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   Table of Contents - Current issue
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September-December 2022
Volume 15 | Issue 3
Page Nos. 263-438

Online since Wednesday, November 2, 2022

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EDITORIAL  

Incontinentia pigmenti: What we know and can we manage it as retinopathy of prematurity? Highly accessed article p. 263
Nouf Al-Farsi, Aseel Al Rashdi
DOI:10.4103/ojo.ojo_287_22  
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EDITORIAL COMMENTARY Top

Accommodating children Highly accessed article p. 266
Isha Chaturvedi, Pradeep Sharma
DOI:10.4103/ojo.ojo_290_22  
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ORIGINAL ARTICLES Top

Visual outcomes and factors predictive of visual loss in Behcet's disease in Sultan Qaboos University Hospital, Oman p. 269
Nadiya Al Kharousi, Khalfan Salim Khalfan Alnaabi, Omar Almahrouqi, Washoo Mal
DOI:10.4103/ojo.ojo_68_22  
PURPOSE: This study aimed to evaluate the visual outcomes and associated factors in Omani patients with Behcet's disease (BD). METHODOLOGY: This is a descriptive retrospective analytical cohort study. All Omani patients of age 5–65 years with a confirmed clinical diagnosis of BD having ocular manifestation who attended the Rheumatology and Ophthalmology clinics at Sultan Qaboos University Hospital, Oman from January 2018 to October 2020. The demographic data, clinical findings, systemic, and ocular examination of all the recruited patients were retrieved from the electronic patient record. RESULTS: The study included 31 male and 16 female participants. The median age is 29.7 ± 10.6 years. Most patients with ocular manifestations presented in the third decade of their life (21–30 years' age). The most common ocular manifestations in our study were uveitis (91.5%) followed by vitritis (40.4%), and retinal vasculitis (36.2%). The most common ocular complications in order of frequency were cataract (27.7%), posterior synechiae (23.4%), and cystoid macular edema (21.2%). In this study, 22.7% of the patients with BD-related ocular manifestations reported severe visual loss. In addition, when adding the patients with severe visual loss secondary to complications such as secondary glaucoma and optic nerve atrophy, the severe visual loss cumulatively reported being 50% for both groups. CONCLUSION: The clinical characteristics of ocular manifestations in BD in Oman are similar to data from studies that have been conducted in other countries. However, our study found that the severity of ocular manifestations was more dominant among females. This study finding can be helpful for clinicians to predict ocular manifestations of BD to plan a timely follow-up and subsequently prevent further severe complications or visual loss.
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Accommodative esotropia: An outcome analysis from a tertiary center in Oman p. 274
OK Sreelatha, Hajar Ali Al-Marshoudi, Maha Mameesh, Sana Al Zuhaibi, Anuradha Ganesh
DOI:10.4103/ojo.ojo_80_22  
AIM: The aim of this study is to determine the outcome of accommodative esotropia (ET) and influencing factors in young Omani children. SUBJECTS AND METHODS: In this retrospective cohort, children diagnosed with accommodative ET who had followed up in a tertiary hospital from 2006 to 2011 were identified. Parameters studied included cycloplegic refraction and its change with time, ocular alignment, binocularity, visual acuity (VA), amblyopia, and requirement for surgery. RESULTS: A total of 51 patients were identified. Twenty-four patients were diagnosed with fully accommodative ET (FAET) and 27 with partially accommodative ET (PAET). The mean (± standard deviation [SD]) age of onset and reporting were 2.6 (±1.58) and 3.2 (±1.84) years in the two groups, respectively. The mean (SD) cycloplegic refraction at presentation was 4.50 (±1.66) in the FAET group and 3.65 (±1.67) in the PAET group. Anisometropia was present in 28% of patients. The mean follow-up period was 4.9 years. The following were detected in the final visit. A reduction in amblyopia from 43% to 6% of patients, binocularity in 75% of patients, and a mean increase of 0.64 (±1.3) D in cycloplegic refraction from the first visit (P = 0.005). The mean angle of deviation at near and distance was 29.86 (±15.21) and 17.80 (±10.14) prism diopters, respectively, in FAET patients and 30.15 (±14.83) and 29.53 (±15.53), respectively, in PAET patients. Thirty-seven percent of the PAET patients underwent surgery within 5 years from diagnosis. All participants in this cohort continued to wear glasses in the last follow-up visit. CONCLUSION: Most children with refractive accommodative ET have an excellent outcome in terms of VA and binocular vision. The PAET group was characterized by delayed reporting, the presence of anisometropia, and lower hypermetropia. Further study is required to determine the possibility of weaning glasses in FAET patients.
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Knowledge, attitude, and practice on digital eye strain during coronavirus disease-2019 lockdown: A comparative study p. 279
Sneha Jain, Oindrila Das, Aindrila Roy, Abhisekh Das
DOI:10.4103/ojo.ojo_135_21  
BACKGROUND: Computer vision syndrome is a group of eye and vision-related problems that result from prolonged computer use. The worldwide pandemic of coronavirus disease-2019 (COVID-19) lockdown has led to an increase in the digital screen exposure as jobs as well as academic learning have majorly shifted online. This has caused an increase in digital eye strain (DES) globally. The aims and objectives of this study were to compare the knowledge, attitude, and practices among medical and nonmedical professionals with regard to DES in a background of COVID-19 lockdown. MATERIALS AND METHODS: A cross-sectional, observational, online questionnaire-based research survey analysis was conducted among medical professionals with age- and sex-matched nonmedical professionals. Responses were collected over a week and analyzed. The level of significance was set at a P < 0.05. Statistical Package for the Social Sciences software version 23.0 was used for the result analysis. RESULTS: Our study included 353 (50.4%) medical and 347 (49.6%) nonmedical personnel. It was noted that 266 (75.4%) of medical professionals and 268 (77.2%) of nonmedical professionals experienced eye problems after prolonged digital screen exposure. A significant proportion of respondents experienced an increase in symptoms following COVID-19 lockdown with 140 (52.6%) being medical professionals and 163 (60.8%) nonmedical professionals (P = 0.015). CONCLUSIONS: DES is a preventable lifestyle-associated disorder. Awareness among the masses can reduce the adverse effects. Proper lighting, adequate viewing distance, voluntary blinking, and using lubricating eye drops are a few ways to reduce the chances of DES. Further studies are needed to formulate standardized guidelines for the management of DES.
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A study on the perception, knowledge, attitude, and practices of eye donation among fresh medical graduates in India p. 284
Roshni Robert, B Abhilash, Mahesh Babu, NA Sudhakar
DOI:10.4103/ojo.ojo_225_21  
OBJECTIVE: The objective of the study was to assess the perception, knowledge, attitude, and practices of eye donation among fresh medical graduates in India. MATERIALS AND METHODS: Responses to a semi-structured questionnaire were collected from 410 respondents using an online Google Form which were analyzed using IBM SPSS software version 21. RESULTS: First information source about eye donation was textbooks (31%), while ophthalmologists accounted for 10.7%. Forty-two respondents had pledged their eyes, 116 were willing to pledge their eyes. Majority had “adequate” knowledge (74.1%). The knowledge levels were directly related to the practice of motivation for eye donation (P = 0.032). Around 62% had “poor” eye donation practices. Significant relationship between practice and knowledge levels (P = 0.004) was noted. Participants who graduated from institutions with eye banks were more likely to have good practice (P = 0.005). CONCLUSIONS: A curriculum focusing on practical exposure to eye donation and eye banking services would address the current deficits in eye donation. Reinforcing knowledge of eye banking among non-ophthalmologist doctors can enhance the eye donation trend. Timely counseling of patients and bystanders by well-informed sensitized doctors is hence of utmost importance.
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Accuracy of Barrett versus third-generation intraocular lens formula across all axial lengths p. 290
Raline Solomon, S Tamilarasi, Gitansha Sachdev, Ramamurthy Dandapani
DOI:10.4103/ojo.ojo_188_21  
PURPOSE: The purpose of this study is to evaluate and compare the accuracy of Barrett Universal II versus third-generation formula for different intraocular lens (IOL) powers for Indian eyes with different axial lengths (ALs). DESIGN: This is a retrospective, nonrandomized consecutive case series. METHODS: This study reviewed 981 eyes from 825 patients who had uneventful cataract surgery and IOL implantation. The eyes were separated into subgroups based on AL as follows: short (<22.0 mm), medium (22.01–23.99 mm), and long (>24.0 mm). The predicted refractive outcome using formulas was calculated and compared with the actual refractive outcome to give the prediction error. The percentage of every refractive error absolute value for each formula was calculated at <±0.50D, 0.50D-0.75D, and >±0.75D. RESULTS: In all, 981 eyes were analyzed. There were no significant differences in the median absolute error predicted by Barrett and the third-generation formulae. The Barrett Universal II formula resulted in significantly lowest mean spherical equivalent in short eyes (P = 0.0047) as well as a higher percentage of eyes with prediction errors within <±0.50D, 0.50D-0.75D, and >±0.75D. We found that the Barrett Universal II formula had the lowest predictive refraction error and mean absolute error across all ALs. CONCLUSION: The Barrett Universal II formula rendered the lowest predictive error compared with SRK/T, Holladay, and Hoffer Q formulas. Thus, the Barrett Universal II formula may be regarded as a more reliable formula for achieving emmetropia and reducing postoperative refractive surprises across all ALs.
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Pattern of astigmatism using partial coherence interferometry in patients of different age groups undergoing cataract surgery p. 295
Sumedha Vats, Lalitha Kumari, Ranjit Goenka, Mohini Agrawal, Sanjay Mishra
DOI:10.4103/ojo.ojo_345_21  
BACKGROUND: Astigmatism is a refractive error that accounts for 70% of refractive errors in the elderly population. It is important to be aware of the distribution, extent, and type of astigmatism in patients undergoing cataract surgery to guide in reducing postoperative spectacle dependency. AIM: To study the demography, amount, and pattern of astigmatism using partial coherence interferometry in patients of different age groups undergoing cataract surgery. MATERIALS AND METHODS: A cross-sectional observational study. Keratometry and demography data were collected for patients planned for cataract surgery at a tertiary care center between January 2018 and December 2019. It was done with noncontact partial coherence interferometry in patients above 50 years undergoing cataract surgery. RESULTS: Out of 385 patients, 216 (56%) were males and 169 (44%) were females. Astigmatism was more common in males than females (P = 0.00). Against-the-rule (ATR) astigmatism was found in 262 cases (68%), while with-the-rule (WTR) astigmatism was seen in 87 cases (23%). ATR was more common than WTR (P = 0.00). The number of patients with ATR seems to be increased with aging eyes and was more common between 61 and 70 years of age group (P = 0.00). The total amount of astigmatism increased with increasing age (P = 0.00029) which was found to be significant. Frthermore, there was a gradual change of WTR to ATR astigmatism with aging eyes. CONCLUSION: Two hundred and sixty-two cases (68%) had ATR astigmatism mainly seen in the age group of 61–70 years. Majority had astigmatism up to 1.0 D that can be easily managed by simple cost-effective keratorefractive procedures like on-axis incision, opposite clear corneal incision, and limbal relaxing incisions.
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Ocular hypertension and its predictor after a single Ozurdex implant: One-year follow-up in Asian Indian eyes p. 299
Tarannum Mansoori, Swathi Shiva, Nagalla Balakrishna
DOI:10.4103/ojo.ojo_326_21  
BACKGROUND: To determine the incidence and risk factors for an increase in the intraocular pressure (IOP) after a single dexamethasone intravitreal implant (Ozurdex). MATERIALS AND METHODS: Medical records of 41 consecutive eyes who had received a single 0.7 mg Ozurdex implant for the various vitreoretinal pathology, between March 2015 and April 2016 were reviewed retrospectively. Ocular hypertension (OHT) was defined as IOP of >22 mmHg or an increase in the IOP of >6 mmHg from the baseline. Univariate regression analysis was used to measure the predictor of OHT after the implant. RESULTS: Among the 41 eyes, who received a single Ozurdex intravitreal implant, 6/41 (14.6%) of the injected eyes had OHT, with the peak of IOP at 1 month after the injection when compared with the baseline IOP. Eight eyes (19.5%) had preexisting glaucoma or OHT, and 4/8 (50%) of them developed sustained elevation of IOP after the injection. Two eyes had transient OHT, a day after the implant, which did not require any treatment. All the eyes were managed with topical antiglaucoma medications and none required surgery to control the IOP. Preexisting OHT or glaucoma was found to be a significant risk factor for OHT after the Ozurdex injection (P < 0.0001). CONCLUSION: Patients with preexisting OHT or glaucoma have an increased risk of OHT following the Ozurdex implant and hence needs to be informed of the possible risk. Follow-up at a regular interval is mandatory to monitor and recognize OHT early and treat it appropriately.
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Year 1 of COVID-19 pandemic in India: Effect of lockdown and unlock on the presentation of patients with ocular and periocular tumors at a referral center p. 304
Anthony Vipin Das, Swathi Kaliki
DOI:10.4103/ojo.ojo_273_21  
PURPOSE: The purpose of the study is to describe the impact of lockdown and unlock phases of the COVID-19 pandemic on the presentation of ocular and periocular tumors at a referral center in India. MATERIALS AND METHODS: This cross-sectional, hospital-based study included 5811 patients presenting between March 25, 2017, and March 31, 2021. The data on the patients diagnosed with ocular and periocular tumors in one or both eyes presenting during the lockdown and unlock phases were compared with the respective time periods in the previous 3 years before COVID-19. RESULTS: The patient numbers dropped by 85% (45/295) of pre-COVID-19 volumes during the lockdown phase. This was mainly because of a 33% reduction in patients requiring inter-state travel. There was complete recovery of the outpatient numbers to 105% (139/132) of pre-COVID-19 volumes by March 2021. This gradual incremental trend was seen in patients with malignant tumors (145%) and was lower in those with benign tumors (89%) than pre-COVID-19 volumes by March 2021. There was an increase in the patients presenting with malignant tumors (49%; P = 0.45) during the lockdown phase. The proportion of patients requiring inter-state travel showed a near-complete recovery to 88% of pre-COVID-19 distribution by March 2021. CONCLUSION: The 1st year of the COVID-19 pandemic saw a significant decline in the number of patients presenting with ocular and periocular tumors. There was an increase in the proportion of malignant tumors and a decrease in benign tumors during the lockdown phase. During unlock period, there was a near-complete recovery in the patients requiring inter-state travel to access eye care services.
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An unusual rise in cases of assault in ophthalmic practice during COVID-19 lockdown in a tertiary care hospital p. 309
Erum Shahid, Uzma Fasih, Uzma Taqi, Asad Raza Jafri
DOI:10.4103/ojo.ojo_323_21  
OBJECTIVE: The objective of the study is to report an unusual rise in cases of assault with ocular injury and their medicolegal implications presenting in an eye department of a tertiary care hospital during COVID-19 lockdown. MATERIALS AND METHODS: A retrospective, observational case series was conducted in the Department of Ophthalmology, Abbasi Shaheed Hospital, Karachi. Data were retrieved from the medicolegal records of the patients from April 1, 2019, to July 31, 2019, and similar months in 2020. We included all the patients of assault with ocular injury as alleged, registered as medicolegal cases. Patients with accidental injuries were excluded from the study. RESULTS: There was 34.3% increase in cases of assault with ocular injury as alleged with 72.35% reduction in the outpatient department patients. The ratio of cases of assault in 2019 and 2020 is 1:4.62. The mean age of the patients in the lockdown year was 33.74 ± 11.9 standard deviation (SD) and in preCOVID year 2019 was 39.74 ± 15.9 SD. Blunt trauma was experienced by 57 (66.3%) and penetrating injury in 2 (2.3%) patients. Sixteen (18.6%) patients had no ocular involvement. Home was the place of assault in 32 (37.2%) and street in 27 (31.4%) individuals. Fist was the source of assault in 46 (53.3%) and rod or stick in 15 (17.4%) individuals. CONCLUSION: There is a fourfold increase in patients of assault during 4 months of COVID-19 lockdown in 2020 as compared to the same time period in 2019. Most of these patients were young age, male gender, and uneducated. The most common place of incident was home, and fist was the most common source of infliction. Most of the injuries were superficial and had minimum effect on visual acuity.
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Comparison of IOP obtained in different kind of eyes with contact and no contact tonometers p. 315
Sandro Sbordone, Adele Ragucci, Gennarfrancesco Iaccarino, Gabriele Scognamiglio, Angelo Leone, Ugo Antonello Gironi Carnevale, Michele Lanza
DOI:10.4103/ojo.ojo_147_21  
BACKGROUND: The aim of this study is to analyze and compare the intraocular pressure (IOP) values measured in three different kinds of participants such as healthy subjects (HS), keratoconus patients (KP), and those who underwent myopic photorefractive keratectomy (MPRK). The devices used in this study are the Goldmann Applanation Tonometry (GAT), the dynamic contour tonometry (DCT), the ocular response analyzer (ORA), and the Corvis ST (CST). SUBJECTS AND METHODS: This research included 92 eyes of 92 h, 63 eyes of 63 KP, and 58 eyes of 58 MPRKM. Each participant underwent a complete ophthalmic evaluation and IOP measurement with GAT, DCT, ORA, and CST. A statistical analysis was conducted to detect possible differences and correlations. RESULTS: First, according to the observed data, HS eyes displayed mean IOP values measured with GAT, DCT, ORA, and CST, respectively, 15.82 ± 2.74 mmHg, 17.63 ± 2.28 mmHg, 16.24 ± 3.14 mmHg, and 17.31 ± 3.21 mmHg. Then, KP eyes showed mean IOP values measured with GAT, DCT, ORA, and CST of, respectively, 14.89 ± 1.64 mmHg, 16.97 ± 2.08 mmHg, 13.09 ± 3.12 mmHg, and 13.78 ± 2.11 mmHg. Finally, MPRK eyes showed mean IOP values measured with GAT, DCT, ORA, and CST of, respectively, 13.92 ± 1.34 mmHg, 15.39 ± 2.86 mmHg, 16.63 ± 2.51 mmHg, and 15.06 ± 1.56 mmHg. CONCLUSION: According to the observed data, ORA and GAT might be used interchangeably in HS, whereas GAT, ORA, and CST in KP eyes. Moreover, it has been noticed that in those eyes that previously undergone a myopic PRK, GAT provided lower values of IOP in comparison with other devices.
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A cross-sectional study on the complications of inferotemporal laser peripheral iridotomy p. 321
Manoj Prathapan, Shreeya Pareshbhai Rughani, Praveena Shyam, Kannisha Nainesh Shah, H Sujithra, Gopal S Pillai
DOI:10.4103/ojo.ojo_8_21  
PURPOSE: The purpose of this study was to identify the incidence of dysphotopsia and other associated complications after inferotemporal laser peripheral iridotomy (IT-LPI). METHODS: This is a cross-sectional study on patients who underwent IT-LPI with neodymium: yttrium–aluminum–garnet laser who were followed up for a minimum of 3 months. RESULTS: In our study, out of a total of 116 patients, new-onset dysphotopsia was reported in 6.03% and significant pain during the procedure in 12.93% of patients. Other complications noticed were photophobia in 29.31% (34/116), rise in intraocular pressure at the end of 3 months in 1.72%, pigment dispersion in 0.86%, epiretinal membrane formation in 04.31%, and cystoid macular edema in 1.72%. No patients had hyphema or diplopia. CONCLUSIONS: The incidence of dysphotopsia following IT-LPI was relatively low in our study and was comparable to the superior PI under full lid cover from the literature. Although dysphotopsia rates were not superior, no patient developed hyphema, which could be due to the remoteness of the laser spot to the larger blood vessels located at 3 and 9 o'clock positions. Furthermore, the procedure was well tolerated as significant pain was reported by only less than a quarter of the patients. Hence, IT-LPI can be considered an easy to perform, safe, and comfortable procedure for the patient.
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Twelve month outcome of manual small-incision cataract surgery in Assiut, Egypt: A retrospective study with a large sample size p. 326
Mohamed Shehata, Mohamed Omar M. Aly, Mohamed Gamal A. Saleh, Mahmoud Abdel-Radi
DOI:10.4103/ojo.ojo_1_22  
BACKGROUND: To assess the visual outcome of manual small-incision cataract surgery (MSICS) as well as safety, cost, and time of the procedure. PATIENTS AND METHODS: A retrospective study involving candidates for cataract surgery with baseline-corrected distance visual acuity (CDVA) ≤20/120. Visual acuity (VA) was the primary outcome measure while surgical complications, cost, and time of surgery were the secondary outcome measures. Follow-up visits were scheduled at 1 day, 1 week, 1 month, and at 6 and 12 months following surgery. RESULTS: The study enrolled 3007 patients with a mean age of 66.45 ± 17.3 years. Out of 3007 patients, 2774 (92.2%) were legally blind before surgery (CDVA <20/200) which was significantly reduced to 55 patients (1.9%) by 1 month following surgery. Uncorrected distance visual acuity was 20/60 or better in 2098 eyes (69.8%) at 1 month, in 2035 eyes (67.7%) at 6 months, and in 2017 eyes (67.1%) at 12 months. The posterior capsular rupture was the most common intraoperative complication. Corneal edema was the most common immediate postoperative complication while the development of posterior capsular opacification was the leading cause for later impaired VA. The mean cost was approximately equivalent to 20 US dollars. The median duration of surgery was 10 min. CONCLUSION: MSICS is a safe, cost-effective, and time-saving technique for improving the vision of cataract patients in areas with high cataract surgery volume and limited facilities.
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Refractive outcomes following yttrium aluminum garnet laser (532 nm green laser) in severe retinopathy of prematurity p. 331
Ajax Jossy, Nirupama Kasturi, Swapnil Parchand Madhukar, K Ramesh Babu, Salin Elias
DOI:10.4103/ojo.ojo_315_21  
PURPOSE: To assess the refractive outcomes in eyes with severe Retinopathy of prematurity (ROP) after treatment with the frequency-doubled neodymium-doped yttrium aluminum garnet (Nd-YAG) laser 532 nm (green laser) at 1–2 years of age and compare with eyes that underwent spontaneous regression of ROP and to identify the risk factors associated with the refractive outcomes in laser-treated eyes with severe ROP. METHODOLOGY: Infants who underwent laser treatment with green laser were enrolled in Group 1 and those who had spontaneous regression of ROP were enrolled in Group 2. All these children underwent a visual assessment, refraction using 1% cyclopentolate eye drops and indirect ophthalmoscopy at 1–2 years of age. Data regarding the gestational age, sex, birth weight, inborn (born in our institution) or outborn (born outside and referred to us), stage and zone of ROP and laser spots given were obtained from the treatment records. Data were analyzed using SSPS 19.0 software for Windows (SSPS Inc., Chicago, Illinois, USA). RESULTS: A total of 102 infants were enrolled, 51 in each group. Visual acuity ranged from 0.25–1 cycles per cm in both groups. Spherical equivalent (SE) ranged from − 8.25 D to + 5.50 D in Group 1 and −1.00D to +4.00D in Group 2. Group 1 had an incidence of 23.5% Myopia and 33.4% Astigmatism which was significantly more than Group 2. The linear regression model predicted a decrease in the SE by 0.658D if the number of laser spots increased by 1000 (P < 0.001). No other risk factors (gestational age/birth weight) were found to have a significant association with refractive errors in the lasered ROP group. CONCLUSIONS: Eyes with laser-treated severe ROP are frequently associated with myopia and astigmatism when compared to spontaneously regressed ROP. The number of laser spots delivered has a direct association with the amount of refractive error.
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Outcomes of Descemet stripping endothelial keratoplasty in cases of corneal endothelial dysfunction p. 337
Dubbaka Srujana, Nabaratna Bista, Mohini Agrawal
DOI:10.4103/ojo.ojo_130_21  
BACKGROUND: Automated microkeratome is commonly used to get donor lenticules for Descemet stripping endothelial keratoplasty (DSEK); however, manual dissection of donor lenticules is also being done with good outcomes. AIM: The aim of this study was to describe the results of manual DSEK performed in cases of corneal endothelial dysfunction caused due to pseudophakic bullous keratopathy, iridocorneal endothelial syndrome, and postpenetrating keratoplasty graft failure. MATERIALS AND METHODS: This was a retrospective observational study. The medical records of all patients with corneal decompensation who underwent DSEK at a tertiary care center performed by the same surgeon were reviewed. A standard DSEK with manually dissected donor lenticules was performed in all cases with the exception of the Descemet membrane not being removed in two cases. A comprehensive ophthalmic examination was performed preoperatively and at each postoperative visit in all patients. RESULTS: Eight eyes of seven patients (four males and three females) were included. The mean age was 64.8 years (range, 49–74 years). The average follow-up was 10.9 months (range, 5–22 months). There was one case of primary graft failure which was managed by repeat DSEK. In the rest, corneas remained clear at the last follow-up. No rebubbling was done as none of the cases showed graft detachment. The preoperative best-corrected visual acuity (BCVA) was 20/2000 or less, and postoperatively, BCVA attained was 20/30 in four eyes and one eye achieved 20/80. CONCLUSIONS: Manual DSEK performed in eyes with corneal decompensation allowed rapid restoration of corneal clarity while minimizing intraoperative and postoperative complications.
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Evaluation of macular perfusion in eyes with proliferative diabetic retinopathy using optical coherence tomography - Angiography following panretinal photocoagulation p. 342
Shraddha Shah, Anusha Venkataraman, Abhishek Appaji, Mahalingam Prabhushanker, Geetha Ganesan
DOI:10.4103/ojo.ojo_191_21  
AIM: The aim of this study is to evaluate the effect of panretinal photocoagulation (PRP) on macular perfusion using optical coherence tomography–angiography (OCT-A) in eyes with proliferative diabetic retinopathy (PDR) by assessing the vessel density (VD) and the size of the foveal avascular zone (FAZ) of the superficial capillary plexus (SCP) and the deep capillary plexus (DCP), before and after PRP. SETTINGS AND DESIGN: Prospective interventional study. SUBJECTS AND METHODS: Twenty-nine eyes of 17 patients with PDR underwent a measurement of best-corrected visual acuity (BCVA) and were imaged using OCT and OCT-A at baseline and 6-months of follow-up. Patients received three sittings of PRP using frequency-doubled neodymium-doped yttrium aluminum garnet laser. STATISTICAL ANALYSIS USED: The OCT-A variables were analyzed using generalized estimating equations. RESULTS: BCVA was unchanged at 6-months follow-up (P = 0.09). FAZ of SCP and DCP (P = 0.28 and 0.89, respectively), VD at foveal SCP (P = 0.08), foveal DCP (P = 0.05), parafoveal SCP (P = 0.13), and parafoveal DCP (P = 0.07) showed no statistically significant difference at 6 months post PRP. CONCLUSIONS: OCT-A parameters were not significantly affected by PRP at 6-months follow-up indicating no alteration in macular perfusion. Further analyses with larger samples and longer duration are warranted to confirm our results.
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Mitigation of photoreceptors abnormalities after low-level laser therapy and chia seeds supplementation in experimental diabetic retinopathy p. 347
Abdel Rahman Hassan Mahmoud, Salwa Ahmed Abdelkawi, Dina Fouad Ghoneim, Aziza Ahmed Hassan, Mona Ebrahim Morsy
DOI:10.4103/ojo.ojo_251_21  
BACKGROUND: This study aimed to assess the effect of low-level laser therapy (LLLT) and chia seeds on the mitigation of photoreceptors abnormalities in experimental diabetic retinopathy (DR). MATERIALS AND METHODS: A total of 65 female Wistar rats, 5 rats were served as a control group and 60 rats were injected intraperitoneally with one dose of 55 mg/kg of streptozotocin (STZ) to induce DR after 6–8 weeks. The rats were divided into (n = 20 rats each): (a) DR group: did not receive any treatment, (b) DR+ LLLT group was exposed to 670-nm LLLT for 6 weeks (two sessions/week), and (c) DR+ LLLT+ chia seed group, in which rats were exposed to LLLT and administrated with 250 mg/kg/day of chia seeds flour for 2 weeks before STZ injection and continued to the end of the experiment. Blood glucose (BG) levels and retinal histological examination were employed after 1, 2, 4, and 6 weeks. RESULTS: The BG level in the DR group and the treated groups were significantly higher (P < 0.001) than in the control group after the four-time periods. Chia seeds group exhibited BG levels less than the DR and the DR+ LLLT groups after 6 weeks (P < 0.01). LLLT improved the degeneration of the photoreceptors after 6 weeks of treatment, while LLLT+ chia seeds supplementation showed early photoreceptors improvement after 2 weeks. CONCLUSION: The early improvement in the photoreceptors after LLLT+ chia seed may be attributed to the potent antioxidant properties of chia seeds. Therefore, the combination between LLLT and chia seeds should be employed to protect the retinal photoreceptors against DR.
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CASE SERIES Top

Uveitis masquerade syndromes: A case series p. 353
Sudha K Ganesh, Arshee S Ahmed
DOI:10.4103/ojo.ojo_169_21  
The aim of this series is to report challenges faced in diagnosis of three cases of recurrent or atypical uveitis not responding to conventional treatment. A high index of suspicion, aided by newer techniques, such as cytology, immunohistochemistry, flow cytometry of ocular fluids, and contrast-enhanced magnetic resonance imaging, may be necessary for a prompt diagnosis of uveitis masquerade syndromes.
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CASE REPORTS Top

Bilateral serous retinal detachment: An initial presentation of mixed phenotype acute leukemia in an adult p. 356
Khulood Al Kalbani, Ahmed Al Hinai, Aisha Al Busaidi
DOI:10.4103/ojo.ojo_93_22  
A 60-year-old female presented with acute onset painless loss of vision in both eyes. Clinical examination and ocular investigations revealed bilateral serous retinal detachments (SRDs) over the macula. There was no obvious intraocular or extraocular cause to the presentation. A blood count showed leukocytosis with the presence of blast cells on the peripheral smear. Further workup confirmed the diagnosis of Philadelphia chromosome-positive mixed phenotype acute leukemia with central nervous system disease stage three. Anatomic improvement in the SRD followed intensive intravenous and intrathecal chemotherapy. Limited functional improvement was attributed to the development of pigment epitheliopathy manifesting as leopard spot chorioretinopathy. This permanent disturbance could be attributed to leukemic infiltration and ischemia to the choroid.
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Presumed herpes simplex virus ulcerative nodular episcleritis treated by topical acyclovir alone p. 360
Abhishek Hoshing, Atul Seth, Abhay Subramaniam
DOI:10.4103/ojo.ojo_138_21  
A 7-year-old female child was referred to the cornea clinic with a painless, ulcerated, and inflamed nodule near the limbus which did not respond to 1-week antibiotic therapy and worsened on starting topical steroids. Clinical examination showed ulcerative nodular episcleritis and raised a suspicion of herpes simplex virus etiology. The patient responded well and resolved completely on topical antiviral therapy alone.
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Persistent hyperplastic primary vitreous in a child with incontinentia pigmenti and infantile spasms p. 363
Siddharth Madan, Zia Chaudhuri
DOI:10.4103/ojo.ojo_194_21  
Incontinentia pigmenti (IP) is a rare neurocutaneous syndrome of X-linked dominant inheritance (1:40000 births in the Caucasian population) which is usually lethal in males. It commonly presents with skin, central nervous system, and dental anomalies. Ophthalmic associations of IP include intra-ocular anomalies such as leukocoria, megalocornea, corneal edema, band keratopathy, bullous keratopathy, iridocorneal attachments, macular capillary dropout, peripheral arteriovenous shunts, retinal neovascularization, vitreous hemorrhage, preretinal fibrosis, traction retinal detachment as well as strabismus. We report an 18-month-old developmentally delayed female child with diagnosed IP and infantile spasms conforming to the west syndrome triad, who presented with left eye microphthalmia and persistent hyperplastic primary vitreous and discuss this rare ophthalmic presentation.
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Intractable hiccups, nausea, and vomiting, an unnerving cause of vision loss p. 366
Shanmugam Mahesh Kumar, Vaishali Venkatraman, Akkayasamy Kowsalya, Jayasri Narayanamoorthy, Marappan Jayasudha
DOI:10.4103/ojo.ojo_65_21  
Acute optic neuritis (ON) is caused by variety of complex disorders that can be differentiated with the help of history, radiology, and serology. Identification of nonneurological symptoms that occur before the demyelinating event aids in timely diagnosis and prevention of further neurological attacks. We describe a case of unilateral ON with a history of intractable hiccups, nausea, and vomiting, wherein the possibility of area postrema syndrome (APS) was overlooked until the development of visual symptoms. APS recently identified as a hallmark of neuromyelitis optica spectrum disorder is a rare neurologic cause of gastrointestinal symptoms. This atypical presentation of APS results from autoantibodies directed against the aquaporin-4 rich sites, such as area postrema. This case brings to light the importance of eliciting history of intractable hiccups, nausea, and vomiting in a patient with ON. Despite being a commonly encountered symptom, it may rarely raise a suspicion for neuromyelitis optica.
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Masson's tumor of the ocular surface – A rare clinical entity p. 370
Marian Pauly, R Sruthi, Krishnakumar Subramanian, Anantharaman Giridhar
DOI:10.4103/ojo.ojo_162_21  
Masson's tumor or intravascular papillary endothelial hyperplasia (IPEH) is a benign vascular lesion usually involving the head-and-neck region. On histopathological examination, it consists of reactive proliferation of endothelial cells with papillary formations which is the key to diagnosis. This rare entity was first described in 1923 by Pierre Masson. Lesions involving orbit and eyelids have been reported before. Here, we report a case of Masson's tumor which occurred in the lid margin and later in the conjunctiva which regressed completely after excision.
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Evolution and successful management of a large postvitrectomy macular hole p. 373
Dhananjay Shukla, Jay Kalliath
DOI:10.4103/ojo.ojo_250_21  
We report the successful closure of a large postvitrectomy macular hole by temporal extension of internal limiting membrane (ILM) peeling. A 25-year-old man underwent pars plana vitrectomy, ILM peeling, and perfluoropropane gas tamponade for optic pit with chronic macular schisis and outer lamellar hole. The macular schisis deroofed into a large, full-thickness macular hole postoperatively. Optical coherence tomography revealed the horizontally oval shape of the secondary macular hole (658 × 824 μ). The best-corrected visual acuity (BCVA) was 20/200. Since ILM had already been peeled and the macular hole was widest horizontally, we combined a repeat gas tamponade with temporal extension of the ILM rhexis. Closure of the large macular hole with no central defect was observed and documented after the gas fill of the vitreous cavity was reduced sufficiently. BCVA remained unchanged for the initial months but gradually improved to 20/63 by the final follow-up visit at 5 years. A simple horizontal extension of ILM peel – in line with the shape of the hole – with repeat gas tamponade successfully closed a large secondary macular hole with progressive visual improvement.
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Suprachoroidal hemorrhage postintracameral bevacizumab injection: An unusual case report and review of literature p. 376
Karthikeyan Mahalingam, Dewang Angmo, Swechya Madhukar Neupane, Shorya Vardhan Azad
DOI:10.4103/ojo.ojo_256_21  
Suprachoroidal hemorrhage (SCH) is a dreaded complication of intraocular surgery. We report a case of a 65-year-old male with left eye primary angle-closure glaucoma and idiopathic elevated episcleral venous pressure with neovascularization of the iris. Due to uncontrolled intraocular pressure even after maximum medical therapy, trabeculectomy with mitomycin C was planned. Preoperative intracameral bevacizumab was given to avoid intraoperative bleeding. Postinjection, localized SCH was noted, which settled spontaneously on conservative management. A combination of ocular and systemic risk factors, such as arteriosclerosis and idiopathic elevated episcleral venous pressure accentuated by intraoperative hypotony during intracameral injection, led to SCH. There are no previous reports of a localized SCH following intracameral bevacizumab.
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Cladosporium spp. endogenous endophthalmitis simulating the classic “headlight-in-the-fog” appearance of active toxoplasmosis p. 379
Abbas Abd Hamid, Amelia Lim Lay Suan, Hanizasurana Hashim, Zabri Kamarudin, Julieana Muhammed
DOI:10.4103/ojo.ojo_459_20  
Endogenous fungal endophthalmitis caused by an unusual fungus poses both diagnostic and therapeutic challenges. We report a case of endogenous endophthalmitis caused by a rare mold, namely Cladosporium spp., which presented with a foveal abscess. A 52-year-old male patient who was diagnosed with rectal carcinoma presented with pain, redness, and a loss of vision in the right eye. He had been experiencing the symptoms for 1 week. The patient had undergone gastrointestinal surgery 2 weeks before experiencing the eye complaint. His best-corrected visual acuity was hand movements. Fundus examination revealed a foveal abscess of around a half-disc diameter in size that simulated retinochoroiditis with vitritis. Optical coherence tomography of the macula revealed a hyperreflective lesion in the fovea, which breached the full thickness of the fovea and extended into the preretinal space. Ocular toxoplasmosis was considered. On that basis, oral trimethoprim/sulfamethoxazole was given for 1 week, although the patient's condition worsened. A vitreous tap and an intravitreal combination of vancomycin, ceftazidime, and amphotericin B were administered twice but did not improve the patient's condition. Pars plana vitrectomy was performed and the vitreous biopsy results revealed the presence of Cladosporium spp. Intravitreal voriconazole was given three times and the foveal abscess resolved into a scar. Endophthalmitis caused by Cladosporium spp. is uncommon and published case reports are extremely limited. The present case may provide insight into the variable presentation of fungal endophthalmitis and, therefore, assist with the early diagnosis and appropriate management of the condition.
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Advanced Coats' disease: Treating the effect before the cause p. 382
Dhananjay Shukla
DOI:10.4103/ojo.ojo_249_21  
An 8-year-old child with Stage 3A Coats' disease and severe submacular lipid exudation was initially treated with intravitreal injections of bevacizumab followed by triamcinolone. The exudative retinal detachment was then treated by scleral buckling, cryotherapy of persistent telangiectasia, and subretinal fluid drainage. The residual telangiectasia on the reattached retina was finally ablated by photocoagulation. The patient had a near-total resolution of submacular hard exudates without macular fibrosis. The peripheral telangiectasia and exudative detachment also regressed, with the sustained recovery of excellent visual acuity.
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An association between bilateral keratoconus in a patient with spondyloocular syndrome and xylosyltransferase II gene mutation p. 385
Sara Fathi-Nieto, Rodrigo Butrón-Ruiz, Enrique García-Soler, Ana Hervás-Ontiveros, Amparo Ortiz-Seller
DOI:10.4103/ojo.ojo_201_21  
Spondyloocular syndrome (SOS) is a rare autosomal-recessive disorder. Since 2015, SOS has been linked to mutations in xylosyltransferase II (XYLT2) locus. Phenotypic features could affect multiple systems, such as sight, hearing, or bones. Herein, we report a case of SOS with multiple bone fractures without trauma, bilateral cataracts, and sensorineural hearing loss. Mutations in XYLT2 gene were detected, and the diagnosis of SOS was made. At the age of 8, the patient presented with progressive vision loss. Slit-lamp examination revealed inferior steepening, apical scarring, and thinning of the cornea. Due to keratoconus suspicion, a corneal tomography was done, confirming the diagnosis of keratoconus. We present the first case of bilateral keratoconus in a patient with SOS.
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A new pattern of bilateral cataracts associated with hypocalcemia secondary to uncontrolled hypoparathyroidism p. 389
Reza Jafari, Mahsa Kamali, Marzieh Movahedi Rad
DOI:10.4103/ojo.ojo_238_21  
Hypoparathyroidism is a disorder characterized by hypocalcemia. Premature cataract is one of the signs of hypoparathyroidism, but it is very rare. The present text is a case report of a rare case of a new pattern of bilateral cataracts associated with hypocalcemia secondary to uncontrolled hypoparathyroidism. The patient is a 30-year-old male with a chief complaint of progressive, painless vision loss and tearing in both eyes and photophobia in the left eye for the past 10 months and paresthesia, muscle spasms, and tingling for 2 years before referral. He had a history of hypoparathyroidism disorder that was undertreated with medication. Central posterior subcapsular cataract in both the eyes had been diagnosed. He underwent cataract surgery of the left eye under topical anesthesia. The visual acuity improved from 20/40 to 20/20 postoperatively, and the patient did not have any visual symptoms. This case is the first report of cataract with feathery opacity pattern reported with high-quality imaging from a patient. This feathery opacity pattern may explain the difference in the morphology of this patient's cataracts from others.
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Intraretinal and subretinal fluid in exudative nonproliferative macular telangiectasia type 2 p. 393
George J Manayath, Rohan Suresh Ninan, Shishir Verghese, Venkatapathy Narendran
DOI:10.4103/ojo.ojo_4_22  
A 62-year-old man presented with complaints of decreased vision in BE. His best-corrected visual acuity (BCVA) was 6/12 in both eyes (BE). Based on his fundus examination and imaging findings, he was diagnosed with BE Macular Telangiectasia type 2 (MacTel 2) and was advised of regular follow-up. Over the course of follow-up, he developed further reduction in vision in the right eye (RE) to 6/24. Spectral-domain optical coherence tomography (SD-OCT) showed the presence of a subfoveal detachment (SFD) with intraretinal cystoid edema. He was diagnosed to have an exudative variant of preproliferative MacTel 2 and underwent three intravitreal injections of bevacizumab in the RE following which there was an improvement in BCVA to 6/12 along with the complete resolution of SFD and IRF on SD-OCT. This report describes a rare case of exudative nonproliferative macular telangiectasia type 2 presenting with the presence of intraretinal fluid.
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Optic neuritis secondary to the Pfizer-BioNTech-162b2 COVID-19 vaccine managed with plasmapheresis: A case report and review Highly accessed article p. 397
Paras P Shah, Samuel Gelnick, Daniel Zhu, Amanda Wong, Rashmi Verma
DOI:10.4103/ojo.ojo_354_21  
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Accommodative insufficiency in post-COVID-19 case with refractive error p. 403
Sultan H Alrashidi
DOI:10.4103/ojo.ojo_19_22  
The aim of the case report is to present refractive error with accommodative insufficiency as a possible postinfectious manifestation of coronavirus disease-2019 (COVID-19). Three weeks after the COVID-19 infection, a 22-year-old subject presented with blurring of distance and near vision with a frontal headache after prolonged near work. The patient was not using any refractive correction before the COVID-19 infection. This case report describes the diagnosis, management, and treatment of accommodative dysfunction in a patient with a history of COVID-19 infection.
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CLINICAL IMAGES Top

Eye gangrene following traumatic enucleation p. 407
Amin Zand
DOI:10.4103/ojo.ojo_100_21  
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Fulminant idiopathic intracranial hypertension p. 409
Rimpi Rana, Siddharth Patel, Raghavendra R Mareguddi, Devesh Kumawat
DOI:10.4103/ojo.ojo_447_20  
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Trapped pearls in the eye p. 411
Pooja Bansal, Maninder Singh, Meenakshi Thakar
DOI:10.4103/ojo.ojo_174_21  
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Acute anterior uveitis with hyphema in ankylosing spondylitis p. 413
Hitesh R Sharma, Jaydeep Avinash Walinjkar, Natarajan Sundaram, Parthopratim Dutta Majumder
DOI:10.4103/ojo.ojo_239_21  
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Persistent pupillary membrane masquerading as a foreign body p. 415
Shikha Gupta, Karthikeyan Mahalingam, Abhishek Singh, Viney Gupta
DOI:10.4103/ojo.ojo_320_21  
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Nairobi eye – “Wake and see” disease p. 417
Anusuya Sadhasivamohan, Vijayasankar Palaniappan, Kaliaperumal Karthikeyan
DOI:10.4103/ojo.ojo_145_21  
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A sporadic case of orbital grease gun granuloma p. 419
Rutuja Malekar, Kirthi Koka
DOI:10.4103/ojo.ojo_150_21  
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Incidental rare intraocular foreign body discovered after penetrating injury 30 years ago p. 421
Shamus Butt, Mohamed El-Ashry
DOI:10.4103/ojo.ojo_237_21  
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Benign fleck retina p. 423
Sashwanthi Mohan, Sujatha Mohan, Mohan Rajan
DOI:10.4103/ojo.ojo_262_21  
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Optic Nerve head melanocytoma: Role of multimodal imaging p. 425
Sheetal Bajirao Kale, Priyanka Walvekar, Virender Sachdeva
DOI:10.4103/ojo.ojo_75_22  
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Doughnut-Shaped Congenital Cataract p. 427
Zahra Farzinvash
DOI:10.4103/ojo.ojo_416_20  
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LETTERS TO THE EDITOR Top

Bee sting-induced central retinal artery occlusion: A new manifestation of Kounis syndrome? p. 429
Nicholas G Kounis, Virginia Mplani, Ioanna Koniari
DOI:10.4103/ojo.ojo_264_21  
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A case of bilateral uveitis in a patient treated with vemurafenib p. 431
Aysel Mehmet, Athanasia Maria Mikropoulou, Eirini-Kanella Panagiotopoulou, Aristeidis Konstantinidis, Georgios Labiris
DOI:10.4103/ojo.ojo_240_21  
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Annular opacification of hydrophobic acrylic intraocular lens p. 433
Alka Tripathi, Richa Agarwal
DOI:10.4103/ojo.ojo_10_22  
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Peripheral primitive neuroectodermal tumor orbit in an elderly woman p. 435
Shabnum Thakur, Sheetal Sharma, Deepak Tuli, Manish Gupta
DOI:10.4103/ojo.ojo_24_21  
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CLINICAL QUIZ Top

Loose lids sync sleep? p. 437
Kirthi Koka, Payal Jagadishbhai Shah, Bipasha Mukherjee
DOI:10.4103/ojo.ojo_70_21  
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