Ligneous conjunctivitis (LC) is a rare form of bilateral chronic recurrent disease in which thick membranes form on the palpebral conjunctiva and other mucosal sites. We report the clinical features and describe the management of two cases. Case 1 was an 8-month-old patient with bilateral membranous conjunctivitis. Case 2 was a 5-year-old patient with unilateral membranous conjunctivitis, esotropia, mechanical ptosis and complicated cataract, and had been treated with a number of medications. Histological investigation of the membrane in both cases showed LC. Treatments with amniotic membrane transplantation and institution of topical cyclosporine have shown good response. There has been complete resolution of the membranes with no recurrence at the end of 40- and 28-month follow-ups, respectively. No treatment related side effects were seen. Thus, it appears that amniotic membrane transplantation and topical cyclosporine are effective alternatives for the treatment of LC.

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Aim: To evaluate the management outcomes amongst various treatment modalities for submacular hemorrhage (SMH) in Indian subjects. Settings and Design: Retrospective, single-center study. Materials and Methods: Patients presenting with SMH between 1999 and 2006 were included. Treatment modalities included: vitrectomy with subretinal recombinant tissue plasminogen activator (r-tPA) assisted SMH evacuation (group 1, n = 14); pneumatic displacement with intravitreal r-tPA and gas (group 2, n = 25); and pneumatic displacement with intraocular gas (group 3, n = 7). Favorable anatomical outcome was defined as complete displacement of SMH from fovea and favorable functional outcome was defined as a gain of >2 Snellen lines from the baseline. Kruskal-Wallis, analysis of variance (ANOVA), and Chi-square tests were used to compare the three groups, while Mann-Whitney and independent t-test were used to evaluate the influence of duration and size of SMH on outcomes. Results: There was no difference amongst groups in terms of favorable anatomical (P = 0.121) or functional outcomes (P = 0.611). Eyes with median duration of SMH less than 7.5 days had a significantly higher probability of achieving favorable anatomical outcome compared to eyes with SMH >14.5 days (P = 0.042). However, duration of SMH did not influence functional outcome (P = 0.595). Similarly, size of SMH did not affect anatomical (P = 0.578) or functional (P = 0.381) outcome. Median follow-up was 31.5, 6.5, and 2.5 months in the three groups, respectively. Conclusions: Co- existing posterior segment conditions and duration of SMH may influence the choice of treatment modality and treatment outcomes. Pneumatic displacement with r-tPA and r-tPA assisted vitrectomy appear to be favorable options for the management of SMH.

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Purpose: Phenylephrine hydrochloride (PHCl), a commonly used mydriatic agent, causes a small but significant deterioration of accommodation. The relative roles of pharmacology and optics in this deterioration, however, remain unascertained. The study determined the combined impact of PHCl concentration (pharmacology) and pupil size (optics) on the static and dynamic characteristics of accommodation. Materials and Methods: A total of 16 emmetropic Indian adults viewed a high-contrast visual target that switched between 67 and 33 cm viewing distance (1.5D stimulus) with their right eye (left eye occluded using infrared transmitting filter) through natural pupils and through 8, 6, 4, and 1 mm diameter artificial pupils. This protocol was repeated once without PHCl and once each with 2.5%, 5%, and 10% PHCl. Consensual accommodation of the left eye was recorded using infrared photorefraction (60 Hz). Results : Relative to no PHCl, the horizontal pupil diameter of left eye was significantly larger (P < 0.001) and the response magnitude and peak velocity of accommodation and disaccommodation were modestly but significantly smaller (P < 0.02 for all) for all concentrations of PHCl tested. There was no significant difference in these parameters across the three drug concentrations (P > 0.4 for all). The response magnitude and peak velocity also decreased significantly with pupil diameter, at similar rates for the no PHCl and the three PHCl conditions (P < 0.001 for all). Conclusion: The reduction in accommodative performance with all drug concentrations and with pupil diameter suggests independent roles of pharmacology and optics in determining accommodative performance with PHCl. The reduction in accommodative performance is, however, modest and may be clinically irrelevant in Indian eyes.

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We report a case of an 18-year-old male who presented with watering and inability to close the left eye completely since 6 months and inability to move both eyes outward and to close the mouth since childhood. Ocular, facial, and systemic examination revealed that the patient had bilateral complete lateral rectus and bilateral incomplete medial rectus palsy, left-sided facial nerve paralysis, thickening of lower lip and inability to close the mouth, along with other common musculoskeletal abnormalities. This is a typical presentation of Moebius syndrome which is a very rare congenital neurological disorder characterized by bilateral facial and abducens nerve paralysis. This patient had bilateral incomplete medial rectus palsy which is suggestive of the presence of horizontal gaze palsy or occulomotor nerve involvement as a component of Moebius sequence.

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Context : Surgical outcomes of vitrectomy for idiopathic macular hole using a "heavy" Brilliant Blue G (HBBG) solution for staining and removal of the internal limiting membrane (ILM). Settings and Design : Prospective interventional case series conducted in a tertiary eye care hospital. Materials and Methods : Nineteen patients (20 eyes) with idiopathic macular hole were enrolled to undergo vitrectomy with ILM peeling using HBBG. BBG dye was made heavy by mixing with 10% dextrose normal saline (DNS) solution in 2:1 ratio. The adequacy of ILM staining was noted intraoperatively. The closure rates of macular hole and visual improvement were recorded. Patients were followed up postoperatively on day 1, week 1, and subsequently at 1, 3, and 6 months, and every 6th month thereafter. Statistical Analysis: Wilcoxon signed-rank test was used; P < 0.05 was considered significant. Results: Preoperative best-corrected visual acuity (BCVA) ranged from 20/1000 to 20/63 (median: 20/100). Intraoperatively, the ILM stained very well in all eyes, and was easily removed. All macular holes closed postoperatively. The mean follow-up was 6.15 ± 2 months (range: 4-10; median: 6 months). Final BCVA ranged from 20/20 to 20/80 (median: 20/40), amounting to a significant visual improvement (P = 0.0001). BCVA improved by 1-8 Snellen lines in 19 eyes (95%); 16 eyes (80%) improved by ≥2 lines; 13 eyes (65%) achieved a final BCVA of 20/40 or better. Conclusions : Addition of 10% DNS to BBG dye allowed good ILM staining with less dye during macular hole surgery, and provided excellent anatomic and visual outcomes.

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Aim: To investigate factors having implications on re-retinal detachments (reRD) after silicone oil removal (SOR). Materials and Methods: A retroprospective study of 412 eyes (with attached retina after vitrectomy with silicone oil for rhegmatogenous RD) which underwent SOR was conducted and were followed up for six months after SOR. They were studied for various factors like encirclage, 360° retinopexy, oil emulsification at the time of SOR, duration of oil tamponade and previous retinal surgeries prior to SOR with their implications on reRD after SOR. Results: Encirclage, 360 laser barrage, both, emulsification of oil (P=0.021, P=0.001, P=0.001, P=0.001, respectively) were associated with lower risks of reRD after SOR whereas duration of tamponade (P=0.980) was not. Conclusion: Factors like encirclage, 360 retinopexy, their combination, oil emulsification reduced the incidence of re RD after SOR whereas duration of tamponade does not have statistical significant correlation with re RD after SOR.

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Purpose: To assess contrast visual acuity (CVA) in patients with retinitis pigmentosa (RP) and compare the result with standard visual acuity (VA), retinal thickness, status of inner segment/outer segment junction, and central visual field. Materials and Methods: Thirty-nine eyes of 39 patients with RP and 39 eyes of 39 healthy individuals were studied. To see the difference in CVA between RP patients and normal controls, only subjects with standard VA of 1.0 (20/20) or better were included. This was a cross-sectional study. CVA in various light conditions was measured with CAT-2000 and was compared between patients and controls. CVA of patients was further analyzed for association with other parameters including foveal retinal thickness, outer nuclear layer thickness, the status of inner segment/outer segment junction measured with optical coherence tomography (OCT), and visual field mean deviation (MD) measured with Humphrey field analyzer 10-2 program. Results: CVA impairment was evident in RP patients compared to controls (P < 0.01, in all measurement conditions). Multivariate analysis showed association of logarithm of the minimum angle of resolution (logMAR) with CVAs in several conditions. None of the OCT measurements was associated with CVA. When patients were divided into three groups based on MD, the most advanced group (MD worse than or equal to –20 dB) showed impairment of mesopic CVA (P < 0.05, under mesopic condition of 100% without glare, with glare, and 25% without glare). Conclusion: CVA impairment was confirmed in RP patients, especially in advanced cases. CVA measured with CAT-2000 may be a useful tool for assessing foveal function in RP patients.

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The purpose of this report is to evaluate the efficacy and safety of combined intravitreal injection of bevacizumab and intravitreal triamcinolone acetonide (IVTA) for recurrent inflammatory choroidal neovascular membrane (CNVM). It was a prospective interventional study of a young female, who was a known case of Vogt-Koyanagi-Harada syndrome. She presented with an inflammatory choroidal neovascualar membrane and signs of panuveitis in the right eye. She underwent a complete ophthalmic examination. She was given intravitreal injection of bevacizumab and IVTA at different sites. There was complete regression of CNVM and ocular inflammation within a week. After six months, she had recurrence of CNVM in the same eye, which was treated similarly. There was a complete resolution of CNVM and ocular inflammation after the combination therapy and systemic steroids, until one year of follow-up. No serious systemic or ocular adverse events were noted. Combination therapy appears to be an effective and safe method in the management of recurrent inflammatory CNVM.

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Context: The eye lens grows throughout life by the addition of new cells inside the surrounding capsule. How this growth affects the properties of the lens is essential for understanding disorders such as cataract and presbyopia. Aims: To examine growth of the human lens in the Indian population and compare this with the growth in Western populations by measuring in vitro dimensions together with wet and dry weights. Settings and Design: The study was conducted at the research wing of a tertiary eye care center in South India and the study design was prospective. Materials and Methods: Lenses were removed from eye bank eyes and their dimensions measured with a digital caliper. They were then carefully blotted dry and weighed before being placed in 5% buffered formalin. After 1 week fixation, the lenses were dried at 80 °C until constant weight was achieved. The constant weight was noted as the dry weight of the lens. Statistical Analysis Used: Lens parameters were analyzed as a function of age using linear and logarithmic regression methods. Results: Data were obtained for 251 lenses, aged 16-93 years, within a median postmortem time of 22 h. Both wet and dry weights increased linearly at 1.24 and 0.44 mg/year, respectively, throughout adult life. The dimensions also increased continuously throughout this time. Conclusions: Over the age range examined, lens growth in the Indian population is very similar to that in Western populations.

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Spectacles are routinely prescribed by the ophthalmologist and dispensed by the opticians. We investigated how frequently the spectacles are not dispensed as prescribed and whether the frequency of inaccurate spectacles would decrease if the patients, at the time of collecting spectacles, ask the optician to verify that the spectacles have been dispensed accurately. We found inaccurate spectacles in about one-third of our patients and incorrect spherocylinders more frequently with an error in the spherical element and cylinder axis. These inaccuracies decreased significantly when patients while collecting spectacles, asked the optician to verify the accuracy of the spectacles dispensed. It is suggested that while prescribing spectacles, the patients should be made aware of the possibility of dispensing errors. To decrease the frequency of incorrect spectacles, the patients while collecting spectacles, should ask the optician to check whether the spectacles have been dispensed accurately.

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Werner's syndrome (WS) is a rare autosomal recessive disorder with multisystem manifestations of premature aging from the second decade of life. Cataract is one of the features of WS. Cataract surgery is complicated with postoperative wound dehiscence and bullous keratopathy when the surgery is done by intracapsular or conventional extracapsular method. We report the short-term result of phacoemulsification and Neodymimum Yettrium-Aluminum-Garnet laser (Nd YAG) capsulotomy in a case of WS with bilateral cataracts. Postoperatively and post capsulotomy, there was no change in the endothelial cell morphology. There was an 8.6% decrease in endothelial cell count at the end of 15 months postoperatively and 11 months post YAG capsulotomy. This decrease is within the acceptable range of cell loss after phacoemulsification and YAG capsulotomy. To the best of our knowledge, this is the first reported case of YAG laser capsulotomy in WS.

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Aims: To create a normative data for lea grating (LG) in the Indian population and to compare LG with Cardiff Acuity Card (CAC). Settings and Design: Normative Data was acquired from normal children between 6 months-3 years coming to the 'Immunisation Clinic' and 'Well-Baby Clinic' at a Civil Hospital. To compare LG with CAC, normal and amblyopic children between 6 months-3 years were evaluated, Materials and Methods: Monocular and binocular visual acuity (VA) was measured using LG and then CAC. VA and time taken to perform the test were compared. Statistical Analysis Used: Pearson's Correlation Coefficient to compare VA and Student paired t-test (significance P<0.005) to compare time. Results: Two standard deviations of VA of 100 normal children overlapped with that published by Lea. Of the 30 amblyopic children aged 18.32 ± 10.5 months (2-36), 18 were females. VA was 0.95 ± 0.3 logMAR (0.7-1.2) and 1.0 ± 0.6 logMAR (0.5-2.1) binocularly and 1.32 ± 0.08 logMAR (0.2-0.6) and 1.15 ± 0.15 logMAR (0.88-1.48) monocularly on CAC and LG respectively. Pearson's correlation coefficient was 0.98 and 0.63 for binocular and monocular assessment respectively. Time taken to perform LG monocularly and binocularly was significantly less (P<0.001) than CAC. Conclusion: Normative data acquired in Indian pre-verbal children is similar to that published by Lea. Though VA by CAC is better than LG, the two tests are comparable.

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Background: Blotchy pigments in the anterior chamber (AC) angle are considered diagnostic of primary angle closure (PAC). But there are no reports either on the prevalence of blotchy pigments in AC angles or the validity of this sign. Aims: To determine the prevalence of blotchy pigments in AC angles and to evaluate their relationship with glaucomatous optic neuropathy (GON) in eyes with occludable angles. Setting and Design: Cross-sectional, comparative study. Materials and Methods: Gonioscopy was performed in 1001 eyes of 526 subjects (245 eyes of 148 consecutive, occludable angle subjects and 756 eyes of 378 non-consecutive, open angle subjects), above 35 years of age. Quadrant-wise location of blotchy pigments was documented. Statistical Analysis: Odds of blotchy pigments in occludable angles against that in open angles were evaluated. Relationship of GON with blotchy pigments in occludable angle eyes was evaluated using a multivariate model. Results: Prevalence of blotchy pigments in occludable angles was 28.6% (95% CI, 22.9-34.3) and in open angles was 4.7% (95% CI, 3.2-6.3). Blotchy pigments were more frequently seen in inferior (16%) and superior quadrants (15%) of occludable angles, and inferior quadrant of open angles (4%). Odds of superior quadrant blotchy pigments in occludable angles were 33 times that in open angles. GON was seen in 107 occludable angle eyes. Blotchy pigments were not significantly associated with GON (odds ratio = 0.5; P = 0.1). Conclusions: Blotchy pigments were seen in 28.6% of occludable angle eyes and 4.7% of open angles eyes. Presence of blotchy pigments in the superior quadrant is more common in occludable angles. Presence of GON in occludable angle eyes was not associated with blotchy pigments.

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We report the surgical technique and outcome of planned posterior assisted levitation (P-PAL) in four cases of subluxated cataract. P-PAL was planned as the preferred approach in all cases. A spatula was inserted via the pars plana, the whole lens was lifted to the anterior chamber and then removed through a scleral tunnel incision. Anterior chamber intraocular lenses were implanted in all cases. All four eyes had severe subluxation of the crystalline lenses with marked phacodonesis. Two eyes had history of blunt trauma, and the other two eyes had severe pseudoexfoliation with spontaneous lens subluxation. Follow-up ranged from 1 to 2 years in three cases. The postoperative visual acuity was 20/80 or better. No intraoperative complications were observed. In conclusion, the P-PAL technique was successfully performed during cataract surgery in four eyes with severe subluxated cataracts. There were no complications over the long-term follow-up.

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Management of endothelial dysfunction in phakic patients is sometimes a dilemma for corneal surgeons. Phakic patients with visually significant cataract and endothelial dysfunction are preferably managed by performing combined cataract surgery with endothelial keratoplasty. However, combined surgery may be deferred in eyes with early incipient cataract, younger age and where anterior chamber is poorly visualized. As cataract formation may be accelerated after endothelial keratoplasty, these eyes may need cataract surgery subsequently. Surgical intervention in eyes with endothelial keratoplasty is of concern as this may affect the graft adversely and threaten graft survival. In this report, we describe the intraoperative surgical details and postoperative clinical course of a patient who underwent phacoemulsification with intraocular lens implantation after Descemet stripping automated endothelial keratoplasty (DSAEK).

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The purpose of this study was to measure peripapillary retinal nerve fiber layer thickness (RNFLT) using spectral domain optical coherence tomography (SD-OCT) in normal Indian eyes, for which, 210 normal volunteers were recruited. One eye of each subject underwent RNFL scanning at 3.4 mm circle diameter around optic nerve using SD OCT. The data were analyzed to determine RNFLT in the sample population and its variation with age and gender. The average peripapillary RNFLT was 114.03 ± 9.59 μm. There was no effect of gender on RNFLT parameters. Age had significant negative correlation with average (P = 0.005), superior (P = 0.04), temporal (P = 0.049), and nasal quadrants (P = 0.01) RNFLT. Inferior quadrant RNFLT also had a negative correlation with age, but it was not statistically significant (P = 0.15).

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We present a case of a Human Immunodeficiency Virus (HIV) positive patient who was referred for retinal evaluation to rule out ophthalmic manifestations of Acquired Immunodeficiency Syndrome (AIDS). She complained of some disturbance in vision in both eyes. Fundus examination showed no abnormality. Perimetry, done to rule out optic nerve pathology, showed a left homonymous hemianopia. Magnetic Resonance Imaging (MRI) scan showed features of Progressive Multifocal Leukoencephalopathy (PML). She had no other neurological symptoms or signs.

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A 63-year-old female patient complained of dimness in the central field of vision in the left eye after viewing an annular partial eclipse without adequate eye protection on 22 July 2009. Fundoscopy showed a wrinkled macular surface. Fundus autofluorescence study revealed well-demarcated hyperautofluorescence at the fovea. Optical coherence tomography demonstrated tiny intraretinal cysts. Fluorescein angiography and indocyanine green angiography were unremarkable. Epimacular membrane developed in the following month with deteriorated vision. Vitrectomy, epiretinal membrane and internal limiting membrane peeling were performed. Vision was restored to 20/20 after the operation. Direct sun-gazing may damage the retinal structures resulting in macular inflammation and increased focal metabolism, which explains the hyperautofluorescence. It may also induce epimacular membrane. Fundus autofluorescence might represent a useful technique to detect subtle solar-induced injuries of the retina. The visual prognosis is favorable but prevention remains the mainstay of treatment. Public health education is mandatory in reducing visual morbidity.

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Background: Retinopathy of prematurity (ROP) is the main cause of visual impairment in preterm newborn infants. Objective: This study was conducted to determine whether insulin-like growth factor binding protein -3 (IGFBP-3) is associated with proliferative ROP and has a role in pathogenesis of the disease in premature infants. Materials and Methods: A total of 71 preterm infants born at or before 32 weeks of gestation participated in this study. Studied patients consisted of 41 neonates without vaso-proliferative findings of ROP as the control group and 30 preterm infants with evidence of severe ROP in follow up eye examination as the case group. Blood samples obtained from these infants 6-8 weeks after birth and blood levels of IGFBP-3 were measured using enzyme-linked immunosorbent assay (ELISA). Results: The mean gestation age and birth weight of the studied patients were 28.2±1.6 weeks and 1120.7±197 gram in the case group and 28.4±1.6 weeks and 1189.4±454 gram in the control group (P=0.25 and P=0.44 respectively). The infants in the case group had significantly lower Apgar score at first and 5 min after birth. Insulin-like growth factor binding protein -3 (IGFBP-3) was significantly lower in the patients with proliferative ROP than the patients without ROP [592.5±472.9 vs. 995.5±422.2 ng/ml (P=0.009)]. Using a cut-off point 770.45 ng/ml for the plasma IGFBP-3, we obtained a sensitivity of 65.9% and a specificity of 66.7% in the preterm infants with vasoproliferative ROP. Conclusion: Our data demonstrated that the blood levels IGFBP-3 was significantly lower in the patients with ROP and it is suspected that IGFBP-3 deficiency in the premature infants may have a pathogenetic role in proliferative ROP.

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