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   Table of Contents - Current issue
May-August 2023
Volume 11 | Issue 2
Page Nos. 75-138

Online since Thursday, April 27, 2023

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Modernizing ophthalmology: The transformative role of artificial intelligence Highly accessed article p. 75
Rajesh Subhash Joshi
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Head and facial anthropometry of South Indian pediatric population Highly accessed article p. 77
Diwakar Rao, L Nivetha, Sowmya Raveendra Murthy, N Nishant, Manaswini Sahoo, K Lakshmi Naveena
Purpose: The purpose of this study is to document and describe the head and facial anthropometric data in the pediatric age group using direct and indirect methods. Materials and Methods: It was a prospective study done from January 2021 to June 2021. All children aged 7 to 18 years who attended our pediatric ophthalmology outpatient department were included. Head and facial anthropometric parameters were defined and collected by direct and indirect methods. Rees-Fairbanks facial gauge was used to collect data in the direct method. In the indirect method, three photographs were taken one in straight gaze, the second toward their right side, and the third toward their left side positioned and analyzed by image processing software called ImageJ. Results: Anthropometric data were collected for 254 children which included 125 boys and 129 girls. Facial parameters were recorded by both direct and indirect methods. The highest mean difference between the two methods was <2 mm for linear measurements and <2° for angular measurements. Conclusion: We found that anthropometric data obtained by direct and indirect methods concur to a great extent. Further, the anthropometric data were different in different age groups and may have a bearing on spectacle prescription in children.
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Clinical and microbiological profile of pediatric infectious keratitis p. 81
Ashi Khurana, Ajit Kumar, Pradeep Agarwal, Mohit Sharma, Lokesh Chauhan
Purpose: Corneal ulcers are more prevalent in tropical developing countries. The purpose of this study is to report the risk factors, microbiological profile, and treatment outcomes of infectious keratitis in children. Materials and Methods: Retrospective case series of 77 consecutive children aged 16 years or younger with a diagnosis of infectious keratitis treated at the cornea service of a tertiary eye care institute. Patient demographics, predisposing factors, microbial susceptibility, microbial smear and culture results, clinical course, and visual outcomes were analyzed. Results: The average age of patients was 9.1 years (range 8 days–16 years). The mean time from the onset of symptoms to the ophthalmological examination was 14.6 (18.9) days. The most common associated risk factor was ocular trauma (n = 32, 43%). A total of 32 (32/77, 42%) eyes were positive on the smear examination. Bacterial infection was reported in 30 (30/77, 39%) and fungal infection was reported in 9 (9/77, 12%) children. Staphylococcus was the most commonly isolated organism (13/39, 33%) followed by Streptococcus (9/39, 23%), Pseudomonas (6/39, 15%), and Fusarium spp. (6/39, 15%). Curvularia spp. was also identified in 3 (3/39, 8%) eyes. Nineteen (19/77, 25%) children require surgical intervention. Therapeutic penetrating keratoplasty was needed in two children. Conclusion: Contrary to previous reports, bacteria are more frequent etiological organisms than fungi causing pediatric infectious keratitis in this study population. Staphylococcus spp. was the most predominant causative organism. Curvularia was not identified in previously reported studies from India. Most of the patients were managed medically. Surgical intervention was less frequent.
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Impact of ocular trauma on vision-related quality of life p. 87
Mehul Shah, Shreya Shah, Pradeep Chandana
Introduction: Ocular trauma is a preventable cause of monocular blindness that results in morbidity and sight loss. In this study, we evaluated the impact of ocular trauma on the quality of life. Materials and Methods: In this prospective cohort study, we included all ocular trauma cases presented at Drashti Netralaya enrolled between August 2019 and August 2020. Demographic, clinical, and trauma documentation were done using a pretested online format for all the enrolled cases with specified inclusion and exclusion criteria. The life quality score was recorded using the Indian Version of Visual Function Questionnaire (VFQ). The VFQ scores were recorded before and after treatment. All data were exported into Excel sheets and analyzed with SPSS 22 using descriptive and cross-tabulation. The numerical variables were tested using one-sample t-test. P < 0.05 was considered statistically significant. Results: Our study cohort consisted of 284 patients, of which 211 (68.1%) were adults and 85 (39.9%) were children. Furthermore, 199 (70.1%) were men, and 93 (30%) were women. The mean age of the patients was 29.36 ± 17.38 years. On a comparative study, a significant difference was found between the pretreatment and posttreatment vision as well as VFQ score. Conclusion: Ocular trauma can cause sight loss and morbidity and affect the quality of life. Successful management of ocular trauma can cause a significant difference in the vision as well as quality of life.
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An open-label randomized clinical trial to evaluate the efficacy and tolerability of flax seed nutritional supplementation in comparison with omega-3 fatty acid capsule in mild dry eye disease p. 92
Meghana Patil, Ravindra Banakar, BH Manjunath, Madhavi Gupta
Background: Dry eye disease (DED) is a multifactorial disease commonly encountered in ophthalmology clinics. Omega-3 fatty acid has been proved to be effective in improving the symptoms of DED. Flax seed being the richest plant source of alpha-linolenic acid can be effective in DED. Aims: To evaluate the efficacy and tolerability of flax seed supplementation in comparison with omega-3 fatty acid capsules in DED. Setting and Design: Single-center randomized open-label clinical trial done at tertiary care hospital. Subjects and Methods: Two hundred sixty-eight subjects with clinically diagnosed mild dry eye received either flax seed supplementation daily for 3 months or omega-3 fatty acid capsule once daily for 3 months. Patients were evaluated at baseline, week 4, week 8, and week 12. On each visit subjects filled ocular surface disease index (OSDI) questionnaire and underwent Schirmer test, tear break up time (TBUT) and ocular staining. Results: One hundred thirty-three patients received flax seeds and 135 received omega-3 fatty acid. Schirmer test and TBUT showed increase in scores at each visit. OSDI scores reduced at subsequent visit and were statistically significant. Two factor repeated measures analyses of variances showed no statistically significant difference between the groups in terms of OSDI scores (P = 0.018). Conclusion: Our study demonstrated a rapid response to nutritional therapy (with flax seeds and omega-3 fatty acid capsules) in alleviating the signs and symptoms of dry eyes in both the groups. Flaxseeds supplementation is comparable to omega-3 fatty acid supplementation in DED and thus forms the cost-effective treatment for dry eyes and can be considered as an adjunctive therapy for the same.
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Long-term motor and sensory outcomes after unilateral recession-resection for pseudodivergence excess intermittent exotropia p. 97
Kanwar Mohan, Suresh Kumar Sharma
Purpose: To report long-term motor and sensory outcomes after unilateral recess-resect surgery for pseudodivergence excess intermittent exotropia. Materials and Methods: The medical records of patients who underwent unilateral lateral rectus recession-medial rectus resection for pseudodivergence excess intermittent exotropia and followed postoperatively for at least 5 years were reviewed retrospectively. Results: A total of 21 patients were included. The mean age at surgery was 11.5 ± 6.3 years. The mean postoperative follow-up was 7.8 ± 2.7 years (range: 5–13 years). Overall, 11 patients (52%) had surgical success at their last follow-up. Strabismus duration, near and distance deviations, fusion at distance, and stereoacuity did not predict motor outcome after surgery. One patient (100%) without fusion at near and 10 of 15 patients (67%) without fusion at distance preoperatively exhibited fusion at their last follow-up. Six out of eight patients (75%) with a preoperative stereoacuity of 120–1980 arcsec and two out of three patients (67%) with nil stereopsis achieved a stereoacuity of 60 arcsec. Overall, 10 patients (48%) had a recurrence of intermittent exotropia at a mean 2.5 years after surgery. Conclusions: Nearly half of our patients with pseudodivergence excess intermittent exotropia achieved a successful long-term ocular alignment after unilateral recess-resect surgery. A large majority of patients who preoperatively had a subnormal or nil stereoacuity exhibited postoperatively a normal stereoacuity at the last follow-up visit.
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Efficacy and safety of intravitreal triamcinolone acetonide in the management of recalcitrant diabetic macular edema p. 101
Sathiskumar Rangasami, Subashree Palani, Menaka Chinnappan, Shankar Radhakrishnan
Background: Diabetic macular edema (DME) is the major cause of visual impairment among patients with diabetic retinopathy. The various treatment modalities available for DME are laser photocoagulation, intravitreal injection of anti-vascular endothelial growth factor drugs, and ocular corticosteroids. Usage of intravitreal injections of triamcinolone acetonide has shown to improve vision by reducing macular thickness and the benefits persisted for a longer duration. Aim: The aim is to evaluate the efficacy and safety of intravitreal triamcinolone acetonide in the management of recalcitrant DME. Methodology: A prospective interventional study was performed for 2 years among patients with DME at a tertiary care institute in Tamil Nadu. A total of 35 patients satisfying our inclusion and exclusion criteria were included in the study. Intravitreal injection of 0.05 ml (2 mg) of triamcinolone acetonide was given to all our study participants. The two major outcome parameters were best-corrected visual acuity (VA) and the central foveal thickness (CFT). Patients were followed up for 6 months. Results: Best-corrected visual acuity showed a statistically significant improvement till the end of 3 months, whereas the values measured at the end of 6 months showed no statistically significant difference. The reduction of values in CFT was found to be statistically significant both at the end of 3 months as well as at the end of 6 months. Conclusion: Intravitreal triamcinolone injection showed a significant improvement in VA and a reduction in CFT without an increase in intraocular pressure and in the incidence of cataracts.
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Choroidal tubercles, an ocular presentation in tuberculosis: A retrospective observational hospital-based study p. 106
Rohit Raina, Neha Chhabra
Aim: The aim of this study was to find the prevalence of choroidal tubercles in tuberculosis (TB) patients. Introduction: TB is the most common cause of infectious cause of death, especially in endemic countries. TB infection spreads hematogenously from the primary infection site to the rest of the body. Ocular presentation manifests in the form of choroidal tubercles being the most common fundus change. Materials and Methods: It was a retrospective, observational hospital-based study. A total of 100 TB patients were studied, and their data were collected from the hospital record system from February 2020 to March 2021. Fundus examinations were reviewed, and the most common ocular presentation was found to be choroidal tubercles. Observations and Results: During the study period, out of 100 patients, 60% were females and 40% were males. Fundus changes were present in 14% of patients, and these were choroidal tubercles in 12% of patients and papillitis in 2%. Choroidal tubercles were present in 7 females and 5 males. Conclusion: We concluded that choroidal tubercles are one of the most common forms of ocular TB. Detection of choroidal inflammation can prevent visual loss as the ocular lesion resolves fully with timely management.
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Evaluation of ocular surface disease due to digital usage during COVID-19 pandemic: A cross-sectional study p. 109
Seema Channabasappa, Sheetal Vishwanath Girimallanavar, Balasubramanyam Aluri, Aiswarya Ann Jose, Greeshma Krishna Reddy
Background: This is the first study to see the effects of COVID-19 pandemic still persisting even after lockdown restrictions were relaxed on ocular health. Aims: To evaluate the presence and severity of ocular surface disease due to digital media usage in COVID-19 pandemic and to assess the severity with comorbidities such as refractive error, diabetes mellitus, and hypertension. Settings and Design: This is a cross-sectional study conducted via an online survey. Materials and Methods: An online survey was conducted among 217 individuals using ocular surface disease index (OSDI) questionnaire to assess the severity of dry eye disease due to digital media usage during the COVID-19 pandemic. Based on the OSDI score, ocular symptoms were classified into normal, mild, moderate, and severe. Statistical Analysis: Continuous variables were presented as mean ± standard deviation or median (Q1, Q3). The categorical variables were presented as frequency and percentage. Results: We included 217 respondents with 55 with mild (25.3%), 25 with moderate (11.5%) and 23 with severe dry eye (10.5%). The average number of hours spent on digital media was between 4 and 5 h before the pandemic and 6–8 h after the pandemic. The dry eye disease was also found to be associated with refractive errors, diabetes mellitus, and hypertension. Conclusion: The COVID-19 pandemic has affected the ocular health in general and had an impact on the dry eye disease in particular due to increase in the digital media usage and other associated risk factors, which has affected the work performance and efficiency was reduced.
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Effect of COVID-19 on glaucoma surgical practice in India: The challenges faced and the outcomes p. 114
Aparna Rao, Sirisha Senthil
Purpose: To report the effect of COVID-19 pandemic on the glaucoma surgical practice in India. Methods: A retrospective chart review of the hospital database of cases that underwent glaucoma surgery during March 2020–September 2020 was compared to surgeries done during the same months in 2017–2018 and 2019–2021. The clinical diagnosis, demographic details, type of surgeries, clinical details (intraocular pressure [IOP] at the time of surgery and IOP at 1 month of surgery, medications, and time from advice to date of surgery) at the time of surgery, and time from surgery-last hospital visit were compared between pre-COVID and post-COVID times. Results: Of a total of 8296 glaucoma surgeries during the study period, secondary glaucoma formed the majority of type of glaucoma requiring surgery (62.5%) during COVID. Of all surgeries, trabeculectomy and bleb-related procedures were the most common surgeries during all study periods, including the COVID times (42.6% in pre-COVID, 30% in COVID 39.8% in post-COVID period, respectively). Minimally invasive glaucoma surgeries (MIGS) increased during the post-COVID period with reduced trabeculectomy procedures paralleled with an increase in the number of implant procedures during COVID time 11.7% (pre-COVID), 15% (COVID), and 10.8% (post-COVID) study periods, correlating with increase in secondary glaucoma. The surgical outcomes were similar in pre-COVID and post-COVID times. Conclusion: COVID-19 provided a fresh direction to glaucoma surgical practice toward increasing implants and MIGS in the post-COVID phase. Despite changes in the surgical trend, there were similar overall surgical outcomes in glaucoma patients undergoing surgery, this provided similar overall surgical outcome in glaucoma patients undergoing surgery during or immediately after active COVID phase compared to pre-COVID times.
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A comparative study of anxiety and depression in primary glaucoma patients p. 119
Enakshi Bose, Swati Majumdar, Sharmila Sarkar
Background: Glaucoma is one of the most common causes of irreversible blindness. Neuroinflammation has a role in the pathogenesis of glaucoma and this inflammatory activity has been found in the brains of patients with depression. The need for prolonged treatment and follow-up and the fear of permanent loss of vision in glaucoma imposes economic and psychological burden. Aims: This study aims to assess the magnitude of anxiety and depression in patients with and without primary glaucoma and compare. Setting and Design: Cross-sectional observational study carried out in a tertiary care institute. Materials and Methods: Sixty-five patients with primary glaucoma (primary open-angle glaucoma, primary angle closure glaucoma as cases) and 65 without glaucoma (controls) were selected after institutional ethics committee approval and consent for participation. Detailed ocular examination for glaucoma diagnosis and screening by Patient Health Questionnaire 9 (PHQ-9) Depression scale and Generalized Anxiety Disorder 7 (GAD-7) anxiety scale done for the assessment of depression and anxiety, respectively. Logistic regression analysis with anxiety, depression, and glaucoma was conducted and adjusted for sociodemographic factors. Results: Mean PHQ (for depression) score (19.3231 ± 5.3564) and mean GAD-7 (for anxiety) score (12.1231 ± 4.1098) were significantly higher in glaucoma patients compared to controls (P < 0.0001). The association between PHQ scale score and GAD-7 score with the type of glaucoma was not significant (P = 0.983). Likewise, gender and the magnitude of depression and anxiety (measured by PHQ-9 scale and GAD-7 scale) were not statistically significant. Conclusion: Moderate and severe anxiety and depression were significantly associated with primary glaucoma when compared to controls.
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A rare case of serous retinal detachment with subretinal fibrin-like material associated with pre-eclampsia, abruptio placentae, and intrauterine fetal death p. 123
Chahveer Singh Bindra, Parminder Singh Bindra, Preeti Bindra, Fazal Khan
A 31-year-old female reported with unilateral serous retinal detachment (SRD) with subretinal fibrin-like material (SRFM) following pre-eclampsia, placental abruption, and intrauterine fetal death. The best-corrected visual acuity was 20/40 in the affected eye. Fundus angiography and optical coherence tomography revealed choroidal ischemia with SRD and SRFM which resolved gradually over 4 weeks posttreatment. The presence of SRFM with SRD could be due to intense ischemia and inflammation following transient disseminated intravascular coagulation, hypovolemia, and hypertension. Multimodal imaging modalities can help in the early diagnosis and prompt management.
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Trypan blue-assisted modified closed circular capsulorhexis in white cataracts: A prospective study of intraoperative and postoperative complications and visual outcome p. 125
Ajit K Joshi, Vemana Ramya, Sakshi R Patil
A prospective study was conducted on 46 eyes of 46 patients having white cataracts, who underwent manual small incision cataract surgery and were followed up on the 1st, 7th, and 30th postoperative days. Intraoperative and postoperative complications were noted, and postoperative visual outcomes were assessed. Of 46 patients with white cataracts, mature cataract constitutes 30 (65.4%) patients, hypermature cataracts – 8 (17.3%) patients, and intumescent cataracts – 8 (17.3%) patients. The most common intraoperative complications were extension of continuous curvilinear capsulorhexis (CCC) (30.4%), Argentinian flag sign (4.34%), hyphema (4.34%), iris prolapse (4.34%), posterior capsular rupture, and vitreous loss (2.17%). The most common postoperative complications were corneal edema (36.9%), striate keratopathy (34.7%), residual cortex (13.04%), and rise in intraocular pressure (6.52%). Visual outcome on day 30 showed vision >6/9 in 67.3%, 6/12–6/9 in 17.3%, and 6/60–6/18 in 6.5%. Patients having a poor vision had moderate nonproliferative diabetic retinopathy (NPDR) with diabetic macular edema in 6.5%, age-related macular degeneration – 4.2%, severe NPDR – 2.1%, and optic atrophy – 2.1%.We conclude that modified techniques such as use of trypan blue, high-density ophthalmic viscosurgical device, mini-rhexis (two-staged CCC), and aspiration of cortical fluid using a 26G needle during CCC can decrease ocular morbidity and achieve a good postoperative visual outcome.
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Multimodal imaging of Dalen–Fuchs nodules in sympathetic ophthalmia p. 128
Paurnima Ulhas Bodhankar, Jay Umed Sheth, Mahesh Gopalakrishnan, Giridhar Anantharaman
We present multimodal imaging in a 40-year-old male with sympathetic ophthalmia who presented with decreased vision in the left eye following penetrating injury to the right eye. A characteristic feature in the acute phase of diseases such as Dalen–Fuchs nodule and choroidal ischemia was captured on optical coherence tomography angiography (OCTA) and compared with indocyanine green angiography. After 1 month of oral steroid treatment, a complete resolution of Dalen–Fuchs nodule with improvement in choroidal vasculature was seen on OCTA. Thus, this case highlights the role of OCTA as a promising substitute to invasive angiography for monitoring disease activity.
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Sympathetic ophthalmitis post retinal detachment surgery p. 132
Amit S Nene, Megha B Patel, Onkar H Pirdankar, Pratik Shenoy, Pushpanjali Badole, Smitesh Shah
We report a case of sympathetic ophthalmitis (SO) post scleral buckling and vitrectomy. A 24-year-old young male underwent retinal detachment surgery followed by silicone oil removal in the left eye. At 2-week follow-up, post oil removal, the patient was diagnosed with SO in the contralateral eye and was treated with bolus intravenous methylprednisolone and oral azathioprine which resulted in resolution of symptoms and best-corrected visual acuity improved to 20/20. Although rare, SO has a poor visual prognosis, if untreated, hence it is important to monitor the contralateral eye post vitreoretinal surgery. The presence of any inflammation in the fellow eye following vitreoretinal surgery should be treated as emergency.
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Morning glory disc anomaly of the second cranial nerve with salt-and-pepper-like retinopathy p. 134
Manisha Nada, Rohan Madan, Jitender Phogat, Surender Kumar
Morning glory disc anomaly (MGDA), commonly seen in females, is a congenital, funnel-shaped staphylomatous excavation of peripapillary retina and optic nerve involving the second cranial nerve head. The anomaly gets its name owing to its resemblance to a flower with the same name. We report a rare case of congenital papilla anomaly in a 21-year-old female patient who presented with diminution of vision and ocular deviation. The objective was to analyze and report functional impairment caused by the anomaly to the patient and its rare association with salt-and-pepper-like retinopathy. After thorough examination and investigations, a diagnosis of MGDA with salt-and-pepper pigmentary retinopathy associated with strabismus was made. Owing to the long-standing strabismus reported in the case, treatment included parental counseling about guarded visual prognosis and cosmetic surgical correction for strabismus.
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Scleritis due to ziziphus plant p. 137
Kavita Vasant Dangra
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