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   Table of Contents - Current issue
Coverpage
March 2017
Volume 65 | Issue 3
Page Nos. 175-259

Online since Monday, April 24, 2017

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EDITORIAL  

Looking back and looking forward: A satisfying journey Highly accessed article p. 175
Sundaram Natarajan
DOI:10.4103/ijo.IJO_297_17  
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REVIEW ARTICLE Top

Pluripotent stem cells: A therapeutic source for age-related macular degeneration Highly accessed article p. 177
Sowmya Parameswaran, Subramanian Krishnakumar
DOI:10.4103/ijo.IJO_1026_15  
Age-related macular degeneration (AMD) leads to progressive loss of central vision in the elderly. At a cellular level, there is aging of the retinal pigment epithelial (RPE) cells, and accumulation of lipofuscin that interferes with the proper functioning of RPE which eventually leads to apoptosis. Treatment depends on the stage of the disease. Wet AMD which has neovascularization is managed by local therapies such as laser photocoagulation and photodynamic therapy and is managed with injections of antivascular endothelial growth factor-based therapy. Unlike the wet AMD, an effective therapy does not exist for dry AMD and geographic atrophy. Cell replacement therapy has shown promise. This review discusses the opportunities in the various types of cell-based therapy, their limitations, and what is possible for India.
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SYMPOSIUM Top

What's new for us in strabismus? p. 184
Pradeep Sharma, Nripen Gaur, Swati Phuljhele, Rohit Saxena
DOI:10.4103/ijo.IJO_867_16  
Strabismus is one of the most challenging subspecialties encountered in the field of ophthalmology. The concept of etiology of strabismus is being advanced with the development of newer imaging modalities and increased understanding of the genetics of strabismus. Imaging is also being used to aid in the planning of strabismus surgery. Newer horizons are being explored in the amblyopia management. The good old eye-pad is being replaced with the iPad. Early detection of loss of stereopsis is being used to decide the timing for strabismus surgery. Improvement of binocular summation has been discovered as a benefit of corrective strabismus surgery. Newer surgical techniques such as new transposition procedures are being developed to correct complex strabismus. Strabismus surgeries aided by adjustable sutures have increased the precision of a strabismologist. A new light has been thrown on the psychosocial impact of strabismus. A present-day strabismologist has advanced from the goal of ocular alignment to a bigger perspective “to regain the paradise lost: stereopsis.”
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Circulating biomarkers in glaucoma, age-related macular degeneration, and diabetic retinopathy p. 191
Madhu Nath, Nabanita Halder, Thirumurthy Velpandian
DOI:10.4103/ijo.IJO_866_16  
Biomarkers to predict the altering physiological conditions over the period leading toward the ocular disorders are of major importance in therapeutics. Isolation and validation of the biomarkers specific to ocular diseases are a challenging task. Glaucoma is a neurodegenerative disease of the eye where the correlation of biomarkers in circulating fluid may be made specific for the eye. However, conditions such as wet age-related macular degeneration (AMD) and proliferative diabetic retinopathy (DR), circulating biomarkers might be having some degree of overlap with other conditions like cancer where a common factor such as angiogenesis is involved. Diabetes, a systemic disorder affecting the target organs such as eye, kidney, heart, and nervous system can be predicted using common circulating biomarkers. However, these markers need to be validated along with various stages of disease progression to enable the possibility of targeted pharmacological interventions apart from good glycemic control alone. This review compiles the attempts made to correlate such circulating biomarkers in the ocular conditions such as glaucoma, AMD, and DR in the search for a surrogate marker for diagnostic and prognostic value. To make biomarkers for the common convenience, genetic markers are excluded from this review.
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Descemet stripping automated endothelial keratoplasty p. 198
Namrata Sharma, Prafulla K Maharana, Shipra Singhi, Neelima Aron, Mukesh Patil
DOI:10.4103/ijo.IJO_874_16  
Endothelial keratoplasty is at present the gold standard for surgical treatment of corneal endothelial pathologies not associated with significant corneal scar. Tremendous progress has been made in recent years in improving the technology of endothelial keratoplasty techniques, such as descemet stripping automated endothelial keratoplasty (DSAEK) and descemet membrane endothelial keratoplasty. In this review, we discuss the current techniques and outcomes of DSAEK.
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Innovations in pediatric cataract surgery p. 210
Sudarshan Kumar Khokhar, Ganesh Pillay, Esha Agarwal, Manish Mahabir
DOI:10.4103/ijo.IJO_860_16  
Advances in technology have made surgery in children safer and faster. The management of pediatric cataract has made rapid progress in the past decade with the availability of safer anesthesia, newer technique's, more predictable intraocular lens (IOL) power calculation, a better understanding of neurobiology, genetics, amblyopia management, improved IOL designs for preventing visual axis opacification, and adjuvant postoperative care. Modern vitrectomy machines with minimally invasive instruments, radiofrequency, diathermy, and plasma blades help immensely in complicated cases. Preoperative evaluation with ultrasound biomicroscopy and optical coherence tomography (OCT) allows better planning of surgical procedure. The future holds good for stem cell research, customized OCT, and Zepto (precision pulse capsulotomy).
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Outcomes of deep anterior lamellar keratoplasty following autologous simple limbal epithelial transplant in pediatric unilateral severe chemical injury p. 217
Divya Singh, M Vanathi, Chanchal Gupta, Noopur Gupta, Radhika Tandon
DOI:10.4103/ijo.IJO_880_16  
Aims: To evaluate outcomes of deep anterior lamellar keratoplasty (DALK) in pediatric eyes with unilateral severe chemical injury which have undergone autologous simple limbal epithelial transplant (SLET). Settings and Design: The study design was a retrospective case series. Materials and Methods: This retrospective, case series of all children <16 years of age that have undergone DALK following autologous SLET procedure in unilateral severe chemical injury evaluates the outcomes and complications in the setting of a tertiary care center in North India. Statistical Analysis Used: Nonparametric data have been expressed as median (range), parametric qualitative data as percentage, and quantitative data as a mean ± standard deviation. Spearman's correlation coefficient is used for finding a correlation between variables. Results: Eleven eyes of 11 children (5 male and 6 female) with a mean age of 8.9 ± 4.7 years underwent DALK following ocular surface reconstruction with autologous SLET earlier for unilateral severe chemical injury with limbal stem cell deficiency. Follow-up ranged from 6 to 18 months (13.00 ± 4.58 months) following DALK procedure. All patients with a minimal follow-up of 6 months were evaluated for visual outcomes. Visual acuity ranged from 0.3 to 3 logMAR units (0.6 ± 0.2 logMAR units). Complications were encountered in three patients. Anatomical success was seen in 72.72% patients and visual success was noted in 54.54% patients. Conclusions: DALK is a feasible option in children with severe unilateral chemical injury who have undergone ocular surface reconstruction with autologous SLET procedures.
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ORIGINAL ARTICLES Top

Accommodative amplitude using the minus lens at different near distances p. 223
Hamed Momeni-Moghaddam, Jason S Ng, Bruno Mario Cesana, Abbas Ali Yekta, Mohammad Reza Sedaghat
DOI:10.4103/ijo.IJO_545_16  
Purpose: The purpose of this study was to compare the mean findings and the repeatability of the minus lens (ML) amplitude of accommodation (AA) at 33 cm and 40 cm. Materials and Methods: AA was measured from the dominant eye of 120 fully corrected subjects using the ML procedure when viewing the target at both 33 and 40 cm. Each measurement was repeated between 24 and 48 hours after the first trial. Results: Mean AA when tested at 33 cm and 40 cm was 10.20 diopter (D) (standard deviation [SD] =1.24) and 8.85 D (SD = 1.23), respectively (P < 0.001). The limits of agreement of the measured amplitude calculated with taking into account of the replicates at 33 and 40 cm were − 0.19 (95% confidence interval [CI]: −0.34 to −0.04) and 2.53 (95% CI: 2.38 to 2.68), respectively. The repeatability of testing at the two distances 33 and 40 cm was ± 1.24 and ± 0.99, respectively. In addition, the retest reliability of measured amplitude using the intraclass correlation coefficient was 0.87 (95% CI: 0.789–0.920) at 33 cm and 0.91 (95% CI: 0.872–0.945) at 40 cm. Conclusion: There is no agreement in the obtained amplitude at the two measurement distances. Testing the ML AA at 40 cm may be superior given that a lower repeatability coefficient was observed. However, it is unclear whether the larger amplitude measured at 33 cm reflects a larger increase in accommodation (greater proximity effect) or a decrease in the ability to perceive the first slight sustained blur.
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Adjustment to acquired vision loss in adults presenting for visual disability certification p. 228
Aditya Nakade, Jolly Rohatgi, Manjeet S Bhatia, Upreet Dhaliwal
DOI:10.4103/ijo.IJO_483_16  
Context: Rehabilitation of the visually disabled depends on how they adjust to loss; understanding contributing factors may help in effective rehabilitation. Aim: The aim of this study is to assess adjustment to acquired vision loss in adults. Settings and Design: This observational study, conducted in the Department of Ophthalmology at a tertiary-level teaching hospital, included thirty persons (25–65 years) with <6/60 in the better eye, and vision loss since ≥6-months. Materials and Methods: Age, gender, rural/urban residence, education, current occupation, binocular distance vision, adjustment (Acceptance and Self-Worth Adjustment Scale), depression (Center for Epidemiologic Studies-Depression Scale), social support (Duke Social Support and Stress Scale), and personality (10-item Personality Inventory scale) was recorded. Statistical Analysis: To determine their effect on adjustment, Student's t-test was used for categorical variables, Pearson's correlation for age, and Spearman's correlation for depression, personality trait and social support and stress. Results: Of 30 persons recruited, 24 were men (80%); 24 lived in urban areas (80%); 9 were employed (30%); and 14 (46.6%) had studied < Class 3. Adjustment was low (range: 33%–60%; mean: 43.6 ± 5.73). Reported support was low (median: 27.2; interquartile range [IQR]: 18.1–36.3); reported stress was low (median: 0.09; IQR: 0–18.1). Predominant personality traits (max score 14) were “Agreeableness” (average 12.0 ± 1.68) and “Conscientiousness” (average 11.3 ± 2.12). Emotional stability (average 9.2 ± 2.53) was less prominent. Depression score ranged from 17 to 50 (average 31.6 ± 6.01). The factors studied did not influence adjustment. Conclusions: Although adjustment did not vary with factors studied, all patients were depressed. Since perceived support and emotional stability was low, attention could be directed to support networks. Training patients in handling emotions, and training family members to respond to emotional needs of persons with visual disability, might contribute to reducing stress and depression.
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Evaluation of meibomian gland and tear film changes in patients with pterygium p. 233
Fen Ye, Fen Zhou, Yuan Xia, Xiaomin Zhu, Yan Wu, Zhenping Huang
DOI:10.4103/ijo.IJO_743_16  
Background: Recent studies have demonstrated that pterygium has a close relationship with dry eye disease. This study is to determine abnormalities in meibomian gland and tear function in patients with pterygium and to assess the relationship between the variables. Materials and Methods: Forty eyes from forty patients with primary nasal pterygium and forty eyes from forty volunteers without ocular pathologies were enrolled in this study. Ocular surface disease index scores, meibomian gland expression scores, lid margin abnormality scores, meiboscore, tear film breakup time (BUT), Schirmer test (SIT) value, and the lower tear meniscus height (TMH), tear meniscus depth (TMD), and tear meniscus area (TMA) using Fourier domain optical coherence were performed. Analysis of variance was applied for intergroup comparisons. A statistical significance level of P < 0.05 was considered. Results: Ocular symptom scores, BUT scores, lid margin abnormality, meibomian gland expression, and meiboscore were significantly higher in pterygium patients than in controls (P < 0.01 for all scores). However, the SIT scores, the lower TMH, TMD, and TMA values did not revealed a significant difference between two groups (all P > 0.05). Multivariate regression analysis demonstrated that meiboscore significantly correlated with ocular symptom scores, BUT, lid margin abnormality scores, and meibomian gland expression scores. Conclusions: Meibomian gland function may be altered in pterygium patients, which is associated with uncomfortable ocular symptoms. Being aware of meibomian gland changes seems essential to understand the complex relationship among pterygium, tear film functions, and ocular surface changes.
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Combined branch retinal vein and branch retinal artery occlusion – clinical features, systemic associations, and outcomes p. 238
Sabyasachi Sengupta, Utsab Pan
DOI:10.4103/ijo.IJO_340_16  
Purpose: Retinal vascular occlusions affecting both the arterial and venous systems are rare events. Combined branch retinal artery (BRAO) and vein (BRVO) occlusion are exceedingly rare and not well characterized. Methods: Six patients with combined BRAO and BRVO underwent a comprehensive eye examination, fundus fluorescein angiography, optical coherence tomography, and cardiovascular evaluation. Results: Mean age at presentation was 54 ± 7.8 years (range: 39–60), and five of the six were men. Patients had a combination of systemic comorbidities such as diabetes (5), hypertension (4), dyslipidemia (5), and hyperhomocysteinemia (1). All had unilateral combined occlusion characterized by narrowing and cattle tracking of blood in arteries and dilated tortuous veins in the involved quadrant. Fluorescein angiography demonstrated complete capillary drop out and a clear demarcation between the perfused and nonperfused retina. Presenting vision ranged from 6/9 to 1/60 Snellen's, and final vision depended on the macular perfusion status. All eyes were treated with angiography-guided sectoral laser photocoagulation, and three eyes required intravitreal bevacizumab due to macular edema or retinal neovascularization. Conclusions: Combined BRAO and BRVO is rare, may have unique underlying pathogenetic mechanisms, is associated with multiple systemic comorbidities and can yield good visual outcome if macula remains well perfused.
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OPHTHALMOLOGY PRACTICE Top

Clinical profile and neuroimaging in pediatric optic neuritis in Indian population: A case series p. 242
Rutika Khadse, Meenakshi Ravindran, Neelam Pawar, Padmavathy Maharajan, Ramakrishnan Rengappa
DOI:10.4103/ijo.IJO_939_16  
Purpose of the study: The purpose of this study was to report clinical features, neuroimaging, and visual outcome in pediatric optic neuritis (ON) in Indian population. Materials and Methods: This is a retrospective study of children up to the age of 16 years, diagnosed with ON, that presented at pediatric and neuroophthalmology clinic of a tertiary eye care center, in South India, within the period of 2010–2015. Results: We identified 62 eyes of 40 children diagnosed as ON within the study period. The mean age was 11.15 ± 3.24 years (1–15 years) with mean follow-up of 13 months. In this series, there was female preponderance (67%). Mean logarithm of the minimum angle of resolution visual acuity at presentation was 1.14 ± 0.93, which after treatment recovered to 0.10 ± 0.26 at final visit (P < 0.001). Involvement was bilateral in 22 children (55%) and recurrent in 3 eyes of 3 children. Preceding febrile illness was reported in seven cases (18%). Four (10%) cases were diagnosed as multiple sclerosis (MS), one with neuromyelitis optica , and one with acute disseminated encephalomyelitis. One case was associated with tuberculous meningitis, 1 with septicemia, and 1 with bilateral maxillary sinusitis. Neuroimaging studies of optic nerve in 14 children demonstrated isolated optic nerve enhancement. Magnetic resonance imaging brain revealed white matter T2 hyperintense lesions separate from optic nerve in ten cases, of which four cases were diagnosed as MS. Conclusions: Bilateral presentation was common, association with MS was low. Papillitis was more frequent than retrobulbar neuritis and prognosis was good in pediatric ON in Indian population.
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PHOTO ESSAY Top

Bilateral internuclear ophthalmoplegia following head trauma p. 246
Jinmann Chon, Moosang Kim
DOI:10.4103/ijo.IJO_236_17  
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BRIEF COMMUNICATIONS Top

Managing multiple caterpillar hair in the eye p. 248
Manisha Agarwal, Manisha C Acharya, Shahana Majumdar, Lagan Paul
DOI:10.4103/ijo.IJO_985_15  
Ophthalmia nodosa with vitreoretinal involvement is rare and may cause permanent loss of eye due to persistent inflammation of the eye. A young female patient having multiple caterpillar hair in the eye including cornea, anterior chamber, sclera, and pars plana presented with recurrent vitritis and pars planitis. Ultrasound biomicroscopy played a vital role and helped in localizing the hair embedded in the pars plana region which were managed by pars plana vitrectomy leading to complete recovery.
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Neuroretinitis as presenting and the only presentation of Lyme disease: Diagnosis and management p. 250
Brahm Prakash Guliani, Sandeep Kumar, Neha Chawla, Anuj Mehta
DOI:10.4103/ijo.IJO_151_17  
We present a case of neuroretinitis as presenting and the only presentation of Lyme disease in a 25-year-old female who visited hilly areas in the Himalayas of North India. She presented with right eye sudden and painless blurring of vision. Her vision at presentation was 20/60. She had fundus examination; fundus fluorescein angiography (FFA) and optical coherence tomography (OCT) imaging showed classical features of neuroretinitis. No other organ was involved. Oral steroids were prescribed and relevant investigations sent for noninfective and infective causes. Worsened visual acuity (VA) to hand movement and positive IgM titers for Borrelia burgdorferi led to the diagnosis of Lyme disease-associated neuroretinitis. Treatment with oral doxycycline plus oral steroids for 4 weeks revealed VA of 20/20 and resolution of fundus and OCT changes. Neuroretinitis as presenting and the only presentation of Lyme disease will be discussed with serial fundus, FFA, and OCT pictures.
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Persistent unilateral nictitating membrane in a 9-year-old girl: A rare case report p. 253
Mallikarjun Heralgi, Ashok Thallangady, Kavitha Venkatachalam, Hariprasad Vokuda
DOI:10.4103/ijo.IJO_436_15  
We report a case of persisting nictitating membrane in a 9-year-old girl presenting to us with the complaints of fleshy mass in the medial part of the left eye since birth, which was nonprogressive. On examination, her left eye was amblyopic with a vision of 20/500. The membrane was continuous with the medial canthus and was spread in a horizontal fashion, covering the underlying bulbar conjunctiva and one-third of the cornea. The globe however moved freely underneath the membrane, indicating no attachment between the globe and overlying membrane. The patient underwent simple excision of the nictitating membrane with good outcome.
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Immortal Ozurdex: A 10-month follow-up of an intralenticular implant p. 255
B Poornachandra, Vinod B M Kumar, Chaitra Jayadev, Subashchandra H Dorelli, Naresh Kumar Yadav, Rohit Shetty
DOI:10.4103/ijo.IJO_634_16  
A 78-year-old male who had received a dexamethasone implant (Ozurdex, Allergan, Inc., Irvine, CA, USA) 15 days back for recalcitrant diabetic macular edema in the left eye came to us for a second opinion. On examination, his corrected distance visual acuity was 20/20 in the right eye and 20/40 in the left eye. Early cataractous changes were present in both eyes. The intraocular pressure was within normal limits. The Ozurdex implant was seen lodged in the posterior cortex of the crystalline lens in the left eye, confirmed on anterior segment optical coherence tomography (OCT) and ultrasound biomicroscopy. Fundus examination showed moderate nonproliferative diabetic retinopathy in both eyes with macular edema and epiretinal membrane in the left eye, confirmed on OCT. The patient was noncompliant and returned after 10 months. Interestingly, the implant was still present in the same location with the same vision and anterior segment findings as before. The OCT showed a reduction in macular edema. The patient was advised regular follow-up and cataract surgery at a later date.
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LETTER TO THE EDITOR Top

Clinical profile of amblyopia in a tertiary care teaching hospital in Southern India p. 258
Himabindu Marthala, Gurudutt Kamath, Manjunath Kamath, Sumana J Kamath
DOI:10.4103/ijo.IJO_930_15  
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