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   2017| October  | Volume 65 | Issue 10  
    Online since October 17, 2017

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Fungal keratitis: The Aravind experience
Venkatesh N Prajna, Lalitha Prajna, Srinivasan Muthiah
October 2017, 65(10):912-919
DOI:10.4103/ijo.IJO_821_17  PMID:29044053
Research becomes very significant and meaningful when it addresses a significant public health problem of a region. Fungal keratitis is a serious problem affecting the agrarian poor and hence requires attention from public health specialists. The approach to a public health issue should focus not only on treatment but also prevention or at least show a significant thrust to reduce the morbidity of the problem. At our institution, we have developed a special interest in fungal keratitis and tried to study it in a multitude of aspects. As we put the pieces of the puzzle together, we believe that interest will be rekindled among policymakers, clinicians, microbiologists, pharmaceutical industry, and basic scientists to work together to join forces and take up an integrative approach to managing this problem. It is also believed that the article underscores the need and importance of having a focused approach to ensuring a successful career in clinical research.
  5,587 844 -
Needle stick injuries in a tertiary eye-care hospital: Incidence, management, outcomes, and recommendations
Ekta Rishi, B Shantha, Abhinav Dhami, Pukhraj Rishi, Hannah C Rajapriya
October 2017, 65(10):999-1003
DOI:10.4103/ijo.IJO_147_17  PMID:29044068
Purpose: The purpose of this study is to assess the incidence, management, and outcomes for needle stick injuries (NSIs) in a tertiary eye-care hospital and provide appropriate recommendations for its prevention. Methods: This was a retrospective database review of NSI recorded between 2010 and 2015 at a tertiary eye care center. All staff members who had NSI were managed with standard treatment protocol. The mode, location, health-care workers affected and/or at risk for NSI were analyzed. Results: One hundred and forty NSI were reported between 2010 and 2015, with ophthalmic fellows under training encountering maximum needle pricks (n = 33; 24%), followed by nursing staff (n = 32; 23%), and consultants (n = 30; 21%). Location wise, the highest incidence of NSI was found in the operating room (n = 94; 67%), followed by the laboratory (n = 17; 12%), and patients' ward (n = 14; 10%). Maximum pricks (n = 10; 20%) occurred while passing sharp instruments, anterior segment surgeons (n = 23; 79%) being affected more than posterior segment surgeons (n = 6; 21%). None of the NSI incidents was attributed to anti-VEGF injections. None of the subjects with NSI had seroconversion to hepatitis B surface antigen, human immunodeficiency virus, or hepatitis C virus in the 5-year study period. Conclusions: NSI is the most commonly encountered in the operating room among training personnel while passing sharp instruments, especially anterior segment surgeons. A proper needle/sharp disposal mechanism, documentation of adverse event, on-going staff training, and prompt prophylactic treatment are essential components of the protocol for NSI management.
  4,457 433 -
Ultrasonographic evaluation of transition from normal to ectatic area: A comparison between myopic staphylomata and coloboma
Anubha Rathi, Brijesh Takkar, Pradeep Venkatesh, Nripen Gaur, Atul Kumar
October 2017, 65(10):1030-1032
DOI:10.4103/ijo.IJO_415_17  PMID:29044079
Choroidal coloboma and posterior staphyloma are two clinically distinct entities, with choroidal excavation being a unifying feature. They are associated with early onset cataract which can make ophthalmoscopy difficult. This report studies the transition between the normal and ectatic area in these cases with ultrasound. We evaluate “posterior hump” as a sign of differentiation between these two conditions.
  2,870 205 -
Ocular surface squamous neoplasia: Are we calling a spade a spade?
Santosh G Honavar
October 2017, 65(10):907-909
DOI:10.4103/ijo.IJO_971_17  PMID:29044051
  2,358 431 -
Management of nasolacrimal duct obstruction in children: How is it changing?
Ashok Kumar Grover
October 2017, 65(10):910-911
DOI:10.4103/ijo.IJO_719_17  PMID:29044052
  2,231 384 -
Femtosecond laser-assisted cataract surgery versus 2.2 mm clear corneal phacoemulsification
H Ranjini, Praveen R Murthy, Gowri J Murthy, Vinay R Murthy
October 2017, 65(10):942-948
DOI:10.4103/ijo.IJO_152_17  PMID:29044058
Purpose: Phacoemulsification is the surgical procedure of choice for cataract, providing excellent visual and safety outcomes. Femtosecond laser-assisted cataract surgery (FLACS) is an addition to the surgical armamentarium. The study aims to compare the outcomes of FLACS using LenSx (Alcon Inc., USA) to standard 2.2 mm clear corneal phacoemulsification. Prospective case–control, comparative, interventional study was conducted in a tertiary care center. Methods: In each group, 55 eyes of 55 patients underwent cataract surgery using either FLACS or conventional phacoemulsification (control group). The primary outcome variables, uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), specular microscopy, pachymetry, mean absolute error (MAE), and anterior chamber depth (ACD) were compared between two groups at 4 weeks postoperatively. Intraoperative effective phaco time (EPT), postoperative circularity of the rhexis, capsular overlap over the edge of the intraocular lens (IOL), and decentration of the IOL were the secondary variables which were compared. Results: No significant difference was found between the groups for UCVA, pachymetry, MAE, and ACD at 4 weeks postoperatively. The FLACS group had better BCVA (P = 0.0294). Circularity of capsulorrhexis (P = 0), circular overlap over the edge of IOL (P = 0), and centration of IOL (P = 0.002) at 4 weeks postoperatively were better in the FLACS group. EPT was lower in FLACS for similar grade of cataract (P = 0). Endothelial cell loss in FLACS group was 4.2% more (P = 0.032). Conclusions: FLACS is superior to conventional phaco in the circularity of rhexis, capsular overlap, and centration of the IOL and uses less EPT. However, conventional phacoemulsification is equivalent to FLACS in most other parameters.
  1,970 399 -
Role of intravitreal/intracameral antibiotics to prevent traumatic endophthalmitis – Meta-analysis
Thanigasalam Thevi, Adinegara Lutfi Abas
October 2017, 65(10):920-925
DOI:10.4103/ijo.IJO_512_17  PMID:29044054
Traumatic endophthalmitis is a devastating condition that can occur following an open globe injury and result in loss of vision. The use of prophylactic antibiotics is empirical as most surgeons fear complications associated with the same. No systematic review has been performed in English on the role of intravitreal/intracameral antibiotics in preventing traumatic endophthalmitis. We searched for randomized controlled trials and controlled clinical trials comparing intracameral/intravitreal antibiotics with placebos on PubMed, Google Scholar, Science Direct, and Cochrane Library using keywords open globe/trauma/penetrating/perforating injuries endophthalmitis. The last search was on 5 May 2017. We included patients of all ages with open globe injuries who received intracameral/intravitreal antibiotics, regardless of the dose. Quality of the trials was assessed using Cochrane collaboration tools to assess the risk of bias. The main outcome measures were endophthalmitis and visual acuity. We included three trials. Overall, intravitreal/intracameral antibiotics were noted to significantly reduce the occurrence of endophthalmitis in open globe injuries (relative risk [RR] 0.19, 95% confidence interval [CI] 0.06–0.57). The use of intravitreal/intracameral antibiotics did not have an effect in improving visual acuity (RR 1.17, 95% CI 0.61–2.23). Two trials (Narang 2003; Soheilan 2001) were observed to have no significant effect on visual acuity while another trial (Soheilan 2007) did not list visual acuity as part of its objectives. Intracameral/intravitreal antibiotics reduce the risk of endophthalmitis in open globe injuries; although, there was no improvement in the visual acuity. We, therefore, recommend the use of intravitreal/intracameral injections in open globe injuries to prevent this devastating complication.
  1,870 465 -
Clinicodemographic profile and treatment outcome in patients of ocular surface squamous neoplasia
Rachna Meel, Rebika Dhiman, Murugesan Vanathi, Neelam Pushker, Radhika Tandon, Saranya Devi
October 2017, 65(10):936-941
DOI:10.4103/ijo.IJO_251_17  PMID:29044057
Purpose: The aim is to study the clinicodemographic profile and treatment outcome of ocular surface squamous neoplasia (OSSN). Methods: This was a retrospective observational study of 57 eyes (56 cases) with clinically diagnosed OSSN, presenting in our center over the past year. Results: The median age of presentation was 55 years with male:female ratio being 4.5:1. Systemic predisposing conditions were xeroderma pigmentosa (1) postkidney transplant immunosuppression (1), and human immunodeficiency virus infection (1). Patients with predisposing conditions had a younger median age of onset (33 years). The majority of tumors were nodular (61.4%), gelatinous (61.4%), and had limbal involvement (96%). On ultrasound biomicroscopy (UBM), mean tumor height was 2.93 ± 1.02 mm, and intraocular extension was evident in seven eyes. OSSN with intraocular extension had a mean tumor height of 4.3 ± 1.32 mm. Nodal metastasis was seen in one case at presentation. As per American Joint Committee for Cancer Classification seventh edition staging-two cases were T1, one was T2, 46 were T3 and eight were T4. Treatment advised included conservative therapy for 39; wide local excision (4 mm margin clearance) with cryotherapy for seven; enucleation in four; and exenteration in four eyes. Overall, complete regression was achieved in 88% of cases during a mean follow-up of 13.5 ± 4.6 months. Recurrence was seen in three cases, which were treated with exenteration, radical neck dissection, and palliative chemo-radiotherapy, respectively. Conclusion: Although associated with old age, earlier onset of OSSN is seen in patients with systemic predisposing conditions. Thicker tumors in the setting of a previous surgery or immunocompromised status should be considered high-risk features for intraocular extension and should be evaluated on UBM.
  1,782 379 -
Prevalence of spheroidal degeneration of cornea and its association with other eye diseases in tribes of Western Rajasthan
Amit Mohan, Zeeshan Jamil, Vishal C Bhatanagar, Manju Gajraj
October 2017, 65(10):1010-1014
DOI:10.4103/ijo.IJO_84_17  PMID:29044071
Purpose: To determine the prevalence of spheroidal degeneration of cornea (SDC) and its association with other eye diseases in the tribes of South-West Rajasthan. Methods: A total of 5012 patients were examined on slit lamp for the diagnosis of SDC. Diagnosis of SDC was made based on presence of amber granules in the superficial stroma of peripheral interpalpebral cornea with increasing opacification, coalescence and central spread or nodular and hazy surrounding stroma and divided in three stages. Results: The prevalence of SDC was 10.7%. Around 55% of the total of 535 cases examined were found to have Stage I followed by Stage II (32%) and Stage III (13%). The prevalence is greatest in both men and women over 70 years of age. The severity of SDC is greater in men. SDC was significantly associated with pterygium and pseudocapsular exfoliation. Conclusion: Extreme temperature, low humidity, dust, high wind, and microtrauma caused by sand particles are the probable etiologies for higher prevalence of this kind of degeneration in this region.
  1,694 167 -
Rickettsial retinitis: Direct bacterial infection or an immune-mediated response?
Rohan Chawla, Gadkar Amit Pundlik, Rama Chaudhry, Chandan Thakur
October 2017, 65(10):1038-1041
DOI:10.4103/ijo.IJO_369_17  PMID:29044082
Infectious retinitis postfebrile illness is known to be caused by chikungunya, dengue, West Nile virus, Bartonella, Lyme's disease, Rift Valley fever, rickettsia, Herpes viruses etc. Rickettsia is Gram-negative bacteria transmitted by arthropods vectors. Ocular involvement is common including conjunctivitis, keratitis, anterior uveitis, panuveitis, retinitis, retinal vascular changes, and optic nerve involvement. Retinitis lesions in rickettsia can occur because of an immunological response to the bacteria or because of direct invasion and proliferation of bacteria in the inner retina. We report such a case of bilateral rickettsial retinitis proven by serology which worsened on systemic steroids and responded dramatically to therapy with oral doxycycline and steroid taper. We thus believe that direct bacterial invasion plays a major role in the pathogenesis of rickettsial retinitis.
  1,512 271 -
The adverse effects of valproic acid on visual functions in the treatment of retinitis pigmentosa
Yüksel Totan, Emre Güler, Aslıhan Yüce, Mehmet Serdar Dervişogulları
October 2017, 65(10):984-988
DOI:10.4103/ijo.IJO_978_16  PMID:29044065
Purpose: To evaluate the efficacy and safety of valproic acid (VPA) treatment in patients with retinitis pigmentosa (RP). Methods: A total of 48 eyes of 24 patients (13 males, 11 females) with RP prescribed VPA were included. The length of VPA treatment was 6–12 months (mean 9.4 months). Parameters evaluated were best-corrected visual acuity (BCVA) (logarithm of the minimum angle of resolution [logMAR]), visual field analyses (VFAs) with Humprey automated perimetry, multifocal electroretinography (ERG) with Roland-RETI scan, and VPA side effects. Results: Mean age was 34.3 ± 10.3 years (range 18–56 years). Fifteen of the patients (30 eyes) had two ERG and VFA tracings, allowing comparison between baseline and follow-up (range 6–12 months). Mean BCVA before and after VPA therapy was 0.36 ± 0.38 and 0.36 ± 0.37 logMAR, respectively (P = 0.32). Quantitative perimetric indices including mean deviation and pattern standard deviation were not significantly changed after VPA therapy (P > 0.05). P1 amplitudes (in terms of nV/deg2 and mV) of ERG waves were significantly decreased in the rings 1, 3, and 4 after VPA therapy (P < 0.05). Regarding the N1 amplitudes, the only significant decrease was observed in area 1 (P = 0.03). In addition, N1 latency was significantly increased in area 3 after VPA therapy (P = 0.04). Conclusions: VPA therapy did not have any significant benefit on BCVA and VFA. In addition, it may be associated with decline in some ERG parameters. Therefore, physicians should avoid prescribing VPA for RP until its safety and efficacy are appropriately evaluated.
  1,541 223 -
Contralateral eye surgery with adjustable suture for management of third nerve palsy with aberrant regeneration
Phuong Thi Thanh Nguyen, Shailja Tibrewal, Suma Ganesh
October 2017, 65(10):1058-1061
DOI:10.4103/ijo.IJO_320_17  PMID:29044090
Aberrant regeneration of the third nerve following its palsy is commonly seen after trauma and compressive lesions. This phenomenon is thought to result due to misdirection of the regenerating axons. Surgical management is a great challenge in the third nerve palsy owing to multiple muscle involvement and is often accompanied by ptosis and poor Bell's phenomenon. We present a case of a 27-year-old male who developed isolated complete third nerve palsy of the left eye following head trauma. Features of aberrant regeneration were seen after 6 months, namely, inverse Duane's sign and Pseudo-Von Graefe's sign. He underwent recess-resect procedure in the unaffected eye with adjustable suture technique which not only corrected the deviation but also the ptosis by utilizing the oculomotor synkinesis. Thus, contralateral eye surgery combined with adjustable suture technique resulted in an accurate alignment of the eye and obviated the need for ptosis correction.
  1,546 212 -
Color vision abnormalities in type II diabetes: Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetics Study II report no 2
Laxmi Gella, Rajiv Raman, Vaitheeswaran Kulothungan, Swakshyar Saumya Pal, Suganeswari Ganesan, Sangeetha Srinivasan, Tarun Sharma
October 2017, 65(10):989-994
DOI:10.4103/ijo.IJO_601_16  PMID:29044066
Purpose: The purpose of this study is to assess color vision abnormalities in a cohort of subjects with type II diabetes and elucidate associated risk factors. Methods: Subjects were recruited from follow-up cohort of Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetics Study I. Six hundred and seventy-three eyes of 343 subjects were included from this population-based study. All subjects underwent detailed ophthalmic evaluation, including the Farnsworth-Munsell 100 hue test. Results: The prevalence of impaired color vision (ICV) was 43% (CI: 39.2–46.7). Risk factors for ICV were higher heart rate (odds ratio [OR]: 1.043, [1.023–1.064]) and a higher intraocular pressure (IOP) (OR: 1.086, [1.012–1.165]). Subjects with clinically significant macular edema (CSME) had three times higher chance of having ICV. C1, C2, and C3 are the commonly found Early Treatment Diabetic Retinopathy Study (ETDRS) patterns. The moment of inertia method showed that the angle did not reveal any specific pattern of color vision defect. Although the major and minor radii were high in those with ICV, we did not observe polarity. Confusion index was high in subjects with ICV, indicating a severe color vision defect. Conclusions: The prevalence of ICV was 43% among subjects with type II diabetes. The most commonly observed patterns were increasing severities of the blue–yellow defect on ETDRS patterns, but no specific pattern was observed at the moment of inertia analysis. The presence of CSME, a higher heart rate, and IOP was significant risk factors for ICV. This functional impairment in color vision could significantly contribute to morbidity among subjects with diabetes.
  1,417 297 -
Pathology and immunohistochemistry of capsular bag in spontaneously late dislocated capsular bag-intraocular lens complex
Harsha Bhattacharjee, Kasturi Bhattacharjee, Dipankar Das, Manpreet Singh, Piruthivi Sukumar, Diva Kant Misra
October 2017, 65(10):949-954
DOI:10.4103/ijo.IJO_790_16  PMID:29044059
Purpose: Our study aims to evaluate the morphology, histopathology, and immunohistochemistry of the spontaneously late dislocated capsular bag-intraocular lens (CB-IOL) complex. Various etiologies and possible pathogenesis of the event are also discussed. Methods: This was a tertiary-care setting and retrospective observational case series. The surgically explanted intact specimens of spontaneously late dislocated CB-IOL complex were studied. The demographics, duration of pseudophakia, IOL design/material, and specimen measurements were noted. Fresh specimens were photographed, and computer software was used for measurements. After processing, a detailed microscopic examination was carried out for three different sections of each specimen with hematoxylin and eosin (H and E), Masson's-trichrome, and immunohistochemistry stain for vimentin. The Mann–Whitney U-test was used for the statistical analysis. Results: Of 12 specimens, the mean CB and capsulorhexis opening size were 8.32 ± 0.8 mm and 3.62 ± 0.61 mm, respectively. The average CB-IOL complex size of our study was significantly lower than the studies reported in the literature (P ≤ 0.001). All (n = 12, 100%) were acrylic IOLs with 11 (91.67%) having single-piece design. All specimens on H and E stain showed extensive subepithelial fibrosis while Masson's trichrome staining showed that none had any pseudoexfoliation material. The circumferential sphincter-like fibrous tissue arrangement was seen in all specimens. Immunohistochemical expression of vimentin suggested the mesenchymal metaplasia of epithelial A-cells. Conclusion: Significant fibrotic contraction of the CB and phimosis of capsulorhexis may cause a progressive zonular tear. This is probably the most important etiology of spontaneous late dislocation of the CB-IOL complex.
  1,435 197 -
Improvement in distance and near visual acuities using low vision devices in diabetic retinopathy
Sarika Gopalakrishnan, Aishwarya Muralidharan, Shwetha Chambayil Susheel, Rajiv Raman
October 2017, 65(10):995-998
DOI:10.4103/ijo.IJO_52_17  PMID:29044067
Purpose: The aim of this study is to elucidate the causes and level of visual impairment (VI) in patients with different pathologies of diabetic retinopathy (DR) who presented to a low vision care (LVC) clinic, to analyze the type of distant and near devices prescribed to them and the visual benefits thereof. Methods: A retrospective chart review was done for 100 consecutive patients with DR who were referred to the LVC clinic from June 2015 to June 2016. The reason for referral was assessed from the electronic medical records and available fundus photographs, fundus fluorescein angiograms, and optical coherence tomography images by a retina specialist. The details of low-vision devices and subsequent improvements were noted. Results: Of the 100 patients, 52% had moderate VI, 19% mild VI, 16% severe VI, and 13% had profound VI or blindness. The most commonly prescribed low vision device was half-eye spectacles (38.4%). The pathologies which had statistically significant improvement (P < 0.05) in distance vision with low vision devices were DR with disc pallor (4.4% improvement), ischemic maculopathy (11.9% improvement), and plaque of hard exudate (10.1% improvement). However, in all pathologies, there was statistically significant improvement (P < 0.05) in near vision. Conclusion: Usually, the patients with DR presented to the LVC clinic with moderate VI. The use of low vision devices can help these patients in cases where medical and surgical treatment have no or a limited role in restoring useful vision.
  1,254 264 -
Amalric sign: An augur of ophthalmic artery occlusion
Prathibha Hande, Babi Sinha, Shivani Nayak, Srilakshmi Srinivasan, Jyothi Shetty
October 2017, 65(10):1033-1035
DOI:10.4103/ijo.IJO_42_17  PMID:29044080
A 75-year-old man presented to us with sudden onset of profound vision loss in his right eye and was identified as suffering from an ophthalmic artery occlusion. Apart from the retinal whitening and box-carring of the retinal arteries, there were characteristic triangular patches of retinal whitening in the midperipheral temporal fundus indicating a previous lateral posterior choroidal artery occlusion. The patient was a chronic smoker and had dyslipidemia. The carotid Doppler study showed complete occlusion of the internal carotid artery. The presence of these triangular patches of retinal whitening or amalric sign can therefore herald a more proximal vessel occlusion. Hence such patients require evaluation on an emergency basis. The characteristic features of the patches on fluorescein angiography and indocyanine green angiography are discussed here.
  1,250 178 -
Congenital sixth nerve palsy with associated anomalies
Nirupama Kasturi
October 2017, 65(10):1056-1057
DOI:10.4103/ijo.IJO_335_17  PMID:29044089
Congenital abduction deficit is most likely due to Duane's retraction syndrome as congenital abducens nerve palsy is very rare. We report two cases of infantile abduction deficit due to sixth nerve palsy associated with other anomalies to highlight the importance of including neuroimaging in the evaluation of an infant presenting with a limitation of abduction.
  1,261 159 -
Pediatric dacryocystorhinostomy
Mohammad Javed Ali
October 2017, 65(10):1008-1009
DOI:10.4103/ijo.IJO_696_17  PMID:29044070
  1,186 218 -
Primary nonendoscopic endonasal versus external dacryocystorhinostomy in nasolacrimal duct obstruction in children
Nandini Bothra, Raashid M Wani, Anasua Ganguly, Devjyoti Tripathy, Suryasnata Rath
October 2017, 65(10):1004-1007
DOI:10.4103/ijo.IJO_188_17  PMID:29044069
Purpose: The aim is to compare the outcome of nonendoscopic endonasal dacryocystorhinostomy (NEN DCR) with external DCR (EXT-DCR) in the treatment of nasolacrimal duct obstruction (NLDO) in children. Methods: A retrospective, comparative chart analysis of all consecutive children <16 years after EXT-DCR or NEN-DCR between June 2012 and February 2016. Results: Seventy-one children (79 eyes) underwent DCR in the study, of which 37 children (40 eyes) underwent EXT-DCR and 34 (39 eyes) NEN-DCR. Mean age of both groups (8.7 vs. 7.7 years) was comparable. Etiologically, persistent congenital NLDO was the most common indication (50% vs. 72%), followed by acquired and secondary NLDO. Mean duration was shorter for NEN-DCR (47 vs. 37 min; P = 0.0021). Mitomycin C 0.04% was used more often in NEN-DCR (10% vs. 56.41%). Success after primary EXT-DCR was 100% as compared to 75% for primary NEN-DCR at median follow-up of 12 and 16 months respectively. At revision, the main cause of failure was granuloma (60%). After revision, all eyes were symptom-free at a median follow-up of 9.5 months. Conclusion: Primary NEN-DCR has a poorer outcome than EXT-DCR in the treatment of NLDO in children and is more likely to need a revision procedure.
  1,070 235 -
Interocular symmetry of retinal nerve fiber layer and optic nerve head parameters measured by Cirrus high-definition optical coherence tomography in a normal pediatric population
Neelam Pawar, Devendra Maheshwari, Meenakshi Ravindran, Renagappa Ramakrishnan
October 2017, 65(10):955-962
DOI:10.4103/ijo.IJO_71_17  PMID:29044060
Purpose: To determine interocular differences in the retinal nerve fiber layer (RNFL) and optic nerve head (ONH) parameters in a pediatric population using Cirrus high-definition optical coherence tomography (HD-OCT). Methods: Seventy normal Indian children aged 5–17 years presenting to the Pediatric Clinic were included in this observational cross-sectional study. All subjects underwent a comprehensive ophthalmologic examination and an evaluation of the RNFL and ONH by Cirrus HD-OCT. Differences between the right and left eyes were calculated and values were compared by means of a paired t-test. Subjects were also divided into two groups based on age (under or over 10 years of age). Interocular differences in RNFL and ONH parameters together with sex and age variations for these differences were determined. Results: The mean age of studied pediatric population was 11.83 ± 3.3 years (range 5–17). Average RNFL thickness was 94.46 ± 8.7 μm (± SD) (range 77–111). Differences in the average RNFL between right and left eyes were not statistically significant (P = 0.060). Superior quadrant RNFL was thicker in the left eye and temporal quadrant was thicker in the right eye. Among ONH parameters, there were no statistically significant differences in any parameters, except vertical cup-disc (CD) ratio which was significant (P = 0.007). The 2.5%–97.5% limits of asymmetry were 9 μm for average RNFL, 0.14 for average CD ratio, and 0.22 for vertical CD ratio. Mean interocular RNFL thickness differences in superior, superior nasal, and temporal superior quadrants were 10.61 (P < 0.001), 12.57 (P < 0.001), and 4.46 (P = 0.002) μm, respectively. Interocular nerve fiber layer thickness differences were not significantly correlated with sex, while only significant differences with age were observed in 12 clock hour sector analysis, mainly in nasal inferior and inferior quadrant. Conclusions: We report the degree of interocular symmetry of RNFL and ONH parameters measured by Cirrus HD-OCT in a healthy pediatric population. The normal interocular RNFL asymmetry should not exceed 9 μm and vertical CD ratio beyond 0.22 should be considered for further investigations. The physiologic asymmetry provided by this study may assist in identifying changes in RNFL thickness and ONH parameters in pediatric glaucoma and ONH disorders.
  1,095 196 -
Changing epidemiology of neovascular glaucoma from 2002 to 2012 at King Khaled Eye Specialist Hospital, Saudi Arabia
Abdullah Al-Bahlal, Rajiv Khandekar, Khalid Al Rubaie, Tariq Alzahim, Deepak P Edward, Igor Kozak
October 2017, 65(10):969-973
DOI:10.4103/ijo.IJO_33_17  PMID:29044062
Purpose: The aim is to present the incidence and determinants of neovascular glaucoma (NVG) in Saudi Arabia. Methods: A retrospective review of NVG cases (2002–2012) was included to estimate the incidence. The determinants included gender, age, comorbidities, lens status, type of NVG, and visual acuity on presentation. The impact of antiangiogenic therapy on NVG incidence was studied. Results: We studied 597 eyes with NVG. The incidence was 6.6/10,000. It declined from 13/10,000 in 2008–0.1/10,000 in 2012 (P < 0.001). The decline in 2008 coincided with the introduction of intravitreal injection bevacizumab in Saudi Arabia. Males had a significantly higher NVG risk (odds ratio [OR] = 2.2). Diabetes and hypertension were associated with NVG in 88% and 42.7% of cases, respectively. In 377 (72%) diabetic patients, the glycemic control was poor (HbA1C >7%). Visual acuity was 20/20–20/40 in 14 (2%), 20/50–20/200 in 79 (13%), 20/200–20/400 in 456 (76%), and <20/400 in 45 (7%) eyes. Intraocular pressure was higher than 30 mmHg in 438 (73%) eyes. The cup-to-disc (CD) ratio was >0.8 in 86 (14%) eyes. During the early period (2002–2007) and later period (2008–2012), CD ratio (χ2 = 4, P = 0.09) and anterior chamber angle (P = 0.8) were not different. The presence of NVG in contralateral eye (OR = 0.8, P = 0.3) in both periods was similar. Conclusions: NVG was associated with diabetes in a very large proportion of patients. It was significantly associated with males, and with poor glycemic control and poor vision at presentation. The incidence of NVG declined after the introduction of intravitreal bevacizumab.
  1,071 203 -
Ophthalmic manifestations in Rothmund–Thomson syndrome: Case report and review of literature
JT Chinmayee, GR Meghana, RK Prathiba, TK Ramesh
October 2017, 65(10):1025-1027
DOI:10.4103/ijo.IJO_89_17  PMID:29044077
A 24-year-old male patient presented to us with diminution of vision in both eyes with watering and photophobia for the past 8 years. General physical examination showed short stature and poikiloderma. Ocular findings include photophobia with reflex tearing, dry eye, cicatricial ectropion, symblepharon approaching pupillary area of cornea, and multiple superficial punctuate erosions on the cornea. Both eyelids showed scanty meibomian glands on infrared meibography. The rest of the anterior and posterior segment was normal. The patient was treated with topical lubricants which reduced photophobia and corneal erosions. He then underwent symblepharon release with buccal mucosal grafting, which improved ectropion. Patient improved symptomatically with reduction of photophobia and improvement in vision as well.
  1,065 181 -
Assessment of BicC family RNA binding protein 1 and Ras protein specific guanine nucleotide releasing factor 1 as candidate genes for high myopia: A case–control study
Li Hepei, Xie Mingkun, Wang Li, Wu Jin
October 2017, 65(10):926-930
DOI:10.4103/ijo.IJO_625_16  PMID:29044055
Purpose: The aim is to evaluate the association between high myopia and genetic variant in the BicC family RNA binding protein 1 (BICC1) as well as its association with Ras protein specific guanine nucleotide releasing factor 1 (RASGRF1) genes in a Chinese Han population with a case–control study. Methods: Five TagSNPs in BICC1 and RASGRF1 genes were selected and genotyped in 821 unrelated subjects, which composed of 419 controls (spherical equivalent within ±1.00 D in both eyes and axial length ≦24.0 mm) and 402 cases (spherical equivalent ≤−6.0D in at least one eye and axial length ≥26.0 mm). Statistical analysis was performed with SNPstats. Results: After an analysis adjusted by age and sex, rs4245599 in BICC1 was found to be significantly associated with high myopia under the codominant, dominant, recessive and log-additive model (P = 0.001, 0.0015, 0.0045 and 2e-04, odds ratio [OR] = 2.15, 1.59, 1.73 and 1.46, respectively), and rs10763559 in BICC1 was associated with high myopia and under the dominant and log-additive model (P = 0.032 and 0.036, OR = 0.72 and 0.78, respectively). Rs4778879 in RASGRF1 was found to be significantly associated with high myopia under codominant, dominant, recessive, and log-additive model (P = 0.0088, 0.0065, 0.026, and 0.0021, OR = 1.87, 1.48, 1.56, and 1.37, respectively). However, no significant association was found between rs745030 in RASGRF1 and high myopia, neither was there any association of rs745029 in RASGRF1. Conclusion: The present study indicated that genetic variants in BICC1 and RASGRF1 are closely associated with high myopia, which appears to be a potential candidate for high myopia in Chinese Han population. Considering the small sample size of this study, further work is needed to validate our results. The function of BICC1 and RASGRF1 in the process of developing high myopia needs to be explored in the future.
  1,047 192 -
Management of a case of divergent strabismus fixus secondary to a congenital fibrosis of extraocular muscles type 2
Jyoti Himanshu Matalia, Pratibha Panmand, Pooja Ghalla
October 2017, 65(10):1061-1063
DOI:10.4103/ijo.IJO_377_17  PMID:29044091
A 17-year-old boy presented with a large exotropia with both eyes fixed in an abduction and upgaze, pupillary involvement since childhood. He had mild optic nerve hypoplasia in the right eye and situs inversus of the retinal vessels in the left optic disc. His ocular motility showed restriction of eye movements in all gazes. He was diagnosed with congenital fibrosis of extraocular muscles, type 2 (CFEOM2) and operated upon in a staged procedure with a satisfactory eye alignment using hang-back sutures in one eye and periosteal fixation in the other. This report highlights the surgical course and final outcome in this case of CFEOM2.
  1,060 146 -
Isolated nonpulsatile enophthalmos in neurofibromatosis: An uncommon entity
Swati Singh, Kaustubh Mulay, Vikas Mittal
October 2017, 65(10):1063-1066
DOI:10.4103/ijo.IJO_396_17  PMID:29044092
Isolated enophthalmos is a rarely observed entity in neurofibromatosis (NF). A 12-year-old male presented with right lower eyelid fat prolapse and enophthalmos for the past 7 years. There was no history of antecedent trauma/surgery. Computed tomography of orbit revealed an ill-defined intraconal hyperdense lesion located between lateral and inferior rectus along with an enlarged inferior orbital fissure (IOF). Superior orbital fissure was minimally widened without prolapse of any intracranial contents. Excision biopsy along with repair of widened IOF was performed through inferior transconjunctival route. Histopathology was suggestive of plexiform neurofibroma with positivity for S-100 and epithelial membrane antigen. No associated cutaneous lesions were present. Nonpulsatile enophthalmos with eyelid fat prolapse can be a presenting sign of NF.
  1,063 130 -
Novel technique of smartphone-based high magnification imaging of the eyelid lesions
Ashish Arjun Ahuja, Piyush Kohli, Sonali Lomte
October 2017, 65(10):1015-1016
DOI:10.4103/ijo.IJO_36_17  PMID:29044072
  981 169 -
Vitrectomy for epiretinal membrane in adult-onset Coats' disease
Pradeep Kumar, Vinod Kumar
October 2017, 65(10):1046-1048
DOI:10.4103/ijo.IJO_322_17  PMID:29044085
Coats' disease is characterized by retinal vascular telangiectasia and subretinal and intraretinal exudation. A relatively benign form of the disease that occurs in adults is referred to as adult-onset Coats' disease. Involvement of macula in the form of macular edema and exudation are the common presenting features in both forms of the disease. We describe a rare case of adult-onset Coats' disease that presented with epiretinal membrane (ERM). Laser photocoagulation of retinal vascular telangiectasia resulted in worsening of patient's symptoms and ERM. Early pars plana vitrectomy resulted in resolution of the patient's symptoms. Utility of ultra-wide-field imaging and rationale of early vitrectomy in such cases are discussed.
  951 149 -
Association of polymorphisms in the intron of TCF4 gene to late-onset Fuchs endothelial corneal dystrophy: An Indian cohort study
Bhavna S Rao, Arokiasamy Tharigopala, Sudhir R Rachapalli, Rama Rajagopal, Nagasamy Soumittra
October 2017, 65(10):931-935
DOI:10.4103/ijo.IJO_191_17  PMID:29044056
Purpose: Fuchs endothelial corneal dystrophy (FECD) is a progressive degenerative disease of the corneal endothelium. It is genetically heterogeneous and follows either an autosomal dominant or sporadic pattern of inheritance. Here, we have explored the association of four previously reported intronic single nucleotide polymorphisms and intronic CTG repeat expansions in TCF4 gene to FECD in an Indian cohort. Methods: The cohort consisting of 52 sporadic late-onset cases, 5 early-onset cases, and 148 controls was taken for the study. rs2286812 and rs613872 were genotyped by allele specific polymerase chain reaction (ASPCR) and PCR-based restriction digestion, respectively; rs17595731 and rs9954153 were genotyped by Taqman assay using real-time PCR. The quantitative assessment of the CTG repeat region was performed by PCR/Sanger DNA sequencing. The repeats were assessed qualitatively by short tandem repeat and triplet repeat primed PCR assays. The statistical analysis was performed using two-tailed Fisher's exact probability test. Results: SNPsrs613872 (G/T) for the 'G' allele (P value: 4.57 × 10−5) and rs17595731 (C/T) for the 'C' allele (P value: 1.87 × 10−5), respectively, showed a significant association to sporadic late-onset FECD. CTG repeat expansions were found to be associated with FECD with a P value = 2.4 × 10−3. Conclusion: rs613872, rs17595731, and CTG repeat expansions in intronic region of TCF4 are associated with increased risk of sporadic late-onset FECD in the Indian cohort studied.
  928 161 -
Utility of angiotensin-converting enzyme activity in aqueous humor in the diagnosis of ocular sarcoidosis
Violeta Mihailovic-Vucinic, Ljubica Popevic, Spasoje Popevic, Mihailo Stjepanovic, Andjelka Aleksic, Anka Stanojevic-Paovic
October 2017, 65(10):979-983
DOI:10.4103/ijo.IJO_645_16  PMID:29044064
Purpose: Many studies include elevated activity of angiotensin-converting enzyme (ACE) in serum in sarcoidosis and in ocular sarcoidosis as well, but there are only a few analyzing ACE activities in aqueous humor. The aim of this study is to illuminate the diagnostic value of ACE in aqueous humor in patients with ocular sarcoidosis. Methods: We analyzed twenty patients with ocular sarcoidosis and 18 patients with nonocular involvement. All patients have biopsy-positive sarcoidosis of the lungs and/or mediastinal lymph nodes. Blood samples for ACE serum levels were obtained from all patients. Aqueous humor samples were taken by paracentesis with a 25-gauge needle in local anesthesia. With appropriate statistical tests, we compared ACE activity in serum and aqueous humor in patients with and without ocular sarcoidosis. Results: The majority of our patients with ocular sarcoidosis were female (12/20), also in the group with systemic sarcoidosis and without ocular involvement (12/6). Mean age of the whole analyzed group of sarcoidosis patients was 45 ± 6 years. There is no statistically significant difference in ACE activity in serum between two groups of patients (with and without ocular sarcoidosis). There is statistically significant difference in ACE activity in aqueous humor among patients with ocular and nonocular sarcoidosis. ACE activity in aqueous humor is significantly higher in patients with ocular sarcoidosis. Conclusion: Increased ACE activity in aqueous humor can point to a diagnosis of ocular sarcoidosis, without the need for ocular biopsy.
  880 209 -
Cognitive functions and normal tension glaucoma
Akvile Daveckaite, Evelina Grusauskiene, Kestutis Petrikonis, Antanas Vaitkus, Lina Siaudvytyte, Ingrida Januleviciene
October 2017, 65(10):974-978
DOI:10.4103/ijo.IJO_756_16  PMID:29044063
Purpose: Only a few studies have analyzed the potential link between glaucoma and cognitive function impairment. They have found controversial results. This study aims to perform quick cognitive function assessment with clock drawing test (CDT) using two different scoring systems and compare between normal tension glaucoma (NTG) and cataract patients. Methods: Totally, 30 NTG and 30 patients with cataracts were included in a prospective, pilot study. The predrawn circle was given, and patients were asked to draw the clock showing a time of 11:10. The test was evaluated using two methods – Freund method using a 7-point scoring scale (optimal cutoff ≤4) and Rakusa using a 4-point scoring scale (optimal cutoff ≤3). The level of significance was set at P < 0.05. Results: CDT result was significantly better in cataract group than in NTG group: 3.5 (2) versus 2 (2) by Freund, (P = 0.003) and 6.5 (1) versus 4.5 (2.75) by Rakusa, respectively (P = 0.004). Sixty percent (n = 18) of NTG group and 10% (n = 3) of cataract group patients completed the CDT in the specific picture manner (the short hand on 11 and the long hand between 11 and 12), (P = 0.001). Conclusions: Lower CDT results were seen in NTG patients according to two different scoring systems. NTG patients showed a specific manner of drawing. Further prospective studies are needed to investigate the CDT reliability as fast screening test of cognitive function impairment in glaucoma patients.
  881 168 -
Optical coherence tomography angiography of circumscribed choroidal hemangioma treated with photodynamic therapy
Giuseppe Lo Giudice, Alessandro Galan
October 2017, 65(10):1049-1051
DOI:10.4103/ijo.IJO_237_17  PMID:29044086
We describe features of a circumscribed choroidal hemangioma (CCH) treated with photodynamic therapy (PDT) by means of optical coherence tomography angiography (OCT-A). A 40-year-old man had a complaint of decreasing visual acuity in his left eye for 10 days. A diagnosis of CCH was confirmed by fundus examination, fluorescein angiography, and indocyanine green angiography. An OCT-A study of choroidal lesion before and after PDT was carried out. Segmented en face OCT-A of CCH showed multiple irregular connected vascular channels with hyperflow and a capillary-like lesion. Absent and/or reduced intrachannel flow in most of the intratumoral vessels was shown by OCT-A soon after treatment (2 days), with normalization of vascular flow 7 days and 1 month after PDT. OCT-A was able to noninvasively visualize intrinsic vasculature of CCH showing vascular remodeling after PDT.
  874 173 -
Infectious chorioretinitis in an immunocompetent patient: A diagnostic dilemma
Sudha K Ganesh, B Sowkath Ali, HN Madhavan
October 2017, 65(10):1043-1046
DOI:10.4103/ijo.IJO_190_17  PMID:29044084
A 44-year-old male presented with a history of defective vision in the right eye for the past 5 months with the previous history of tubercular cervical lymphadenitis. On examination, right eye revealed panuveitis with dense vitritis and chorioretinitis in the superotemporal quadrant. His Mantoux test was positive (25 mm × 25 mm induration), QuantiFERON-TB Gold was test positive, aqueous aspirate was positive for Mycobacterium tuberculosis genome, negative for viruses and toxoplasma, and hence he was initiated on four-drug antitubercular therapy (ATT) with oral steroids. On follow-up, he had worsening of vitritis and intravenous methylprednisolone was given suspecting paradoxical reaction to ATT; however, a repeat AC tap was positive for toxoplasma B1 genome, IgG antitoxoplasma antibody was also positive in serum and aqueous; hence, we switched to systemic antitoxoplasma therapy. He underwent a therapeutic vitrectomy along with intravitreal clindamycin and dexamethasone for persistent vitreous membranes and vitritis. The patient responded well to the treatment with a reduction in vitritis and scarring of the lesion.
  846 185 -
Fundus autofluorescence imaging of subinternal limiting membrane hemorrhage in anemic retinopathy
T Lekha, P Safiya, Denesh Narasimham
October 2017, 65(10):1021-1022
DOI:10.4103/ijo.IJO_340_17  PMID:29044075
  874 150 -
Anterior capsule rupture: Does this ring, ring a bell?
Sahil Thakur, Parul Ichhpujani, Suresh Kumar
October 2017, 65(10):1019-1020
DOI:10.4103/ijo.IJO_397_17  PMID:29044074
  839 137 -
Management of idiopathic intracranial hypertension in an infant with bilateral congenital cataract and associated comitant sensory esotropia
Jyoti Himanshu Matalia, Sheetal Shirke, Hemant Anaspure, Pooja Ghalla, Minal Kekatpure
October 2017, 65(10):1053-1055
DOI:10.4103/ijo.IJO_345_17  PMID:29044088
In this report, we describe the management of a child with bilateral cataract, nystagmus, and comitant sensory esotropia. Routine ultrasonography done before cataract surgery revealed bilateral disc edema confirmed as idiopathic intracranial hypertension by a pediatric neurologist. The primary intervention for cataract surgery was followed by nonresolving papilledema, despite maximum medical therapy. To salvage the optic nerve function in a nonverbal child, bilateral optic nerve sheath decompression was planned with simultaneous medial rectus recessions for the persistent esotropia with the satisfactory postoperative outcome.
  843 129 -
Bilateral disc drusen in a diabetic patient simulating diabetic papillopathy as a cause of disc edema
Rohan Chawla, Soman Nair, Pradeep Venkatesh, Satpal Garg, Kanhaiya Mittal
October 2017, 65(10):1051-1053
DOI:10.4103/ijo.IJO_355_17  PMID:29044087
Bilateral optic disc edema in a diabetic patient may be caused by diabetic papillopathy. We herein report on a patient with bilateral optic disc drusen simulating diabetic papillopathy. A 55-year-old patient with type 2 diabetes presented with decreased vision of 1-month. Diabetic papillopathy was initially considered as there was disc edema in both eyes with focal hemorrhages at the disc margin and mild visual loss. Ultrasound of the optic nerve head revealed optic disc drusen in both eyes and this was also confirmed by the control photograph. Optic nerve head drusen should be considered in the differential diagnosis of a diabetic patient presenting with disc edema.
  818 153 -
Primary calcareous degeneration of the cornea
Gustavo Longhi Bordin, Fabio Dornelles, Juliana Amaral Martins, Otavio Azevedo Magalhaes
October 2017, 65(10):1027-1030
DOI:10.4103/ijo.IJO_858_16  PMID:29044078
Primary calcareous degeneration is a rare corneal disease. In the past 50 years, only four cases have been described. We present the case of a 26-year-old male patient with progressive calcium deposition in both eyes with negative laboratory parameters. For the first time, anterior segment optic coherence tomography was used to investigate and establish the proper treatment.
  829 127 -
Type 2 big bubble deep anterior lamellar keratoplasty-serial anterior segment optical coherence tomography documentation showing resolution of bubble in the postoperative period
Prateek Gujar
October 2017, 65(10):1017-1018
DOI:10.4103/ijo.IJO_343_17  PMID:29044073
  818 126 -
Long-term scanning laser ophthalmoscopy and perimetry in different severities of primary open and chronic angle closure glaucoma eyes
Ramanjit Sihota, Aparna Rao, Geetha Srinivasan, Viney Gupta, Ajay Sharma, Tanuj Dada, M Kalaiwani
October 2017, 65(10):963-968
DOI:10.4103/0301-4738.216734  PMID:29044061
Purpose: To determine rate of change over time on scanning laser ophthalmoscopy, HRT, compared to perimetry, and to determine incidence, parametric changes, and risk factors for progression in primary open angle glaucoma (POAG) and chronic primary angle closure angle glaucoma (CPACG) eyes. Methods: Prospective clinical study of 116 POAG eyes and 129 CPACG eyes of different severities of glaucoma. Standard automated perimetry and optic nerve head topography were studied at baseline and thereafter every 6 months. Changes in HFA and HRT parameters, in response to IOP, were compared over at least 5 years. Results: Fourteen POAG eyes (12.1%) and 20 CPACG eyes (15.5%) showed progression on SAP over time. Percentage drop of IOP was similar in eyes that progressed and in stable eyes. The change in MD in CPACG eyes was 1.8 dB/year on SAP and 1.36 dB/year in POAG eyes, P = 0.1. Twenty-nine eyes showed progression on HRT with 24 confirmed on SAP. Trend analysis picked up progression more frequently than other HRT parameters. Eyes that progressed in both groups, in all severities of glaucoma, had intermittent fluctuations of ≥ 4 mmHg over mean IOP on ≥3 follow up visits, P ≤ 0.001. Conclusion: IOP fluctuations of ≥ 4 mmHg over the mean IOP and duration of disease were associated with progression in POAG and CPACG eyes.
  732 149 -
Commentary: Rickettsial retinitis – Direct bacterial infection or an immune-mediated response?
Apoorva Ayachit, Guruprasad Ayachit, Shrinivas Joshi, VV Sameera
October 2017, 65(10):1041-1043
DOI:10.4103/ijo.IJO_681_17  PMID:29044083
  729 136 -
Vitreous opacities causing artifacts in optical coherence tomography angiography
Vinaya Kumar Konana, P Mahesh Shanmugam, Rajesh Ramanjulu, KC Divyansh Mishra
October 2017, 65(10):1023-1024
DOI:10.4103/ijo.IJO_538_17  PMID:29044076
  696 137 -
Retained intraocular iron foreign body presenting with acute retinal necrosis
Manavi D Sindal, Sabyasachi Sengupta, Dhaivat Vasavada, Sivaraman Balamurugan
October 2017, 65(10):1036-1038
DOI:10.4103/ijo.IJO_363_17  PMID:29044081
We report an unusual case of retained metallic intraocular foreign body (IOFB) presenting with acute retinal necrosis (ARN). A healthy young man presented with signs of ARN including hypopyon, dense vitritis, and peripheral retinal necrosis following alleged history of trauma with a high-velocity projectile. After initial management of ARN with systemic antivirals, a retained metallic IOFB was identified and subsequently removed surgically. The patient was followed up for 12 months postoperatively and retained excellent vision without recurrence of the ARN. The diagnosis of an IOFB in a case with associated inflammation can be challenging. A strong clinical suspicion with proper investigations can achieve optimum results.
  699 128 -
Erratum: Variation in the vitreoretinal configuration of Stage 4 retinopathy of prematurity in photocoagulated and treatment naive eyes undergoing vitrectomy

October 2017, 65(10):1067-1067
DOI:10.4103/0301-4738.216776  PMID:29044093
  502 97 -