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   Table of Contents - Current issue
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January-April 2022
Volume 15 | Issue 1
Page Nos. 1-124

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EDITORIAL  

Cytomegalovirus retinitis in children post hematopoietic stem cell transplantation: Can we develop a screening protocol? Highly accessed article p. 1
Nouf Al-Farsi, Samira Al Jabri
DOI:10.4103/ojo.ojo_28_22  
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How to treat diabetic retinopathy and diabetic macular edema most efficiently Highly accessed article p. 3
Anselm Kampik
DOI:10.4103/ojo.ojo_27_22  
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ORIGINAL ARTICLES Top

Role of hyperhomocysteinemia and Vitamin B12 deficiency in central and hemi-central retinal vein occlusion: A case–control study p. 6
Dhipak Arthur, Deepa John, Jude Joseph Fleming, Grace Rebekah, Mahasampath Gowri, Sheeja Susan John
DOI:10.4103/ojo.ojo_349_20  
BACKGROUND: Retinal venous occlusive diseases have been recognized as a major cause of ocular morbidity. Hyperhomocysteinemia could be a potentially modifiable risk factor. OBJECTIVE: To determine the association of hyperhomocysteinemia with central and hemi-central retinal vein occlusion (CRVO and HCRVO), the correlation of serum levels of homocysteine with Vitamin B12 and folate levels and the association of Vitamin B12 deficiency with hyperhomocysteinemia. METHODS: In this case–control study, patients with CRVO and HCRVO, and age- and gender-matched controls without CRVO and HCRVO, who met the eligibility criteria, were enrolled after obtaining informed consent. Data obtained from participants using a questionnaire, complete ophthalmological examination and relevant investigations, including estimation of serum homocysteine, Vitamin B12 and folate levels, were collated and analyzed. RESULTS: Thirty-nine cases with CRVO and HCRVO and 39 age- and gender-matched controls were studied. We found a significant association of hypertension (P < 0.01), hyperlipidemia (P = 0.01), and abnormal blood profile (P < 0.01) with retinal vein occlusion. There was no statistically significant association of hyperhomocysteinemia with CRVO and HCRVO (P = 0.81). However, we found a high prevalence of both hyperhomocysteinemia (43.58% of cases and 53.84% of controls; P = 0.81) and Vitamin B12 deficiency (23.08% of cases and 38.46% of controls; P = 0.14) in cases and controls, without a statistically significant difference between the two groups with respect to both parameters. Our study also found a negative correlation of serum levels of homocysteine with Vitamin B12 (Pearson correlation co-efficient − 0.3874, P = 0.0005), and folate (Pearson correlation coefficient − 0.3886, P = 0.0004) of the study participants. Among the study participants (n = 78), the odds of patients with Vitamin B12 deficiency having hyperhomocysteinemia were 7.0 (2.26–21.72) times those of patients without Vitamin B12 deficiency (P = 0.001). Similarly, among the cases (CRVO, n = 39), the odds of patients with Vitamin B12 deficiency having hyperhomocysteinemia were 7.0 (1.22–40.09) times those of patients without Vitamin B12 deficiency (P = 0.029). In the control group also (non-CRVO, n = 39), the odds of patients with Vitamin B12 deficiency having hyperhomocysteinemia were 6.67 (1.47–30.21) times those of patients without Vitamin B12 deficiency (P = 0.014). CONCLUSION: Hyperhomocysteinemia was not found to be an independent risk factor for retinal vein occlusion in our study. However, we found a high prevalence of hyperhomocysteinemia and Vitamin B12 deficiency in both cases and controls, without a statistically significant difference between the two groups with respect to both parameters. We also found a negative correlation of serum homocysteine levels with Vitamin B12 and folate levels. The odds of patients with Vitamin B12 deficiency having hyperhomocysteinemia were seven times those of patients without Vitamin B12 deficiency. Hypertension, hyperlipidemia, and abnormal blood profile had a significant association with CRVO and HCRVO. Many of the systemic risk factors for retinal vein occlusions are found to be associated with elevation of serum homocysteine levels, which may be part of a final common pathway in bringing about a state of accelerated atherosclerosis, leading to CRVO or HCRVO. Therefore, lowering serum levels of homocysteine by Vitamin B12 and folate supplementation could have a role in the prevention of these diseases.
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Human immune deficiency virus conundrum: An everlasting challenge! p. 13
Anju Kochar, Shaheen Farooq
DOI:10.4103/ojo.ojo_125_21  
BACKGROUND: Human immune deficiency virus (HIV) causes a wide spectrum of diseases worldwide and has the capability to affect every organ system in the body. Ocular manifestations have been reported in up to 70% of individuals infected with HIV and the ocular manifestations reflect systemic disease and maybe the first sign of disseminated infection. PURPOSE: To study the pattern of ocular manifestations related to HIV in seropositive patients with the objective of identifying its spectrum in highly active antiretroviral therapy (HAART) era and to emphasize on the role of ophthalmologists in fighting the battle against HIV. MATERIALS AND METHODS: A cross sectional study was undertaken on 300 HIV positive patients. Data were collected, tabulated and analyzed using MSTAT software. Chi-square test was applied and P < 0.05 was considered significant. RESULTS: Ocular lesions were observed in 50.33% of patients. Conjunctival microvasculopathy being the most common finding seen in 27 (9%) patients, followed by retinal microvasculopathy and trichomegaly in 20 (6.66%) patients each. Herpes zoster ophthalmicus and cytomegalovirus retinitis were observed in four (1.33%) and three (1%) patients respectively. In the study 78.33% patients were on ART. CONCLUSION: HAART has reduced serious ocular opportunistic infections and ocular malignancies, but HAART mediated visually disabling immune recovery uveitis has emerged as a clinical challenge for ophthalmologists. Improved communication between the two broad specialties of HIV medicine and ophthalmology will definitely go a long way in the battle against this dreadful disease.
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Endophthalmitis Postintravitreal Bevacizumab Injections: Incidence, Management, and Visual Outcome in Tertiary Care Center in Pakistan p. 20
Amna Rizwan, Asfandyar Asghar, Ume Sughra, Naila Yasmin
DOI:10.4103/ojo.ojo_103_21  
PURPOSE: The purpose is to study the incidence, characteristics, management, and visual outcome of endophthalmitis postintravitreal bevacizumab (Avastin®) injections. METHODS: Retrospective cohort study conducted at Fauji Foundation Hospital that is a tertiary care center in Rawalpindi, Pakistan. The study duration was from January 1, 2015 to March 31, 2020. A total of 2321 eyes of 1407 patients were treated with Intravitreal bevacizumab (IVB) in a minor operation theater using standard aseptic measures. We studied the incidence, clinical characteristics, treatment, and visual outcomes of endophthalmitis post-IVB. RESULTS: Seven eyes (0.30%) out of 2321 eyes developed post-IVB endophthalmitis during the study period. Three eyes (42.8%) were culture positive and four eyes (57.2%) were culture negative. Five eyes (71.4%) showed visual improvement and two eyes (28.6%) did not show visual improvement. CONCLUSION: Prompt intravitreal antibiotic along with vitreous tap in cases of postintravitreal endophthalmitis may prevent vision loss which provides a useful alternative to immediate pars plana vitrectomy that requires more expertise, equipment, and an operation theater.
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Prevalence and determinants of refractive error and related ocular morbidities among Saudi adolescence population in Riyadh, Saudi Arabia p. 25
Ziaul Haq Yasir, Fatimah Abdullah Basakran, Nora Ali Alhumaid, Malek Abdulrahman Balous, Abdulrahman Salem Banaeem, Ahmad Khaled Al-Shangiti, Rajiv Khandekar
DOI:10.4103/ojo.ojo_114_21  
PURPOSE: The purpose of this study was to determine the magnitude and determinants of refractive error (RE) and related ocular morbidities among preparatory and secondary Saudi students in Riyadh. METHODS: This study was conducted in 2017–2018 at preparatory (12–14 years) and secondary (15–18 years) schools. A “Spot Screener” was used to determine if the child passed or failed a refraction test. Fail test meant RE ≥ ± 0.50 D. Data were collected on refractive status in each eye, anisometropia, and strabismus. The type of RE was estimated and analysis was performed for an association to gender, age, and education levels. The use of spectacle while screening defined the compliance of spectacle wear. RESULTS: The study sample was comprised of 708 Saudi students. There were 59.5% of boys. The prevalence of RE was 43.6% (95% confidence interval [CI]: 40.0, 47.3). The prevalence of RE in preparatory and secondary students was 44.5% and 43.2%, respectively. The proportion of myopia (≥ −0.5 D) and hyperopia (≥ +0.5 D) among students with RE was 82.2% and 17.8%, respectively. Family history of RE was positively associated to RE in students (odds ratio: 1.8 [95% CI: 1.3, 2.5]). The current screening initiative identified 45 (6.4%) new cases of RE who required spectacles. The compliance rate for using visual aid among students with RE was 74.6%. The prevalence of anisometropia and strabismus was 3.0% and 4.1%, respectively. CONCLUSIONS: A high proportion of Saudi adolescence in Riyadh have RE. Periodic ophthalmic assessment and refractive services are recommended as part of school health screening initiatives.
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Can trainees perform Ahmed glaucoma valve surgery as effectively as attendings? p. 31
Melih Ustaoglu, Hugh Huynh, Sharmenie Esin, Aakriti Garg Shukla, Reza Razeghinejad
DOI:10.4103/ojo.ojo_412_20  
OBJECTIVE: To compare the surgical outcomes and early postoperative complications of Ahmed glaucoma valve (AGV) implantation performed by residents with those performed by attending physicians. METHODS: This is a retrospective, case–control study. Data were gathered from chart reviews of consecutive cases of AGV model FP7 implantation between January 2014 and July 2017. Postoperative 1-year results of patients who had at least 3 months follow-up were evaluated. RESULTS: One hundred and forty-four eyes of 144 patients were included in this study: 72 patients in the resident group, and 72 age- and sex-matched patients in the attending group. Hyphema and shallow anterior chamber were significantly more common in the resident group vs. attending group (25% vs. 2.8% and 19.4% vs. 7.0%; P = 0.001 and P = 0.04, respectively). Neovascular glaucoma (NVG) was more common in resident vs. attending group (30.6% vs. 1.4%; P < 0.001). No significant difference in mean intraocular pressure (IOP) was found at any postoperative follow-up visits between the surgery groups (P > 0.05, for all). The number of postoperative visits within 3 months was similar between the groups (P = 0.84). CONCLUSION: Resident-performed AGV surgery lowered IOP, similar to attending-performed surgery. More frequent complications were observed in the resident group, which might be due to the predominance of NVG in this group.
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Correlation of retinal nerve fiber layer thickness with perimetric staging in primary open-angle glaucoma – A cross-sectional study p. 36
K Subrahmanya Bhat, M Vaishnavi Reddy, Vijay Pai
DOI:10.4103/ojo.ojo_345_20  
BACKGROUND: Glaucoma is a progressive optic neuropathy, characterized by structural optic nerve damage with corresponding field defects. Primary open-angle glaucoma (POAG) is the most common. Although perimetry is the gold standard, retinal nerve fiber layer (RNFL) thickness by spectral-domain optical coherence tomography (SD-OCT) has proved reliable in the detection of pre-perimetric glaucoma. There is preferential involvement of various sectors of the peripapillary RNFL in the different stages of POAG. PURPOSE: The purpose of this study is to assess RNFL thickness and determine preferential involvement of different sectors of peripapillary RNFL in the various stages of POAG using SD-OCT. MATERIALS AND METHODS: Forty-nine patients with POAG underwent complete ophthalmic examination including visual field testing and RNFL thickness measurement. Perimetric findings were used to categorize them into mild, moderate, and severe stages of glaucoma. The RNFL thickness values were analyzed and compared with perimetric results. RESULTS: The average RNFL loss in mild, moderate, and severe POAG was 25.44%, 29.67%, and 44.15%, respectively. A statistically significant correlation (P < 0.05) between RNFL loss and severity of glaucoma was found in all except the superior and temporal sectors. A statistically significant (P < 0.05) negative correlation was noted between visual field index and RNFL loss in all sectors except the nasal-superior in moderate POAG and all sectors in severe POAG. Mean deviation and RNFL loss showed a significant positive correlation in temporal-inferior (TI) sector in mild POAG and all sectors in the severe group. CONCLUSION: RNFL thickness decreases with increase in glaucoma severity and is a reliable parameter to differentiate mild from severe POAG. The TI followed by nasal-inferior RNFL sector is the most sensitive to glaucomatous damage in all three stages.
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Outcome of cataract surgery in pediatric uveitis (experience at King Khalid Eye Specialist Hospital) p. 43
Ahmad Mohammed AlAmeer, Mohammed Al Shamrani
DOI:10.4103/ojo.ojo_15_21  
BACKGROUND: Cataract is a major complication of uveitis in children that requires timely management to restore good vision and prevent amblyopia. In surgical management of uveitic pediatric cataracts, published literature has shown a variety of clinical factors affecting the final visual outcome. The aim of this study is to investigate and report the clinical outcomes of cataract surgery and contributing factors impacting such outcomes in children with uveitis. MATERIALS AND METHODS: A retrospective case series of all pediatric patients (<18 years) who were diagnosed with uveitis and had cataract surgery at a tertiary eye institutions, between January 2000 and October 2016. Outcomes measures include best-corrected visual acuity (BCVA) and postoperative complications. Success was defined as BCVA of ≥20/60. Factors related to successful outcome were analyzed. RESULTS: The study sample was comprised of 26 patients (39 eyes). The median postoperative follow-up was 6.4 years. At the last follow-up, only 2 eyes had active uveitis, 3 eyes were controlled without medications, and 34 eyes were controlled with systemic or topical medications. At the last follow-up, 64% of eyes had BCVA ≥20/60. Anterior uveitis and postoperative aphakia were two determinants, in statistically significant manner, found to be positively related to clinical success (P = 0.01 and 0.04, respectively). Etiology of uveitis and use of preoperative intravenous methylprednisolone were not related to the success of obtaining BCVA ≥20/60 (P = 0.5 and 0.99, respectively). CONCLUSIONS: Cataract surgery improves the visual function of children with clinically significant uveitic cataracts. In this study, we found diagnosis of anterior uveitis and postoperative aphakia to be associated with better final postoperative visual outcomes.
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Analysis of choroidal structure and vascularity indices with image binarization of swept source optical coherence tomography images: A prospective study of 460 eyes p. 49
Pukhraj Rishi, Zeeshan Akhtar, Rupesh Agrawal, Ashutosh Agrawal, Ekta Rishi
DOI:10.4103/ojo.ojo_207_21  
PURPOSE: To evaluate choroidal vascularity index (CVI) among normal subjects using image binarization of swept source optical coherence tomography (SS-OCT). MATERIALS AND METHODS: Four hundred and sixty eyes of 230 normal participants were included. Total circumscribed choroidal area, luminal area, stromal area (SA), and CVI were derived from SS-OCT scans using open-source software (ImageJ) with the modified Niblack method. Both CVI and subfoveal choroidal thickness (SFCT) were correlated with age, refractive error, intraocular pressure, and mean ocular perfusion pressure (MOPP) using mixed linear model analysis. Pearson's correlation coefficient was used to determine the relationship between age and each dependent factor. Analyses were performed using the SPSS software version 20.0 (IBM Corp., Armonk USA) and statistical significance was tested at 5%. RESULTS: The mean age was 42.1 (±17.6) years. Mean SFCT was 307 ± 79 μm. Mean CVI was 66.80 (±3.8)%. There was statistically significant positive correlation between CVI and increasing age (r = 0.259, P < 0.0001) and statistically significant negative correlation between SFCT and age (r = −0.361, P < 0.0001). There was positive linear correlation between refractive error and CVI (r = 0.220, P < 0.0001) and negative correlation between SFCT and refractive error. There was no significant effect of MOPP on both CVI (P = 0.07) and SFCT (P = 0.7). CONCLUSION: CVI and SFCT are significantly correlated with age and refractive error in normal Indian eyes.
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Evaluation of lacrimal duct probing in adults with 0.02% and 0.04% mitomycin-C in primary acquired nasolacrimal duct obstruction: A randomized comparative pilot study p. 56
Manu Saini, Mandeep Singh Bajaj, Neelam Pushker, Rachna Meel, Kulbhushan Saini, Shweta Chaurasia, Aditi Mehta
DOI:10.4103/ojo.ojo_33_21  
PURPOSE: The purpose of the study is to evaluate the safety and efficacy of adjunctive use of mitomycin-C (MMC) using two different concentrations 0.2 mg/ml and 0.4 mg/ml for lacrimal duct probing to treat the nasolacrimal duct obstruction (NLDO) in adults. SUBJECTS AND METHODS: Prospective, an interventional comparative randomized pilot study of lacrimal duct probing conducted in the two study groups 0.02% MMC group (n = 30) and 0.04% MMC group (n = 30) in confirmed primary acquired NLDO of <1-year duration. Patency of lacrimal duct probing confirmed by syringing was compared at 1, 3, and 6-month follow-up in the two study groups, and corresponding subjective improvement of watering was appraised according to Kraft and Crawford grading. RESULTS: Patency of lacrimal duct probing in 0.02% MMC versus 0.04% MMC group was 66.66%/73.33% (P = 0.71) at 1 month, 46.66%/66.66% (P = 0.09) at 3 months and 46.66%/66.66% (P = 0.03) at 6-month follow-up, respectively. Subjective improvement of watering (no watering and mild watering) observed in 0.02% MMC versus 0.04% MMC group was 46.66%/73.33% (P = 0.03), at 1 month, 66.66%/83.33% (P = 0.13) at 3 months and 56.66%/73.33% (P = 0.17) at 6-month follow-up. CONCLUSION: Adult lacrimal duct probing with 0.04% MMC was associated with significant higher objective success rate than adult lacrimal duct probing with 0.02% MMC, without added concurrently side effects.
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Effect of legislation and changing trends of Diwali ocular firecracker injuries in Northern India p. 61
Rebika Dhiman, Karthikeyan Mahalingam, Neelima Balakrishnan, Atul Kumar, Rohit Saxena, Ramanjit Sihota
DOI:10.4103/ojo.ojo_303_21  
OBJECTIVE: The objective of this study is to study the impact of temporary legislation implemented during Diwali on ocular firecracker injuries in Delhi-National Capital Region (NCR) region. MATERIALS AND METHODS: In this retrospective study, records of the patients presenting with ocular firecracker injury during 10 days of Diwali (prediwali, Diwali and 8 days postdiwali) from 2014 to 2019 were retreived from the medical record section. Clinico-demographic profile, relevant history pertaining to the use of firecracker, and details of eye examination, namely presenting visual acuity (VA), laterality and classification of injury based on Birmingham Eye Trauma Terminology System were noted. RESULTS: Six hundred and sixty-seven eyes of 646 patients were recruited. The median age of patients was 14 years (R = 3–65 years) and male: Female ratio was 4.9:1. Majority of patients (57.7%; n = 373) were from outside Delhi. Most of them were open globe injuries (66.8%). In 55.4% (n = 356) eyes, presenting VA was perception of light to finger counting close to face and 28% (n = 180) eyes could not perceive any light. A significant reduction was noted in the number of ocular firecrcaker injuries after regulation (preregulation [2014–2016] n = 456; postregulation [2017–2019] n = 211; [P = 0.01, t-test]). During preregulation period, presenting VA was worse than 1/60 in significantly higher number of eyes (85.5%; n = 376) than post regulation (78.8%, n = 160) (P = 0.03, Chi-square test). CONCLUSION: Although temporary legislation seems to be effective in reducing ocular firecracker injuries (52.7% reduction) in NCR, uniform implementation of stricter laws nationwide is essential to further minimize the problem.
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Multipiece posterior chamber intraocular lens as sutureless, glueless scleral fixated intraocular lens p. 69
Anuja Mohanty, Santosh K Mahapatra, Navya Mannem
DOI:10.4103/ojo.ojo_115_21  
PURPOSE: The purpose of the study is to report the outcomes of sutureless, glueless multipiece posterior chamber intraocular lens (PCIOL) as scleral fixated intraocular lens (SFIOL) implantation in patients with poor or no posterior capsular support. METHODS: Medical records of 45 eyes of 42 patients who underwent SFIOL implantation where no suture or glue was used to fixate intraocular lens (IOL) to the sclera from November 2016 to October 2017, with minimum 18 months of follow-up were retrospectively analyzed. The best-corrected visual acuity, indication of surgery, other significant eye examination findings, and complications were analyzed. RESULTS: Out of 42 patients, 62% were males and 38% were females. Mean age of subjects was 48.5 ± 16.5 years (range 13–79 years). Mean preoperative and postoperative visual acuity was 1.48 ± 0.6 Logarithm of the Minimum Angle of Resolution (logMAR) units and 0.6 ± 0.3 logMAR units, respectively. Most common complication was vitreous hemorrhage six eyes (13.3%) followed by postoperative hypotony in five eyes (11.11%). Other complications such as transient postoperative intraocular pressure rise, hyphema, tilted IOL, cystoid macular edema, retinal detachment were also noted. CONCLUSION: Multipiece PCIOL used as SFIOL without any sutures and glue is a viable, cost-effective method of IOL implantation in eyes with aphakia following surgical complication or trauma, with comparable outcome to other techniques of SFIOL implantation.
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Awareness and practice regarding use of digital devices and ocular health among Saudi adolescents p. 73
Abdulrahman AlDarrab
DOI:10.4103/ojo.ojo_283_21  
PURPOSE: To review the knowledge of ocular health and practices of digital device usage among adolescent Saudi Arabia population. METHODS: This cross-sectional web-based survey was conducted in 2021 at a university in central Saudi Arabia. We asked questions regarding demographics, knowledge related to computer vision syndrome (CVS), and the use of digital devices for participants' daily activities. The acceptable grades of knowledge (”excellent” and “good”) and practice scores were associated with the determinants using the nonparametric method of analysis. RESULTS: Of 521 participating students, knowledge about CVS and its relation to digital device usage were excellent in 41 students (7.9%), good in 161 (39%), poor in 300 (57.6%), and very poor in 19 (3.6%). Twenty-eight (5.4%) students scored an “excellent” grade on practices for digital device usage, 216 (41.4%) scored “good,” and 277 (53.2%) scored “poor.” The knowledge score median was 1.0 (interquartile range 1.0; 2.0), and the practice score median was 6.0 (4.0; 9.0). Health studies students had better knowledge than other students (P = 0.004). Smartphone users had worse knowledge than users of other devices (P = 0.017). Females (P < 0.001) and health studies students (P = 0.004) were significantly associated with acceptable practices of using digital devices. CONCLUSIONS: Awareness of ocular health because of abuse of digital devices was poor among participating students. The practice of digital device use was not healthy and needed improvement through preventive measures and counseling.
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CASE REPORTS Top

Surgical resection of orbital primitive neuroectodermal tumor without adjuvant chemotherapy p. 78
Faizan Mehmood, Abhishek Agrawal, Nishat Afroz, Syed Ali Raza Rizvi
DOI:10.4103/ojo.ojo_137_21  
Primitive neuroectodermal tumor (PNET) of the orbit is a very rare entity. We report a case of a 10-year-old boy having progressive protrusion of the eyeball, restricted ocular motility, ptosis, and ocular pain for 2 months. On examination, a fixed, nontender, firm, hyperemic, nonpulsatile globular mass was palpated in the superomedial quadrant of the orbit. Computed tomography scans of the orbit depicted a well-defined, soft tissue density lesion within the orbit without evidence of any bone defect or erosion. Surgical resection of the encapsulated lesion through anterior orbitotomy followed by histopathology and immunohistochemistry examination confirmed the diagnoses of PNET. The patient has been on regular follow-up for 2 years and has shown no sign of recurrence.
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Pegylated interferon-alpha-2a for the treatment of ocular surface squamous neoplasia p. 81
Murtuza Nuruddin, Soma Rani Roy, Fahmida Hoque
DOI:10.4103/ojo.ojo_146_21  
Ocular surface squamous neoplasia (OSSN) is the most common nonpigmented ocular surface neoplasm. Interferon-alpha (IFNα)-2b has been proved to be an effective immunotherapeutic agent to treat OSSN. We have used intralesional and topical (36 μg/ml) pegylated (peg) IFNα-2a to treat a recurrent surgically failed case of OSSN instead of IFNα-2b. In this case report, we have shared our initial experience with the novel use of peg-IFNα-2a to treat OSSN. According to our brief clinical experience, peg-IFNα-2a is nontoxic to ocular surface and has a promising role to treat OSSN.
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Orbital metastases as the initial clinical manifestation of thyroid carcinoma: A case series p. 85
Mutmainah Mahyuddin, Kania Theresia, Neni Anggraini, H Imam Subekti
DOI:10.4103/ojo.ojo_76_21  
Thyroid carcinoma rarely metastasizes to the orbit. Approximately only 2%–7% of orbital metastatic lesion were found originally from thyroid carcinoma. We present three cases to increase the awareness of orbital metastases as the initial manifestation of thyroid carcinoma. Three female patients aged 28–65 years old presented with initial complaint of orbital mass. Further examination discovered an asymptomatic lump on every patient's neck. However, one patient was unaware of her lump. Examination revealed that all lesions were metastases from papillary thyroid carcinoma. These cases conclude several similarities. First, prominent unilateral proptosis, orbital mass in the superior quadrant, limited eyeball movement, and orbital bone destruction were found in every patient. Second, all the orbital computed tomography scan showed extraconal solid masses involving adjacent structures and expanding intra-cranially or intrasinusly. These findings should raise one's suspicion of a metastatic lesion primarily caused by thyroid carcinoma. Despite the rarity of orbital metastases, thyroid carcinoma must be considered as a potential primary tumor in patients with initial presentation of orbital mass. Thorough physical examination is important to determine the origin of metastases.
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Tractional retinal detachment and juxtapapillary retinal capillary hemangioma in a 6-year-old girl: A case report p. 89
Franco Benvenuto, Mariana Sgroi, Gabriela Lamas, Luis Diaz Gonzalez, Adriana Fandiño
DOI:10.4103/ojo.ojo_348_20  
A 6-year-old girl with visual impairment in the right eye (OD) was referred for an eye evaluation. The fundus of the OD showed a fibrotic orange endophytic lesion located adjacent to the optic disc. In retinal optical coherence tomography, a local tractional retinal detachment and choroidal neovascular membrane were observed together also with the presence of subretinal fluid. Due to the vision of the OD evolved to nonlight perception in the following exam, enucleation was performed. The pathology report was correlated with hemangioblastoma. Herein, we describe a case of a young girl with a retinal hemangioblastoma with quick evolution and without prior systemic diagnosis.
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Bilateral central serous chorioretinopathy in a patient with angioid streaks p. 92
Hamidreza Torabi
DOI:10.4103/ojo.ojo_415_20  
This report describes a case of bilateral central serous chorioretinopathy (CSCR) in a patient with angioid streaks. A 39-year-old male was referred for worsening vision. Best-corrected visual acuity (BCVA) at presentation was 5/10 in his right eye and 4/10 in his left eye. Fundus examination, fluorescein angiography, and optical coherence tomography were compatible with angioid streaks in both eyes associated with macular atrophy due to previous CSCR attack in the right eye and active nonresolving CSCR in the left eye. Macular laser photocoagulation was done in the left eye. After 3 months, subretinal fluid was absorbed and BCVA improved to 7/10. CSCR may occur rarely in patients with angioid streaks and ophthalmologists should consider CSCR in cases with angioid streaks and vision deterioration.
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Multimodal imaging including optical coherence tomography angiography of benign familial fleck retina p. 95
George J Manayath, Shishir Verghese, Hirika Vipul Gosalia, Anuradha Kanakath, Venkatapathy Narendran
DOI:10.4103/ojo.ojo_286_21  
A 44-year-old woman presented with complaints of pain in the right eye (RE). Fundus examination revealed disc edema in the RE along with retinal flecks sparing the macula in both eyes (BE). Fundus autofluorescence demonstrated a symmetrical pattern of white flecks in BE. Spectral-domain optical coherence tomography (SD-OCT) revealed the lesions at the level of retinal pigment epithelium with impingement onto the outer retina. SD-OCT angiography through the flecks revealed hyperreflective lesions at the level of avascular retina. RE B-scan revealed a T-sign. Based on these findings, she was diagnosed with BE benign familial fleck retina (BFFR) with RE posterior scleritis. We describe the multimodal imaging features in a middle-aged patient with BFFR and provide an insight into the probable pathogenesis.
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Bilateral optic disc edema with subconjunctival hemorrhage: Attributed to scrub typhus? p. 99
Saswati Sen, Bhagabat Nayak, Sucheta Parija
DOI:10.4103/ojo.OJO_262_2019  
A 15-year-old female patient presented with complaints of headache, blurring of vision, and redness of both eyes for 15 days and fever for 20 days. Her best-corrected visual acuity (BCVA) was 20/40 in both eyes. Anterior segment examination was normal except for subconjunctival haemorrhage in both eyes. Examination of the posterior segment showed disc oedema in both eyes. Her blood investigations revealed platelet count to be 1.5 lakhs per cubic mm, and leucocyte count to be10,700 per cubic mm.CSF culture showed seven cells per microlitre,76% lymphocytes and CSF samples negative for gram stain, acid-fast bacilli, and culture. Further investigation for IgM titre for scrub typhus was positive. She was treated with oral doxycycline. On follow up after three weeks, both the subconjunctival haemorrhage and bilateral disc oedema resolved with BCVA of 20/20 in both eyes. She was kept on follow up and has not presented with any fresh complaints until six months after the initial presentation.”
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CLINICAL IMAGES Top

Hypertensive anterior uveitis with papillitis: A diagnostic dilemma p. 102
Nivedita Nair, Sudha K Ganesh
DOI:10.4103/ojo.ojo_109_21  
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Isolated incomplete third cranial nerve palsy due to presumed cavernous sinus meningioma p. 104
Divya K Natarajan, Mohan Kannam, Srinivasa Perraju Ponnapalli, Virender Sachdeva
DOI:10.4103/ojo.ojo_406_20  
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Floating islands-ultra-widefield imaging of rapid silicone oil emulsification p. 107
Kushal Delhiwala, Rushik Patel, Bakulesh Khamar, Parth Rana
DOI:10.4103/ojo.ojo_3_21  
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Pseudo double elevator palsy p. 109
Rajesh Subhash Joshi
DOI:10.4103/ojo.ojo_54_21  
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Choroidal neurofibromas in neurofibromatosis 1 p. 111
Taha Muneer Ahmed, MA Rehman Siddiqui
DOI:10.4103/ojo.ojo_389_20  
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Gas bubble in anterior chamber with orbital emphysema following blunt trauma: A novel presentation p. 113
Jyoti Shakrawal, Karthikeyan Mahalingam, Ayushi Sinha
DOI:10.4103/ojo.ojo_120_21  
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Anterior segment optical coherence tomography features of netarsudil-associated reticular corneal edema p. 115
Ashley Khalili, Reza Razeghinejad, Zeba Almas Syed
DOI:10.4103/ojo.ojo_108_21  
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Blindness as the presenting sign of osteopetrosis in a child p. 117
Bipasha Mukherjee, Aman Agrawal, Olma Veena Noronha
DOI:10.4103/ojo.ojo_113_21  
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LETTER TO THE EDITOR Top

Inadvertent intralenticular Ozurdex removal p. 119
Madhurima Roy, Aniruddha Maiti, Sayan Das, Sagnik Surya Das
DOI:10.4103/ojo.ojo_144_21  
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DSEK for corneal decompensation post bee sting injury p. 121
Pallavi Joshi, Shruti Bhat
DOI:10.4103/ojo.ojo_260_21  
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CLINICAL QUIZ Top

Bumps on the iris! p. 123
Sashwanthi Mohan, Sujatha Mohan
DOI:10.4103/ojo.ojo_295_21  
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