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   Table of Contents - Current issue
Coverpage
May-August 2019
Volume 12 | Issue 2
Page Nos. 71-141

Online since Tuesday, June 4, 2019

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EDITORIAL COMMENTARY  

Vitrectomy versus Phaco-vitrectomy Highly accessed article p. 71
Ahmed Sulaiman Al-Hinai
DOI:10.4103/ojo.OJO_105_2019  
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REVIEW ARTICLE Top

Android mobile applications in eye care Highly accessed article p. 73
Siddharth Karuppasamy Karthikeyan, Rajesh Thangarajan, Nagarajan Theruvedhi, Krithica Srinivasan
DOI:10.4103/ojo.OJO_226_2018  
Google Play Store was used to search for eye care-related applications the android simulator using various general terms related to eye care to review and categorize various interactive eye care-related applications in android platform from the details available in the application website. Data collected from application description and application developer's webpage include target audience, category of apps, estimated number of downloads, average user rating, involvement of eye care professionals in developing the application, and cost of the app. All these data were collected only from the details provided in the application website considering on online user perspective and the developers were not contacted to collect any other details. In total, 475 applications were identified and grouped into 13 categories depending on the type of service the application provide. Out of which, only 107 (22.53%) applications had mentioned about the eye care professional involvement in their design or development of the application. The applications were also stratified according to the target audience, and many had no user rating with very few downloads. The lack of evidence-based principles and standardization of application development should be taken into consideration to avoid its negative impact on the community, especially in eye care.
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ORIGINAL ARTICLES Top

The epidemiology of ocular trauma in Northern India: A teaching hospital study p. 78
Rajendra P Maurya, Tanmay Srivastav, Virendra Pratap Singh, CP Mishra, Abdullah Al-Mujaini
DOI:10.4103/ojo.OJO_149_2018  
AIM: The aim was to determine the epidemiology of ocular trauma in a large teaching hospital in northern India over 4 years from 2010 to 2014. MATERIALS AND METHODS: This prospective, hospital-based, observational study was conducted at the Ophthalmology and Emergency Outpatient Departments of S. S. Hospital, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India, from March 2012 to February 2016. Detailed history was taken with special consideration to time, place and session of trauma, mode of injury, and type and nature of traumatic agent. All patients were thoroughly examined as per the standard clinical procedures to identify the type, extent, and severity of injury and impact on ocular structure and vision. Follow-up period was 6 months. Statistical analysis was based on age, sex, residence, marital status, occupation, per capita income, type of trauma and nature of damage, etc. RESULTS: Out of 402 patients, 293 (72.9%) were male and 109 (27.1%) were female. Overall male-to-female sex ratio was 2.7:1. Patients were aged between 2 and 70 years (mean: 26.48 ± 15.88, median: 23 years). The most vulnerable age group was 6–15 years (24.38%) followed by 16–25 years (23.88%). Maximum patients belonged to rural background (61.94%). The extent of ocular trauma was 3.93% (95% confidence interval: 3.23–4.63). Majority of participants were single (78.11%) and rest were married. About 112 (27.9%) participants were illiterate and 24.4% had primary education only. One hundred and eighty-eight (46.8%) participants belonged to lower and lower middle socioeconomic status. The cases were clustered in Rs. 1000–5000 per capita income. Most of the injuries occurred in summer season (46.18%) and in afternoon between 12.00 and 17.59 h (48.8%). Majority of trauma occurred away from home (66.20%) mainly on street (28.6%) and playground (9.2%). The most common injury was nonoccupational (82.3%) including sports related (23.9%) and road traffic accident (23.6%). Mechanical injuries were accounted for 89.3% of all eye injuries, and most common source was wooden object (24.9%) followed by metallic objects (20.9%). Traumatic agents were blunt and sharp in 56% and 17% of cases, respectively. Majority of traumatic agents were solid (82.1%). Seven percent of victims were drowsy during trauma and 98.4% of participants were not using any protective device at the time of injury. In 60.7% of cases, time elapsed between injury and treatment was between 1 and 24 h. Around 44.5% had isolated ocular trauma and rest 55.5% were polytrauma cases. Three hundred and sixty-eight (91.5%) participants had unilateral involvement and 8.5% had bilateral involvement. Almost 52.8% had injuries of adnexa and 32.8% had globe injuries. More than half of the study participants had ≥3 ocular structure involvement. After 6 months, 14.8% of the right eyes and 25.5% of the left eyes showed poor outcome. CONCLUSION: This study highlights epidemiology of ocular trauma in northern India. Mass health education and awareness about risk of ocular trauma, morbidity caused by delayed presentation, and need to adopt safety or preventive strategies should be focused, especially during travel, playground, and at workplace.
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The feasibility and efficacy of intraoperative laser retinopexy in scleral buckling surgery p. 84
Roshija Khanal Rijal, Deepesh Mourya
DOI:10.4103/ojo.OJO_255_2017  
BACKGROUND: This study was performed to assess the feasibility and efficacy of intraoperative laser retinopexy in scleral buckling (SB) surgery. MATERIALS AND METHODS: This was a retrospective, noncomparative, and interventional study. Records of 25 patients who had undergone intraoperative laser retinopexy during SB were retrospectively analyzed. RESULTS: All patients were phakic and macula was off in all cases. Adequate intraoperative laser retinopexy was achieved in 22 (88%) patients, and 3 (12%) patients required additional postoperative laser. Retina was attached in all patients at 6-month follow-up. CONCLUSION: Intraoperative laser retinopexy can give comparable results to cryoretinopexy with lesser postoperative complications in SB surgery. Although further comparative studies are needed, this study establishes the feasibility of intraoperative laser retinopexy in SB which has never been described before in the literature as per our knowledge.
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Sensitivity and specificity of teachers for vision screening among primary school children in South India p. 88
R Muralidhar, P Vijayalakshmi
DOI:10.4103/ojo.OJO_55_2016  
AIMS: This study aims to determine the sensitivity and specificity of vision screening by school teachers among primary school children. SETTINGS AND DESIGN: Prospective nonrandomized clinical trial. SUBJECTS AND METHODS: The study was carried in primary school children of Madurai, Tamil Nadu from April 2007 to October 2007. Sixty-five primary school teachers from 57 schools around Madurai, Tamil Nadu, India, underwent a half-day training programme at the hospital. Each teacher on return to the school screened around a hundred children using the tumbling E. All screened children were subsequently screened by a team from the hospital. The optometrists used tumbling E (Snellen's 20/30 and Early Treatment of Diabetic Retinopathy Study (ETDRS) 20/32) to check the vision of all children. Any child complaining of defective vision or noted to have defective vision on screening underwent a comprehensive ophthalmic evaluation. The sensitivity and specificity of teacher screening was assessed based on the data obtained. RESULTS: Screening was completed for 5150 children. The prevalence of vision <20/30 was 2.82%. Teacher screening was noted to have a sensitivity of 24.8% and a specificity of 98.65%. Tumbling E ETDRS screening by the optometrist had the highest sensitivity of 94.48% and specificity of 97.09%. CONCLUSIONS: Our study shows that vision screening by trained optometrists is a very useful tool to identify visual impairment in primary school children. Measures need to be taken to improve the sensitivity of teacher screening before recommending its generalized use.
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Risk factors for endothelial cell damage in diabetics after phacoemulsification p. 94
Niruban Ganesan, Renuka Srinivasan, K Ramesh Babu, Muthukrishnan Vallinayagam
DOI:10.4103/ojo.OJO_200_2017  
Background: To assess the corneal endothelium, central corneal thickness and the factors associated with endothelial cell damage after phacoemulsification in diabetics in comparison with non-diabetics Methods: It was a case control study with 80 eyes each in the diabetic group and the control group. Intraoperative mydriasis, effective phaco time (EPT) and postoperative inflammation were measured. Preoperative, 1st week, 6th week and 3rd month postoperative endothelial cell density (ECD), coefficient of variation (CV), hexagonality and central corneal thickness (CCT) were also measured using Konan noncon robo specular microscope (Model - NSP 9900). Results: In the control group, patients in the age group of 60-69 years were 3.8 times more at risk of ECL compared to patients in the age group of 50-59 years. Patients in whom EPT was ≥0.50 min, were 8.8 times more at risk of ECL when compared to patients in whom EPT <0.25 min. In the diabetic group, patients who had an inflammatory score of 1+ in the first postoperative week; also had 5.7 times more risk of ECL when compared to patients in whom the inflammatory score was 0.5+ in the first postoperative week. There was a significant increase in CV (p-0.03) and CCT (p-0.03), significant decrease in the hexagonality (p-0.01) and no statistically significant difference in the endothelial cell loss (ECL) (p-0.34) in diabetics after phacoemulsification when compared to controls. Conclusion: The present study reveals postoperative inflammation as a risk factor for ECL in diabetics and not intraoperative mydriasis and EPT.
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Twenty-four-month real-world visual outcomes of intravitreal aflibercept as monotherapy for the treatment of neovascular age-related macular degeneration p. 99
Thomas Siempis, Mariam El Abiary, Radhika Patel, Manish Gupta
DOI:10.4103/ojo.OJO_24_2018  
BACKGROUND: Aflibercept is widely used as a treatment for neovascular age-related macular degeneration (nAMD). Nevertheless, there is no consensus in the optimal injection frequency in the 2nd year of treatment along with little real-world data on visual outcomes. On that basis, the primary aim of this study was to assess the visual acuity (VA) and the total number of injections needed on average for these patients during the 24-month follow-up. MATERIALS AND METHODS: This is a retrospective observational study from an electronic medical record of consecutive patients treated with intravitreal aflibercept (both naïve and nonnaïve eyes) who had completed the 24-month follow-up since the commencement of treatment. Patients followed the VIEW protocol in year 1 whereas in year 2, an as required approach/Pro Re Nata (PRN) was used. RESULTS: Eighty-seven eyes of 78 patients were analyzed. 43.7% were nonnaive eyes. Baseline VA for all eyes (logMAR) was 52.6 letters, improving to 56.2 letters at 12 months and 55 at 24 months. Almost 83.9% of the treated eyes (81.3% of the patients) did not experience any significant visual loss receiving on average of 9.9 injections in the 24 months of follow-up and attending the hospital eye service 20.3 times in total. CONCLUSIONS: Aflibercept as monotherapy for the treatment of nAMD is associated with good 2nd year outcomes in a real-world setting using the PRN approach in year 2 and fewer injections comparing to the clinical studies, but a higher proportion of follow-up visits compared to the treat and extend regimen.
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Outcomes of lacrimal gland injection of botulinum toxin in functional versus nonfunctional epiphora p. 104
Swati Singh, Akshay Gopinathan Nair, Md Shahid Alam, Bipasha Mukherjee
DOI:10.4103/ojo.OJO_52_2018  
PURPOSE: The purpose of this study is to assess the outcomes of lacrimal gland injections of botulinum toxin A (BoNTA) for epiphora secondary to lacrimal drainage disorders and functional epiphora. METHODS: This was a retrospective interventional case series where cases were divided into functional and nonfunctional epiphora. RESULTS: A total of 37 eyes of 31 patients were identified: 13 males and 18 females. The mean age was 52 years (median = 53, range 29–86). The functional epiphora group had seven patients (8 eyes), subcategorized into hypersecretion (5), crocodile tears (1), and post seventh nerve palsy (1). Obstructive group (nonfunctional) had 24 patients (29 eyes), subcategorized into proximal canalicular block (12), common canalicular block (6), punctal stenosis (3), posttraumatic nasolacrimal duct obstruction (1), and partial nasolacrimal duct obstruction (1). Median preinjection Munk scores were similar in both groups (Grade 4). At 1 month, the median Munk score improved to 1 and 2 in functional and nonfunctional groups, respectively, after receiving a median dose of 4 units of BoNTA. Median reduction in Munk score was 75% in functional group versus 50% in nonfunctional group (P = 0.07). No difference in terms of complications was noted (transient ptosis). CONCLUSIONS: Reduction in epiphora after lacrimal gland injection of botulinum toxin is seen in cases with functional epiphora as well as those with a physical obstruction in the lacrimal drainage pathway. While the symptomatic improvement was more in functional epiphora, the difference between the two groups was not statistically significant.
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Evaluation of interface reflectivity and corneal aberrations following Descemet's stripping automated endothelial keratoplasty p. 108
Hamid Khakshour, Malihe Nikandish, Maryam Salehi, Haleh Ghooshkhanehei, Amirhosein Vejdani
DOI:10.4103/ojo.OJO_188_2017  
PURPOSE: This study aims to evaluate visual outcome after Descemet's membrane stripping automated endothelial keratoplasty (DSAEK) and relate to interface and corneal higher-order aberrations (HOAs). MATERIALS AND METHODS: We enrolled 16 eyes of 16 patients (eight males and eight females) in this interventional case series and followed DSAEK operation for about two to 20 months. OCULUS Pentacam, as well as other ophthalmic evaluations in follow-up visits, examined interface reflectivity and HOAs. Statistical relations were analyzed. RESULTS: There was statistically significant correlation between interface reflectivity and best corrected visual acuity (BCVA) (r = 0.56, P = 0.021). Pachymetry (central corneal thickness) and BCVA had a moderate correlation (r = 0.6, P = 0.013). There was no statistically significant correlation between pachymetry and follow-up time (r = −0.36, P = 0.16). Negative correlation between follow-up and interface reflectivity was also not statistically significant (r = −0.24, P = 0.35). Coma had a significant correlation with BCVA in cornea and cornea front maps (r = 0.74, P = 0.009 and r = 0.71, P = 0.013, respectively). CONCLUSION: Significant correlation between interface reflectivity and BSCVA was found, and anterior corneal HOAs are significantly higher than posterior HOAs.
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Refractive error of Saudi children enrolled in primary school and kindergarten measured with a spot screener p. 114
Ziaul Haq Yasir, Nada Almadhi, Salma Tarabzouni, Abdulrahman Alhommadi, Rajiv Khandekar
DOI:10.4103/ojo.OJO_62_2017  
AIMS: To evaluate the refractive status of young Saudi schoolchildren with a “Spot Screener.” SUBJECTS AND METHODS: This cross-sectional study was conducted from January to July 2016 in Riyadh, Saudi Arabia. Children of kindergarten (3–5 years) and grades 1 and 2 (6–7 years) were screened for refractive error (RE) using the handheld Spot Screener (Welch Allyn, Skaneateles Falls, NY, USA). Data were collected on age, gender, and spectacle use. The pass/fail notation from the Spot Screener and the RE were documented. Children with a “fail” were re-tested with an autorefractor (AR). The rate of agreement was evaluated for the spherical equivalent (SE) from the Spot Screener and AR. RESULTS: We examined 300 schoolchildren and 114 preschool children. The prevalence of RE was 22% in schoolchildren and 25% in preschoolers. There were 183 (61%) hyperopes, 110 (36.7%) myopes, 6 (2%) emmetropes, and 29 (9.7%) astigmats (>2 D cylinder) in grade 1 and 2. There were 85 (74.6%) hyperopes, 22 (19.3%) myopes, 7 (6.1%) emmetropes, and 10 (8.8%) astigmats among preschoolers. The SE differed between the AR and the Spot Screener in 17 (28%) children of 61 failed Spot Screener tests. Accommodation (9, 53%) and high astigmatism (8, 47%) were the main underlying causes of the difference. The Spot Screener could identify RE for the first time in 51 (17%) schoolchildren and 26 (22%) preschoolers. End-users suggested that Spot Screener was child-friendly and quick to test RE. CONCLUSIONS: The Spot Screener could be a good initial screening tool for RE in young schoolchildren.
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CASE REPORTS Top

Retinoblastoma in a 23-year-old adult treated with primary intra-arterial and intravitreal chemotherapy p. 119
Jeffrey F McMahon, Pascal Jabbour, Carol L Shields
DOI:10.4103/ojo.OJO_162_2018  
Intra-arterial chemotherapy (IAC) continues to provide a globe-sparing alternative as primary treatment for retinoblastoma with few adverse events. While there is growing evidence to highlight the utility of IAC in children with retinoblastoma, adult cases treated with primary IAC have not previously been characterized. We describe a rare case of Group D retinoblastoma in a 23-year-old adult treated successfully with IAC and intravitreal chemotherapy. This is a retrospective case report of a single patient. Subsequent to IAC and intravitreal chemotherapeutic treatments, at last follow-up 14 months following initial presentation and 8 months since last treatment, the retinoblastoma demonstrated complete regression into a partially calcified scar, with complete resolution of intravitreal and subretinal seeds and no evidence of tumor recurrence. Visual acuity improved to 20/30 in the left eye. There were no adverse events from therapy. Despite its rarity, it is important to consider retinoblastoma in the differential diagnosis of a white mass, even in an adult. Furthermore, this case highlights the utility of IAC for retinoblastoma, despite older patient age.
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Subthreshold laser treatment for retinal arterial macroaneurysm associated with exudative maculopathy p. 122
Parvez Ahmad Bhat, Arsalan Un Nisa
DOI:10.4103/ojo.OJO_227_2016  
In this article, we present a case of retinal arterial macroaneurysm (RAM) complicating into exudative maculopathy who was successfully treated with subthreshold laser treatment (STLT). A 45-year-old Indian female was referred to our institution with diminution of vision in her left eye for 1 month with best-corrected visual acuity (BCVA) of counting fingers at 2 m in the left eye. A dilated fundus examination of the left eye revealed deposition of lipid exudates in the macular area and a reddish round vascular lesion superior to macula around two disc diameters from the center of fovea. Optical coherence tomography (OCT) showed serous neurosensory detachment in the macular area in the left eye. Fundus fluorescein angiography showed leakage at the site of vascular lesion in the arterial phase of angiogram. Laser treatment using subthreshold laser parameters was done with three mirror contact lens at the site of vascular lesion. Over the next 12-month follow-up, her BCVA as well as OCT picture improved gradually, and at the last follow up, her BCVA was 20/30 in the left eye with complete resolution of subretinal fluid as detected by OCT. STLT offers promising results in the treatment of symptomatic RAM without causing any complications.
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Choroidal schwannoma presenting with neovascular glaucoma: A report of two cases p. 125
Sai Divya Jajapuram, Dilip K Mishra, Swathi Kaliki
DOI:10.4103/ojo.OJO_123_2018  
Schwannoma is a rare benign tumor, which is more commonly found elsewhere in the body along myelin-producing peripheral nerves and is rarely reported within the eye. In this report, we describe two adult patients presenting with a choroidal mass lesion and neovascular glaucoma who underwent enucleation with clinical differential diagnoses of choroidal melanoma and choroidal hemangioma. Histopathology confirmed the diagnosis of choroidal schwannoma. This case series highlights the variable presentation of intraocular schwannoma and how they masquerade as other choroidal tumors.
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Effect of intravitreal dexamethasone implant on the contralateral eye in recalcitrant radiation maculopathy p. 129
Srishti Kamalmani Gulati, Gopal S Pillai, Natasha Radhakrishnan
DOI:10.4103/ojo.OJO_68_2016  
Radiation maculopathy, a subset of significant radiation retinopathy, is one of the most common causes of visual loss following localized, regional, or whole-brain radiotherapy. Ozurdex (Allergan Inc., Irvine, CA, USA), a sustained-release intravitreal implant of 0.7 mg dexamethasone, has been used as an off-label treatment for treating recalcitrant radiation maculopathy. However, to the best of our knowledge, the beneficial effect of intravitreal dexamethasone in the contralateral eye in a patient with radiation maculopathy has not been described in the literature so far. In this case report, we report the efficacy of dexamethasone 0.7 mg intravitreal implant in recalcitrant radiation maculopathy which was refractory to intravitreal bevacizumab therapy. The patient showed good anatomical and functional outcomes in both the eyes after unilateral injection of intravitreal dexamethasone as evident by optical coherence tomography scans and fundus fluorescein angiography. It is noteworthy that the contralateral was not treated for 4 years. The case reveals systemic exposure of dexamethasone after intravitreal injection by demonstrating the bilateral effect after unilateral injection of intravitreal dexamethasone
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Anterior chamber migration of a sustained-release dexamethasone intravitreal implant: A case report and review of literature p. 133
Parthopratim Dutta Majumder, Amit H Palkar, Nikita Pathare, Jyotirmay Biswas
DOI:10.4103/ojo.OJO_5_2018  
The purpose of the study was to report a case of migration of a dexamethasone intravitreal implant (Ozurdex®) into anterior chamber and review the literature pertaining to the anterior chamber migration of implant. Clinical data were collected from a patient, in whom a dexamethasone intravitreal implant migrated to anterior chamber. A review of literature was conducted to analyze additional reports. A 59-year-old aphakic patient with recalcitrant cystoid macular edema due to chronic idiopathic uveitis was treated with intravitreal injection of dexamethasone implant. Migration of the implant into anterior chamber was noted after a month of injection. Since his cornea was clear and intraocular pressure was normal, he was managed conservatively. Sixteen such reports of migration of implant into anterior chamber was analyzed to look into the possible etiologies and outcome. Disruption of lens capsule, large basal iridectomy, and prior vitrectomy are the primary risk factors for migration of dexamethasone implant into the anterior chamber.
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CLINICAL IMAGE Top

Closure of microperforation during deep anterior lamellar keratoplasty with a corneal tissue fragment p. 138
Arjun Srirampur, Kavya Reddy Katta
DOI:10.4103/ojo.OJO_5_2019  
We present a case of intraoperative microperforation during routine deep anterior lamellar keratoplasty, managed with sealing the leak with the help of corneal tissue fragment and fibrin glue. Post operatively the graft was clear with complete closure of the perforation and without any further complications.
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CLINICAL QUIZ Top

The golden ring p. 141
Simar Rajan Singh, Sonam Yangzes, Jagat Ram
DOI:10.4103/ojo.OJO_172_2018  
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