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   Table of Contents - Current issue
Coverpage
January-April 2021
Volume 14 | Issue 1
Page Nos. 1-65

Online since Saturday, February 27, 2021

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EDITORIAL  

Are our legal visual requirements for driving adequate? Highly accessed article p. 1
Aisha Al Busaidi
DOI:10.4103/ojo.OJO_34_21  
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ORIGINAL ARTICLES Top

Single-snip paralimbal incision: A quick approach to rectus muscles Highly accessed article p. 3
Juhi Saxena, Naheed Akhtar, Yogesh Gupta, Abadan Khan Amitava, Farnaz Kauser, Shiraz Ahmed, S Aisha Raza, Anam Masood
DOI:10.4103/ojo.OJO_188_2020  
INTRODUCTION: Less invasive and quicker surgeries have become common. We compared two conjunctival incisional approaches in strabismus, namely Follow standard paralimbal approach for (SPLA) and single-snip paralimbal (SSPLA). MATERIALS AND METHODS: Forty-four patients with horizontal strabismus qualifying for uniocular recession–resection surgeries were randomized to SPLA and SSPLA. SSPLA involved a single v-shaped incision, with the apex of the V near the limbus, and the limbs facing away: by pinching up the conjunctiva with a forceps and delivering the single snip with a spring scissors. We compared the postoperative grades of redness, congestion, chemosis, foreign body sensation, and drop intolerance at day 1, 2 weeks, and 6–8 weeks; scar visibility, as yes or no, at 6–8 weeks; success rates, considered to be within 10 prism diopters of orthophoria, at 6–8 weeks; and operation duration in minutes. STATISTICAL ANALYSIS: Statistical analysis was done using Mann–Whitney U-test, for inflammatory grades, Chi-square for proportions, and t-test for parametric measures. Statistical significance was set at P < 0.05. RESULTS: On postoperative day 1, congestion (P = 0.02), foreign-body sensation (P = 0.04), and total inflammatory score (P = 0.003) were statistically significantly favoring the SSPLA group. While at 2 weeks, only congestion (P = 0.02) was found to be significantly less in the SSPLA group. There were no significant differences in the proportions of scar visibility (5/22 in the SPLA vs. 3/22 in the SSPLA) and success rate: 20/22 vs. 18/22. The SSPLA was quicker on an average by 6 min (P < 0.001, 95% confidence interval: 3.2–8.7). CONCLUSION: Compared to the SPLA, the SSPLA is quicker and results in lesser inflammation in the immediate postoperative period.
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Ocular cysticercosis at a teaching hospital in Northern India p. 8
Rajendra P Maurya, CP Mishra, Meghna Roy, Virendra P Singh, Mahendra K Singh, Mahima Yadav, Abdullah S Al-Mujaini
DOI:10.4103/ojo.OJO_122_2020  
BACKGROUND: Ocular cysticercosis (OC) is common in tropical countries. This study aimed to analyze the clinical presentation patterns, management and treatment outcomes of OC cases seen at a teaching hospital in North India. METHODS: This study took place between March 2014 and February 2019. A total of 36 patients with OC were analyzed to determine clinical presentation and outcomes. RESULTS: Of the 36 patients, 13 (36.11%) were male and 23 (63.89%) were female. The most frequently affected age group was 10–29 years (n = 22; 61.11%). All of the patients had unilateral lesions, with involvement of the left eye in 22 (61.11%) and the right in 14 (38.89%). The majority of cases were isolated to the ocular region; however, five (13.89%) demonstrated neural involvement as well. In terms of cyst location, 15 (41.67%) were orbital, 13 (36.11%) were subconjunctival and four each (11.11%) were intraocular or on the eyelid. The most common clinical presentations were subconjunctival masses or proptosis in 13 each (36.11%) and periorbital swelling in 12 (33.33%). Most patients received medical treatment (n – 23; 63.89%), while the others required surgical excision. Recurrence was noted in seven patients (19.44%), of which three underwent surgery while the rest were treated medically. Two patients (5.56%) developed phthisis. Conclusions: In this study, OC cysts were more often orbital or subconjunctival compared to findings reported from Western countries. In addition, a female preponderance was noted in contrast to previously reported findings. Advanced radioimaging is crucial to ensure early diagnosis and treatment.
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Comparison between Plusoptix A09 and gold standard cycloplegic refraction in preschool children and agreement to detect refractive amblyogenic risk factors p. 14
Jyothi Thomas, B Rajashekar, Asha Kamath, Parikshit Gogate
DOI:10.4103/ojo.OJO_284_2019  
BACKGROUND: The preschool children hardly complain about their vision problems. It is of paramount importance to screen them with an objective tool and compare with the gold standard technique. AIM: To compare the values obtained with Plusoptix A09 and cycloplegic refraction in 36 years children and agreement to detect refractive amblyogenic risk factors. SUBJECTS AND METHODS: A cross-sectional study was conducted in the Outpatient Department of Ophthalmology in a tertiary care hospital. Informed consent from parents and verbal assent from children were obtained. Each subject had monocular vision assessment with Lea symbol chart, stereo acuity measurement with Frisby, refractive screening with Plusoptix A09, squint assessment, and anterior segment evaluation before administering Homatropine hydrobromide (homide) 2% eye drops. Cycloplegic refraction and posterior segment evaluation were performed for final diagnosis. STATISTICAL ANALYSIS: Descriptive statistics were used to summarize the data. Spearman correlation coefficient and kappa statistics were also employed. RESULTS: In total, data of 94 children were analyzed. The correlation values obtained between plusoptix and cyclorefraction values for spherical, cylindrical, spherical equivalent were 0.508 (P < 0.0001), 0.779 (P < 0.0001), and 0.407 (P < 0.0001), respectively. Refractive errors were seen in 32% and amblyopia in 17% of eyes. Kappa value was κ = 0.974 in detecting refractive amblyogenic risk factors. CONCLUSION: Good correlation was found between the plusoptix and cyclorefraction values. Cylindrical values showed a better correlation. Refractive errors and amblyopia were the major ocular disorders observed. There was significant agreement between the refractive techniques in detecting amblyogenic risk factors.
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Comparison of retropupillary fixated iris claw lens versus sclera fixated lens for correction of pediatric aphakia secondary to ectopia lentis p. 20
Bhavatharini Muthukumar, Preeti Patil Chhablani, Amjad Salman, Vipul Bhandari, Rajat Kapoor
DOI:10.4103/ojo.OJO_91_2020  
AIM: To evaluate the postoperative visual acuity and complications in eyes with ectopia lentis in children who underwent lens removal and then implantation of retropupillary fixated iris claw lens versus scleral fixated intraocular lens (SFIOL) implantation. MATERIALS AND METHODS: A retrospective analysis of pediatric cases who presented with lens subluxation secondary to ectopia lentis and who underwent lens extraction (57 eyes of 38 patients) with either retropupillary iris fixated intraocular lens (IOL) implantation (Group A – 36 eyes of 20 patients) and SFIOL implantation (Group B – 21 eyes of 18 patients) was done over a period of 5 years from March 2010 to February 2015. The main outcome measures were preoperative and postoperative best-corrected visual acuity (BCVA) and secondary postoperative complications. RESULTS: The study patients were divided into two groups: Group A patients were implanted with retropupillary iris claw lens whereas Group B patients were implanted with SFIOL. The mean age of presentation was 12 years, the mean follow-up period was of 24 months (range 14–36 months), and the median follow-up period was 26 months in both the groups. An improvement in the mean BCVA (LogMAR) was seen in both the groups. In Group A, the mean BCVA improved from 1.5 ± 0.2 preoperatively to 0.3 ± 0.2 postoperatively, whereas in Group B, the mean BCVA improved from 1.5 ± 0.3 preoperatively to 0.3 ± 0.2 postoperatively (P < 0.001). None of the eyes in either of the groups had any serious complications such as glaucoma, uveitis, cystoid macular edema, or endophthalmitis. CONCLUSION: Retropupillary iris fixation and scleral fixation of IOL are both safe and viable options for the correction of ectopia lentis in pediatric age group.
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Treatment outcome with interferon alpha 2b in ocular surface squamous neoplasia: Recommendation as primary treatment by peripheral ophthalmologists p. 27
Rachna Meel, Rebika Dhiman, Murugesan Vanathi, Seema Sen, Noopur Gupta, Radhika Tandon
DOI:10.4103/ojo.OJO_201_2018  
BACKGROUND: To evaluate the role of interferon alpha 2b (IFNα2b) in the management of primary/recurrent cases of ocular surface squamous neoplasia (OSSN). METHODOLOGY: Medical records of 27 OSSN cases managed with IFNα2b (topical drops and/or perilesional injection) in 1 year were retrospectively reviewed. RESULTS: The median age of presentation was 60 years with a male: female ratio of 3.5:1. American Joint Commission on Cancer tumor grading was T1 in 1 eye (3.7%) and T3 in 26 eyes (96.3%). Eighteen cases were treated with topical drops (1 million IU/ml), 4 cases with perilesional subconjunctival injection (3–6 million IU/ml), and 5 cases with combined therapy. Overall, treatment response was seen in 88% cases. Complete regression was achieved in 80% cases. Median time to complete regression of tumor was 3 months (range 1–11 months) in cases treated with topical interferon therapy and 2.5 months (range 0.7–3 months) in cases managed with injections or a combination of the two. The mean duration of follow-up was 24 months. All cases with partial/no response showed complete regression on subsequent management with topical mitomycin C. None of the patients required surgery. Acute ocular surface congestion was seen in two patients necessitating discontinuation of therapy. CONCLUSION: In view of excellent treatment outcome and few side-effects, interferons can be considered as a primary, safe, and cost-effective treatment option for OSSN not only in tertiary centers but also by peripheral ophthalmologists.
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Comparison between two intravitreal injection techniques with respect to fluid reflux, intraocular pressure, and therapeutic effect p. 33
Shashi Tanwar, Arun Kumar Sharma, Rajat Mohan Srivastava, Vishal Katiyar, Siddharth Agrawal, Sanjiv Kumar Gupta
DOI:10.4103/ojo.OJO_67_2020  
CONTEXT: Effect of fluid reflux on intraocular pressure (IOP) and therapeutic benefits. AIMS: The aim of this study is to compare two intravitreal injection techniques in terms of fluid reflux, short-term IOP changes, and therapeutic effect. SETTINGS AND DESIGN: A prospective, double-blinded, randomized interventional study. SUBJECTS AND METHODS: Sixty eyes were randomly allocated to two groups (direct intravitreal injection technique and oblique intravitreal injection technique). IOP was measured before and immediately after the injection of 0.1 ml comprising of bevacizumab (1.25 mg/0.05 ml) and dexamethasone (0.2 mg/0.05 ml) and then at 30 min after the injection. Occurrence and amount of vitreous reflux were recorded. Best-corrected visual acuity (BCVA) and central macular thickness (CMT) were assessed preinjection and 6 weeks postinjection. RESULTS: IOP (mmHg ± standard deviation) increased significantly immediately after injection to 24.30 ± 3.02 (direct intravitreal injection) and 31.50 ± 3.49 (oblique intravitreal injection). These pressure rise differed significantly between both groups (mean difference: 7.2, P < 0.0001). Thirty minutes after injection, there was no significant difference in IOP increase between the groups. Occurrence and amount of fluid reflux were significantly higher with direct intravitreal injection. There was no significant difference in BCVA and CMT outcome between both groups. CONCLUSIONS: Direct intravitreal injection technique has lower rise in IOP and higher incidence of fluid reflux than the oblique intravitreal technique. Fluid reflux does not cause a therapeutic compromise in terms of BCVA or CMT changes, so the reflux fluid must be the vitreous not the drug. Thus, direct injection technique seems to be the preferred technique.
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Clinical profile and surgical outcomes in children with posterior lenticonus p. 38
Divya Harshwardhan Jain, Sumita Agarkar, Hennaav Kaur Dhillon
DOI:10.4103/ojo.OJO_215_2020  
AIMS: The purpose of this study is to describe the clinical profile of children presenting with posterior lenticonus. We also report on visual outcomes following surgery in these patients. SUBJECTS AND METHODS: Medical records of patients with a diagnosis of posterior lenticonus between January 2000 and December 2016 were reviewed. Data collected included demographic details, preoperative, intraoperative details like type of intraocular lens (IOL) and surgery, and amblyopia therapy. Only the patients with a follow-up of at least 6 months from the time of presentation were included in the analysis. RESULTS: Forty-eight eyes with posterior lenticonus with at least 6 months of follow-up were studied. Twelve (25%) eyes had a preoperative posterior capsule (PC) dehiscence as seen on slit-lamp biomicroscopy or on ultrasonography. The mean presenting visual acuity in all eyes was 1.034 ± 0.56 logarithm of the minimum angle of resolution (logMAR) units. The mean final visual acuity in these patients was 0.57 ± 0.5 logMAR units. Postoperative visual acuity was found to have a borderline positive correlation with the presence of preoperative strabismus (P = 0.049). Younger age at presentation (P = 0.533) or the presence of preoperative PC dehiscence (P = 0.735) did not influence final visual acuity. CONCLUSION: Visual acuity improves following surgery with IOL implantation in children with posterior lenticonus and cataract. With the availability of foldable lenses and improved surgical techniques, it is possible to place the IOL in bag despite a preexisting posterior capsular dehiscence. Children with posterior lenticonus who present with strabismus are likely to have poorer visual outcomes.
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CASE REPORTS Top

Masquerading solitary plasmacytoma; an eyelid lump in disguise p. 42
Aleza Andron, Uri Peleg, Chezi Genzel, Elena Drabkin
DOI:10.4103/ojo.OJO_147_2019  
Solitary plasmacytoma is a rare orbital lesion, most commonly appearing in patients with multiple myeloma. We report a case of a 75-year-old woman who presented with a left upper eyelid lesion, initially misdiagnosed and treated as a chalazion. Histopathological testing revealed plasmacytoma originating from the frontal sinus. This case demonstrates a rare presentation for this malignancy.
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Dome shaped macula with serous macular detachment in an elderly myopic woman: Case report and review of literature p. 45
Devdatta Deshmukh, Rashid Al Saidi, Roshini Issac, Santosh Philip
DOI:10.4103/ojo.OJO_181_2020  
Dome-shaped macula (DSM) is a recently described entity characterized by convex protrusion of the macula within a posterior staphyloma. Serous macular detachment is the most common complication, but the condition often remains stable despite lack of intervention. Spontaneous resolution of the condition has also been reported in many cases. The condition may be observed with periodic review with optical coherence tomography (OCT). We report a 56-year-old Omani woman, a high myope without significant ocular complaints who was incidentally detected to have bilateral DSM with serous macular detachment and review the literature regarding its diagnosis, pathogenesis, and treatment options. As the patient was asymptomatic, she was followed with serial OCTs for 6 months and is stable in terms of visual acuity and subretinal fluid.
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Full-thickness macular hole formation following antivascular endothelial growth factor injection in a case of hemicentral retinal vein occlusion p. 49
Srijita Mitra, Sahil Sarpal, Abhijit Chattopadhyay, Subhankarsri Paul, Jonaki Ghosh Roy
DOI:10.4103/ojo.OJO_103_2020  
A rare case reporting the occurrence of full-thickness macular hole (MH) formation following intravitreal antivascular endothelial growth factor injection in a case of hemicentral retinal vein occlusion and the subsequent management of the case. As described in few other similar case reports in the literature, there are quite a few probabilities of factors causing this pathology. An acute posterior vitreous detachment or sudden decompression of the macular edema can quite possibly lead to the above situation. This case report shares light on the evolution of a MH following intravitreal injection and the subsequent treatment process.
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Neovascularization of angle following trabeculectomy augmented with mitomycin-C p. 52
Wesam Shamseldin Shalaby, Reza Razeghinejad
DOI:10.4103/ojo.OJO_71_2020  
The purpose of this study was to report a case of neovascularization of angle (NVA) following trabeculectomy with mitomycin-c (MMC) in a patient with primary open-angle glaucoma. This case report describes a 68-year-old woman who developed NVA and hyphema 2 weeks following an uneventful trabeculectomy with MMC. Trabeculectomy may be associated with serious and vision-threatening complications such as hypotony, suprachoroidal hemorrhage, endophthalmitis, and bleb-related complications. However, neovascularization of the anterior segment is not a commonly reported complication. Neovascularization of the anterior segment is a rare postoperative complication that usually occurs following strabismus or retinal detachment surgeries. The underlying ischemic trigger for anterior segment neovascularization is usually a posterior segment pathology or carotid artery insufficiency. These causative factors were excluded in our patient by lack of any abnormal finding in fundus fluorescein angiography and carotid Doppler ultrasonography. The patient received three subconjunctival bevacizumab injections (1.25 mg/0.1 ml) with frequent topical steroids and showed marked regression of the neovessels. The bleb was functional, and intraocular pressure remained at low teen afterward. NVA following trabeculectomy without any posterior segment or carotid pathologies responded well to subconjunctival bevacizumab and topical steroids.
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Sub-internal limiting membrane hemorrhage as an unusual presentation of polypoidal choroidal vasculopathy p. 56
George Joseph Manayath, Shishir Verghese, Ratnesh Ranjan, Venkatapathy Narendran
DOI:10.4103/ojo.OJO_310_2020  
We report the two cases who presented with sudden decreased vision and sub-internal limiting membrane (ILM) hemorrhage without a history of Valsalva maneuver, trauma, or hematological disorders. Multimodal imaging revealed the features suggestive of polypoidal choroidal vasculopathy (PCV) in addition to the sub-ILM hemorrhage. A provisional diagnosis of sub-ILM hemorrhage secondary to PCV was made and was treated with intravitreal Bevacizumab injection. Treatment resulted in the improved visual acuity along with the resolution of the sub-ILM hemorrhage. These cases highlight the possibility of isolated sub-ILM hemorrhage as a presenting fundus finding in PCV, which is previously unreported. This report also highlights the importance of multimodal imaging in diagnosing chorioretinal disorders with unusual presentation.
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CLINICAL IMAGE Top

Misdirected ozurdex implant p. 60
Amber Amar Bhayana, Suneel Kumar, Shorya Vardhan Azad
DOI:10.4103/ojo.OJO_292_2019  
Ozurdex is one of the most commonly inserted intravitreal steroid implants in cases of posterior uveitis and recalcitrant macular edema in cases of diabetic retinopathy and vascular occlusions. Here we report accidental malpositioning of this implant in patellar fossa.
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CLINICAL QUIZ Top

Superficial punctate keratitis: A diagnostic dilemma p. 62
Rashmi Mittal
DOI:10.4103/ojo.OJO_167_2019  
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LETTER TO THE EDITOR Top

Re: Unsal et al. Preoperative prognostic factors for macular hole surgery: which is better? Oman J Ophthalmol 2019;12:20-4. [doi: 10.4103/ojo.OJO_247_2017] p. 64
Piergiacomo Grassi
DOI:10.4103/ojo.OJO_155_2019  
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