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   Table of Contents - Current issue
October-December 2020
Volume 58 | Issue 4
Page Nos. 237-338

Online since Thursday, December 17, 2020

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Editorial Highly accessed article p. 237
Sharmila Devi Vadivelu
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Dematiaceous fungal keratitis: Clinical and microbiologic experience Highly accessed article p. 239
Pratik Gajanan Kunde, V Anitha, R Meenakshi, SH Fathima
Objective: The objective was to study the epidemiology, clinical features, and treatment outcomes of dematiaceous fungal keratitis. Design: This was a retrospective, noncomparative, observational study. Materials and Methods: Fifty-nine cases of dematiaceous fungal keratitis seen at tertiary care hospital from January 2017 to June 2018 were analyzed for demographic features, predisposing factors, clinical characteristics, microbiological profile, and treatment outcomes. Statistical Analysis: Mean (standard deviation) and frequency (percentage) were used to represent continuous and categorical variables, respectively. Wilcoxon signed rank test was used for comparative analysis. Results: Of 236 cases of fungal keratitis seen during the study period, dematiaceous fungi were the third most common isolates in 59 cases (25%) after Fusarium (n = 101; 43%) and Aspergillus species (n = 76; 32%). Majority of the patients were adult males (male: female = 2:1) from rural areas (51%) with agricultural occupation (51%). Trauma with vegetable matter was the most common predisposing factor in 27 cases (45.8%). The characteristic macroscopic pigmentation was seen in only eight eyes (13.6%). In our study, 24 (40.7%) patients revealed Curvularia species, followed by Bipolaris and Exserohilum species in 20 cases (33.9%) and 10 cases (17%), respectively. The median time of antifungal therapy was 21 days (interquartile range: 21–41 days). Fifty-four (91.5%) responded to medical therapy, whereas five eyes required surgical intervention. Conclusions: This study signifies the importance of dematiaceous fungi as the important causative agent of fungal keratitis. Medical therapy along with debridement of ulcer alone can be effective in treating patients with superficial infiltrate who seek treatment early.
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Advanced keratoconus with very low pachymetry – Can contact lens avoid corneal surgery? Highly accessed article p. 245
Radhika Natarajan, Amrutha Mahalakshmi Anandan, Manokamna Agarwal
Clinical relevance: Keratoconic eyes with low pachymetric values, precluding safe CXL can show significant improvement in vision with newer scleral Contact lenses(CL), which was not possible with older rigid CLs. Purpose: To describe diagnostic and management difficulties in keratoconic eyes with pachymetry too low for CXL (Collagen Cross linking)necessitating surgery for improving tensile strength, yet having significant improvement in vision with newer rigid contact lenses such that immediate keratoplasty can be deferred. Methods: Case records of 16 patients (20 eyes) were reviewed. All patients had advanced keratoconus with low pachymetric values but had significant improvement in vision with rigid CLs. CXL was not safely feasible in these eyes and immediate surgical treatment for tissue strengthening was deferred as they had good vision with newer rigid CLs. Patients were kept under close observation due to the risk of developing corneal hydrops. Results: Mean age was 25.68 years. Mean best-corrected visual acuity with glasses was 0.54logMAR, whereas, with rigid CLs was 0.18logMAR. Mean steep-keratometry (K) was 62.66D. Mean central pachymetry, highest posterior surface elevation, and pachymetry at thinnest location was 314.4, 119.6 and 313.61microns respectively. Mean follow-up was 4 years. Conclusion: Advanced keratoconic eyes may have pachymetric values too low for CXL, therefore needing keratoplasty for tissue strengthening and yet can have good vision with rigid CLs. Quantitative analysis of further progression of keratoconus in these eyes is difficult as imaging techniques become unreliable in advanced stages of the disease. Significant improvement in vision with newer rigid and scleral CLs makes the decision to operate, purely for tissue building, difficult.
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Ocular myasthenia gravis: A case series p. 249
Sandra C Ganesh, Amrutha Sindhu, Jogitha
Aim: To report the clinical profile of patients with myasthenia gravis (MG) at a tertiary eye care center in Tamil Nadu. Material and Methods: This is a retrospective case series of patients in a single center between February 2019 and March 2020. Result: We present a series of five cases of ocular myasthenia in the pediatric age group (0–16 years), comprising three males and two females. The patients had varied presentations on the initial examination. Conclusion: It is important to differentiate MG from other diagnostic mimics such as neurological causes such as cranial nerve palsy, myopathies, ocular pathologies, and neuromuscular junction pathologies such as botulism and brainstem tumors. Diagnosis and treatment of myasthenia is done as a team effort of ophthalmologist and neurologist. This study is to reinforce a vigilant lookout for this great masquerader.
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Preoperative and postoperative comparison of higher order aberrations in individuals 1 month after small incision lenticule extraction p. 253
N V Arulmozhi Varman, Aadithreya Varman, Dinesh Balakumar
Aim: This study analysed the visual outcomes of patients with myopia and myopic astigmatism following Small Incision Lenticule Extraction (SMILE). Visual outcomes were determined by Post-operative refraction, Uncorrected Visual Acuity and aberrometry estimated with iTrace aberrometer post operatively immediately and upto day 30. Results: On Post-Operative day 1, the spherocylinder group, attained an uncorrected visual acuity of 6/6. Materials and Methods: The final post-operative refraction in all cases was within ±0.25 diopters of sphere in 18 eyes and within ±0.50 diopters of sphere in 10 eyes. The aberrometry values recorded on iTrace at the end of 30 days revealed a decrease in the total higher order aberrations. Mean higher order aberration is significantly (P<0.05) reduced in the post-operative status Similarly the pure cylinder group attained uncorrected visual acuity of 6/6 in all eyes on POD 30, with a decrease in higher order aberrations. Mean higher order aberration is significantly (P<0.05) reduced in the post-operative status. The final post-operative refraction in all cases was within ±0.25 diopters of cylinder in 48 eyes, within ±0.50 diopters of cylinder in 16 eyes and within ±0.75 in 14 eyes. Conclusion: SMILE is a successful procedure in treatment of both myopic spherical and cylindrical refractive errors. The faster healing and flapless advantage along with lesser incidence of dry eyes has an edge over conventional laser vision corrective procedures. The other important advantage is the reduction of higher order aberrations and better quality of vision. To conclude SMILE is safe and effective procedure for correction of myopic refractive errors and is also beneficial in reducing higher order aberrations.
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A retrospective study of patients with visual impairment: Its magnitude, causes, and acceptance of the low vision Aids in a tertiary eye care hospital p. 258
Annamalai Odayappan, Tiruvengadakrishnan Nirmala Devi, Girish Velis, Priya Sivakumar, Sivagami Nachiappan
Aim: The study aims to highlight the importance of a low vision clinic and give a profile of patients presenting to a low vision clinic at a tertiary eye care hospital. Materials and Methods: Design: Retrospective study. Setting: Institutional. Study population: Details of 9,601 patients who presented to our low vision clinic between January 2009 and June 2015 were analyzed from our database. Data obtained include age group, best-corrected visual acuity, cause of low vision, type of low vision aids (LVA) prescribed, acceptance of the device, and the provision of additional rehabilitation services. Statistical Analysis: Categorical variables were given in the frequency tables with percentages. Results: Around 70.7% of patients were found to have low vision and 29.3% were found to have blindness. We note that 65% of the patients were <40 years of age. The major causes of visual impairment were retinitis pigmentosa, macular degeneration, diabetic retinopathy, pathological myopia, optic atrophy, glaucoma, albinism, and congenital nystagmus. LVA was prescribed to 2689 individuals. The most commonly prescribed LVA were spectacle magnifiers, hand, and stand magnifiers. However, the acceptance rate was just 38%. The rest were given either standard spectacles or were referred to rehabilitation centers if the vision was very poor. Conclusion: There is a young population with visual impairment and highly under-utilized low vision services. Improving the acceptance rate of these devices would help enhance the individual's quality of life part of which could be done by reducing the cost of these devices.
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Dexamethasone implant – An update p. 262
Richa Pyare, Jyotirmay Biswas
Uveitic entities may be infectious or noninfectious in etiology. Corticosteroids remain the first-line treatment for noninfectious posterior uveitis. Intravitreal injections of steroids have been useful in targeted therapy of the posterior segment. However, a host of systemic and local adverse effects limits the usefulness of steroids. Intravitreal implants of dexamethasone with sustained release of the drug over months are a more effective and safer option. Various formulations with varying dosage and lifespan such as retisert, ozurdex, and yutiq are available. Ozurdex has a very successful track record over numerous studies in treating posterior uveitis in adults and children. It is important to rule out infectious causes of uveitis before administering ozurdex. We can achieve optimal control of ocular inflammation with minimal systemic side effects when used judiciously.
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Newer anti-vascular endothelial growth factor agents p. 268
Priya Rasipuram Chandrasekaran
Ocular angiogenesis is a major cause of ocular morbidity worldwide. Vascular endothelial growth factor (VEGF) is a critical regulator of angiogenesis and vascular permeability with diverse roles both during the development and adulthood. This is believed to be the most powerful mediator of angiogenesis leading to ischemia-induced neovascularization in the retinal and choroidal diseases. Anti-VEGF has revolutionized the treatment of such angiogenic and exudative diseases of the retina and choroid. This article gives a brief view of the newer anti-VEGF agents and their role in retinal diseases.
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Current concepts in the management of cyclodialysis p. 274
Vijayalakshmi A Senthilkumar, Sharmila Rajendrababu
Cyclodialysis clefts are rare. The most common reason for presentation is blunt ocular trauma followed by various iatrogenic interventions. Although gonioscopy is the gold standard technique, diagnosis is particularly challenging, and various noninvasive techniques such as ultrasound biomicroscopy and the newer anterior segment swept-source optical coherence tomography have been found effective. The management of cyclodialysis clefts should be conservative initially followed by a variety of nonsurgical and surgical modalities to achieve closure. In this article, we report the most recent developments in the diagnosis and surgical and nonsurgical treatment strategies of cyclodialysis cleft. An extensive literature search was done using PubMed and Google Scholar with the search terms such as cyclodialysis cleft, ocular hypotony, hypotony maculopathy, cyclopexy, and cyclotamponade.
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Myopia: Current concepts and review of literature p. 280
Kirandeep Kaur, Bharat Gurnani, Veena Kannusamy
Myopia is the most common cause of refractive error in children. It is the most common ocular disorder worldwide. Apart from genetic factors, age and environmental factors have also been found to be closely associated as predictors of myopia. A comprehensive literature search was on online platforms using terms Myopia review, onset, progression, treatment, control, updates, bifocals, Atropine, and Orthokeratology. All the relevant articles published in English in last 10 years were analyzed and included. Excessive near work and prolonged screen usage have been proven as definite risk factors apart from genetics. Role of Vitamin D and outdoor activities are still having a controversial stand. Myopia treatment has come a long way from glasses/contact lenses to advanced minimally invasive refractive procedures such as femtosecond-assisted procedures and small incision lenticule extraction. With tremendous improvement in technology and increased dependence on digital devices, control of myopia progression remains a big challenge. Use of bifocals, progressive glasses, rigid contact lenses, and soft bifocals lenses have been studied widely. These all measures seem to do well in initial years, but long-standing results are not encouraging. The results with low-dose atropine have been convincing, but long-term follow-up results are still awaited.
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Tele-eye care models during COVID-19 pandemic: A systematic review p. 288
Ramya K Kharvi, Soujanya Padmashali, Suchithra Poojary, Siddharth K Karthikeyan, Pooja Nandagopal, Malathi Acharya
Coronavirus disease 2019 (COVID-19) pandemic has affected eye care practices in several ways. To reach out to people who need eye care services during this pandemic, eye care practitioners started tele-eye care (TEC) practice worldwide. This review aims to describe the methods, including protocols, regulations of TEC, and its usefulness during the COVID-19 pandemic. Articles relevant to the aim were searched from various databases such as “PubMed, Scopus, Wiley Online Library, ProQuest, CINAHL, and Web of Science.” The last date of the search was June 16, 2020. Retrieved articles underwent screening process against the predefined inclusion and exclusion criteria, and the irrelevant articles were excluded. Data extraction was done using excel sheets. Quality assessment and risk of bias were assessed. The results of the included articles were summarized and tabulated. A total of 188 articles were retrieved from database screening, of which only two articles met the inclusion criteria. Results of the included studies reported that TEC practice was favorable to patients in saving their time, money, and was easy to use. Patients would like to continue TEC practices in future as an alternative to an in-person consultation. TEC practice mainly benefited people in rural areas and people living far from the hospital. The percentage of patients utilizing TEC practice has been increasing.
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Bilateral proptosis as initial manifestation of granulocytic sarcoma in a child p. 293
Bipasha Mukherjee, Neha Shrirao, Anita Ramesh
Proptosis in the pediatric age-group can augur an ominous underlying pathology. These patients should be investigated promptly and thoroughly to rule out life-threatening disorders such as leukemia. This can mean the difference between life and death. Granulocytic sarcoma, earlier known as chloroma or extramedullary myeloblastoma is usually seen in patients with acute myeloid leukemia (AML). It can either precede or emerge in conjunction with the systemic disease. One of the extramedullary locations is the orbits, more so in children. Here, we present a case of bilateral proptosis in a child due to extramedullary deposits of AML. Despite the best possible treatment measures, she succumbed to her disease process 5 months from the presentation.
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Primary conjunctival amyloidosis causing ptosis, ectropion, and chalazion-like eyelid lumps p. 296
Rwituja Thomas, Parvathi Hari, Anjali Kiran, Roshmi Gupta
Primary conjunctival amyloidosis is a rare entity. We present a patient with bilateral conjunctival amyloid, presenting with ptosis, ectropion, and chalazion-like lumps. Histopathology showed an amorphous eosinophilic lesion, and staining with Congo red showed apple-green birefringence.
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A rare case report of peri-papillary choroidal neovascularization in vogt-koyanagi-harada disease p. 298
Sarvesswaran Prakash, SR Rathinam
Vogt-Koyanagi-Harada (VKH) disease is a bilateral, granulomatous panuveitis with neurologic and cutaneous manifestations. Late complications include cataract, glaucoma, choroidal neovascularization (CNVM), and subretinal fibrosis; the latter two carries poor visual prognosis. We report a known case of VKH complicated with peri-papillary CNVM, who was steroid responder as well as steroid dependent, the patient had recurrent episodes of anterior uveitis with steroid-sparing immunosuppressive therapy. Because of the recurrent and uncontrolled inflammation, she developed peri-papillary CNVM in the right eye, which was effectively treated with intravitreal bevacizumab. Even though CNVM is a known complication of VKH, peri-papillary CNVM occurs very rarely and is least reported in the literature. The main therapeutic goal in VKH is to control underlying recurrent inflammation to prevent late complications.
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Ocular manifestations of homocystinuria due to cystathionine beta-synthase deficiency: A rare case report with genetic analysis p. 302
Damaris Magdalene, Ronel Soibam, Riddhi Raichura, Saurabh Deshmukh, Surpriya Hawaibam, Krati Gupta
Microspherophakia is a developmental lens anomaly characterized by increased anteroposterior diameter and reduced equatorial diameter, which predisposes to secondary glaucoma. A 12-year-old boy presented with diminution of vision. Slit-lamp examination showed anteriorly dislocated crystalline lens. Blood analysis revealed elevated homocysteine levels. Genetic analysis showed cystathionine beta-synthase gene mutation, thus confirming the diagnosis of homocystinuria. To prevent secondary glaucoma, the patient was taken up for surgical intervention. This report highlights a case of homocystinuria with microspherophakia diagnosed with the help of genetic testing.
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Gliomatosis cerebri - A rare cause of bilateral blindness p. 304
Priyanka Sekar, P Rajarajeswary, Hannah Ranjee Prasanth, TS Ishwarya, Renuka Srinivasan, Ramesh Kannan
We describe a rare case of gliomatosis cerebri (GC) with bilateral blindness. A 45-year-male presented with gradual painless loss of vision both eyes (BE), with generalised tonic–clonic seizures. On examination, the patient denied light perception BE, with sluggishly reacting pupil. Fundus examination revealed papilledema and absent foveal reflex. Magnetic resonance imaging showed features of diffuse infiltrating glial tumor suggesting GC. Visual impairment can occur rarely due to optic nerve involvement, however bilateral cases has not been reported. Early recognition of GC may allow preservation of vision through focal radiotherapy to the optic nerve.
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Skin lesions over the neck with vision loss: Pseudoxanthoma elasticum with angioid streaks p. 307
Gauri Khare, Chitaranjan Mishra, Naresh Babu Kannan
Pseudoxanthoma elasticum (PXE) is an autosomal recessive multisystem disorder characterized by the involvement of skin, cardiovascular system, and the eyes. Angioid streaks (AS) are the most common ophthalmoscopic finding in PXE. Choroidal neovascular membrane (CNVM) is the most severe sight-threatening ophthalmic complication associated with AS in PXE. Prompt ophthalmologic referral, early diagnosis of CNVM, and appropriate therapy with intravitreal injection of antivascular endothelial growth factors are crucial to preserve the vision of patients of PXE with AS-associated CNVM. In this short case series of three patients, we describe different forms of retinopathy in PXE and their management.
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Double whammy: Congenital glaucoma in phakomatosis pigmentovascularis with Sturge–Weber syndrome and nevus of Ota p. 310
S Podury, Bipasha Mukherjee
Phakomatosis pigmentovascularis (PPV) is a rare congenital condition characterized by a combination of cutaneous capillary hemangiomas and dermal melanocytosis. The dual presentation of Sturge–Weber syndrome (SWS) and nevus of Ota in the same patient is a rare finding. Individually, both these conditions can predispose to developmental glaucoma. The combined presentation of these two predisposing conditions has a very high chance of coexisting glaucoma. We report a patient of PPV presenting with bilateral SWS, nevus of Ota, and congenital glaucoma.
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Late-onset limbal ischemia in alkali burns p. 313
Zeba Muzammil Shaikh, Krishnagopal Srikanth, Vallinayagam Muthukrishnan
Chemical injury is one of the common ocular emergencies in ophthalmology practice. Ocular burns, especially with alkaline solution, can lead to hazardous effects on eye structures. Limbal ischemia resulting from such injury carries a grave prognosis. Lack of standard criterion results in difficult assessment of limbal ischemia. Diagnosis of limbal ischemia is purely dependent on subjective assessment. A 40-year-old female presented to our emergency department with alkali injury. Alkali injury was promptly diagnosed and treated. There was no sign of limbal ischemia during initial evaluation. On follow-up, the patient developed late-onset limbal ischemia.
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Unilateral ophthalmomyiasis externa p. 316
Shruthy Vaishali Ramesh, Prasanna Venkatesh Ramesh, Ramesh Rajasekaran, Meena Kumari Ramesh
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A rare presentation of bilateral subclinical macular commotio retinae p. 318
Shruthy Vaishali Ramesh, Prasanna Venkatesh Ramesh, Ramesh Rajasekaran, Meena Kumari Ramesh
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Fish eggs in the eye p. 320
Vinit J Shah, Syed Mohideen Abdul Khadar, Syed Saifuddin Adeel, Shobita Nair
An interesting postoperative complication was noted after a routine retinal detachment surgery with scleral buckling with pars plana vitrectomy and silicone oil injection. Anterior segment examination on the 1st postoperative day showed multiple small nonemulsified silicone oil globules, giving a fish egg appearance. Such an appearance is not seen routinely in the immediate postoperative period.
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Pigmented optic disc lesion: A melanoma masquerade p. 322
Zeba Muzammil Shaikh, V Muthukrishnan, Shravya Choudhary Balla
A 67-year-old male was diagnosed with a pigmented lesion on the optic disc. Optic disc melanocytoma (ODM) is a rare benign, nonprogressive, heavily pigmented lesion arising from the melanocytes of the optic disc. The archetypal characteristics include dark pigmentation, feathery borders, and obscuration of the optic disc. It may be indistinguishable from choroidal melanoma occasionally. A regular follow-up with fundus photography is needed for early diagnosis of unusual complications.
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Brimonidine tartrate-induced delayed hypersensitivity reaction p. 324
Chitaranjan Mishra, Vijayalakshmi A Senthilkumar
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Mercedes benz sign-intraocular triradiate thorn injury during COVID-19 pandemic p. 325
Bharat Gurnani, Kirandeep Kaur
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Hans Goldmann (1899–1991): Remembering the man behind our current ophthalmic practice p. 327
Gunjan Saluja, Asha Samdani
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Journal Review p. 329
Vijayalakshmi A Senthilkumar
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COVID journal review p. 332
Niranjan Karthik Senthil Kumar, Sharmila Devi Vadivelu
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Photo quiz: Holistic integrative ophthalmology with multiplex imaging p. 334
Shruthy Vaishali Ramesh, Prasanna Venkatesh Ramesh
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Photo Quiz Answers p. 336
Shruthy Vaishali Ramesh, Prasanna Venkatesh Ramesh
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History over phone – A safe and innovative idea to reduce chair time with ophthalmologists during COVID-19 pandemic p. 337
Kirandeep Kaur, Kavitha Srinivasan, Rengaraj Venkatesh, Megha Gopalakrishna, Bharat Gurnani, Rajesh Vedachalam
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