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   Table of Contents - Current issue
Coverpage
May-August 2021
Volume 33 | Issue 2
Page Nos. 107-238

Online since Saturday, August 21, 2021

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EDITORIAL  

Original research or research waste? Highly accessed article p. 107
V Sudha
DOI:10.4103/kjo.kjo_110_21  
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GUEST EDITORIAL Top

Eye care in India– past, present, and future Highly accessed article p. 109
Cherungottil Viswanathan nair Radhadevi
DOI:10.4103/kjo.kjo_158_21  
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PERSPECTIVES Top

Retinopathy of prematurity: Current status, treatment, prevention, and future directions from the perspective of developing countries Highly accessed article p. 112
Eduardo Camacho-Martinez, Karla Torres-Navarro, Mayra Narvaez-Albarracin, Iryna M Kuzhda, Marco Antonio Ramirez-Ortiz
DOI:10.4103/kjo.kjo_154_21  
Retinopathy of prematurity (ROP) is the leading cause of preventable blindness in pediatric population living in developing countries. Increasing survival rates of premature patients have been globally improving during the last years and this is the main reason of blindness rate escalation secondary to ROP. The advent of intravitreal injections of antiangiogenic agents in therapeutic ophthalmological arsenal has provided an easier and faster way to prevent retinal detachment in this extremely fragile population. In the nearest future, we will witness, how medical science will provide enough scientific evidence to treat properly these patients with the lowest and safest dose of anti-vascular endothelial growth factor intraocular injections with the fewer systemic side effects. Meanwhile, transpupillary retinal laser photocoagulation of the avascular retina will remain the “gold standard” for ROP treatment, and for sure, this option could also provide a feasible alternative in the future for those cases, where intravitreal injections will fail. Neonatologists and ophthalmologists should keep on working together to fight against children's blindness, synchronizing retinal examinations timing criteria by adequate eye screening. Low- and middle-income countries' health governmental care suppliers should organize suitable programs for providing adequate neonatal care for premature patients and preventing, detecting, and treating effectively ROP. Training and teaching ROP screening and treatment programs are also a responsibility to be taken by local health care authorities and university residency courses for young ophthalmologists. This review describes the situation, state-of-the-art treatment, blindness prevention options from developing countries' viewpoints.
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OPHTHA INSTA Top

Acute traumatic maculopathy p. 123
Shruthy Vaishali Ramesh, Prasanna Venkatesh Ramesh, Meena Kumari Ramesh, Ramesh Rajasekaran
DOI:10.4103/kjo.kjo_116_20  
Traumatic retinopathy may occur secondary to direct or indirect trauma to the globe. Presentation of retinopathy may either be a coup (direct site of injury) and or contre-coup (distant sites including the macula). Commotio retinae in the posterior pole is referred to as Berlin's edema. The fovea is extremely thin, and blunt trauma may cause a full-thickness macular hole by either one or a combination of mechanisms, including contusion necrosis and vitreous traction. Holes may be noted immediately or soon after blunt trauma due to severe Berlin's edema, or after a subretinal hemorrhage caused by a choroidal rupture, or following severe cystoid macular edema, or after a whiplash separation of the vitreous from the retina. Post-traumatic macular holes (TMHs) may be successfully closed with vitrectomy and gas injection. We report a case of blunt trauma leading to Berlin's edema and TMH.
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MAJOR REVIEWS Top

Designing clinical trials p. 126
Smita Narayan
DOI:10.4103/kjo.kjo_51_21  
A clinical trial is the gold standard study design to assess the effectiveness of interventions in health care. Yet, often paradoxically, clinicians find that the benefits of the randomized controlled clinical trial cannot be replicated in an actual clinical practice. A tradeoff between practicality and ideal trial requirements is needed to develop a pragmatic clinical trial. The results of a pragmatically constituted trial are more likely to be acceptable to practicing clinicians. The major steps and requirements and practices for a clinical trial by clinicians are summarized in this article. The PICOT format is a helpful approach to summarize research questions that explore the effects of therapy. Next, depending on the feasibility, the study population is selected by using inclusion and exclusion criteria. The needed sample size is calculated from this representative study population by providing clinical data inputs to a statistician. It is essential that chance, all possible forms of bias and confounding factors are eliminated or balanced between the study groups. This is ensured by randomization, proper allocation concealment, and masking. A clinical trial also needs to pass through relevant review boards and should be ethical. The good clinical practice guidelines throw light on this aspect. Finally, it is very important that a clinical trial is reported adequately such that readers understand the trial's design, conduct, analysis and interpretation, and can assess the validity of its results. The CONSORT guidelines are very useful in this regard.
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Retinal manifestations of COVID-19 disease - A review of available information p. 132
Kaberi Biswas Feroze
DOI:10.4103/kjo.kjo_131_21  
Ocular signs and symptoms have been reported in COVID-19 patients, and there is a surge of information about corneal, uveal, retinal, and neuro-ophthalmological involvement in COVID-19 infection. This review attempts to determine from various researches published during the time of the pandemic, the retinal manifestations of COVID-19 infection, and its significance and correlation to severity of systemic disease. An extensive search strategy was employed using keywords “novel corona virus”, “COVID-19”, “SARS CoV2,” or “retina,” either singly or variably combined, to retrieve the articles of retinal manifestations of COVID-19 published from January 2020 till date. Retinal manifestations are ubiquitous and include microangiopathy, occlusive vascular conditions, alterations in vascular caliber, and capillary density, among others. They seem to correlate with disease severity and reflect on similar changes in other parts of the body as well. Newer studies are bringing out more and more evidence of hitherto unknown retinal manifestations of COVID-19 disease.
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RESEARCH METHODOLOGY Top

Design and development of objective questionnaires p. 139
Praveen K Nirmalan
DOI:10.4103/kjo.kjo_204_20  
Measurements are a fundamental concept in healthcare. Questionnaires are integral to healthcare research and provide healthcare practitioners with objective tools for measurement of several aspects of health care. Questionnaires are developed based on certain contexts and validated for further use in larger populations. The primary goal of questionnaires is to provide valid measures of underlying constructs. The use of inappropriate questionnaires or poorly designed questionnaires affects the quality of data collected and the validity of the study. In this manuscript, we describe issues related to the design and development of questionnaires. These include conceptualization of target constructs and development of item pools, the basic principles of writing the items, formats and derivative versions of questionnaires, and translations. In the second part of this series, we will describe the concepts and process for validation of questionnaires.
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ORIGINAL ARTICLES Top

Clinical profile and outcomes of ophthalmia nodosa in South India: A retrospective study p. 142
Kanika Chhabra, Pankaja Dhoble, Vaibhav Khanna
DOI:10.4103/kjo.kjo_97_20  
Aim: The aim of the study was to report the clinical presentation, course, and final outcomes of ophthalmia nodosa and create awareness among general ophthalmologists regarding the disease. Materials and Methods: A retrospective analysis of the cases of ophthalmia nodosa was carried out from January 2018 to December 2018. Ninety-eight eyes were included in the study. Results: Patients presented with redness (76.53%), foreign-body sensation (61.91%), pain (48.98%), lacrimation (28.57%), and photophobia (7.14%). Hairs were found in the conjunctiva in 63.26%, cornea in 39.80%, anterior chamber in 4.08%, lens in 3.06%, and vitreous in 8.16%. Patients with anterior segment involvement responded well to treatment, which included caterpillar hair removal, topical steroids, and cycloplegics. Patients with retinal exudates responded to therapy which included systemic antibiotics and steroids. Multiple sittings of hair removal were required in 38.78% of patients. Follow-up of the patients ranged from a minimum of 30 days to a maximum of 180 days. Conclusion: Ophthalmia nodosa is a relatively common condition in this part of the world. It has a good outcome when timely diagnosed and appropriately managed.
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Prevalence of subclinical keratoconus in children presenting with refractive errors: A cross-sectional study p. 146
Rani Menon, Sharika Menon, Thekkuttuparambil Ananthanarayanan Ajith
DOI:10.4103/kjo.kjo_103_20  
Background: Keratoconus is a progressive noninflammatory condition that often starts to develop at the age of puberty. The subclinical disease remains unexplored geographically for its prevalence in children. This study was aimed to determine the prevalence of subclinical keratoconus in children presenting with refractive errors. Methods: A cross-sectional study was conducted among children (below 14 years of age) with refractive errors. Corneal topography indices such as Belin/Ambrosio enhanced ectasia total deviation value (BAD_D), index of vertical asymmetry (IVA), and index of surface variance (ISV) of both eyes were selected from the medical records. The prevalence of subclinical keratoconus was identified using the parameters BAD_D = 1.54–2.38, IVA >0.14, and ISV >22. The incidence was calculated and statistically analyzed. Results: Total 726 eyes (354 right and 372 left eyes) from 363 children (190 males and 173 females) were included in the study. Among the total 726 eyes studied, 132/726 (18.18%) showed subclinical keratoconus with 58/132 (43.93%) in right eyes and 74/132 (53.06) in left eyes (P = 0.3411). Definite keratoconus was observed in total 37/726 eyes only (5.09%) with 23/37 in right eyes (62.16%) and 14/37 left eyes (37.83). No statistically significant (P = 0.1678) difference was found between the incidence of definite or subclinical keratoconus with cases of normal indices. Conclusion: The incidence of subclinical keratoconus among children presenting with refractive errors was 18.18%. Corneal topography and tomography may be recommended for children presenting with refractive errors for identifying subclinical keratoconus and to arrest its progression at the onset.
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Visual rehabilitation in pediatric cataract with primary intraocular lens implantation p. 151
Pradeep Ramteke, Dhaivat Shah, Hardik Jain, Garima Vaishnav, Rahul Singh, Amit Neema, Rajesh Vasure
DOI:10.4103/kjo.kjo_134_20  
Aim: The aim of this study was to show visual rehabilitation in pediatric cataract with primary intraocular lens implantation. Materials and Methods: 106 eyes of 91 pediatric patients between 2 to 20 years of age who underwent cataract surgery with primary IOL implantation from June 2018 to January 2020 were included in the study. All the surgeries were performed by a single experienced pediatric ophthalmologist. Phacoemulsification, anterior vitrectomy, and primary posterior capsulorhexis with primary IOL implantation were done in all patients. Patients were reviewed 1 week, 1 month, and 6 months postoperatively. Results: Visual acuity improved from 1.7 logarithm of the minimum angle of resolution (logMAR) before the surgery to 0.74 logMAR at the last follow-up. Twelve eyes had postoperative complications which included posterior capsule opacification in 12 eyes, pupillary fibrin membranes in 17 eyes, and corneal edema in 2 eyes. Conclusion: The current study suggests that primary IOL implantation is safe when in an experienced hand for pediatric age group.
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Effect of position on the safety and efficacy of neodymium-doped: Yttrium aluminium garnet laser peripheral iridotomy in patients with primary angle-closure disease p. 155
Anitha S Maiya
DOI:10.4103/kjo.kjo_152_20  
Purpose: The aim is to evaluate the safety and efficacy of neodymium-doped: yttrium–aluminum–garnet laser peripheral iridotomy (LPI) in the superior versus inferior quadrant in the treatment of primary angle-closure (PAC) disease. Design: Randomized, prospective, single-masked, comparative clinical study. Materials and Methods: Patients with PAC or PAC suspects were recruited and randomized to receive LPI in the superior or inferior quadrant in both eyes. Patients were masked to the location of treatment in each eye. The main outcome measures assessed were patency of iridotomy, laser parameters, complications, and visual symptoms between the two groups at 1 week and 1 month after the laser intervention. Results: A total of 100 patients were recruited, 50 into each group. The mean age was 51.46 ± 7.91 years. Average intraocular pressure (IOP) measurements before LPI was 18.24 ± 5.37 mm Hg and 18.6 ± 5.63 mm Hg in superior LPI and inferior LPI eyes, respectively. After LPI, average IOP was 17.4 ± 3.31 mm Hg and 17.1 ± 3.13 mmHg in superior LPI and inferior LPI eyes, respectively. Inferior LPIs required less use of mean total laser energy (P = 0.001) and less number of laser shots (P = 0.016) to perforate the iris tissue. There was a lower incidence of iris bleeding and focal corneal damage at the time of treatment; a lower postlaser iritis and lower need for PI enlargement in the inferior LPI group. All the iridotomies were patent at 1 month follow-up. There was no statistically significant difference between the two groups in terms of the dysphotopsias and visual symptoms experienced after the LPI (P = 0.122). Conclusions: LPI in the inferior quadrant appears to be a safe and efficient alternative to superior LPI with fewer complications in the treatment of PAC disease. Dysphotopsias and visual symptoms following inferior LPI are similar to superior LPI.
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Ocular biometric parameters of children with refractive errors in the age group of 6–15 years p. 160
P Thanusree, V Mallika, Suma Unnikrishnan
DOI:10.4103/kjo.kjo_171_20  
Background: Refractive errors are one of the leading causes of visual impairment in children. Studies on the association between refractive errors and ocular biometrics have shown inconclusive results; hence, this study aims to examine this relationship. Objectives: The objective of this study is to investigate the association between ocular biometrics such as axial length (AL), anterior chamber depth (ACD), lens thickness, vitreous chamber depth (VCD), and corneal curvature (CC) with different refractive errors in children aged 6–15 years. Materials and Methods: This was a cross-sectional study and studied 130 eyes of children. Children with congenital and acquired anterior or posterior segment diseases were excluded. All underwent detailed ocular examination, visual acuity measurement, and cyclopegic refraction. Children were divided into emmetropia, myopia, and hypermetropia. Ocular biometrics measured using A-scan and automated keratometer. Results: AL, ACD, and VCD significantly increased in the higher levels of myopia (P ≤ 0.0001), (P = 0.04), and (P ≤ 0.0001), respectively, whereas hypermetropes had the lowest. Spherical equivalence was significantly correlated with AL in myopes (ρ= −0.624; P < 0.0001) and hypermetropes (ρ = −0.803; P < 0.001). It was also significantly correlated with ACD more strongly for hypermetropes (ρ = −−0.58; P = 0.002) and VCD more strongly for myopes (ρ = −0.59; P < 0.0001). There was a significant difference between the age group of 6–10 years and 11–15 years for AL (P = 0.001), ACD (P ≤≤ 0.0001), VCD (P = 0.001), and CC (P = 0.03). Conclusion: AL and VCD make the greatest contribution to refractive errors. ACD has more important role in hypermetropes and VCD in myopes. A relative higher AL, ACD, VCD, and CC were found in the age group of 11–15 years.
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Relationship among standard vision tests, quality of life, and ability to do daily activities in patients with glaucoma p. 167
Neethu Pradeep, Smita Narayan, N Sujatha, Sinumol Thulaseedharan, V Sudha
DOI:10.4103/kjo.kjo_163_20  
Background and Objectives: (1) To assess the quality of life (QoL) in patients with glaucoma by (a) clinical assessment, (b) subjective (Visual Functioning Questionnaire-25 [VFQ-25]), and (c) objective (Assessment of Disability Related to Vision [ADREV]) tests and (2) to find out the relationship between glaucoma stages and QoL. Materials and Methods: This cross-sectional study includes 100 patients attending the glaucoma clinic of a tertiary institution in Kerala. Best-corrected visual acuity, baseline intraocular pressure, slit-lamp and fundus examination, gonioscopy, and visual field examination were carried out. Patients were categorized as early, moderate, and advanced on the basis of disc damage likelihood scale (DDLS) and modified Hodapp–Parrish–Anderson criteria. QoL was assessed subjectively using VFQ-25 and objectively by ADREV test by assessing the ability to perform activities of daily living. Contrast sensitivity and stereopsis were the other parameters assessed. Results: Of the 100 patients, 50 (50%) were POAG, 46 (46%) were PACG, and 4 were secondary glaucoma. Based on the DDLS and Anderson criteria, there were 33 early, 34 moderate, and 33 advanced glaucoma cases. The mean ADREV/VFQ scores were as follows: early, 56.9/81.1; moderate, 54.9/75; and advanced, 45.8/52.6. In ADREV tasks, the lowest mean score was for motion detection (5.1) and maximum score was for ambulation (6.1) in the study population. Patients with advanced glaucoma have difficulty in detecting motion (4.1), recognizing street signs (4.3), and color matching (4.8). Stereopsis was seen in 60% of patients with early, 29% of moderate, and 6% of advanced glaucoma. Contrast sensitivity was also reduced with glaucoma progression. Conclusion: ADREV (objective) scores correlate significantly with VFQ (subjective) scores in all the three categories of glaucoma. ADREV (objective test) scores correlate better with the severity and stages of glaucoma and degree of impairment patients experience than VFQ-25 (subjective test). With respect to QoL, patients with glaucoma faced difficulty in performing fine tasks. However, even advanced glaucoma cases were able to carry out their daily activities without much help. Stereopsis and contrast sensitivity were the most affected with advancement of disease.
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Comparison of applanation ultrasound biometry with optical biometry for intraocular lens power estimation in cataract surgery and their impact on prediction error p. 173
Merine Paul
DOI:10.4103/kjo.kjo_48_21  
Aim: The aim of this study is to determine the agreement between applanation ultrasound biometry (AUB) and optical biometry using Lenstar 900 for precataract surgery axial length measurement and intraocular lens (IOL) power estimation and their effect on postoperative refractive outcomes. Methods: A case record-based retrospective study of 229 eyes which underwent phacoemulsification with foldable IOL, in a private hospital setting was done. All the eyes were evaluated using AUB and optical biometry for IOL power prediction. The IOL power was chosen based on the optical biometry and the final refraction was used to calculate the prediction error (PE) for both optical and ultrasound biometry. The concordance coefficient and Bland Altman's limits of agreement were determined to examine the disagreement between the two technologies. Results: The mean axial length ± standard deviation (SD) in the study eyes by ultrasound was 23.46 ± 1.01 mm and 23.57 ± 0.99 mm by optical biometry (P = 0.19). The axial length of 4.37% of eyes could not be measured by optical biometry. The mean IOL power prediction ± SD in the study eyes by ultrasound was 20.98 ± 2.68 D and 20.89 ± 2.85 D by optical biometry (P = 0.72). The mean ± SD absolute value of the refractive PE was − 0.32 ± 0.44 D (median − 0.25, interquartile range: −0.75–0). All eyes achieved a postoperative visual acuity of 6/18 or better including 204 (89.87%) that had a visual acuity of 6/6. One hundred and sixty-four eyes (71.62%) eyes had a postoperative spherical equivalent of 0 to ± 0.5D at 30 days. Two hundred and twenty eyes (96.07%) had a postoperative spherical equivalent of 0 to ± 1.0 D. Conclusions: The findings of the study prove that carefully done AUB is comparable to optical biometry and should not be a deterrent in providing the best possible refractive outcomes in a majority of our cataract patients. To ensure that these results are replicable on a wider scale will necessitate adequate training of personnel in the art and science of biometry.
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Evaluation of retinal changes in normal pregnancy and gestational hypertension – A spectral domain optical coherence tomography based study p. 179
Niya Babu, Anthrayos C.V. Kakkanatt, Bindu Menon, Anchitha Meenu Rajeev
DOI:10.4103/kjo.kjo_179_20  
Background and Objectives: Hypertensive disorders complicating pregnancy is a complication of pregnancy, which includes gestational hypertension, preeclampsia and eclampsia syndrome, preeclampsia superimposed on chronic hypertension, and chronic hypertension of any etiology. The pathogenesis of the first three and last two varies. The present study focuses on the first three categories of patients. Optical coherence tomography (OCT) is a noninvasive medical imaging modality used for in vivo visualization of retinal layers in human eyes. This study analyzed the retinal thickness changes in patients with gestational hypertension and compared it with normal pregnant study participants. Furthermore, the duration of gestational hypertension with changes in retina was compared. Materials and Methods: A comparative study was performed in 206 patients (103 normal pregnant and 103 gestational hypertensive patients). Macular thickness in nine segments and ganglion cell inner plexiform layer thickness (GC-IPL) in six sectors were assessed using cirrus high-definition OCT and compared between two groups. The study period was 18 months. Results: Among the 412 eyes in two groups, there was a statistically significant increase in macular thickness in six segments in the gestational hypertension group compared to the healthy pregnant group (P < 0.05). A statistically significant positive correlation was found between macular thickness and duration of hypertension in two segments and a negative correlation between the GC-IPL thickness in two sectors and duration of hypertension was observed (P < 0.001). Conclusion: Spectral-domain OCT can be used for detecting early retinal changes in gestational hypertension before any clinical signs appear.
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Awareness of retinopathy of prematurity screening among healthcare professionals in Palakkad district of Kerala p. 185
V KP. Geetha, Jayaraman Thrikkovil Pisharam, Parag K Shah
DOI:10.4103/kjo.kjo_54_21  
Purpose: To understand the level of knowledge and create awareness about retinopathy of prematurity (ROP) among Pediatricians, General Practitioners, and Paramedical staff in the Palakkad district. Materials and Methods: A Questionnaire with multiple choice answers, created to determine the knowledge and current practices of ROP screening, was administered to 216 participants including 97 Pediatricians, 61 General Practitioners, and 58 Paramedical staff (staff nurses and optometrists) in a period of 1 year. The responses were collected and analyzed. Results: Most respondents (70.7%) were from the public sector. More than 90% of respondents in the three groups reported awareness of ROP as a preventable disease in premature babies. However, the knowledge of screening criteria and timing of screening was poor among all participants including Pediatricians. The awareness and knowledge did not differ significantly by respondents in the public and private sector (all P > 0.05). Conclusion: There is an urgent need to focus on strategies to increase awareness of the timing and criteria for the screening are suboptimal even among Pediatricians.
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SURGICAL CORNER Top

A new technique of phacoemulsification without hydroprocedures p. 189
Narayan Bardoloi, Sandip Sarkar
DOI:10.4103/kjo.kjo_60_21  
Purpose: We describe a new technique where phacoemulsification can be safely performed without doing hydroprocedure. Materials and Methods: We conducted a prospective, nonrandomized, noncomparative, single-center study where Group A had undergone phacoemulsification without hydroprocedure and Group B had undergone conventional phacoemulsification. After capsulorhexis, we insert the phacoemulsification tip into the eye without doing any hydroprocedure. First shaving of the cortex and epinucleus is done within the capsulorhexis area. Then, the tip is buried into the center of the nucleus and an anteroposterior crack is fashioned. Then, the tip is placed at 8 o'clock position to chop away a piece of nucleus and emulsified. A similar maneuver is done at 4 o'clock position. The phacoemulsification tip and the chopper are now positioned at the cracked site of the lower fragments. Using the two instruments, the fragments are pushed to the opposite direction and emulsified. Results: The mean age of the patients of Group A was 65.7 ± 8.16 years and Group B was 68.9 ± 9.85 years (P = 0.127). The mean best-corrected visual acuity in Group A improved from 0.92 ± 0.49 logarithm of the minimum angle of resolution (logMAR) to 00.01 ± 0.02 logMAR at 3 months postoperatively. The mean endothelial cell loss was 145 ± 123 cells/mm2 at 3 months postoperatively. There was no significant difference in postoperative outcomes between both the groups. Conclusion: The technique can be safely applied in all cataracts, especially posterior polar cataract and white mature cataract where hydrodissection is contraindicated.
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CASE REPORTS Top

Bilateral vitreous hemorrhage with branch retinal vein occlusion secondary to hyperhomocysteinemia: A rare case report p. 194
Amit Kumar Deb, Nithya Rathinam, Sandip Sarkar, Sangaraju Suneel, MalvikaMani, Subashini Kaliaperumal
DOI:10.4103/kjo.kjo_74_20  
Retinal vascular occlusions are uncommon in young people and require more in-depth investigation into the cause. A high level of circulating homocysteine carries a risk for retinal vaso-occlusive events. We, hereby, report a rare case of hyperhomocysteinemia-related bilateral branch retinal vein occlusion (BRVO). A 27-year-old male presented with sudden painless gross diminution of vision in the left eye (LE) for 10 days. Further assessment revealed inferotemporal BRVO (ITBRVO) in the right eye (RE) with mild vitreous hemorrhage (VH) and dense VH in the LE. Extensive investigations into the cause revealed an elevated level of serum homocysteine. The patient was started on Vitamin B6 and B12 supplementation. RE sectoral panretinal photocoagulation and LE pars plana vitrectomy were done. LE ITBRVO was noted intraoperatively for which endolaser was done. Hyperhomocysteinemia through its prothrombotic properties is an independent modifiable risk factor for vascular thrombotic events. Hence, it should be considered as a differential diagnosis for retinal vascular occlusions to prevent further recurrences and cerebrovascular events, especially in young adults.
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Solitary eccrine spiradenoma of caruncle: A rare occurrence p. 197
Ankita Patil, Shahnawaz Kazi
DOI:10.4103/kjo.kjo_67_20  
Eccrine spiradenoma (ES), a sweat gland tumor, is rarely found in the caruncle. Although the occurrence of spiradenoma of carbuncle are rare. On account of the histological composition of the caruncle, which includes, in addition to conjunctiva, hair follicles, sebaceous glands, sweat glands, and accessory lacrimal tissue, the caruncle may develop lesions that may be similar to those found in the skin, conjunctiva, or lacrimal gland. We encountered a 39-year-old female with a nodular growth in her left caruncle, which had developed over the last 10 years. Excision biopsy was carried out under local anesthesia. The histopathology was suggestive for a benign ES. Clinical preoperative diagnosis is very difficult for caruncular lesions and is reached only in about half of the cases. Most lesions of the caruncle are benign, mainly nevi. Reported malignant lesions are very rare, but can be potentially fatal. The possibility of sweat gland tumor should be kept in mind in the diagnosis of caruncle tumors.
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A descriptive presentation of a family showing various features of aniridia and its genetic analysis p. 201
Meenakshi Wadhwani, Manoj Kumar, Rima Dada
DOI:10.4103/kjo.kjo_78_20  
The abnormal neuroectodermal development due to the PAX 6 gene mutation results in aniridia, a rare disorder. We report herein a family that presented with aniridia, myopia, ptosis, glaucoma, cataract, and sensory nystagmus. This family provides a unique resource for the mutational analysis of the CRYBB1, CRYBA4, and PAX-6 gene. In addition, it is important to remember that mutations are often a part of these ocular abnormalities. Patient awareness, education, and involvement in treatment are essential to prevent amblyopia associated with the cataract and nystagmus related to aniridia.
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Challenges in the diagnosis of early endogenous fungal endophthalmitis p. 205
Nusrath Parambil, Sheena Liz Mani, Anabi Shahi, Revati Ramesh
DOI:10.4103/kjo.kjo_87_20  
Endogenous fungal endophthalmitis (EFE) is an uncommon disease caused by the dissemination of fungal infection to posterior segments of the eye and has a high rate of visual loss. Most patients have associated predisposing risk factors, including immunocompromised conditions, and the condition is less likely to occur in healthy individuals. Here, we report two patients who presented like uveitis and deteriorated after starting standard treatment for uveitis, which included steroids. They were later diagnosed with EFE. Fungal endophthalmitis should be suspected even in ambulatory individuals with immunocompromised states, when they present with uveitis like features, before starting steroid treatment. Polymerase chain reaction based diagnosis is extremely useful and should be considered in diagnosing EFE.
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Complete eyelid loss due to dog bite: A rare presentation p. 209
Vinisha Dhawade Naik, Ugam P.S. Usgaonkar, Akshaya Nagvenker
DOI:10.4103/kjo.kjo_88_20  
A 46-year-old male presented with a history of dog bite to the left eye. Examination revealed complete loss of the left upper eyelid with loss of the upper punctum and the surrounding tissue with extensive tissue damage. Anterior segment examination revealed an irregular epithelial defect, and the rest of the findings were unremarkable. After a thorough assessment and cleaning, anti-rabies immunoglobulin injection was given around the wound and anti-rabies vaccination schedule was started. Locally the eye was covered with plastic shield to prevent exposure after instillation of homatropine eye drop as a cycloplegic and chloramphenicol eye ointment as a broad-spectrum antibiotic. Systemically amoxicillin-clavulanic acid and metronidazole was started. Daily dressing was done for about a week. Once signs of healing were seen, the patient was posted for multi-step lid transplantation.
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Pseudoxanthoma elasticum: Pathognomonic ocular and skin lesions with histopathological confirmation p. 211
M Manjunatha, Jayant Kumar, Amit Kumar Deb, Shanthi Radhakrishnan
DOI:10.4103/kjo.kjo_98_20  
A 34-year-old female presented to us with complaints of decreased vision in her left eye for 1 month. Best-corrected visual acuity was 20/20 in the right eye and 20/60 in the left eye. Anterior segment examination was normal in both the eyes. Fundus examination showed angioid streaks and comet tail lesions in both eyes. The left eye in addition showed a choroidal neovascular membrane (CNVM) at the macula. Systemic examination revealed skin lesions on the neck with a plucked chicken appearance and multiple papules. Biopsy from the lesions provided histopathological confirmation of pseudoxanthoma elasticum (PXE). CNVM in the left eye was treated successfully with a single dose of intravitreal bevacizumab injection with no further recurrence. No cardiovascular association was found in our case. This case report describes the pathognomonic fundus lesions seen in PXE. This case also emphasizes the need for thorough systemic evaluation, including biopsy from skin lesions for histopathological confirmation of the diagnosis in all cases with ocular features of PXE.
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PHOTO ESSAY Top

Fundus fluorescein angiography and optical coherence tomographic characteristics in acute multiple evanescent white dot syndrome p. 214
Priya Rasipuram Chandrasekaran
DOI:10.4103/kjo.kjo_14_21  
A 38-year-old female presented with a best-corrected visual acuity of 20/60 N18 and 20/20 N6. Fundus examination showed multiple yellow-white dots and spots at the posterior pole with disc edema and orange-yellow granularity at fovea. Fundus fluorescein angiography showed dots showing punctate hyperfluorescence and spots showing late staining and disc leakage. Optical coherence tomographic macula showed sub foveal hyperreflective elevated lesion on the retina pigment epithelium extending into the inner retina as far as the outer nuclear layer through disruption of inter digitation zone, ellipsoid zone (EZ), external limiting membrane and hyporeflectivity, and disruption of ELM and EZ corresponding to parafoveal lesions (predominantly spots).
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INNOVATIONS Top

Smartphone microscope in eye clinic to visualize fungus and Demodex p. 217
Pawan Prasher, Brahmjot Singh, Vipan K Vig, John Davis Akkara
DOI:10.4103/kjo.kjo_125_21  
Purpose: Ophthalmologists often need to use a compound microscope to see slides of corneal scrapings, Demodex blepharitis, histopathology, or tear ferning test for diagnostic purposes. While such a microscope may be available in tertiary care centers, most eye clinics do not have it due to cost, space required, and infrequent use. These tests are often not done or delayed till a tertiary referral is possible. We demonstrate an alternative method using smartphone and an inexpensive attachment. Materials and Methods: Using the smartphone microscope attachment, the authors were able to capture excellent photographs and videos of corneal scrapings, histopathology, and Demodex. Photographs of the same slides were taken with a standard compound microscope as well. Trypan blue dye was used for staining the corneal scraping specimens to make the fungal hyphae in it clearly visible. Results: Photographs and videos captured by the smartphone microscope were compared with those from a compound microscope and found to be of adequate quality. They were determined to be good enough for diagnostic use. Conclusions: We determined that smartphone microscope attachment can be a useful adjunctive diagnostic tool for eye clinics corneal scrapings, histopathology, and Demodex, perhaps even for more applications.
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HISTORY CORNER Top

The Ophthalmologist who won the Nobel Prize and declined one too p. 222
C Biju John
DOI:10.4103/kjo.kjo_134_21  
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JOURNAL REVIEW Top

Journal Review p. 226
TU Laly
DOI:10.4103/kjo.kjo_129_21  
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PG CORNER Top

Post trabeculectomy situations: Hypotony p. 230
Priyanka Sudhakar, Meena G Menon
DOI:10.4103/kjo.kjo_83_21  
Hypotony, characterized by a low intraocular pressure <6.5 mm Hg or <5 mm Hg with possible clinical complications, can lead to dreaded complications, posttrabeculectomy. It leads to a breakdown of blood-aqueous barrier, leading to an inflammatory cascade, scarring, and bleb failure, in the long term. It also predisposes to blebitis and other hypotony-related complications. Identifying the cause of hypotony, such as bleb leak or overfiltration, is vital to addressing the underlying cause. It can be managed conservatively with pressure patching, and medically with steroids or cycloplegics, or would require surgical bleb revision, depending on the cause and extend of underlying damage. In this article, we review the definition, pathophysiology, risk factors for hypotony, and posttrabeculectomy and identify the various possibilities, and their respective management strategies.
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LETTERS TO THE EDITOR Top

Integration of research with clinical skills for house surgeons p. 236
Nandini Varma
DOI:10.4103/kjo.kjo_115_21  
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Research in ophthalmology p. 238
Iodine Reghunadhan
DOI:10.4103/kjo.kjo_119_21  
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