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   Table of Contents - Current issue
Coverpage
May-August 2022
Volume 15 | Issue 2
Page Nos. 125-262

Online since Wednesday, June 29, 2022

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EDITORIALS  

Ignorance is not bliss when it comes to eye health: Lifestyle diseases in a neuro-ophthalmology practice Highly accessed article p. 125
Farida Al Belushi
DOI:10.4103/ojo.ojo_150_22  
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Ongoing debates in endothelial keratoplasty: DMEK is not the new DSAEK! Highly accessed article p. 128
Haitham Al-Mahrouqi, Charles N McGhee
DOI:10.4103/ojo.ojo_137_22  
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EDITORIAL COMMENTARY Top

Duane retraction syndrome: Where and how is the abducens nerve? p. 131
Meenakshi Swaminathan
DOI:10.4103/ojo.ojo_141_22  
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REVIEW ARTICLE Top

Management of neurovascular emergencies with ophthalmic manifestations p. 133
Jawahar Lal Goyal, Shalini Singh, Sarvesh Chandra Mishra, Shipra Singh, Divya Singh
DOI:10.4103/ojo.ojo_215_21  
Patients with neurovascular disorders sometimes approach the ophthalmologists with mild ophthalmic clinical features such as conjunctival congestion, slowly progressive proptosis, lateral rectus palsies and at other times with ophthalmic emergencies like sudden increase in proptosis, ophthalmoplegia, diplopia, and ptosis before the onset of neurological manifestations which may be life-threatening if not detected in time. The aim of this article is to focus on ophthalmic manifestations of neurovascular emergencies and role of ophthalmologists in its management. In this communication, to make the ophthalmologist aware of clinical presentations, the imaging modality of choice, diagnostic features, medical and interventional treatments. We have searched PubMed, Web of Science, Google Scholar and reviewed some of the commonly encountered neurovascular emergencies with ocular manifestations such as carotid-cavernous fistula, cerebral venous sinus thrombosis, cerebral artery aneurysms, arterio-venous malformations.
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ORIGINAL ARTICLES Top

Knowledge, attitudes, and practices toward research among Oman medical specialty board residents p. 140
Hajar Al Abri, Elham Atiq, Abdul Hakeem Alrawahi
DOI:10.4103/ojo.ojo_336_21  
OBJECTIVES: The Accreditation Council for Graduate Medical Education has mandated residency programs to teach the basic principles of research in residency programs. This study aimed to assess the research knowledge, attitude, and practice among the Oman Medical Specialty Board (OMSB) residents. Secondarily, it aimed to asses associations between different factors and research-related knowledge, attitude, and practice. MATERIALS AND METHODS: This cross-sectional study was conducted among all residents who were involved in OMSB various training programs in the academic year 2018/2019. A validated self-administered questionnaire was used. Hard copies of the questionnaire were delivered to residents in addition to the online forms. Data were entered using EpiData entry software and analyzed using SPSS version 24. RESULTS: A total of 256 residents participated in the study with a response rate of 46.5%. Around 55% of included residents have poor knowledge level, and 44% have moderate knowledge level. The study showed that the majority (93%) of the residents have positive research attitude. However, the practice domain showed that only 27.8% of residents have published articles as first or coauthor. Lack of time was reported as a major hindrance in nearly two-thirds of the residents. Lack of training (56%), lack of research-focused curriculum (47%), and lack of effective supervision (46%) were among major reported obstacles beside others. CONCLUSIONS: This study showed that OMSB residents have inadequate knowledge and lagging research practices, but a positive attitude toward research. This emphasizes the need for research-focused curricula and further training. In addition, applying new regulations, including mandatory manuscript submission, may improve the practice status.
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Clinical profile and magnetic resonance imaging characteristics of Duane retraction syndrome p. 147
Unnikrishnan Suma, Mohammed Ferzana, Valiyaveetil Babitha, Poothatta Jyothi
DOI:10.4103/ojo.ojo_133_21  
PURPOSE: To describe the clinical profile and magnetic resonance imaging findings of the brain in Duane retraction syndrome (DRS) and determine whether there is an association between clinical presentation and magnetic resonance imaging (MRI) brain characteristics. MATERIALS AND METHODS: This was a cross-sectional study done at a tertiary care center in South India. We recruited and analyzed the clinical characteristics of 54 patients with DRS. MRI of the brain with fast imaging employing steady-state acquisition (FIESTA) was performed in 41 cases, and the cisternal segment of the sixth nerve was studied. Statistical analysis was done to determine any association between the radiological and clinical features. RESULTS: Type 1 DRS was predominant, followed by Type 3 DRS and Type 2 DRS. 9.3% of cases were bilateral and 11.1% were familial. Orthotropia was most common, followed by esotropia and exotropia. The MRI brain showed the absence of the cisternal part of the sixth nerve on the affected side in 82% of Type 1 and 75% of Type 3 unilateral DRS. Both the abducens nerves were visualized in 19.5% of the patients with unilateral DRS. There was no statistically significant association between MRI brain findings and the clinical features. CONCLUSIONS: MRI brain with FIESTA shows absent or hypoplastic sixth nerve in most cases of Type 1 and Type 3 DRS. However, around 20% of DRS cases may show the presence of the cisternal part of the sixth nerve. Hence, clinicians must be cautious when ruling out DRS on the basis of MRI brain findings. Although aplasia of the sixth nerve is the most frequent MRI finding, it may not be the sole etiologic factor.
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Clinical profile, treatment, and visual outcome of scleritis: A single ophthalmologist experience p. 153
Kowsigan Magesan, Gazal Patnaik, Parthopratim Dutta Majumder, Jyotirmay Biswas
DOI:10.4103/ojo.ojo_168_21  
PURPOSE: The purpose of this study was to analyze the clinical profile of patients with scleritis managed by a single ophthalmologist in a tertiary eye care center. METHODS: This was a retrospective analysis of 107 eyes of 96 patients with scleritis from January 2007 to December 2018. RESULTS: Female predominance (68%) with a relatively young-onset (46 ± 14 years) of scleritis was observed. Diffuse anterior scleritis (41%) was the most common subtype of scleritis, and the most common systemic association was rheumatoid arthritis (18%). Three-fourth of patients received immunosuppressive treatment (74%) along with corticosteroids. The mean follow-up period was 3 ± 2.5 (range: 0.6–10) years. Necrotizing scleritis was at a 3.5 times higher risk of developing ocular complications. Eighty percent of patients maintained the same vision. Recurrence of scleritis was noted in 25 eyes (23%). CONCLUSION: Diffuse scleritis is the most common scleritis in our population. Tuberculosis was commonly seen with diffuse scleritis. The likelihood of developing ocular complications (cataract and glaucoma) was higher in necrotizing scleritis, thus requiring periodic monitorization.
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Ocular findings in children with acute leukemia at a tertiary care center in South America p. 159
Franco Benvenuto, Mariana Sgroi, Soledad S Guillen, David Ancona, Adriana Fandiño
DOI:10.4103/ojo.ojo_347_20  
PURPOSE: The purpose of this study was to evaluate ophthalmological findings in patients with acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) in a Latin American population. MATERIALS AND METHODS: This was a single-center, retrospective study. The observational analysis was conducted in AML and ALL patients seen as a routine examination at the department of ophthalmology of tertiary care center in Argentina between March 1, 2017, and February 28, 2018. RESULTS: Overall, 137 patients with acute leukemia were included. The mean age was 7.9 ± 5.2 years (0–18), and 55% were male (n = 75) and 45% female (n = 45). At least one-fifth (n = 31) of the patients presented some type of ocular manifestation (23%). The most frequently observed manifestation was retinal hemorrhages (n = 14), followed by papilledema (n = 9) and ocular surface involvement (n = 5). The eye involvement was more frequently identified in the AML group (24%), compared to the ALL group (22%), especially papilledema with central nervous system compromise ALL (5%) and AML (11%), P < 0.01. The presence of hemorrhages was similar in both groups. In patients with retinal hemorrhage (n = 14), the mean hematological findings were hemoglobin 7.4 ± 0.4 g/dL (6.5–8.0), erythrocytes 2.5M ± 0.3/mm3 (confidence interval [CI], 2.0–3.1), and platelets 76,000 ± 32,000/mm3 (CI, 8000–384,000). Patients without retinal findings (n = 123), the mean hematological findings were hemoglobin 9.1 ± 0.6 g/dL (8.0–10.2), erythrocytes 3.2M ± 0.6/mm3 (CI, 2.5–3.5), and platelets 92,000 ± 44,000/mm3 (CI, 42.000–390.000). Multivariable analysis found that hemoglobin levels were the most reliable predictive factor for retinal findings. It was observed that the risk diminishes in patients with levels higher than 8.5 g/dL, and that it increased in patients with levels ranging between 6.5 and 7.5 g/dL at least twice (P < 0.01). CONCLUSIONS: Our results show that ocular involvement occurs in a high percentage of patients with leukemia with a clear clinical, humoral, and sometimes prognostic correlation, suggesting routine ophthalmologic evaluation in these patients.
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Diagnostic accuracy of indigenously developed computer-based binocular vision assessment p. 163
P Praveen Kumar, T Shajahan, Jameel Rizwana Hussaindeen
DOI:10.4103/ojo.ojo_460_20  
CONTEXT: The increased prevalence of nonstrabismic binocular vision anomalies (NSBVA) has given rise to the need for cost-effective screening and diagnostic tools. AIMS: The aim of the study is to assess the efficacy of an indigenously developed computer-based binocular vision assessment software (Train Your Eyes®) in screening NSBVA. SUBJECTS AND METHODS: Subjects who visited the binocular vision clinic of a tertiary eye care center with asthenopic symptoms between January 2019 and January 2020 were included in the study. Patients with other ocular comorbidities and stereopsis poorer than 500 arc seconds were excluded. All subjects underwent a comprehensive eye examination followed by binocular vision assessment using both the manual and computer-based methods. STATISTICAL ANALYSIS USED: Receiver operating characteristic (ROC) curves were utilized to choose the cut-off points that maximize the sensitivity and specificity. RESULTS: The mean (standard deviation) age of 88 subjects was 22 (4.5) years with 34 males. Based on the conventional manual assessment, 71 (81%) were diagnosed to have NSBVA and 17 (19%) had normal binocular vision. Based on the ROC analysis, the following cut-off points are proposed: 14 prism diopter (PD) for near positive fusional vergence amplitudes, 4.5 PD for near negative fusional vergence amplitudes, 4.5 cycles per minute (cpm) for binocular accommodative facility, and 3.5 cpm for monocular accommodative facility. All the binocular vision parameters demonstrated statistical significance in the ROC analysis (P < 0.05). CONCLUSIONS: The software-based screening tool was found to be highly sensitive in identifying NSBVA and thus could be used as a potential screening tool in the clinic and community.
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Impact of COVID-19-related lockdown on retinal disorders treated with intravitreal injections p. 168
Manpreet Brar, Satinder Pal Singh Grewal, Dilraj S Grewal, Mansi Sharma, Mangat Ram Dogra
DOI:10.4103/ojo.ojo_74_21  
PURPOSE: To study functional changes in vision and morphological changes on optical coherence tomography (OCT) scans in patients where intravitreal therapy (IVT) with injections has been delayed due to COVID-19 pandemic lockdown. METHODS: Retrospective cross-sectional study included 77 eyes with the diagnosis of exudative age-related macular degeneration (eAMD), diabetic macular edema (DME), and retinal vein occlusion (RVO), regularly receiving IVT with anti-vascular endothelial growth factor (Anti-VEGF) injections or dexamethasone implant and were not able to receive the injections as intended due to lockdown. Best-corrected visual acuity (BCVA), central foveal thickness (CFT), and qualitative morphological features on OCT were analyzed pre- and post-therapy break off. RESULTS: The mean duration of IVT break-off was 57 days. Mean BCVA logarithm of minimum angle of resolution (logMAR) worsened from 0.33 (20/42) to 0.35 (40/44) (P = 0.02) and mean CFT increased from 297.90 μm to 402.16 μm (P < 0.01), from pretherapy break-off to return visit. Worsening of the visual acuity was seen across all the three disease cohorts, significantly more in the eyes with eAMD. CONCLUSION: Marginal decline in the visual acuity and worsening of the OCT features were observed as a result of delay in the IVT injections of DME, eAMD and RVO patients.
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Exposure keratopathy and its associated risk factors in patients undergoing general anesthesia in nonocular surgeries p. 175
Nazanin Amini, Korosh Rezaei, Hesameddin Modir, Rezvan Kazemi Majd, Neda Graminejad, Fatemeh Rafiei, Reza Rezaei, Zohreh Davoodabady, Akram Bayati
DOI:10.4103/ojo.ojo_81_21  
INTRODUCTION: The most common eye injury during and after general anesthesia is corneal abrasion which can occur at any time after anesthesia and even up to 24 h after it. The aim of this study was to investigate the incidence and factors associated with corneal injury in patients undergoing nonocular surgery. METHODS: This was a descriptive cross-sectional study. A total of 170 patients, who were admitted to the operating room and met the inclusion criteria, were selected through simple nonprobability sampling. Data collection forms were used in order to assess the incidence of corneal injury and its related risk factors. The National Eye Institute scale with fluorescein paper and cobalt blue light by slit lamp were utilized to examine exposure keratopathy. RESULTS: Overall, the results showed that the incidence of keratopathy immediately after eye care removal was found to be 64.7% in the operating room, 65.9% in the recovery room, and 41.2% in 24 h after the surgery. Smokers' patients and drug abusers under general anesthesia underwent endotracheal intubation, received more opioids preoperatively, and had more perioperative bleeding and fluid intake. Moreover, in patients who had received more oxygen flow in the recovery room; the rate of keratopathy was higher. CONCLUSION: Smoking, drug usage, and receiving endotracheal intubation are the risk factors of keratopathy. Therefore, for high-risk patients and procedures, it is indispensable to both obtain preoperative information and take intraoperative precautions in order to prevent eye injuries. Future studies are needed to demonstrate these finding.
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Optical density changes of subretinal hyperreflective material in age-related macular degeneration after switching therapy from ranibizumab to aflibercept p. 182
Armagan Filik, Hulya Gungel
DOI:10.4103/ojo.ojo_139_21  
BACKGROUND: Subretinal hyperreflective material (SHRM) is a hyperreflective material seen on optical coherence tomography (OCT) and located under the retina and above the retinal pigment epithelium. This study aims to examine the effect of SHRM on the functional prognosis of age-related macular degeneration (AMD) patients who switched from intravitreal ranibizumab to intravitreal aflibercept treatment. MATERIALS AND METHODS: This is a retrospective, nonrandomized clinical study. AMD patients meeting the switching criteria underwent a complete ophthalmic examination, including spectral-domain OCT and fundus fluorescein angiography. The best-corrected visual acuity and OCT parameters were measured at the switch and 3, 6, 12, and 24 months after. SHRM(+/−), maximum SHRM thickness, and subjective and objective reflectivity stages of SHRM (grades 1–3) were evaluated. RESULTS: SHRM was observed in 24/48 (50.0%) of eyes at the time of the switch. The differences in maximum SHRM thicknesses were not statistically significant. SHRM's mean subjective reflectivity stages at the switch and subsequent examinations were 2.37, 2.75, 2.75, 2.74, and 2.81; SHRM's objective reflectivity staging also confirmed them. Functional changes after the switch showed a significant VA loss in the SHRM(+) group and significant gain in the SHRM(−) group. CONCLUSION: This study showed that the presence of SHRM and higher optical reflectivity at the switch from ranibizumab to aflibercept caused a poor prognosis after the switch. On the other hand, SHRM(−) patients achieved good functional results after the switch.
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Bilateral enucleation for retinoblastoma: A study of 14 patients p. 188
Khaleel Machakuri, Swathi Kaliki
DOI:10.4103/ojo.ojo_272_21  
PURPOSE: To study the clinical profile of patients who underwent bilateral enucleation for retinoblastoma (RB). METHODS: Retrospective study of 14 cases. RESULTS: Of >3000 RB cases, 14 (<1%) underwent bilateral enucleation for treatment of RB. The mean age at diagnosis of RB was 26 months (median, 24 months; range, 5–72 months). All patients had bilateral RB at presentation. Intraocular RB was evident in 23 (82%) eyes and orbital tumor extension was noted in 5 (18%) eyes. Based on the International Classification of Intraocular RB, tumors were classified as Group B (n = 1; 4%), D (n = 4; 14%), or E (n = 14; 50%) at presentation. Based on the International RB Staging System, tumors were classified as Stage 1 (n = 23; 82%) or Stage 3 (n = 5; 18%). Two patients (four eyes with intraocular RB) had undergone prior treatment before presenting to us and thus could not be classified. Primary treatment included systemic chemotherapy (n = 27; 96%) or enucleation (n = 1; 4%). Five patients were lost to follow-up for a mean duration of 15 months (median, 12 months; range, 7–24 months) during treatment and presented with the orbital extension of RB in one (n = 4; 29%) or both (n = 1; 7%) eyes. Secondary enucleation was performed in 27 (96%) eyes. Over a mean follow-up period of 49 months (median, 29 months; range, 3–340 months), there was no evidence of metastasis and 1 (7%) child died due to pneumonia. CONCLUSION: Bilateral enucleation is rare in the treatment of RB. Advanced tumor presentation or noncompliance to treatment necessitates bilateral enucleation.
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Tuck in versus cauterisation of graft edge in pterygium management: A comparative retrospective interventional analysis p. 193
Shreesha Kumar Kodavoor, Neha Rathi, Ramamurthy Dandapani
DOI:10.4103/ojo.ojo_277_21  
PURPOSE: To compare and evaluate surgical outcome between tuck in and cauterisation in the management of primary pterygium. MATERIALS AND METHODS: Two groups of 56 eyes and 58 eyes with primary pterygium underwent pterygium excision with conjunctival autograft fixation by tucking in alone (Group 1) and with cauterization (Group 2), respectively. A retrospective comparative analysis was done between the two groups. RESULTS: This study included a total of 114 eyes in the final analysis. The recurrence was noted in 3 eyes in Group 1 (5.35%), whereas only 1 eye (1.72%) in Group 2. Other complications included graft edema in 25 eyes (44.64%), in Group 1 and 29 eyes (50%) in Group 2, subconjunctival hemorrhage seen in 28 eyes (50%) in Group 1 and 32 eyes (55.17%) in Group 2, graft retraction observed in 28 eyes (50%) in Group 1 and 13 eyes (22.4%) in Group 2, granuloma formation was seen only in one patient (1.72%) in Group 2, graft loss was observed in four patients (7.14%) in Group 1 and 2 patients (3.44%) in Group 2. CONCLUSION: Graft fixation in pterygium surgery using low-cost procedures with tuck in or cauterization proves to be tolerable, safe and successful method. An additional step of fixing the graft to the cut conjunctival margin using bipolar cautery proves to be safer.
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Outcomes of canalicular trephination versus canaliculodacryocystorhinostomy in common canalicular blocks p. 198
Tejaswini Vukkadala, Mandeep Singh Bajaj, Neelam Pushker
DOI:10.4103/ojo.ojo_181_21  
AIM: This study aimed to compare the outcomes and efficacy of canalicular trephination with monocanalicular stenting and canaliculodacryocystorhinostomy (canaliculoDCR) with silicone intubation. MATERIALS AND METHODS: A prospective comparative study was done in 30 patients (30 eyes) with common canalicular blocks who were randomized into two groups. Fifteen patients underwent canalicular trephination with monocanalicular stenting and 15 patients underwent canaliculoDCR with silicone intubation. Common canalicular obstruction was diagnosed by preoperative syringing and the location of block was confirmed on probing. Stents were kept in both the groups for 3 months and followed up till 6 months postoperatively. Success was defined based on both anatomical and functional outcomes. Anatomical success was defined by the free passage of fluid on syringing with the fluid felt in the throat. Functional success was defined in terms of relief from epiphora based on the subjective opinion and its categorization by Kraft and Crawford's grading and the fluorescein dye disappearance test (FDDT). RESULTS: Eighty percent of eyes in canalicular trephination group and 73.3% of eyes in canaliculoDCR group were anatomically patent on syringing at the final follow-up. Sixty-six percent of eyes in trephination group and 53.3% in canaliculoDCR group were reported to have absent epiphora (complete recovery). Ten eyes in both groups had Grade 0 and 1 FDDT indicating a functional success of 66.6% in both groups. CONCLUSIONS: Canalicular trephination can produce results comparable to canaliculoDCR with silicone intubation in cases of common canalicular blocks. The average duration of surgery is significantly less in canalicular trephination which gives this procedure an added advantage.
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CASE SERIES Top

Acute postoperative infectious endophthalmitis caused by Gram-negative organisms p. 204
Mohamed Al-Abri, Ahmed Al-Hinai, Abdulrahman Al-Abri, Rashmi Mercy Lobo
DOI:10.4103/ojo.ojo_334_21  
Endophthalmitis is a rare but potentially sight-threatening ophthalmic condition characterized by marked inflammation of intraocular tissues and fluids. Bacteria is the most common cause of postoperative acute infectious endophthalmitis of which Gram-positive (GP) bacteria is the predominant isolate which constituted 47% of all positive vitreous cultures in endophthalmitis vitrectomy study. On the other hand, Gram-negative bacteria constituted 11.5% with poor visual outcomes compared to GP cases due to the fulminant and destructive nature of such pathogens despite prompt and appropriate treatment initiation. In this report, we would like to share the three cases of acute postoperative infectious endophthalmitis caused by Gram-negative organisms and highlight the challenges that might be faced when dealing with such presentations.
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CASE REPORTS Top

Role of oral acetazolamide in refractory glaucomatous deep cup-related maculopathy p. 208
George Joseph Manayath, Ratnesh Ranjan, Shubhank Khare, Swapnil Vidhate, Narendran Venkatapathy
DOI:10.4103/ojo.ojo_319_21  
A 39-year-old man, a known case of primary open-angle glaucoma on treatment, presented with defective central vision in the left eye. On examination, his intraocular pressure (IOP) was 26 mmHg in the right eye and 30 mmHg in the left eye with best-corrected visual acuity of 6/12 in each eye. Fundus examination showed glaucomatous optic neuropathy in both eyes and macular thickening in the left eye. Optical coherence tomography of the left eye showed macular detachment with peripapillary retinoschisis and a hyporeflective tract connecting schitic retina and the deep cup in the absence of an optic disc pit. A diagnosis of glaucomatous deep cup maculopathy (DCM) was made in the left eye, which persisted despite well-controlled IOP and peripapillary laser photocoagulation. The addition of oral acetazolamide (250 mg twice daily) to his regimen resulted in prompt resolution of maculopathy. Glaucomatous DCM is relatively rare, and its primary management is adequate IOP control with antiglaucoma medications. Including oral acetazolamide in the antiglaucoma regimen can help in faster resolution of maculopathy due to its additional effect on retinal pigment epithelial pump induction and stabilization of the pressure gradient.
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A case of non-Hodgkin lymphoma diagnosed after 35-month of initial presentation as recurrent vitritis with multiple negative biopsies p. 212
Parthopratim Dutta Majumder, Mayur R Moreker, Satish V Khadilkar, Bharat Bhosale, Vikas Khetan
DOI:10.4103/ojo.ojo_198_2020  
To report a case of non-Hodgkin lymphoma (NHL) that was diagnosed 35-month of initial ocular manifestation. Retrospective chart review. A 53-year-old male presented with painless diminution of vision in both eyes. He subsequently underwent extensive laboratory investigations including multiple vitreous biopsies with a suspicion of intraocular lymphoma. Cytology from the vitreous aspirate failed to diagnose any relevant pathology. After 35-month from the onset of his ocular symptom, a brain biopsy revealed a round cell tumor suggestive of NHL. Even with high index of suspicion, consultation with ocular oncologist, imaging, and diagnostic vitrectomy, the diagnosis of lymphoma remains challenging
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Rhegmatogenous retinal detachment following femtosecond laser-assisted cataract surgery p. 215
Subhendu Kumar Boral, Deepak Agarwal, Ayan Mohanta
DOI:10.4103/ojo.ojo_308_2020  
Rhegmatogenous retinal detachment (RRD) following femtosecond laser-assisted cataract surgery (FLACS) has not been reported till date. We described the first case of RRD after FLACS. A 29-year-old male presented with complaints of sudden, painless dimness of vision in the left eye (LE) for the past 2 days. He was operated for refractive lens exchange in both eyes for high myopia using FLACS 3 months back. On examination, his LE vision was perception of light and accurate projection of rays with fundus showing bullous RRD. His right eye fundus was absolutely normal with 20/20 vision. A 25-gauge vitrectomy was performed in LE. The retina was settled with silicone oil (1300 centistokes) endotamponade. After 4 weeks, the patient gained 20/60 vision in LE with attached retina under silicone oil. RRD is a potential complication following FLACS and thus frequent follow-ups are required for high-risk patients after FLACS.
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Cluster headache associated with oculomotor nerve palsy: A case report and review of literature p. 218
Hamzeh Mohammad Alrawashdeh, Bahaa Al-Din Mustafa Jaber, Abdelrahman Alharazneh, Omar Al-Habahbeh
DOI:10.4103/ojo.ojo_32_21  
Cluster headaches are a series of short, excruciating, and unilateral pain that happens for a short period at a time over days, weeks, or months and may awake people from sleep. It is situated behind, in, or around one eye only with possible radiation to the forehead at the same side. Cluster headache is characterized by many ocular features. However, extraocular muscle involvement is unusual in this type of headache. We present a case of chronic cluster headache associated with diplopia due to oculomotor nerve palsy in a 24-year-old man, which responded successfully to oral steroid. This presentation is rare. Therefore, ophthalmologists and neurologists should consider it in their list of a differential diagnosis. A short course of oral prednisolone has a role in the management of patients in such cases.
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Childhood hypertension, sixth nerve palsy, and renal artery stenosis p. 222
Siddharth Madan, Zia Chaudhuri
DOI:10.4103/ojo.ojo_161_21  
This short report demonstrates an uncommon presentation of intracranial bleeding and sixth nerve palsy in a child with systemic hypertension due to long-standing unilateral renal artery stenosis of unknown etiology that resulted in contracture of the affected kidney and compensatory hypertrophy of the contralateral kidney. Structural renal damage and cardiac ventricular hypertrophy suggested the pathology and ensuing hypertension to be long-standing; however, renal function tests were normal at presentation. The importance of routine outpatient evaluation of systemic blood pressure in children, similar to adults, so as to diagnose and treat secondary hypertension and its causes early, before further systemic and neurological complications set in, is emphasized. The primary neuro-ophthalmological clinical presentation of the child with subsequent confluence of major pediatric domains of medicine, surgery, neurology, cardiology, nephrology, interventional radiology, and ophthalmology toward optimum multidisciplinary etiological and symptomatic management of the condition and its sequelae and subsequent rehabilitation is described.
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Dacryocystitis in a patient with Samter's triad p. 225
Ahmad Abdel-Aty, Andrew Jin, R Peter Manes, Mohammad Khan, Renelle Pointdujour-Lim
DOI:10.4103/ojo.ojo_178_21  
Samter's triad, also known as aspirin-exacerbated respiratory disease, is characterized by nasal polyposis, bronchial asthma, and aspirin intolerance. Here, we present a case of a 36-year-old woman with a history of Samter's triad and recurrent dacryocystitis. After combined dacryocystorhinostomy and endoscopic sinus surgery, pathological specimens of the lacrimal sac showed respiratory fibrosis with chronic inflammation and eosinophilic infiltration. Our case demonstrates that Samter's triad is a potential etiology for inflammatory nasolacrimal duct obstruction.
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Wolf in sheep's clothing: Primary orbital Ewing sarcoma in a child masquerading as internal angular dermoid p. 228
Teena Mariet Mendonca, Harsha Prasada Lashkari, Pooja K Suresh, Rahul Kondaveti, Faraz Ali, Gladys R Rodrigues
DOI:10.4103/ojo.ojo_180_21  
Ewing sarcoma is one of the rare, highly malignant neuroectodermal tumors frequently involving bones. Primary orbital Ewing sarcoma is extremely uncommon. We report a rare case of a 5-year-old boy who presented to us with a painless, slow-growing mass above the medial canthus of the left eye, the clinical appearance of which was masquerading as an internal angular dermoid. The child was subsequently diagnosed to have primary orbital Ewing sarcoma. Primary orbital Ewing sarcoma is a rare tumor with poor prognosis, poses diagnostic challenges, and demands a high index of clinical suspicion.
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Occult globe perforation during posterior sub-tenon injection diagnosed by ultrasound biomicroscopy p. 231
Sweksha Priya, Amitabh Kumar, Md Shahid Alam
DOI:10.4103/ojo.ojo_190_21  
Inadvertent globe perforation during posterior sub-tenon (PST) injection is rare, and the use of ultrasound biomicroscopy (UBM) in the diagnosis of occult globe perforation is not reported yet in the literature. We hereby intend to discuss the case of a 42-year-old male who presented with left eye loss of vision following PST triamcinolone acetate (TA) injection. On examination, right eye vision was 20/20 and it was 20/120 for the left eye. Fundus examination of the left eye showed a whitish fluffy mass like preretinal lesion over the macula with vitreous haze. The patient was thoroughly investigated for intermediate and posterior uveitis. However, all reports turned out to be within the normal limits. The 360° UBM scan of the left eye showed well-defined hypoechoic scleral tract suggestive of globe perforation at 2 o'clock position. The, whitish preretinal mass in the left eye was suspected to be intravitreal TA deposit following an inadvertent globe perforation during the posterior sub-tenon TA injection. UBM can be considered important diagnostic aid in ruling out possibility of occult globe perforation in certain circumstances.
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Retrospective diagnosis of COVID-19 following the detection of central retinal artery occlusion p. 234
T Lekha, Rosina Thomas, Anantharaman Giridhar, Mahesh Gopalakrishnan
DOI:10.4103/ojo.ojo_226_21  
Thromboembolic complications are being increasingly reported in patients with COVID-19 due to the associated hypercoagulability and are an important cause for morbidity and mortality. Retinal vascular occlusions especially arterial occlusions are one of the gravest ocular complications reported. This complication may occur in severe cases with cytokine storm or even in mild or asymptomatic patients and presentation can be anytime from few days to weeks after the onset of symptoms. Ophthalmologists should be aware of this new etiology when dealing with patients having features of retinal vascular occlusions and should investigate for the same in this pandemic situation. Although reverse transcriptase polymerase chain reaction is the diagnostic test for COVID-19, serological assays have a role in patients with delayed presentation. We describe the clinical features and multimodal imaging findings in a patient who presented with features of central retinal artery occlusion with cilioretinal artery sparing wherein his ophthalmic condition led to the diagnosis of previously undetected COVID-19 through serology. To the best of our knowledge, this is the first documentation of a case of isolated central retinal artery occlusion leading to a retrospective diagnosis of COVID-19.
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Management of acute hydrops with pre-Descemet's deep anterior lamellar keratoplasty p. 237
Sujatha Mohan, Madhuvanthi Mohan, Sujitha Danasekar, Sashwanthi Mohan
DOI:10.4103/ojo.ojo_317_21  
This case report describes a 23-year-old female patient who had bilateral keratoconus and a history of right eye penetrating keratoplasty who presented with acute hydrops in the left eye which did not respond to conservative management. Pre-Descemet's deep anterior lamellar keratoplasty was performed in the acute stage for management of the impending perforation with good visual outcomes.
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Localized orbital amyloidosis – A varied presentation p. 240
Akila V Ramkumar, M Muthumeena Muthumalai, Sumita Agarkar, Nirmala Subramaniam
DOI:10.4103/ojo.ojo_148_21  
Localized orbital amyloidosis is rare, usually slowly progressive and benign disorder. The most common signs and symptoms include visible periocular mass, ptosis, proptosis, globe displacement, ocular motility disturbances, recurrent periocular subcutaneous hemorrhages, and dry eyes. Herein, we report a case of localized recurrent orbital amyloidosis with strabismus, restricted eye movement, ptosis, and orbital mass as the presentation in a 60-year-old female and managed with debulking and strabismus surgery, resulting in a good cosmetic and functional outcome.
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CLINICAL IMAGES Top

Circumscribed choroidal hemangioma in a case of neurofibromatosis type 1 p. 243
Harshit Vaidya, Vikas Khetan
DOI:10.4103/ojo.ojo_369_20  
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“Out of the ashes and into the fire”- Choroidal neovascular membrane at the intersection of traumatic choroidal rupture and brittle bruch's membrane p. 245
Roshni Mohan, Divya Yadav, Sourabh Prasad Behera
DOI:10.4103/ojo.ojo_420_20  
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Multimodal imaging in central areolar choroidal dystrophy p. 247
B Poornachandra, Ram Snehith, Nikitha Reddy, Chaitra Jayadev, Santosh Gopi Krishna Gadde
DOI:10.4103/ojo.ojo_83_21  
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Pleomorphic adenomas of palpebral lobe of the lacrimal gland p. 250
Bipasha Mukherjee, Neelam Pankaj Kalbande, Olma Veena Noronha, Krishnakumar Subramanian
DOI:10.4103/ojo.ojo_231_21  
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Idiopathic intracranial hypertension sine disc edema with rare neuroimaging features of cranial nerve compression p. 252
Goura Chattannavar, Jenil Nilesh Sheth, Dandu Ravi Varma, Ramesh Kekunnaya
DOI:10.4103/ojo.ojo_244_21  
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Iodine-125 plaque brachytherapy for aggressive squamous cell carcinoma with corneal and scleral invasion p. 255
Aaron R Kaufman, Kai B Kang
DOI:10.4103/ojo.ojo_335_21  
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LETTERS TO THE EDITOR Top

Bell's palsy as a presenting feature of COVID-19 p. 258
Richa Agarwal, Mohit Agarwal, Alka Tripathi, Vijeta Bajpai
DOI:10.4103/ojo.ojo_38_21  
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Widefield examination of the fundus with the portable slit lamp p. 260
Jagdeep Singh Gandhi
DOI:10.4103/ojo.ojo_63_22  
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CLINICAL QUIZ Top

Painful red eye and blurred vision after Crohn's disease debut in a young woman p. 261
Enrique Garcia-Soler, Sara Fathi Nieto, Rodrigo Butron Ruiz
DOI:10.4103/ojo.ojo_353_21  
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