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   Table of Contents - Current issue
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January 2018
Volume 66 | Issue 1
Page Nos. 1-181

Online since Thursday, December 28, 2017

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EDITORIAL  

Indian Journal of Ophthalmology: Right on track Highly accessed article p. 1
Santosh G Honavar
DOI:10.4103/ijo.IJO_1296_17  PMID:29283113
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GUEST EDITORIALS Top

Vascular lesions of the orbit: Conceptual approach and recent advances Highly accessed article p. 3
Gangadhara Sundar
DOI:10.4103/ijo.IJO_1272_17  PMID:29283114
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One-minute ophthalmology: Spend just a minute to challenge your skills Highly accessed article p. 7
Carol Shields, Fairooz P Manjandavida
DOI:10.4103/ijo.IJO_1271_17  PMID:29283115
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ONE MINUTE OPHTHALMOLOGY Top

Soft drusen or not? Highly accessed article p. 9
Carol L Shields, Elizabeth B Elimimian, Fairooz P Manjandavida
DOI:10.4103/ijo.IJO_1200_17  PMID:29283116
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REVIEW ARTICLES Top

Refractive lenticule extraction small incision lenticule extraction: A new refractive surgery paradigm p. 10
Sri Ganesh, Sheetal Brar, Raghavender Reddy Arra
DOI:10.4103/ijo.IJO_761_17  PMID:29283117
Small incision lenticule extraction (SMILE), a variant of refractive lenticule extraction technology is becoming increasingly popular, as a flapless and minimally invasive form of laser vision correction (LVC) for the treatment of myopia and myopic astigmatism. This review aims at summarizing the principles, surgical technique, and clinical outcomes in terms of visual and refractive results, safety, efficacy, postoperative dry eye, aberrations, and biomechanics of SMILE and its comparison with other conventional techniques of LVC, such as laser in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK). Recent advancements in the laser frequency and energy delivery patterns, instrumentation, and surgical techniques have shown significant improvement in the visual recovery and outcomes after SMILE, compared to the initial results published by Sekundo and Shah et al. Most of the recently published literature on long-term outcomes of SMILE shows excellent stability of the procedure, especially for higher myopia. In terms of the postoperative dry eye, SMILE shows a clear advantage over LASIK as numerous studies have shown significant differences about the Schirmer's, Tear film break up time, corneal sensitivity, and corneal nerve regeneration to be better following SMILE compared to LASIK. There is some evidence that since the Bowman's membrane (BM) and the anterior lamellae remain intact after SMILE, this may be a potential advantage for corneal biomechanics over LASIK and PRK where the BM is either severed or ablated, respectively, however, the data on biomechanics are inconclusive at present. Overall, this procedure has proved to be promising, delivering equivalent, or better visual and refractive results to LASIK and providing clear advantage in terms of being a flapless, minimally invasive procedure with minimal pain and postoperative discomfort thus offering high patient satisfaction.
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Optical coherence tomography: A guide to interpretation of common macular diseases p. 20
Muna Bhende, Sharan Shetty, Mohana Kuppuswamy Parthasarathy, S Ramya
DOI:10.4103/ijo.IJO_902_17  PMID:29283118
Optical coherence tomography is a quick, non invasive and reproducible imaging tool for macular lesions and has become an essential part of retina practice. This review address the common protocols for imaging the macula, basics of image interpretation, features of common macular disorders with clues to differentiate mimickers and an introduction to choroidal imaging . It includes case examples and also a practical algorithm for interpretation.
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ORIGINAL ARTICLES Top

Demodex and rosacea: Is there a relationship? p. 36
Diana Gonzalez-Hinojosa, Alejandro Jaime-Villalonga, Gustavo Aguilar-Montes, Lorena Lammoglia-Ordiales
DOI:10.4103/ijo.IJO_514_17  PMID:29283119
Purpose: The objective of the study is to compare the frequency of Demodex on the eyelash follicle of patients with rosacea and referents without rosacea or ophthalmological disorders. Methods: This is a comparative, open, observational, and cross-sectional study that included 41 patients diagnosed with rosacea and 41 referents without rosacea diagnosis or ophthalmic alterations. The individuals underwent a slit-lamp examination in which two eyelashes per eyelid were removed with fine forceps. The presence of Demodex was sought by direct visualization under a light microscope. The results were expressed as “positive” when at least one mite on one lash was found and “negative” when no mite was identified. Chi-square test was used to compare the presence of mites in both groups. Results: Eighty-two study individuals (45 females and 37 males) were included, of which 41 patients were diagnosed with rosacea and 41 were without rosacea or ophthalmic alterations. The average mean age was 37 years with a minimum of 19 and a maximum of 87 years. Of the 41 patients with rosacea, 31 had erythematotelangiectatic rosacea and 10 had papulopustular rosacea. There were no patients with phymatous or ocular rosacea. The presence of Demodex was found in 32 patients: 24 patients with rosacea diagnosis (16 of the erythematotelangiectatic subtype and 8 of papulopustular subtype) and 8 patients without rosacea or ophthalmic alterations (P ≤ 0.001). Conclusion: Rosacea was found to be a statistically significant risk factor for Demodex infestation in eyelashes, irrespective of age and sex, with a higher prevalence in papulopustular variety.
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Correlation of interleukin-33 with Th cytokines and clinical severity of dry eye disease p. 39
Guoping Luo, Yan Xin, Dajun Qin, Aihua Yan, Zhiyan Zhou, Zhaoxia Liu
DOI:10.4103/ijo.IJO_405_17  PMID:29283120
Purpose: The purpose of this study is to determine the tear and serum protein levels of interleukin-33 (IL-33) and its correlation with Th cytokines and disease severity in dry eye (DE) syndrome. Methods: Tear and serum samples were collected from 30 healthy volunteers, 30 DE patients with non-Sjogren's syndrome DE (NSSDE) and 30 DE patients with primary SSDE. The eight most frequent symptoms of DE were scored. All patients underwent corneal and conjunctival staining, tear film breakup time (TBUT), and Schirmer I test. The serum and tear levels of IL-33 were measured by enzyme-linked immunosorbent assay. The levels of IL-33 expression and its correlation with Th cytokines and disease severity were also analyzed. Results: We found that symptom scores and corneal staining grade were significantly higher in SSDE group compared with NSSDE and control group, whereas the results of TBUT and Schirmer I test were significantly lower in SSDE group compared with NSSDE and control group. The tear levels of IL-33 were significantly increased in tears of SSDE patients compared with those of controls and NSSDE patients (P < 0.05). Moreover, the elevated tear levels of IL-33 were positively correlated with symptom scores but negatively correlated with tear film breakup time and Schirmer I test in both NSSDE and SSDE patients (P < 0.05). The tear levels of IL-33 of both NSSDE and SSDE patients were also positively correlated with tear levels of IL-4 and IL-5 (P < 0.05). Correlation between the serum levels of IL-33 with Th1/17/Treg cytokines was not found. Conclusion: Elevated tear levels of IL-33 were associated with the Th2 cytokines and disease severity of DE. Therefore, IL-33 may have important roles in the immunopathogenesis of the DE.
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COMMENTARY Top

Ocular surface inflammation in dry eye disease: What we know and what we do not p. 44
Jayesh Vazirani
DOI:10.4103/ijo.IJO_1018_17  PMID:29283121
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ORIGINAL ARTICLE Top

Results of simple limbal epithelial transplantation in unilateral ocular surface burn p. 45
Nidhi Gupta, Jagdish Joshi, Javed Hussain Farooqui, Umang Mathur
DOI:10.4103/ijo.IJO_602_17  PMID:29283122
Purpose: This study aimed to report the long-term outcomes of autologous Simple Limbal Epithelial Transplantation (SLET) performed for unilateral limbal stem cell deficiency (LSCD) following chemical burn at a tertiary eye center in North India. Methods: This was a single-center prospective interventional case series of patients who developed unilateral LSCD after suffering from ocular surface burns and who underwent SLET between October 2012 and May 2016 with a follow-up period of at least 6 months. The primary outcome measure was restoration of a completely epithelized, stable, and avascular corneal surface. The secondary outcome measure was percentage of eyes, which reported visual gain. Results: The study included 30 eyes of 30 patients, 18 adults and 12 children, at a median follow-up of 1.1 years (range: 6 months to 3.5 years), 21 of 30 eyes (70%; 95% confidence interval, 53.6%–86.2%) maintained successful outcome. Visual acuity gain was seen in 71.4% of successful cases. The clinical factors associated with failure were identified as acid injury, severe symblepharon at the time of presentation, and SLET combined with penetrating keratoplasty (PK). Conclusion: Autologous SLET is an effective limbal cell transplantation technique for the treatment of unilateral LSCD. It is especially beneficial for centers where cell cultivation laboratory is unavailable. Presence of severe symblepharon, which requires PK peroperatively , has poor outcome.
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COMMENTARY Top

Simple limbal epithelial transplantation: Impactful innovation p. 53
Sayan Basu, Chirag Bahuguna, Vivek Singh
DOI:10.4103/ijo.IJO_947_17  PMID:29283123
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ORIGINAL ARTICLES Top

Topical chemotherapy for giant ocular surface squamous neoplasia of the conjunctiva and cornea: Is surgery necessary? p. 55
Sonal S Chaugule, Jennifer Park, Paul T Finger
DOI:10.4103/ijo.IJO_590_17  PMID:29283124
Purpose: The purpose of this study is to report on the efficacy and safety of topical chemotherapy alone for giant ocular surface squamous neoplasia (OSSN). Methods: In this retrospective, interventional series, 10 eyes with giant OSSN underwent exfoliative biopsy to confirm the diagnosis followed by application of interferon alpha 2b (IFN α2b) and/or 5 fluorouracil, 1% (5FU). Reported outcome measures were tumor response, visual acuity, recurrence, systemic metastasis, and treatment complications. Results: Ten patients (3 female, 7 male) had a mean age of 73 (median, 69; range 40–89) years. Mean tumor diameter was 13.1 (median, 12.3; range 8.2–19.4) mm. Five (50%) eyes were treated with IFN-α2b alone; 1 (10%) with 5-FU alone and 4 (40%) required both IFN-α2b and 5-FU. The mean duration of treatment was 3, 0.5, and 6.4 months for IFN-α2b alone, 5-FU alone, and both IFN-α2b and 5-FU respectively. Complete tumor response was observed in all 10 cases at mean follow-up of 12.8 (median, 11.5; range, 3–25) months. Complications noted were transient irritation and burning (n = 4), dry eyes (n = 2), and transient flu-like symptoms (n = 2). There was no evidence of chemotherapy-related symblepharon, stem cell deficiency, scleral thinning, or corneal opacity. There were no tumor recurrences, and no patient required surgical excision or cryotherapy. Conclusion: Topical chemotherapy was a safe and effective treatment, inducing complete regression in all cases of giant OSSN in this series. There were no sight-limiting complications.
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Factors affecting the serological testing of cadaveric donor cornea p. 61
Anuradha Raj, Garima Mittal, Harsh Bahadur
DOI:10.4103/ijo.IJO_656_17  PMID:29283125
Purpose: The purpose of this study was to evaluate the serological profile of the eye donors and to study the influence of various factors on serological test results. Methods: A cross-sectional, observational study was conducted, and data of 509 donors were reviewed from the records of eye bank from December 2012 to June 2017. Various details of donors analyzed included the age, sex of the donor, cause of death, source of tissue, time since blood collection after death, macroscopic appearance of blood sample, and details of discarded tissues. Serological examination of blood was performed for human immunodeficiency virus (HIV), hepatitis B virus, hepatitis C virus (HCV), venereal disease research laboratory (VDRL), and serology reports reactive or nonreactive were analyzed. Results: Among the 509 donors, 295 (58%) were male, and 420 (82.50%) belonged to age group ≥60 years. Most donors (354, 69.5%) died due to cardiac arrest. Macroscopically, sera were normal in the majority of 488 (95.9%) cases. Among 509 donors, 475 (93.3%) were nonreactive, 12 (2.4%) donors were found to be reactive to hepatitis B surface antigen (HBsAg), and 1 (0.2%) was reactive to HCV, but no donor serology was reactive to HIV or VDRL. Twenty-one (4.12%) donors' sera were not fit for serological testing. Among all donors, 475 (93.32%) donors were accepted and 34 (6.67%) were rejected or discarded on the basis of serological testing. Cause of death and macroscopic aspect of sera influenced the serological results in a highly significant manner (P = 0.00). Acceptance or rejection of the donor was significantly influenced by the serological results of the donor (P = 0.00). Conclusion: The seroprevalence among eye donor for HBsAg and HCV was 12 (2.4%) and 1 (0.2%), respectively. Factors such as cause of death and macroscopic aspect of sera influence the serological results. Time since blood collection or sampling will not show any impact on viral serological results if postmortem sampling will be done in < 10 hours(h) after death which can improve the safety and utility of the donor cornea.
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Comparison of surgical outcomes between canaloplasty and trabeculectomy with mitomycin C at 2-year follow-up: A longitudinal cohort study p. 66
Winston J Garris, Crystal Le, David Zurakowski, Ramesh S Ayyala
DOI:10.4103/ijo.IJO_543_17  PMID:29283126
Purpose: To compare operative outcomes of patients after canaloplasty and trabeculectomy with mitomycin C (MMC) through 2-year follow-up. Methods: We included 31 eyes of 31 patients with primary open-angle glaucoma (POAG) who underwent canaloplasty and 37 eyes of 37 patients with POAG who underwent trabeculectomy with MMC with 24 months of postoperative follow-up. All surgeries were performed by a single surgeon between January 2005 and May 2011. Failure was defined as intraocular pressure (IOP >18 or <4 mmHg at 2 years), second operative procedure, or loss of light perception. Change in IOP, visual acuity (VA), glaucoma medications, and complication rates at 24 months were analyzed. Results: Caucasians made up to half of the patients included in this study (58% vs. 43%) while the rest where either African Americans (32% vs. 43%) or Hispanic (10% vs. 14%) patients between the canaloplasty and trabeculectomy group. Both groups showed significant reduction in IOP from baseline at 24 months. Trabeculectomy patients had a greater mean reduction of IOP compared to canaloplasty patients (12.2 ± 12 vs. 4.7 ± 7.5, P = 0.003) and also achieved lower IOP at 24 months (12.2 ± 4.1 vs. 14.9 ± 6.0, P = 0.03). Postoperative glaucoma medication use was less in the trabeculectomy group (n = 0, interquartile range [IQR] 0–2) compared to those in whom canaloplasty was performed (n = 2, IQR 0–3, P = 0.02). VA showed no statistical change in either group over 2 years. Overall failure rates at 2 years were comparable between the two groups: 32% for trabeculectomy and 26% for canaloplasty (P = 0.6). Subgroup analysis revealed a lower failure rate in Caucasions (15%) when compared to Blacks (42%) and Hispanics/others (50%, P = 0.03). Conclusion: Canaloplasty and trabeculectomy both achieved significant reduction in IOP with comparable success rates. Trabeculectomy can achieve a greater reduction in IOP while requiring fewer medications however is associated with more intensive postoperative care and frequent interventions. Pigmented populations have worse outcomes compared to Caucasians.
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Rescue of failing or failed trabeculectomy blebs with slit-lamp needling and adjunctive mitomycin C in Indian eyes p. 71
Vanita Pathak-Ray, Nikhil Choudhari
DOI:10.4103/ijo.IJO_523_17  PMID:29283127
Purpose: The aim of this study is to investigate the efficacy and safety of needling-revision augmented with a high dose of mitomycin C (MMC) in failing or failed blebs after trabeculectomy in Indian eyes. Methods: Prospective, noncomparative, interventional study. All patients (>18 years) who had raised intraocular pressure (IOP) following trabeculectomy (>6 weeks and <2 years), who had a flat bleb, bleb encapsulation, and/or required antiglaucoma medication (AGM) for IOP control were eligible for inclusion. MMC was injected subconjunctivally at least ½ hour before the needling procedure was carried out at the slit lamp in the outpatient's clinic. Results: Thirty-nine eyes of 38 patients were included. The median follow-up was 20 months and time interval between trabeculectomy and needle revision was 113 days. Initially, in all cases, aqueous flow was re-established with a raised bleb; 7 eyes required repeat needling. IOP decreased from median 24 mmHg (Q1 21, Q3 27, interquartile range [IQR] 6, range 18–35) preneedling to median 14 mmHg (Q1 10, Q3 16, IQR 6, range 6–18) postneedling at last follow-up (P < 0.0001, 95% confidence interval [CI]: 8.2–13.0). The use of AGM reduced from median 1 (Q1 0, Q3 3, IQR 3, range 0–4) preneedling to median 0 postneedling (P < 0.0001, 95% CI: 1–2). Complete success was seen in 28 eyes (71.8%, 95% CI: 71.1%–96.4%); another 5 eyes (12.8%) were controlled with AGM (qualified success) with overall success of 84.6%. Most complications were transient in nature with resolution within 1 week. One patient developed hypotony, and another developed a late bleb leak. Conclusion: Needling revision augmented with high-dose MMC, at the slit lamp, effectively rescues failing or failed filtration, and appears to be safe.
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Age and myopia associated optical coherence tomography of retina and choroid in pediatric eyes p. 77
Jyoti Matalia, Neha Sutheekshna Anegondi, Leio Veeboy, Abhijit Sinha Roy
DOI:10.4103/ijo.IJO_652_17  PMID:29283128
Purpose: To evaluate the association between retinal and choroidal thickness and volume along with choroidal vessel volume in children using optical coherence tomography (OCT) images. Methods: 113 normal eyes of children ranging from 5-17 years of age were imaged with a clinical OCT scanner (Optovue Inc., Fremont, USA). The retina, choroid and choroidal vessels were automatically segmented with algorithms. Parameters evaluated were thickness and volume. Location specific analyses of thickness were also performed at a distance of 2.5 mm from foveal center. Multivariate analyses of variance were used to analyze the effect of age and myopia. Manual segmentation of the fovea and subfoveal choroid thickness was also performed to compare with the algorithm segmentation. Results: There was excellent agreement between manual and automatic segmentation (intra-class correlation of 0.95). Within the same eye, total retinal and choroid thickness of nasal and temporal location were significantly lower than the superior and inferior thickness (P < 0.0001). With age (P = 0.026) and myopia (P < 0.001), foveal thickness increased. Choroid volume, vessel volume and temporal choroid thickness increased with increasing myopia (P < 0.05). There was significant positive correlation between choroid volume and retinal volume (r = 0.62, P < 0.0001), choroid volume and vessel volume (r = 0.48, P < 0.0001), and with foveal thickness (r = 0.31, P = 0.009). Choroid vessel volume also showed significant positive correlations with the other metrics (P < 0.05). Conclusion: Retinal and choroidal structural features were quantified simultaneously from OCT images. Magnitude of myopia had a greater effect on retino-choroid features than age in children.
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Retinal pigment epithelium aperture: A late-onset complication in adult-onset foveomacular vitelliform dystrophy p. 83
Reema Bansal, Sonam Yangzes, Ramandeep Singh, Deeksha Katoch, Mangat R Dogra, Vishali Gupta, Amod Gupta
DOI:10.4103/ijo.IJO_676_17  PMID:29283129
Purpose: The purpose of the study was to report aperture of retinal pigment epithelium (RPE) as a late complication and an unreported finding during the natural course of adult-onset foveomacular vitelliform dystrophy (AFVD). Methods: Four diagnosed cases of AFVD followed for a period ranging from 4 to 8 years. All patients had documented records of clinical examination, fundus autofluorescence and fluorescein angiography, and spectral domain-optical coherence tomography at regular intervals. Results: Besides the known stages in the natural course of AFVD, RPE aperture was noted as an additional finding during the vitelliruptive stage of the disease. The vitelliform material was noted beneath the disrupted RPE before disappearance. Accumulation of vitelliform material continued even after the vitelliruptive stage. Conclusion: RPE aperture may represent an ongoing process in the natural course of AFVD.
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Color Doppler imaging of the retrobulbar circulation and plasmatic biomarkers of vascular risk in age-related macular degeneration: A pilot study p. 89
Fermin Rodrigo, José María Ruiz-Moreno, Juan Bernabé García, María Eugenia Torregrosa, José Vicente Segura, David P Piñero
DOI:10.4103/ijo.IJO_488_17  PMID:29283130
Purpose: To evaluate preliminarily and compare the level of plasmatic biomarkers of vascular risk in patients with and without exudative age-related macular degeneration (ARMD) and to relate it to vascular resistance alterations in the ophthalmic artery (OA), central retinal artery (CRA), posterior temporal ciliary artery (PTCA), and posterior nasal ciliary artery (PNCA). Methods: Color Doppler imaging of the OA, CRA, PTCA, and PNCA was performed in 30 eyes of 30 cataract patients (control group) as well as in 30 eyes of 30 patients with naive exudative ARMD (study group), measuring the peak systolic velocity, end-diastolic velocity (EDV), and Pourcelot resistive index (RI). Likewise, in both groups, a blood test was performed to determine the plasmatic levels of homocysteine, C-reactive protein (CRP), B12 vitamin, and folic acid. Results: A positive and significant correlation was found between the level of CRP and RI of the OA in the ARMD group (r = 0.498, P = 0.005), with an increased RI in all arteries compared to controls, although differences only reached statistical significance for the PTCA (P = 0.035). Likewise, a significantly lower EDV for the CRA was found in ARMD eyes compared to controls (P = 0.041). In the study group, significantly higher plasmatic levels of homocysteine (P = 0.042) and CRP (P = 0.046) were found. In contrast, no significant differences were found between groups in the levels of folic acid (P = 0.265) and B12 vitamin (P = 0.520). Conclusion: The decrease of the choroidal perfusion related to hyperhomocysteinemia, and increase in the CRP plasmatic levels may play an etiological role on the exudative ARMD. This should be investigated in future studies with larger samples of patients.
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The diagnostic accuracy of single- and five-field fundus photography in diabetic retinopathy screening by primary care physicians Highly accessed article p. 94
Parinya Srihatrai, Thanita Hlowchitsieng
DOI:10.4103/ijo.IJO_657_17  PMID:29283131
Purpose: The aim is to evaluate the diagnostic accuracy of digital fundus photography in diabetic retinopathy (DR) screening at a single university hospital. Methods: This was a cross-sectional hospital-based study. One hundred and ninety-eight diabetic patients were recruited for comprehensive eye examination by two ophthalmologists. Five-field fundus photographs were taken with a digital, nonmydriatic fundus camera, and trained primary care physicians then graded the severity of DR present by single-field 45° and five-field fundus photography. Sensitivity and specificity of DR grading were reported using the findings from the ophthalmologists' examinations as a gold standard. Results: When fundus photographs of the participants' 363 eyes were analyzed for the presence of DR, there was substantial agreement between the two primary care physicians, κ = 0.6226 for single-field and 0.6939 for five-field photograph interpretation. The sensitivity and specificity of DR detection with single-field photographs were 70.7% (95% Confidence interval [CI]; 60.2%–79.7%) and 99.3% (95% CI; 97.4%–99.9%), respectively. Sensitivity and specificity for five-field photographs were 84.5% (95% CI; 75.8%–91.1%) and 98.6% (95% CI; 96.5%–99.6%), respectively. The receiver operating characteristic was 0.85 (0.80–0.90) for single-field photographs and 0.92 (0.88–0.95) for five-field photographs. Conclusion: The sensitivity and specificity of fundus photographs for DR detection by primary care physicians were acceptable. Single- and five-field digital fundus photography each represent a convenient screening tool with acceptable accuracy.
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Efficiency of fenofibrate in facilitating the reduction of central macular thickness in diabetic macular edema p. 98
Srilakshmi Srinivasan, Prathibha Hande, Jyoti Shetty, Sindhu Murali
DOI:10.4103/ijo.IJO_566_17  PMID:29283132
Purpose: The purpose of this study is to study the benefit of addition of oral fenofibrate to the current regimen of diabetic macular edema (DME) management and quantify its effect on macular thickness and visual function in DME. Methods: Fifty-three eyes of 50 patients were randomized into treatment (Group A) (oral fenofibrate 160 mg/day) and control groups (Group B). Both groups underwent treatment of DME as per the standard treatment protocol of our hospital including intravitreal injections (anti-vascular endothelial growth factor/steroid) and grid laser. Patients were followed up every 2 months to note the visual acuity and central macular thickness (CMT) for 6 months. Results: Our groups were matched with respect to age (P = 0.802), mean diabetic age (P = 0.878), serum HbA1C levels (P = 0.523), and serum triglyceride levels (P = 0.793). The mean reduction in CMT was 136 μ in Group A and 83 μ in Group B at the end of 6 months. This difference was statistically significant (P = 0.031). Visual acuity improvement was 0.15 in Group A and 0.11 in Group B at the end of 6 months (P = 0.186). On subgroup analysis in Group A, we found that there was no difference in reduction of CMT between hypertensives and normotensives (P = 0.916), in patients with normal triglyceride levels and increased triglyceride levels (P = 0.975). Conclusion: Addition of fenofibrate to the standard protocol of DME management seems to facilitate reduction of CMT and probably have an added benefit on the visual functions.
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Use and validation of mirrorless digital single light reflex camera for recording of vitreoretinal surgeries in high definition Highly accessed article p. 106
Sumeet Khanduja, Raju Sampangi, BC Hemlatha, Satvir Singh, Ashish Lall
DOI:10.4103/ijo.IJO_511_17  PMID:29283133
Purpose: The purpose of this study is to describe the use of commercial digital single light reflex (DSLR) for vitreoretinal surgery recording and compare it to standard 3-chip charged coupling device (CCD) camera. Methods: Simultaneous recording was done using Sony A7s2 camera and Sony high-definition 3-chip camera attached to each side of the microscope. The videos recorded from both the camera systems were edited and sequences of similar time frames were selected. Three sequences that selected for evaluation were (a) anterior segment surgery, (b) surgery under direct viewing system, and (c) surgery under indirect wide-angle viewing system. The videos of each sequence were evaluated and rated on a scale of 0-10 for color, contrast, and overall quality Results: Most results were rated either 8/10 or 9/10 for both the cameras. A noninferiority analysis by comparing mean scores of DSLR camera versus CCD camera was performed and P values were obtained. The mean scores of the two cameras were comparable for each other on all parameters assessed in the different videos except of color and contrast in posterior pole view and color on wide-angle view, which were rated significantly higher (better) in DSLR camera. Conclusion: Commercial DSLRs are an affordable low-cost alternative for vitreoretinal surgery recording and may be used for documentation and teaching.
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WINROP algorithm for prediction of sight threatening retinopathy of prematurity: Initial experience in Indian preterm infants p. 110
Gaurav Sanghi, Anil Narang, Sunny Narula, Mangat R Dogra
DOI:10.4103/ijo.IJO_486_17  PMID:29283134
Purpose: To determine the efficacy of the online monitoring tool, WINROP (https://winrop.com/) in detecting sight-threatening type 1 retinopathy of prematurity (ROP) in Indian preterm infants. Methods: Birth weight, gestational age, and weekly weight measurements of seventy preterm infants (<32 weeks gestation) born between June 2014 and August 2016 were entered into WINROP algorithm. Based on weekly weight gain, WINROP algorithm signaled an alarm to indicate that the infant is at risk for sight-threatening Type 1 ROP. ROP screening was done according to standard guidelines. The negative and positive predictive values were calculated using the sensitivity, specificity, and prevalence of ROP type 1 for the study group. 95% confidence interval (CI) was calculated. Results: Of the seventy infants enrolled in the study, 31 (44.28%) developed Type 1 ROP. WINROP alarm was signaled in 74.28% (52/70) of all infants and 90.32% (28/31) of infants treated for Type 1 ROP. The specificity was 38.46% (15/39). The positive predictive value was 53.84% (95% CI: 39.59–67.53) and negative predictive value was 83.3% (95% CI: 57.73–95.59). Conclusion: This is the first study from India using a weight gain-based algorithm for prediction of ROP. Overall sensitivity of WINROP algorithm in detecting Type 1 ROP was 90.32%. The overall specificity was 38.46%. Population-specific tweaking of algorithm may improve the result and practical utility for ophthalmologists and neonatologists.
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Retinal nerve fiber layer and ganglion cell layer changes on optical coherence tomography in early multiple sclerosis and optic neuritis cases p. 114
Ganesh Pillay, Anita Ganger, Digvijay Singh, Rohit Bhatia, Pradeep Sharma, Vimla Menon, Rohit Saxena
DOI:10.4103/ijo.IJO_539_17  PMID:29283135
Purpose: To study the retinal nerve fiber layer (RNFL) and ganglion cell layer (GCL) changes on optical coherence tomography in early multiple sclerosis (MS) patients. Methods: A prospective cohort study was conducted at a tertiary care center. Patients of early MS (expanded disability status scale <3) with or without optic neuritis (ON) and idiopathic ON were included. Twenty age-matched individuals were taken as controls. Changes in RNFL and GCL thickness were evaluated along with the correlation with visual function parameters such as visual acuity, contrast sensitivity, and visual evoked response at first visit and again at six months. Results: Forty-four patients of MS with or without ON (24 and 20 patients respectively), 29 patients with idiopathic ON, and 20 healthy controls constituted the cohorts. Mean LogMAR best-corrected visual acuity was found to be significantly reduced in all groups except fellow eyes (FE) of ON group. Mean values of average RNFL thickness and values in superior, temporal, and inferior quadrant were significantly reduced. Similarly, overall mean values of average GCL-inner plexiform layer (IPL) thickness and values in superior, superonasal, superotemporal, inferonasal, and inferotemporal quadrant were significantly reduced in all groups except FE of ON group (P < 0.05). All the visual parameters significantly correlated with GCL + IPL thickness. Conclusion: GCL + IPL thickness is a more sensitive clinical structural marker than RNFL in early MS with/without ON and ON patients and correlates with all the visual parameters better than RNFL thickness.
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SURGICAL TECHNIQUE Top

Single-pass four-throw pupilloplasty for angle-closure glaucoma p. 120
Priya Narang, Amar Agarwal, Dhivya A Kumar
DOI:10.4103/ijo.IJO_559_17  PMID:29283136
Angle-closure glaucoma is characterized by appositional or synechial closure of the anterior chamber angle with glaucomatous field defects that may or may not be associated with a pupillary block. Surgical pupilloplasty with single-pass four-throw technique helps to alleviate the appositional closure along with the breakage of peripheral anterior synechia, thereby increasing the aqueous outflow and decreasing intraocular pressure.
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PHOTO ESSAY Top

Optic nerve aplasia p. 125
Vinod Kumar, Ruchir Tewari, Divya Kumari
DOI:10.4103/ijo.IJO_614_17  PMID:29283137
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Chronic papilledema in a child with classical tuberous sclerosis p. 127
Khyati Amit Jain, Amit Bhurmal Jain
DOI:10.4103/ijo.IJO_612_17  PMID:29283138
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OPHTHALMIC IMAGES Top

Congenital retinal macrovessels p. 129
Pratyusha Ganne, Nagesha C Krishnappa
DOI:10.4103/ijo.IJO_475_17  PMID:29283139
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CASE REPORTS Top

Aripiprazole-induced transient myopia: A rare entity p. 130
KV Praveen Kumar, P Chiranjeevi, Md Shahid Alam
DOI:10.4103/ijo.IJO_907_16  PMID:29283140
Aripiprazole is a new drug for the treatment of adults with schizophrenia. Ocular side effects of aripiprazole are very rare. Review of literature revealed few cases of aripiprazole-induced myopia. We report a rare case of aripiprazole-induced transient myopia. A 22-year-old female patient presented to the department of psychiatry with worsening of symptoms of schizophrenia and was started on aripiprazole. She presented with complaints of blurring of vision in both eyes for 1 week which started on the 3rd day following the use of aripiprazole. Anterior segment examination revealed a shallow anterior chamber and narrow angles. Intraocular pressure was normal. A diagnosis of aripiprazole-induced acute myopia was made and the treating psychiatrist was advised to stop the medication. At 2-week follow-up, the unaided visual acuity improved to 20/20 in both the eyes. Ophthalmologists should be aware of the myopic shift that may occur as an ocular side effect with aripiprazole.
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Bilateral disciform keratitis of presumed adenoviral etiology p. 132
Rana Altan-Yaycioglu, Serkan Poyraz
DOI:10.4103/ijo.IJO_688_17  PMID:29283141
Adenoviral conjunctivitis may lead to subepithelial corneal infiltrates as a late complication. Herein, we aim to present a 19-year-old healthy female, who developed bilateral disciform keratitis three weeks after suffering adenoviral conjunctivitis. She presented with widespread subepithelial corneal infiltrates in addition to central corneal edema with white distinct border resembling immune stromal ring, as well as Descemet's folds and keratic precipitates in the central area. Following topical corticosteroid and ganciclovir for 10 days, her condition improved. After 1 month, she had another episode. Short-term topical corticosteroids in addition to long-term topical cyclosporine and nonpreserved artificial tears were able to prevent further recurrences.
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Bilateral idiopathic spontaneous filtering bleb with ectopia lentis: A case report and review of literature p. 134
Premanand Chandran, Anjali S Khairnar, Nabeed Aboobacker, Ganesh V Raman
DOI:10.4103/ijo.IJO_630_17  PMID:29283142
A 26-year-old male presented with superior filtering bleb with scleral thinning, dislocated lens, and hypotony in both the eyes. His cornea was normal without any sign of ectasia, and there was no history of recurrent redness, trauma, or surgery in either eye. Anterior segment optical coherence tomography did not reveal communicating fistula between the anterior chamber and subconjunctival space. Physical examination and blood investigations did not reveal any systemic association. He was diagnosed to have spontaneous filtering bleb, which is a rare condition observed with ocular or systemic abnormalities.
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Ocular infections caused by Scedosporium apiospermum: A case series Highly accessed article p. 137
Seema Ramakrishnan, Kunal Mandlik, Tejashree Sanket Sathe, Joseph Gubert, Thiruvengada Krishnan, Prabu Baskaran
DOI:10.4103/ijo.IJO_524_17  PMID:29283143
The aim of our retrospective study is to report a case series of ocular infections caused by a rare fungus, Scedosporium apiospermum, in a South Indian population. Thirteen cases of culture-positive S. apiospermum infections diagnosed between January 2011 and March 2016 were included in this study. The parameters evaluated were predisposing factors, treatment and final clinical outcome. The most common mode of presentation was keratitis (84.6%) followed by sclerokeratitis (15.3%). The predisposing factors involved were unspecified foreign body injury (30.7%), organic matter injury (15.3%), uncontrolled diabetes (7.6%), and recent manual small-incision cataract surgery (7.6%). Five cases (38.46%) had no predisposing factor. Of the 11 keratitis cases, nine (69.2%) responded well to combination medical therapy while one case (7.6%) required therapeutic keratoplasty. One case was lost to follow-up. Both cases which presented with sclerokeratitis showed no response to medico-surgical treatment progressing to panophthalmitis and evisceration.
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Swept-source optical coherence tomography of an optic disc melanocytoma: The importance of the hyperreflective foci p. 140
Brijesh Takkar, Kabiruddin Molla, Pradeep Venkatesh
DOI:10.4103/ijo.IJO_642_17  PMID:29283144
Optic disc melanocytoma (ODM) has been considered as a benign tumor with few reports of malignant transformation. We present swept-source optical coherence tomography (SSOCT) imaging of a case of ODM. As attaining histopathology is impossible in most cases, we discuss the possibility of using SSOCT as a tool for ruling out choroidal invasion or juxtapapillary melanoma.
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Optical coherence tomography angiography features of bilateral retinopathy associated with Chikungunya fever p. 142
Aniruddha Agarwal, Tripti Choudhary, Vishali Gupta
DOI:10.4103/ijo.IJO_572_17  PMID:29283145
A 66-year-old male patient presented with decreased vision in both eyes following episode of Chikungunya fever. Examination revealed bilateral retinal lesions with stippled pigmentary changes at the level of the choriocapillaris, involving the macula in the left eye. The retinopathy consisted of outer retinal disruption and retinochoroidal flow abnormalities detected using with additional imaging, including spectral-domain optical coherence tomography (OCT), autofluorescence, and OCT angiography (OCTA). The index case report describes unique OCTA findings in both eyes of an elderly male secondary to Chikungunya fever. Using the technique of OCTA, insights into the mechanisms of visual damage in viral retinopathies such as Chikungunya fever can be understood.
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Branch retinal artery occlusion post-penetrating globe injury with intraocular foreign body p. 146
Manish Nagpal, Pranita Chaudhary, Ashish Jain
DOI:10.4103/ijo.IJO_573_17  PMID:29283146
Intraocular foreign body (IOFB) in cases of penetrating eye injury accounts for an important indication of vitreoretinal intervention following ocular trauma. Vascular occlusion as a complication of IOFB is rare. Here we present a case of a 34-year-old male with post-traumatic cataract and an intraocular metallic foreign body (IOFB) lodged in the superficial layers of the retina inferotemporal to the disc, causing an inferotemporal branch retinal artery occlusion. The case was managed by lensectomy with pars plana vitrectomy and IOFB removal followed by a second procedure of secondary IOL implantation. Final best-corrected visual acuity improved to 6/24. This case highlights an unusual sequelae following penetrating ocular trauma.
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Bilateral proliferative retinopathy in B-cell acute lymphoblastic leukemia p. 148
Devesh Kumawat, Vinod Kumar, Pranita Sahay, Parijat Chandra
DOI:10.4103/ijo.IJO_608_17  PMID:29283147
A 4-year-old child with B-cell acute lymphoblastic leukemia presented with vitreous hemorrhage due to proliferative retinopathy in both eyes. Pars plana vitrectomy was performed in both eyes to clear nonresolving vitreous hemorrhage after systemic stabilization. Visual recovery was limited by the disc drag in the right eye and subfoveal exudation in the left eye. Etiopathogenesis and management of proliferative retinopathy in acute leukemias are discussed.
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Combined approach to management of periocular arteriovenous malformation by interventional radiology and surgical excision p. 151
Bipasha Mukherjee, Vathsalya Vijay, Swatee Halbe
DOI:10.4103/ijo.IJO_663_17  PMID:29283148
Periorbital arteriovenous malformations (AVMs) are congenital lesions that may cause significant morbidity such as amblyopia, cosmetic disfigurement, or chronic pain. Due to the rarity of these lesions, they are frequently misdiagnosed and treated inappropriately. We managed a 6-year-old girl with preseptal AVM by endovascular embolization followed by complete surgical excision after 2 days. She was previously diagnosed as capillary hemangioma and was being treated with intralesional steroid injections and oral propranolol. Neuroimaging revealed an AVM fed by the branches of both external and internal carotid arteries and drained by the superior ophthalmic vein. Endovascular embolization with glue followed by complete surgical excision of the lesion was done. The resultant cosmetic and functional outcome was gratifying. Diagnosis and management of periorbital AVM remain a challenge requiring a multidisciplinary approach involving interventional radiologist and trained oculoplastic surgeons. Combined endovascular embolization followed by surgical excision proved safe and effective.
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Unilateral isolated superior ophthalmic vein thrombosis p. 155
Raksha Rao, Yasmin Ali, Chinmay P Nagesh, Unnikrishnan Nair
DOI:10.4103/ijo.IJO_791_17  PMID:29283149
Superior ophthalmic vein (SOV) thrombosis is an uncommon orbital pathology that can present with sudden onset proptosis, conjunctival injection, and visual disturbance. SOV thrombosis is frequently secondary to a cavernous sinus pathology. A 32-year-old female with a known history of autoimmune hemolytic anemia presented with sudden painful proptosis left eye, and on imaging, she was found to have SOV thrombosis without cavernous sinus involvement. She was diagnosed with unilateral isolated SOV thrombosis and was managed conservatively. A careful history and clinical evaluation can help diagnose such rare disorders and initiate appropriate therapy.
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A multidisciplinary approach to sphenoid wing dysplasia presenting with pulsatile proptosis in neurofibromatosis Type 1: A rare case report p. 157
S Prathibha, Vandana Parasar, S Yasmin, VV Seetha Pramila
DOI:10.4103/ijo.IJO_429_17  PMID:29283150
Neurofibromatosis (NF) with sphenoid wing dysplasia is a rare clinical entity. Herewith, we present a case of NF with sphenoid wing dysplasia which presented with pulsatile progressive proptosis. Other ocular symptoms or visual disturbances were absent. Diagnosis of the condition was not easy and the management was a challenging task which needed multidisciplinary approach as there were ocular, neurological, orthopedic, and dermatological manifestations. With neurosurgical intervention, reconstruction of the sphenoid wing was possible. Proptosis was corrected without any disturbance of vision.
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Unusual intraconal localization of orbital giant cell angiofibroma p. 160
Meryem Altin Ekin, Seyda Karadeniz Ugurlu, Fulya Cakalagaoglu
DOI:10.4103/ijo.IJO_755_16  PMID:29283151
Giant cell angiofibroma (GCA) is a recently reported rare soft-tissue tumor that can develop in various sites including orbit. Orbital GCAs were mainly located in the eyelid or extraconal regions such as lacrimal gland and conjunctiva. We report an atypical case of a GCA arising in the intraconal area of the orbit in a 65-year-old male patient. The tumor was excised in total by lateral orbitotomy. Histological and immunohistochemical features were consistent with the diagnosis of GCA. No recurrence was observed during the follow-up of over 2 years. GCA is a rare tumor that should be considered in the differential diagnosis of intraconal orbital tumors. Complete surgical removal is the current optimal treatment option.
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Intravascular Papillary Endothelial Hyperplasia as an unusual diagnosis for peri-orbital tumour - A case report p. 163
Anupama Kakhandaki, US Dinesh, B Akash
DOI:10.4103/ijo.IJO_645_17  PMID:29283152
Intravascular papillary endothelial hyperplasia (IPEH) is a rare cause of orbital mass which can affect healthy individuals of any age/sex/race/region. It usually requires a histopathological examination, characterized by the appearance of papillary proliferation of vascular endothelial cells within the lumen of the blood vessel, for the final diagnosis. One should be aware that this is a highly vascular lesion which can cause excessive intraoperative bleeding and incomplete removal can lead to recurrences. IPEH of the orbit/eyelid has been reported in few parts of the world as isolated case reports but none from India so far.
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Bilateral medial rectus palsy due to midbrain infarction following concussion head injury p. 166
Hansa H Thakkar, Apeksha Agrawal, Stuti Trivedi, Kartikey Singh
DOI:10.4103/ijo.IJO_570_17  PMID:29283153
Here, we report a rare case of bilateral medial rectus palsy following closed head injury. An adult male had an accidental fall which rendered him unconscious. This was followed by diplopia and restricted ocular motility. He received supportive medical therapy. He was examined for systemic medical and ophthalmic findings. Routine laboratory tests and imaging techniques were employed as per the symptoms. Diffusion-weighted imaging on magnetic resonance imaging proved it to be a rare presentation of small bilateral midbrain infarct. He recovered fully after 8 months.
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Idiopathic intracranial hypertension associated with anaemia, secondary to antiretroviral drug in a human immunodeficiency virus positive patient p. 168
J Vijay Ananth, S Sudharshan, Ambika Selvakumar, Bella J Devaleenal, Kavitha Kalaivani, Jyotirmay Biswas
DOI:10.4103/ijo.IJO_592_17  PMID:29283154
Papilledema in a patient with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome is an alarming finding. Any condition giving rise to raised intracranial tension (ICT) can cause papilledema, and in these patients, it could be secondary to opportunistic infections like meningitis to neoplasm. We report a case of a 28-year old female with HIV on antiretroviral therapy, who presented to us, with papilledema. Her fundus examination revealed superficial hemorrhages and Roth's spots along with papilledema. Patient was diagnosed with idiopathic intracranial hypertension (IIH), and all other possible systemic associations were ruled out. Her blood tests showed severe anemia. The papilledema and retinal changes resolved with treatment of anemia. This is a rare presentation of IIH in HIV positive patient due to anemia, secondary to zidovudine adverse effect.
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Transcanalicular laser-assisted dacryocystorhinostomy: First report from Oman p. 170
Upender Wali, Buthaina Sabt, Yahya Al Badaai, Abdullah Al-Mujaini
DOI:10.4103/ijo.IJO_464_17  PMID:29283155
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LETTERS TO THE EDITOR Top

Training: The way we do it p. 173
Smita Praveen
DOI:10.4103/ijo.IJO_885_17  PMID:29283156
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Intravitreal bevacizumab p. 173
Bakulesh M Khamar
DOI:10.4103/ijo.IJO_802_17  PMID:29283157
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Comment on: “Case report of a secondary macular hole closure after intravitreal bevacizumab therapy in a patient with retinal pigment epithelial detachment” p. 174
Koushik Tripathy
DOI:10.4103/ijo.IJO_733_17  PMID:29283158
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Response to comment on “Case report of a secondary macular hole closure after intravitreal bevacizumab therapy in a patient with retinal pigment epithelial detachment” p. 175
Marcus Storch, Hans Hoerauf
DOI:10.4103/ijo.IJO_788_17  PMID:29283159
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Comment on: “Multimodal imaging in dominant cystoid macular dystrophy” p. 176
Koushik Tripathy
DOI:10.4103/ijo.IJO_862_17  PMID:29283160
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Response to comment on “Multimodal imaging in dominant cystoid macular dystrophy” p. 176
Rupak Roy, Kumar Saurabh, Sourav Bhattacharyya, Nicey Roy Thomas, Kaustav Datta
DOI:10.4103/ijo.IJO_897_17  PMID:29283161
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Comment on “Impact of expansion of telemedicine screening for retinopathy of prematurity in India” p. 177
T Lalit Agarwal, Kshitij Aditya, Nisha Agrawal, Ichhya Joshi
DOI:10.4103/ijo.IJO_777_17  PMID:29283162
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Response to comment on “Impact of expansion of telemedicine screening for retinopathy of prematurity in India” p. 178
Anand Vinekar, Shwetha Mangalesh, Chaitra Jayadev, Clare Gilbert, Mangat Dogra, Bhujang Shetty
DOI:10.4103/ijo.IJO_832_17  PMID:29283163
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Comment on “Prevalence of ocular morbidity in school going children in West Uttar Pradesh” p. 179
Sara Varughese
DOI:10.4103/ijo.IJO_827_17  PMID:29283164
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Response to comment on “Prevalence of ocular morbidity in school going children in West Uttar Pradesh” p. 180
Veer Singh, K P S Malik, VK Malik, Kirti Jain
DOI:10.4103/ijo.IJO_872_17  PMID:29283165
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ERRATUM Top

Erratum: Evaluating ocular blood flow p. 181

DOI:10.4103/0301-4738.221849  PMID:29283166
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Erratum: Long-term results of trypan blue dye irrigation in the capsular bag to prevent posterior capsule opacification: A randomized trial p. 181

DOI:10.4103/0301-4738.221858  PMID:29283167
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