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   Table of Contents - Current issue
Coverpage
May-August 2016
Volume 9 | Issue 2
Page Nos. 79-121

Online since Thursday, June 23, 2016

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EDITORIAL  

Imaging in ophthalmology and need for slit-lamp and ophthalmoscopy examinations p. 79
Anselm Kampik
DOI:10.4103/0974-620X.184508  
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REVIEW ARTICLE Top

Surgical management of third nerve palsy p. 80
Anupam Singh, Chirag Bahuguna, Ritu Nagpal, Barun Kumar
DOI:10.4103/0974-620X.184509  
Third nerve paralysis has been known to be associated with a wide spectrum of presentation and other associated factors such as the presence of ptosis, pupillary involvement, amblyopia, aberrant regeneration, poor bell's phenomenon, superior oblique (SO) overaction, and lateral rectus (LR) contracture. Correction of strabismus due to third nerve palsy can be complex as four out of the six extraocular muscles are involved and therefore should be approached differently. Third nerve palsy can be congenital or acquired. The common causes of isolated third nerve palsy in children are congenital (43%), trauma (20%), inflammation (13%), aneurysm (7%), and ophthalmoplegic migraine. Whereas, in adult population, common etiologies are vasculopathic disorders (diabetes mellitus, hypertension), aneurysm, and trauma. Treatment can be both nonsurgical and surgical. As nonsurgical modalities are not of much help, surgery remains the main-stay of treatment. Surgical strategies are different for complete and partial third nerve palsy. Surgery for complete third nerve palsy may involve supra-maximal recession - resection of the recti. This may be combined with SO transposition and augmented by surgery on the other eye. For partial third nerve, palsy surgery is determined according to nature and extent of involvement of extraocular muscles.
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ORIGINAL ARTICLES Top

Long-term outcomes of combination photodynamic therapy with ranibizumab or bevacizumab for treatment of wet age-related macular degeneration p. 87
Ekta Rishi, Pukhraj Rishi, Vishal Sharma, Vikram Koundanya, Renu Athanikar
DOI:10.4103/0974-620X.184511  
Aim: To evaluate and compare the efficacy of combination of ranibizumab or bevacizumab with photodynamic therapy (PDT) in treating choroidal neovascularization (CNV) secondary to age-related macular degeneration (ARMD) on long-term follow-up. Materials and Methods: Of 42 eyes, 18 were treated with bevacizumab (Group A) and 24 with ranibizumab (Group B) in combination with verteporfin PDT. Treatment was initiated after informed consent. Complete ophthalmic examination including optical coherence tomography (OCT) was performed at presentation, 1 month, 3 months, and subsequent follow-up visits. OCT measures used were lesion thickness (LT) of the CNV, retinal thickness above the lesion (RT), and central macular thickness (CMT). Mean follow-up period was 33 months (median 18, range 1-84). Additional treatment on follow-up was left at treating surgeon's discretion. Results: Visual acuity improved significantly from baseline by 0.3 LogMAR in Group A and 0.26 LogMAR in Group B. LT decreased significantly from 1 st month onward and remained significant at all the subsequent visits, in both the groups. CMT and RT showed a decreasing trend in both the groups. No difference was seen in visual acuity (VA), LT, CMT, and RT between Group A and Group B at any of the visits. The mean number of additional anti-vascular endothelial growth factor injections given postcombination therapy were 1.5 (median 1, range 0-7) injections per eye. Conclusions: PDT in combination with either ranibizumab or bevacizumab was equally effective in preventing vision loss in eyes with wet-Age-related macular degeneration (ARMD). Such combination also reduces the economic burden of the treatment.
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Radiotherapy for iris metastasis from esophageal carcinoma: A series of three cases p. 93
Chandana Das, Carol L Shields
DOI:10.4103/0974-620X.184526  
Background: Description of three cases of metastatic esophageal carcinoma to the iris and focus on management strategies. Methods: A 48-year-old man (Case 1) with previously treated stage IV esophageal carcinoma presented with blurred vision in the left eye (OS) for 3 weeks. Initial fine needle aspiration biopsy (FNAB) was negative for malignant cells, so incisional biopsy was performed and confirmed metastatic carcinoma. A 53-year-old man (Case 2) with previously treated stage III esophageal cancer experienced 2 months of pain and 1 month of blurred vision OS. Documented tumor growth suggested esophageal carcinoma metastasis. A 65-year-old man (Case 3) with previously treated stage IV esophageal carcinoma developed hyphema in the right eye (OD), and FNAB confirmed metastatic carcinoma. Results: Case 1 was treated with external beam radiotherapy (EBRT), delivered over 16 days which resulted in complete tumor regression. Case 2 received stereotactic body radiotherapy (SBRT) over 21 days leading to complete tumor regression. Case 3 was treated with plaque radiotherapy over 4 days, resulting in complete tumor regression. Conclusions: In all three cases, radiotherapy was employed, and enucleation was avoided. Plaque radiotherapy achieved tumor control in a shorter period of time (4 days) compared to EBRT (16 days) or SBRT (21 days). Knowing the short life expectancy of these patients, plaque radiotherapy appears most favorable.
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Risk factors for late presentation of chronic glaucoma in an Iranian population p. 97
Behzad Fallahi Motlagh, Tahere Jangjou Pirbazari
DOI:10.4103/0974-620X.184527  
Purpose: To identify risk factors for late presentation in chronic glaucoma. Materials and Methods: In a hospital-based case-control study, 312 newly diagnosed consecutive patients with chronic glaucoma were recruited to study in Nikookari Hospital in Tabriz - Iran. Cases were defined as patients presenting with absolute field loss within 5° of fixation or a cup to disc ratio >0.8 in one or both eyes (188 patients). Controls were patients with no absolute field loss within 20° in either eye but otherwise glaucomatous field loss and a cup to disc ratio >0.5 or a difference of 0.2 or greater between the discs (124 patents). Results: In logistic regression model, there was a significant association between late presentation and male gender, lower education status, pseudoexfoliative glaucoma, high intraocular pressure (IOP) in the first presentation and no eye exam in last 2 years. Patients with pseudoexfoliative glaucoma had 1.5 times more odd for late presentation (1.52 confidence interval [CI]: 1.14-2.24 P = 0.004). Patients that visited by an ophthalmologist in the last 2 years had 0.5 less likely to present with advanced glaucoma (0.54 CI: 0.32-0.92 P = 0.025). Higher IOP in initial examination was associated with advanced glaucoma. We estimated 1.08 increase in odd (CI: 1.03-1.04 P = 0.001) per increase in 1 mmHg in IOPs above 25 mmHg. Conclusion: Our study shows that several risk factors present for late presentation in chronic glaucoma. Our results suggest planning screening programs in high-risk individuals for early detection of glaucoma and prevention of blindness.
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CASE REPORTS Top

Contact lenses, migraine, and allodynia p. 101
Ozgur Bulent Timucin, Mehmet Fatih Karadag, Baykara Mehmet
DOI:10.4103/0974-620X.184528  
Clinical trials and electrophysiologic studies demonstrated increased perceptual sensitivity in patients suffering from migraines. At least, one triggering factor is described in 85% of migraine patients. The aim of this report was to investigate the relationship between contact lens (CL) usage and migraine attacks in two cases. Two patients who were diagnosed with migraine reported that the frequency of migraine attacks increased after they switched to using CL with different base curves (BCs). These two patients, who began using CL with different BCs experienced discomfort and dryness of the eye. The ocular complaints were followed by migraine attacks. CL intolerance was also developed during migraine attack in one of the cases. The frequency of migraine attacks decreased and allodynia relieved significantly when flatter BCs were selected. CL related stimulus could have triggered the migraine attack. CLs should be well fitted in migraine patients with allodynia.
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Ultrawide field fluorescein angiogram in a family with gyrate atrophy and foveoschisis p. 104
Koushik Tripathy, Rohan Chawla, Yog Raj Sharma, Varun Gogia
DOI:10.4103/0974-620X.184529  
Gyrate atrophy of choroid and retina is an autosomal recessive condition characterized by peripheral multiple sharp areas of chorioretinal atrophy which become confluent with age. Macula and central vision is typically involved late in the disease. Macular involvements such as cystoid macular edema, epimacular membrane, and choroidal neovascularization have been reported in gyrate atrophy. In this report, we present a family with diminished central vision presenting within 8 years of age. All of three siblings had typical peripheral chorioretinal atrophic lesions of gyrate atrophy and hyperornithinemia. On spectral domain optical coherence tomography, two of elder siblings showed macular edema. Hyporeflective spaces appeared to extend from outer nuclear layer to the inner nuclear layer level separated by multiple linear bridging elements in both eyes. Ultrawide field fluorescein angiogram (UWFI) even in late phase did not show any leak at macula suggesting foveoschisis. Foveoschisis in gyrate atrophy has not been reported before.
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Spontaneous closure of macular hole following blunt trauma p. 107
Clovis Arcoverde Freitas-Neto, Douglas Pigosso, Katia Delalibera Pacheco, Viviane Oliveira Pereira, Pranav Patel, Luiz Guilherme Freitas, Marcos Pereira Avila
DOI:10.4103/0974-620X.184530  
Ocular trauma can result in macular hole and it can lead to complete loss of central vision. We are reporting a case of traumatic macular hole associated with retinal hemorrhages and choroidal ruptures with spontaneous resolution and total vision recovery.
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Purtscher-like retinopathy in acute alcoholic pancreatitis p. 110
Nitin Nema, Saba Ishrat, Abha Verma, Manoj Kela
DOI:10.4103/0974-620X.184531  
A 23-year-old man with a history of alcoholism presented with vomiting, fever, and sharp epigastric pain radiating to the back and flanks. He was diagnosed as a case of acute alcoholic pancreatitis on the basis of clinical findings and investigations. On the next day of presentation, he developed sudden bilateral visual loss. His best-corrected visual acuity was finger counting at one-foot distance in both eyes. He had diffuse whitening in the circumpapillary area, haloes around the retinal vessels (Purtscher flecken) and intra-retinal hemorrhages on ophthalmoscopic examination. Optical coherence tomography revealed bilateral macular edema. These findings were characteristic of Purtscher-like retinopathy. The patient showed systemic and visual improvement at 8 weeks follow-up after receiving the conventional treatment for acute alcoholic pancreatitis. This case emphasizes the importance of fundus examination by an ophthalmologist in the diagnosis of this rare under-diagnosed entity.
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Transient ischemic attack presenting in an elderly patient with transient ophthalmic manifestations p. 113
Sparshi Jain, Tishu Saxena, Sweta Singh, Nidhi Singh
DOI:10.4103/0974-620X.184532  
Transient ischemic attack (TIA) is a transient neurological deficit of cerebrovascular origin without infarction which may last only for a short period and can have varying presentations. We report a case of 58-year-old male with presenting features of sudden onset transient vertical diplopia and transient rotatory nystagmus which self-resolved within 12 h. Patient had no history of any systemic illness. On investigating, hematological investigations and neuroimaging could not explain these sudden and transient findings. A TIA could possibly explain these sudden and transient ocular findings in our patient. This case report aims to highlight the importance of TIA for ophthalmologists. We must not ignore these findings as these could be warning signs of an impending stroke which may or may not be detected on neuroimaging. Thus, early recognition, primary prevention strategies, and timely intervention are needed.
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Acute lymphoblastic leukemia as second primary tumor in a patient with retinoblastoma p. 116
Anasua Ganguly, Swathi Kaliki, Faraz Ali Mohammad, Dilip K Mishra, S Vanajakshi, Vijay Anand Reddy
DOI:10.4103/0974-620X.184533  
Second primary tumor (SPT) is defined as a second tumor that presents either simultaneously or after the diagnosis of an index tumor. Second primary malignancies are the leading cause of death in patients with heritable retinoblastoma (RB). Acute lymphoblastic leukemia (ALL), as SPT in RB patients, is extremely rare. To the best of our knowledge, only five cases of ALL as SPT in patients with RB has been documented in the literature. Herein, we report a case of a 6-year-old girl with bilateral RB, who developed ALL during the course of treatment of RB. This case highlights the importance of reviewing blood investigations regularly to diagnose leukemia as SPT in RB and also the necessity for proper counseling and lifelong follow-up in these patients.
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CLINICAL QUIZ Top

A 56-year-old male with unilateral painless diminution of vision p. 119
Koushik Tripathy, Rohan Chawla, Vivek Kumar, Yog Raj Sharma, Pradeep Venkatesh
DOI:10.4103/0974-620X.184534  
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LETTERS TO THE EDITOR Top

Clinical risk factors for age-related macular degeneration: A case-control study p. 120
Ali Tabatabaei, Mostafa Mafi, Saeed Shoar, Mohammad Naderan
DOI:10.4103/0974-620X.184535  
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Peripheral ulcerative keratitis associated with chronic malabsorption syndrome and miliary tuberculosis in a child p. 121
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/0974-620X.184536  
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