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   Table of Contents - Current issue
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January-March 2021
Volume 59 | Issue 1
Page Nos. 1-122

Online since Saturday, March 27, 2021

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EDITORIAL  

From the editor's desk Highly accessed article p. 1
Sharmila Devi Vadivelu
DOI:10.4103/tjosr.tjosr_24_21  
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ORIGINAL ARTICLES Top

Visual rehabilitation using miniscleral lens in advanced keratoconus Highly accessed article p. 2
Sudhakar Potti, Aparna N Nayak
DOI:10.4103/tjosr.tjosr_131_20  
Aim: The aim of this study is to visually rehabilitate patients with advanced keratoconus with miniscleral contact lens. Materials and Methods: Miniscleral lens were prescribed in 11 eyes of 8 patients with advanced keratoconus. Inclusion criteria Amsler Krumeich Grade 2 with poor spectacle corrected visual acuity (<0.5logMAR) for the duration of 1 year. Results:Mean age was 18.75 years. Males and females were 50% each. Mean of uncorrected, spectacle corrected, best-corrected visual acuity with contact lens was 1.28logMAR, 0.96logMAR, and 0.12logMAR, respectively. Visual improvement was minimal with spectacles (0.5 Snellen lines, 0.32logMAR), whereas miniscleral contact lens showed additional improvement of 4.5 Snellen lines (1.16logMAR), respectively. Conclusion: Visual rehabilitation with miniscleral contact lens in advanced keratoconus showed excellent improvement in visual acuity and reduced the need for corneal transplantation.
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Relationship between levels of vascular endothelial growth factor in blood and severity of diabetic retinopathy Highly accessed article p. 5
Jebinth Brayan, D Sundar, Sanjana B Singh, Niranjana B Singh, Manu Thomas, Prithvi Chandrakanth
DOI:10.4103/tjosr.tjosr_124_20  
Aim: The aim of the study was to establish the relationship between levels of vascular endothelial growth factor (VEGF) in blood and severity of diabetic retinopathy (DR). Background: The importance of VEGF in the pathogenesis of DR is evident from numerous studies demonstrating a significant increase in VEGF levels in samples obtained from the eye. However, a correlation between blood levels of VEGF and DR has not been conclusively proven or disproven. In this article, we demonstrate the relationship between blood levels of VEGF and the severity of DR. Materials and Methods: This is a hospital-based descriptive analytic study. The study population consisted of 75 Type 2 diabetic patients attending outpatient department for routine DR screening. After obtaining informed consent, 5 ml of blood was drawn from each patient and estimated for the levels of serum VEGF. The data thus obtained were correlated with the grade of DR. Additional parameters studied were duration of diabetes mellitus (DM), hemoglobin levels, blood urea, serum creatinine, fasting blood sugar (FBS) and random blood sugar (RBS), and hemoglobin A1c (HBA1c) levels. Statistical analysis used in this study was Chi-square test, Student's t-test, independent one sample t-test, and analysis of variance using SPSS software version. 19. Results: Overall mean VEGF levels for the study population of 75 diabetic patients were 577.01 ± 291.13 pg/ml. The average duration of DM in the study population was 7.2 years. The average hemoglobin level in the study population was 11.53 ± 2.00 g/dl. The mean urea levels in mg/dl of the whole population were 35.47 ± 25.80 mg/dl. The mean creatinine levels for the population were 1.42 ± 1.55 mg/dL. The mean RBS levels for the whole population were 228.95 ± 74.499 mg/dL. The mean FBS levels for the 75 patients were 165.87 ± 59.04 mg/dl. The mean HBA1c levels were 9.49 ± 2.37%. Conclusion: Levels of blood VEGF are elevated in diabetic patients regardless of whether they have DR or not. There is no statistically significant relationship between blood levels of VEGF and the severity of DR. Even though severe grades of DR showed more anemia, there is no statistically significant relationship between anemia and DR. The levels of urea and creatinine were elevated in the more severe grade of DR. VEGF, therefore, could present a potential treatment and preventive strategy for not only DR but also DM and its complications in general.
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Ocular blood flow study using color doppler imaging: Normative value and its relevance in glaucoma p. 10
Pratheeba Devi Nivean, Murali Ariga, M Nivean, Malarchelvi Palani
DOI:10.4103/tjosr.tjosr_135_20  
Aim: The aim was to study the normative pattern of ocular blood flow (OBF) using color Doppler imaging. Materials and Methods: It was a prospective study including healthy volunteers without any ocular pathology. Results: We analyzed ocular blood flow for 25 eyes of consecutive normal patients. Our study had 14 males and 11 females. The standard deviation of the resistive index of Ophthalmic artery, Central retinal artery and short posterior ciliary artery were 0.07, 0.08 and 0.12 respectively. Discussion: Ischemia to the optic nerve and dysfunctional vascular regulation are likely responsible for glaucomatous damage. Ocular hemodynamics, though complex, can be assessed to an extent by many ways. The quantification of blood flow in these vessels can give great lengths of information with regard to the pathological processes behind retinal and optic nerve head diseases such as glaucoma. Lower ocular perfusion pressure, vascular dysregulation, and lower OBF can worsen glaucoma. Conclusion: To our knowledge, there are no South Indian studies showing the normative data.
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Association between central corneal thickness and ocular dominance in a South Indian population Highly accessed article p. 13
Prasanna Venkatesh Ramesh, Sathyan Parthasarathi, Rajesh Kumar John
DOI:10.4103/tjosr.tjosr_116_20  
Aims: The aim of the study is to investigate the association between ocular dominance and central corneal thickness (CCT) among normal eyes. Settings and Design: A cross-sectional study was conducted in the outpatient department of a tertiary care center in Southern India. Subjects and Methods: Participants of the study included 87 outpatients and volunteers with bilateral nonpathological eyes. This study was performed according to the tenets of the Declaration of Helsinki. To determine the dominant eye, hole-in-card test was utilized. Masked of the ocular dominance result, an independent observer measured CCT at the visual axis with specular microscopy (CEM-530, Nidek, Canada) by noncontact modality. Three readings were obtained from each eye. The right eye was first examined. Average of the three CCT readings was used for analysis. Statistical Analysis Used: Statistical methods included paired t-test (for comparison of eyes within patient) and Chi-square test to assess the association between ocular dominance and CCT. A P < 0.05 was considered statistically significant. Results: The 87 volunteers studied were aged 37.6 ± 14.8 years and 62.1% were female. CCT was 525.5 ± 28.4 μm in the right eye and 534.8 ± 29.8 μm in the left eye. Right eye was dominant in 63 (72.4%) patients. CCT in the dominant eye was 528.0 ± 29.5 μm and was significantly thinner (P < 0.001) than the nondominant eye (532.2 ± 29.3 μm). This was true in 69.0% of the patients. However, thinner cornea in a person was not indicative of a dominant eye (P = 0.535). Conclusions: As with other populations, right eye dominance was seen in South Indian population among nonpathological eyes. CCT is predominantly thinner in the dominant eye. Yet, this result cannot be applied to an individual by labeling the eye with thinner cornea as dominant with precision.
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The clinical and risk profile of presenile cataract in a semi-urban population of South India p. 18
Lily Daniel, Christina Mary Paul
DOI:10.4103/tjosr.tjosr_162_20  
Background: The aim of this study was to assess the morphological characteristics of presenile cataract and analyze its risk profile in a semi-urban population in a South Indian state. Subjects and Methods: This cross-sectional, observational, and descriptive study was conducted in the Outpatient Department of Ophthalmology at a University Teaching Hospital, Chennai, from June 2018 to May 2019. Eighty-two consecutive study participants underwent detailed medical history, ocular examination, and blood investigations such as fasting blood sugar, fasting lipid profile, post prandial blood sugar, hemoglobin, blood urea, serum creatinine, serum calcium, thyroid function tests (TFT) and Electrocardiogram (ECG). Data analysis was done using International Business Machines, United States of America, Statistical Package for the Social Science, (IBM, US, SPSS), version 20. Results: A female predominance of 69.5% was noted. The mean age was 43.8 ± 7 years. Presenile cataract was higher in the age group of 41–49 years (odds ratio = 6.55). Posterior subcapsular cataract (PSC) was found in 65 eyes (39.6%), grade 2 nuclear sclerosis in 42 eyes (25.06%), and cuneiform cataract in 22 eyes (13.4%). The risk profile in presenile cataract was hypocalcemia (54.9%), diabetes mellitus (50%), and hypertension (17.07%). Hypertriglyceridemia was found in 22% of diabetics (P = 0.026). 25.6% was idiopathic. Conclusion: PSC was the predominant type of presenile cataract in this semi-urban population group. Patients with hypocalcemia and diabetes are significantly at risk in developing presenile cataract. Diabetics with hypertriglyceridemia have a higher risk.
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A cross-sectional study to assess the knowledge, attitude, and practice toward eyecare among the ophthalmology postgraduates of Karnataka during COVID-19 pandemic p. 23
MS Mashitha, Mahesh Babu, NA Sudhakar, Shruthi Bidari
DOI:10.4103/tjosr.tjosr_169_20  
Aim: The aim of this study is to assess the knowledge, attitude, and practice toward eye care among ophthalmology postgraduate of Karnataka in coronavirus disease 2019 (COVID-19) pandemic. Methods: A self-designed questionnaire was prepared and sent to ophthalmology postgraduates in the various colleges in Karnataka using Google form platform as an online survey. The sample size was calculated to be 100. Results: Out of 100 participants, 80% were female with 84% aged between 26 and 30 years. The rates for correct answer for knowledge about COVID-19 ranged from 60% to 92%. In terms of practice, 65% of them showed good practice. Ninety-four percent of the participants told that COVID-19 has adversely affected their postgraduation training, especially the surgical training. Conclusion: The postgraduate residents of ophthalmology showed a satisfactory level of knowledge and attitude toward COVID-19 with an obvious difference in practice with regard to disciplines. Practice can be further improved by webinars, Continuing Medical Education Programs (CMEs), and guidance from the experts. Since the surgical training has been greatly affected, more frequent video-based surgical teaching programs, virtual simulation platforms, and practice on model eyes must be encouraged for the surgical training of the residents.
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Analysis of visual outcome following cataract surgery in axial myopic patients p. 28
Dhivya Ramakrishnan, Venkatesh Sugantharaj
DOI:10.4103/tjosr.tjosr_56_20  
Aim: The primary outcome is to assess visual outcomes following cataract surgery in axial myopic patients. The secondary outcome assessed is perioperative complications rate due to high axial length. Materials and Methods: Type of study: It was a retrospective, noncomparative case series study. Inclusion criteria: Patients with axial length more than or equal to 25 mm with visually significant cataract in one or both eyes were recruited for the study. Patients with pathological myopia were also included – visual recovery was assessed in conjunction with the preoperative best-corrected visual acuity. Exclusion criteria: Myopic patients with cataract with other causes of visual loss such as macular scar, diabetic retinopathy, age-related macular degeneration, disc edema, vein occlusion, and epiretinal membrane were excluded from the study. Sample Size: The sample size of the study was 32 patients (49 eyes). All patients recruited for the study underwent complete anterior segment examination in slit lamp with due importance to the type of cataract, visual acuity examination, and refraction to assess preoperative best-corrected visual acuity and posterior segment examination with 90 D lens. If the posterior segment was not visualized, B-scan was done. Blood investigations include complete blood count, random blood sugar, HIV, hepatitis B virus surface antigen, and urine albumin/sugar. With the test results and electrocardiogram, anesthetist fitness was obtained. Duct patency and intraocular pressure (IOP) were measured. Automated keratometry and axial length were measured by immersion technique done to calculate intraocular lens (IOL) power. IOL power calculation was performed using the SRK/T which was found to be reliable in axial lengths above 25 mm. Anterior chamber depth and lens thickness were also measured. All patients underwent phacoemulsification with IOL implantation by experienced single surgeon. The main outcomes measured were visual acuity after cataract surgery with implantation of zero or negative or very low IOL power at 1-month postoperative period and intraoperative and postoperative complications. The method of surgery did not influence the visual outcome. Results: The mean age of the patient operated on was about 61.9 years. In our study, the most common type of cataract was nuclear cataract (63.2%). Only 4.1% had previous refractive surgery. About 65.3% had 6/6 vision postcataract surgery with axial myopia. About 51.1% of axial myopic patients' fundus changes before cataract surgery which could be one of the causes for poor visual acuity. No significant perioperative complications were observed. Conclusion: Good postoperative outcomes following cataract surgery were observed in patients with cataract and high myopia. Refractive error is a potential complication as the hyperopic error appears to increase with axial length, especially in patients receiving negative power lens. If a sulcus IOL is inserted, it is more likely to be unstable or decenter because of the larger sulcus size. The need for Nd: YAG capsulotomy for posterior capsular opacity was found to be more common in myopes with high axial length compared to the general population. IOP reduction is slower and unstable for the first 30 days of postcataract surgery in highly myopic eyes.
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A clinical study of episcleritis and scleritis p. 32
Pawan N Jarwal
DOI:10.4103/tjosr.tjosr_93_20  
Purpose: Episcleritis and scleritis, considered as different forms of the same spectrum of disease, are clinically distinct, having different prognosis and requiring different management. They participate in a variety of systemic diseases, particularly in connective tissue disorders. As they are uncommon disorders, documentation of clinical experience with them is limited. In this study, the clinical profile and associated disorders of episcleritis and scleritis were studied. Methodology: Detailed clinical history was taken in every patient relating to ocular and systemic disorders. Ocular and systemic examinations were done in all patients. Essential investigations pertaining to the cases were done. The patients were followed up throughout the course of the study for a variable period. Results: One-fourth of episcleritis cases were of nodular type. All the six cases of scleritis were of anterior type. Episcleritis showed a peak age incidence in the third decade of life, whereas scleritis in the fourth decade. Episcleritis occurred slightly more commonly in females than males. Scleritis showed equal sex distribution. Fifty-five percent of episcleritis patients presented within 3rd week of onset of symptoms, whereas majority of scleritis patients presented during 3rd week of onset. Twenty five percent of episcleritis patients had recurrent disease. One out of 20 cases of episcleritis and one out of six cases of scleritis patients had an associated systemic disorder. In 45% of episcleritis patients, artificial tears were sufficient for treatment. In 15% of cases oral nonsteroidal anti-inflammatory drug (NSAID) was required for controlling their episcleral inflammation. In 5 out of 6 cases of scleritis, oral NSAID was sufficient for controlling inflammation. None of the episcleritis patients had a decreased best corrected visual acuity (BCVA). Whereas one-third of scleritis patients had a fall in BCVA. Conclusion: Episcleritis is a benign, self-limiting, and recurrent disorder which typically affects young adults. Scleritis of whatever variety is a serious condition and usually affects the older age group. Episcleritis patients do not develop any sight-threatening complications. Whereas a half of scleritis patients develop ocular complications, which are usually severe and sight threatening. In majority of episcleritis patients, topical medication will suffice. All patients with scleritis must be treated with systemic anti-inflammatory medications.
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REVIEW ARTICLES Top

Current concepts and future trends in dry eye syndrome – A review of literature p. 38
Bharat Gurnani, Kirandeep Kaur, Maddala Chaitanya Kumar
DOI:10.4103/tjosr.tjosr_108_20  
Keratoconjunctivitis sicca, also known as dry eye (DE), is an extremely common and often unrecognized pathological entity. It is characterized by decreased tear production or increased evaporation and manifests with a wide spectrum of signs and symptoms. Due to multifactorial and elusive etiology, it is often a challenge to treat DE syndrome. Ocular surface disorders are also clinically very important to manage especially in terms of visual acuity. A comprehensive understanding of the pathophysiology and etiology of DE disease (DED) leads to more meticulous management and treatment of the pathological process. The present review article after detailed literature review aims to provide information on the definition, epidemiology, classification, causes, diagnostic tests, and medical and surgical management and futures trends of DED.
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Bionic eye: An iconic innovation p. 52
Tarun Kumar Suvvari, Mansi Thipani Madhu, Sowmyashree Nagendra
DOI:10.4103/tjosr.tjosr_168_20  
The bionic eye is a visual prosthesis that restores the vision fully or partly in blind people suffering from retinitis pigmentosa and macular degenerations. Many bionic eyes have completed human clinical trials and become functional but still need newer technical approaches to make it available to all people. A bionic eye illuminates the dark world of blind people. To date, many bionic eyes were developed like Argus II Retinal Prosthesis System, Artificial silicon retina and many more, whereas Gennaris Bionic vision System is the recent advanced bionic eye. In our paper, we have covered the basic structure and working of the bionic eye, projects on the bionic eye to date, vision through the bionic eye, implants and restoration of sight, limitations, and the future of the bionic eye.
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NEW DRUG UPDATE Top

Rho-kinase inhibitors in ophthalmology p. 56
Megha Gopalakrishna, Srinivasan Kavitha
DOI:10.4103/tjosr.tjosr_146_20  
Rho-kinase (ROCK) inhibitor is the newer drug available for glaucoma in the Indian market. It seems to target the actual area of disease pathology which has not been the case with the available medications. With the ever-evolving potential of these drugs in various diseases in ophthalmology, it would be wise to know about them. This review article aims to provide information regarding the role of ROCK and its inhibitors in glaucoma, corneal diseases, and retinal pathologies. A thorough search of several databases was conducted with ROCK inhibitors being one of the main keywords.
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CASE SERIES Top

Tuck-in tenon's patch graft for corneal perforation p. 61
Sharmila Devi Vadivelu, Amogh Laxman Jambagi, G Thiruvengada Senthilkumar, Nivetha Gandhi, M Sivakami
DOI:10.4103/tjosr.tjosr_139_20  
Corneal perforation remains to be one of the most dreaded complications of ocular trauma and its prompt diagnosis and management is key to quick recovery. Tuck-in Tenon's patch graft is an extremely viable and handy technique to tackle corneal perforation. The tenon's tissue, being autologous, reduces the chance of rejection while providing good tectonic support. This is a case series of tuck-in Tenon's patch graft done for cases of corneal perforation. Through the case series, we try to put forth our experience with this novel technique.
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CASE REPORTS Top

Topical beta-blockers: A noninvasive treatment for pediatric pyogenic granuloma p. 65
Pratheeba Devi Nivean, M Nivean, Murali Ariga
DOI:10.4103/tjosr.tjosr_125_20  
Ocular pyogenic granulomas (PG) are common benign tumors seen by general ophthalmologists. Topical beta-blockers can be an effective noninvasive treatment for them. It is particularly very useful in the pediatric population where both surgical excision or steroid use can be risky. We present this case to report yet another use of timolol in ophthalmology.
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Goldmann favre syndrome: A rare case report p. 67
M Hemanandini, V Savithiri, S Dhana Priya
DOI:10.4103/tjosr.tjosr_9_20  
Goldmann Favre syndrome (GFS) is a vitreotapetoretinal degeneration also called as Favre microfibrillar vitreoretinal degeneration. We report the case of a 24-year-old male who presented with defective vision in both eyes for 10 years with a history of defective night vision. He was diagnosed with GFS, by fundus examination and electroretinogram. He was treated with low vision aids.
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Nonhealing epithelial defect after collagen cross-linking for keratoconus with vernal keratoconjunctivitis p. 70
Josephine S Christy, Fredrick Mouttapa, Shivananda Narayana
DOI:10.4103/tjosr.tjosr_107_20  
Here we report a case of nonhealing epithelial defect after corneal collagen cross-linking (C3R) in a 24-year-old young adult with progressive keratoconus and concomitant vernal keratoconjunctivitis (VKC). Epithelium off C3R with hypoosmolar riboflavin and ultraviolet -A irradiation was done in the right eye for progressive keratoconus. The preoperative minimum corneal thickness was 388 microns. Chronic VKC was stabilized with mast cell stabilizer and lubricants before C3R. The patient presented with nonhealing epithelial defect until 1-month post cross-linking due to possible limbal stem cell deficiency (LSCD) and underlying VKC with giant papillae. Amniotic membrane grafting was done twice for ocular surface stabilization which occurred at the end of 7 weeks. Final best-corrected visual acuity at 1 year was 6/12 with nebular corneal scarring. Preemptive management of giant papillae and proper stabilization of the ocular surface is essential before C3R. In cases of keratoconus with VKC, LSCD should be strongly suspected and reactivation of VKC with a prolonged course of epithelial healing can be a possible complication after C3R.
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Aggressive posterior retinopathy of prematurity in baby showing features of cardiofacial syndrome overlapping with pearl syndrome p. 74
Vinit Jayendra Shah, Syed Mohideen Abdul Khadar, Syed Saifuddin Adeel, Shobita Nair
DOI:10.4103/tjosr.tjosr_138_20  
We report the case of a preterm infant referred to us for retinopathy of prematurity (ROP) screening at postmenstrual age of 35 weeks who presented with right-sided congenital lower motor neuron type facial nerve palsy, lagophthalmos, normal anterior segment findings, and aggressive posterior ROP on the fundus examination in both eyes. Right-sided microtia, normal left ear, and asymmetric crying facies were noted. The baby received intravitreal bevacizumab 0.625 mg in both eyes after systemic workup which revealed a ventricular septal defect with patent ductus arteriosus and normal brain magnetic resonance imaging. At 2 months postinjection, the plus disease decreased significantly with vessels developing up to zone 3 with no ROP in both the eyes.
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Recurrent bilateral optic neuritis associated with neuromyelitis optica spectrum disorder in a child p. 77
Alap Jayesh Bavishi, Sapna Sinha, Manoharbabu Balasundaram
DOI:10.4103/tjosr.tjosr_132_20  
Reports of bilateral optic neuritis in children associated with viral infection or postimmunization are relatively common. Neuromyelitis optica spectrum disorders (NMOSD) is a rare syndrome of severe inflammatory immune-mediated demyelination of central nervous system, with median age of presentation being 37.5 years reported in south Indian population. NMOSD associated with optic neuritis in children is very rare. We present a case of 10-year-old girl with bilateral recurrent optic neuritis, seropositive for NMO-IgG (anti-AQP4) supporting the diagnosis of NMOSD. With prompt treatment, patient made a remarkable visual recovery without neurologic deficit. This report highlights prompt diagnosis, leading to better visual outcomes in NMOSD.
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Devic's disease: A rare case presentation p. 80
Sahebaan S Sethi, Aditya Sethi
DOI:10.4103/tjosr.tjosr_129_20  
We report a case of a young patient with sudden drop in vision and lower limb weakness. On examination was found to have left eye disc edema and abnormal CNS function. On further investigation, the patient was diagnosed to have optic neuritis with associated transverse myelitis-a syndrome referred to neuromyelitis optica or Devic's Disease. This case emphasizes the need for timely intervention to prevent permanent vision loss.
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Psychogenic blindness as a rare cause of presumed vision loss p. 83
Sandra C Ganesh, Vanathi Narayanasamy, Lucy P Thaliath, Shilpa G Rao
DOI:10.4103/tjosr.tjosr_118_20  
A 12-year-old girl presented with unilateral, sudden painless loss of vision for the past 2 days. Ocular examination was normal. Optical coherence tomography, visually evoked potential, and magnetic resonance imaging of the brain and orbits were normal. With no organic cause found for vision loss, psychiatrist opinion was sought. After evaluation, she was diagnosed to have psychogenic blindness and treated with psychotherapy. When findings are inconsistent and no organic etiology can be diagnosed for the vision loss, psychogenic blindness is suspected and prompt referral to a psychiatrist is essential for complete recovery.
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An uncommon complication from a common procedure p. 85
Rithulaa Raja, M Nivean, Sangeetha Rajagopal, Pratheeba Devi Nivean
DOI:10.4103/tjosr.tjosr_157_20  
The study aims to highlight the importance of appropriate sizing of yttrium-aluminum-garnet (YAG)–capsulotomy. We report a case of a patient who developed sudden loss of vision, due to an unprecedented posterior dislocation of the posterior chamber intraocular lens, following an apparently uncomplicated YAG laser capsulotomy for a posterior capsular opacification (PCO), which was restored to complete visual recovery. We also stress the importance of appropriate size of the YAG openings. Although neodymium: YAG laser posterior capsulotomy is a safe procedure for treating PCO, it is not free from complications. Limiting the size of the YAG opening to meet the basic requirements is necessary.
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Triple procedure in blood-stained cornea of a hemophilia patient p. 88
Rajesh Mimmithi, Nivetha Gandhi, M Anand Babu, Sharmila Devi Vadivelu, B Meenakshi
DOI:10.4103/tjosr.tjosr_166_20  
A 16-year-old male Type A hemophiliac patient has been reported with complaints of defective vision in the right eye (OD), following ocular trauma 9 months back for which he took treatment outside. On examination, he had blood staining of cornea and cataract in his right eye. His vision was perception of light + and projection of rays intact. After hematologist opinion, under peribulbar anesthesia, he underwent penetrating keratoplasty with pupillary membranectomy and cataractous lens removal with posterior chamber intraocular lens implantation under the cover of Factor VIII (antihemophilic factor). On day 21, the best-corrected visual acuity in OD was 6/6P. This case report emphasizes the fact that hemophiliac patients can be operated safely with appropriate hematological support.
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Apert syndrome: A rare case requiring multidisciplinary approach for a better living p. 91
Sasikala A Elizabeth, Kalpana S Narendran
DOI:10.4103/tjosr.tjosr_43_20  
A 7-year-old boy presented with watering, prominent eyes and defective vision. He had brachycephaly, hypertelorism, shallow proptotic orbits, large exotropia, and syndactyly of the hands and feet. Lateral cephalogram showed fused sutures and mid-facial hypoplasia. He had typical features and diagnosed with Apert syndrome. He underwent lateral tarsorrhaphy and advised to use regular artificial tear substituents. Further, he was referred and received multidisciplinary care helping the child for a better living. Apert syndrome is a rare challenging form of craniosynostosis, and the role of an ophthalmologist in monitoring the visual development in these children is extremely important.
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Spontaneous resolution of primary congenital glaucoma p. 95
Shylesh Dabke, Rengappa Ramakrishnan, Mohideen Abdul Kader
DOI:10.4103/tjosr.tjosr_25_20  
Newborn primary congenital glaucoma (PCG) is an important subtype of PCG. Affected patients manifest specific signs that facilitate its recognition at birth and become important in the determination of appropriate treatment for this severe expression of PCG. Objective clinical evidence supports the occurrence of spontaneous resolution of PCG, explanation for which is unknown. Its mechanism could be related to continued postnatal development of the angle structures in eyes possessing milder angle abnormalities. The anterior segment findings are similar to those of patients with treated PCG such as normal intraocular pressures (IOPs), the optic nerve damage is stable, and filtration angles possess mild or moderate abnormalities. We describe a case of spontaneously resolved PCG in an 8 yearold female presenting with large cornea, Haab's striae, and normal IOP in one eye. Literature review shows limited data about such a case report being described from the Indian subcontinent.
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PHOTO ESSAY Top

Staging and optical coherence tomography characteristics of gyrate atrophy of choroid and retina p. 98
Priya Rasipuram Chandrasekaran
DOI:10.4103/tjosr.tjosr_152_20  
This photo essay describes the optical coherence tomography (OCT) characteristics seen in gyrate atrophy (GA). A 39-year-old female presented with decreased night vision and peripheral vision, best-corrected visual acuity of 20/60 N10 and 20/40 N8 in both eyes, respectively. Fundus examination showed large confluent areas of chorioretinal atrophy involving the disc and leaving an annular zone of the normal retina at the macula. OCT of the macula of the right eye showed hyporeflective cystic spaces in the inner retina and epiretinal membrane, and the left eye was normal while that through the GA showed loss of reflectivity from the nerve fiber layer, extensive loss of inner segment/outer segment layer, thinning of inner retinal layers, retinal pigment epithelium, and Bruchs membrane (BM) and increased visibility of large choroidal-like vessels which appear to be in close proximity to the interpreted BM.
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Bilateral macular coloboma viewed through multimodal imaging p. 101
Akruti Gunderia, Vinit Jayendra Shah, Syed Mohideen Abdul Khadar, Syed Saifuddin Adeel, Aditya Ghorpade, Shobita Nair
DOI:10.4103/tjosr.tjosr_153_20  
A 55-year-old female presented with a defective vision since childhood. The fundus examination revealed a well-demarcated macular excavation of 2 1/2 disc diameters. Optical coherence tomography (OCT) of both eyes revealed a bowl-like depression at the macula, absence of retinal pigment epithelium, and choroid with atrophic neurosensory retina. She was diagnosed as a case of bilateral macular coloboma. We wish to stress OCT and multimodal imaging's importance to diagnose macular colobomas and differentiate it from other disorders of the macula.
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OPHTHALMIC IMAGES Top

Pigmented free floating vitreous cyst p. 103
Nitu Kumari, Nilutparna Deori, Harsha Bhattacharjee, Hemalata Deka
DOI:10.4103/tjosr.tjosr_33_20  
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Bilateral congenital fetal nuclear cataract p. 104
Vijayalakshmi A Senthilkumar
DOI:10.4103/tjosr.tjosr_120_19  
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A vanishing brown lens: Interesting case findings! p. 105
Priyanka S Gupta
DOI:10.4103/tjosr.tjosr_87_20  
Lens absorption has been reported to be associated with uveitis, downs syndrome, morgagnian cataract and trauma. However, spontaneous absorption of hard brown lens is a rare entity. The exact mechanism by which a lens undergoes spontaneous absorption despite an intact capsular bag is still unknown. Here we present a case of elderly female who presented to us with right eye hard brown cataract with ongoing process of getting absorbed and intact capsular bag.
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A rare case of goldenhar syndrome with situs inversus p. 107
D Sakthi Priya, Sharmila Devi Vadivelu, G Thiruvengada Senthil Kumar, B Meenakshi, Nivetha Gandhi
DOI:10.4103/tjosr.tjosr_156_20  
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Traumatic cataract with linear anterior lens capsular rupture and zonular dehiscence in a child p. 109
Sharmila Rajendrababu, Vijayalakshmi A Senthilkumar
DOI:10.4103/tjosr.tjosr_144_20  
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Rare traumatic expulsion of the iris presenting as aniridia p. 110
Bharat Gurnani, Josephine Christy, Kirandeep Kaur, Fredrick Mouttappa
DOI:10.4103/tjosr.tjosr_170_20  
A 55 year old male presented with pain and defective vision in left eye following blunt trauma with sugarcane stick. Anterior segment examination revealed periorbital edema, circumcorneal congestion, ruptured sclerocorneal tunnel with 360 iridodilaysis and iris extrusion through the scleral tunnel, corneal edema, blood staining of endothelium, anterior chamber was flat with eight ball hyphema and vitreous prolapse. A corneoscleral repair was performed with iris abscission, Intraocular lens explantation, anterior vitrectomy and anterior chamber reformation. Postoperative day 1 patient had well opposed sutured scleral tear, corneal edema with descemet membrane folds, anterior chamber hyphema, fibrinous membrane with blood clot over iris and aphakia. B-scan revealed 360 degree hemorrhagic choroidal detachments, retinal detachment with vitreous hemorrhage.
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HISTORY/REMEMBERING THE PAST Top

Jules Gonin (1870–1935): The man behind retinal detachment p. 112
Gunjan Saluja, Asha Samdani
DOI:10.4103/tjosr.tjosr_97_20  
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LETTERS TO THE EDITOR Top

Utilization of hospital car parking garage for COVID-19 triage and screening in a high-volume tertiary eye care center p. 114
Prasanna Venkatesh Ramesh, Shruthy Vaishali Ramesh, Meena Kumari Ramesh, Ramesh Rajasekaran
DOI:10.4103/tjosr.tjosr_106_20  
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The hidden culprit for toric intraocular lens selection - Influence of posterior corneal astigmatism in various astigmatism types p. 117
Shruthy Vaishali Ramesh, Prasanna Venkatesh Ramesh, Meena Kumari Ramesh, Ramesh Rajasekaran
DOI:10.4103/tjosr.tjosr_109_20  
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PHOTO QUIZ Top

Photo quiz - Residents corner p. 120
Josephine S Christy, Saloni Joshi, Vinitha Susan John
DOI:10.4103/tjosr.tjosr_178_20  
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PHOTO QUIZ ANSWERS Top

Photo Quiz Answers p. 122
Josephine S Christy, Saloni Joshi, Vinitha Susan John
DOI:10.4103/2589-4528.312305  
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