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   Table of Contents - Current issue
January-April 2022
Volume 34 | Issue 1
Page Nos. 1-88

Online since Thursday, April 21, 2022

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KJO and the Ophthalmologists of Kerala Highly accessed article p. 1
Smita Narayanan
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Ushering in the era of MIGS in India Highly accessed article p. 3
Vanita Pathak-Ray
Incisional filtration surgery with bleb formation has been the mainstay of glaucoma surgery for decades and is particularly useful in progressing or advanced glaucoma. However, the flipside of these procedures is the sight-threatening complications that may occur. Minimally Invasive Glaucoma Surgery has made in-roads in the past two decades – these are known to be high on the safety aspect and therefore can be used much earlier on in the disease spectrum. Some of these relatively new devices and procedures are now available in India also.
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How to minimize litigations and medical malpractice claims during ophthalmic practice? Highly accessed article p. 8
Suresh K Pandey
The health profession is considered to be one of the noblest professions in the world. While Indian medical infrastructure is being noticed and praised on the global map, on the contrary, the doctor-patient relationship is deteriorating, our internal medical setup is facing extensive problems with consumer cases/medical litigation fast becoming one of the most serious of all issues. The number of cases against ophthalmologists for malpractice is increasing. While very few cases may be legitimate and based on clinical negligence exercised by the doctors, most medical professionals are wrongfully accused because of the lack of public understanding. The eye care professionals must communicate empathetically, emphasize diligent service delivery and also maintain proper records about the patient history, examination, consent, treatment and follow-up, and referral. Eye camp surgery should be done only in the operation theater of the hospital set up and the permissible number of cataract-IOL surgery can be done following all checklist/protocols and precautions. Lawsuits for medical negligence in ophthalmic practice can be minimized or avoided by following surgical checklists, protocols, proper documentation (maintaining medical records), taking informed consent, communication about the cost and outcome of the procedure or treatment, timely referral of the patient (in case of any complication), and obtaining adequate professional liability insurance.
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Refractive Corneal surgeries: A Review Highly accessed article p. 12
Jyothi Vengalil Menon
Refractive corneal surgeries are procedures for correction of refractive errors. Modern keratorefractive procedures include laser in situ keratomileusis, surface ablation, relatively newer refractive lenticule extraction, and corneal inlays. This article aims to present an overview of currently performed refractive corneal procedures. Basic aspects of patient selection, principles, advantages, limitations, complications, and clinical outcomes are discussed.
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Dense fibrin membrane mimicking anterior dislocated lens p. 19
Shivraj Tagare, Harsh Vardhan Singh, Iva Rani Kalita
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Atropine in myopia – Does it reduce progression? Results of Phase 1 clinical trial in children attending a tertiary eye care center in South India p. 21
R Neena, Ayshathu Nasheetha, Nimmy Prakash, Anantharaman Giridhar
Aim: The aim of this study was to analyze the effectiveness of low-dose atropine (0.01%) in reducing the progression of myopia in Indian children. Materials and Methods: This was a clinical trial of Indian children with axial myopia from January 2018 to May 2019, who were prescribed low-dose atropine (0.01%) to reduce progression. Parameters studied before and after starting low-dose atropine were as follows: visual acuity for distance and near, cycloplegic refraction, ocular alignment for distance and near, near point of accommodation (NPA), near point of convergence, axial length (AXL), pupil diameter (PDM), lens thickness (LT), anterior chamber depth (ACD), adverse reaction, compliance, and dropouts. Patients were evaluated at the initiation of treatment, at 1 month, and thereafter 6 monthly with a minimum follow-up of 6 months. Any increase in spherical equivalent (SE) of myopia was taken as progression and rapid progression of myopia was considered if there was a ≥0.5 DS increase in SE of myopia within 6 months. Results: Seventy-one eyes of 36 children who opted for low-dose atropine (18 males and 18 females) and 37 eyes of 19 age-matched children (10 females and 9 males) were included in the final study and control groups, respectively. The mean age was 8.31 years (standard deviation [SD] =1.191) in the cases compared to 9.68 years (SD = 3.606) in the controls. Progression of myopia was noted in 40 eyes (56.338%) in the study group as compared to 35 eyes (94.59%) in the control group (P = 0.00). Rapid progression was noted in 23 eyes (32.39%) in the study group as compared to 23 eyes (62.16%) in the control group (P = 0.003). The mean SE of myopia increased by 0.28 D (as compared to 0.63 D increase among the controls) (P = 0.01), and the mean AXL increased by 0.14 mm (as compared to 0.25 mm among the controls) in the study group at the end of 6 months (P = 0.01). There was also a statistically significant increase in mean PDM by 0.83 mm (P = 0.01) and receding of mean NPA by 1.14 cm in cases (P = 0.03). However, these changes were clinically insignificant. No significant changes were noted in ACD, LT, NPC, and ocular alignment. No adverse reactions were reported. Conclusion: Low-dose atropine (0.01%) therapy was able to reduce the progression of myopia in the study group as compared to the controls with a good tolerance and no change in the vision-related quality of life. Long-term follow-up is, however, needed for extrapolation into the general population.
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Agreement of gonioscopy and anterior segment-optical coherence tomography in the assessment of the anterior chamber angle: A cross-sectional study p. 27
K Jaseena, PS Rekha
Purpose: The aim of the study was to evaluate the inter instrument agreement between gonioscopy and anterior segment optical coherence tomography (AS-OCT) in the assessment of the anterior chamber angle (ACA) in eyes with all Van Herick's grades. Methods: A single examiner performed AS-OCT and gonioscopy with a Goldman single mirror for all study patients. An angle opening distance at 500 μm from the scleral spur in the AS-OCT was considered as the quantitative parameter to assess the ACA. A closed ACA on AS-OCT was defined by the presence of any contact between the iris and angle wall anterior to scleral spur. The agreement between gonioscopy and AS-OCT of the nasal and temporal angles was estimated using the Kappa statistic and the concordance between the instruments using the Lin's concordance coefficient. Results: The mean age of the seventy participants in the study was 52.11 ± 5.37 years. Five (15.15%) of nasal angles and 4 (12.12%) of temporal angles identified as closed by gonioscopy were called as open by AS-OCT. The Kappa statistic (0.59), pairwise correlation (0.60), and Lin's concordance correlation coefficient (0.59) showed only moderate agreement and concordance between AS-OCT and gonioscopy. AS-OCT had a moderate sensitivity (73%) and better specificity (86.4%). Conclusion: The results of our study show that AS-OCT can be used as a clinical diagnostic test but has limited use as a screening test for ACA. The significant proportion of subjects with a mismatch in the categorization of open and closed ACA and the moderate agreement highlights the need for better objective diagnostic criteria for closed ACA.
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Demographical and etiological diagnosis of infective corneal ulcer in a tertiary care center in West Bengal: A cross-sectional study p. 32
Garvita Joshi, Pinaki Sengupta, Anindya Gupta
Purpose: The purpose was to study the demographical factors and microbial etiology associated with infective keratitis in a tertiary care center in West Bengal. Materials and Methods: In this cross-sectional study, 142 patients with suspected microbial keratitis were enrolled from June 2019 to May 2020. After taking the history and diagnosing the infective ulcer clinically, the corneal scrapings and cultures were evaluated. The smears were fixed with Gram stain and 10% potassium hydroxide wet preparation. The scrapped material was inoculated in blood agar and Sabouraud dextrose agar for culture. Results: Ocular trauma was the most common predisposing factor in 94 (70.6%) corneal ulcers (P < 0.0001). The most common etiologic agent causing corneal injury was wooden object (38.3%). Microbial etiology was established in 76 (53.52%) corneal scrapings. Out of the total culture-positive cases, 45 patients (31.7%) had pure fungal infections, 25 patients (17.6%) had pure bacterial infections, and 6 patients (4.2%) reported mixed infections. Among the fungal pathogens, Aspergillus species was the most common fungal isolate (29 cases, 56.8%), followed by Fusarium species (17 cases, 33.3%) and Candida species (5 cases, 9.8%). The most common bacterial isolate was Staphylococcus aureus (16 cases, 51.6%), followed by Pneumococcus species (7 cases, 22.5%). Conclusion: Trauma with wooden material was the most common predisposing factor for infective keratitis. Fungal ulcers predominated in the study findings. Aspergillus species and S. aureus were the most common fungal and bacterial isolates, respectively. Regional variations exist in the microbial etiology of infective keratitis.
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Factors associated with poor prognosis in corneal ulcer: A clinical and epidemiological study p. 37
Mini Mathew, AR Arya, Ajith Cherian
Aim: To explore the factors associated with culture positivity and worsening of corneal ulcers in patients presenting to a tertiary care teaching hospital in south Kerala. Methods: We did a retrospective review of hospital-based case records from June 2018 to May 2019 and included all cases of infective corneal ulcer admitted during the period of study with corneal stromal infiltrate on slit-lamp examination. Results of gram stain, potassium hydroxide stain, and culture result were noted. The treatment history (moxifloxacin (0. 3%) or fortified cephalosporin and gentamicin or natamycin) was recorded. The data were exported to the statistical software SPSS V27.0 for further analysis. Results: The data of 125 culture-positive and 250 culture-negative ulcers were studied. Most patients were aged >55 years (n = 201, 53.6%) and 35–55 years (n = 120, 32.0%). The association of culture negativity with nontraumatic risk factors was significant (P = 0.01) but not with the size of the ulcer, progress score, or worsening clinical status of the ulcer. More persons with pretreatment (15.2%) showed worsening of the clinical status compared to those who did not (6.3%) (P = 0.005). 63% of the culture-positive cases had not taken any pretreatment. Compared to noncentral ulcers there was a marked deterioration of central ulcers (16.7%) (P = 0.005). Conclusion: Pretreatment and centrally located ulcers were significantly associated with a worsening clinical condition in this study. Culture-positive corneal ulcers showed a tendency toward improvement, but we could not find an association between the detection of the organism and its favorable response to treatment.
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A study on ocular symptomatology and clinical profile of coronavirus disease-19 positive patients admitted at a tertiary care institute in South India p. 42
Shruthi Bidari, Roshni Robert, B Abhilash, Mahesh Babu, MS Mashitha
Purpose: To study the ocular symptomatology and clinical profile of coronavirus disease-19 (COVID-19) positive patients admitted at a tertiary care institute. Methods: This cross-sectional, observational, and descriptive study was conducted on 200 reverse transcriptase-polymerase chain reaction positive confirmed COVID-19 patients in a tertiary care institute from September 2020 to October 2020. Ocular and systemic history was collected from the patients, clinical findings and investigation values were noted and analyzed. Results: Out of 200 COVID-19 positive patients in our study, 54% of the patients were graded as mild COVID-19 cases, 34% of the patients were graded as moderate, and 12% of the patients were graded as severe COVID-19 cases. The prevalence of ocular symptoms was 10.5%. Burning sensation of the eyes was the most common ocular symptom. A higher occurrence of ocular symptoms was observed in febrile patients and it was found to be statistically significant. The ocular symptoms worsened with a rise in temperature. Conclusion: Our study reveals that in COVID-19 positive patients, the most common systemic symptom was fever and the most common ocular symptom was burning sensation. In most of the cases, ocular symptoms appeared before or with the appearance of systemic symptoms. Most ocular symptoms were either mild or moderate grade. Ocular symptoms were higher in febrile patients with the severity increasing during febrile period in most patients. With this, we need to consider all patients coming to the outpatient department with complaints of burning sensation of eyes, eye pain and red eye as possible COVID-19 cases, and do due diligent workup.
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Spectrum of herpetic eye disease during COVID-19 pandemic p. 47
Shruti Bhat, Pallavi Joshi, Anand Balasubramaniam, Yash Gala
Purpose: To analyze clinical presentation, outcome and upsurge in the acute presentation of Herpetic eye disease (Herpes simplex keratits and Herpes Zoster Ophthalmicus) cases during coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: Retrospective analysis of case records of patients diagnosed with either acute HSV or HZO from April 2020 to March 2021 for demography, ocular manifestations, and management and clinical outcome was done. Results: We had 71 patients presenting to our hospital with herpetic eye disease with 50.70% being HZO. The majority (64.78%) of the patients were <50 years of age. The mean time to presentation from the onset of symptoms was earlier in HZO compared to HSV. Three patients were post-COVID-19 infection while six patients were post-COVID-19 vaccination. Stromal keratitis (48.5%) was the most common presentation in patients with HSV while keratitis and uveitis (31.57% each) were the most common presentation in HZO. 83.08% resolved without any visual sequelae. We also observed atypical presentation in the form of multidermatomal involvement and recurrence of keratitis in HZO patients. We observed an alarming two-fold increase in the number of cases that presented this year (2020–21) as compared to the same time (n = 33) in the past year (2019–20). Conclusion: This study highlights an increase in viral eye disease presenting atypically and higher incidence in young individuals during the COVID pandemic. Viral disease of the eye during the pandemic may be related to the altered immunity in coexisting asymptomatic COVID-19-infected patients and similar in postvaccinated individuals or the stress-induced immune alteration by the pandemic itself in healthy individuals. However, though this study suggests direct causal relation of either of the above as possibility and needs to be kept in mind in clinical practice, for definite association, we need further exploration and more data.
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Neuro-ophthalmic manifestations of central nervous system tuberculosis: Compilation of three diverse unique presentations p. 51
Harsha Sammer Pagad, Rishwa Hariyani, Akash Jain, Nita Shanbhag
Tubercular meningitis is the most devastating form of tuberculosis. Neuro-ophthalmic involvement can manifest as cranial nerve palsies, pupil abnormalities, disc changes, like papillitis, papilloedema, or optic atrophy and choroidal tubercles. The rate and extent of recovery are strongly. Related to early diagnosis and treatment. Herein, we describe a constellation of three cases of central nervous system tuberculosis with aberrant regeneration of oculomotor nerve, optochiasmatic arachnoiditis presenting as bilateral primary optic atrophy and the last case of parietal lobe tuberculoma presenting as homonymous hemianopia, each one with its own characteristic ocular findings.
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Ethambutol-induced optic neuropathy: A case series p. 55
Anna Elias, R Neena, A Giridhar
In this observational case series, we describe the clinical features and investigations of three patients with ethambutol-induced optic neuropathy (EION). All three patients had a significant visual loss within 3 months to 1 year of starting antitubercular treatment. Visual field examination revealed bitemporal hemianopia in one patient and central scotomas in another. Optical coherence tomography showed significant global thinning of the ganglion cell layer and thinning of the temporal quadrants of the retinal nerve fiber layer. Visual evoked potential revealed prolonged P1 or P2 latency and reduced amplitude in all three patients. Ethambutol was stopped in all three patients. The visual acuity continued to deteriorate even after stopping the drug but showed gradual improvement over a period of one and a half years. However, the visual recovery was not full in all three patients. Considering the severity and partially irreversible nature of the loss of vision caused by EION, it is imperative to detect it at an early and subclinical stage.
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Custard apple-induced toxic keratopathy p. 62
R Sruthi, GS Kalaimathi, Vinay S Pillai
Custard apple seeds are a natural remedy for head lice. We report a case series of three patients with ocular exposure to custard apple seeds. All three developed toxic keratopathy which was treated with topical antibiotics and soft steroids and they responded well to the treatment. This report is intended to increase the awareness in this regard.
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A rare case of Vogt–Koyanagi–Harada disease presenting simultaneously with pituitary macroadenoma p. 65
Pradeep Kumar Panigrahi
A 45-year-old female presented with sudden painful loss of vision in both eyes of 1-week duration. Clinical findings and imaging studies suggested Vogt–Koyanagi–Harada (VKH) disease. She was started on systemic steroids. Nonresolution of periocular pain and presence of color vision defects prompted us to do neuroimaging study which detected a pituitary macroadenoma. The patient underwent surgical removal of the mass lesion. There was a complete resolution of VKH features with systemic steroids.
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Case of multiple sclerosis presenting as unilateral internuclear ophthalmoplegia p. 68
Aishwarya M Angadi
A 30-year-old female presented with complaints of decreased vision and diplopia since 1 week along with headache and gait disturbances. Examination revealed medial restriction of ocular movements in the right with left abducting nystagmus suggestive of right-sided internuclear ophthalmoplegia and right-sided facial palsy. The patient was admitted under neurology as a suspected case of demyelinating disorder. Magnetic resonance imaging with gadolinium contrast revealed features suggestive of probably multiple sclerosis (MS). The patient was given 5 days of high-dose intravenous steroids following which the patient showed improvement and was discharged on multivitamins. Subsequent follow-up showed significant improvement in symptoms, visual acuity, and ocular movements. Hereby presenting a rare case of MS presenting as unilateral internuclear ophthalmoplegia.
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Pachychoroid disease mimicking pattern dystrophy p. 71
Soman Manoj, Sameer Iqbal, Padmanaban Meleth, R Unnikrishnan Nair
We report a case of pachychoroid disease with bilateral vitelliform lesions simulating pattern dystrophy. One eye showed spontaneous resolution of the deposits, while the other eye demonstrated recurrent deposition with onset of choroidal neovascular membrane over a 3-year follow-up. The purpose of this manuscript is to highlight the importance of multimodal imaging which would help us to differentiate mimics of pattern dystrophy.
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A white daisy on intraocular lens p. 74
Prateek Jain, Pooja Sah, Anshuman Pattnaik
We report two patients with precipitation of Pseudo-exfoliative material (PXF) material on intraocular lens (IOL), a rare entity, years after uneventful cataract surgery. The PXF material was present on the anterior surface of the IOL optic in a characteristic radiating spoke-like manner, a pattern resembling shape of a white daisy flower. Emphasis is given on differentiating features between PXF deposition on natural lens and PXF deposition on IOL. Furthermore, how opacification of IOL is different from PXF on IOL is briefly explained. In the first case, PXF deposits were not found elsewhere except on anterior IOL surface and in the second patient, pupillary involvement was also noted along with settling on IOL optic. The fellow eyes in both the patients did not have PXF. PXF on IOL is a vital sign and should not be overlooked as it can be the only clue warranting thorough glaucoma evaluation.
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Variables and risk p. 76
Smita Narayanan
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Journal Review p. 79
Aishwarya Sadanand
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Journal Review p. 81
Allen Mathew
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Corneal biopsy p. 84
RB Radhika Krishnan
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Dilemma of diagnostic criteria p. 87
Anubhav Chauhan, Deepak Kumar Sharma
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Continuing the service despite the pandemic: Ocular surgery on a COVID-19 patient p. 88
Karthikeyan Mahalingam, Somya Kumari, Monika Arora, Ramanjit Sihota
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