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   Table of Contents - Current issue
Coverpage
July 2020
Volume 68 | Issue 7
Page Nos. 1237-1511

Online since Thursday, June 25, 2020

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EDITORIAL  

Indian Journal of Ophthalmology - A new direction Highly accessed article p. 1237
Santosh G Honavar
DOI:10.4103/ijo.IJO_2077_20  
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GUEST EDITORIALS Top

All India Ophthalmological Society: Stance on COVID-19 pandemic Highly accessed article p. 1239
Namrata Sharma, Mahipal S Sachdev
DOI:10.4103/ijo.IJO_1887_20  
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Distancing? But still I-care: Tele-ophthalmology during COVID-19 era Highly accessed article p. 1243
Karthika Bhaskaran, Pradeep Sharma
DOI:10.4103/ijo.IJO_1875_20  
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The SARS-CoV-2, tears, and ocular surface debate: What we know and what we need to know Highly accessed article p. 1245
Mohammad Javed Ali
DOI:10.4103/ijo.IJO_1881_20  
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An editorial perspective on the infamous COVID-19 studies retracted by Lancet and NEJM Highly accessed article p. 1247
Sabyasachi Sengupta
DOI:10.4103/ijo.IJO_1853_20  
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Management of cluster endophthalmitis does not stop at clinical care p. 1249
Taraprasad Das
DOI:10.4103/ijo.IJO_502_20  
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ONE MINUTE OPHTHALMOLOGY Top

Orange pigment overlying a choroidal tumor p. 1252
Lucas Antonio Garza-Garza, Carol L Shields, David Ancona-Lezama
DOI:10.4103/ijo.IJO_311_20  
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PERSPECTIVE Top

Henry Oldenburg: The first journal editor p. 1253
Parthopratim Dutta Majumder
DOI:10.4103/ijo.IJO_269_20  
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INNOVATION Top

Smartphone wide-field fundus photography in retinoblastoma with a nasal endoscope p. 1255
Anirban Bhaduri, Sima Das, Smriti Bansal, Neha Shree
DOI:10.4103/ijo.IJO_1666_19  
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COMMENTARY Top

Commentary: Bringing frugal Indovation to eyes of babies p. 1256
John D Akkara, Anju Kuriakose
DOI:10.4103/ijo.IJO_480_20  
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PREFERRED PRACTICE Top

All India Ophthalmological Society - Eye Bank Association of India consensus statement on guidelines for cornea and eyebanking during COVID-19 era p. 1258
Namrata Sharma, Sharon D'Souza, Rakhi Nathawat, Rajesh Sinha, Nikhil S Gokhale, Rajesh Fogla, JS Titiyal, Quresh B Maskati, Gobinda Mukherjee, Mahipal S Sachdev (Writing Committee)
DOI:10.4103/ijo.IJO_1554_20  
The COVID-19 pandemic has brought with it the huge burden of mortality and morbidity across the world and the added effects of the mandatory lockdown measures to try and control the spread. A number of aspects of healthcare including eye donation and eye collection require adequate safety precautions in place to keep both the involved healthcare workers and patients safe. This paper highlights the consensus-based guidelines by an expert panel on how to restart eye banking and eye collection services and carry out emergency corneal surgeries during this COVID-19 time. These guidelines will be applicable to all eye banks across the country and should help ophthalmologists and eye banking staff to restart eye banking while safeguarding themselves and their patients.
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All India Ophthalmological Society - Preferred practice in refractive surgery during the COVID-19 pandemic p. 1263
Namrata Sharma, Pooja Khamar, Mahipal S Sachdev, Sonia Maheshwari, Krati Gupta, Rajesh Sinha, Sneha Gupta, Rohit Shetty
DOI:10.4103/ijo.IJO_1754_20  
Coronavirus pandemic has strained the healthcare system with mortality and morbidity. A number of elective surgeries have come to standstill due to lockdown and movement restrictions. Refractive surgery being a purely elective procedure and quite a fresh subset of ophthalmology, there is a lack of unanimity as to what precautions should be followed to resume the practice of same. This article attempts to highlight simple guidelines in accordance with an expert panel, which can be followed by all those involved directly or indirectly in refractive surgery services while addressing safety of doctors, supporting staff as well as patients as a primary concern.
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A new normal with cataract surgery during COVID-19 pandemic Highly accessed article p. 1269
Jagadesh C Reddy, Pravin K Vaddavalli, Namrata Sharma, Mahipal S Sachdev, YL Rajashekar, Rajesh Sinha, Amar Agarwal, Amit Porwal, Arup Chakrabarti, Barun Kumar Nayak, Bhudhendra Kumar Jain, D Chandrasekhar, Chitra Ramamurthy, Cyres Keiki Mehta, Debasish Bhattacharya, Gaurav Luthra, Haripriya Aravind, Harsha Bhattacharjee, Himanshu Rasiklal Mehta, JS Titiyal, Jagat Ram, Jatinder Singh Bhalla, Keerthi Kumar Dasari, Keiki R Mehta, Krishna Prasad Kudlu, R Krishna Prasad, Kumaran Murugesan, Mandeep Jot Singh, Mohan Rajan, Om Parkash Rohit, Parikshit Gogate, Partha Biswas, Prema Padmanabhan, Ragini Hasmukuray Parekh, Rohit Khanna, Santosh G Honavar, Somasheila I Murthy, Sonu Goel, Sri Ganesh, Vinod Kumar Arora
DOI:10.4103/ijo.IJO_1528_20  
Cataract is the second leading cause of preventable blindness on the globe. Several programs across the country have been running efficiently to increase the cataract surgical rates and decrease blindness due to cataract. The current COVID-19 pandemic has led to a complete halt of these programs and thus accumulating all the elective cataract procedures. At present with the better understanding of the safety precautions among the health care workers and general population the Government of India (GoI) has given clearance for functioning of eye care facilities. In order to facilitate smooth functioning of every clinic, in this paper, we prepared preferred practice pattern based on consensus discussions between leading ophthalmologists in India including representatives from major governmental and private institutions as well as the All India Ophthalmological Society leadership. These guidelines will be applicable to all practice settings including tertiary institutions, corporate and group practices and individual eye clinics. The guidelines include triage, use of personal protective equipment, precautions to be taken in the OPD and operating room as well for elective cataract screening and surgery. These guidelines have been prepared based on current situation but are expected to evolve over a period of time based on the ongoing pandemic and guidelines from GoI.
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Preferred practice guidelines for glaucoma management during COVID-19 pandemic p. 1277
Sushma Tejwani, Dewang Angmo, Barun Kumar Nayak, Namrata Sharma, Mahipal S Sachdev, Tanuj Dada, Rajesh Sinha
DOI:10.4103/ijo.IJO_1724_20  
The COVID-19 pandemic has threatened the humanity at a global level to a large extent by the burden of the disease with significant mortality and to a certain extent as a byproduct of the necessary efforts to contain the same. There is a significant impact on the health care system, as we not only have to contain pandemic, but continue to treat our non-COVID-19 patients in a safe and responsible manner. Ophthalmology practice in general and glaucoma in particular needs certain modifications and additional precautions while examining as well as managing these patients keeping their and our safety in mind. As the lockdown relaxations are in vogue we need to learn how to deal with our regular patients as well in addition to emergency care. This paper presents the consensus-based guidelines by an expert panel on how to restart glaucoma practice during this COVID-19 time. These guidelines will be applicable across the country and should help ophthalmologists and glaucoma specialist to restart their practices while safeguarding the patients and their own selves from getting infected.
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Ocular oncology practice guidelines during COVID-19 pandemic-An expert consensus p. 1281
Fairooz P Manjandavida, Santosh G Honavar, Usha Kim, Usha Singh, Vikas Menon, Sima Das, Swathi Kaliki, Mahesh Shanmugam Palanivelu, Vikas Khetan, Parag K Shah, Pukhraj Rishi, Kaustubh Mulay, Arpan Gandhi, BM Vadhiraja, Vijay Anand Reddy, Sunil Bhat, Vasudha Rao
DOI:10.4103/ijo.IJO_1669_20  
The outbreak of rapidly spreading COVID-19 pandemic in December 2019 has witnessed a major transformation in the health care system worldwide. This has led to the re-organization of the specialty services for the effective utilization of available resources and ensuring the safety of patients and healthcare workers. Suspension of oncology services will have major implications on cancer care due to delayed diagnosis and treatment leading to irreversible adverse consequences. Therefore various oncology organizations have called for a continuation of cancer care during this crisis with diligence. The COVID-19 pandemic has forced the clinicians to transform the components of care from screening to outpatient care and primary management. The purpose of this article is to establish guidelines and recommendations for ocular oncology in the management of ocular tumors set by a multidisciplinary team of experts including ocular, medical and radiation oncologists, and pathologists. As the pandemic is evolving fast, it will require constant updates and reformation of health strategies and guidelines for safe and quality health care.
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COVID-19 pandemic and lacrimal practice: Multipronged resumption strategies and getting back on our feet p. 1292
Mohammad Javed Ali
DOI:10.4103/ijo.IJO_1753_20  
The aim of this review was to propose multi-pronged resumption strategies for lacrimal practice in an effort to plan a sustainable recommencement of elective surgeries after we emerge from the peak of COVID-19 pandemic. The strategies for lacrimal practice were classified into 7 subtypes, and each of the blueprints were reassessed based on existing information on resumption strategies of elective surgeries from other specialties in COVID-19 era. The specific needs of lacrimal practice were then added to construct algorithms summarizing the resumption strategies. The basic principle of 'primum non nocere' needs to be followed. The overall proposed plan advocates the transition to a more sustainable health care reality in a world where we would still co-exist with COVID-19. A comprehensive effort involving screening, laboratory testing, appropriate triage, effective personal protection and specific precautionary measures for lacrimal clinics and operating room are needed to be able to safely resume elective surgery when the pandemic peak declines. To predict the timing of the resumption of elective surgeries is quite complex and influenced by several geographic, political and economic factors. It is equally important to remember that COVID-19 crisis is a dynamic situation and constantly evolving, hence the strategies provided are subject to change. Strict adherence to standard COVID-19 guidelines combined with effective testing and personal protection strategies can ensure slow yet smooth and safe return to full lacrimal practice after the COVID-19 pandemic calms down. The local government directives, individual and institutional discretion are advised.
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Pediatric ophthalmology, strabismus and neuro-ophthalmology practice in the COVID-19 era: All India Ophthalmological Society guidelines p. 1300
Rohit Saxena, Digvijay Singh, Jitendra Jethani, Pradeep Sharma, Rajesh Sinha, Namrata Sharma, Mahipal S Sachdev (Writing Committee), Prepared in Association with the AIOS Pediatric and
DOI:10.4103/ijo.IJO_1789_20  
The COVID-19 Pandemic has prompted substantial changes in the way ophthalmology is practiced globally. General guidelines on safe ophthalmic practice have been issued by various bodies across the globe including the All India Ophthalmological Society. While these are suitable to ophthalmology overall, they are not entirely suitable to a subspecialty practice, particularly pediatric ophthalmology, strabismus and neuro-ophthalmology, which entails dealing with children, surgery under general anesthesia and managing possible life threatening situations. A group of sub-specialists and anesthetists met virtually and arrived at a consensus with regard to practice and general anesthesia protocols pertaining to these subspecialties of ophthalmology. The recommendations made by the expert group are specific yet can be universally followed to ensure the best and safest outcome for the practitioner and patient alike. The recommendations pertain to listing conditions which need emergency or urgent care in the fields of pediatric ophthalmology and neuro-ophthalmology, precautions and technique of pediatric and neuro-ophthalmic eye examination and a protocol for delivering a safe general anesthesia for a pediatriceye surgery.
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Community eye-health and vision center guidelines during COVID-19 pandemic in India p. 1306
Praveen Vashist, Suraj S Senjam, Vivek Gupta, Souvik Manna, Surbhi Agrawal, Noopur Gupta, Namrata Sharma, Rajesh Sinha, Rohit Saxena, Mahipal S Sachdev
DOI:10.4103/ijo.IJO_1527_20  
The severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has disrupted our society on an unprecedented scale since its inception in December 2019. As the health-care system is finally re-organizing to mitigate the impact of the pandemic, it was necessary to re-structure primary eye care (PEC) activities as well on the same lines. A consensus meeting was held with leading eye-care experts on 2nd May 2020 to prepare a roadmap for PEC in the days to come. Guidelines are needed for PEC activities like vision testing, refraction, optical dispensing, counseling, etc., Some of the activities at vision centers (VCs) may be postponed or modified in light of the current pandemic situation. PEC workers need to strictly follow social distancing norms (minimum 3 feet) for minimizing risk of exposure and need access to appropriate personal protective equipment (PPE), like gloves, masks and shields while examining beneficiaries. For optometrists, sterilization of instruments and encouraging the people to remain silent during the examination is recommended. Because conjunctivitis may be an early sign which can present at VCs, extra precautions in the form of PPE has to be ensured while examining such patients. This is also an opportunity to start running telemedicine clinics for all emergent cases that cannot be managed at the primary level. The guidelines also need to be updated based on the context of the working environment and changes in government directives from time to time.
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COMMENTARY Top

Commentary: Preferred practice pattern for primary eye care in the context of COVID-19 in L V Prasad Eye Institute network in India p. 1311
Srinivas Marmamula, Yanamala Niranjan Kumar, Varda Rajashekar, Asha Latha Mettla, Joji Prasad Satya Vemuri, Varsha M Rathi, Rohit C Khanna
DOI:10.4103/ijo.IJO_1417_20  
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PREFERRED PRACTICE Top

Tele-consultations in the wake of COVID-19 – Suggested guidelines for clinical ophthalmology p. 1316
Chaitra Jayadev, Padmamalini Mahendradas, Anand Vinekar, Vasudha Kemmanu, Roshmi Gupta, Zia S Pradhan, Sharon D'Souza, Chaithra D Aroor, Luci Kaweri, Rohit Shetty, Santosh G Honavar, Bhujang Shetty
DOI:10.4103/ijo.IJO_1509_20  
While telemedicine has been around for a few decades, it has taken great importance and prominence in recent times. With the fear of the virus being transmitted, patients and physicians across specialties are using consultation via a telephone call or video from the safety of their homes. Though tele-ophthalmology has been popular for screening, there are no clear guidelines on how to comprehensively manage patients seeking advice and treatment for a particular eye condition. Some major barriers to diagnosis and management are compromised detailed examination, no measurement of the visual acuity or intraocular pressure and a retinal evaluation not being feasible. Despite these limitations, we do need to help those patients who need immediate care or attention. Hence, this article has put together some guidelines to follow during such consultations. They are important and timely due to the medicolegal and financial implications.
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REVIEW ARTICLES Top

Tele-ophthalmology: Need of the hour p. 1328
Mohita Sharma, Neha Jain, Sridhar Ranganathan, Naman Sharma, Santosh G Honavar, Namrata Sharma, Mahipal S Sachdev
DOI:10.4103/ijo.IJO_1784_20  
Telemedicine and tele-ophthalmology have been in existence since many years, but have recently gained more importance in the present scenario of pandemic COVID-19. The attitude and perception of the doctors and patients has been changing gradually. Telemedicine has many advantages including providing care in inaccesible areas.In the present scenario, tele-ophthalmology gives an oppurtunity to patient for seeking consultation while also protecting against the contagion. There are many barriers faced by the patients and doctors that have restricted use of this technology in the past. However, with a systematic approach to designing the best suited technology, these barriers can be overcome and user friendly platforms can be created. Furthermore, the demand and use of teleconsulation had increased presently in this area of pandemic. Recent survey conducted by the All India Ophthalmological Society also reveals that many ophthalmologists who have not used tele-ophthalmology in the past are more keen to use it presently. In this article, we have reviewed telemedicine and tele-ophthalmology literature on Google and PubMed to get a holistic idea towards teleconsultation, its advantages, increased importance and prefrence during COVID-19 pandemic and various barriers faced so that the known challenges can be understood, which can pave way for better understanding and future incorporation into practice.
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Insights into the growing popularity of artificial intelligence in ophthalmology p. 1339
Sreetama Dutt, Anand Sivaraman, Florian Savoy, Ramachandran Rajalakshmi
DOI:10.4103/ijo.IJO_1754_19  
Artificial intelligence (AI) in healthcare is the use of computer-algorithms in analyzing complex medical data to detect associations and provide diagnostic support outputs. AI and deep learning (DL) find obvious applications in fields like ophthalmology wherein huge amount of image-based data need to be analyzed; however, the outcomes related to image recognition are reasonably well-defined. AI and DL have found important roles in ophthalmology in early screening and detection of conditions such as diabetic retinopathy (DR), age-related macular degeneration (ARMD), retinopathy of prematurity (ROP), glaucoma, and other ocular disorders, being successful inroads as far as early screening and diagnosis are concerned and appear promising with advantages of high-screening accuracy, consistency, and scalability. AI algorithms need equally skilled manpower, trained optometrists/ophthalmologists (annotators) to provide accurate ground truth for training the images. The basis of diagnoses made by AI algorithms is mechanical, and some amount of human intervention is necessary for further interpretations. This review was conducted after tracing the history of AI in ophthalmology across multiple research databases and aims to summarise the journey of AI in ophthalmology so far, making a close observation of most of the crucial studies conducted. This article further aims to highlight the potential impact of AI in ophthalmology, the pitfalls, and how to optimally use it to the maximum benefits of the ophthalmologists, the healthcare systems and the patients, alike.
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COMMENTARIES Top

Commentary: Artificial intelligence for everything: Can we trust it? p. 1346
John Davis Akkara, Anju Kuriakose
DOI:10.4103/ijo.IJO_216_20  
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Commentary: Artificial intelligence in ophthalmology: Potential challenges and way ahead p. 1347
Divya Agarwal, Atul Kumar
DOI:10.4103/ijo.IJO_737_20  
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REVIEW ARTICLES Top

Potential ocular and systemic COVID-19 prophylaxis approaches for healthcare professionals Highly accessed article p. 1349
Rohit Shetty, Vaitheeswaran Ganesan Lalgudi, Pooja Khamar, Krati Gupta, Swaminathan Sethu, Archana Nair, Santosh G Honavar, Arkasubhra Ghosh, Sharon D'Souza
DOI:10.4103/ijo.IJO_1589_20  
The COVID-19 pandemic has brought with it, innumerable challenges in healthcare, both through the direct burden of morbidity and mortality of the disease, and also by the curtailing of other essential albeit less emergency medical services to reduce the risk of community spread. Reports from around the world are showing mounting number of cases even in healthcare professionals spite of usage of adequate personal protective equipment. There are a number of factors which could account for this, be it the affinity of the virus to the respiratory and other mucosa or to patient risk factors for developing severe forms of the disease. In view of the growing need for resuming other medical services, it is essential to find newer ways to protect ourselves better, whether by systemic or topical mucosal prophylaxis with various medications or lifestyle changes promoting wellbeing and immunity. This article discusses additional prophylactic measures including drug repurposing or new indication paradigms to render protection. Certain medications such as chloroquine, trehalose, antihistaminics, and interferons used topically for various ocular conditions with reasonably good safety records are known to have anti-viral properties. Hence, can be harnessed in preventing SARS-CoV-2 attachment, entry, and/or replication in host cells. Similarly, use of hypertonic saline for nasal and oral mucosa and dietary changes are possible methods of improving our resistance. These additional prophylactic measures can be cautiously explored by healthcare professionals to protect themselves and their patients.
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A review of long-term corneal preservation techniques: Relevance and renewed interests in the COVID-19 era p. 1357
Sunita Chaurasia, Sujata Das, Aravind Roy
DOI:10.4103/ijo.IJO_1505_20  
The growth of eye banking in India was showing positive trends until the nation was hit by unprecedented times as a result of the COVID-19 pandemic. The impact of this has led to a downward spiraling in eye banking activities globally. Several measures had to be implemented to tide over the crisis and strategies planned for future to prepare for the needs of corneal transplantation. While eye banks in India have been practicing short- term and intermediate storage preservation media, there is a definite need to evolve other methods of very long-term preservation. This review discusses various methods of long term corneal preservation, their relevance and applications in the present times. We reviewed relevant medical literature in English from PUBMED with the key words “Corneal preservation”, “Cryopreservation”, “Glycerol preservation”, Gamma Irradiation”, “Eye Banking” ,”COVID-19”.
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COMMENTARIES Top

Commentary: Long-term solutions to revive eye banking in India in COVID-19 era - Needs more than long-term corneal preservation p. 1364
Samar K Basak, Soham Basak
DOI:10.4103/ijo.IJO_1896_20  
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Commentary: A review of long-term corneal preservation techniques: Relevance and renewed interests in the COVID-19 era p. 1365
Rinky Agarwal, Namrata Sharma
DOI:10.4103/ijo.IJO_1877_20  
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CURRENT OPHTHALMOLOGY Top

Impact of COVID-19 pandemic on people living with visual disability p. 1367
Suraj S Senjam
DOI:10.4103/ijo.IJO_1513_20  
People living with visual disabilities/impairment are more likely vulnerable to get contracted from the severe acute respiratory syndrome coronavirus-2 (SARS-CoV 2) than people without visual impairment. This means more than 253 million people globally will be at higher risk of affecting by the COVID-19. The current pandemic, followed by a nationwide emergency lockdown to slow the unprecedented spread of the virus, will have a serious impact on people living with visual disabilities and even endangers their lives in the long run. Many restrictive and control measures, including the adoption of new behavioural changes (for example, social distance during outdoor movement, limiting touch or tactile contact) recommended by the government will pose immense challenges to individuals with a visual loss. This serious impact, including challenges in healthcare access, can be minimized through inclusive service approaches, involving persons with visual disabilities, caregivers, family members, and healthcare providers, along with the community to a large extent, and finally, support to improve the overall outcomes. The government, along with profit or non-profit private sectors, should consider initiating such inclusive approaches while planning responses to the pandemic. Indeed, the present COVID-19 pandemic provides an opportunity for health care planners and decision-makers of various organizations across India for a reformation of disabilities care. Impacts due to the pandemic and lockdown can be reduced substantially if planning and policy are in place before any emergency happened in the future.
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Differential diagnosis of acute ocular pain: Teleophthalmology during COVID-19 pandemic - A perspective p. 1371
Somasheila I Murthy, Sujata Das, Parul Deshpande, Sushmita Kaushik, Tarjani Vivek Dave, Prachi Agashe, Nupur Goel, Anuj Soni
DOI:10.4103/ijo.IJO_1267_20  
Ocular pain is a common complaint which forces the patient to seek immediate medical attention. It is the primeval first response of the body to any severe condition of the eye such as trauma, infections and inflammation. The pain can be due to conditions directly affecting the eye and ocular adnexa; or indirect which would manifest as referred pain from other organ structures such as the central nervous system. Paradoxically, there are several minor and non-sight threatening conditions, which also leads to ocular pain and does not merit urgent hospital visits. In this perspective, we intend to provide guidelines to the practising ophthalmologist for teleconsultation when a patient complains of pain with focus on how to differentiate the various diagnoses that can be managed over teleconsultation and those requiring emergency care in the clinic. These guidelines can decrease unnecessary hospital visits, which is the need of the hour in the pandemic era and also beyond. Patients who are under quarantine and those who are unable to travel would be benefitted, and at the same time, the burden of increased patient load in busy hospital systems can be reduced.
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COMMENTARY Top

Commentary: Teleophthalmology: Opportunities and challenges p. 1379
Jayesh Vazirani
DOI:10.4103/ijo.IJO_1757_20  
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ORIGINAL ARTICLE Top

Teleconsultation at a tertiary care government medical university during COVID-19 Lockdown in India – A pilot study p. 1381
Nitika Pandey, Rajat M Srivastava, Gaurav Kumar, Vishal Katiyar, Siddharth Agrawal
DOI:10.4103/ijo.IJO_1658_20  
Purpose: COVID-19 related pan- India lockdown brought teleophthalmology to the forefront. The study ventures to understand the relevance of this modality in a government setup. The objective is to understand the feasibility, clinical profile and addressability of patients using teleconsultation in ophthalmology at a tertiary care government medical university during the COVID-19 Lockdown in India. Methods: An online survey targeting faculty members and resident doctors in a tertiary eye center in a government medical university in north India was conducted. Various aspects of teleconsultation were analyzed including the number and preferential mode of consultations, commonest complaints and diagnoses made. Frequency and factors mandating physical examination of patients was also analyzed. Results: The questionnaire was sent to 40 ophthalmologists of whom 38 responded. A total of 4880 teleconsultations were given. The commonest mode of communication was by WhatsApp messages (65.6%) and E-mail was the least preferred medium. More than 80% consultations were from previously seen patients. Red eye was the commonest presenting complaint (22.8%), followed by watering (18.7%) and foreign body sensation (14.5%). Computer vision syndrome was the commonest diagnosis (25.9%) followed by conjunctivitis (17.7%) and refractive error (17.7%). About 40% required physical examination, mostly due to uncertain diagnosis (22%) or inadequate response to prescribed treatment (19%). Conclusion: Teleconsultation was feasible in a government medical university for providing ophthalmic services during lockdown. WhatsApp was the preferred communication modality, computer vision syndrome was the most frequent tentative diagnosis and approximately 60% did not require in-person physical examination.
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COMMENTARIES Top

Commentary: Teleconsultation at a tertiary care set-up during COVID-19 lockdown in India p. 1384
Atul Kumar, Harpreet Kaur Narde
DOI:10.4103/ijo.IJO_1874_20  
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Commentary: Telemedicine in ophthalmology: No distance too far, no future too distant p. 1385
Anthony Vipin Das
DOI:10.4103/ijo.IJO_1879_20  
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Pivoting to teleconsultation for paediatric ophthalmology and strabismus: Our experience during COVID-19 times p. 1387
Ajinkya V Deshmukh, Akshay Badakere, Jenil Sheth, Manjushree Bhate, Sampada Kulkarni, Ramesh Kekunnaya
DOI:10.4103/ijo.IJO_1675_20  
Purpose: The objective is to analyse and report the data of teleconsultations provided to paediatric ophthalmology and strabismus patients during COVID-19 times and to elaborate our experience for guiding future teleconsultation practices to General, paediatric Ophthalmologists and Strabismologists. Methods: Retrospective analysis of electronic medical record data of teleconsultations provided in the department of Strabismus, Paediatric and Neuro-ophthalmology was done. Patients with optic nerve related disorders were excluded. Study period was one month. Statistical analysis of collected data was done using Microsoft excel. Results: A total of 198 patients were provided teleconsultations (an average of seven teleconsultations/day). The final analysis included 161 patients after excluding optic nerve related disorders. The median age was seven years. We had a near equal gender distribution (53% males and 47% females) of whom a third were new cases. Video calling was used in 14%, review of clinical photos shared was used in 53%. Rest of the 33% were given telephonic advice. Allergic conjunctivitis (14%), pseudophakia (9%), strabismus (12%), status post strabismus surgery (8%), cranial nerve palsies (11%) were common diagnoses. 19% (n = 30) were advised/needed visit in emergency services on same or next day. Conclusion: Our experience of teleconsultation during COVID-19 times for paediatric ophthalmology and strabismus patients was very encouraging. Pivoting teleconsultation platform can provide primary eye care to most of the patients and work as essential forward triage for rest. As we continue to further explore the currently available avenues in multimedia such as video conferencing and web/mobile based applications, we believe that tele-ophthalmology platform can provide a reliable service in patient care.
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COMMENTARY Top

Commentary: Teleophthalmology is a different ball game for kids p. 1391
John Davis Akkara, Anju Kuriakose
DOI:10.4103/ijo.IJO_1850_20  
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Demographics and clinical presentation of patients with ocular disorders during the COVID-19 lockdown in India: A report p. 1393
Anthony Vipin Das, Raja Narayanan
DOI:10.4103/ijo.IJO_1171_20  
Purpose: The aim of this study is to describe the demographics and clinical profile of patients with ocular disorders presenting during the novel coronavirus (COVID-19) lockdown in India. Methods: This cross-sectional hospital-based study included patients presenting between March 23, 2020 and April 19, 2020. All patients who presented to the emergency department were included as cases. The data were collected using an electronic medical record system. Results: Overall, 1,192 patients (mean 42.57 per day) presented to the ocular emergency department and were included for analysis. The median age of the patients was 35 (Interquartile range, IQR: 20-52) years and they were mostly adults (77.85%). The majority of patients were male (62.16%) and presented from the local metropolitan region (56.21%). On triaging based on the ocular disorders at presentation, the majority of the patients were emergency related (65.02%), followed by urgent (8.14%) and routine (26.85%) in nature. The most common emergencies were microbial keratitis (23.74%), followed by corneal trauma (16.39%). There was an increasing trend seen in emergency patients (46.11%; week 1 to 71.78%; week 4) and a decreasing trend seen in routine patients (45%; week1 to 21.20%; week 4). A subset of patients (23.49%) underwent surgery where indicated and the most commonly performed procedures were vitreo-retinal procedures (32.86%) followed by trauma related (31.43%). Conclusion: The enforcement of the nationwide lockdown due to COVID-19 resulted in a fewer patients presenting to the hospital. The majority of them presented from the local metropolitan region and the common emergencies were microbial keratitis and corneal trauma. About one fourth required a surgical intervention which was most commonly a vitreo-retinal procedure.
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COMMENTARY Top

Commentary: COVID-19—How it has impacted ophthalmic care and where do we go from here? p. 1399
Vivek Gupta, Praveen Vashist, Suraj S Senjam
DOI:10.4103/ijo.IJO_1873_20  
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Perspectives of physicians in general and ophthalmologists in particular about restarting services post-COVID-19 lockdown p. 1401
VG Madanagopalan, MR Sriram Gopal, Sabyasachi Sengupta
DOI:10.4103/ijo.IJO_1221_20  
Purpose: To assess the perspectives of physicians in general and ophthalmologists in particular about restarting elective out-patient (OP) and operating (OT) services after relaxation of lockdown for COVID-19. Methods: An online survey, containing 31 questions, was conducted among medical doctors using a secure Google forms link. The survey was open for 48 hours from 16th-18th April 2020. Results: Responses were received from 556 physicians (including 266 ophthalmologists). About a third (n = 205) wanted to start OP immediately after lockdown. In OP, mask of any kind for patient (60.8%), 3-ply for assistants (52.7%) and N95 for doctors (72.7%) were most common preferences. In OP, 31.5% and 46.6% felt full PPE and gloves alone were sufficient respectively. Ophthalmologists were more likely to start immediately after lockdown compared to other specialists (P = 0.004). Among 299 surgeons, an almost equal number (27%) wanted to start routine OT services immediately and 2 weeks post lockdown. A large majority (76.9%) would mandate COVID-19 tests before elective surgeries. In OT, 34.1% wanted N95 for surgical team and 3-ply for patient, 23.4% wanted 3-ply masks for everyone. 40.5% felt additional personal protective equipment (PPE) is not required and 33.1% felt that full PPE is required for everyone in OT. Ophthalmic surgeons preferred 3-ply masks and were less inclined to use full PPE (P < 0.001). Conclusion: Perspectives of doctors vary, especially with regarding to timing of restarting services and precautions to be taken in the OT. Ophthalmologists may tend to err on the side of taking lesser stringent precautions when restarting services post lockdown.
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Application of deep learning and image processing analysis of photographs for amblyopia screening p. 1407
Kaushik Murali, Viswesh Krishna, Vrishab Krishna, B Kumari
DOI:10.4103/ijo.IJO_1399_19  
Purpose: Photo screeners and autorefractors have been used to screen children for amblyopia risk factors (ARF) but are limited by cost and efficacy. We looked for a deep learning and image processing analysis-based system to screen for ARF. Methods: An android smartphone was used to capture images using a specially coded application that modified the camera setting. An algorithm was developed to process images taken in different light conditions in an automated manner to predict the presence of ARF. Deep learning and image processing models were used to segment images of the face. Light settings and distances were tested to obtain the necessary features. Deep learning was thereafter used to formulate normalized risks using sigmoidal models for each ARF creating a risk dashboard. The model was tested on 54 young adults and results statistically analyzed. Results: A combination of low-light and ambient-light images was needed for screening for exclusive ARF. The algorithm had an F-Score of 73.2% with an accuracy of 79.6%, a sensitivity of 88.2%, and a specificity of 75.6% in detecting the ARF. Conclusion: Deep-learning and image-processing analysis of photographs acquired from a smartphone are useful in screening for ARF in children and young adults for a referral to doctors for further diagnosis and treatment.
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COMMENTARY Top

Commentary: How useful is a deep learning smartphone application for screening for amblyogenic risk factors? p. 1411
Abadan K Amitava
DOI:10.4103/ijo.IJO_1900_20  
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ORIGINAL ARTICLE Top

Glycerol-preserved corneal tissue in emergency corneal transplantation: An alternative for fresh corneal tissue in COVID-19 crisis p. 1412
Neeti Gupta, Renu Dhasmana, Amit Maitreya, Harsh Badahur
DOI:10.4103/ijo.IJO_1198_20  
Purpose: Due to the COVID-19 pandemic, most of the eye banks have limited/stopped corneal collection, as this is a highly contagious disease. This has led to shortage of donor corneas worldwide. Glycerol preservation of tissue remains a viable option in this scenario. The objective is to compare fresh corneal tissue (FCT) with glycerol-preserved cornea (GPC) in emergency corneal transplantation. Methods: This was a retrospective cohort study conducted in a tertiary care centre of Uttarakhand. Medical records of the patients who underwent therapeutic penetrating keratoplasty (TPK) were reviewed. FCT group included patients who underwent TPK with fresh corneal tissue and GPC group included patients who underwent TPK with glycerol preserved cornea. The indications and outcomes of TPK in the terms of therapeutic success were analysed and compared between both the groups. Results: A total of 94 eyes of 91 patients underwent TPK from October 2011 to August 2017. FCT group included 60 eyes of 57 patients and GPC group included 34 eyes of 34 patients. The primary indication of TPK was infectious keratitis in both the groups (FCT-81.6%; GPC - 91.2%) There was no significant difference in the therapeutic success in both the groups (P = 0.741, Odds ratio- 1.59 with 95% CI- 0.39-6.44). Complications included glaucoma (FCT-21.7%; GPC- 35.2%) graft infection (FCT- 18.33% GPC- 2.9%); graft rejection (FCT-11.66%, GPC- 0%); and graft failure (FCT-88.33%, GPC-100%). Conclusion: The GPC is comparable to FCTs in therapeutic transplant and can be a useful interim procedure in saving the eyes in cases of infective keratitis in the time of crisis.
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Commentary: Revisiting the methods of corneal preservation in the COVID-19 era p. 1416
Uma Sridhar, Koushik Tripathy
DOI:10.4103/ijo.IJO_1886_20  
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An anterior segment optical coherence tomography study of the anterior chamber angle after implantable collamer lens-V4c implantation in Asian Indian Eyes p. 1418
Rashmi Singh, Murugesan Vanathi, Alisha Kishore, Radhika Tandon, Divya Singh
DOI:10.4103/ijo.IJO_1540_19  
Purpose: To quantitatively assess anterior chamber and angle parameters by anterior segment optical coherence tomography (AS-OCT) in myopic eyes undergoing Implantable Collamer Lens (ICL V4c) implantation. Methods: Prospective noncomparative observational case series. Pre and postoperative (1st and 3rd month) AS-OCT angle parameters (anterior chamber depth [ACD], anterior chamber angle [ACA], Angle opening distance [AOD], trabecular iris space area [TISA], scleral spur angle [SSA]) were evaluated in 32 eyes (16 patients). SPSS version 20 with paired t-test for intragroup and Mann-Whitney U value test for intergroup comparisons. Results: It included 6 (37.5%) males and 10 (62.5%) females. Preoperative ACA of 34.6 ± 2.3° reduced to 32.2 ± 2.4°, 31.9 ± 2.5° at 1 and 3 months postoperatively (P = 0.001). Preoperative mean AOD500, AOD750, TISA500, TISA750, SSA of 0.34 ± 0.06 mm, 0.52 ± 0.15 mm, 0.09 ± 0.02 mm2, 0.20 ± 0.04 mm2, 34.27 ± 4.6° decreased to 0.32 ± 0.06 mm, 0.48 ± 0.15 mm, 0.08 ± 0.02 mm2, 0.17 ± 0.05 mm2, 32.5 ± 4.3° at 1-month (P = 0.001); 0.32 ± 0.06 mm, 0.47 ± 0.13 mm, 0.08 ± 0.02 mm2, 0.17 ± 0.05 mm2 and 32.4 ± 4.6° (P = 0.001) at 3-months, respectively. Correlation analysis between preoperative ACD/intraocular pressure (IOP) was − 0.62 (P = 0.0002) [1st month], −0.40 (0.024) [third month]; between IOP/postoperative ACA, AOD500, AOD750, TISA500, TISA750, SSA was − 0.04 (0.81), −0.03 (0.85), −0.08 (0.64), −0.12 (0.48), −0.10 (0.57), −0.06 (0.73) at 1 month; −0.09 (0.58), 0.04 (0.78), 0.12 (0.48), −0.02 (0.9), −0.04 (0.79), 0.02 (0.88) at 3 months; between ICL vault/ACA, AOD500, AOD750, TISA500, TISA750, SSA was 0.38 (0.02), 0.24 (0.17), 0.21 (0.25), 0.05 (0.75), 0.15 (0.41), 0.27 (0.13) at 1st month; 0.19 (0.28), 0.06 (0.71), −0.03 (0.85), 0.005 (0.97), 0.05 (0.78), 0.07 (0.68) at 3rd month. Conclusion: Postoperatively significant angle narrowing was noted. There was a negative correlation between IOP and preoperative ACD. There was no significant correlation between IOP and ICL vault with postoperative AS-OCT angle parameters.
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Post-cataract surgery cluster endophthalmitis due to multidrug-resistant Pseudomonas aeruginosa: A retrospective cohort study of six clusters p. 1424
Swapnil M Parchand, Deepanshu Agrawal, Samrat Chatterjee, Anil Gangwe, Mihir Mishra, Deepshikha Agrawal
DOI:10.4103/ijo.IJO_1612_19  
Purpose: To analyze clinical presentations, antibiotic susceptibility, and visual outcomes in six clusters of post cataract surgery endophthalmitis caused due to multidrug-resistant Pseudomonas aeruginosa (MDR-PA). This was a hospital-based retrospective cohort study. Methods: Our study comprised sixty-two patients from six nonconsecutive clusters of post cataract surgery endophthalmitis caused by MDR-PA referred to our tertiary eye care institute. Demographic details, best-corrected visual acuity (BCVA), clinical features, microbiological findings, and patient management were reviewed. Results: The interval between onset of symptoms and presentation ranged from 1 to 7 (mean: 4.61 and median: 5) days. The presenting BCVA was no light perception in 17 (27.4%) eyes, light perception in 35 (56.4%) eyes, and hand movement or better in 10 (16.1%) eyes. All patients had hypopyon and vitreous exudates. Corneal infiltrates were noted in 40 (64.5%) eyes. Panophthalmitis was diagnosed in 20 (32.2%) eyes. The surgical intervention included intraocular antibiotics (IOAB) in 8 (12.9%) eyes, pars plana vitrectomy with IOAB in 26 (41.9%) eyes, and evisceration in 23 (37.09%) eyes. At 6 weeks, BCVA of 20/200 or better was achieved in 9 (14.5%) eyes. Pseudomonas aeruginosa was least resistant to colistin (8.3%), piperacillin (31.8%), and imipenem (36.1%). Ceftriaxone and ceftazidime resistance was seen in 80.5% and 70% isolates, respectively. Conclusion: Cluster endophthalmitis due to MDR-PA has poor visual outcomes with high rates of evisceration. In the setting of cluster endophthalmitis where MDR-PA is the most common etiology, piperacillin or imipenem can be the first drug of choice for empirical intravitreal injection for gram-negative coverage while awaiting the drug susceptibility report.
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Incidence and management of rhegmatogenous retinal detachment after pars plana vitrectomy and sutureless scleral-fixated intraocular lens p. 1432
Karthik Kumar, Piyush Kohli, Naresh Babu, Gauri Khare, Kim Ramasamy
DOI:10.4103/ijo.IJO_1974_19  
Purpose: To evaluate the incidence, risk factor(s), and surgical outcomes of rhegmatogenous retinal detachment (RRD) in patients undergoing pars plana vitrectomy (PPV) with sutureless scleral-fixated intraocular lens implantation (SFIOL). Methods: Records of patients (1311 eyes, 1234 patients) who underwent PPV and sutureless SFIOL from 2017 to 2018 were retrospectively analyzed. Results: The indications SFIOL were subluxated lens (33.7%), dislocated IOL (21.7%), surgical aphakia (20.1%), congenital lens subluxation (11.1%), nucleus drop (6.9%), and post-open globe injury (OGI) repair (6.5%). History of closed-globe injury (CGI) was present in 27.2% eyes.Twenty-two eyes (1.7%) developed RRD. The incidence of RRD in eyes, which underwent SFIOL surgery for subluxated lens, dislocated IOL, surgical aphakia, congenital lens subluxation, nucleus drop, and post-OGI repair was 1.4% (n = 6), 2.5% (n = 7), 1.1% (n = 3), 3.4% (n = 5), 0 and 1.2% (n = 1), respectively (P = 0.382). The incidence of RRD in eyes with and without CGI was 1.7% each (P = 0.996).Twenty-one eyes underwent RD surgery. Retinal reattachment was achieved in 76.2% eyes, while 66.7% eyes required only one surgery. The eyes in which retina failed to reattach had a high grade of proliferative vitreoretinopathy present at the time of presentation. Final best-corrected visual acuity of ≥20/60 and <20/60 to ≥20/200 and <20/200 was seen in 38.1%, 19.0%, and 42.9% eyes. Conclusion: Eyes with the congenital subluxated lens are at a marginally higher risk of developing post-SFIOL RRD. The surgical outcome of RD surgery in these eyes is good.
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Macular morphometrics in foveal displacement following full thickness macular hole surgery p. 1436
Unnikrishnan Nair, Ashwin Mohan, KR Sheera, Asmita Indurkar, Manoj Soman
DOI:10.4103/ijo.IJO_1845_19  
Purpose: To investigate if the ratio of the preoperative nasal and temporal “arms” of the macular hole (MH) can have a predictive value in the magnitude of foveal displacement postoperatively. Methods: This is retrospective interventional case series of eyes of 40 patients with full-thickness macular hole (FTMH), which underwent vitrectomy with internal limiting membrane (ILM) peeling and had Type 1 closure.All subjects underwent pre and postoperative optical coherence tomography (OCT, Heidelberg, Spectralis, Germany). Their pre and postoperative foveo-papillary distance (FPD) was measured and the magnitude of shift was calculated. The nasal and temporal arm lengths, their ratio (N/T ratio), and the hole base diameter were measured in the preoperative OCTs.The main outcome measure was the correlation of the N/T ratio with the postoperative foveal displacement. Results: We observed that in 25% (n = 10) the fovea shifted temporally; in 75% (n = 30) it shifted nasally. The shift did not show a significant correlation with either N/T ratio (r = 0.155, P = 0.34) or with base diameter (r = -0.008, P = 0.961). The odds ratio (OR) was 4.92 (P = 0.04) and the relative risk (RR) was 3.12 (P = 0.039) for a longer temporal segment to predict a temporal shift. Conclusion: Both nasal and temporal shifts are possible after successful hole closure and temporal shifts can also occur in a significantly high proportion of patients. Temporal shifts are more likely in eyes with a longer temporal segment.
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PHOTO ESSAY Top

Corneal calcium deposition as a plaque following collagen cross linking and vitamin D insufficiency p. 1441
Sushmita G Shah, Gaurav Y Shah
DOI:10.4103/ijo.IJO_2160_19  
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Multi-drug resistant Burkholderia cepacia keratitis following laser in situ keratomileusis complicated by interface fluid syndrome p. 1443
Vaibhav Kanduri, Bhagyashree Madduri, Nitin Mohan, Merle Fernandes
DOI:10.4103/ijo.IJO_1633_19  
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A rare case of temporal atypical retinochoroidal coloboma associated with posterior embryotoxon p. 1445
Megha Gulati, Bhavik Panchal, Avinash Pathengay
DOI:10.4103/ijo.IJO_2213_19  
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Acquired retinal astrocytoma: Transpupillary thermotherapy may be a viable alternative treatment option p. 1446
Devashish Dubey, Rajesh Ramanjulu, Mahesh P Shanmugam, Divyansh K Mishra
DOI:10.4103/ijo.IJO_1724_19  
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Indocyanine green angiography and multimodal imaging in a case of torpedo maculopathy p. 1448
Manoj Soman, Sheera Arun, Anshuman Gehlot, Rejina Mohan, Unnikrishnan Nair, Ashwin Mohan
DOI:10.4103/ijo.IJO_2277_19  
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Subretinal drusenoid deposits versus drusen on multicolor imaging p. 1450
Ramesh Venkatesh, Arpitha Pereira, Sherina Thomas, Sajjan Sangai, Kushagra Jain, Vivek Singh, Nikhita G Reddy, Naresh K Yadav
DOI:10.4103/ijo.IJO_1900_19  
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OPHTHALMIC IMAGES Top

The bifocal scotoma p. 1452
Amber A Bhayana, Vinit Tanwar
DOI:10.4103/ijo.IJO_26_20  
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Frosted lens opacities p. 1453
Savleen Kaur, Surbhi Khurana, Jagat Ram
DOI:10.4103/ijo.IJO_2264_19  
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Concurrent solitary and multifocal congenital hypertrophy of the retinal pigment epithelium in a single eye p. 1454
Anand D Gopal, Jenna M Kim, Carol L Shields
DOI:10.4103/ijo.IJO_2038_19  
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Anterior segment optical coherence tomography-guided management of traumatic iris cyst p. 1455
Aftab Abdul Khader, Sushank Ashok Bhalerao, Nandini R Banad, Ajay Krishnamurthy
DOI:10.4103/ijo.IJO_1860_19  
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Meningoencephalitis due to endogenous endophthalmitis by Klebsiella pneumoniae in a diabetic patient p. 1456
Carlos Rocha-de-Lossada, Tania Díaz Antonio, Rahul Rachwani Anil, Elisa Cuartero Jiménez
DOI:10.4103/ijo.IJO_2016_19  
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CASE REPORTS Top

Herpes zoster ophthalmicus with ocular involvement in overtreated hyperthyroidism p. 1457
Surbhi Khurana, Parul Chawla Gupta, Ashok Kumar Singh, Jagat Ram
DOI:10.4103/ijo.IJO_1759_19  
A 25-year-old man, with a history of hyperthyroidism presented with herpes zoster ophthalmicus (HZO) with neurotrophic ulcer and superadded infection 4 weeks after a sudden decrease in his thyroid hormones, caused by overtreatment of hyperthyroidism and radioactive iodine therapy. He underwent lateral tarsorrhaphy and was started on conservative treatment for the ulcer. The ulcer had resolved after 2 months. HZO is caused by reactivation of varicella-zoster virus by a decline in cell-mediated immunity. The decrease in thyroid hormones can also reactivate varicella-zoster by immunosuppression. This case highlights the importance of stability in thyroid hormones in a patient with thyroid disease and history of varicella.
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Posttraumatic deep anterior lamellar keratoplasty dehiscence: Descemet's resistance p. 1459
Meena Lakshmipathy, Prabhat Nangia, Rashima Asokan
DOI:10.4103/ijo.IJO_1235_19  
An 18-year-old girl who had undergone deep anterior lamellar keratoplasty in her left eye for keratoconus a year back presented with inferonasal graft dehiscence with intact host Descemet's membrane and intact anterior chamber after sustaining blunt injury a week prior. The graft was sutured to the host bed, and complete resolution of graft edema was seen in 4 weeks. One year later, she underwent cataract surgery with foldable intraocular lens implantation. At her final follow-up, the best-corrected visual acuity in her left eye was 20/40 with a clear corneal graft and a stable posterior chamber intraocular lens implantation.
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Conidiobolus, a hitherto unidentified pathogen in microbial keratitis p. 1461
Anita Raghavan, Balakrishna Balaka, Narendran Venkatapathy, Ram Rammohan
DOI:10.4103/ijo.IJO_1436_19  
Fungal infections are a significantly increasing cause of ocular and systemic morbidity; the vast majority of cases being ascribed to a handful of species. Fungal keratitis, unlike systemic infections, usually occur in immunocompetent individuals. Rarely, systemic infections can be associated with ocular involvement (e.g., Candida, Mucor, Pythium), or a fungus that predominantly causes systemic disease can affect the eye. One such fungus is Conidiobolus which is known to cause muco-cutaneous infections. We report the identification and successful treatment of a case of Conidiobolus corneal ulcer in an immunocompetent individual, who had no co-existing muco-cutaneous disease. Identification of this particular fungus and awareness of its potential to cause systemic disease is especially relevant, given its potential for chronic indolent infection of the subcutaneous tissues. To the best of our knowledge, this is the first reported case of a Conidiobolus corneal ulcer.
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Kocuria kristinae interface keratitis following deep anterior lamellar keratoplasty p. 1463
Anahita Kate, Joveeta Joseph, Bhupesh Bagga
DOI:10.4103/ijo.IJO_1455_19  
A 21-year-old boy underwent deep anterior lamellar keratoplasty (DALK) for advanced keratoconus. Postoperatively, slit lamp examination revealed multiple foci of interface infiltrates. Medical therapy was non-responsive, and therefore, a repeat lamellar transplantation was done. Scrapings were taken from host stroma and under the surface of the initial graft. Microbiological examination, aided by VITEK-2, revealed the causative organism as Kocuria kristinae. The postoperative course was uneventful and at a 1-year follow-up, the graft was clear with no recurrence of infection. This case highlights the pathogenic potential of Kocuria species, which has previously been disregarded as a commensal or contaminant.
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Dramatic response to topical dorzolamide in X-linked retinoschisis p. 1466
Rajeswari Thangavel, Abhidnya Surve, Shorya Azad, Vinod Kumar
DOI:10.4103/ijo.IJO_2061_19  
Macular involvement is commonly seen in cases with X-linked retinoschisis (XLRS) which includes foveal schisis and cystic maculopathy. Although no definitive treatment has been described, the use of topical 2% dorzolamide hydrochloride in such cases has shown varied response. We herein report a case of XLRS with foveal schisis showing good response to topical dorzolamide. This case highlights the importance of topical dorzolamide in a patient with XLRS.
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Intraoperative optical coherence tomography-guided subretinal cocktail injection in a case of ruptured retinal artery macro-aneurysm with multilevel bleed p. 1468
Atul Kumar, M Dheepak Sundar, Rohan Chawla, Divya Agarwal, Nasiq Hasan
DOI:10.4103/ijo.IJO_1803_19  
Submacular hemorrhage (SMH) following ruptured retinal artery macro aneurysm (RRAM) has better prognosis as compared to other etiologies. Timely intervention from as early as 24 h to less than 7 days is known to provide better visual outcomes in such cases. A variety of surgical techniques have been described in the treatment of RRAM. In this case report, we describe the advantages of intraoperative optical coherence tomography-guided sub-retinal injection of a cocktail mixture consisting of recombinant tissue plasminogen activator, bevacizumab, and air. Faster visual recovery with an immediate displacement of sub-macular bleed can be achieved with this technique in cases of RRAM-associated SMH.
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Intravitreal piperacillin-tazobactam in endophthalmitis caused by Mycobacterium abscessus in silico ne-filled eye: A case report p. 1471
G Suganeswari, Dhaivat Shah, Appakkudal R Anand
DOI:10.4103/ijo.IJO_1886_19  
A 28-year-old female came to us one month after retinal detachment surgery with a sudden painless drop in vision. The condition gradually worsened with ongoing treatment so she was taken up for lensectomy with silicone oil removal and intravitreal antibiotics and steroids. The microbiological analysis of silicone oil revealed Mycobacterium complex and gene sequencing isolated Mycobacterium abscessus, which showed antibiotic sensitivity to only piperacillin-tazobactam. Repeated intravitreal injections of the same led to the resolution of infection. This case report highlights the impact of sparsely used piperacillin-tazobactam in cases of Mycobacterium positive endophthalmitis, and the role of gene sequencing.
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Retinal detachment with spontaneous dialysis of the ora serrata in a 13-year-old child with neurofibromatosis type 1: A case report p. 1473
Rodrigo Clemente-Tomás, Noemí Ruíz-del Río, Amparo Gargallo-Benedicto, Francisca García-Ibor, José M Hervas-Hernándis, Antonio M Duch-Samper
DOI:10.4103/ijo.IJO_1895_19  
A 13-year-old child diagnosed with neurofibromatosis type 1 who on a routine control presented with rhegmatogenous retinal detachment associated to dialysis of the ora serrata in the left eye (OS). There were no clinical signs or history of contuse ocular trauma. Neurofibromatosis produces alterations in fibroblasts of the cortex of the vitreous base. This results in deficient production of the collagen fibers that anchor the vitreous base to the pars plana and the peripheral neurosensory retina. Thus, suboptimal function of the fibroblasts explains spontaneous avulsion of the vitreous base. Such avulsion in turn is related to dialysis of the ora serrata.
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Unilateral high myopia leading to asymmetric disc edema in idiopathic intracranial hypertension p. 1475
Sumit Monga
DOI:10.4103/ijo.IJO_1799_19  
Asymmetrical disc edema in idiopathic intracranial hypertension (IIH) is an uncommon finding, with an unclear understanding. This report reinforces the importance of recognizing this entity in IIH diagnosis, and not misdiagnose the condition as unilateral disc edema. In this unique report, the causative association of asymmetric optic disc edema, with optic nerve kink, due to unilateral high myopia, is documented.
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Congenital third cranial nerve palsy with prenuclear dysinnervation involving otolithic pathways: Underpinnings of a novel congenital cranial dysinnervation disorder p. 1478
Pramod K Pandey, Divya Kishore, Annu Joon, Priya Saraf
DOI:10.4103/ijo.IJO_1627_19  
A 10-year-old boy with unilateral cryptorchidism and renal aplasia displayed features of unilateral congenital pupil sparing third cranial nerve palsy with exotropia manifesting novel dysinnervation encompassing synergistic divergence with upshoot, convergence on attempted upgaze, gaze-evoked phasic conjugate torsion, and gaze-evoked nystagmus. Congenital third nucleus/nerve hypoplasia with secondary dysinnervation is classfied as congenital cranial dysinnervation disorder (CCDD). It is speculated that miswiring between prenuclear structures, otolithic pathways, interstitial nucleus of Cajal (INC), nucleus prepositus hypoglossi, and third and sixth nerve nuclei likely resulted in this novel dysinnervation. Cryptorchidism and renal aplasia if seen may point towards an overlapping phenotype with Duane-radial ray syndrome and acro-renal-ocular/IVIC syndromes.
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COMMENTARY Top

Commentary: Practical use of rubric for assessment of eye bank professionals for eye retrieval p. 1481
Sunita Chaurasia
DOI:10.4103/ijo.IJO_167_20  
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LETTERS TO THE EDITOR Top

Fighting the COVID-19 pandemic: An ophthalmologist's experience in an intensive care unit at the All India Institute of Medical Sciences p. 1482
Swechya Neupane
DOI:10.4103/ijo.IJO_1226_20  
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Lockdown diary of an ophthalmologist: Nineteen tips for unlocking your life during the ongoing COVID-19 pandemic p. 1483
Suresh K Pandey, Vidushi Sharma
DOI:10.4103/ijo.IJO_1157_20  
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Impact of COVID-19 on a tertiary eye hospital p. 1485
Srinivasan Sanjay, Arushi Garg, Rohit Shetty, Naren Shetty, Bhujang K Shetty
DOI:10.4103/ijo.IJO_921_20  
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Changes in the interaction of ophthalmologists and ophthalmic industry during and after COVID-19 lockdown: A perspective p. 1487
Srinivasan Sanjay, Arushi Garg, Naren Shetty, Rohit Shetty, Narendra Pindipapanahalli, K Bhujang Shetty
DOI:10.4103/ijo.IJO_1239_20  
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Telerehabilitation during COVID-19: Experiences in service delivery from South India p. 1489
Beula Christy, Jill Keeffe
DOI:10.4103/ijo.IJO_1197_20  
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Undergraduate ophthalmology teaching in COVID-19 times: Students' perspective and feedback p. 1490
Rouli Sud, Pallavi Sharma, Vaishali Budhwar, Sumeet Khanduja
DOI:10.4103/ijo.IJO_1689_20  
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Effect of COVID-19 on ocular diseases and ophthalmology residency training program-A developing country's perspective p. 1491
Bhagabat Nayak, Saswati Sen, Sucheta Parija
DOI:10.4103/ijo.IJO_1556_20  
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Smartphone assisted slit lamp evaluation during the COVID-19 pandemic p. 1492
Sourav Damodaran, Naresh Babu, Dhipak Arthur
DOI:10.4103/ijo.IJO_1653_20  
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Non-contact tonometer use during the COVID-19 pandemic Highly accessed article p. 1492
Dinesh Talwar, Harsh Kumar, Mithun Thulasidas
DOI:10.4103/ijo.IJO_1676_20  
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A pilot study on the perspectives of pediatric ophthalmologists and their patients towards online consultation during COVID-19 lockdown in India p. 1494
Mihir Kothari, Vivek Rathod, Susha Sugathan, Megha M Kothari
DOI:10.4103/ijo.IJO_1306_20  
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Will COVID-19 pandemic-associated lockdown increase myopia in Indian children? p. 1496
Muthu Sumitha, Srinivasan Sanjay, Vasudha Kemmanu, Madhav Rao Bhanumathi, Rohit Shetty
DOI:10.4103/ijo.IJO_1443_20  
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New challenges and workaround: Ultrasound biomicroscopy in time of COVID-19 pandemic p. 1496
PV Jayasree, AV Sathidevi, Anjali Kiran, Srinivasan Sanjay
DOI:10.4103/ijo.IJO_1793_20  
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Evolving consensus on managing vitreo-retina and uvea practice in post-COVID-19 pandemic era p. 1498
Mahesh P Shanmugam, Devashish Dubey, Divyansh Mishra, Kaushik Murali
DOI:10.4103/ijo.IJO_1704_20  
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Dry eye disease in India p. 1499
Samrat Chatterjee, Deepshikha Agrawal, Arpit Sharma
DOI:10.4103/ijo.IJO_2299_19  
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Biomass fuel and cataract: An unrecognized epidemic p. 1500
Rohit C Khanna
DOI:10.4103/ijo.IJO_159_20  
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Comments on: Development and introduction of a communication skills module for postgraduate students of ophthalmology p. 1501
Naomi Melamed, Vilomi Bhatia, Grace O J Poole, Eyal I Ben-David
DOI:10.4103/ijo.IJO_81_20  
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Response to comments on: Development and introduction of a communication skills module for postgraduate students of ophthalmology p. 1502
Purvi R Bhagat, Kamini M Prajapati, Rupal B Bhatt, Vipul K Prajapati, Rohit Dureja, Gunjan P Tank
DOI:10.4103/ijo.IJO_410_20  
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Comments on: A comparative study of tarsorrhaphy and amniotic membrane transplantation in the healing of persistent corneal epithelial defects p. 1503
Arjun Srirampur, Pravallika Kola, Tarannum Mansoori, Sritha Vemuganti
DOI:10.4103/ijo.IJO_2405_19  
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Response to comments on: A comparative study of tarsorrhaphy and amniotic membrane transplantation in the healing of persistent corneal epithelial defects p. 1504
Hennaav Kaur Dhillon, Anuradha Raj, Harsh Bahadur
DOI:10.4103/ijo.IJO_163_20  
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Comments on: Using corneal graft from keratoconic donor for lamellar and penetrating keratoplasties p. 1505
Manokamna Agarwal, Radhika Natarajan
DOI:10.4103/ijo.IJO_138_20  
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Response to comments on: Using corneal graft from keratoconic donor for lamellar and penetrating keratoplasties p. 1506
George D Kymionis, Michael A Grentzelos
DOI:10.4103/ijo.IJO_514_20  
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Comments on: Evaluation of Barrett universal II formula for intraocular lens power calculation in Asian Indian population p. 1507
Ankur K Shrivastava, Swatishree Nayak
DOI:10.4103/ijo.IJO_190_20  
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Response to comments on: Evaluation of Barrett's universal II formula for intraocular lens power calculation in Asian Indian population p. 1508
Murugesan Vanathi, Nikhil Kuthirummal, Ritika Mukhija, Radhika Tandon
DOI:10.4103/ijo.IJO_335_20  
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Comments on: Outer retinal tubulation and inner retinal pseudocysts in a patient with maternally inherited diabetes and deafness evaluated with optical coherence tomography angiogram p. 1509
Josef Finsterer
DOI:10.4103/ijo.IJO_2358_19  
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Response to comments on: Outer retinal tubulation and inner retinal pseudocysts in a patient with maternally inherited diabetes and deafness evaluated with optical coherence tomography angiogram p. 1510
Koushik Tripathy, Barsha Sarma, Shahana Mazumdar
DOI:10.4103/ijo.IJO_416_20  
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