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   Table of Contents - Current issue
Coverpage
January-April 2020
Volume 13 | Issue 1
Page Nos. 1-53

Online since Monday, February 17, 2020

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EDITORIAL COMMENTARY  

Femtosecond laser-assisted cataract surgery p. 1
Milind Prasannakumar Suryawanshi, Rashid Alsaidi
DOI:10.4103/ojo.OJO_279_2019  
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REVIEW ARTICLE Top

Management of vernal keratoconjunctivitis in children in Saudi Arabia Highly accessed article p. 3
Dora Hamad AlHarkan
DOI:10.4103/ojo.OJO_263_2018  
Vernal keratoconjunctivitis is a chronic inflammatory disease of the ocular surface and one of the worst types of allergic conjunctival diseases. Because of its chronic nature, it can damage the cornea, resulting in sight-threatening complications if left untreated. The disease affects mainly young children starting around the age of 7 years. We used keywords to search for published English articles in PUBMED, Google Scholar, EMBASE, and Cochrane Database of Systematic Reviews. Most of the published literature is focusing on general management of the disease and few publications focusing on treatment in the pediatric age group. We highlight the importance of how is the topical management differs between age groups. We focused on the importance of doing cycloplegic refraction for each child as the risk of keratoconus and oblique astigmatism is high in these cases. Furthermore, we highlight the importance of using eye lubricants as a therapeutic and preventive tool for the attacks of the disease. We highlight that most of the recent effective medications (especially the off-label ones) are not available in Saudi Arabia, such as tacrolimus, and some are only available to be prepared in tertiary center pharmacies as Cyclosporine A with higher concentrations.
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ORIGINAL ARTICLES Top

Pterygium excision with conjunctival autograft fixed with sutures, glue, or autologous blood p. 13
Milind Prasannakumar Suryawanshi, Roshini Isaac, Madhur Milind Suryawanshi
DOI:10.4103/ojo.OJO_113_2019  
AIMS AND OBJECTIVES: This retrospective study compared surgical outcome of pterygium excision with conjunctival autograft fixed with sutures, tissue glue or autologous blood in relation to recurrence rate and surgical complications. MATERIALS AND METHODS: Surgical records of 148 patients operated for excision of primary nasal pterygium with conjunctival autograft were reviewed retrospectively for the period between January 2015 and June 2018. Based on surgical technique used to fix the graft, patients were divided into three groups. In Group A, 8 “0” vicryl suture was used to fix the graft in 90 patients. In Group B, fibrin glue was used to fix the graft in 23 patients. In Group C, autologous blood was used to fix the graft in 35 patients. Patients who were operated by single surgeon and had followed up for minimum six months were included in the study. RESULTS: Group A had recurrence in 7 cases (7.78%) whereas; Group B and C had no recurrence. But, in Group C two patients (5.71%) lost their graft. Overall recurrence rate in the study was 4.72%. CONCLUSION: Among the three techniques used in the study, recurrence was seen in the suture group and autologous blood group had loss of graft. The fibrin glue group was free of complications.
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Profile of infectious and sterile keratitis after accelerated corneal collagen cross-linking for keratoconus p. 18
Shreesha Kumar Kodavoor, Nitin Narendra Tiwari, Dandapani Ramamurthy
DOI:10.4103/ojo.OJO_115_2018  
PURPOSE: The aim of this study was to assess the potential risk factors and causes of infectious and sterile keratitis after accelerated collagen cross-linking. METHODS: Case records of 968 eyes that underwent accelerated corneal collagen cross-linking (ACXL) over the period of 4 years were reviewed retrospectively. ACXL was done using (Avedro KXL® system, Waltham, MA, USA) 9 mW/cm2 for 10 min protocol providing total energy of 5.4 J/cm2. RESULTS: Of 968 eyes, a total of three eyes developed infectious keratitis and seven eyes developed sterile infiltrates. Three of this infectious keratitis had two cases which were resistant to fourth-generation fluoroquinolones. Seven cases of sterile infiltrates had excellent resolution after treatment with topical steroids. Sterile infiltrates were common in corneas with thinnest pachymetry of <400 μm, except in one case of intra stromal corneal ring segments (INTACS) + ACXL. CONCLUSION: Judicious use of steroids in the initial postoperative period is recommended so as to prevent any form of microbial keratitis. Very steep corneas and too thin corneas should be looked with high index of suspicion in view of chances of developing sterile infiltrates.
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Pattern of ocular morbidity among students in a school for visually impaired children in North India p. 24
Shaik Mohammed Zakir, Md Shahid Alam, Saiyid Nasir Askari, Mohd Imran
DOI:10.4103/ojo.OJO_194_2018  
AIMS: The aim of this study was to identify the ocular morbidity pattern among children attending a blind school in North India and comparing the data with similar studies conducted across India and abroad. STUDY DESIGN: This was a cross-sectional observational study. MATERIALS AND METHODS: A cross-sectional study was performed during September 2017 where 94 students attending a blind school were interviewed, and a detailed ocular examination was performed by an ophthalmologist. RESULTS: Sixty-three (67%) children were blind since birth and 29 (30.9%) had absolute blindness. Anatomical site of blindness included retinal disorders in 38 (40.42%), whole globe pathology in 20 (21.40%), optic nerve disorders in 17 (18.09%), corneal diseases in eight (8.51%), and congenital cataract in four (4.26%). A history of consanguinity among parents was reported by 12 (12.8%) students. Blindness was potentially avoidable in 22 (23.4%) children. CONCLUSION: Retinal pathologies were the most common cause for blindness in the present study. The proportion of corneal scarring and congenital cataract is decreasing and majority of cases had unavoidable or incurable blindness. Health education about consanguineous marriages, establishment of pediatric ophthalmology units across the country is essential to eliminate or minimize avoidable blindness among children.
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Prevalence and causative agents of allergic conjunctivitis and its determinants in adult citizens of Western Saudi Arabia: A survey p. 29
Khaled A Alqurashi, Ashjan Yousef Bamahfouz, Bayan Mutlaq Almasoudi
DOI:10.4103/ojo.OJO_31_2019  
PURPOSE: To estimate the prevalence of allergic conjunctivitis (AC) and its related allergic ailments among Saudi adults in the western region. METHODS: Adult population of Taif, Makkah, and Jeddah cities was surveyed from 2017 to June 2018. Subjective questionnaire was used to collect the response. Participants were asked about symptoms (redness, itching, watering, based diagnosis and details of AC, treatment taken in the pasts, and associated conditions, such as allergic asthma and rhinitis). The age-sex-adjusted prevalence, its determinants, and associations to other ailments were assessed. RESULTS: We surveyed 2187 participants (mean age 26.0 ± 9.1 years). The age-sex-adjusted prevalence of AC was 70.5% (95% confidence interval [CI] 68.6–72.4). There could be 2.1 million AC patients among 3.1 million adult populations in Western KSA. It was significantly higher in females compared to males (odds ratio [OR] = 1.7 [95% CI 1.4–2.2]). The risk of AC did not vary by age group (χ2 = 2.5, df = 3, P = 0.1). The variation of AC in three provinces was not significant (χ2 = 0.3, df = 3, P = 0.6). Dust (42.6%) and unknown (24.8%) allergens were the main causative agents of AC. AC was significantly associated to asthma (OR = 2.8) and allergic rhinitis (OR = 2.2). CONCLUSION: AC affects seven in ten adults in Western Saudi Arabia. AC is positively associated to allergic rhinitis and bronchial asthma. Public health policies at primary eye-care level should focus on early detection and care of persons with AC.
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CASE REPORTS Top

A case of isolated bilateral cataract following high-voltage electrical injury p. 34
Ankur Yadav, Vishal Katiyar, Prateep Phadikar, Sanjiv Kumar Gupta
DOI:10.4103/ojo.OJO_129_2016  
High voltage electric burns can cause various ocular injuries and may manifest in the form of conjunctival hyperemia, corneal opacities, uveitis, miosis, spasm of accommodation, cataract, retinal edema, papilledema, choroidal rupture, chorio-retinal necrosis/atrophy, retinal detachment and optic atrophy. The involvement of crystalline lens exclusively with sparing of other ocular structures is rare. We report a case of 16 year old male with bilateral total cataract after electrical injury by over-head high tension electric transmission cable accidentally falling on patient's head 6 months back. B scan showed no abnormality in both the eyes. The intra ocular pressure in both the eyes was within normal limits. Patient underwent lens aspiration with posterior chamber intraocular lens (PCIOL) implantation in both the eyes, under peribulbar anaesthesia (with an interval of 1 week between both the operations). Intra-operative and post-operative period were uneventful. Post operative BCVA was 6/6 in both eyes and fundus examination was within normal limits. Outcomes after surgery are very good if not associated with other ocular lesion like optic atrophy, chorio-retinal lesion, uveitis etc. This observation should encourage the ophthalmologist to undertake surgery for electric cataract, where necessary.
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Unusual case of endophthalmitis: Case report and literature review p. 37
Mohamed Al-Abri, Ahmed Al-Hinai, Ammar Al-Farsi, Nawal Al-Fadhil
DOI:10.4103/ojo.OJO_48_2018  
Endophthalmitis is an inflammation of both the anterior and posterior chamber. It is diagnosed clinically and involvement of retina and choroid has been documented. (1) Endophthalmitis is classified into infectious and no-infectious categories. Furthermore, the infectious categoery is classified into endogenous and exogenous (Postoperative, Posttraumatic, Bleb associated) which can be caused by either bacterial or fungal infection. Blurry of vision and pain are main symptoms and coagulase negative organisms (gram positive) are main causative of exogenous endophthalmitis. (2) We report a rare case of delayed-onset postoperative endophthalmitis secondary to a rare causative pathogen.
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Innovative usage of the remaining portion of ahmed glaucoma valve tube as an implant in nonpenetrating glaucoma surgery p. 40
Saeed Shokoohi-Rad, Mohammad Yaser Kiarudi, Mohammad-Reza Ansari-Astaneh
DOI:10.4103/ojo.OJO_11_2019  
With the advent of nonpenetrating glaucoma surgeries (NPGS), these techniques are noticed more considerably by glaucoma surgeons due to lower complications in comparison to penetrating surgeries with comparable outcomes. One of the main objectives in these surgeries is the creation of an intrascleral filtering space as an alternative for subconjunctival filtering bleb. Intrascleral fibrosis in the long term reduces the volume of intrascleral bleb, so the use of implants as a space holder for preventing the collapse of scleral flaps and continued aqueous humor drainage is recommended. A lot of materials with diverse designs have been used as implants in NPGS. In this study, the remaining of Ahmed valve's tube was used as an implant in four eyes of four patients. The technique for the implant we introduced, offers significant advantages over previously reported implants. The material is biocompatible, low cost, and easily accessible in all the centers performing glaucoma surgeries.
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Intralesional bleomycin: A treatment modality for conjunctival lymphangioma p. 43
Smriti Bansal, Sima Das
DOI:10.4103/ojo.OJO_44_2019  
Lymphangioma is a benign hamartomatous lesion of vascular system which frequently involves orbit and ocular adnexa. A 35-year-old male patient presented with a subconjunctival mass extending from limbus to fornices. There was a history of recurrent swellings following episodes of upper respiratory tract infection. Bleomycin is an antineoplastic agent which acts on endothelial cells of the vascular channels, helps in collapsing the cystic cavity, and prevents its recurrence. We report a case where only bleomycin injection has been used intralesionally at multiple spots and patients have shown good cosmetic outcome without any recurrence noted after 1 year of follow-up.
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CLINICAL IMAGES Top

Posttraumatic maxillary and ophthalmic herpes zoster in an immune-competent female – A unique presentation p. 46
Rajat Mohan Srivastava, Vishal Katiyar, Siddharth Agrawal
DOI:10.4103/ojo.OJO_142_2019  
Herpes Zoster is a neuro-cutaneous disorder caused by reactivation of Varicella-Zoster Virus. A number of factors such as old age, psychological stress, low immune states, radiation exposure and physical trauma have been implicated for reactivation. Post traumatic herpes zoster involving maxillary and ophthalmic division of trigeminal nerve is very rare and has been reported in presence of Immune deficiency and following iatrogenic trauma (nerve block injection). We report a unique presentation of simultaneous ophthalmic and maxillary herpes zoster following a facial injury with a wooden stick in an immune-competent female.
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Snowman in the eye p. 48
Sonam Yangzes, Simar Rajan Singh, Jagat Ram
DOI:10.4103/ojo.OJO_225_2018  
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Gradual resolution of foveal herniation after epiretinal membrane peeling p. 49
VG Madanagopalan, CK Nagesha, Girish Velis, Manavi D Sindal
DOI:10.4103/ojo.OJO_104_2018  
We demonstrate the gradual resolution of foveal herniation with optical coherence tomography (OCT) images after epiretinal membrane (ERM) removal. A young male presented with diminished vision in the left eye (OS). Examination of OS revealed an ERM and thickening of the foveal region. OCT delineated the ERM clearly. It also showed a central defect in the ERM through which the inner retinal layers had prolapsed into the vitreous cavity leading to foveal herniation. The patient underwent vitrectomy and surgical removal of the ERM. After removing the source of macular traction, over a period of 4 months, gradual reduction in height of the elevated central foveal tissue was observed. At 6 months, the foveal bulge had reduced remarkably and remained stable. The resolution of foveal herniation after ERM removal is a slow process. The OCT images convey that it may take few months for the foveal bulge to decrease in height. When the outer retinal layers are normal, visual recovery, though delayed, is appreciable.
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Pseudomonas aeruginosa scleritis initially presenting as idiopathic diffuse anterior scleritis p. 51
Shweta Agarwal, Parthopratim Dutta Majumder
DOI:10.4103/ojo.OJO_256_2018  
Pseudomonas aeruginosa remains the most common cause of bacterial scleritis. This report illustrates an unusual presentation of P. aeruginosa scleritis, which initially presented as diffuse anterior scleritis with anterior uveitis. The detailed laboratory work-up of the patient was negative, and the initiation of high-dose oral corticosteroid therapy led to further deterioration of clinical condition, with the appearance of a yellowish-white nodule within 3 days. The aspirate from the nodule grew P. aeruginosa, and the scleral inflammation resolved with anti-microbial therapy.
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CLINICAL QUIZ Top

Bony ball in a bony wall p. 53
Nandini Bothra, Swathi Kaliki, Sreedhar Boyinpally Rao, Dilip K Mishra
DOI:10.4103/ojo.OJO_64_2019  
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