Central serous chorioretinopathy (CSC), the fourth most common nonsurgical retinopathy with a usual self-limiting course, is known to present with persistent or recurrent form with distressing visual loss. Evolution of newer mutimodal imaging techniques have revolutionized the understanding about the pathophysiology of CSC, and hence the diagnosis and management. Multifactorial etiopathology of CSC promotes the use of multiple treatment modalities. With advances in investigative options, treatment options including conventional focal laser, micropulse laser, photodynamic therapy, and transpupillary thermotherapy are also advancing and refining. Medical management for CSC is also under evaluation with a wide spectrum of new drugs in vogue. However, standard of treatment is yet to be established through randomized clinical trials. This review article discusses the current approach to multimodal treatment options for CSC including conventional as well as newer therapeutic modalities.

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OBJECTIVE: The objective of this study is to describe the epidemiology, risk factors, etiology, and outcome of microbial keratitis in a tertiary care center in Muscat, Oman. METHODS: The electronic records of all patients diagnosed with keratitis or corneal ulcer between January 2013 and January 2016 in Al-Nahdha Hospital were retrospectively reviewed. Patients who presented with a corneal ulcer requiring admission and who underwent culture and sensitivity studies were included in the study. Patients with viral keratitis or sterile corneal ulcers were excluded from the study. RESULTS: A total of 606 electronic medical records of all presumed microbial keratitis were reviewed. Out of these, 304 met the eligibility criteria. The mean age of patients was 52.2 years (standard deviation [SD]: ±23.2 years; range: 0.1–89 years). A total of 198 (65%) microbial cultures yielded positive results. Of these, 182 (92%) were bacterial, 13 (7%) were fungal, and 3 (1%) cases were due to a combined (bacterial and fungal) etiology. Gram-positive bacteria accounted for 102 (55.1%), of which the majority was due to Streptococcus pneumoniae. Gram-negative bacteria accounted for 77 (41.6%) cases; half were caused by Pseudomonas aeruginosa. Keratitis in patients aged 18 years and younger was more likely to be associated with trauma (48.3%, P < 0.001) in young adults with contact lens wear (64%, P < 0.001) and in adults over 40 years with blepharitis (55.6%), sequelae of previous trachoma infection (26.3%), and eyelid abnormalities (18.4%). Following recovery, corneal scarring was seen in 63.2% of patients. CONCLUSION: Microbial keratitis affects patients of all age groups but is more common in older adults. The vast majority of culture-proven cases are due to bacterial infections. Children and teenagers are more likely to develop keratitis following eye trauma whereas young adults mostly develop the condition in association with contact lens wear. Ocular surface disease is the most important risk factor in older adults. The majority of patients end up with corneal scarring.

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Glaucoma is a chronic, progressive disease of the optic nerve which is relatively uncommon in childbearing age; however, its management is a real challenge. Although the intraocular pressure decreases in pregnancy, many glaucoma patients continue to require treatment. In addition to the side effects, antiglaucoma medications on the mother, the possible side effects of drugs on the fetus must be taken into account. The only antiglaucoma medication categorized in Category B is brimonidine, and all others are in Category C. Most evidence on glaucoma medications in pregnancy comes from single case reports or animal studies with the limitations that these impose. Theoretically, glaucoma medications may damage the fetus; however, they may not have substantial clinical significance with routine dosages and no topical antiglaucoma agents have strong evidence of safety to the fetus based on the human studies. When discussing possible options for glaucoma management with the pregnant patient, it is important to emphasize the lack of definitive studies and the patient may be involved in the therapeutic decision-making process.

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Glial heterotopia is a rare congenital mass that often presents as a unilateral mass lesion in or around the nose. Complete surgical excision is the treatment of choice. However, before any surgical intervention for suspected glial heterotopia, distinction should be made both clinically and radiologically from the pathologically related encephalocele to prevent the risk of cerebrospinal fluid leak and meningitis. Here, we report a rare case of bilateral orbital glial heterotopia in a 2-year-old child with review of the literature.

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AIM: The aim of this study is to compare the surgical outcomes of pterygium excision with conjunctival autograft using sutures, fibrin glue (tisseel), and autologous blood for the management of primary pterygium. PATIENTS AND METHODS: A retrospective study done in 681 eyes with primary nasal pterygium. Excision of the pterygium was performed followed by closure of the bare sclera with conjunctival autograft using interrupted 10-0 monofilament nylon sutures in 173 eyes (Group 1), fibrin glue (tisseel-baxter healthcare corporation, westlake village, ca-91362 USA) in 351 eyes (Group 2), and autologous blood in 157 eyes (Group 3). Patients were followed up for a period of 5–52 months. During follow-up, graft-related complications such as recurrence, graft loss, graft retraction, granuloma if any were noted and compared among the three groups. RESULTS: A total of 681 eyes who had primary nasal pterygium were included in this study. Pterygium excision with conjunctival autograft was performed using 10-0 monofilament nylon interrupted sutures in 173 eyes (25.4%), tisseel fibrin glue in 351 eyes (51.54%), and autologous blood in 157 (23.05%) eyes. The mean duration of follow-up was 5–52 months. The overall recurrence rate was 2.9% (20 eyes). In Group 1, recurrence was seen in 5 eyes (2.89%), in Group 2, it was seen in 7 eyes (1.99%) and in Group 3, 8 eyes (5.10%). However, the recurrence rate was not significant (P = 0.160). The rate of graft retraction in the 3 study groups were 12 eyes (6.94%), 10 eyes (2.85%), and 56 eyes (35.67%) with a significant P < 0.001. Granuloma was seen in 2 eyes (1.16%), in Group 1, and in 1 eye (0.64%) in Group 3. Graft loss was seen in 3 eyes (1.73%), 4 eyes (1.14%), 6 eyes (3.82%) in Group 1, 2, and 3, respectively. CONCLUSION: The outcomes of the three most commonly performed surgical technique of conjunctival autograft fixation has shown us that all three techniques are equally comparable and can be offered to our patients with equally good results.

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We describe a case of a man with neurotrophic keratitis of unknown ethiology, who developed a massive stromal melting during treatment of a persistent epithelial defect. A tectonic keratoplasty combined with amniotic membrane grafting was made. Host cornea specimen was analyzed, and Sphingomonas paucimobilis was isolated.

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OBJECTIVE: To determine the demographics and associated clinical features of Omani keratoconus patients presenting to the Ministry of Defence Hospital (MODH) in Muscat. METHODS: This is a retrospective, descriptive study whereby the electronic medical records of all Omani keratoconus patients presenting to the MODH between January 2011 and December 2015 were reviewed. Demographic details, corrected distance visual acuity, refraction, corneal topography, pachymetry, and treatment received were all documented. RESULTS: There were 458 new keratoconus patients (257 males, 201 females) comprising a total of 893 eyes with a mean age of 20 years ± 5.6 (standard deviation) (range 6–46 years). On their first visit, 35% of eyes had spectacle-corrected distance visual acuity <0.5 logarithm of the minimum angle of resolution (LogMAR), 38% had central corneal thickness <450 um, and 25% had a mean keratometry more than 53 Diopter (D). According to the Amsler-Krumeich classification, 37%, 30%, 18%, and 16% of eyes classified into stages I, II, III, and IV, respectively. The severity of keratoconus did not correlate with the age of patients (rs = −0.13, P < 0.05). Over the 5-year period of the study, 502 eyes were fitted with rigid gas permeable lenses with 91% achieving the vision of 0.1 LogMAR or better, 22% of eyes underwent collagen cross linking, 3% underwent intracorneal ring segments implantation, and 4% underwent corneal grafting. CONCLUSION: A significant proportion of Omani keratoconus patients seen in the MODH showed advanced disease on their first visit. There was no correlation between severity and age suggesting that keratoconus can progress quickly in our pediatric group. Population-based studies are an important next step. Meanwhile, early detection and timely interventions to limit the burden of the disease are crucial.

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This report describes a lamellar macular hole formation subsequent to intravitreal bevacizumab injection for the treatment of choroidal neovascularization (CNV) by age-related macular degeneration. A 67-year-old woman with bilateral CNV underwent 3 monthly intravitreal bevacizumab injections in her both eyes. One month after the third bilateral injection, vision loss happened. Optical coherence tomography performed for further evaluation that showed reduction of intra- and sub-retinal fluid associated with lamellar macular hole development in both eyes. Although macular hole formation, especially bilateral form, is a rare complication of intravitreal injections, surgeons should consider macular hole development in cases with vision deterioration following intravitreal bevacizumab injection.

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Acute exudative polymorphous vitelliform maculopathy (AEPVM) is a rare bilateral maculopathy characterized by chronic and long-term course. We report a case of AEPVM with an unusual presentation and management in a middle-aged man. He presented with clinical features of bilateral AEPVM accompanied by multiple intraretinal cysts, with a sudden increase of intraretinal fluid and visual function deterioration over a span of few days. Therefore, we administered empirically an intravenous bolus injection of methylprednisolone. One week after, there was a full recovery of visual acuity and cystic intraretinal spaces completely disappeared.

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Langerhans cell histiocytosis (LCH) is rarely encountered in ophthalmology practice. It is a spectrum of disorder characterized by accumulation of histiocytes in various tissues. Diagnosis is challenging as it may simulate periorbital hematoma, rhabdomyosarcoma, and neuroblastoma. We report a case of unifocal LCH with orbital extension. Diagnosis was obtained from incisional biopsy, and histopathological examination showed numerous histiocytes with eosinophilic infiltrations. The presence of Langerhans cells was confirmed by the presence of protein S-100, CD1a, and/or Langerin (CD207). Treatment depends on the degree of organ involvement. She responded well to cytotoxic drugs and steroids. This emphasized that prompt tissue diagnosis is crucial for early management.

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Isolated eyelid Rosai–Dorfman disease without orbital disease or systemic involvement is very rare and needs a high degree of suspicion. In this report, we describe a 16-year-old boy who presented with isolated eyelid Rosai–Dorfman disease involving the right upper eyelid. The lesion was treated by surgical debulking followed by intralesional steroid injection for the residual lesion. The child did well with no evidence of recurrence of the lesion at 1-year follow-up.

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AIM: The aim of this study is to evaluate the efficacy of 2% rebamipide ophthalmic solution on the tear functions and ocular surface status in patients with dry eyes. MATERIALS AND METHODS: A prospective study was carried out on forty eyes of patients having signs and symptoms of dry eye. Two percent rebamipide ophthalmic solution was applied four times a day for a period of 4 weeks. Patients were evaluated on the basis of dry eye-related symptom score, tear film break-up time (TFBUT), tear meniscus height, fluorescein ocular surface staining score (FOSS), and the Schirmer's test at the end of 2, 4, 6, and 12 weeks and their values were compared with the baseline. RESULTS: Significant improvement was noted in the mean dry eye-related symptom score, TBUT, and the FOSS values from the baseline at the end of 2, 4, 8, and 12 weeks. The values of tear meniscus height and Schirmer's test were improved at the end of 8 weeks but were not statistically significant. CONCLUSION: Nearly 2% rebamipide ophthalmic solution provided relief in the symptoms of patients having dry eyes. It also prevented further ocular surface damage and aided in stabilizing the tear film.

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BACKGROUND: Glaucoma is the leading cause of blindness after penetrating keratoplasty (PK) and its early diagnosis and management is mandatory to salvage the graft. AIMS: This study aimed to evaluate the incidence and risk factors for post penetrating keratoplasty glaucoma (PKG). METHODS: Data of 155 eyes of 155 patients were reviewed retrospectively who underwent PK from March 2013 to February 2016. Data were analyzed from recipient records for recipient age, sex, indications, type of PK, lens status, recipient graft size or any additional procedure. Detailed ophthalmological examination was recorded for all cases including best corrected visual acuity (BCVA), slit lamp examination, intraocular pressure (IOP) by applanation tonometry or tonopen, central corneal thickness (CCT) and gonioscopy. IOP measurement records were reviewed at each visit of one week, two weeks,one, three and six months and if IOP was elevated (>22 mmHg) medical management was initiated. Uncontrolled IOP with antiglaucoma medication (AGM) required surgical management. RESULTS: Overall incidence of raised IOP after PK was 32.25%. Increase in IOP post PK was reported mainly in 32 (64%) among age group >40 years. Raised IOP showed significant association with age group, indications of PK, recipient size and CCT (P value 0.00, 0.01, 0.00, 0.00) respectively. Two weeks after PK 46 (29.67%) patients reported an increase in IOP ,47(30.32 %) after 1 months, 33 (21.29%) at 3 months and 30 (19.35%) at 6 months. In 11 (39.28%) cases cataract was major long term complication seen in PKG cases. 35 (70%) cases of PKG were treated medically and 15 (30%) patients required surgical treatment. CONCLUSION: Subjects with age group >40 years, corneal opacity, increased recepient size and increased CCT are risk factors for PKG. IOP monitoring in early post operative period especially one month after PK is mandatory to avoid graft failure due to PKG which is difficult to diagnose otherwise.

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BACKGROUND AND OBJECTIVE: The objective of the study was to compare the efficacy of intravitreal bevacizumab (IVB) as monotherapy versus combination with modified macular grid (MMG) laser photocoagulation in the primary treatment of diffuse diabetic macular edema (DDME). MATERIALS AND METHODS: A prospective randomized trial was carried out in sixty eyes with DDME after Institutional Ethical clearance. Group A received three doses of IVB at a 1-month interval. Group B received MMG in addition to IVB. Complete examination including best-corrected visual acuity (BCVA) (Snellen's), central macular thickness (CMT) using spectral domain-optical coherence tomography was carried out at 0, 1, 4, 8, 12, and 24 weeks. RESULTS: mean CMT at baseline, 12 and 24 weeks in Group A was 401 (±76), 280 (±49), and 307 (±46) and in Group B, 405 (±73), 237 (±33), and 242 (±45), respectively. Group B had significantly greater reductions (P < 0.001) from 12 weeks onward. BCVA and contrast sensitivity showed improvements with no significant difference. CONCLUSION: Combined therapy has more advantage in primary DDME by reducing CMT on longer follow-up.

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We aim to present a case of bilateral rhegmatogenous retinal detachment (RRD) after successful phacoemulsification procedures performed 23 years before RRD onset and surgical management. A 57-year-old female presented with blurred vision due to floaters in the left eye. The patient was followed up with dilated fundus examination. The patient underwent bilateral uneventful cataract extraction 23 years before the baseline visit with the use of phacoemulsification. Dilated fundus examination revealed RRD in the left eye that was managed with a 25G pars plana vitrectomy, cryopexy, and 16% C3F8 expandable gas. Thirty-three days following the procedure in the left eye, the patient presented with RRD in the right eye. Management included a 25G pars plana vitrectomy with cryopexy and 20% SF6 expandable gas. Phacoemulsification ultrasound energy appears to bring about changes in the peripheral vitreous and retina that may manifest several decades following uncomplicated cataract extraction.

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The purpose of this study was to present the surgical outcome in optic disc pit associated maculopathy in a patient who was treated with vitrectomy, internal limiting membrane (ILM) peeling, barrage laser photocoagulation, and silicone oil tamponade. A 21-year-old Indian male was diagnosed with optic disc pit maculopathy in his left eye with a best-corrected visual acuity (BCVA) of 20/200. A 23-gauge pars plana vitrectomy with peeling of ILM was done using brilliant blue dye. After completion of vitrectomy, fluid-air exchange was performed and silicone oil was instilled into eye. Peripapillary endolaser barrage photocoagulation using two rows of low-intensity laser was performed temporally. Silicone oil was removed 4 months after surgery. During the next 24 months, the retina gradually flattened with gradual improvement of BCVA in the left eye. At 24 months, fundus examination showed retinal pigment epithelium atrophy temporal to optic disc not involving the fovea, and optical coherence tomography showed complete resolution of subretinal fluid, with a BCVA of 20/60. The patient maintained the same vision 4 years following the surgery. vitrectomy combined with posterior hyaloid and ILM peeling followed by silicone oil tamponade, with additional laser photocoagulation, was successful for the treatment of optic disc pit maculopathy in our patient. Further studies are warranted to explore the various treatment options and try to set a standard treatment protocol for this rare challenging condition.

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Rosai–Dorfman Disease also called as Sinus Histiocytosis with Massive Lymphadenopathy is a rare, benign, idiopathic histiocytic proliferative disorder that occurs predominantly in children and young adults. Orbital involvement can occur in 11% of cases. Isolated lacrimal gland involvement without any local or systemic recurrence is very rare. To the best of our knowledge, only seven cases have been reported in the literature till date. Histopathological and immunohistochemical confirmation is essential in establishing the diagnosis. A benign course is usual, but in some cases, blindness or even fatality may result. We report a case of 30-year-old female with isolated lacrimal gland involvement and 19 months' follow-up.

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Giant Congenital Melanocytic Nevus (GCMNs) is mostly reported in area of trunk followed by limbs and head. Their incidence is <1:20,000 newborns It derives attention due to its association with malignant melanoma.The risk of developing malignant melanoma is between 5 to 10%.We report a case of twelve year old boy with hyperpigmented lesion on face.

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A 17-year female was referred for complaints of blurring and decreased vision in the right eye. The patient underwent fundus examination, optical coherence tomography and B-scan ultrasonography. A well-defined, yellow-orange colored lesion was present in the posterior pole. This lesion created an echodense lesion on B-scan even with low gain. The patient was diagnosed with choroidal neovascularization (CNV) associated with choroidal osteoma. The patient was treated with seven consecutive intravitreal anti-vascular endothelial growth factor (VEGF) injections over 14 months. Intravitreal anti-VEGF was effective for CNV associated with choroidal osteoma. Long- term follow-up is necessary to resolve the fluids, possible development of CNV, and possible of bilateral occurrence.

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Drusen are seen as an end result of various biochemical insults to the retina and have been described in various clinical settings. We would like to report the histopathology of a case of large drusen, seen associated with chronic retinal detachment in a case of childhood trauma, where the eye was eviscerated for other reasons.

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AIM: The aim of this study is to compare the efficacy of intravitreal bevacizumab and posterior subtenons triamcinolone acetate in the management of diffuse diabetic macular edema (DME) and to evaluate their efficacy as an adjunct to modified grid laser in management of DME. DESIGN: This was a prospective, randomized clinical trial of 30 patients. MATERIALS AND METHODS: A total of 30 patients attending the medical ophthalmology clinic at a tertiary care hospital were included in the study. These 30 patients were divided into two groups. Group I (15 eyes) received intravitreal bevacizumab followed by modified grid photocoagulation 2 weeks after injection. Group II (15 eyes) received posterior subtenons triamcinolone followed by modified grid photocoagulation 2 weeks after injection. Each patient in our study was followed up at 1 week, 2 weeks, 1 month, 2 months, 3 months, and 6 months after the initial injection to record the central macular thickness (CMT) and best-corrected visual acuity (BCVA). RESULTS: Both the combination therapies have efficacy to reduce the CMT (P = 0.001). The percentage fall in CMT was greater in bevacizumab + laser group, and there was a significant difference in the CMT values at the end of the study in the bevacizumab group (P = 0.013). The mean BCVA improved in both the groups and this difference was statistically significant compared to the baseline (P = 0.005). However, there was no statistically significant difference in BCVA between the two groups at the end of the study. CONCLUSION: Both intravitreal bevacizumab and posterior subtenons triamcinolone given as an adjuvant therapy along with modified grid laser are equally efficacious in the reduction of the CMT; however, the percentage fall in the CMT was greater in bevacizumab + laser group, and there was a significant difference in the fall in CMT at all the visits as compared to a plateau in the fall of CMT in posterior subtenons triamcinolone group.

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PURPOSE: The purpose of this study is to evaluate the changing trends in myopia over an 11-year period among Omani schoolchildren. METHODS: This retrospective study took place from January to June 2012. National vision screening data from 1999 to 2010 were reviewed for information concerning all children in the fourth, seventh, and tenth grades of Omani public schools. Changes in the rate of myopia by gender, grade, severity, and governorate were evaluated. RESULTS: Among 397,430 fourth-grade students, the prevalence of myopia was 2.44%. In contrast, the prevalence of myopia among 533,003 and 461,307 children in the seventh and tenth grades, respectively, was 4.41% and 7.36%. Compared to 2002, the rate of myopia in 2010 was 1.43% higher for fourth-grade students (P < 0.001). Myopia prevalence rates among seventh-grade students increased by (5.36–3.36 = 2.0) 1.11% between 1999 and 2010, but declined by 7.62% versus 6.34% = 1.28% between 1999 and 2010 for seventh- and tenth-grade students, respectively (P < 0.010 and <0.001, respectively). The risk of myopia in the fourth, seventh, and tenth grades was significantly higher for females in 2002 and 2010 (P < 0.001). The regional variation of myopia was also significant (χ² = 495; P < 0.001). Among seventh- and tenth-grade students in 2010, the ratio of children with mild-to-moderate/severe myopia was 1.5:1 and 1:2.7, respectively. CONCLUSION: Although the rate of myopia increased with grade, the trend over time suggests that myopia affected more children at a younger age. Female students had a significantly higher risk of myopia.

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PURPOSE: To evaluate the impact of venting incision on graft detachment in Descemet stripping automated endothelial keratoplasty (DSAEK). MATERIALS AND METHODS: Retrospective comparative study on DSAEK procedure performed with (n = 13) and without (n = 39) venting incision. Patients were treated with DSAEK for various causes of endothelial decompensation between February 2014 and April 2016. The rate of postoperative graft detachments documented on anterior segment optical coherence tomography was compared in both groups. RESULTS: Paracentral venting incision decreases the rate of graft displacement. Non-venting group (nvg) had 28.2% graft displacement compared to venting group (vg) which had 7.6% graft displacement. CONCLUSION: Venting incision is a simple and safe manoeuvre to facilitate graft adherence in DSAEK, especially in caseswith presence of high-risk factors for graft detachment.

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PURPOSE: An assessment of variation in Macular Volume and RNFL Thickness in myopes using OCT, and their significance for early diagnosis of Primary Open Angle Glaucoma( POAG). MATERIALS AND METHOD: Total of 122 eyes of 61 Indian Myopic subjects of both sex and various age groups underwent retinal nerve fiber layer thickness, macular volume in 6mm analysis by Rtvue Avanti SD-OCT, Optovue Technology V6.1.1,after taking due consent from ethical committee. Subjects were divided into two groups based on their refractive error, Group A <6 D and Group B >6D. The results were evaluated to determine the above mentioned measurements and their variation with myopic refractive error. RESULTS: The RNFL thickness in four Quadrants and an inner circle were taken. The mean thickness in inner circle in both groups were 101.48μm (SD±13.34 μm) and 92.38 μm (SD±11.99μm) respectively, which was statistically significant. The difference was also significant in superior, nasal and inferior quadrant. Statistically the difference was not significant in temporal quadrant. The macular volume was calculated in 6mm diameter. The mean value in Group A was 7.82mm³±0.54 mm³. The mean value in Group B was 7.44mm³±0.98mm³. The statistical analysis showed the difference between the two groups is statistically significant. CONCLUSION: RNFL thickness is an established way to diagnose open angle glaucoma in preperimetric stage. Macular Volume is also found to be co-related with the risk. Myopes are known to be at higher risk to develop POAG. Hence, measurement of RNFL thickness by OCT should be made a mandatory investigation in High Myopes.

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