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   Table of Contents - Current issue
Coverpage
September-December 2019
Volume 12 | Issue 3
Page Nos. 143-207

Online since Friday, October 11, 2019

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EDITORIAL  

Periocular esthetic procedures: Do patients understand the risks? p. 143
Abdullah S Al-Mujaini
DOI:10.4103/ojo.OJO_207_2019  
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ORIGINAL ARTICLES Top

Prevalence of visual impairment in school-going children among the rural and urban setups in the Udupi district of Karnataka, India: A cross-sectional study Highly accessed article p. 145
Avinash V Prabhu, Ramesh S Ve, Juthika Talukdar, Varalakshmi Chandrasekaran
DOI:10.4103/ojo.OJO_190_2018  
AIM: The aim of this study is to estimate the prevalence of visual impairment among school-going children in Udupi district, Karnataka. MATERIALS AND METHODS: A cross-sectional study across eleven schools from both urban and rural parts of Udupi taluk was conducted to report the magnitude of visual impairment among the schoolchildren. Complex survey design was used in allocating the sample size through stratification and clustering. Totally 1784 schoolchildren between the age groups of 5 and 15 years participated in the study. Presenting visual acuity and objective refraction was measured using computerized logMAR acuity charts and Plusoptix A09 photorefractor, respectively. Manifest ocular deviation or squint was also recorded. RESULTS: The mean age of the students was found to be 10.62 ± 2.72 years. The prevalence of visual impairment, i.e., visual acuity worse than or equal to 20/40 in the better eye was found to be 4.32% (95% confidence interval: 3.38%, 5.26%). The prevalence rate was significantly higher among students from urban area (5.6%) compared to those from rural area (3.6%) (P = 0.011). CONCLUSION: Visual impairment was found to be 4.32% in the school-going population of Udupi district. Effective and user-friendly devices aided the visual deficit screening including refractive error and squint.
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Relationship between optical perfusion pressure and systemic blood pressure on glaucoma: Case–control study p. 150
Varshav Gore, Parthav Shah, Minal Kanhere, Shalini Gore
DOI:10.4103/ojo.OJO_112_2018  
AIM: To investigate the relationship between blood pressure (BP), ocular perfusion pressure (OPP), intraocular pressure (IOP) and open angle glaucoma (OAG) in Primary Open Angle Glaucoma (POAG) patients and normal population. DESIGN: Cross-sectional observation study. MATERIALS AND METHODS: Hospital-based, case control cross-sectional study conducted on 150 patients, of which 75 people were included in the control group and 75 people in the glaucoma group. The diagnosis of cases was based on disc evaluation, gonioscopy, perimetry and applanation tonometry. Systolic and diastolic blood pressure (SBP and DBP) was measured with a Mercury Sphygmomanometer. Mean ocular perfusion pressure (MOPP) = ⅔ (mean arterial pressure − IOP), where mean arterial pressure (MAP) = DBP + ⅓ (SBP − DBP), systolic perfusion pressure (SPP) = SBP – IOP and diastolic perfusion pressure (DPP) = DBP − IOP was calculated. RESULTS: DBP, OPP, SPP and DPP showed positive association with POAG. There is positive correlation between IOP and SBP, DBP and there is a negative correlation between IOP, OPP, SPP and DPP. Lower OPP was strongly associated with an increased risk for POAG, with a relative risk of 6.27 and the odds ratio of 0.075 for those with OPP less than 50 mmHg. Similarly, a low DPP less than 55 mmHg were also associated with increased risk for POAG with relative risk of 5.3 and the odds ratio of 0.020. CONCLUSION: Low MOPP and low DPP show strong association with increased prevalence of POAG and are independent risk factors for OAG.
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Neonatal retinoblastoma: A study of five cases p. 156
Swathi Kaliki, Sai Divya Jajapuram
DOI:10.4103/ojo.OJO_176_2018  
PURPOSE: The purpose was to study the clinical features, treatment, and outcome of retinoblastoma (RB) in neonates. METHODS: This was a retrospective study of five patients with RB detected in the 1st month of life. RESULTS: The mean age at diagnosis of RB was 22 days (median, 24 days; range, 14–28 days). There were one female and four males with neonatal RB. Two patients had a known family history of RB, and the tumor was detected by routine fundus screening in these children. Two patients were brought in with complaints of leukocoria and one patient with complaints of red-eye. All patients had an intraocular tumor at presentation. Four patients had bilateral involvement, whereas only one had unilateral involvement. Based on the International Classification of Intraocular Retinoblastoma, the tumors were classified as Group A (n = 2), Group B (n = 3), Group C (n = 1), Group D (n = 1), and Group E (n = 2). Macular involvement was noted in 6 (67%) eyes. The primary treatment included systemic chemotherapy with/without focal treatment in all patients. One patient subsequently underwent secondary enucleation as the globe became phthisical. One child died while on treatment due to pneumonia secondary to chemotherapy-induced neutropenia. Of the four patients who completed treatment, globe salvage was achieved in 6 (86%) eyes over a mean follow-up period of 89 months (median, 92 months; range, 29–144 months). CONCLUSION: Neonatal RB though rare, if detected early, has a favorable outcome of ocular and life salvage. Sporadic RB can occur in neonates, and a family history may not always be elicited.
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Intraoperative and postoperative complications of cataract surgery in eyes with pseudoexfoliation – An 8-year analysis p. 160
Thanigasalam Thevi, Adinegara Lutfi Abas
DOI:10.4103/ojo.OJO_238_2018  
INTRODUCTION: Pseudoexfoliation (PXM) is a fibrillar material deposited in the anterior chamber of the eye and can cause disintegration of zonules and make pupillary dilatation difficult. This can make surgery difficult and result in intraoperative and postoperative complications. The aim of this study was to learn about whether the presence of pseudoexfoliation caused significant complications during cataract surgery. MATERIALS AND METHODS: We did a secondary data analysis of 12,992 eyes from 2007 to 2014 using the National Eye Database of Melaka Hospital Malaysia on intraoperative and postoperative cataract surgery complications of patients with PXM. RESULTS: Patients with PXM were 2.68 times more likely to get intraoperative complications (P < 0.001). They had a higher incidence of lens subluxation, zonular dehiscence, and vitreous loss (P < 0.001). Although posterior capsule rupture (PCR) was the most common intraoperative complication during cataract surgery (4.8%), the presence of pseudoexfoliation was not associated with PCR (P > 0.05). We did not observe any association between patients with pseudoexfoliation and any of the postoperative complications such as corneal decompensation, raised intraocular pressure, and intraocular lens decentration (P > 0.05). Pseudoexfoliation did not cause corneal decompensation (P > 0.05) although corneal decompensation was the highest postoperative complication of cataract surgeries (0.18%). CONCLUSIONS: Patients with PXM had a higher rate of intraoperative complications which were mainly vitreous loss and zonular dehiscence and also lens subluxation/dislocation. We observed poorer visual outcomes in those with PXM following cataract surgery. Patients with pseudoexfoliation should be identified and precautions taken to minimize these complications to get better visual outcomes.
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Long-term analysis of an unconventional way of doing double-head pterygium excision p. 166
Shreesha Kumar Kodavoor, Nitin Narendra Tiwari, Dandapani Ramamurthy
DOI:10.4103/ojo.OJO_69_2017  
AIM: The aim of the study is to describe an unconventional technique of vertically split conjunctival autograft (CAG) for primary double-head pterygium and its long-term outcome. MATERIALS AND METHODS: This was a retrospective, noncomparative, interventional case series of 95 eyes of 95 patients, who underwent vertical, split CAG surgery without maintaining limbus–limbus orientation for primary double-head pterygium from January 2013 to January 2017. All patients were reviewed for recurrence in their follow-up period. RESULTS: The mean follow-up was 14.12 ± 9.42 months. The baseline characteristics included 44 males and 51 females, with a mean age of 56.24 ± 10.03 years. The only significant complication was recurrence rate of 2.10% (2 eyes out of 95). The most common secondary outcome was graft edema (36.84%, 35 eyes out of 95), which resolved without any intervention. The other outcomes such as graft retraction (12.63%), Tenon's granuloma (1.05%), and subconjunctival hemorrhage (34.73%) were also recorded. CONCLUSION: Unconventional vertical split CAG without maintaining limbus–limbus orientation has convincing results in treating double-head pterygium with lower recurrence rate.
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Outcomes of preoperative intrapterygial injection of mitomycin C for pterygium excision with and without inferior conjunctival flap p. 171
Ved Prakash Gupta, Shekhar Sanghi, Jolly Rohatgi, Upreet Dhaliwal
DOI:10.4103/ojo.OJO_129_2018  
PURPOSE: This study aimed to report the comparison of recurrence rate and complications of intrapterygial injection of mitomycin C (MMC) 1 month before bare sclera excision of pterygium with and without conjunctival flap from the inferior bulbar conjunctiva. METHODS: This prospective interventional study enrolled 60 patients of pterygia from November 2010 to June 2012. All eyes received 0.1 ml (0.02%) of intrapterygial MMC injection 1 month preoperatively. Patients were divided into two groups of 30 each: Group 1 – bare scleral excision (BSE) and Group 2 – BSE with conjunctival flap from the inferior bulbar conjunctiva to cover the bare sclera. Chi-square test, Fisher's exact test, and unpaired t-test were used for statistical analysis. RESULTS: The mean age was 40.6 ± 12.8 years and 36.9 ± 10.9 years in Group 1 and 2, respectively, (P = 0.2329). There were 11 (36.7%) males and 19 (63.3%) females in Group 1 and 7 (23.3%) males and 23 (76.7%) females in Group 2 (P = 0.101). The recurrence rate was 0% in Group 1 and 3.3% (1 eye) in Group 2 (P = 1.00). Postoperatively, scleral whitening occurred in 6 (20%) eyes in Group 1 and none in Group 2 (P = 0.015). CONCLUSION: Both techniques, BSE alone or with conjunctival flap from the inferior bulbar conjunctiva 1 month after intrapterygial MMC, resulted in negligible (0%–3.3%) recurrence of pterygium. Conjunctival flap significantly reduced (0%) the postoperative complication of scleral whitening. This is the first report of efficacy of conjunctival flap in reducing scleral whitening after intrapterygial MMC.
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Contact lens fitting after corneal collagen cross-linking p. 177
Preeji Suderman Mandathara, Parthasarathi Kalaiselvan, Varsha M Rathi, Somasheila I Murthy, Mukesh Taneja, Virender S Sangwan
DOI:10.4103/ojo.OJO_43_2018  
BACKGROUND: Contact lenses (CLs) remain the mainstay in improving vision in patients having keratoconus. With corneal collagen cross-linking (CXL) performed worldwide, whether the same CLs can be used or needs replacement needed to be assessed and considered. AIMS: The aim of this study was to evaluate the changes in CL fitting following CXL. SETTINGS AND DESIGN: This is a retrospective study conducted at a tertiary center. SUBJECTS AND METHODS: We analyzed the medical records of patients who underwent CXL and used CL. Data collected included demographics, pre- and post-CXL refraction, corneal topography, anterior-segment examination, and CL [rigid gas permeable(RGP)] fitting details and duration between CXL and RGP fitting. STATISTICAL ANALYSIS: Descriptive analysis and paired t-test were used to compare the pre- and post-CXL data on refraction, visual acuity, and CL parameters. The statistical significance was kept at P < 0.05. RESULTS: Thirty-four eyes (keratoconus = 32, pellucid marginal degeneration = 1, and post-LASIK ectasia = 1) of 27 patients who used CL before and after undergoing CXL were analyzed. Mean duration between CXL and RGP lens use was 2.53 months. Mean sphere and cylinder post-CXL was −4.11 ± 4.32 D and −3.54 ± 2.51 D, respectively. A mean change of 0.75 ± 3.72 D sphere and 0.71 ± 3.39 D cylinder was noted post-CXL. The post-CXL best spectacle-corrected visual acuity (CVA) was 0.52 ± 0.36 and with RGP lens it was 0.09 ± 0.18. There was no significant difference in pre- and post-CXL RGP lens CVA (0.07 ± 0.09 and 0.09 ± 0.18, respectively; P = 0.556). Pre-CXL, 3-point-touch fitting was in 24 eyes (70.59%) and central fluorescein pooling was in 10 eyes (29.41%). Post-CXL, 30 eyes (88.24%) had 3-point-touch and central fluorescein pooling was found in four eyes (11.76%). One patient had CL intolerance after CXL. Of the 32 keratoconus eyes, 62.5% (n = 20 eyes) were prescribed new lenses; 37.5% (n = 12 eyes) continued using own lenses. CONCLUSIONS: There was no significant difference in refraction, topography indices, and RGP lens parameters pre- and post-CXL. However, changes in RGP lens fitting characteristics suggest a possible change in shape or apex location of the cornea after CXL. RGP lenses remain the best option to improve visual acuity after CXL in corneal ectasia.
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Long term effect of panretinal photocoagulation on retinal nerve fiber layer parameters in patients with proliferative diabetic retinopathy p. 181
Meenakshi Wadhwani, Shweta Bali, Shibal Bhartiya, Manish Mahabir, Ashish Upadhaya, Tanuj Dada, Anu Sharma, Sanjay Kumar Mishra
DOI:10.4103/ojo.OJO_39_2018  
PURPOSE: This study aimed to evaluate the long-term effect of panretinal photocoagulation (PRP) on the retinal nerve fiber layer (RNFL) in patients with proliferative diabetic retinopathy (PDR). METHODS: This was a prospective longitudinal cohort study examining 42 eyes of 42 patients with PDR undergoing PRP. Peripapillary RNFL thickness (RNFLT) was measured using spectral-domain optical coherence tomography at baseline, 1 year, and 3 years following PRP. RESULTS: The mean “average RNFLT” was 89.88 ± 14.26 μm at baseline, 85.75 ± 11.36 μm at 1-year follow-up, and 83.33 ± 11.96 μm at 3-year follow-up. There was a statistically significant difference in the average RNFL thickness at baseline and 1 year and 3 years after PRP. At 1-year follow-up, superior, inferior, and nasal RNFL measurements reduced significantly from baseline (P < 0.01). The reduction in RNFL remained statistically significant for superior and inferior quadrants 3 years after PRP. CONCLUSION: PRP causes a reduction in RNFL thickness until 3 years after the procedure. Caution should be exercised while interpreting peripapillary RNFL thickness scans in patients who have undergone PRP for diabetic retinopathy.
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Corneal thickness and endothelial cell density in children with type 1 diabetes mellitus p. 186
Sheldon Ignatius Fernandes, Shubha Nagpal
DOI:10.4103/ojo.OJO_21_2018  
BACKGROUND: The aim of this study was to detect the effect of diabetes on the corneal endothelium in patients of Type 1 diabetes in the pediatric age group and to compare them with age-matched controls. Further, it was proposed to establish any correlation between these changes and risk factors of diabetes, viz., age, duration of diabetes, and hemoglobin A1c (HbA1c) values. MATERIALS AND METHODS: This was a prospective cross-sectional study. Fifty children with Type 1 diabetes, between the ages of 7 and 17 years (average, 12.16 ± 2.63 years), and fifty healthy age-matched controls (average 12.28- ±3.00 years) were examined. The central corneal thickness (CCT) and endothelial cell density (CD) were assessed by the Topcon SP-1P specular microscope. The duration of diabetes (average, 3.91 ± 1.65 years) and the HbA1c values (average, 10.92 ± 2.28) were also noted. RESULTS: The average CCT in the diabetics was 525.16 ± 33.14 μ and in the controls 513.44 ± 29.46 μ. This was significantly higher (P = 0.015). The average endothelial CD in the diabetics was 3039.64 ± 292.84 cells/mm2 and in the nondiabetics 3360.41 ± 268.04 cells/mm2. This was significantly lower (P < 0.001). A significant correlation was found between the endothelial CD and age of the diabetic patients (P = 0.008). However, there was no significant correlation between the endothelial CD and the CCT with either duration of diabetes or HbA1c. CONCLUSIONS: A significant decrease in the endothelial CD and increase in the CCT occurs in children and adolescents with Type 1 diabetes. With the age of the diabetic patients, the endothelial CD significantly reduces. However, duration of diabetes and HbA1c do not affect these values.
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CASE REPORTS Top

Bilateral nongranulomatous uveitis with transposition of the great arteries: A rare case report p. 191
Dipankar Das, Saurabh Deshmukh, Harsha Bhattacharjee, Krati Gupta, Pranjal Mishra
DOI:10.4103/ojo.OJO_7_2019  
In this case report, we describe for the first time an association between transposition of the great arteries (TGAs), a congenital heart disease, and uveitis. We hope that this atypical finding in a patient with TGA will add to the clinical spectrum of ophthalmic conditions that can be seen with TGA. A 16-year-old boy, diagnosed and operated for TGA, presented with redness and pain in the left eye. The patient underwent complete ophthalmological and systemic examination. Detailed blood workup was done to rule out other causes of uveitis. A working diagnosis of bilateral nongranulomatous uveitis in status postopen-heart surgery was made, and the patient was successfully treated. Thus, uveitis can develop in patients with TGA, and prompt treatment can restore vision in these patients.
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Medroxyprogesterone to treat corneal thinning postcurvularia keratitis p. 194
Lubna Khan, Ekta Batavia
DOI:10.4103/ojo.OJO_228_2018  
Keratitis of varied etiology is not uncommon in the Indian subcontinent. This case is one such an instance of keratitis caused by dematiaceous fungus in an urban dweller not engaged in farming or any other soil/earth-related work. Although healing of the ulcer occurred in the usual course, thinning persisted for a fortnight. This case highlights medroxyprogesterone acetate used topically to achieve collagen synthesis, thereby affect repair of the thinned cornea.
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Limbal schwannoma: Clinicopathological study of a case with review of literature p. 197
Rachna Agarwal, Shabari Pal, Nandita Chaudhary, Kumudini Sharma, Vikas Kanaujia
DOI:10.4103/ojo.OJO_81_2018  
Schwannomas involving the perilimbal conjunctiva is an extremely rare clinical entity and has been reported scantily in literature. In this case, a 27-year-old healthy female presented with a pinkish smooth globular mass involving the limbus in the superonasal quadrant of the left eye. The mass was completely excised and histopathology revealed an encapsulated tumor, with cells displaying elongated nuclei, bland chromatin, and few Verocay bodies with palisaded nuclei, suggestive of schwannoma. Immunohistochemistry showed strong S100 positivity. This case thus highlights schwannoma as a differential diagnosis of limbal masses.
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A rare case of focal choroidal excavation associated choroidal neovascularization in angioid streaks p. 200
F Nidhee Jain, George J Manayath, V Narendran, VR Saravanan, Karan Kumarasamy, Ramya Appanraj
DOI:10.4103/ojo.OJO_61_2018  
The purpose is to report a case of focal choroidal excavation (FCE) in a patient with angioid streaks (ASs) associated with secondary choroidal neovascularization (CNV). A 26-year-old man was referred for the treatment of CNV. On further evaluation, he was found to have ASs and optical coherence tomography revealed the presence of the choroidal neovascular complex associated with FCE. The patient was treated with a single dose of intravitreal bevacizumab (1.25 μg/0.05 ml). There was resolution of the lesion, and on further follow-up over 6 months, there were no recurrences. CNV in patients with ASs may also be associated with FCE. These patients have a good response to intravitreal antivascular endothelial growth factor injection.
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Micrococcus keratitis following microkeratome-assisted laser in situ keratomileusis p. 203
Mukesh Taneja, Varsha M Rathi, Bhupesh Bagga, Somasheila I Murthy, Jatin Ashar, Ashok Kumar Reddy, Pravin K Vaddavalli
DOI:10.4103/ojo.OJO_54_2017  
We hereby report a case of infectious keratitis after laser in situ keratomileusis (LASIK) caused by Micrococcus luteus, a commensal, managed successfully in a nonimmunocompromised individual. A 25-year-old healthy male underwent uneventful bilateral simultaneous LASIK for myopia using disposable blades. Postoperatively, topical antibiotic and steroids were advised; he discontinued antibiotic on his own after using for a day. On the 5th postoperative day, he had pain, redness, decreased vision, and white spot in the left eye (LE) for 1-day duration. Uncorrected visual acuity (UCVA) of LE reduced to 20/80 from postoperative 20/20. Slit-lamp biomicroscopy revealed tiny infiltrate in the interface with reticular haze in the flap and stroma. Gram-positive cocci in pairs and tetrads were found on corneal smears that were collected after lifting the flap from infiltrate, stromal bed, and undersurface of the flap. M. luteus was isolated on culture. The infiltrate resolved with scarring with intensive topical antibiotics. UCVA was 20/25. To the best of our knowledge, this is a first case report of post-LASIK infectious keratitis caused by M. luteus.
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CLINICAL QUIZ Top

The black eye p. 206
Simar Rajan Singh, Sonam Yangzes, Jagat Ram
DOI:10.4103/ojo.OJO_174_2018  
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