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   Table of Contents - Current issue
Coverpage
January-April 2016
Volume 9 | Issue 1
Page Nos. 1-70

Online since Wednesday, February 10, 2016

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EDITORIAL COMMENTARY  

Advances in glaucoma surgery: Paradigm shift in management p. 1
Vanita Pathak-Ray
DOI:10.4103/0974-620X.176092  
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REVIEW ARTICLE Top

Clinical utility of anterior segment swept-source optical coherence tomography in glaucoma p. 3
Dewang Angmo, Monisha E Nongpiur, Reetika Sharma, Talvir Sidhu, Ramanjit Sihota, Tanuj Dada
DOI:10.4103/0974-620X.176093  
Optical coherence tomography (OCT), a noninvasive imaging modality that uses low-coherence light to obtain a high-resolution cross-section of biological structures, has evolved dramatically over the years. The Swept-source OCT (SS-OCT) makes use of a single detector with a rapidly tunable laser as a light source. The Casia SS-1000 OCT is a Fourier-domain, SS-OCT designed specifically for imaging the anterior segment. This system achieves high resolution imaging of 10΅m (Axial) and 30΅m (Transverse) and high speed scanning of 30,000 A-scans per second. With a substantial improvement in scan speed, the anterior chamber angles can be imaged 360 degrees in 128 cross sections (each with 512 A-scans) in about 2.4 seconds. We summarize the clinical applications of anterior segment SS-OCT in Glaucoma. Literature search: We searched PubMed and included Medline using the phrases anterior segment optical coherence tomography in ophthalmology, swept-source OCT, use of AS-OCT in glaucoma, use of swept-source AS-OCT in glaucoma, quantitative assessment of angle, filtering bleb in AS-OCT, comparison of AS-OCT with gonioscopy and comparison of AS-OCT with UBM. Search was made for articles dating 1990 to August 2015.
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ORIGINAL ARTICLES Top

Eye drop administration in patients attending and not attending a glaucoma education center p. 11
Aisha Al-Busaidi, Debbie Anne Samek, Oscar Kasner
DOI:10.4103/0974-620X.176094  
Background: To assess the technique of glaucoma eye drop instillation in patients who have and have not attended glaucoma education sessions. To compare this with their subjective perception of eye drop use and identify factors associated with improved performance. Patients and Methods: An observational study of 55 participants who instill their topical glaucoma medication for more than 1 year. Twenty-five patients attended (A) glaucoma teaching sessions >1 year before the study and were compared to thirty patients who never attended (NA). Patients completed a self-reporting questionnaire. They instilled their eye drop, and the technique was video-recorded digitally and later graded by two masked investigators. The results were analyzed using Fisher's exact test and Chi-square test. Predictors were assessed using logistic regression models. Results: There was no significant difference in overall performance scores between the two groups. Good technique was observed in 16% of (A) group versus 23% (NA) group, (P = 0.498). There was a mismatch between patient's subjective and actual performance. Female gender and higher educational level were found to be predictors of good performance of drop instillation on univariable logistic regression analysis. Conclusion: Glaucoma patients are challenged with eye drop instillation despite receiving education on drop administration. There is a discrepancy between patient's perceptions and observed technique of drop administration.
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Primary angle-closure glaucoma: A retrospective interventional case series in South India p. 17
HH Suresh, HR Samhitha, H Kishore, Krishna Prasad, Sneha Solse, P Divya
DOI:10.4103/0974-620X.176095  
Purpose: To report the outcome of surgically managed primary angle-closure glaucoma (PACG) cases in 84 eyes at a tertiary eye hospital in South India. Materials and Methods: Retrospective analysis of medical records of 84 eyes of 81 patients with PACG, who were surgically managed over 4 years at tertiary eye hospital in South India. Data were obtained from medical and surgical records of the patients identified from October 2010 to October 2014. The patients were operated by two surgeons in the Glaucoma Department of the institute. Results: The patients' mean age at surgery was 56.21 years. Twenty-four eyes with a mean intraocular pressure (IOP) of 45.8 mmHg underwent trabeculectomy, and 60 eyes with a mean IOP of 29.9 mmHg underwent trabeculectomy with cataract extraction with or without intraocular lens implantation with good postoperative IOP control. A statistically significant greater reduction in IOP was noted in 14 patients who underwent augmentation with Mitomycin C (P = 0.0060, Student's t-test). Conclusion: Knowing the risk factors, the diagnostic methods and treatment options for PAC disease is vital to every ophthalmologist as it is potentially treatable yet visually debilitating if untreated. Trabeculectomy or trabeculectomy with cataract extraction preferably with antifibrotics is an excellent treatment modality for PACG, which also effectively halts the disease progression.
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Comparison of Goldmann applanation tonometer, Tono-Pen and noncontact tonometer in children p. 22
Usha Kaul Raina, Neha Rathie, Anika Gupta, Shantanu Kumar Gupta, Meenakshi Thakar
DOI:10.4103/0974-620X.176096  
Background: To evaluate the agreement of Goldmann applanation tonometer (GAT) with Tono-Pen and noncontact tonometer (NCT) for measurement of intraocular pressure (IOP) in pediatric age group and to evaluate the correlation between central corneal thickness (CCT) and IOP measured with the tonometers used. Materials and Methods: IOP was measured in 200 eyes in a group of Indian children, aged between 8 and 18 years using three different tonometers: NCT, the Tono-Pen and GAT. All IOP readings were made in the office settings by the same examiner. Readings obtained were compared between the instruments and with the CCT for each tonometer. Tonometer inter-method agreement was assessed by the Bland-Altmann method. The relations of CCT with absolute IOP values and inter-tonometer differences were analyzed by linear regression. Results: The mean age was 13.37 ΁ 3.51 years. The mean IOP values recorded with NCT; Tono-Pen and GAT were 14.38, 15.63, and 12.44 mmHg, respectively. Both Tono-Pen and NCT recorded statistically higher IOP values than the GAT (P = 0.00) regardless of the CCT. The percentage increase of IOP measured over GAT was 15.66% for NCT and 25.70% for Tono-Pen which was also statistically significant. A correlation was found between CCT and IOP values obtained with all the three tonometers. Conclusion: IOP measurements on children vary significantly between instruments and correlations are affected by the corneal thickness. Further studies on children are needed to determine which instrument is most appropriate and to derive a normative IOP scale for the growing eye.
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Visual acuity and refractive status of Omani students with refractive error in grades 1, 4 and 7: A retrospective cohort study p. 27
Saleh Al Harby, Tariq Al-Asbali, Rajiv Khandekar
DOI:10.4103/0974-620X.176097  
Background: The visual and refractive status were assessed for grade 7 students in seven governorates in Oman. The health records were reviewed to assess the rationale for their previous school-based vision screening. Methods: A representative sample of 7 th grade students with a refractive error (RE) was examined by optometrists in 2012. Their compliance with spectacle wear was also reviewed. Each student's vision and refractive status in grades 1 and 4 were compared with the status in grade 7. Each student's use of eye care services between grade 4 and 7 was evaluated to determine the uptake of existing eye services for vision problems. Results: This study had 286, 7 th grade students with RE (myopia [94%], hyperopia [4%] and astigmatism [>1D] [2%]). The types of RE between genders in each grade were not significant (P > 0.05). During their vision screening when they were in grade 4, 5 of 13 moderate myopes (>−2D to − 6D) and 3 of 4 high myopes (>−6D) were detected and managed. Ten students with moderate and high myopia were already using spectacles before they were screened in grade 7. The compliance for spectacle wear was 62% in grade 7. Between grades, 4 and 7, 140 (49%) students did not visit eye clinics or an optician. Conclusions: Refractive services in grade 4 were an additional initiative from the eye health care systems in Oman to the actual World Health Organization recommendations of conducting vision screening and RE corrections at grade 7 and 10. However, this was not proved to be significantly effective in early detection, and even the uptake of eye care services by school children was also low.
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Quantitative spectral domain optical coherence tomography thickness parameters in type II diabetes p. 32
Laxmi Gella, Rajiv Raman, Tarun Sharma
DOI:10.4103/0974-620X.176098  
Purpose: To elucidate the changes in retinal thickness and individual layer thickness in subjects with diabetic retinopathy (DR) using spectral domain optical coherence tomography (SDOCT). Materials and Methods: A total of 251 eyes from 170 subjects were included in this study. The study sample was subdivided into nondiabetic subjects; subjects with diabetes but no DR; subjects with mild, moderate, and severe nonproliferative DR (NPDR); and proliferative DR. Various retinal thickness parameters were assessed using SDOCT. Results: The mean age of the study population was 55.34 ± 9.02 years (range: 32-80 years) and 56.6% of the subjects were males. Men had significantly greater central foveal thickness, central subfield thickness, retinal nerve fiber layer thickness, and retinal thickness in all the quadrants of 3 mm and 6 mm zones compared to women (P < 0.001). Superior (293.11 ± 25.46 vs. 285.25 ± 19.17; P = 0.044) and temporal (282.10 ± 25.26 vs. 272.46 ± 16.21; P = 0.011) quadrants showed an increased retinal thickness in any DR group when compared with diabetic subjects without DR. Photoreceptor layer thickness was significantly reduced in diabetic subjects with no DR when compared with nondiabetic subjects and also in cases of severe NPDR when compared with mild and moderate NPDR. Conclusion: Here, we analyze the quantitative retinal thickness parameters in diabetic subjects using SDOCT. Neuronal degenerative changes such as photoreceptor and retinal pigment epithelial thinning in case of DR are also reported.
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Awareness, knowledge, and barriers to low vision services among eye care practitioners p. 37
Judy Jose, Jyothi Thomas, Premjit Bhakat, S Krithica
DOI:10.4103/0974-620X.176099  
Background: Eyesight plays an important role in our day today life. When the vision gets hampered, daily activities of an individual will be affected. The prevalence of visual impairment is increasing across the globe, with more burdens on the developing world. The uptake of low vision services remains to be low in developing countries like India. Methods: A newly constructed questionnaire using information from previously conducted telephonic interviews and article search was administered among 50 eye care practitioners from Kerala, India for the pilot study. Modifications were made in the questionnaire, based on the responses obtained from the pilot study. From their responses, awareness, knowledge, and barriers for the low vision services among eye care practitioners were assessed. Results: (1) Pilot study - the Cronbach's alpha values obtained for knowledge, awareness and barrier questions were 0.814, 0.297, and 0.810, respectively, and content validity index was found to be 0.64. (2) Main study - 211 eye care practitioners from 12 states of India took part in the study that accounted for a response rate of 16.7%. The participants included were 95 (45%) men and 116 (55%) women with a mean age of 28.18 ± 7.04 years. The lack of awareness was found to be the major barrier in the provision and uptake of low vision services from the practitioner's perspective. Conclusion: The study results showed that there is a lack of awareness among eye care practitioners about low vision services, which acts as a major barrier in the effective delivery of these services.
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The effect of intravitreal bevacizumab and ranibizumab on macular edema of the contralateral eye: A comparative study of two anti-VEGFs p. 44
Berker Bakbak, Banu Turgut Ozturk, Saban Gonul, Sansal Gedik
DOI:10.4103/0974-620X.176100  
Purpose: To compare the effects of bevacizumab and ranibizumab on the visual function and macular thickness in the contralateral (untreated) eye of patients with bilateral diabetic macular edema (DME). Materials and Methods: Thirty-nine patients with bilateral DME, who had been treated with both bevacizumab and ranibizumab in the same eye, were considered retrospectively for this study. Recorded outcome measurements included the best-corrected visual acuity (BCVA) assessment with the Early Treatment Diabetic Retinopathy Study (ETDRS) chart and the central subfield macular thickness (CSMT) measurement of the contralateral, uninjected eye before and at 4 weeks after the injections. Results: The median BCVA of the uninjected eye was 50 ETDRS letters and the median CSMT was 459 μm preceding the bevacizumab injection whereas at the control appointment, 4 weeks after the injection, the median BCVA had increased to 52 letters (P = 0.098), and the median CSMT had decreased to 390 μm (P = 0.036). The mean interval between the bevacizumab and ranibizumab treatments was 4.79 ΁ 1.52 months. The measurements of the untreated eye after the ranibizumab treatment showed that the median BCVA decreased from 55 to 52 letters, and the median CSMT increased from 361 μm to 418 μm (P = 0.148 and P = 0.109, respectively). Conclusions: In contrast to ranibizumab, the intravitreal administration of bevacizumab resulted in a statistically significant decrease in macular thickness in the untreated eye in patients with bilateral DME.
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CASE REPORTS Top

Organophosphate retinopathy p. 49
Hang Pham, Michelle D Lingao, Anuradha Ganesh, Jenina E Capasso, Rosanne Keep, Karthikeyan A Sadagopan, Alex V Levin
DOI:10.4103/0974-620X.176101  
Organophosphates have rarely been reported to cause various ocular sequelae including retinal degeneration. Retinal manifestations have been rarely reported and poorly characterized. We describe a case of a 76-year-old man with vision loss beginning in his 20s due to acute on chronic exposure to dimethoate, an organophosphate. He presented with bilateral geographic macular atrophy and midperipheral pigmentary clumping which we characterized by dilated fundoscopic examination, optical coherence tomography, and fundus autofluorescence.
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Tuberculosis presenting as posttraumatic panophthalmitis p. 52
Pankaj Gupta, Ramandeep Singh, Suruchi Gupta, Abhiraj Kumar, Nandita Kakkar
DOI:10.4103/0974-620X.176102  
Panophthalmitis is one of rare manifestations of tuberculosis described in atypical situations such as children, immune compromised patients, or drug abuse. The present report describes the first case of tubercular panophthalmitis developing after trauma in an otherwise healthy adult patient. A 46-year-old female patient presented with corneal infiltrate and endophthalmitis that developed after an injury to right eye with wooden object. Corneal scrapings and vitreous tap were sterile. The patient did not improve with antibiotics and developed panophthalmitis. On evisceration of the painful blind eye, histopathology showed the presence of granulomatous inflammation and acid-fast bacilli. The patient had no other systemic focus of tubercular infection. The patient was managed with anti-tubercular therapy for 6 months. Atypical presentations of tuberculosis like panophthalmitis pose a difficult problem in diagnosis as well as treatment. Direct inoculation of bacilli during trauma is a rare source of infection. This case report presents unusual development of tubercular panophthalmitis following direct inoculation of bacilli during trauma. Ocular tuberculosis should be considered in differential diagnosis of posttraumatic endophthalmitis and panophthalmitis, especially in endemic regions like India.
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Structural and functional evaluation of macula in a 9-year-old boy with occult macular dystrophy and his affected elder sibling p. 55
Tapas Ranjan Padhi, Chetan Videkar, Subhadra Jalali, Sujoy Mukherjee, Krushna Gopal Panda, Taraprasad Das
DOI:10.4103/0974-620X.176103  
Two siblings aged 9 and 15 years with unexplained visual loss had normal pupillary reactions, unremarkable anterior and posterior segment, normal fluorescein angiography, visual evoked potential, and flash electroretinogram (ERG). Spectral domain optical coherence tomography (OCT) showed loss of normal inner segment-outer segment (IS-OS) junction line bump at fovea in one and absent IS-OS junction line at fovea in the other. Characteristic hypovoltaged responses from central macula in multifocal ERG (mfERG) confirmed the diagnosis of occult macular dystrophy (OMD) in both siblings. Marked difference in OCT findings despite same visual acuity indicate that structural changes in OCT might not always correlate with the extent of functional loss. Obvious mfERG changes and very subtle OCT defect in the younger one suggests that functional changes probably appear much earlier than the structural changes. OMD is often underdiagnosed because of lack of high index of suspicion and detailed work up. The patients presented here represent first OMD report from India, one of them being the second youngest reported so far (medline search).
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Posterior scleritis in pediatric age group: A case report and review of literature p. 59
Radha Shenoy, Milind Suryawanshi, Roshini Isaac, Santhosh K Philip
DOI:10.4103/0974-620X.176121  
Posterior scleritis is rare in both the adult and pediatric age groups. Increased awareness and availability of advanced diagnostic facilities aid in early diagnosis and management. Visual recovery is possible with systemic steroids and immunosuppression. We report the case of a 12-year-old male child who presented with poor vision in his right eye and was found to have retinal striae and disc edema due to posterior scleritis.
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Phaco-endocycloplasty: A novel technique for management of ring iridociliary cyst presenting as acute angle closure p. 63
Vanita Pathak-Ray, Iqbal Ike K Ahmed
DOI:10.4103/0974-620X.176123  
Iridociliary cysts of pigment epithelium are rare, ring cysts being rarer still, and usually benign in their clinical course. Presented here is a case of ring iridociliary cyst that resulted in secondary synechial angle closure with an acutely elevated intraocular pressure, refractory to medical treatment. Primary endocycloplasty and cataract extraction with implant were used successfully to manage the case.
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CLINICAL QUIZ Top

A case of sudden painless loss of vision with partial spontaneous recovery p. 66
Pradnya Jayant Kamat, Pratik Yogesh Doshi
DOI:10.4103/0974-620X.176124  
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LETTERS TO THE EDITOR Top

Macular coloboma p. 67
Mary Varghese, Joel A Kavalakatt, Shweta Pandey, Jerry J Kolath
DOI:10.4103/0974-620X.176126  
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Salmon pink patch sign: Diagnosing persistent fetal vasculature p. 68
Sudarshan Khokhar, Shikha Gupta, Varun Gogia, Bhagabat Nayak
DOI:10.4103/0974-620X.176128  
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IN A LIGHTER VEIN Top

Some silly ophthalmic limericks p. 70
Akshay Gopinathan Nair
DOI:10.4103/0974-620X.176129  
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