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   Table of Contents - Current issue
September-December 2015
Volume 8 | Issue 3
Page Nos. 139-219

Online since Friday, November 20, 2015

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Choroidal imaging: Looking ahead p. 139
Jay Chhablani, Vikas Khetan
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Femtosecond laser assisted cataract surgery, beginning of a new era in cataract surgery p. 141
Muhammad Hassaan Ali, Mamoona Javaid, Samreen Jamal, Nadeem Hafeez Butt
The purpose of this article is to analyze and understand the mechanism of action, effectiveness, cost and time benefits, advantages and disadvantages of the femtosecond laser (FSL) assisted cataract surgery. A PubMed search was done using the topic and the keywords. Research shows considerable improvements in corneal incisions, anterior capsulotomy, and phacofragmentation using FSL. We will also discuss and compare FSL with conventional cataract extraction techniques in terms of both short-term and long-term advantages and disadvantages. Limitations of the studies reviewed include small sample size and short-term follow-up. The major dilemma is still considered to be its heavy financial feasibility to date.
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Phlyctenular keratoconjunctivitis among children in the tertiary eye hospital of Kathmandu, Nepal p. 147
Pragati Gautam, Gauri Shankar Shrestha, Ananda Kumar Sharma
Background: This study was conducted to determine clinical profile and etiological factors for phlyctenular keratoconjunctivitis (PKC) in our patients. Materials and Methods: In the descriptive study, 50 pediatric cases of PKC were enrolled into the study from outpatient department of BP Koirala Lions Center for Ophthalmic Studies between August 2011 and August 2012. The age, sex, exposure to tuberculosis, ocular symptoms, and systemic complaints were recorded. Morphological description of PKC such as number, type, location and scars HISTORY and number of recurrence was also noted. The conjunctival swab was taken from all patients and sent for microbiological examination. Report of systemic involvement, worm infestation was also noted. Mantoux testing for possibility of tuberculosis was also performed. Results: PKC was detected in 59 eyes of 50 children having mean age of 8.0 ± 6.2 years including 54% males, unilateral involvement in 82%, the limbal involvement in 52% and multiple PKC in 34% children. Associated ocular disorder was blepharitis in 12 (24%) children. Conjunctival swab and culture revealed Staphylococcus infection in 10 (20%) children. Of eight recurrent cases, two had urinary tract infection managed with systemic antibiotics, three had parasitic infestation treated with antihelmentics, one had mantoux positive without having evidence of tuberculosis and two cases had blepharitis as a local factor. Conclusions: PKC is mostly presented as unilateral disorder of conjunctiva. PKC is associated with blepharitis, Staphylococcus infection, worm infestation and systemic infection.
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Prevalence and associated factors of dry eye: Our experience in patients above 40 years of age at a Tertiary Care Center p. 151
Suchi Shah, Harsha Jani
Context: Dry eye is a very common as well as under-diagnosed ocular disorder. It is not only troublesome in terms of its symptoms but also imposes a great financial burden. Aims: To determine the prevalence of dry eye in ophthalmology out-patients at a Tertiary Care Hospital and its association with various clinico-epidemiological factors. Settings and Design: A hospital-based study at a Tertiary Care Center was conducted including 400 out-patients of age 40 years and above. Materials and Methods: Patients were consecutively selected and underwent a routine ophthalmological examination along with tear film break-up time (TBUT) as a screening tool for detecting the presence of dry eye. Statistical Analysis: We performed a descriptive, univariate and multivariable logistic regression analysis to calculate odds ratios and 95% confidence interval. Results: The mean age of the study population was 58.6 years. The overall prevalence of dry eye was found to be 54.3%. An association was found between dry eye prevalence and outdoor workers, participants working indoor using air conditioners, housewives, diabetics, patients who have undergone previous ocular surgery and those with meibomian gland dysfunction. Conclusions: Dry eye is a very common condition with a high prevalence among the elderly. We recommend the screening of all out-patients by TBUT, which is a simple test to perform and examination of lids for meibomian gland disease, which if present can be treated. Further studies are needed to establish uniform diagnostic criteria for dry eye, which will help to get more concrete prevalence data, as well as its etiological factors.
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Optic nerve head granuloma as a primary manifestation of ocular sarcoidosis - A tertiary uveitis clinic experience p. 157
Sudha K Ganesh, Anushree Vijay Kaduskar
Purpose: To report a case series of ocular sarcoidosis manifesting as optic nerve head granuloma. Design: Observational case series. Results: Unilateral presentation in three females and a male. None of them had symptoms suggestive of systemic involvement. Fundus examination in all the patients showed hyperemic optic discs with peripapillary subretinal granuloma. Serum angiotensin converting enzyme was elevated in all patients. Chest radiograph was within normal limits in all patients. High resolution computed tomography of the chest showed features of sarcoidosis in two patients. All patients were treated with oral steroids. Immunosupressants were given in three patients, intravenous steroid, followed by oral steroids given in three patients. Improvement in visual acuity was noted in all four patients. Conclusion: Primary optic nerve involvement in sarcoidosis is rare. Isolated optic nerve sarcoidosis may exist without any systemic manifestations. Corticosteroids with immunosuppressants form the mainstay of therapy.
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Magnitude and determinants of diabetic retinopathy among persons with diabetes registered at employee health department of a tertiary Eye Hospital of central Saudi Arabia p. 162
Rajiv Khandekar, Arif Al Hassan, Hassan Al Dhibi, Abdullah Al Bahlal, Muneera Al-Futais
Background: To estimate the magnitude and determinants of diabetic retinopathy (DR) among persons with diabetes registered at the employee health department of King Khaled Eye Specialist Hospital (KKESH). Methods: A retrospective review of medical records was conducted in 2013–14 at KKESH. The case record review extracted demographic, profile of diabetes, diabetic complications, and different blood indices to determine the status of potential risk factors. Ocular profile, especially DR was also noted. Results: Our cohort had 94 staff with diabetes. Eye examination was carried out in 51 (54.8%) of them. The rate of DR was 52% (95% confidence interval (CI) 28–66). Sight-threatening diabetic retinopathy (STDR) (proliferative DR and/or diabetic macular edema) was present in 40% of those examined. Good glycemic control was noted in 42% of participants. Duration of diabetes was associated with DR (P = 0.04). Good glycemic control was negatively associated to DR (odds ratio = 0.2 [95% CI 0.04–0.6]). The coverage of eye screening was 55% only. Laser treatment was given to 80% of STDR cases. The lens opacity and glaucoma rate was 15% and 8.3%, respectively. Conclusions: Low coverage for eye screening and laser treatment to diabetics among the staff of an eye hospital is a matter of concern. The underlying causes of low coverage of screening, digital fundus photography as a screening tool and management should be addressed.
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Experience of intravitreal injections in a tertiary Hospital in Oman p. 166
Ahmed S Al-Hinai
Aim: To find out statistical data regarding intravitreal injections in an outpatient department setup at a tertiary center in Oman. Design: Retrospective chart review. Methods: Data collection of patients who underwent intravitreal injections from November 2009 to May 2013 at Sultan Qaboos University Hospital. Results: Throughout a period of 42 months, a total of 711 intravitreal injections were performed. That included 214 patients (275 eyes). Around one-third of the eyes received two injections or more. The injected agents were bevacizumab (59.8%), ranibizumab (32.3%), triamcinolone (7.5%), and very few patients with endophthalmitis received intravitreal antibiotics and antifungal agents. The three most common indications for the injection therapy were diabetic macular edema (50.9%), choroidal neovascularization (24.3%), and retinal vein occlusive diseases (11.5%). Serious adverse events were rare, and they occurred as ocular (0.9% per patient) and systemic (3.3% per patient). There were 42 eyes received intravitreal triamcinolone, and 24% of them developed intraocular hypertension that required only medical treatment. Conclusion: Different intravitreal agents are currently used to treat many ocular diseases. Currently, therapy with intravitreal agents is very popular, and it carries a promising outcome with more efficiency and safety.
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Indications and outcomes of scleral buckle removal in a tertiary eye care center in South India p. 171
Mohmmad Salman Kazi, Vishal Ranjan Sharma, Saurabh Kumar, Pramod Bhende
Purpose: To study the clinical profile of patients undergoing scleral buckle removal (SBR) surgery. Materials and Methods: All consecutive patients undergoing SBR surgery following scleral buckle for retinal detachment repair between January 2002 and December 2011 with a minimum postSBR follow-up of 6 months were included in this study. A record based on analysis of indications, methods, complications, and outcomes of the eyes was performed. Results: One hundred and two eyes of 101 patients (men = 77; 76.24% and women = 24; 23.76%) belonging to the age group of 15–78 years (mean 50 ± 15 years) were included in this study. Time gap between scleral buckle and SBR ranged from 2 to 216 months (mean 61 ± 51 months). Buckle exposure with clinical infection (81; 79.41%) was the most common indication. Of 90 (88.2%) eyes with positive culture, 75 (83.3%) revealed single and 15 (16.6%) revealed multiple microorganisms. Staphylococcus epidermidis (42; 41.2%), was the most common isolate. Fungus was isolated in 3 (2.94%) eyes. Globe perforation (14; 13.7%) and recurrent retinal detachment (7; 6.9%) were the commonest complications. Time gap between SBR and recurrent retinal detachment ranged from 15 days to 50 months (mean 12.2 ± 18.3 months). Conclusions: Most of the exposed scleral buckles developed clinical infection few months to years after surgery, ultimately requiring SBR. Recurrent retinal detachment after SBR may appear from few days to years later warranting a long-term follow-up.
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Conventional extracapsular cataract extraction and its importance in the present day ophthalmic practice p. 175
Preeti Mohanty, Vishnu Vahan Prasan, U Vivekanand
Purpose: A retrospective study aimed to evaluate high risk cases where conventional Extracapsular cataract extraction (ECCE) was performed, their intra-operative and post-operative outcomes. Setting: Sri Srinivasa Sankara Nethralaya (Tirupati) Tirumala Tirupati Devastanams Central Hospital, Tirupati, India. Subjects and Methods: Retrospective study of 207 patients who underwent ECCE at the hospital between august 2010 to June 2012. Operative data included details like grade of risk, intra and postoperative complications and visual outcome. Results: Out of 207 cases, 188 were in group 3 (moderate risk, 3-5 points) and 19 in group 4 (high risk, 6 points or more). The intra operative complications in group 3 were 8 (0.042%) and none in group 4. Final best corrected visual acuity (BCVA) of 6/12 and more were 184 (88.88%). Final refraction of less than 2.0 astigmatism was seen in 80.19% (n=166). Conclusion: Segregation of cases depending on the risk factors can lead to lower intra operative complications and therefore good postoperative outcome. We believe that phacoemulsification, manual small incision cataract surgery (MSICS) and ECCE each has its own importance and should be used as per the cataract with risk factors.
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Isolated abducens nerve palsy after closed head injury in a child p. 179
Ioannis Asproudis, Eleni Vourda, Paraskevas Zafeiropoulos, Andreas Katsanos, Meropi Tzoufi
The authors present the rare case of a 5-year-old child with an isolated right abducens nerve palsy following a minor closed head injury. Occlusion of the left eye for 4 h daily was prescribed, and the child remained under close ophthalmological follow-up. Significant improvement was noticed in the following 6 months.
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Dual intravitreal foreign body: Intravitreal cilia in penetrating injury p. 181
Shorya Azad, Brijesh Takkar, Rajvardhan Azad, Ravi Bypareddy, Anubha Rathi
Intraocular cilia, though a rare condition, has been previously reported in cases of open globe injury. We discuss a unique case of intravitreal cilia, found incidentally during vitrectomy for intravitreal foreign body removal.
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A rare case of delayed onset capsular block syndrome managed using 25-gauge vitrector p. 183
Usha Kaul Raina, Gauri Bhushan, Supriya Arora, Neha Rathie
We report a case of delayed onset capsular block syndrome in a patient 6 years after undergoing cataract surgery. Ocular examination revealed marked diminution of vision accompanied with a collection of milky fluid between the intraocular lens and posterior capsule. To treat and to understand the pathology of the condition, aspiration of fluid using 25-gauge vitrector through pars plana was done, and contents sent for microbiological analysis which did not reveal any growth. Postoperative period was uneventful with the absence of intraocular inflammation and excellent visual recovery.
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Anti-vascular endothelial growth factors for choroidal neovascularization secondary to choroidal osteoma: Long-term results p. 185
T Lekha, N Sarwate Renuka, Hari Narayan Prasad
Choroidal osteoma is an uncommon benign osseous intraocular tumor typically seen unilaterally in young women. Visual loss can occur due to choroidal neovascularization (CNV) complicating osteoma. We report a rare case of bilateral choroidal osteoma with secondary CNV in a young male and the long-term results following anti-vascular endothelial growth factor (VEGF) therapy. A 30-year-old male with history of defective vision in both eyes since several years and recent worsening in the right eye (RE) since 2 months was found to have bilateral macular osteoma with CNV in the RE based on clinical evaluation, fluorescein angiography, optical coherence tomography, and ultrasonography. Intravitreal injection of ranibizumab at monthly intervals for three doses resulted in resolution of CNV and remained stable for 5 years. Recurrent CNV detected 6 years later responded to an injection of intravitreal bevacizumab and has remained stable till date. Anti-VEGF therapy stabilized the secondary CNV in our patient for 7 years with satisfactory structural and functional outcome, demonstrating the long-term efficacy of this modality of treatment.
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Dome-shaped macula simulating choroidal hemangioma in a myopic patient p. 188
Prashanth G Iyer, Emil Anthony T Say, Carol L Shields
To describe a case of dome-shaped macula simulating a choroidal hemangioma and discuss multimodal imaging features to distinguish between these disorders. A 52-year-old myopic male with a refraction of –8.00 D in both eyes developed blurred vision in the left eye OS) over 4 years. Fundus examination of the right eye (OD) was unremarkable. In OS, there was a subtle orange-colored mass in the macular region with subretinal fluid, suggestive of choroidal hemangioma. Upon referral, our examination disclosed an echodense mass on ultrasonography of OS, measuring 1.0 mm thickness, and additional staphyloma was noted. Enhanced depth imaging optical coherence tomography (EDI-OCT) confirmed subfoveal fluid over a dome-shaped mass that originated in the sclera and not the choroid, consistent with the dome-shaped macula. The OD showed similar features, but to a lesser degree. Both eyes demonstrated choroidal thinning on EDI-OCT, related to high myopia. Dome-shaped macula can masquerade as choroidal hemangioma, especially when associated with subretinal fluid. In these cases, EDI-OCT can document "tumor" origin from within the sclera and not the choroid.
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Propranolol therapy in a case of capillary hemangioma p. 191
Vishal Vohra, Pulkit Gupta, Praveen K Malik, Ashok Pathak
Capillary hemangioma is one the most common tumors of eyelid and orbit reported in pediatric age group. Oral propranolol therapy is latest addition to the armamentarium of treatment options available to ophthalmologists in treating capillary hemangiomas. We report the successful response to propranolol therapy to a 5-year-old child with capillary hemangioma involving lids, orbit, and the paranasal sinuses. A long-term follow-up is necessary for the prognostic efficacy of the therapy.
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Microphthalmos, orbital cyst, and missing thumbs: A rare case report p. 194
Tayyab Afghani, Hassan Mansoor, Waseem Shehzad
A 5-month-old girl was presented to us with a right orbital cyst covering a microphthalmic eye, absent digits (thumbs) in both hands, and absence of right radius and left kidney. The hematological profile of the patient was within normal limits. The patient had a family history of leukemia and the chromosomal analysis was suggestive of Fanconi's anemia (FA). The cyst was excised in toto and sent for histopathology. To the best of our knowledge, this is the first case report of an orbital cyst covering a microphthalmic eye in a patient with FA. This case report also stresses the fact that FA can be missed by ophthalmologists in the patients with congenital microphthalmos and missing thumbs and efforts should be made to avoid doing so.
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Delayed sclerotomy wound dehiscence after lensectomy and vitrectomy in Marfan syndrome p. 198
Jayanth Sridhar, Jonathan S Chang, Hassan A Aziz, Benjamin P Erickson
Marfan syndrome (MFS) is associated with abnormal fibrillin development that can cause morbidity and mortality. A case of acute onset hypotony due to sclerotomy wound dehiscence 13 years after 20-gauge pars plana vitrectomy and lensectomy is reported in a patient with MFS. Slit lamp examination revealed a leaking sclerotomy wound and intraoperatively the source was noted to be the prior sclerotomy site. On postoperative follow-up, the patient's vision returned to baseline, and intraocular pressure normalized. Twenty-gauge sclerotomy wound dehiscence may occur years after surgery, especially in patients with abnormal collagen as in MFS.
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Scleral necrosis in congenital erythropoietic porphyria: A case report and review of the literature p. 200
Shweta Agarwal, Parthopratim Dutta Majumder, Bhaskar Srinivasan, Geetha Iyer
A 28-year-old presented with complaints of severe pain and redness in the left eye since 2 weeks. He had similar complaints in the right eye 2 years back for which he had undergone a scleral patch graft. Best corrected visual acuity was 20/20 in both eyes. The right had a well vascularized scleral graft and rest of the anterior segment was normal. The left eye had inferior conjunctival congestion with an area of the scleral melt with uveal show just temporal to the limbus in the interpalbebral area. The cornea was clear and anterior chamber was quiet in the left eye. Applanation tonometry and fundus evaluation were normal in both eyes. Physical examination revealed hyperpigmented skin lesion, hypertrichosis and absorption of distal phalanges. Laboratory, ocular and physical findings confirmed the diagnosis of congenital erythropoietic porphyria. He was on oral steroids 40 mg/day since 2 weeks and topical antibiotics and lubricants. He was advised to continue the same and was taken up for scleral patch graft with fibrin glue in the left eye. Postoperatively he was continued on topical and oral steroids and lubricants.3 weeks later the left eye had stabilized however patient came with a melt in the right eye. Since it was an early melt, we went ahead with cyanoacrylate glue and bandage contact lens in the right eye and started him on topical steroids for the right eye also. Three months later both the eyes were stable, and the patient was gradually tapered off the steroids.
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Peripheral ulcerative keratitis associated with chronic malabsorption syndrome and miliary tuberculosis in a child p. 205
Tarun Arora, Namrata Sharma, Adarsh Shashni, Jeewan S Titiyal
A 16-year-old girl presented with pain, redness, watering, and blurring of vision in her right eye. Slit lamp examination revealed the presence of peripheral ulcerative keratitis (PUK) and nodular scleritis. On clinical examination, the patient had stunted growth, low body mass index, and enlarged axillary nodes. Giardia cysts were present in the stool sample and histopathology of axillary lymph nodes showed caseating necrosis suggestive of tuberculosis (TB). A diagnosis of PUK with chronic malabsorption syndrome secondary to giardiasis and miliary TB was made. Oral metronidazole, anti-tubercular treatment, high protein diet and vitamin supplements were started. Topical steroids were started for peripheral ulcerative lesions following, which the PUK resolved.
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Pulsatile enophthalmos, severe esotropia, kinked optic nerve and visual loss in neurofibromatosis type-1 p. 208
Virender Sachdeva, Nazmul Haque, Avinash Pathengay, Ramesh Kekunnaya
Neurofibromatosis Type I if associated with aplasia of greater wing of sphenoid may be associated with a pulsatile exophthalmos. However, very rarely it may be associated with a pulsatile enophthalmos. This clinical image describes a rare presentation with pulsatile enophthalmos, esotropia and kinking of the optic nerve due to neurofibomatosis type I.
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Rapidly reversible visual loss in posterior reversible encephalopathy syndrome: An ophthalmologist's enigma p. 211
Virender Sachdeva, Ravi Garg, Avinash Pathengay, Anjali Chandrasekharan, Ramesh Kekunnaya
Posterior reversible encephalopathy Syndrome (PRES) may present with a sudden onset reversible visual loss under special visual conditions. Such patients' may initially be misdiagnosed as Malingering. Ophthalmologists may be the first physicians to be confronted by such patients. Hence, a knowledge of this condition is vital to diagnosis and management of such conditions.
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High altitude subhyaloid hemorrhage p. 213
Abdul Hanifudin, Lik Thai Lim, Elliott Yann Ah-Kee, Tarek El-Khashab
Subhyaloid hemorrhages can occur as a result of exposure to high altitude. We hereby report a clinical picture of subhyaloid hemorrhage associated with high altitude. The case demonstrates optical coherence tomography findings that aid diagnosis of subhyaloid hemorrhage.
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Nonprogressive, bilateral painless swellings of the lacrimal glands p. 215
Upender Wali, M Kashinatha Shenoy, Buthaina Al-Sabt, Abdullah Al-Mujaini
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Necrotizing scleritis in a case of Vogt-Koyanagi-Harada disease p. 216
Kumar Sambhav, Parthopratim Dutta Majumder, Jyotirmay Biswas
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Stiffened hang-back: A suggested modification using cyanoacrylate glue p. 217
Abadan K Amitava, Shivani Grover, Namita Kumari
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A fellow's life p. 219
Akshay Gopinathan Nair
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