual impairment. Here, we report a case of isolated lacrimal gland agenesis in association with microblepharon in a 2-year-old child.
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OPHTHALMIC IMAGES Top

Supernumerary punctum p. 313
Carlos Izquierdo-Rodriguez
DOI:10.4103/tjosr.tjosr_32_21  
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Unilateral MRCS syndrome: A rare clinical entity p. 314
Prateek Jain, Poulami Pal, Anshuman Pattnaik
DOI:10.4103/tjosr.tjosr_2_21  
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Neodymium-doped yttrium–aluminum–garnet painting: A curious capsulotomy design p. 317
Carlos Izquierdo-Rodriguez
DOI:10.4103/tjosr.tjosr_27_21  
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HISTORY/REMEMBERING THE PAST Top

Albrecht von graefe (1828–1870) p. 318
Gunjan Saluja
DOI:10.4103/tjosr.tjosr_88_20  
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PHOTO ESSAY Top

Scars of an old story: Laser pointer injury p. 320
Sandra C Ganesh, Shilpa G Rao, Murali Krishnan Srinivasan
DOI:10.4103/tjosr.tjosr_25_21  
A 12-year-old boy presented to us with complaints of nonprogressive diminution of vision and seeing a black spot at the center of his visual field in his right eye following exposure to a red laser pointer accidentally, while playing, 2 years ago. On examination, his best-corrected visual acuity was 6/12 OD and 6/6 OS. His anterior segment examination was clinically normal. Fundus examination revealed a well-defined, pigmented, slightly elevated, hypoautofluorescent scar involving the nasal parafoveal region of the macula in his right eye. His left fundus appeared normal. Optical coherence tomography (swept source) imaging showed an irregular, raised, hyperreflective inner layer with back-shadowing in the parafoveal region corresponding to the pigmented scar seen in his right eye. Laser pointer injuries are fairly common but under-reported health hazard.
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PHOTO QUIZ Top

Photo quiz questions p. 322
Jiz Mary Santhosh, Niranjan Karthik Senthil Kumar
DOI:10.4103/tjosr.tjosr_66_21  
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Photo quiz answers p. 324
Jiz Mary Santhosh, Niranjan Karthik Senthil Kumar
DOI:10.4103/tjosr.tjosr_67_21  
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