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   Table of Contents - Current issue
Coverpage
September-December 2020
Volume 13 | Issue 3
Page Nos. 109-177

Online since Monday, November 2, 2020

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EDITORIAL  

Minimally invasive glaucoma surgery devices in glaucoma: A time for reflection Highly accessed article p. 109
Rebecca D Sarran, Deepak P Edward
DOI:10.4103/ojo.OJO_240_2020  
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ORIGINAL ARTICLES Top

Comparison of ophthalmic artery blood flow between open-angle glaucoma and nonglaucomatous eyes of Indian patients Highly accessed article p. 112
Vijay Mathur, Hiteshi Saini, Piyush Kumar Chaturvedi, Amandeep Singh, Bhupesh Bhatkoti
DOI:10.4103/ojo.OJO_16_2018  
This study was undertaken to compare ophthalmic artery blood flow in eyes having primary open angle glaucoma (POAG) with age matched non glaucomatous eyes using the technique of Color Doppler imaging in Indian patients. One hundred patients of either sex over 40 years of age were divided into two groups of 50 patients each. Group 1 included 50 patients diagnosed with POAG whereas group 2 included patients who did not have POAG. Tests like visual fields and OCT RNFL were conducted and a radiologist assessed the ophthalmic artery blood flow using Color Doppler imaging. Hemodynamic calculations of ocular blood flow were done using the parameters of resistivity index (RI) and pulsatility index (PI). Statistically significant increase in the values of RI and PI were noted in patients with POAG as compared to those who did not have POAG.
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Giant retinal tear retinal detachment etiologies, surgical outcome, and incidence of recurrent retinal detachment after silicone oil removal p. 117
Eman Abo Taleb, Manish P Nagpal, Navneet S Mehrotra, Kalyani Bhatt, Sangeeta Goswami, Abdulrahaman Noman
DOI:10.4103/ojo.OJO_206_2017  
PURPOSE: The purpose of this study was to evaluate etiologies, management, and outcomes of patients with giant retinal tears (GRTs) undergoing primary surgery at a tertiary referral center. METHODS: This was a retrospective, consecutive case series of 94 patients with at least 3 months follow-up after silicone oil removal (SOR). Fifty-seven eyes (60.6%) underwent vitrectomy, 36 eyes (38.3%) underwent combined vitrectomy with buckling, and 1 eye (1.1%) underwent scleral buckling. Perfluorocarbon liquid (PFCL) heavy liquid to flatten GRT flap intraoperative has been used then PFCL air exchange then air–silicon exchange in all eyes undergoing vitrectomy. Fellow eye was observed for retinal detachment (RD). RESULTS: Idiopathic cause constitutes 47 eyes (50%), in which 25 eyes (26.6%) are myopic and 22 eyes (23.4%) have a history of trauma. Eighty-five eyes (90.4%) achieved anatomic success. Visual acuity at the last follow-up was at least 20/400 in 71 eyes (75.5%) of patients. Recurrent RD after SOR was found in 21 eyes (22.3%), of which 50% had proliferative vitreoretinopathy grade C (PVR-C) or more (P = 0.03) and 20% had GRT size more than 180° (P = 0.04). Pars plana vitrectomy (PPV) alone (P = 0.89) or combined PPV with buckling (P = 0.98) has no significant correlation with recurrent RD. Twenty-one percent of the fellow eye had RD. CONCLUSION: Idiopathic cause constitutes the majority (50%). Patients with GRT who underwent surgery achieved a high anatomic success rate. PVR-C or more and GRT size more than 180° remain the most significant risk factor for recurrent RD after SOR, whereas PPV alone or combined PPV with buckling has no significant correlation with recurrent RD.
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Prognostic factors for eye globe salvage by external beam radiation therapy for resistant intraocular retinoblastoma p. 123
Yacoub A Yousef, Mona Mohammad, Imad Jaradat, Raed Shatnawi, Mustafa Mehyar, Ibrahim Al-Nawaiseh
DOI:10.4103/ojo.OJO_250_2019  
PURPOSE: To analyse the prognostic factors for eye salvage for eyes with intra-ocular retinoblastoma (RB) that is resistant to systemic chemotherapy and focal therapy by external beam radiation therapy (EBRT). METHODS: A retrospective analysis of 28 eyes with intra-ocular RB that was resistant for systemic chemotherapy and focal consolidation therapy and received EBRT. Outcome measures included tumor stage at diagnosis, stage migration, type of tumor seeds, treatment modalities, eye globe salvage, metastasis, and survival. RESULTS: Most of the patients (83%) had bilateral RB, and 42% were females. All eyes were treated initially by combination of systemic chemotherapy and focal consolidation therapy. The dose of EBRT was 45 Gy. The mean follow-up was 6.5 years, and the overall eye globe salvage rate post EBRT was 46%: 67% (2/3) for group B, 71% (5/7) for group C, and 33% (6/18) for group D. Patient's gender, tumor site, laterality, and tumor stage at diagnosis were not significant prognostic factors (p> 0.05) for final outcome. The significant poor prognostic factors were tumor stage migration during systemic chemotherapy (p= 0.03) and presence of vitreous seeds at time of EBRT (p=0.001). Post EBRT complication rate was 68% (19/28) including; retinal detachment (3), vitreous hemorrhage (4), neovascular glaucoma (1), cataract (16), radiation retinopathy (2), and second malignancy (2). CONCLUSION: EBRT is an alternative for enucleation when RB is resistant to combined chemoreduction/focal consolidation therapy in absence in vitreous seeds. The known risks for EBRT are not justified for patients with unilateral RB and for those who have functional vision in the other eye.
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Periocular basal cell carcinoma: 20-years experience at a tertiary eye care center of South India p. 129
Vathsalya Vijay, Md Shahid Alam, Nirmala Subramanian, Subramanian Krishnakumar, Jyotirmay Biswas, Bipasha Mukherjee
DOI:10.4103/ojo.OJO_130_2020  
PURPOSE: To study the clinical profile and management outcomes of periocular basal cell carcinoma (BCC). MATERIALS AND METHODS: A retrospective analysis of all histopathologically proven cases of BCC between 1995 and 2015 was done. The demographic data, clinical presentation, histopathological subtype, and management outcomes were analyzed. RESULTS: We had a total of 185 malignant eyelid tumors during the study period, out of which 37 (20%) were BCC. Thirty-two (86.5%) out of 37 cases were primary BCC. The mean age was 63.3 years. Pigmented ulcerative lesion (14, 38%), lower eyelid (19, 51%), and nodular BCC (15, 40%) were the most common presentation, periocular site, and histological subtype, respectively. 28 patients underwent excision under frozen section with an average tumor-free margin of 3.5 mm. Mean follow-up period was 18.78 months. Recurrence rate of 0% and 3.1% was noted in primary and recurrent BCC, respectively. CONCLUSION: Periocular BCC commonly presents as pigmented ulcerative lesion in the lower lid. Excision biopsy under frozen section with an average tumor-free margin of 3.5 mm offers cure in most cases.
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Optical coherence tomography biomarkers as predictive factors for postoperative visual acuity in patients with epiretinal membrane treated with vitrectomy p. 136
Irini Chatziralli, Eleni Dimitriou, Tina Xirou, Stamatina A Kabanarou, George Theodossiadis, Panagiotis Theodossiadis
DOI:10.4103/ojo.OJO_79_2020  
BACKGROUND: The purpose of this retrospective study was to evaluate potential predictive factors of postoperative visual outcome in patients with idiopathic epiretinal membrane (iERM), treated with pars plana vitrectomy (PPV). METHODS: Participants in the study were 46 patients diagnosed with iERM, who underwent PPV. Best-corrected visual acuity measurement and spectral domain-optical coherence tomography (OCT) were performed at baseline (preoperatively), and at months 6 and 12 postoperatively. Demographic characteristics and OCT parameters were assessed as potential predictive factors for postoperative visual outcome. RESULTS: Increasing age, retinal thickness, presence of disorganization of inner retinal layers, ellipsoid zone disruption, and presence of vitreomacular traction were found to be negatively associated with postoperative visual acuity. Gender, presence of subretinal fluid, cysts in the inner or outer nuclear layer, and hyperreflective foci were not found to affect visual acuity. There was statistically significant improvement in visual acuity and central retinal thickness between baseline and months 6 and 12 in the study sample. CONCLUSIONS: It is important to determine predictive factors for visual outcome, so as to inform patients about prognosis and help in the decision-making of patients' management.
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Endophthalmitis in Oman: A descriptive retrospective multi-center study p. 141
Mohamed Al-Abri, Ahmed Al-Hinai, Youssef Al Hamar, Hisham Al-Abri, Asaad-Al Habsi, Abdullah Al-Kaabi, Chandrashekar Nooyi
DOI:10.4103/ojo.OJO_249_2020  
PURPOSE: The aim of this study is to report the anatomical and functional outcome, microbiology profile and treatment used for endophthalmitis in Oman. DESIGN: The study design involves retrospective descriptive multicenter study. METHODS: Demographic and clinical data of patients diagnosed with endophthalmitis over a period of 9 years were collected in three tertiary hospitals in Oman. RESULTS: A total of 50 endophthalmitis cases were included in the study. Exogenous endophthalmitis was diagnosed in 48 cases, whereas 2 cases were endogenous endophthalmitis. Culture-positive cases constituted 16 cases (32%) out of these, 12 cases were Gram-positive, 3 cases were Gram-negative and one case had a positive fungal culture. Immediate first-line treatment was vitreous tap and inject in 33 eyes and vitrectomy in 13 eyes. In 45 eyes in which the visual acuity (VA) was recorded; VA after treatment improved in 22 eyes (49%), remained the same in 16 eyes (36%) and worsened in 7 eyes (16%). CONCLUSION: Although endophthalmitis is rare, it is a devastating ocular emergency. Early diagnosis and prompt intervention are crucial in management. Awareness among the patients undergoing intraocular surgeries about this rare condition is very crucial. Moreover, frontline health-care providers must be aware and critical if they encounter patients with suspicion of endophthalmitis as early recognition, prompt referral, and timely treatment are the key for better visual prognosis. Finally, establishing a National Endophthalmitis Registry is recommended as it will help analyze the incidence, treatment instituted and the outcome of this condition across Oman.
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CASE REPORTS Top

Intravitreal aflibercept treatment for choroidal neovascularization secondary to laser pointer p. 146
Ali Keles, Suleyman Korhan Karaman
DOI:10.4103/ojo.OJO_10_2019  
A 15-year-old male was presented with blurred vision in his right eye for 2 weeks. The patient had a history of looking with the right eye for 5–6 s at a distance of 20 cm from green laser beam (class 3a, 5 mW, 532 nm). Dilated fundus examinations revealed a yellow lesion in the right eye, resulting in loss of foveal reflection at the fovea. Fundus fluorescein angiography (FFA) images and spectral-domain optical coherence tomography (OCT) scans were compatible with active classic choroidal neovascularization (CNV). A single dose of intravitreal aflibercept was performed to the right eye, and at the 1st month after the injection, the best-corrected visual acuity improved to 20/100 from 20/200. FFA showed staining of the scar with no leakage, and OCT revealed scar formation. At the follow-up visits, during 38-month follow-up, no CNV activity was observed. Intravitreal aflibercept may be an appropriate treatment option in cases with laser pointer injury-induced CNV.
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Bilateral central retinal artery occlusion - A catastrophic presentation of systemic lupus erythematosus p. 149
Somya Ish, Deepa Sharma, Rahul Verma, Sudha Kumari, Himanshu Garkoti
DOI:10.4103/ojo.OJO_133_2019  
Systemic lupus erythematosus (SLE) is a multisystem autoimmune disorder. Here, we present a rare case of a middle-aged male, diagnosed with SLE, manifesting as bilateral central retinal artery occlusion (CRAO). Severe ocular complications such as CRAO may occur during an acute flare or even early in the disease process. It is important to recognize this potentially devastating complication.
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Plasminogen activator inhibitor-1 4G/5G polymorphism and dyslipidemia with branch retinal artery occlusion in a young lady p. 152
Bengi Ece Kurtul, Ahmet Elbeyli, Sait Coskun Ozcan
DOI:10.4103/ojo.OJO_266_2019  
Branch retinal artery occlusion (BRAO) leads obstruction of blood flow in the distribution of the affected vessel giving rise to ischemia and reorganization of the retinal layers. It is a very rare diagnosis and the etiological risk factors of BRAO are not clean in the young population. Various hypercoagulable states leading to thrombosis appeared to be more responsible. Here, the authors present an interesting case of a 25-year-old female patient with BRAO accompanying with plasminogen activator inhibitor-1(PAI-1) 4G/5G gene polymorphism and dyslipidemia together, for the first time. There was a history of sudden painless blurred vision in her right eye 3 months ago. Her visual acuity was 20/20 in both eyes at the admittion. Fundus photo, red-free photo, optical coherence tomography images of 3 months ago revealed BRAO in the right eye. Fundus exam and images taken at the 3th month confirmed the recovery of retinal edema. Attenuation of inferotemporal retinal artery still mildly appeared. Applied confrontation fields showed a visual field defect corresponding with affected area. Ophthalmologists are advised to be aware of the importance of PAI-1 4G / 5G gene polymorphism and dyslipidemia conditions besides the other genetic mutations and thrombophilic markers regarding BRAO in young patients.
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Focal choroidal excavation and giant choroidal cavern in an eye with pachychoroid p. 155
Samarth Mishra, Barun Garg, Deepak Senger, Anushree Kumar, Ashwin C Somarajan, Sugandha Goel, Kumar Saurabh, Rupak Roy
DOI:10.4103/ojo.OJO_189_2019  
Focal choroidal excavation (FCE) is a localized excavation of the choroid, which can be diagnosed by enhanced depth optical coherence tomography (OCT). Choroidal caverns are focal cavitation areas in the choroid which appear hyporeflective on OCT. These are angular or round, empty spaces with posterior tail of hypertransmission. A 47-year-old female presented to us for a routine eye check-up. The best-corrected visual acuity was 20/20 in both the eyes. On fundus examination, a localized pigmented lesion was seen in the right eye inferior to the optic disc, while the fundus of the left eye was normal. Spectral-domain OCT scan through the lesion showed an FCE and a giant cavern with a posterior tail of hypertransmission. The diameter of the cavern was 977 μ ×264 μ, with a subfoveal choroidal thickness (SFCT) of 360 μ. The SFCT of the other eye was 300 μ. Coexistence of FCE and cavern in an eye with thickened choroid is not yet reported in the literature, and their coexistence provides possible insight into the formation of FCE and caverns in the setting of thickened choroid.
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Pneumatic displacement for management of traumatic macular hole with submacular hemorrhage p. 158
Maithili Mishra, Rajesh Ramanjulu, Mahesh Shanmugam, Divyansh Mishra, Preethi Sridharan
DOI:10.4103/ojo.OJO_267_2019  
Complications of closed-globe injury such as submacular hemorrhage (SMH) and traumatic macular hole (TMH) can be visually devastating. It is observed that TMH occurs in 1.4% of closed-globe injuries and 0.15% of open-globe injuries. There is limited data regarding the incidence of TMH with SMH, given its relatively rare occurrence. Treatment options for SMH include vitrectomy with subretinal r-tissue plasminogen activator (TPA)-assisted clot lysis, intravitreal r-TPA-assisted pneumatic displacement using an expansile gas and postoperative positioning, and finally pneumatic displacement alone. We report a unique case of a 26-year-old female with blunt trauma who developed SMH with TMH and breakthrough vitreous hemorrhage. Successful displacement of subretinal blood from the macula and resolution of the macular hole was achieved on day 1 with pneumatic displacement alone using undiluted C3F8 injection.
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Papillophlebitis as an initial presentation of Eales' disease p. 161
Dhaval Patel, Parthopratim Dutta Majumder, Jyotirmay Biswas
DOI:10.4103/ojo.OJO_90_2020  
Eales' disease (ED), which is an idiopathic obliterative vasculitis, is a diagnosis of exclusion. The optic nerve involvement in ED is not very common. We report a case of ED in a 36-year-old male who initially presented as papillephlebitis. He presented with complaints of decreased vision in his right eye for 2 months. Fundus examination revealed that optic disc edema with hemorrhages, and he was started on oral corticosteroid after the exclusion of infectious etiology. Fundus examination after 2 months revealed thet resolution of optic disc edema, but active periphlebitis with multiple superficial retinal hemorrhages involving inferior and inferotemporal quadrant. Based on negative laboratory results and clinical findings a diagnosis of ED was considered. Regular monitoring of patients with papillephlebitis is recommended.
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COVID casualty: Bilateral blindness due to ingestion of spurious sanitizer p. 164
Lav Kochgaway, Akshay Gopinathan Nair, Ankita Mitra, Sagar Bhargava, Maneesh Singh
DOI:10.4103/ojo.OJO_277_2020  
Intentional ingestion of alcohol-based handrub (ABHR) or sanitizer solution is uncommon. The coronavirus disease-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 has led to lockdowns being put in place in many countries across the globe and resulted in a surge in ABHR usage to maintain hand hygiene. In this communication, we report the case of a 56-year-old male, a chronic alcoholic who presented during the lockdown period, with acute bilateral loss of vision following ingestion of ABHR. The handrub was found to be a nonstandardized sanitizer with no labels mentioning its constituents. Typically, the ingestion of ABHR solutions results in isopropanol or ethanol poisoning, both of which have low toxicity. Based on the clinical history and findings in our patient, a diagnosis of optic neuropathy due to accidental ingestion of sanitizer containing methyl alcohol as an unlisted ingredient was made. Our report underscores the need for strict guidelines, toxicovigilance, and surveillance systems to be in place to prevent such adulterated ABHRs from being commercially available.
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CLINICAL IMAGES Top

Persistent macular detachment after successful macular hole closure and its management in an emmetropic eye p. 167
CK Nagesha, Romana Fazal, Pratyusha Ganne
DOI:10.4103/ojo.OJO_221_2019  
Macular hole with a concomitant macular detachment is unusual in emmetropic eyes. A middle aged women was operated for a full thickness macular hole with inverted flap technique. There was persistence of subretinal fluid for 4 months even after the hole was successfully closed. A second surgery was performed to remove the highly viscous subretinal fluid. This report highlights the technical difficulties in managing such cases. This case also highlights the need for recognition of coexisting pathologies before deciding the surgery.
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Optical coherence tomography angiography in miliary tuberculosis p. 169
Salil Mehta
DOI:10.4103/ojo.OJO_155_2020  
A 14-year-old female was admitted with a history of high-grade fever. On admission, she underwent a comprehensive clinical, laboratory, and radiological evaluation. A contrast-enhanced computed tomography (CT) scan of the chest revealed multiple, tiny, nodular opacities in a ground-glass pattern bilaterally. Sputum studies were positive for Mycobacterium tuberculosis. Dilated fundus examination revealed multiple, yellow-white, deep choroidal lesions consistent with choroidal tubercles. She underwent optical coherence tomography angiography (OCTA) in both eyes, which revealed normal superficial and deep retinal plexuses but multiple areas of flow void in the choriocapillaris. The optical coherence tomography (OCT) sections showed hyperreflective areas in the choriocapillaris/superficial choroid with absence of choriocapillaris circulation.
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My child has watering from above his left eye p. 171
Meenakshi Wadhwani, Manika Manika
DOI:10.4103/ojo.OJO_218_2019  
Lacrimal fistula can occur due to trauma, iatrogenic or congenital. The most common presentation in patients with congenital lacrimal fistula is epiphora or purulent discharge due to cystic dilatation from secondary infection.
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PRACTITIONER SECTION Top

A modified air-assisted silicone oil removal from the anterior chamber p. 173
Prabu Baskaran, VG Madhanagopalan, Seema Ramakrishnan
DOI:10.4103/ojo.OJO_196_2019  
Silicone oil (SO) is a commonly used tamponading agent in retinal detachment surgeries. Inadvertent anterior migration of SO and complete anterior chamber (AC) oil fill in an aphakic or pseudophakic eye is occasionally encountered. This can cause secondary glaucoma with very high intraocular pressure and pain. In this scenario, an urgent silicone oil removal (SOR) is warranted. Since SO is buoyant, in the supine position, it tends to rise anteriorly. Hence, removal of SO trapped in the AC will invariably lead to further migration of oil from the posterior segment into the AC to replace the volume removed. Simultaneous replacement of AC volume is necessary to prevent this. We describe a modified technique of partial SOR that employs air to prevent recurrent migration of SO into AC.
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CLINICAL QUIZ Top

3D: Decreased vision, dizziness, and disc edema p. 176
Ramanuj Samanta, Athul S Puthalath, Neeraj Saraswat, Ajai Agrawal
DOI:10.4103/ojo.OJO_222_2018  
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