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   Table of Contents - Current issue
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September-December 2017
Volume 10 | Issue 3
Page Nos. 133-265

Online since Thursday, October 5, 2017

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EDITORIAL  

Classification of retinoblastoma: Evolution with time and the need for uniformity p. 133
Aditya Maitray, Vikas Khetan
DOI:10.4103/0974-620X.216017  PMID:29118485
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REVIEW ARTICLE Top

Choroidal melanoma: A short review with an Indian perspective p. 135
Bikramjit P Pal, Saili Garge, Vikas Khetan
DOI:10.4103/ojo.OJO_234_2016  PMID:29118486
Choroidal melanoma (CM), the most common intraocular tumor in adults, is still a rarity in Asia. Having a high propensity for metastasis with a poor survival, recognizing it early is essential. Although it has typical clinical features, there are instances of simulating lesions. Fine-needle aspiration biopsy can be a valuable tool not only to confirm our clinical suspicion but also aid in prognosticating it. From days of histopathological prognostic markers, we are moving on to genetic markers which are reliably providing insights, helping us in providing a better care for our patients. Eye preservation has taken an all new important meaning in CM with many centers opting for different modalities of radiation. Herein, we try to provide a short synopsis of CM looking into its epidemiology, clinical features, diagnosis, and management. We also look briefly into the role of fine-needle biopsy in managing CM. Being a tertiary referral ocular center in India, we do come across CM; we have shared the preliminary reports of our analysis of managing CM over a 9-year period.
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ORIGINAL ARTICLES Top

Long-term use of 0.003% tacrolimus suspension for treatment of vernal keratoconjunctivitis p. 145
Abdulrahman Mohammed Al-Amri, Sandra Flavia Fiorentini, Maan A Albarry, Ashjan Yousef Bamahfouz
DOI:10.4103/ojo.OJO_232_2014  PMID:29118487
PURPOSE: To evaluate the safety and efficacy of 0.003% tacrolimus suspension for the treatment of refractory vernal keratoconjunctivitis (VKC). MATERIALS AND METHODS: This prospective study included 40 eyes of 20 patients with severe VKC. After discontinuing all other medications, patients were treated with varying doses of 0.003% tacrolimus suspension. All were followed for at least 24 months. Changes in signs and symptoms after treatment were evaluated; adverse events were assessed. The clinical response to the treatment was the most important measurement to achieve the conclusion. RESULTS: The mean age of the patients was 15.7 ± 1.4 years. Two patients discontinued treatment due to severe burning sensation and were excluded from the study. Significant improvements in all signs and symptoms, including itching, foreign body sensation, papillae, and Trantas dots, were seen in all patients 6 weeks after starting topical tacrolimus. Itching was the first symptom to improve. Treatment was gradually reduced, and intervals were increasing between applications. Recurrence occurred in all patients who attempted to discontinue treatment. No additional medications were required to provide relief, and no significant changes in visual acuity or refraction were seen. CONCLUSIONS: The safety and efficacy of 0.003% Tacrolimus suspension treatment for refractory VKC were achieved and it can be considered a useful option instead of steroids, despite the poor compliance in few patients due its adverse effects.
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The role of trabeculectomy in enhancing glaucoma patient's quality of life p. 150
Ibrahim H Binibrahim, Anders K Bergström
DOI:10.4103/ojo.OJO_61_2016  PMID:29118488
PURPOSE: Is to control intraocular pressure (IOP) (up to 21 mmHg), to decrease medical treatment after trabeculectomy and to slow down or stop progression and deterioration in visual fields in glaucoma patients. METHODS: A retrospective study. The charts of all trabeculectomies done in the Department of Ophthalmology at the Skåne University Hospital, Sweden during 2010 were retrospectively evaluated. The study was performed during fall 2012, so the longest follow-up is almost 2 years. RESULTS: In total, 38 patients (21 males and 17 females) underwent trabeculectomy. The IOP was measured in both visits (pre- and post-operative); with a difference of −15.49 mmHg (−50.09%) respectively, showing a very highly statistical significance (P < 0.001). The amount of antiglaucoma drops was measured before and after the trabeculectomy, of average 3.5 drops and 1.2 drops, respectively. Showing a −2.30 difference (−66.41%), illustrating a very highly statistical significant value (P < 0.001). From 36 patients, 17 patients (45%) took Diamox before trabeculectomy, whereas 19 patients (50%) did not. After the trabeculectomy, only 1 patient (3%) took Diamox and 35 patients (92%) stopped taking Diamox, showing a very highly significant statistical value (P < 0.001). The visual field was measured for 13 patients showing a difference of −13.22 (−21.86%) before and after the trabeculectomy. CONCLUSION: Trabeculectomy showed very high statistical significant results regarding IOP reduction and decrease in the amount of topical and systemic antiglaucoma medications.
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Minimal duration cataract surgery with oblique limbal stab incision technique p. 155
Deepti Mahajan, Ram Lal Sharma, Kulbhushan Prakash Chaudhary
DOI:10.4103/ojo.OJO_76_2015  PMID:29118489
PURPOSE: Small incision cataract surgery (SICS) and phacoemulsification with oblique limbal stab incision technique were studied and compared. SETTING: The study was conducted in the Department of Ophthalmology, Indira Gandhi Medical College, Shimla, for 1 year. DESIGN: This was a prospective randomized study. METHODS: One hundred patients undergoing SICS (6–7 mm) were compared with another age- and sex-matched 100 patients undergoing phaco (2.8 mm) surgery with oblique limbal stab incision technique. These two groups were further subdivided into two groups of 50 each. Patients with traumatic cataract, corneal diseases, and preoperative astigmatism >1.5 D were excluded from the study. The patients were subjected to standard preoperative evaluation. Follow-up was done at 1, 2, 4, 6, and 12 weeks. RESULTS: Mean surgically induced astigmatism at 12 weeks was <1 D in both groups (+0.62 D ± 0.34 in Group A and +0.46 D ± 0.39 in Group B) (statistically significant P < 0.0010). Mean surgical duration was 690.09 s in SICS and 792.29 s in phacoemulsification (statistically significant, P < 0.0010). Visual outcome was between 6/6 and 6/9 in 86% of the patients in Group A and 97% of patients in Group B at 12 weeks. CONCLUSION: SICS and phacoemulsification with this technique yield lesser astigmatism than clear corneal and scleral incisions, with the advantage of extension without suturing in complicated cases of phaco and in patients with rigid intraocular lens phacoemulsification gives better BCVA in a larger proportion of patients at 12 weeks.
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Corneal epithelial defect after pars plana vitrectomy p. 162
Ahmed Sulaiman Al-Hinai
DOI:10.4103/ojo.OJO_122_2016  PMID:29118490
AIM: This study aims to study the incidence of corneal epithelial defect (CED) after pars plana vitrectomy (PPV) and associated patient-related risk factors. The incidence of other immediate postoperative complications was also in the scope of this study. DESIGN: Retrospective descriptive case series study. METHODS: Review of electronic medical records of all patients who underwent PPV alone or combined with cataract surgery and/or scleral buckle in a tertiary hospital by one retinal surgeon. All demographic data, surgery notes, and immediate postoperative findings were obtained for all patients. RESULTS: The cohort of the included cases was composed of a total of 168 procedures that were performed in 121 eyes of 106 patients over 5 years. CEDs occurred in 19 eyes (15.7%) of 19 patients (17.9%). Males were affected more than females (90% vs. 10%). Patients with postoperative CED were found to have longer duration of surgery when compared to patients without postoperative CED (P = 0.0038). All cases of CED had a complete resolution of the defects after supportive therapy. Immediate intraocular hypertension (IOH) was found in 30 eyes (24.8%). IOH was controlled in all cases with medical therapy only. Post-PPV immediate complications, other than CED and IOH, occurred in 10.7% of the eyes. These included vitreous hemorrhage, choroidal detachment, corneal edema, anterior chamber fibrin, and hyphema. CONCLUSION: Development of CED is not uncommon after PPV. This complication is more common in males and may be related to prolonged duration of surgery. It also develops more in older patients. CED after PPV can be managed with conservative treatment with good outcome.
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Retinopathy of prematurity like retinopathy in full-term infants p. 167
Dhanashree Ratra, Lala Akhundova, Manmath Kumar Das
DOI:10.4103/ojo.OJO_141_2016  PMID:29118491
PURPOSE: The purpose of this study is to assess clinical characteristics, risk factors, and management outcomes of retinal changes similar to retinopathy of prematurity (ROP), seen in full-term infants. PATIENTS AND METHODS: This is a retrospective review of 46 eyes of 23 patients, born at full term or near full term and diagnosed to have active ROP-like retinopathy or sequelae of ROP-like retinopathy. RESULTS: Mean birth weight (BW) and gestational age (GA) were 2342 ± 923 g (range, 1200–4160 g) and 38.5 ± 1.85 weeks (range, 37–40 weeks). Mean age at the time of diagnosis was 3.5 ± 8.75 years (range, 1 month–16 years). Stage 1 and 2 of retinopathy was seen in 10 eyes (21.7%), threshold disease with plus disease in 12 eyes (26%) and Stage 4 or 5 in 14 eyes (30.4%). Involutional sequelae were noted in 10 eyes (21.7%). Twenty-one eyes (45.6%) underwent appropriate treatment in the form of laser, cryotherapy, or retinal detachment surgery. Eight eyes (17.4%) with advanced sequelae such as total closed funnel retinal detachment and macular fold were not treated. Mean follow-up was 3 years (range, 1 month to 12 years). At the last follow-up, 29 eyes (63%) had a favorable structural outcome (P < 0.001). Among the patients in whom visual acuity could be assessed (16 eyes), favorable visual outcome was noted in 9 eyes (56.2%). Low BW (P = 0.038), multiple births (P = 0.013), respiratory distress syndrome (RDS) (P = 0.001), phototherapy (P = 0.001), and oxygen administration (P < 0.001) were significantly associated with the development of ROP-like retinopathy in these full-term infants. CONCLUSIONS: ROP-like retinopathy can occur in full-term and near full-term infants and can potentially lead to permanent visual impairment. Screening of infants with risk factors such as oxygen administration, RDS, multiple births, and low BW, regardless of GA, may reduce visual impairment.
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Association of ocular findings and outcome in cerebral venous thrombosis p. 173
Samira Yadegari, Alireza Keshtkar Jafari, Elham Ashrafi
DOI:10.4103/ojo.OJO_39_2016  PMID:29118492
BACKGROUND: Cerebral venous thrombosis (CVT) is a potentially life-threatening underdiagnosed disease. Headache is a common but nonspecific finding in CVT. Other features such as ocular finding can assist to correct diagnosis, but their frequency in CVT has not been previously evaluated. The aim of this study is to evaluate the ocular symptoms and signs in CVT and their association with outcome. METHODS: The demographic, clinical, laboratory, radiological, and outcome data were collected and analyzed from patients referred to a tertiary hospital during 6 years. Based on delay from symptom onset to hospital admission, mode of onset was categorized as acute (<2 days), subacute (2–14 days), or chronic (>14 days). RESULTS: Fifty-three patients were identified with a mean age of 33.7 years (17–60 years). Ocular symptoms and signs were the most frequent clinical presentations (77.4%) following headache (83%). Papilledema and diplopia were the main findings in chronic CVTs (P = 0.003 and 0.002, respectively). Proptosis was significantly associated with thrombosis in cavernous sinus (P = 0.00). Otherwise, there was no relationship between any specific ocular findings and the type or number of thrombosed sinus or hemorrhagic infarction. Mortality rate and recurrence in our patients were 3.8% and 5.7%. Absence of proptosis and vision loss was associated with favorable outcome (P = 0.001 and 0.003, respectively). CONCLUSION: Ocular features were among the most common presentation of CVT in every three phases of CVT and could be the sole finding of CVT. Patients who do not have vision loss and proptosis might have a better outcome in CVT.
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Experience of intravitreal triamcinolone acetonide for treatment of diabetic macular edema among Omani population p. 177
Ahmed Al Hinai, Upender Krishen Wali, Tayseer Abdul Rasool, Syed G Rizvi
DOI:10.4103/ojo.OJO_173_2016  PMID:29118493
PURPOSE: The purpose of this study was to evaluate the outcome of intravitreal (IVT) triamcinolone in diabetic macular edema (DME). MATERIALS AND METHODS: A retrospective study of 42 eyes diagnosed clinically and supported with optical coherence tomography (OCT), with DME of more than 300 μm in thickness. All eyes were injected with a single IVT injection of preservative free triamcinolone acetonide (TA) with dose of 4 mg. Patients were subjected to visual acuity (VA) and OCT on each follow-up visit which was continued for 6 months. The total number of IVT injections given was 48. Six eyes had a repeat injection. None of the eyes had any other IVT injection within 6 weeks of TA. Twenty-one eyes were pseudophakic. RESULTS: Mean age of the patients was 58.8 years. The mean central subfield thickness (CST) at baseline was 504.6 μm. At 6 weeks, the mean CST dropped by 183.6 μm (P < 0.00001). At 6-month follow-up, the mean CST had increased by 74.6 μm from 6 weeks level; however, the 6-month mean CST was 109 μ less than mean baseline thickness (P < 0.0005). The mean baseline VA was 0.80 LogMAR units. At 6 weeks, the mean VA dropped by 0.01 LogMAR. At 6 months, VA improved by 0.02 LogMAR units from baseline. Overall, VA improved in 47% eyes, dropped from baseline in 35% eyes, and remained unchanged in 18% eyes. CONCLUSION: Triamcinolone acetonide is a safe, effective, and promising therapy in DME.
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Comparison between Ologen implant and different concentrations of Mitomycin C as an adjuvant to trabeculectomy surgery p. 184
Zeiad H Eldaly, Ali A Maasoud, Mohamed S Saad, Abdelsalam A Mohamed
DOI:10.4103/ojo.OJO_199_2016  PMID:29118494
CONTEXT: Trabeculectomy is the most common surgical procedure for treatment of glaucoma. To improve success rates, adjuvants were utilized as Mitomycin C (MMC) and Ologen implant. AIMS: This study aims to establish efficacy and safety of Ologen implant versus MMC in trabeculectomy. SETTING AND DESIGN: A prospective, comparative clinical study was conducted at the Department of Ophthalmology, Assiut University, between December 2014 and April 2016. SUBJECTS AND METHODS: Patients with primary open-angle glaucoma (OAG), primary narrow-angle glaucoma and secondary OAG were assigned equally to trabeculectomy with Ologen, 0.4 mg/mL or 0.2 mg/mL MMC. The study outcome measures were reduction in intra-ocular pressure (IOP), success rates, survival analysis, and rate of complications. STATISTICAL ANALYSIS USED: SPSS software Version 17.0 (SPSS, Inc., IL, USA) was utilized. RESULTS: Thirty eyes were included in the study. Mean baseline IOP in Ologen, MMC 0.4 and MMC 0.2 groups were 27.43 ± 2.97, 28.4 ± 3.24, and 27.56 ± 2.69 mmHg, respectively. At week 24 follow-up, mean IOP in Ologen, MMC 0.4 and MMC 0.2 groups were 18.55 ± 3.18, 16.2 ± 3.22, and 16.93 ± 3.04 mmHg, respectively. No significant inter-group difference was noticed at any visits. Complete success was achieved in 10%, 40%, and 30%, whereas incomplete success in 70%, 50%, and 60%, respectively in Ologen, MMC 0.4 and MMC 0.2 groups. No treatment group difference was reported by Kaplan–Meier analysis. Shallow anterior chamber occurred more in Ologen and MMC 0.4 groups. A single case of serous choroidal effusion had occurred in MMC 0.4 group. CONCLUSION: Ologen implant is a promising alternative to MMC for improving the success rate of trabeculectomy.
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Emergency visits after corneal transplantation in Yemen p. 193
Mahfouth Abdalla Bamashmus, Saleh A Al-Akily, Hisham A AlAkhalee, Khaldoon O Al-Nuseriy, Marwan H Farhan
DOI:10.4103/ojo.OJO_217_2016  PMID:29118495
PURPOSE: Awareness of symptoms and signs of possible complications after corneal transplantation is very important. Early presentation can enhance long-term survival of the cornea. This study evaluates the reasons for emergency presentation and management of postcorneal transplantation complications. PATIENTS AND METHODS: This retrospective study included a total of 134 postkeratoplasty patients at the cornea unit in Yemen Magrabi Eye Hospital in Sana'a between 2008 and 2010. RESULTS: The most common indication for keratoplasty was keratoconus in 103 patients (76.9%) followed by bullous keratopathy (4.5%) and corneal dystrophy (4.5%). 80 (59.7%) patients presented for emergency visits. Pain and foreign body sensation were the main presenting symptoms. Loose irritating sutures (29.9%) and graft rejection (10.4%) were the most common diagnoses. Twelve patients (8.9%) were admitted to the hospital for re-suturing. CONCLUSION: Proper postoperative care is critical for a successful keratoplasty; early intervention of sight-threatening complications increases the chance of graft survival and best-obtained vision. In our corneal transplantation service, all patients are routinely instructed to arrange a same day emergency visit if they experience any symptom in eyes that have undergone keratoplasty.
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Visual outcome and complications of various techniques of secondary intraocular lens p. 198
Santosh Kumar, Satyaprakash Singh, Gyanendra Singh, Nilesh S Rajwade, Sushank A Bhalerao, Vinod Singh
DOI:10.4103/ojo.OJO_134_2016  PMID:29118496
BACKGROUND/AIMS: The purpose of this study was to compare and evaluate the visual outcome and complications of various techniques of secondary intraocular lens (IOL) (i.e., anterior chamber IOL [ACIOL], suture-fixated posterior chamber IOL [PCIOL], and glue-fixated PCIOL). STUDY DESIGN AND SETTING: This was a randomized, prospective, interventional, comparative, clinical trial study. SUBJECTS AND METHODS: Patients of either sex having aphakia and lacking posterior capsular support were included in the study, and patients having corneal or scleral pathology, optic atrophy, uncontrolled glaucoma, retinal detachment, and other retinal pathology were excluded from the study. The patients were divided into three groups after comprehensive ophthalmological examination – Group A (secondary ACIOL) included 44 patients, Group B (secondary scleral-fixated sutured PCIOL) included 32 patients, and Group C (fibrin glue-fixated sutured PCIOL) included 34 patients. RESULTS: A total of 110 patients were included in this study, of which 59 (53.63%) were males and 51 (46.37%) were females. The best-corrected visual acuity (VA) after 6 weeks was in the range of 20/60–20/40 in 36.4% of Group A and 40.6% of Group B patients. In Group C, 52.9% of patients had best-corrected VA in the range of 20/30–20/20. The overall complications were less in glued PCIOL group. CONCLUSION: It can be concluded that fibrin glue-assisted PCIOL implantation provides better visual outcome with minimal complications in eyes with deficient capsular support.
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Comparing ganglion cell-inner plexiform layer thickness with focal and global responses on multifocal electroretinogram in glaucoma p. 205
Aparna Rao, Rohit V Chandrashekhar, Debananda Padhy, Sujoy Mukherjee, Gopinath Das, Sarada Sarangi
DOI:10.4103/ojo.OJO_15_2015  PMID:29118497
BACKGROUND: The aim of this study was to evaluate responses on multifocal electroretinogram (mfERG) with ganglion cell-inner plexiform layer (GCIPL) thickness on cirrus spectral-domain optical coherence tomography (SD-OCT) in glaucoma. METHODS: All diagnosed glaucoma patients attending glaucoma services at our institute from November 2012 to April 2013 were screened for this observational hospital-based study. Controls included patients attending our outpatient services for general eye checkup. Structural parameters on SD-OCT including GCIPL and retinal nerve fiber layer (RNFL) thickness were compared with functional parameters on mfERG in early (mean deviation <−6 dB), moderate (−6 to − 12 dB), and controls. RESULTS: A total of 54 cases and 33 controls fulfilling inclusion criteria were recruited for the study. The average and minimum GCIPL thickness did not vary significantly between early and control eyes while moderate glaucoma eyes had marginally lower GCIPL thickness than early glaucoma eyes. The GCIPL minimum thickness on univariate regression was found to be influenced by N2 amplitudes (β = −0.5, P = 0.012) and global N2P1amplitudes (β =0.6, P = 0.01) in moderate glaucoma. In early glaucoma, these were influenced only by RNFL parameters with no association with functional mfERG responses. Multivariate logistic regression identified global N2P1 amplitude to be significantly influencing GCIPL average and minimum thickness (P = 0.01 and 0.02, R2 = 47.8% and 52.3%, respectively) in moderate glaucoma. Maximum area under the curve was found for GCIPL minimum (95% confidence interval [CI] 0.53–0.81) and N2P1 amplitude (95% CI 0.55–0.80). CONCLUSIONS: The second order responses N2P1 and N2 amplitude on mfERG predict function that correlated with structural GCIPL thickness in moderate glaucoma. Early glaucoma may be best predicted by RNFL thickness rather than on mfERG responses.
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Comparison of clinical outcome between 23-G and 25-G vitrectomy in diabetic patients p. 213
Eman Abo Taleb, Manish P Nagpal, Navneet S Mehrotra, Kalyani Bhatt, Sangeeta Goswami, Yewande O Babalola, Abdulrahman Noman
DOI:10.4103/ojo.OJO_42_2016  PMID:29118498
PURPOSE: To compare the clinical outcomes and complications between 23-G and 25-G vitrectomy in patients with diabetic vitreous hemorrhage (VH). MATERIALS AND METHODS: A retrospective comparative study comprising 69 eyes (36 eyes in 23-G group and 33 eyes in 25-G group) of 65 patients who underwent vitrectomy with air tamponade for diabetic vitreous hemorrhage (VH) with at least 6 months of follow-up was conducted. RESULTS: There were no significant differences between the two groups in age, gender, bilaterality, type of diabetes, presence of hypertension, lens status, and previous argon laser photocoagulation state (P > 0.05). Best-corrected visual acuity (BCVA) of both groups at postoperative 1 month logarithm of the minimum angle of resolution (logMAR) (1.06 ± 0.99, 0.90 ± 0.96), 3 months logMAR (1.07 ± 0.93, 0.83 ± 0.85), and 6 months logMAR (1.03 ± 0.89, 0.83 ± 0.85) significantly improved from the preoperative BCVA logMAR (2.03 ± 0.83, 2.15 ± 0.99) for 23-G group, 25-G group, respectively (P < 0.0001). There was no significant difference in BCVA between the two groups preoperatively and at 1, 3, and 6 months postoperatively (P = 0.566, 0.506, 0.333, and 0.445, respectively), incidence of intraoperative wound suturing (21.4%, 15.2%), postoperative hypotony (0.0%, 0.0%), early postoperative VH (POVH) (11.1%, 15.2%), late POVH (5.6%, 0.0%), retinal detachment (2.8%, 6.1%), neovascular glaucoma (92.8%, 9.1%), and endophthalmitis (0.0%, 0.0%) for 23-G group, 25-G group, respectively (P > 0.05). CONCLUSION: 25-G vitrectomy is as effective for PDR as 23-G vitrectomy.
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Causes and management of small pupil in patients with cataract p. 220
Ioannis Halkiadakis, Irini Chatziralli, Evangelos Drakos, Michail Katzakis, Sotirios Skouriotis, Eleni Patsea, Panagiotis Mitropoulos, Artemios Kandarakis
DOI:10.4103/ojo.OJO_102_2016  PMID:29118499
BACKGROUND: The purpose of the study was to present the causes and management of small pupil (<6 mm) in Greek patients with cataract. METHODS: About 1144 consecutive patients with cataract comprised the study group. The pupil size was measured after maximal dilation by means of Rosenbaum cards and Colvard pupillometer. Dilation regimen included phenylephrine 10%, tropicamide 1%, cyclopentolate 1%, and ketorolac trometamol 0.5% administered 3 times at 5 min intervals starting 1 h before surgery. The presence of possible risk factors for small pupil was recorded. The need of additional maneuvers and devices to dilate the pupil during cataract surgery was examined, and the complication rate in cases with small pupils was recorded. RESULTS: Small pupil was observed in 78 out of 1144 eyes (6.8%, 95% confidence interval = 5.2%–8.8%). Nine eyes had pupil size <4 mm (0.78%) preoperatively. Six cases (0.52%) developed intraoperative pupillary miosis. The major cause of small pupil was pseudoexfoliation (PEX) in 47.4% (37/78) of patients. No significant associations were observed regarding age, gender, history of diabetes mellitus, the maturity of cataract, and phacodonesis. Techniques for small pupil management included pupil stretching in 14 cases (17.9%), use of iris hooks in 6 cases (7.7%), iris sphincter cuts in 2 cases (2.6%), and placement of a Malyugin Ring in 4 cases (5.1%). Seven eyes (9%) with small pupil had capsular rupture versus 16 eyes (1.5%) with normal dilation (P < 0.001). CONCLUSIONS: Small pupil is not very common in Greek population, is mostly caused by PEX, and it is associated with increased complication rate.
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CASE REPORTS Top

Iridoplasty of fixed-dilated pupil (Urrets-Zavalia syndrome) after deep anterior lamellar keratoplasty p. 225
Efthalia Ntora, Nikolaos Ziakas
DOI:10.4103/ojo.OJO_177_2015  PMID:29118500
A 38-year-old woman with advanced keratoconus initially developed Urrets-Zavalia Syndrome (UZS) in the left eye after deep anterior lamellar keratoplasty. During the uneventful surgery, a 7-mm-wide pupil unresponsive to light was noticed. On the first postoperative day, intraocular pressure (IOP) was elevated up to 45 mmHg with shallow anterior chamber (AC). A peripheral iridotomy in 2 o'clock position was conducted and a fixed combination of brinzolamide 1% and timolol 0.5% was administered topically. In the subsequent postoperative period, IOP was successfully reduced, but the patient reported severe photophobia, glare, and decreased vision. Twelve months after surgery, her best-corrected visual acuity (BCVA) was 20/200, the fixed-dilated pupil persisted, iris was atrophic, and lens opacities were detected. She was submitted for phacoemulsification cataract surgery combined with iridoplasty using the closed chamber slipping suture technique. Three months after surgery, her BCVA was 20/25, pupil diameter remained stable at 4 mm, and glare symptoms were significantly reduced. A very adequate cosmetic outcome was also achieved. Iridoplasty in postkeratoplasty patient with unilateral UZS was effective in improving patient's visual function disability and restoring residual anisocoria. This technique can be applied as a single procedure or combined with another one for the management of UZS.
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Novel PDE6A mutation in an Emirati patient with retinitis pigmentosa p. 228
Pratibha Nair, Abdul Rezzak Hamzeh, Ethar Mustafa Malik, Darshjit Oberoi, Mahmoud Taleb Al-Ali, Fatma Bastaki
DOI:10.4103/ojo.OJO_213_2016  PMID:29118501
Mutations in the PDE6A gene are known to cause a form of retinitis pigmentosa (RP43), characterized by progressive retinal degeneration. We describe an Emirati patient with RP caused by a novel mutation in PDE6A. Clinical diagnosis of RP was made based on clinical evaluation and electroretinograms. The molecular analysis involved performing whole-exome sequencing, which enabled the identification of a homozygous 2-bp deletion (c.1358_1359delAT) in PDE6A, which was predicted to result in a frameshift and premature termination (p.Ile452Serfs*7). The mutation completely removed the catalytic PDEase domain in the protein. The parents were found to be heterozygous carriers of the variant. We thus report the first known case of a pathological variant in the PDE6A gene from the Arabian Peninsula.
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Bilateral sensorineural hearing loss secondary to sympathetic ophthalmia in a human leukocyte antigen-A2 positive patient p. 232
Konstantinos T Tsaousis, Vasileios E Konidaris, Theodoros Empeslidis
DOI:10.4103/ojo.OJO_170_2014  PMID:29118502
We report a case of sympathetic ophthalmia 1 month following trauma in a 71-year-old immunocompetent female patient of Indian origin. The patient was hospitalized with signs and symptoms of meningism, ataxia, and neurosensory deafness. We explore and provide further clinical evidence in supporting the hypothesis of antigen cross-reactivity derived from tissues with common neural crest embryological background such as the uvea and cells of the labyrinth. The patient was human leukocyte antigen-A2 positive and treatment with oral steroids and cyclosporine has managed to have favorable results and control the inflammation.
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Inadvertent intralenticular dexamethasone implant: 1-year follow-up and management p. 235
Cagatay Caglar
DOI:10.4103/ojo.OJO_47_2016  PMID:29118503
We report the case of a 72-year-old female who developed macular edema (ME) due to hemicentral retinal vein occlusion in her right eye. A dexamethasone implant was inadvertently injected into the crystalline lens. The patient was followed without repositioning of the dexamethasone implant during the 12 months. Besides, the posterior subcapsular cataract and ME had progressed significantly; hence, cataract extraction and intravitreal ranibizumab injection were performed in the same session. A three-piece intraocular lens was implanted in the sulcus with optic captured, and then intravitreal ranibizumab injection was performed. The patient had an uncomplicated postoperative recovery. At 2 months, best-corrected visual acuity was 0.7, and the macula was dry.
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Bilateral early capsular block syndrome following implantation of the new trifocal toric lens p. 238
Ashbala Khattak
DOI:10.4103/ojo.OJO_67_2016  PMID:29118504
A young patient underwent phacoemulsification with endocapsular implantation of trifocal toric lens in both eyes (AT LISA tri toric 939 MP, Carl-Zeiss, Germany). One-week postsurgery, he developed capsular block syndrome (CBS) in both eyes. There was deterioration of uncorrected visual acuity at 1-week postsurgery, with a myopic shift of 2.5 diopters (D) in the right eye and 2.0 D in the left eye. The intraocular pressure was only elevated in the left eye. Neodymium: yttrium-aluminum-garnet laser posterior capsulotomy resolved the block successfully in both eyes. A thick lens with a plate haptic design may have contributed to the early CBS.
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Descemet's membrane macroperforation during interface irrigation in big bubble deep anterior lamellar keratoplasty p. 241
Mohammed Ziaei, Susan E Ormonde
DOI:10.4103/ojo.OJO_66_2016  PMID:29118505
This report describes the macroperforation of descemet's membrane (DM) during irrigation of the interface following successful removal of stromal tissue in big bubble (BB) deep anterior lamellar keratoplasty (DALK). A 42-year-old woman with keratoconus underwent a BB DALK procedure. After successful formation of Type 2 bubble and removal of stromal tissue, interface irrigation was performed to remove residual viscoelastic. This led to a macroperforation of DM, and the case was converted to penetrating keratoplasty. To the best of our knowledge, this is the first report of such a complication in the literature. Recognition of a 2 bubble formation during pneumodissection should alert the surgeon to a high risk of DM rupture. We advise against the removal of DM from the donor in such cases as an added measure of safety.
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Localized retinal degeneration secondary to Waldenström's macroglobulinemia p. 244
Dhanashree Ratra, Vineet Ratra, Mansi Kishnani
DOI:10.4103/ojo.OJO_126_2016  PMID:29118506
A 52-year-old man, treated for Waldenström's macroglobulinemia (WM), continued to experience decreased vision even after 24 months. He was evaluated using multimodal imaging and electroretinography. The retina did not show any hyperviscosity changes but revealed a yellow lesion at macula with atrophic changes causing a pattern on fluorescein angiography similar to a leopard's skin. Optical coherence tomographic imaging revealed uniformly reflective material deposited in the outer retina with degeneration of outer retinal layers. Full-field electroretinography was normal, but multifocal electroretinography revealed reduced foveal responses. This case highlights the degenerative effects of long-standing immunogammopathy maculopathy in WM.
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Periventricular leukomalacia with −16 DS high myopia in a 2½ months old infant: A rare case presentation p. 247
Praveen Jeyaseelan, Tulika Kar, P Vijayalakshmi
DOI:10.4103/ojo.OJO_194_2015  PMID:29118507
Periventricular leukomalacia (PVL) is coagulation necrosis of white matter seen in preterm, low birth weight (LBW) infants and associated with a range of ocular manifestations. We report a case of 2½ months old (47 weeks gestational age) female infant with PVL associated with bilateral high myopia (−16 DS). On examination, child had difficulty in tracking objects and inferior field defect with preference for superior gaze. She was prescribed spectacles and visual stimulation exercises to preserve existing vision and prevent amblyopia. Periventricular leukomalacia can affect full-term infants although it is more common in preterm and LBW infants. All preterm, LBW infants, and those with positive neuroradiological findings must be assessed by an ophthalmologist as early as possible to detect the associated ocular manifestations.
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Treatment of unilateral zone I cytomegalovirus retinitis in acute lymphoblastic leukemia with oral valganciclovir and intravitreal ganciclovir p. 250
Koushik Tripathy, Kanhaiya Mittal, Pradeep Venkatesh, Sameer Bakhshi, Rohan Chawla
DOI:10.4103/ojo.OJO_190_2016  PMID:29118508
Cytomegalovirus retinitis (CMVR) is an opportunistic infection seen in immunocompromised patients, especially suffering from acquired immune deficiency syndrome. It is uncommonly seen in hematological malignancies and in patients on immunosuppressants. The authors present a 12-year-old girl with unilateral CMVR who was on maintenance phase therapy for mixed phenotype (B/myeloid) leukemia. Serology for human immunodeficiency virus was negative. The child was successfully treated with oral valganciclovir and repeated intravitreal ganciclovir injections. CMVR in pediatric population with leukemia can be successfully treated with oral valganciclovir and intravitreal ganciclovir injections.
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CLINICAL IMAGES Top

Epiretinal membrane development after submacular perfluorocarbon liquid removal p. 253
Parijat Chandra, Vinod Kumar, Brijesh Takkar, Atul Kumar
DOI:10.4103/ojo.OJO_39_2015  PMID:29118509
Optical coherence tomography of submacular perfluorocarbon liquid and its safe removal with a small gauge cannula have been presented in the report. This case was complicated by development of an epiretinal membrane, though visual acuity was preserved.
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Foveal neovascularization in a patient with Type 2 diabetes mellitus p. 255
Anisha Seth, Basudeb Ghosh, Vishaal Bhambhwani, Anika Gupta, Usha K Raina
DOI:10.4103/ojo.OJO_64_2015  PMID:29118510
Retinal neovascularization in Diabetes mellitus (DM) is commonly seen at the optic disc and mid-periphery. It is rare at the fovea as the fovea is an avascular zone and there are very few case reports of foveal neovascularization in Type 1 DM. We report a case of unilateral foveal neovascularization in Type 2 DM.
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Pigmented ciliary body medulloepithelioma in a newborn infant p. 257
Parag K Shah, Prajna Meeralakshmi, R Shanthi, VR Saravanan, Narendran Kalpana, Venkatapathy Narendran
DOI:10.4103/ojo.OJO_1_2017  PMID:29118511
Ciliary body medulloepithelioma is a nonpigmented tumor which presents during the first decade of life. It is rarely seen in newborn infants. We report a pigmented medulloepithelioma in a newborn infant, which showed a rapid growth. Ciliary body medulloepithelioma should be considered in the differential diagnosis in a newborn infant presenting with leukocoria.
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Multiple white dots on posterior capsule p. 259
Chidanand Kulkarni
DOI:10.4103/ojo.OJO_206_2015  PMID:29118512
A 38 years old female patient presented with unilateral cataract without known predisposing factors. During cataract extraction, the surgeon noticed multiple white dots scattered over inner surface of the posterior capsule. These dots were of uniform size and shape. They were distributed uniformly and involved all the areas of the posterior capsule and extended up to equator. The surgeon decided to implant IOL and tackle the opacities in a later setup. In spite of the extensive opacities, the patient's Uncorrected Corrected Visual Acuity (UCVA) at six weeks was 6/9, Best Corrected Visual Acuity(BCVA) was 6/6 and near vision with correction was N6. The other eye was normal. This case is reported for the peculiar appearance and distribution of the capsular opacities and good visual outcome in spite of this.
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CLINICAL QUIZ Top

The shining eye p. 261
Swati Singh, Swathi Kaliki
DOI:10.4103/ojo.OJO_222_2015  PMID:29118513
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Progressive visual loss with systemic symptoms in an adult p. 262
Sitara Azeem, Mohamed Al-Abri, Ahmed Al-Hinai, Nawal Al-Fadhil
DOI:10.4103/ojo.OJO_110_2017  PMID:29118514
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Two brothers with reduced vision p. 263
Anupam Singh, Barun Kumar, Bhawna Piplani, Chirag Bahuguna, Gaurav Kumar
DOI:10.4103/ojo.OJO_12_2015  PMID:29118515
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LETTER TO THE EDITOR Top

Retrobulbar alcohol injection for phantom eye pain syndrome in bilateral eviscerated orbit p. 264
Venkatakrishnan V Jaichandran, Srinivasan Bhaskar
DOI:10.4103/ojo.OJO_216_2016  PMID:29118516
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