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   Table of Contents - Current issue
Coverpage
May-August 2022
Volume 34 | Issue 2
Page Nos. 89-191

Online since Tuesday, August 30, 2022

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EDITORIALS  

Ophthalmic simulation: The need of the times Highly accessed article p. 89
Smita Narayanan
DOI:10.4103/kjo.kjo_62_22  
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Sustainable global vision care Highly accessed article p. 92
Bindu Narayana Das
DOI:10.4103/kjo.kjo_64_22  
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GUEST EDITORIAL Top

Ensuring patient safety in eye care Highly accessed article p. 94
RD Ravindran
DOI:10.4103/kjo.kjo_61_22  
Due to the frequent and rapid development of new drugs, changes in treatment protocols and patient care delivery systems including technology, patient care in health care settings is becoming increasingly complex. However, there is a greater expectation from the patient and the community regarding the quality of patient care, outcomes, and timely delivery. These create stressful situations, making the care process prone to errors, resulting in unsafe incidents. Common errors in ophthalmology include incorrect procedures, identification errors, technical errors, medical or diagnostic errors, and documentation errors. Hence, there is a dire need to create comprehensive methods to support error-free patient care. These include standardization, developing safety protocols, safety checklists, training the staff, creating a platform for reporting, performing a root-cause analysis, monitoring, and periodical meetings to improve and continue the process. Providing a dignified, non-punitive approach with a well-defined system is paramount for ensuring patient safety in eye care.
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REVIEW ARTICLE Top

Update on imaging and anti-VEGF therapy for diabetic retinopathy Highly accessed article p. 98
Sagnik Sen, Sobha Sivaprasad
DOI:10.4103/kjo.kjo_65_22  
The classification of diabetic retinopathy has been based on 7-field photographs. With advances in retinal imaging, there is an unmet need to reclassify this condition as new predictive factors have been identified in the peripheral retina. In addition, we have transitioned from an era of laser treatment for vision-threatening complications to robust evidence that anti-VEGF therapy can modulate the diabetic retinopathy scores. In this review, the literature on both retinal imaging and role of anti-VEGF on diabetic retinopathy highlights both the merits and shortcomings of available evidence in this area.
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ORIGINAL ARTICLES Top

Comparative evaluation of the thickness of macula, ganglion cell layer, and retinal nerve fiber layer in emmetropes, myopes and myopes with lattice degeneration by using Cirrus high-definition optical coherence topography p. 104
Mamta Singh, Bibhuti Prassan Sinha, Pradeep Karak
DOI:10.4103/kjo.kjo_138_21  
Purpose: To know the quantitative thickness changes occurring in the macula, retinal nerve fiber layer (RNFL), and ganglion cell layer (GCL) of the retina in myopic eyes (ME) and in ME with lattice degeneration (ME-LD) in comparison to emmetropic eyes, with the help of Cirrus HD Optical coherence topography (OCT) 5000 (Carl Zeiss Meditec Inc.). Methods: Hospital-based, nonrandomized prospective study involving 90 eyes, divided into three groups – Group A comprising 30 eyes with − 3–−6D of myopia, Group B comprising 30 eyes with − 3–−6D of myopia with LD and Group C with 30 emmetropic eyes. The central macular thickness (CMT), RNFL, and GCL analysis was done with Cirrus HD OCT 5000 (Carl Zeiss Meditec). Results: The CMT was significantly higher in Group A and B than Group C. There was no significant difference in CMT between Group A and B. Any of the group did not reveal significant difference in parafoveal thickness in any quadrant. Average RNFL, average GCL + inner plexiform layer (IPL), minimum GCL + IPL was significantly thicker in Group C than Group A and B. There was no significant difference between in CMT, average RNFL thickness, average GCL + IPL between Group A and B. Conclusion: There is a significant change in thickness of macula, RNFL, and GCL between emmetropes as compared to myopes and ME-LD but not between myopes and ME-LD. This underscores the need of incorporating a myopic normative database in the present normative built-up of Cirrus OCT. Patients of ME-LD, when being evaluated on different OCT-based parameters, can be considered the same as the myopic population.
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Role of teachers in screening of ocular disorders in school children: A multistage school screening program p. 110
KS Aparna, Resmi Bhaskar, Unnikrishnan Nair
DOI:10.4103/kjo.kjo_213_21  
Purpose: The aim of the study was to find out whether teachers can be introduced as an effective tool in ocular screening of school children and to list out various causes of visual impairment and ocular abnormalities in school children and provide appropriate measures. Method: A multistage school screening program from August to December 2019 in Trivandrum included 33,990 students from 52 schools. Five stages of the study were training of selected teachers, screening by teachers in the school, comprehensive examination by the hospital team in schools, detailed evaluation of referred children in the hospital, and corrective measures by pediatric ophthalmologists in our hospital. A total of 1480 children were selected randomly from the children identified as normal by teachers to detect false negatives. The pattern of ocular disorders children was analyzed. Results: Out of 33,990 students, 6343 students who were detected to have ocular disorders by teachers (18.6%) were examined by our team. 74.2% (4707 students) of them were confirmed to have ocular problems. Thus teachers were able to identify the eye problems correctly (true positives) in 74.2% children, 25.8% being false positives. True positives include refractive errors (73.4%), allergic conjunctivitis (7.9%), strabismus (1.9%), amblyopia (0.098%), pediatric cataract (0.08%), etc. Out of 1480 randomly selected children, 8 (0.54%) children were false negatives (none had refractive errors). Spectacles were given to 2484 children free of cost. Conclusion: Simplicity of multistage screening, ease of its application, time and cost effectiveness, wider coverage, utility as a continuous process in coming years signifies that introducing teachers as primary vision screeners at their schools is an innovative community-based strategy to address the challenges of childhood blindness in resource-constrained settings.
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Outcome of cataract surgery with 1 h of preoperative antibiotic regimen: A strategy during COVID-19 Pandemic: Study from a tertiary eye care hospital p. 115
Sasikala Elizabeth Anilkumar, Navaneeth Saggam, Madhuri Thotakura, Ram Rammohan, Kalpana Narendran
DOI:10.4103/kjo.kjo_190_21  
Purpose: This study aims to describe the visual and surgical outcomes of 810 eyes of 805 patients who underwent unilateral cataract surgery on the same day with 1 h of preoperative antibiotic regimen. Setting: Tertiary Care Ophthalmic Hospital. Design: Retrospective, descriptive study. Methods: This study comprised of consecutive adult patients who underwent preoperative cataract work up, received 1 h of preoperative antibiotic regimen, and underwent cataract surgery on the same day of consultation with a minimum 3-week follow-up period. This study describes the demographic profile, preoperative, intraoperative details, postoperative (PO) best-corrected visual acuity (BCVA), and surgical outcomes of these patients. Results: 810 eyes of 805 patients with a mean age of 61.0 ± 9.7 years, 50% had systemic and 9% had ocular comorbidities. The mean preoperative BCVA was 0.8 ± 0.7 LogMAR. Phacoemulsification was performed in 90.1%. Intraoperative complications had occurred in 8 (1%) eyes. The mean PO BCVA of the study group on PO day 1 (POD1) and PO 3 weeks was 0.13 ± 0.3 LogMAR and 0.07 ± 0.3 LogMAR, respectively. Our study showed that 95.68% had improvement in vision, while 96.8% achieved BCVA 6/18 or better. None had PO endophthalmitis. Comparison between preoperative and both POD 1 day and PO 3-week BCVA showed statistically significant improvement (P < 0.001). Conclusion: Our study results satisfied the benchmark set by the World Health Organization (WHO) for PO BCVA with good surgical outcome. Preoperative antibiotic applied 1 h before cataract surgery provided safety and comfort and with low risk for endophthalmitis. This strategy can be adopted to tackle the backlog of cataract surgeries due to COVID-19 (or any other emergency situation) in developing countries.
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Etiology of permanent visual impairment among persons attending a disability board in Central Kerala p. 123
Sinumol Sukumaran, Nandini Varma, N Sujatha, T Devu Krishna
DOI:10.4103/kjo.kjo_205_21  
Introduction: Permanent visual handicap is one of the most troublesome disabilities to affect an individual, a family, and a society. Objectives: To determine the important etiological factors leading to permanent visual impairment (VI) in Kerala and their frequency trends over the recent years. Materials and Methods: Retrospective study of case records of the medical board of a government medical college hospital in Kerala from 2017 to 2020. Inclusion Criteria: Data of all individuals with permanent VI of categories 1 to 4. Exclusion Criteria: Category zero of permanent disability. The guidelines included under the Rights of Persons with Disabilities Act, 2016 were followed for assessing the extent of visual disability. The age, gender, place, diagnosis in the right eye, diagnosis in the left eye, and percentage of disability were entered in an Excel spreadsheet and analyzed by SPSS software (version 20.0). Results: Data of 545 persons were analyzed. The mean age ± SD was 36.21 ± 17.70 years. Most of the study population were males (n = 348, 63.85%). The most frequent etiological factors noted are congenital malformations of the eye (20.18%), high myopia (14.13%), corneal blindness (13.58%), trauma (11.56%), optic atrophy (10.46%), retinitis pigmentosa (7.34%), and advanced diabetic eye disease (3.85%). 50% of factors were preventable and nearly 50% were causing progressive worsening of disability. Conclusion: There is a slowly increasing proportion of congenital malformations, congenital cataracts, and glaucoma. Corneal blindness showed a decreasing trend.
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The consequences of dermis fat graft in the reconstruction of anophthalmic socket with large orbital implant exposure p. 130
Titap Yazicioglu
DOI:10.4103/kjo.kjo_34_21  
Purpose: To present our results of dermis-fat graft as a secondary procedure after implant extrusion. Materials and Methods: A retrospective chart review was performed to examine 34 anophthalmic socket carriers undergoing dermis-fat graft. All patients had a history of ocular trauma and underwent evisceration surgery. Small defects and Grade 5 contracted sockets were not included. The patients reported the complaints of pain and discharge. Data were collected on the characteristics of the exposed implant material and surgical technique used for implant insertion; complications related with dermis-fat graft, cosmesis; and functional results such as the ability to hold an external prosthesis. For socket reconstruction, the graft was taken from the lateral upper quadrant of the gluteal region, 30% larger than the orbital defect. The mean follow-up period was 12.26 ± 1.13 months. Results: Of the 34 patients, 26 had porous polyethylene implants and 8 had acrylic implants. The average diameter of the conjunctival defect with scleral melting was 11.6 mm. The findings encountered in the follow-up of patients who underwent socket reconstruction with dermis-fat graft were as follows: graft necrosis in one patient, reduction in graft size in two patients, insufficient vascularization of the graft in one patient, ptosis in two patients, deep superior sulcus in one patient, cysts over the dermis-fat graft in one patient, and necrosis at the donor site in two patients. Except for two patients with fornices shrinkage, all of them used their ocular prosthesis well. Conclusion: Dermis-fat graft with low complication rate is a good option for anophthalmic socket reconstruction, but care of the donor site should not be neglected.
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Comparative study of sutureless and glue-free versus conjunctival autograft with sutures in primary pterygium surgery p. 137
K Jipina, NV Latha, Sikha Radhakrishnan, KK Praveena, AV Asha
DOI:10.4103/kjo.kjo_79_21  
Context: Sutureless glue-less surgery (SGF) is a newer alternative to the conventional conjunctival autograft with sutures (CAGS) techniques used for pterygium surgery. Aims and Objectives: To compare the safety, efficacy, and complications of SGF technique versus CAGS in the management of primary pterygium. Subjects and Methods: We performed a hospital based prospective study among 46 patients who underwent pterygium excision during an 18-month period from 2017 to 2018. Results: The duration of SGF procedure was <15 min with fewer incidences of overall symptoms postoperatively (P < 0.001) which were significantly higher in the CAGS group. The duration of symptoms was 4 days for SGF and 4 weeks for CAGS group. Although signs like graft edema and retraction were more in the SGF group in the immediate postoperative period, it resolved by 6 weeks. Three cases of recurrence were noted in the SGF group, but this was statistically insignificant. No graft loss occurred. Paired t-test showed that there is a significant reduction in astigmatism and improvement in keratometric values in both groups, with greater change in SGF group, however, this was not statistically significant. Conclusion: Sutureless and glue-free technique is a safe, effective, time-saving, and economical option for the management of pterygium with less postoperative symptoms. SGF has more postoperative signs which resolved in 6 months. The recurrence rate was higher in SGF but within the expected range reported in the literature.
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The incidence of retinopathy of prematurity and the common risk factors associated with it: A retrospective study in a tertiary care center in Central Kerala p. 144
Deepa Molathe Gopalan, Manju Abraham, VS Dhanya, Reshmi Ramachandran, Adeline Liza Roy
DOI:10.4103/kjo.kjo_73_21  
Aim: The aim of this study is to determine the incidence and risk factors for retinopathy of prematurity (ROP) among newborn babies screened at a public sector teaching hospital in Central Kerala. Materials and Methods: A retrospective case record-based study that included all newborns screened at the study center from May 2015 to May 2017. Newborn babies with significant media opacities and missing data were excluded from this study. A detailed ophthalmic assessment was done and association of ROP with maternal and perinatal risk factors was assessed. Results: Thirty-nine (6.9%, 95% confidence interval [CI]: 5.02, 9.23) of the 565 newborns screened at the department had ROP. This included 14 (2.48%) babies with Stage 1, 17 (3.01%) babies with Stage 2, and 8 (1.42%) babies with plus disease. Placenta previa or abruption (odds ratio [OR] 3.72, 95% CI: 1.32, 10.52), Respiratory distress syndrome (OR: 2.05, 95% CI: 1.05, 4.01) and hyaline membrane disease (OR: 4.19, 95% CI: 1.96, 8.99), a birth weight <2500 g (adjusted OR: 5.06, 95% CI: 1.20, 21.32) were associated with ROP. The risk of ROP reduced significantly with every unit increase of birth weight in a linear regression model (coefficient = ‒511.5, R2 = 0.03). Conclusion: The incidence of ROP is lower in this study population compared to reports from other areas of India. The significant associations with birth weight and gestational age are important as global preterm births are increasing and may possibly lead to an epidemic of ROP More ophthalmologists must be trained in the management of ROP and integrated with neonatal intensive care services.
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Falling prey to superglue ocular injuries: A case series p. 149
Agrima Bhatia, S Mohan, Sridhara Reddy
DOI:10.4103/kjo.kjo_20_22  
Aim: Cyanoacrylate synthetic glue is an instant acting adhesive material often used for household, biomedical and industrial requirements. Accidental instillation of glue into eyes seems to be the commonest mode of chemical eye injuries especially in the paediatric and geriatric population. Methods: A series of five cases of synthetic glue eye injuries following accidental instillation into eyes that presented to our hospital were reported. Results: All the cases were managed conservatively as per the current guidelines with good visual outcome. Conclusion: These case series highlight how even daily activities utilizing the superglue may result in unexpected serious eye injuries. Creating awareness and provision of immediate medical aid can prevent ocular morbidity in such eye injuries.
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CASE REPORTS Top

A case of cerebellar stroke/Wallenberg syndrome postx-COVID-19 infection p. 154
Roopashri Lakkundi, Himani Manral, Manasi More, Harsha Sameer Pagad
DOI:10.4103/kjo.kjo_11_22  
Stroke has been reported as one of the several deadliest complications noted in COVID-19 infection. Stroke in COVID-19 is multifactorial and has propensity to involve large vessels and multiple territories. The most appealing mechanisms for strokes in COVID infection are the cytokine-induced coagulopathy and the endotheliopathy triggered by the infection. Stroke in young patients has been particularly observed. The treatment is also challenging in terms of judicious use of antithrombotic/anticoagulation agents concomitant to oral or intravenous steroids administration. We report a case of cerebellar stroke/ Wallenberg syndrome in a diagnosed COVID-19 patient with deranged coagulation profile and elevated interleukin-6. She presented with binocular diplopia, oscillopsia and had a very well documented skew deviation with torsional nystagmus. She also had impaired cerebellar functions. We also highlight the characteristic features of COVID stroke, its management, and shed light on the diagnosis of skew deviation and its management.
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Peripheral ulcerative keratitis with multiple punctate scleral abscess – A rare presentation of ocular tuberculosis p. 157
I Karthiga, Charmaine Bridgette Solomon, Sanaa Mohammed Konnakkodan, V Babitha, A Arun Kumar
DOI:10.4103/kjo.kjo_214_21  
This case report represents an unusual presentation of ocular tuberculosis (TB). Ocular TB is rare, but it can be the first clinical manifestation of the disease. Here, we report a case of a 67-year-old male, a chronic smoker who presented with pain, redness, and photophobia (BE), and slit-lamp examination showed multiple corneal infiltrate along the limbus with multiple scleral abscesses not responding to routine treatment. Investigations revealed high erythrocyte sedimentation rate value, positive Mantoux reaction, and changes on contrast-enhanced computed tomography of the thorax. Sputum CBNAAT was negative, and pus aspirate revealed no growth with negative staining for acid-fast bacillus. With high suspicion of TB, we started on Anti tuberculosis therapy, and there was rapid healing of lesions. In endemic areas, even when microbiological studies are not positive, ocular TB should be kept in mind in atypical cases so that early treatment can be instituted to prevent serious complications.
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Recurrent sphenoid wing meningioma extending into the orbit p. 161
Cherungottil Viswanathannair Radhadevi, Kaplinghat Bhavadasan, Kolady Jayakrishnan
DOI:10.4103/kjo.kjo_30_21  
Sphenoid wing meningiomas are slow-growing tumors that originate from outer arachnoid meningeal epithelial cells. They can present with progressive symptoms of an orbital or temporal fossa mass, including temporal fullness, proptosis, globe displacement, ptosis, and impaired ocular motility. The ophthalmic manifestations of sphenoid wing meningiomas vary depending on the location of the primary tumor. In this case report, we discuss a 52-year-old female with meningioma of unusual presentation which was reported to be removed completely, and recurrence was noticed after a lapse of 3 years with subsequent extension into the orbit resulting in the structural and functional destruction of the eye.
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Off-center presentation of ocular myasthenia p. 164
Mary A Stephen, P Jayasri, PJ Harigaravelu
DOI:10.4103/kjo.kjo_227_21  
Myasthenia gravis is an autoimmune condition with varied presentations. In this, we report a 70 years old diabetic male who came complaining of diplopia. On examination, he had ptosis and restriction of extraocular movements on the right side with bilateral normal pupillary reflexes. We diagnosed him to have diabetic neuropathy initially, however his ptosis worsened, leading us to revise the diagnosis. Ice pack test was positive, repetitive nerve stimulation showed a decremental response, and serum acetylcholine receptor antibodies were positive, confirming the diagnosis of ocular myasthenia. We started the patient on oral pyridostigmine and steroids and his symptoms improved. This report emphasizes the need for a high degree of suspicion for the timely diagnosis of ocular myasthenia gravis.
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Vision “wipe-out” phenomena following a nonincisional laser procedure in the management of narrow-angle glaucoma p. 167
Irshad Ahamed Subhan, Ismail A Bantan, Waleed M Alkhuraimi, Taha Alaidaroos, Ahmed M Abdelaal
DOI:10.4103/kjo.kjo_171_21  
The “Wipe-out” or “Snuff-out” phenomenon refers to a permanent and severe loss of vision without an identifiable cause and is considered a rare but dreaded consequence of incisional ocular surgery. It is believed to occur in patients with advanced glaucoma who demonstrate a residual central island of vision. A 42-year-old female patient presented to the general ophthalmology clinic with complaints of painless blurring of vision of the left eye for 8 months. Best-corrected visual acuity (BCVA) was 20/30 and 20/40 and intraocular pressure (IOP) was 26 mmHg and 28 mmHg in the right and left eyes, respectively. Relative afferent pupillary defect was noted in the left eye. Anterior segment examination showed peripherally shallow anterior chamber and gonioscopy revealed appositionally closed angles (Shaffer-<20 Deg) in both eyes. Fundus examination showed advanced glaucomatous optic neuropathy of the left eye. Generalized depression in the right eye and inferior arcuate scotoma with a superior nasal step, and split fixation in the left eye was seen on Humphreys 30-2 visual fields. A diagnosis of chronic primary angle closure glaucoma was made and the patient was offered Nd: Yag Laser Peripheral Iridotomy (LPI). LPI was completed for the right eye and Argon Laser Iridoplasty was performed in the left eye as Iridotomy was not possible due to the proximity of the iris to the cornea as the pupil was mid-dilated. After the procedure, the patient was prescribed topical antiglaucoma medications with topical steroids at 1 week follow-up, the patient had BCVA of 20/30 in the right eye and hand motion in the left eye, IOPs were well controlled on topical anti-glaucoma medication. A thorough examination including a dilated fundus examination, B-Scan ultrasound, and fundus fluorescein angiography were unremarkable. Magnetic resonance imaging scan of the brain and orbits was normal. “Wipeout” phenomenon is a rare but notorious complication associated with incisional surgeries in patients with advanced glaucoma. It is also reported to occur following cataract and retinal incisional surgeries. There are no reports of a wipe-out after a commonly performed laser procedure.
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Identifying the white forelock for early visual stimulation and speech therapy among X-men (van der Hoeve-Halbertsma-Waardenburg syndrome) in ophthalmology p. 171
Shruthy Vaishali Ramesh, Prasanna Venkatesh Ramesh, Ramesh Rajasekaran, Meena Kumari Ramesh
DOI:10.4103/kjo.kjo_40_21  
A day-old male neonate presented with white forelock on his forehead. On evaluation, the neonate had telecanthus, broad nasal bridge, and surprisingly homochromic but hypochromic irides bilaterally. The W-index was 2.38 which was an indication of Type 1 Waardenburg syndrome (WS) with dilated fundus evaluation revealing pigmentary deficit in the retina depicting a orangish hue. The corneal diameter was 9 mm in both eyes. Both the external auditory meatus and external ears appeared normal. The parents who had a history of second-degree consanguineous marriage had visual acuity of 20/20 with normal dark brown irides and normal fundi. Genetic counseling, visual rehabilitation, and auditory evaluation to rule out sensory neural hearing loss were stressed upon for good quality of life, which is mandatory among neonates diagnosed with van der Hoeve-Halbertsma-Waardenburg syndrome.
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PHOTO ESSAY Top

Spectral domain optical coherence tomographic findings in Welder's maculopathy p. 174
Priya Rasipuram Chandrasekaran
DOI:10.4103/kjo.kjo_31_21  
This photo essay shows the spectral domain optical coherence tomographic (SD OCT) findings in Welder's maculopathy. A 34-year-old welder presented with metamorphopsia and a best-corrected visual acuity of 20/30 N8 in both eyes, respectively. Fundus examination showed absent foveal reflex and revealed orange-red spot surrounded by a pigmentary halo. The corresponding SD OCT showed a rectangular-shaped solitary hyporeflective space called the outer retinal hole. The hole extends from the inner layer of the retinal pigment epithelium to external limiting membrane, which in turn corresponds to inner segment/outer segment photo receptor junction (IS/OS). The straight edges of the hole and the top surface at the level of IS/OS junction line are lined by hyperreflective material. Central subfield thickness was 205 μm and 209 μm, respectively. SD OCT findings were similar to photic/solar maculopathy.
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Bilateral lens coloboma in child with Marfan's syndrome treated with lens surgery p. 176
Sandra C Ganesh, Krishnababu , Sasikala Elizabeth, Jogitha
DOI:10.4103/kjo.kjo_120_21  
Lens coloboma can occur with ocular or systemic associations like Marfan's and Stickler's syndrome. Causes of poor vision include refractive error, anisometropia and amblyopia. Visual rehabilitation and surgery is technically challenging in these patients. Here we report a child with progressive defective vision with Marfans syndrome and lens coloboma who underwent successful surgery with intraocular lens (IOL) placement. The bag was stabilised with capsule tension ring and iris hooks, and the IOL was further stabilised with optic capture. Postoperatively, the child regained good vision in the operated eye with very good centration of the IOL at three month follow up visit.
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STATISTICS CORNER Top

Statistical analysis of quantitative and qualitative variables—A quick glimpse p. 178
Sandhya Somasundaran
DOI:10.4103/kjo.kjo_37_22  
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JOURNAL REVIEWS Top

Effect of cataract surgery on wet age-related macular degeneration activity p. 182
K Husna
DOI:10.4103/kjo.kjo_31_22  
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Effects of Lipiflow treatment prior to cataract surgery: A prospective, randomized, controlled study p. 184
K Husna
DOI:10.4103/kjo.kjo_30_22  
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PG CORNER Top

Supranuclear and internuclear ophthalmoplegia - Gaze palsy p. 186
Cyril Mathew George, Padmaja Krishnan, Ashwati Sankar
DOI:10.4103/kjo.kjo_79_22  
Gaze palsy is the loss of binocular control because of lesions of the pathways above the level of the nucleus.[1] To localize the lesion, an understanding of the supranuclear and internuclear pathways is necessary.
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LETTER TO THE EDITOR Top

Atypical presentation of multiple sclerosis – A few points to ponder p. 191
Anisha T Augustin
DOI:10.4103/kjo.kjo_85_22  
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