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   Table of Contents - Current issue
September-December 2016
Volume 9 | Issue 3
Page Nos. 123-198

Online since Friday, October 14, 2016

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Vision restoration in glaucoma: Nihilism and optimism at the crossroads Highly accessed article p. 123
Muneeb A Faiq
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Glaucoma and its association with obstructive sleep apnea: A narrative review Highly accessed article p. 125
Aditya Chaitanya, Vijaya H Pai, Aswini Kumar Mohapatra, Ramesh S Ve
Obstructive sleep apnea (OSA) is one of the systemic risk factors for glaucoma which causes irreversible visual field (VF) damage. We reviewed the published data of all types of studies on the association between these two conditions and papers regarding functional and structural changes related to glaucomatous damage using Scopus, web of science, and PubMed databases. There is evidence that the prevalence of glaucoma is higher in OSA patients, which independent of intraocular pressure (IOP). Studies have reported thinning of retinal nerve fiber layer (RNFL), alteration of optic nerve head, choroidal and macular thickness, and reduced VF sensitivity in patients of OSA with no history glaucoma. A negative correlation of apnea-hypopnea index with RNFL and VF indices has been described in some studies. Raised IOP was noted which is possibly related to obesity, supine position during sleep, and raised intracranial pressure. Diurnal fluctuations of IOP show more variations in OSA patients before and after continuous positive airway pressure (CPAP) therapy when compared with the normal cases. The vascular factors behind the pathogenesis include recurrent hypoxia with increased vascular resistance, oxidative stress damage to the optic nerve. In conclusion, comprehensive glaucoma evaluation should be recommended in patients with OSA and should also periodically monitor IOP during CPAP treatment which may trigger the progression of glaucomatous damage.
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Validity and cost-effectiveness of cone adaptation test as a screening tool to detect retinitis pigmentosa p. 135
Rahul Deshpande, Prajakta Save, Madan Deshpande, Mahadev Shegunashi, Marium Chougule, Rajiv Khandekar
Background: The cone adaptation test is to detect retinitis pigmentosa (RP) cases confirmed by electroretinogram (ERG). We present the validity and cost-effectiveness of cone adaptation test as a screening tool for detecting RP. Methods: This cross-sectional study was conducted between November 2013 and December 2013. All RP cases diagnosed by ophthalmologists of H. V. Desai Eye Hospital in the last 5 years were participated in this study. The cone adaptation test was done in photopic and scotopic illumination. Failed test means 10 s or more to complete the test under scotopic illumination. A technician who was masked for cone adaptation test finding carried out ERG. Demographics, symptoms, and history of treatment were inquired. Those with flat ERG wave in scotopic condition and corresponding clinical findings were defined as having RP. Sensitivity, specificity, and false-positive and false-negative parameters of validity were estimated. The unit cost of performing test and ERG was calculated. Results: All 32 RP patients (28 male, age median 23.5 ΁ 14.5 years) had a vision more than 6/60 and flat wave in ERG under mesopic/scotopic illumination. Thirty-one participants failed cone adaptation test. The sensitivity was 31/32 Χ 100 = 97%. The specificity was 100%. There was no false-positive case. Consanguinity rate among parents was 43%. The cost of testing one child using "cone adaptation test kit" was 2.5 US $. The unit cost of diagnosing RP using ERG was 10 US $. Conclusion: Cone adaptation is a valid and cost-effective screening tool test for RP. The consanguinity rate among parents of an RP patient was high.
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Combined argon laser photocoagulation and antivascular endothelial growth factor for management of macular polypoidal choroidal vasculopathy p. 139
Parveen Sen, S Vinay Kumar, Muna Bhende, Tarun Sharma
Aim: To evaluate the efficacy of combination therapy of argon laser photocoagulation and intravitreal antivascular endothelial growth factor (VEGF) injection in idiopathic polypoidal choroidal vasculopathy (PCV) involving macula. Materials and Methods: A retrospective interventional study involving 12 eyes of 11 patients diagnosed with PCV involving the macula on indocyanine green angiography (ICGA). Intravitreal anti-VEGF was given in eyes with significant subretinal/sub retinal pigment epithelium hemorrhage or exudation. ICGA-guided focal laser was done to extrafoveal leaking polyps. Mean change in best-corrected visual acuity (BCVA) and regression of polyp as seen on ICGA were evaluated at the final follow-up. Statistical Analysis: It was done using SPSS 17.0. - Mann-Whitney test. Results: 12 eyes of 11 patients underwent argon laser with intravitreal anti-VEGF injection. Ten patients were males and one female. Mean age was 65.75 ± 5.2 years. The mean number of injections given was 3.66 ± 1.5 (2-6) per eye. Mean number of laser sessions required was 1.33 ± 0.65 (1-3) per eye. BCVA improved in 25% (n = 3), remained stable in stable in 50% (n = 6) eyes, and decreased in 25% (n = 3) eyes. The regression of polypoidal lesions on ICGA was seen in 75% (n = 9) of eyes. Persistent subretinal fluid seen in 25% (n = 3) of eyes. The mean duration of follow-up was 15.41 ± 10.27 (3-36) months. Conclusion: Combined argon laser photocoagulation with intravitreal anti-VEGF injection helps in decreasing exudation and results in stabilization of the disease with visual improvement in eyes with PCV involving macula.
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Study of efficacy and timing of laser suture lysis in reducing intraocular pressure after trabeculectomy with mitomycin-C p. 144
Swati Ramakrishna, Sirish Nelivigi, Asha Maganahalli Sadananda, Sri Ganesh
Context: Laser suture lysis is used to enhance filtration after trabeculectomy. Aims: The aim of this is to evaluate the change in intraocular pressure (IOP) after laser suture lysis after trabeculectomy with mitomycin-C and to correlate the efficacy of suture lysis in relation to the time of lysis. Settings and Design: Prospective interventional study of seventy eyes of seventy patients. Subjects and Methods: Trabeculectomy with mitomycin-C was performed for 352 patients with glaucoma. Laser suture lysis was carried out when indicated for seventy patients during 2 nd -8 th week posttrabeculectomy. Primary outcome measures were IOP at immediate postsuture lysis, 1, 2, 4, 6, and 8 weeks, 3 and 6 months following laser suture lysis. For the purpose of statistical analysis, patients were divided into three groups depending on the week of suture lysis as <3 weeks, 3 rd -5 th week, and >5 weeks posttrabeculectomy and 21 mmHg was used as the cutoff for the achievement of target IOP. Statistical Analysis Used: Descriptive statistical analysis has been carried out. Significance is assessed at 5% level of significance. Student's t-test (two-tailed, independent) has been used to find the significance of study parameters on continuous scale between two groups. Chi-square/Fisher exact test has been used to find the significance of study parameters on categorical scale between two or more groups. Results: On immediate postsuture lysis, 62 patients (88.6%) had IOP of <21 mmHg which increased to 68 patients (98.6%) at the end of 6 months postsuture lysis. When laser suture lysis was performed during 3 rd -5 th week posttrabeculectomy, 34 patients (73.9%) achieved the target IOP. Conclusions: Laser suture lysis during 3 rd -5 th week posttrabeculectomy with mitomycin-C is an effective and safe technique for reducing IOP.
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A comparative study of various topical nonsteroidal anti-inflammatory drugs to steroid drops for control of post cataract surgery inflammation p. 150
Anu Malik, Anup Sadafale, Yogesh Kumar Gupta, Alka Gupta
Background: Postoperative inflammation continues to be a cause of patient discomfort, delayed recovery, and in some cases, suboptimal visual results. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) and steroid are commonly used in the management and prevention of noninfectious ocular inflammation following cataract surgery. Aims: The aim was to study the safety and efficacy of various NSAIDs drops for control of postoperative inflammation following cataract surgery and compare with steroid eye drops in a patient following cataract surgery. Subjects and Methods: Totally, 200 patients undergoing phacoemulsification with posterior chamber intraocular lens implantation were randomly assigned to receive either nepafenac 0.1% 3 times daily, bromfenac 0.09% twice daily, ketorolac 0.5% 4 times daily for 1 month or 1% prednisolone eye drops as their postoperative anti-inflammatory medication with 50 cases in each group. The patients were examined at the 1 st day (baseline), 1 st week, 2 nd week, and 4 th week after surgery. Postoperative inflammation was evaluated subjectively by intraocular pressure, slit-lamp assessment of signs of inflammation, including conjunctival hyperemia, ocular pain, and aqueous cells and flare. Statistical Analysis: Statistical analysis was performed by the SPSS program for Windows, version 17.0. Results and Conclusions: In our study, we found that prednisolone 1% was more effective in controlling postoperative intraocular inflammation in terms of reducing anterior chamber cells and flare. We found that ketorolac 0.5% and nepafenac 0.1% were equally effective in controlling postoperative ocular pain and inflammation. All four drugs are effective in controlling post cataract surgery ocular inflammation. Intraocular inflammation is best controlled with prednisolone 1%, while ocular pain and hyperemia are better controlled with NSAIDs in the early postoperative periods.
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Preclinical cataract masquerading as post-LASIK regression p. 157
Rohit Shetty, Nikhil Negalur, Mathew Kurian, Rushad Shroff
The purpose of this case report is to bring forth a rare clinical scenario where preclinical cataract mimics post-LASIK regression and to describe the role of aberrometry in detecting higher order aberrations (HOAs) and early lens changes. A 36-year-old female presented with blurring of vision since 1 year after having undergone an uneventful LASIK surgery 3 years prior. Corneal topography and aberrometry were within normal limits. Although the lens was morphologically normal on slit lamp examination, increased HOAs and lenticular density were detected. Since there were no cataractous changes, the patient was advised regular follow-up. A year later, the patient had developed lenticular changes along with a further increase in aberrations and worsening of scatter on densitometry. Increase in aberrations and lenticular density may serve as a marker for cataract development before clinically detectable lenticular changes. This report shows how preclinical cataract can mimic post-LASIK regression with a change in spherical and cylindrical power of the eye. This could result in patients undergoing re-correction in eyes where the primary pathology is in the lens.
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Anterior ischemic optic neuropathy following dengue fever p. 160
Reshma Ramakrishnan, Saurabh Shrivastava, Shrikant Deshpande, Priyanka Patkar
Dengue fever is caused by a flavivirus. This infection is endemic in the tropics and warm temperate regions of the world. Ocular manifestations of dengue fever include subconjunctival, vitreous, and retinal haemorrhages; posterior uveitis; optic neuritis; and maculopathies, haemorrhage, and oedema. However anterior ischemic optic neuropathy is a rare presentation. Optic nerve ischemia most frequently occurs at the optic nerve head, where structural crowding of nerve fibers and reduction of the vascular supply may combine to impair perfusion to a critical degree and produce optic disc oedema. Here we present a case of anterior ischemic optic neurapathy associated with dengue fever.
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Minimal exposure intra-arterial chemotherapy for children with retinoblastoma and 13q syndrome p. 164
Alexander B Dillon, Alexzandra Douglass, Pascal Jabbour, Carol L Shields
Two infants with retinoblastoma and 13q syndrome with multiorgan system anomalies were treated with targeted intra-arterial chemotherapy (IAC) using one-to-three cycles of melphalan 5 mg to avoid systemic chemotherapeutic side effects. Both patients showed good response, with tumor control and no systemic chemotherapy side effects. Of the treatment modalities currently available, IAC may represent an optimal balance between tumor extermination and adverse drug reactions in this patient population with classically reduced multiorgan reserve.
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Role of pars plana vitrectomy and membrane peel in vitreomacular traction associated with retinal vasoproliferative tumors p. 167
Veronica Castro-Navarro, Jarin Saktanasate, Emil Anthony T Say, Allen Chiang, Carol Lally Shields
To report a case of retinal vasoproliferative tumor (VPT) with secondary epiretinal membrane (ERM) formation and vitreo-macular traction managed by pars plana vitrectomy (PPV) and membrane peel. A 29-year-old male was referred for management of decreased vision in the right eye (OD) for 1 week. Presenting visual acuity was 20/50 Snellen feet (ft) OD, and fundus examination showed an ERM associated with a reddish-yellow mass in the inferotemporal quadrant with overlying exudation, hemorrhage, and subretinal fluid consistent with VPT, and cryotherapy was recommended. Two months later, there was complete tumor regression, but there was decreased vision from progressive vitreomacular traction to 20/400 ft. PPV with combined ERM and internal limiting membrane (ILM) peel were performed with resolution of vitreomacular traction and improvement of visual acuity to 20/50 ft at 6 months. PPV with combined ERM and ILM peel is effective for vision loss secondary to ERM and vitreomacular traction associated with retinal VPT.
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Progressive keratoconus, retinal detachment, and intracorneal silicone oil with obsessive-compulsive eye rubbing p. 170
Kartik Panikkar, George Manayath, Revathi Rajaraman, Veerappan Saravanan
An 18-year-old boy with an obsessive-compulsive disorder of eye rubbing presented with forme fruste keratoconus (KC) and posterior subcapsular cataracts. After evaluation, he underwent phacoemulsification in his left eye with intraocular lens implantation. The aggressive eye rubbing, however, aggravated the rapid progression to established KC, and further acute corneal hydrops within 3 months. Within the next 3 months, the eye rubbing precipitated rhegmatogenous retinal detachments (RDs) in both eyes. Furthermore, after undergoing a combined cataract and RD surgery with belt buckling and silicone oil endotamponade in his right eye, the repeated eye rubbing caused extrusion of the implanted silicone oil into the subconjunctival space and within the corneal stroma. This is the first report to our knowledge describing this unique complication associated with eye rubbing. It also highlights the need for increased vigilance and care that needs to be directed toward patients predisposed to such complications.
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Flat choroidal melanoma masquerading as central serous chorioretinopathy p. 174
Timothy Patrick Higgins, Chloe T.L Khoo, George Magrath, Carol L Shields
There are several mimickers of choroidal melanoma. We report a patient with recent family stress who developed blurred vision to 20/50 OD and was found to have unilateral central serous chorioretinopathy and a coincidental choroidal nevus. After 1 year without resolution of the subretinal fluid, the patient was referred for our opinion. On examination, visual acuity was 20/50 in the right eye and 20/20 in the left eye. The left eye was normal. Evaluation of the right eye showed a small, pigmented submacular choroidal lesion measuring 4 mm Χ 3 mm. Ultrasonography documented an isoechoic mass measuring 1.71 mm in thickness. Optical coherence tomography showed subretinal fluid with shaggy photoreceptors and hyper-reflective material within the subretinal fluid, likely indicative of lipofuscin within macrophages. Autofluorescence revealed orange pigment overlying the lesion. These features were strongly suggestive of small choroidal melanoma with five risk factors for tumor growth. Treatment with Iodine-125 plaque brachytherapy was performed on the patient. The readers should keep in mind that choroidal melanoma can manifest as a tiny choroidal mass with related multimodal imaging features of subretinal fluid and orange pigment.
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Mycobacterium chelonae in a tectonic corneal graft p. 177
Haziq Raees Chowdhury, Oliver Comyn, Gill Jones, Mayank A Nanavaty
Atypical mycobacterial infections of the cornea can present with nonspecific inflammatory changes and graft rejection, with no obvious focus to culture and a subsequent delay to diagnosis. These pathogens are well documented in the literature following laser-assisted in situ keratomileusis but have rarely been described following corneal transplant surgery. We report a single case of Mycobacterium chelonae keratitis 1 year after tectonic keratoplasty.
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Demonstration of cornea Dua's layer at a deep anterior lamellar keratoplasty surgery p. 179
Yusuf Kocluk, Ayse Burcu, Emine Alyamac Sukgen
The authors aimed to present a deep anterior lamellar keratoplasty (DALK) surgery case with mixed type bubble demonstrating Dua's layer (DL). This was a reported case of DALK surgery. The authors encountered cornea DL structure at DALK surgery while cleaning the remaining stromal pieces. We also observed perforation in the central part of DL. However, DALK surgery could be completed. It is possible to encounter DL in a DALK surgery performed with mixed type big-bubble.
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Optic neuritis with secondary retinal venous stasis in a case of abdominal tuberculosis p. 182
Harshika Chawla, Vishal Vohra, Praveen Malik
The authors report a case of unilateral optic neuritis along with secondary retinal venous stasis in a patient diagnosed with abdominal tuberculosis. Patient presented with diminished visual acuity, colour perception and Marcus Gunn pupillary response, pointing towards optic nerve involvement. Associated findings of disc edema, dilated and tortuous veins, along with hemorrhages on disc and superotemporal quadrant made diagnosis of retinal venous stasis secondary to optic neuritis imperative. The visual outcome of the patient paralleled that expected with optic neuritis. The authors believe that impairment of retinal venous outflow secondary to optic neuritis is a distinct but a rare presentation.
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Unique neuro-ophthalmic presentation of gun pellet injury p. 185
Reena Sharma, Sanjay Sharma, Swati Phuljhele, Rohit Saxena
We describe a unique case of orbital gunshot injury with isolated intraorbital pellets lodged symmetrically in the two apices, causing identical clinical presentation, and absence of any associated globe or cerebral injury. He developed bilateral complete third nerve palsy with bilateral traumatic optic neuropathy. The optic nerve strut prevented the pellets from going into the brain on both the sides.
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Choroidal melanoma masquerading as multifocal central serous chorioretinopathy p. 187
Pukhraj Rishi, Ramya Appanraj, Tarun Sharma
A 56 year-old-male presented with diminution of vision in right eye of 2 months duration. His best corrected visual acuity (BCVA) was 20/25. Anterior segment examination was bilaterally normal. Right fundus revealed oval, raised, pigmented lesion in superotemporal quadrant with subfoveal fluid. Fundus fluroscein angiography (FFA) showed multiple pinpoint leakages. Acoustic hollowing on ultrasound (USG) was typical of choroidal melanoma. A high index of suspicion is required for the diagnosis of small choroidal melanoma that could present with multiple focal leaks and subretinal fluid simulating multifocal central serous retinopathy (CSR).
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Unusual course of interferon-related retinopathy in chronic hepatitis C p. 189
Gaurav Mathur, Deependra V Singh, Ayush Singal
Interferon Alfa retinopathy usually presents as cotton wool spots, superficial hemorrhages and macular edema. We describe a rare case of severe retinopathy involving hard exudates at macula that lead to permanent visual loss in one eye. Elderly male presented with diminution of vision in right eye of 8 month duration. He was a diagnosed case of compensated chronic hepatitis C and had received interferon Alfa therapy before. Fundus examination of both eye showed multiple hard exudates at macula with a plaque involving the foveal center in right eye. OCT and FFA confirmed the findings seen clinically. Patient was advised regular follow up and on 3 months follow up his clinical picture was same. Ours is the first case report where patient had significant visual loss secondary to hard exudate plaque at center of fovea and ischemic fovea in right eye.Presence of hard exudates at any stage of therapy of hepatitis C could be an indicator of the severity of retinopathy with possible indication for stopping the drug.
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Ultrawide field imaging of multiple intraretinal cysts in old rhegmatogenous retinal detachment p. 191
Vinod Kumar, Kumar Vivek, Parijat Chandra, Atul Kumar
A middle ages male presented with old rhegmatogenous retinal detachment with multiple intraretinal macrocysts. Clinical significance of these macrocysts and utility of ultra-wide field imaging in such cases is described.
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An 18-year-old female with unilateral painless vision loss p. 193
Bhushan Wadekar, Koushik Tripathy, Rohan Chawla, Pradeep Venkatesh, Yog Raj Sharma, Rajpal Vohra
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Plateau iris: An important anatomical configuration not to miss p. 194
Haitham Hilal Al Mahrouqi, Ali Alsheikheh
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Orthoptic relevance of refractive correction in the phakic plane in unilateral high refractive errors in adults p. 196
Siddharth Agrawal, Vinita Singh, Ankur Yadav, Vishal Katiyar
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