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   Table of Contents - Current issue
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January-March 2021
Volume 35 | Issue 1
Page Nos. 1-80

Online since Thursday, September 9, 2021

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ORIGINAL ARTICLES  

Ocular manifestations in children with developmental delay at a tertiary center in South India p. 1
Vidya Hegde, Rashmi Jain, Anupama Bappal, Rashmi Shambhu
DOI:10.4103/1319-4534.325773  
PURPOSE: Developmental delay occurs when a child exhibits a significant delay in the acquisition of milestones, in one or more domains of development. This study was planned to determine the distribution of ocular disorders and to assess the correlation between ocular findings and systemic co morbidity, antenatal and postnatal factors, and perinatal history. METHODS: This cross-sectional study included children with developmental delay <16 years of age. All children underwent complete ophthalmological evaluation including full cycloplegic refraction. Vision assessment was done as appropriate for age. Spearman's correlation test was used to analyze the correlation between ocular findings and causes for developmental delay and antenatal, perinatal, and postnatal history. RESULTS: A total of 128 children were evaluated. Mean age of the study group was 5.59 ± 2.12 years, 64.8% were males, and 76.6% of children were from rural area. Ocular findings were seen in 110 (85.93%) children, refractive error being the most common finding seen in 87 children (astigmatism n = 47, hypermetropia n = 28, and myopia n = 12). Strabismus was seen in 65 children, esotropia being the most common (n = 36). Vision impairment was present in 39.84% of children. Other ocular findings included disc pallor, cataract, ptosis, amblyopia, keratoconus, telecanthus, lagophthalmos, blepharitis, retinitis pigmentosa, and morning glory syndrome. Spearman's correlation showed no statistical association between ocular findings and various causes for developmental delay. There was a weak negative correlation between antenatal history, mode of delivery, gestational age, and ocular findings. CONCLUSION: More than three-fourths of children with developmental delay had ocular findings which necessitates the need for ocular evaluation.
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Determinants of the risk of intraoperative complications in phacoemulsification among patients with pseudoexfoliation p. 5
Pedro Vazquez-Ferreiro, Francisco J Carrera-Hueso, Lidia Barreiro Rodriguez, Marta Diaz-Rey, María Auxiliadora Ramón Barrios, Jaime E Poquet Jornet
DOI:10.4103/1319-4534.325774  
PURPOSE: The purpose of the study was to study the relationship between pseudoexfoliation (PES) and other predictors in the development of complications in cataract surgery by phacoemulsification in patients with PES. METHODS: A retrospective cohort study of patients undergoing cataract surgery by phacoemulsification in the health area of Cee in northwestern Spain during the 2-year period from 2009 to 2010. Capsule rupture, choroidal hemorrhage, and vitreous loss were included as complications and intraoperative nucleus or lens dislocation as the independent variable. PES, age, hardness, type of cataract, myopia, preoperative visual acuity, antiplatelet use, anticoagulant uses, alpha agonist use, mydriasis prior to surgery, anterior chamber depth, and axial length were included as predictor variables. All predictive hierarchical models were tested using as a selection criterion the one minimizing the Akaike index. RESULTS: A total of 551 patients were initially identified from hospital register, of which 48 were excluded due to the presence of an exclusion factor. After the initial selection, the final sample was 681 eyes of 503 patients. Of the 8192 possible models, a model with the following seven variables was selected: PES, steroid use, alpha agonist use, nuclear hardness, mydriasis, anterior chamber depth, and axial length. The selected model had an Akaike index of 435.4 and an area under the curve of 0.7895 corresponding to a sensitivity of 6.2% and a specificity of 98.5%. CONCLUSION: PES, nuclear hardness, and alpha agonist use are risk factors strongly predictive of complications.
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Ocular parameters alterations after hemodialysis in patients with chronic kidney diseases Highly accessed article p. 9
Abdullah Almaznai, Sarah Alsaud, Rania Fahmy
DOI:10.4103/1319-4534.325775  
PURPOSE: To evaluate the effects of hemodialysis (HD) on visual acuity (VA), central corneal thickness (CCT), intraocular pressure (IOP), and macular thickness (MT) in chronic kidney disease (CKD) patients and also to investigate the relationship between the ocular parameters and blood biochemical parameters such as serum albumin, creatinine, sodium, and urea levels. METHODS: A prospective cohort study including a total of 24 CKD patients of both genders (above 18 years old) undergoing HD in XXX was conducted. The participants were divided into three sub-groups based on the primary cause of renal failure, group 1: Hypertensive kidney disease, group 2: Diabetic kidney disease, group 3: Other causes. All subjects underwent full ophthalmological examinations including measurement of VA using LogMAR, IOP, CCT, and CMT. Comparisons between different ocular parameters during pre- and post-HD sessions were done using the paired t-test. The relationship between changes in ophthalmologic and blood biochemical parameters was calculated using Pearson correlation coefficient. RESULTS: HD did not significantly alter any ocular parameter within and between CKD groups. Spherical equivalent changes were found to be significantly correlated with serum K (r = −0.315; P = 0.038), and IOP results were positively correlated with serum creatinine (r = 0.330; P = 0.029) and negatively correlated with hemoglobin (r = −0.349; P = 0.020). Bodyweight alterations were significantly correlated with CCT (r = −0.03; P = 0.0001). However, no correlation between ocular parameters and duration of HD was detected. CONCLUSION: Following a single HD session, ocular parameters did not alter significantly.
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Agreement between three methods for measuring near point of convergence among patients with different refractive errors p. 15
Antony A Baskaran, Tanuja Britto, Raja T Sowndher, Philip A Thomas
DOI:10.4103/1319-4534.325776  
PURPOSE: To describe the agreement of three methods of Near Point of Convergence (NPC) measurement among patients with different refractive errors. METHODS: 60 asymptomatic subjects, 18 – 25 yrs old, were included in 3 groups: emmetropes, myopes and hypermetropes. All subjects underwent NPC break point and recovery point measurement by Royal Air Force (RAF) rule, Pencil Rule (PR) and penlight with red green glasses (RG) using standard techniques. The values obtained were compared within each group by Friedman test. Bland Altman plots were constructed and Limits of Agreement calculated. RESULTS: Hypermetropes performed poorly in RG test with significantly receded break point and recovery point values (10.30 ± 1.45cm, 13.13± 1.20cm) compared to RAF test (7.18 ± 1.86 cm, 10.15 ± 2.11cm ) and PR test (7.78 ± 1.75 cm, 10.75 ± 1.44cm). The recovery point values of the emmetropes with RG test (10.15 ± 2.32cm) was significantly receded compared to PR (9.30 ± 1.72 cm) and RAF test (Emm: 9.08 ± 2.30cm). The myopes performed better with PR test with significantly better recovery point values with PR test (8.70 ± 1.97 cm) compared to RAF (9.68 ± 2.08) and RG (9.45 ± 1.73) tests. The limits of agreement were wide suggesting disagreement between the tests. CONCLUSION: The RG test yields more receded results in hypermetropes compared to the RAF and PR tests, and the PR test yields better results than the RAF test in myopes. Thus, the results obtained by these different methods show a lack of agreement. The variability is not uniform in patients with different refractive errors.
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Analyses on the distribution and influence of higher-order aberrations both clinically and experimentally among varied refractive errors p. 21
Venkataramana Kalikivayi, Lavanya Kalikivayi, AR Ganesan
DOI:10.4103/1319-4534.325777  
PURPOSE: The aim of this work is to determine and compare the distribution and influence of higher-order aberrations (HOAs) both clinically and experimentally between different refractive errors. METHODS: Commercially available Shack–Hartmann aberrometer was employed to measure the HOA clinically in human eyes. Experimentally, HOA was measured in a model eye by simulating various refractive errors by constructing an aberrometer based on the same Shack Hartmann principle. One-way analyses of variance and simple regression were employed to analyze the distribution and influence of HOA among various refractive errors. RESULTS: A total of 100 eyes were clinically measured for aberrations, of which 35, 50, and 15 eyes were emmetropes, myopes, and hyperopes, respectively. Out of the total root mean square (RMS) value, the HOAs found in the human eyes were 23%, 7%, and 26% and in the model eye, it was 20%, 8%, and 10% between emmetropes, myopes, and hyperopes, respectively. The mean higher-order RMS was almost similar between the groups and among various refractive errors. There was no statistical significance between the individual Zernikes except for the coma in both human and model eyes. CONCLUSION: The mean HOA is similar amidst the different refractive errors. The presence of 23% HOA in emmetropes signifies that larger part of the human eye is capable of complying with HOA without compromising the image quality. This work signifies that HOA does not play an important role in image clarity for human eyes with regular refractive surface unlike irregular refractive surfaces.
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Presentation and outcomes of orbital cellulitis caused by Group F Streptococcus p. 29
Viraj J Mehta, Eric N Brown, Rachel K Sobel
DOI:10.4103/1319-4534.325780  
PURPOSE: To compare the presentation and outcomes of patients with orbital cellulitis requiring surgical intervention caused by the Group F Streptococcus (GFS) versus other bacteria. We hypothesize that patients with GFS infections have a more severe presentation and worse clinical outcomes compared to infections by other bacteria. METHODS: After Institutional Review Board approval at a large academic institutional center, 70 patients with culture-positive orbital cellulitis who required surgical intervention were identified. Clinical examinations before and after surgery as well as preoperative imaging with computed tomography and/or magnetic resonance imaging were reviewed. The study measures were preoperative and postoperative vision, motility, involved sinus disease, complications, and total hospital length of stay. Multiple imputation was used for missing data. Characteristics of patients were compared using Chi-square and Wilcoxon rank-sum. RESULTS: Nineteen patients (27%) had positive cultures for GFS and 51 patients (73%) had positive cultures for other bacterial species. There was no significant difference in visual acuity, motility, or inflammatory markers in patients with GFS compared to other patients. Patients with GFS were noted to have more sinus involvement on presentation compared to patients with other bacterial infections (P = 0.007). CONCLUSION: GFS associated orbital cellulitis is associated with significantly more sinus involvement, but has similar outcomes as orbital cellulitis from other bacterial species.
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Community ophthalmology clinic utilization and morbidities results from a private primary healthcare center in Saudi Arabia p. 34
Afaf A Bin Khathlan
DOI:10.4103/1319-4534.325781  
PURPOSE: To study the utilization of the ophthalmology clinic in a primary care setting through number and type of ophthalmic cases that were managed. METHODS: This retrospective descriptive study included all ophthalmic cases treated during a 6-month period in a private sector primary healthcare center ophthalmology clinic in 2018. We measured clinic utilization by recording the proportion of patients treated among the total number of patients treated in the center, the number of visits during different times of day, and the most common diagnoses encountered. RESULTS: Among 32,518 visits to the health center during the study period, we recorded 422 (1%) visits to the ophthalmic clinic. First visits were 406 cases, and 16 were the follow-up visits. Patients tended to utilize the evening sessions more than morning sessions, with a median of 23 patients per month. Refractive errors in 89 cases (22%) and blepharitis in 88 cases (22%) were the most common diagnoses encountered. Visually significant cataract was not recorded in this study with a prevalence of 31% (14/45) in the >50 years of age group. Seven cases (2%) required referral to hospital during the study period for secondary eye care. CONCLUSION: Since most cases in this study were managed in the clinic with good utilization of the services offered, we concluded that a community ophthalmology clinic as a first contact would be useful in some primary healthcare centers. More studies are needed in different regions/settings before widely establishing the service in Saudi Arabia.
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Effect of intraoperative optical coherence tomography on anatomic and cosmetic results of intrastromal tattooing p. 39
Rinky Agarwal, Jayanand Urkude, Sridevi Nair, Md Ibrahime Asif, Rajesh Sinha, Namrata Sharma
DOI:10.4103/1319-4534.325784  
PURPOSE: The aim of the study was to evaluate the effect of intraoperative optical coherence tomography (i-OCT) on anatomic and cosmetic outcomes of intrastromal keratopigmentation (i-KTP) performed by novice lamellar corneal surgeons. METHODS: Thirty patients presenting with unilaterally disfiguring corneal scar and nil visual prognosis were subjected to i-OCT-guided intrastromal tattooing with rotring ink, by ophthalmology residents undergoing training in corneal surgeries at our center, who were later asked for a subjective feedback and mean stromal depth dissected was measured objectively. All patients were followed up for 9 months after surgery, and the subjective satisfaction of the patient, an independent observer, and surgeon was graded as poor, good, and excellent. RESULTS: The mean age of the patients was 29.53 ± 13.82 years (8–56 years). The most common cause of corneal opacity was healed keratitis with (6/30) or without (3/30) adherent leukoma, trauma-induced ocular disfigurement (7/30), and bullous keratopathy (6/30). All residents reported that feed-back images on i-OCT were “helpful” in all eyes and “very helpful” in eyes with corneal thinning, stromal scarring, adherent leukoma, bullous keratopathy, and hypotony. The mean depth of lamellar dissection was 51.16% ±4.62% of preoperative corneal thickness. The cosmetic results as perceived by the patient, an independent observer, and the surgeon were excellent and good in 23 and 7, 26 and 4, and 20 and 10 patients, respectively. CONCLUSION: I-KTP may be employed as a primary method of cosmetic correction of unsightly corneal scars. Centers equipped with i-OCT may employ this tool for teaching i-KTP to their ophthalmology residents for better surgical results with minimal complications.
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Electron microscopic comparison of the donor cut edges using femtosecond laser-assisted keratoplasty versus conventional keratoplasty p. 47
Mohamed Y Tolba, Iman M A. Zaki, Karim A Raafat, Amr A Al Dib, Taher Eleiwa, Collin Chase, Ibrahim M Taher
DOI:10.4103/1319-4534.325785  
PURPOSE: To describe and compare the histological changes in the cut edges of the remaining donor corneal rim using femtosecond laser-assisted keratoplasty (FAK) versus conventional penetrating keratoplasty (PK) via light and transmission electron microscopic examination. METHODS: This was a prospective observational study of 10 eyes; 5 FAK (top-hat technique) and 5 conventional PK. Main outcomes were histological findings at the cut edge of the donor corneal rim (at 3, 6, 9, and 12 o'clock). RESULTS: Cellular and ultra-cellular changes in the form of stromal edema, disorganized collagen fibers, and nuclear changes were more prominent in the FAK eyes as compared to the conventional PK ones. CONCLUSION: FAK induces more collateral damage in the cut edge of corneal donor graft at cellular and ultra-cellular levels, compared to conventional trephination. Further studies are required to investigate the clinical ramifications of this observation.
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BRIEF COMMUNICATION Top

Iris thickness and volume be measured using iris base instead of scleral spur as reference in anterior optical coherence tomography scan p. 52
Alka Mahale, Rajiv Khandekar, Yasir Zia
DOI:10.4103/1319-4534.325788  
PURPOSE: To compare the iris parameters (iris thickness [IT] and volume) measured at different locations on iris determined using iris base (IB) and scleral spur (SS) in healthy Saudi eyes and factors affecting the differences. METHODS: Healthy eyes of Saudi persons were evaluated using anterior segment optical coherence tomography (AS-OCT). The IT was measured using Image J software and OCT scans in the horizontal axis in light on and light off condition. First IB was used as reference, and then, SS was used as reference for these measurements. RESULTS: One hundred healthy eye's AS-OCT scan was studied. The IT at the temporal side of the horizontal axis at 750 μ away from IB with lights on was 0.526 ± 0.08 μ, whereas it was 0.52 ± 0.08 μ from SS. The difference was significantly more in IB than SS method (P = 0.005). This difference if IT in SS and IB method was not affected by gender (Mann–Whitney P = 0.3), type of refractive error (K W P = 0.7), and level of illumination (K W P = 0.7). CONCLUSION: IT and IV measured using IB provided reliable data but overestimates compared to SS method. In the absence of SS visibility, IB could be alternative to assess iris parameters.
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CASE REPORTS Top

Multimodal ocular imaging in diagnosis and management of occupational ocular argyrosis p. 56
Rinky Agarwal, Asmita Mahajan, Vinod Kumar, Namrata Sharma
DOI:10.4103/1319-4534.325786  
Occupational ocular argyrosis is a rare disorder associated with accumulation of silver in the eye due to its occupational exposure. A 39-year-old male patient, a silver utensils polisher for the past 30 years, presented with bilateral gradual diminution of vision (presently 20/200) for 2 years. His serum silver levels were raised and ocular examination revealed bilateral greenish brown corneal deposits and complicated cataract. Anterior segment optical coherence tomography (OCT) and confocal microscopy suggested deposition of silver in various corneal layers. Multifocal electroretinogram showed a generalized decrease in sensitivity of P1 waves. Increased internal aberrations on aberrometric profile favoured phacoemulsification followed by intraocular lens implantation in both eyes. Postoperatively, the visual gain of 20/20 and normal fundus picture on indirect ophthalmoscopy, macular OCT, and fundus autofluorescence favored good prognosis in both eyes.
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A new gene mutation in a family with idiopathic infantile nystagmus p. 61
Alberto Galvez-Ruiz, Alicia Galindo-Ferreiro, Anthony J Lehner
DOI:10.4103/1319-4534.325787  
Idiopathic infantile nystagmus (IIN) is an inherited disease, which can occur through a number of different inheritance patterns (autosomal dominant, recessive, or X-linked). The most common of these is X-linked inheritance with incomplete penetrance and variable expressivity, and can also be dominant or recessive. To date, only two mutations have been described: the first, affecting the FPR143 gene, which is associated with ocular albinism type I, and located on chromosome Xp22, and the second, affecting the FRMD7 gene located on chromosome X26-q27. To date, a causative gene on locus Xp11.3p11.4 has not yet been identified. The most common cause of IIN is due to mutations in the FRMD7 gene, located on chromosome Xq26. We present a case of a new mutation found in three siblings from a family with FRMD7-related infantile nystagmus, whose parents are consanguineously related in the first degree. A complex mutation has occurred in this family, which, to date, has not been previously reported in the scientific literature. The complex mutation consists of the presence of three consecutive 1 bp deletions in exon 12 (c.1248delT; 1299del C; and 1312delT), causing a secondary deletion (c. 1340–2145 + 214del), and resulting in a truncated protein. We also present a 7-year-old patient from a different family, with periodic alternating nystagmus, having no mutation in the FRMD7 gene, which we assume may be an example of non-FRMD7-related IIN. This patient does not have a family history of nystagmus.
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Isolation of unusual bacteria in canaliculitis: A series of four cases p. 66
Vijitha S Vempuluru, Sanchita Mitra, Devjyoti Tripathy, Samir Mohapatra, Suryasnata Rath
DOI:10.4103/1319-4534.325778  
With increased availability of sophisticated microbiological techniques for isolation, growth and identification of micro-organisms the spectrum of organisms is rapidly. Herein we report four cases of canaliculitis with unusual organisms and highlight their clinical significance. To the best of our knowledge, there are no reports of isolation of Brucella melitensis and Leuconostoc species reported in English literature; and only one report of isolation of Myroides species from canaliculitis exists. Sphingomonas paucimobilis, is an uncommon isolate in canaliculitis. Extremes of age and occupational exposure may be possible risk factors for infection with uncommon organisms. Clinical features at presentation do not vary greatly with uncommon or multi drug resistant organisms' hence sampling and microbiological assessment is warranted. The benefit of curettage in canaliculitis is manifold. Unusual organisms and opportunistic pathogens can be multi-drug resistant and determination of antibiotic susceptibility is important to initiate targeted therapy to ensure disease cure and prevent recurrences.
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Tropicamide and anaphylaxis: A case report p. 71
Nazife Sefi-Yurdakul, Özlem Sancakli
DOI:10.4103/1319-4534.325779  
A 6-month-old boy was brought to the ophthalmology outpatient clinic of our hospital by his parents with the suspicion of esotropia of his left eye. He was able to follow the objects, pupillary light reactions were normal, orthophoric in primary position with corneal light reflex (Hirschberg) test, ductions and versions were normal in all gaze positions. One drop of tropicamide (1%) was instilled in both eyes of the infant for cycloplegic retinoscopy and fundus examinations. After 10 min, anaphylaxis, respiratory and circulatory failure developed. He was immediately examined by the pediatrician, and emergency code was announced. At the 5th min of treatment, he regained consciousness, his respiratory and circulatory symptoms started to improve, and blood pressure returned to normal. In this case report, we aim to point out that tropicamide may rarely lead to life-threatening complications
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Uveitis and autoimmune hepatitis, a real entity? A case report with review of the literature p. 73
Saeed Alshahrani, Abdulrahman A Aljumah, Adel Alluhaidan
DOI:10.4103/1319-4534.325782  
A 63-year-old man presented with a 10-day history of severe pain, redness of the right eye, and reduced vision in both eyes. In addition, he had been diagnosed incidentally with liver cirrhosis and splenomegaly 1 week before he was admitted to our center. The patient was found to have severe intraocular inflammation that initially involved the right eye and then progressed to bilateral panuveitis. The presenting visual acuity was 20/60 for the left eye and lumbar puncture (LP) for the right eye. Vitreous tap revealed a nonturbid, yellow fluid that was negative for organism culture, polymerase chain reaction (PCR), and tumor markers. Oral prednisolone significantly improved the clinical status of both ocular and hepatic inflammation. During the admission period, the patient developed several medical comorbid complications that temporarily altered the management of our case. After a full evaluation of uveitis causes, the patient was diagnosed with biopsy-proven autoimmune hepatitis. In addition to a high-dose oral steroid, azathioprine was given for 3 months before the patient developed decompensated liver failure, which was successfully managed with a liver transplant. The patient was stable for 1 year following the transplant but eventually developed blindness of the right eye and visual acuity of 20/30 in the left eye.
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Anterior clinoid mucocoele presenting as progressive fluctuating visual loss mimicking inflammatory optic neuropathy p. 78
H M. M T. B Herath, A M. B D. Alahakoon, MS Mohideen, AA R. Chandrakumara, S Senanayaka, IK Goonarathne
DOI:10.4103/1319-4534.325783  
Optic nerve lesions usually produce monocular visual loss, and in compressive optic neuropathies, gradual vision loss is the more usual presentation. Mucocele in the anterior clinoid process is a rare cause of compressive optic neuropathy that can lead to monocular visual loss. A 19-year-old Sri Lankan girl presented with progressive, painless fluctuating right-sided monocular visual loss over 1-year duration. On presentation, right side visual acuity was 6/60 and fundoscopy revealed pale disk on the right side. Ocular tomography showed right-sided temporal retinal thinning. Magnetic resonance imaging revealed right anterior clinoid process mucocele causing compression and kinking of the right optic nerve. Because the right side, optic disc was already pale and retina was thinned, we decided to manage conservatively. Early imaging in compressive optic neuropathy is useful for the diagnosis and early neurosurgical intervention. Delaying the diagnosis can lead to permanent visual loss.
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