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   Table of Contents - Current issue
April-June 2019
Volume 9 | Issue 2
Page Nos. 61-137

Online since Friday, May 31, 2019

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To reduce the number of blinded by glaucoma p. 61
Tetsuya Yamamoto
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Superior segmental optic hypoplasia as a differential diagnosis of glaucoma p. 63
Tetsuya Yamamoto
Superior segmental optic hypoplasia (SSOH) is a congenital anomaly affecting the optic nerve head and retina. Although the conventional characterization of SSOH emphasizes the relatively superior entrance of the central retinal artery, the pallor of the superior optic disc, a superior peripapillary halo, and thinning of the superior nerve fiber layer, we encounter many cases with rim thinning in the superior nasal region that corresponds to a nerve fiber layer defect and an inferior wedge-shaped visual field defect connecting to the blind spot. However, among Asians, such cases usually lack pallor of the superior optic disc and more resemble glaucomatous optic neuropathy. We found the prevalence of SSOH to be 0.2%/eye and 0.3%/case among Japanese. We also noted that approximately half of all SSOH eyes show visual field changes. SSOH is an important differential diagnosis of glaucoma, especially normal-tension glaucoma, in Asian populations.
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Ab-interno trabeculotomy-related glaucoma surgeries p. 67
Masaki Tanito, Masato Matsuo
Reductions of intraocular pressure during trabeculotomy result from relieving the resistance to aqueous flow by cleavage of the trabecular meshwork and inner walls of Schlemm's canal at the point of outflow resistance of the aqueous humor. Since trabeculotomy does not result in bleb formation, development of late-onset sight-threatening complications, such as hypotony maculopathy and endophthalmitis, that are associated occasionally with trabeculectomy develop less frequently after trabeculotomy. The ab-interno approach is used in several new procedures, including the Trabectome, Kahook Dual Blade, microhook abinterno trabeculotomy, and 360° suture trabeculotomy, instead of the ab-externo approach as in conventional trabeculotomy. These newly developed novel, minimally invasive, and trabeculotomy-related glaucoma surgeries can be good options for certain glaucoma cases, including early-stage open-angle glaucoma, developmental glaucoma, and glaucoma in elderly patients.
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Polypoidal choroidal vasculopathy: An update on current management and review of literature Highly accessed article p. 72
Amit Harishchandra Palkar, Vikas Khetan
Polypoidal choroidal vasculopathy (PCV) is a subtype of neovascular age-related macular degeneration (nAMD), commonly seen in the Asian population. It is dissimilar in epidemiology, genetic heterogeneity, pathogenesis, natural history, and response to treatment in comparison to nAMD. Confocal scanning laser ophthalmoscopy-based simultaneous fluorescein angiography and indocyanine green angiography, spectral-domain optical coherence tomography (OCT) with enhanced depth imaging, swept-source OCT, and OCT angiography have improved the ability to detect PCV, understand its pathology, and monitor treatment response. A plethora of literature has discussed the efficacy of photodynamic therapy, anti-vascular endothelial growth factor (VEGF) monotherapy, and combination of both, but only a few studies with higher level of evidence and limited follow-up duration are available. This review discusses the understanding of PCV with respect to epidemiology, pathogenesis, clinical features, natural history, imaging techniques, and various treatment options. Recent clinical trials (EVEREST-II and PLANET study) have emphasized that either anti-VEGF monotherapy or combination treatment is equally capable to strike a balance between polyp regression and stabilization of visual acuity. The recurrent nature of the disease, the development of macular atrophy, and the long-term poor visual prognosis despite treatment are concerns that open avenues for further research.
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Assessment of the optic nerve head, peripapillary, and macular microcirculation in the newly diagnosed patients with primary open-angle glaucoma treated with topical tafluprost and tafluprost/timolol fixed combination p. 93
Natalia Ivanovna Kurysheva
RELEVANCE: The ability of antiglaucoma drugs to improve ocular hemoperfusion is an important aspect of their action. Tafluprost is the first preservative-free prostaglandin analog. The efficacy and safety of tafluprost, as well as tafluprost/timolol fixed combination (FC), were demonstrated in randomized multicenter trials. However, there is no literature on the effect of tafluprost and its FC on the peripapillary and macular blood flow. PURPOSE: To determine the changes of microcirculation in the optic nerve head (ONH), peripapillary retina, and macula in patients with newly diagnosed primary open-angle glaucoma (POAG) under the topical tafluprost and tafluprost/timolol FC treatment. MATERIALS AND METHODS: Optical coherence tomography angiography (OCT-A) was performed in dynamics with an interval of a week in 36 patients (36 eyes) with a newly diagnosed initial stage of POAG: 12 eyes with tafluprost, 12 – tafluprost/timolol FC, and 12 – no topical treatment (the control group). The change in intraocular pressure (IOP), mean ocular perfusion pressure (MOPP) of the eye, and vessel density (VD) inside the ONH (inside disc), as well as in the peripapillary retina and macula, was evaluated by comparing paired repeated observations using the median growth analysis. RESULTS: In the tafluprost group, there were a decrease in IOP by 19.4% and an increase in MOPP by 8.7% from the reference level. In the tafluprost/timolol group, these figures were 43% and 30.1%, respectively. OCT-A values did not change reliably, except for VD inside disc: the median growth of the tafluprost group was 2.28 (P = 0.02) and of the tafluprost/timolol group was 1.82 (P = 0.03). These changes were obtained in 11 of 12 patients in each group under treatment. In control group, all indicators remained unchanged. CONCLUSIONS: A significant increase of MOPP and a decrease of VD in the ONH in patients with initial glaucoma occurred within a week under the topical tafluprost or its FC. This can be explained by the restoration of autoregulation of the ocular blood flow in conditions of pronounced hypotensive effect of the drugs.
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Lotrafilcon B with HydraGlyde moisture matrix or Samfilcon A: Contralateral comparison study for comfort p. 100
Nilay Yuksel, Derya Yaman
PURPOSE: The purpose of this study was to compare two new silicone hydrogel contact lens (CL) models of lotrafilcon B with HydraGlyde moisture matrix (Air Optix plus HydraGlyde®) and samfilcon A (Bausch and Lomb Ultra®) using the Contact Lens Dry Eye Questionnaire-8 (CLDEQ-8) test. METHODS: This prospective study included 30 patients between the ages of 19 and 35 years. Lotrafilcon B with HydraGlyde moisture matrix (Air Optix plus HydraGlyde®) and samfilcon A (Bausch and Lomb Ultra®) CLs were fitted on the right and the left eye of the patients, respectively. All of the patients have not used any CLs before. After 4 weeks, the CLs were compared by asking the Contact Lens Dry Eye Questionnaire-8 (CLDEQ-8) test. RESULTS: The mean scores of CLDEQ-8, frequency and intense of discomfort, dryness, blurry vision, frequency of needing to blink eye, and removal of the CL were assessed. There was no statistically significant difference between two groups (P > 0.05). CONCLUSION: The main reasons for CL discontinuation are dryness and discomfort. These two new CLs used new advanced technology have a good compliance among the first-time CL users.
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A study of endothelial cell count pre- and post-neodymium-doped yttrium aluminum garnet laser iridotomy in subacute angle closure using specular microscope p. 104
Nancy Bansal, Anand Aggarwal, Prempal Kaur, Jaspreet Bedi, Sandhya Jeria, Priyanka Gusain
AIM: The aim of this study was to study the effect of neodymium-doped yttrium aluminum garnet (Nd:YAG) laser iridotomy on corneal endothelial cell count in patients with subacute angle closure using specular microscope. MATERIALS AND METHODS: In this prospective study, 50 cases of narrow-angle Grade 1 and Grade 2 (Shaffer gonioscopic grading) visiting the Regional Institute of Ophthalmology, Government Medical College, Amritsar underwent Nd:YAG laser peripheral iridotomy. After obtaining informed written consent, specular microscopy was performed before and after iridotomy at 1 week, 1 month, 3rd month, and at 6th-month follow-up visits. Central, nasal, and temporal endothelial cell counts were evaluated through noncontact specular microscopy. RESULTS: The mean participant age was 51.52 ± 7.9 years, and majority of the participants were females (76%). The mean IOP before the laser was 19.25 ± 1.914 mmHg and it varied from 18.50 ± 1.647 to 18.25 ± 1.699 mmHg (day 1, p = 0.06 and at 6 months, p = 0.04) following laser procedure. The mean corneal endothelial cell count at superotemporal site before laser peripheral iridotomy was 2844 ± 260, and this value decreased to 2807 ± 263, 2699 ± 267, 2656 ± 270, and 2591 ± 275 cells/mm2 at postiridotomy, 1, 3, and 6 months' follow-up visits, respectively; these differences were statistically significant (p < 0.05). The mean total energy required to produce iridotomy was 14.88 ± 6.71 mJ, ranging from 5 to 37 mJ. The linear regression analysis indicated no statistical correlation between change in endothelial cell count at the treated site and total mean energy used. No significant difference was found between preiridotomy and postiridotomy corneal thickness at any site. CONCLUSION: This study demonstrated a significant endothelial cell loss at the treated site in 6 months' follow-up and suggested that Nd:YAG laser iridotomy may pose hazard to the corneal endothelium, although corneal decompensation at the treated site or as a whole was not seen.
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Semi-permanent smartphone adapter for microscopes: Design demonstration and workflow testing using a slit-lamp biomicroscope p. 111
Chieh-Hung Yen, Guo-Quan Wang, Tommy Y Lin, Chun-Hsiu Liu
BACKGROUND: A smartphone microscope adapter is an alternative to a permanently mounted camera, which often requires a specially designed light path as well as a computer system for data storage and network connectivity. A common disadvantage of these adapters is that they need to be repeatedly mounted and dismounted; this is inconvenient during serial observations. PURPOSE: The study purpose is to develop and test a semi-permanent microscope adapter. METHODS: Our prototype was designed using three-dimensional (3D) computer-aided design software and was 3D printed for testing. Two tests were designed to quantify the workflow improvement by measuring the time required to complete specific movements, which simulated the actions of capturing photographs by using an adapter and a slit-lamp biomicroscope. Our prototype was the experimental adapter, and two commercially available products were used as references. A single-shot test measured the average time required to complete a photographing cycle, in which a single photograph was recorded. A multiple-shot test measured the time required to complete cycles in which a different number of photographs were captured; thus, the time required specifically for the preparation phase of photographing was determined. Both tests were performed by 4 researchers. RESULTS: The average time required to complete a cycle using our prototype in single-shot test was significantly shorter than that using one of the references. For the other reference, significances were shown in 2 testers' results. In the multiple-shot test, the linear regression analysis also showed that the preparation phase of our prototype was significantly shorter than the preparation phase of the two commercially available products (P < 0.001). CONCLUSIONS: The semi-permanent design may improve the workflow of photography using smartphone adapters, thereby reducing the time and effort required for preparing devices, particularly when making multiple consecutive observations or when the targets disappear fast.
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Microvascular change in acute macular neuroretinopathy by using optical coherence tomography angiography p. 118
Yen-Chih Chen, San-Ni Chen
A 27-year-old pregnant female underwent cesarean section due to preeclampsia. Two days after the delivery, she presented with acute onset of blurred vision in the left eye. Optical coherence tomography (OCT) revealed characteristic findings of acute macular neuroretinopathy (AMN) in both eyes. During the follow-up, her vision improved gradually, but outer nuclear layer thinning with disruption of ellipsoid zone was identified from OCT. OCT angiography was arranged and revealed both vascular defect in superficial and deep vascular plexus, which correlated with previous AMN lesions in both eyes. Subsequent microvascular change in AMN was found to involve both superficial and deep vascular plexus, which is different from the current consensus that AMN mainly involved deep vascular plexus. By using the OCT angiography, we can better visualize the detail retinal vascular structure and may identify the real mechanism in this rare retinal disorder.
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Bilateral cytomegalovirus retinitis comorbid with diabetic macular edema p. 122
Yu-Jang Chao, Yi-Ming Huang, Yu-Chien Chung, De-Kuang Hwang, Shih-Jen Chen, Catherine Jui-Ling Liu
Cytomegalovirus (CMV) retinitis comorbid with diabetic retinopathy is uncommon. We report a case of bilateral CMV retinitis and diabetic retinopathy in a patient who underwent pancreas transplantation and share the experience of the treatment outcome. An 18-year-old male diagnosed with type-1 diabetes mellitus received pancreas transplantation and immunosuppressive therapy suffered from progressively blurred vision in both eyes for several days. His visual acuity was 20/100 in the right eye and 20/50 in the left eye. Ophthalmic examination revealed bilateral diabetic macular edema (DME) without intraocular inflammatory signs in either eye. The DME subsided after 2 monthly intravitreal injections of aflibercept. However, bilateral panuveitis with CMV retinitis was observed after antivascular endothelial growth factor therapy. The retinitis subsided gradually but completely after systemic and intravitreal antiviral therapy. However, bilateral DME recurred and persisted despite repeated injections of aflibercept during the resting follow-up period. Our case suggests that CMV retinitis can coexist with other retinal diseases, including diabetic retinopathy. Treatment is difficult in such cases.
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Serpiginoid choroiditis associated with presumed ocular tuberculosis p. 127
Te-An Wang, Kang-Jung Lo, De-Kuang Hwang, Shih-Jen Chen
The purpose of this study is to present a case with serpiginoid choroiditis with possible ocular tuberculosis. The intraocular inflammation and choroiditis were successfully controlled by systemic antituberculosis treatment. A 63-year-old female presented with progressive bilateral blurred vision for over a year. At presentation, her best-corrected visual acuity was 6/20 in her right eye and counting fingers at 10 cm in her left eye. A fundus examination showed diffuse patchy geographic retinal pigment epithelium (RPE) changes with some pigmentation in both eyes. Fluorescein angiography disclosed leakage from RPE lesions and discs as well as retinal vasculitis. Systemic survey results for rheumatic and infectious diseases were normal except for a positive QuantiFERON-TB Gold test result. Her uveitis improved and chorioretinal lesions stabilized from the 2nd month of antituberculosis treatment. The antituberculosis treatment was discontinued after a 12-month course. No recurrence of uveitis was noted during the following 2 months. Diagnosing ocular tuberculosis is challenging. The clinical presentation, interferon-gamma release assay test, and clinical response to antituberculosis therapy can support a presumed diagnosis of tubercular uveitis. This case highlights that serpiginoid choroiditis can be a clinical presentation of ocular tuberculosis. Clinicians should pay attention to this etiology when facing a serpiginous-like retinal appearance.
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Dendrite-like anterior stromal keratitis coinfected with Acanthamoeba and Pseudomonas in an orthokeratology contact lens wearer p. 131
Chih-Chien Hsu
Acanthamoeba species can cause a keratitis misdiagnosed as herpes keratitis or fungal keratitis. We report an unusual dendrite-like anterior stromal keratitis coinfected with Acanthamoeba and Pseudomonas aeruginosa in an orthokeratology contact lens wearer in Taiwan. Topical 1% voriconazole and 0.5% levofloxacin were prescribed because besides Acanthamoeba keratitis, fungal keratitis was also highly suspected initially. Topical 0.02% chlorhexidine was added after the culture of the scraped cornea showed positive results of Acanthamoeba and P. aeruginosa. The lesion subsided using this triple combination therapy for 1 week. Both Acanthamoeba and P. aeruginosa are potentially devastating causes of infectious keratitis. Our case highlights the importance of considering the possibility of a concurrent infection and atypical presentation in cases with contact lens-related keratitis. The use of topical levofloxacin combined with voriconazole should be considered as the first-line treatment in such patients.
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Comment on “bevacizumab or laser for aggressive posterior retinopathy of prematurity” p. 134
Ramanuj Samanta
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Reply to comment on: “Advantages of bevacizumab for aggressive posterior retinopathy of prematurity” p. 136
Sidney A Schechet, Sarah Hilkert Rodriguez, Michael J Shapiro, Michael P Blair
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