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   Table of Contents - Current issue
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January-March 2020
Volume 10 | Issue 1
Page Nos. 1-75

Online since Wednesday, March 4, 2020

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EDITORIAL  

New strategy to restore ocular surface health p. 1
Scheffer C. G. Tseng
DOI:10.4103/tjo.tjo_78_19  
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REVIEW ARTICLES Top

Basic science review of birth tissue uses in ophthalmology p. 3
Sean Tighe, Olivia G Mead, Amy Lee, Scheffer C. G. Tseng
DOI:10.4103/tjo.tjo_4_20  
The birth tissue is predominantly comprised of amniotic membrane (AM) and umbilical cord (UC), which share the same cell origin as the fetus. These versatile biological tissues have been used to treat a wide range of conjunctival and corneal conditions since 1940. The therapeutic benefits of the birth tissue stem from its anti-inflammatory and anti-scarring properties that orchestrate regenerative healing. Although the birth tissue also contains many cytokines, growth factors, and proteins, the heavy chain 1–hyaluronic acid/pentraxin 3 (HC–HA/PTX3) matrix has been identified to be a major active tissue component responsible for AM/UC's multifactorial therapeutic actions. HC–HA/PTX3 complex is abundantly present in fresh and cryopreserved AM/UC, but not in dehydrated tissue. In this review, we discuss the tissue anatomy, the molecular mechanism of action based on HC–HA/PTX3 to explain their therapeutic potentials, and the various forms available in ophthalmology.
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Amniotic membrane transplantation for managing dry eye and neurotrophic keratitis p. 13
Olivia G Mead, Sean Tighe, Scheffer C. G. Tseng
DOI:10.4103/tjo.tjo_5_20  
Neurotrophic keratitis (NK), a degenerative disease caused by damage to the trigeminal nerve, abolishes both tearing and blinking reflexes, thus causing the most severe forms of dry eye disease (DED). Conversely, the increasing severity of DED also leads to progressive loss of corneal nerve density, potentially resulting in NK. Both diseases manifest the same spectrum of corneal pathologies including inflammation and corneal epithelial keratitis, which can progress into vision-threatening epithelial defect and stromal ulceration. This review summarizes the current literature regarding outcomes following sutured and sutureless cryopreserved amniotic membrane (AM) in treating DED as well as epithelial defects and corneal ulcers due to underlying NK. These studies collectively support the safety and effectiveness of cryopreserved AM in restoring corneal epithelial health, improving visual acuity in eyes with NK and DED, and alleviating symptomatic DED. Future randomized controlled trials are warranted to validate the above findings and determine whether such clinical efficacy lies in promoting corneal nerve regeneration.
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ORIGINAL ARTICLES Top

The long-term surgical outcomes of conjunctival-limbal autograft procedure with or without penetrating keratoplasty in eyes with unilateral limbal stem cell deficiency p. 22
Muhammet Derda Ozer, Emre Altinkurt, Nilufer Alparslan
DOI:10.4103/tjo.tjo_55_19  
AIM: The aim of the study is to report the results of conjunctival-limbal autograft (CLAU) transplantation and penetrating keratoplasty (PK) in eyes with limbal stem cell deficiency (LSCD) due to chemical or thermal injury. METHODS: Thirty-one eyes of the 31 patients, who had unilateral LSCD due to chemical or thermal injury, were included in the study. Bilaterally affected cases and LSCD due to Steven-Johnson syndrome and mucous membrane pemphigoid were excluded from the study. All patients underwent a complete ophthalmologic examination. The surgical procedures, postoperative complications, ocular surface status, and visual outcomes were noted. RESULTS: In the CLAU group, regular corneal epithelium and ambulatory vision (≤1.0 logarithm of the minimum angle of resolution [20/200]) were achieved in 81% of eyes, including 22 eyes (71%) that were assessed after a mean follow-up period of 58 months, respectively. The 5-year survival rate of corneal allograft was 33%, 4 ± 13.9 in the CLAU applied eyes. In addition, the corneal graft clarity maintenance rate was found to be higher in patients having ≥12 months duration between CLAU and PK, which is statistically significant (62% vs. 23%,P = 0.046). CONCLUSION: Waiting at least 1 year after CLAU transplantation to perform PK increases corneal clarity. Eyelid problems, even if the eyelids were reconstructed properly, remain a major risk factor for the development of the epithelial disorder in the early and late postoperative period in CLAU applied eyes.
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Amblyopia therapy in children with penetrating corneal injuries p. 29
Khyati Jain, Amit Jain, Jayesh Patil, Trupti Gadiya
DOI:10.4103/tjo.tjo_13_18  
BACKGROUND: The role of part-time occlusion therapy in children with penetrating ocular injuries has not been studied. The aim of the study is to analyze the role of part-time occlusion therapy in children with penetrating ocular trauma following surgical intervention. MATERIALS AND METHODS: This is a retrospective case series with a median follow-up of 17 months (range: 3–105 months). The study was carried out at a tertiary referral center. Consecutive children with penetrating corneal tear injury who underwent surgical intervention were included in the study. These patients were subjected to part-time occlusion, and those with good compliance and follow-up were included in the study. The role of part-time occlusion therapy in children with ocular trauma is studied. RESULTS: There were 26 patients included in the study of which 23 were male and 3 were female, with a median age at presentation of 5 years (range: 1–11 years). The vision following surgical intervention at 6 weeks was 0.85 logMAR units (range: 0.3–2.8). Final median visual acuity was 0.48 logMAR units (range: 0–2). Paired t-test done for improvement in visual outcome before and after amblyopia therapy was statistically significant (P = 0.007). CONCLUSION: Amblyopia therapy shows promising results for patients following penetrating intraocular injury despite corneal scar in the visual axis in our group. A study on larger population is indicated.
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Traumatic wound dehiscence after penetrating keratoplasty: Clinical features and outcome in 53 cases in Yemen p. 32
Mahfouth Abdalla Bamashmus, Mohammed A Al-Shekeil, Fady A Mukred, Hisham A Al-Akhlee
DOI:10.4103/tjo.tjo_107_18  
AIMS: Penetrating keratoplasty (PKP) carries the risk of developing wound dehiscence, which can lead to vision loss. The main aim of this study is to analyze the management and outcome of surgery for traumatic wound dehiscence occurring in patients who had PKP. SUBJECTS AND METHODS: This retrospective study included post-PKP patients who sustained traumatic wound dehiscence at the Cornea Unit in Yemen Magrabi Eye Hospital between 2008 and 2016. Fifty-three eyes with a history of wound dehiscence were treated with primary wound closure. Patient files were reviewed for type and time of injury, distance visual acuity (VA), and outcome. RESULTS: Ruptured globe with dehiscence of wound occurred on average 2.4 years (3 months to 13 years) after PKP. The mean age at wound dehiscence was 22.27 years and males accounted for 77.4% (41). All patients were managed with primary closure of the wound. Lensectomy of traumatic or dislocated lens was the most frequent additional surgical procedure (14, 26.4%), followed by anterior vitrectomy (6, 11.3%). In the end, 43 (81.1%) grafts remained clear. In the last follow-up, 34 eyes (64.1%) had best-corrected VA of 20/200 or better and two eyes had no perception of light. CONCLUSION: Rupture globe and wound dehiscence occurs after PKP at the graft–host junction. Wound dehiscence is a lifelong risk after PKP and wound weakness persisted for a long period after PKP. Visual outcome and graft survival are generally poor after the injury, and the restoration of a satisfactory visual result is possible if treated early.
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Accelerated epithelium-on or accelerated epithelium-off corneal collagen cross-linking: Contralateral comparison study p. 37
Erdem Yuksel, Mehmet Ozgur Cubuk, Nuriye Gokcen Yalcin
DOI:10.4103/tjo.tjo_11_19  
PURPOSE: The aim of the study is to compare the accelerated epithelial-on corneal collagen cross-linking (epi-on CXL) and accelerated epithelial-off corneal collagen cross-linking (epi-off CXL) in terms of clinical and confocal microscopy results. MATERIALS AND METHODS: Forty-two eyes of 21 patients with progressive keratoconus and simultaneously undergoing accelerated epi-on CXL in one eye and accelerated epi-off CXL in other eye were evaluated. Uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA) with spectacle in logMAR and topographic findings (mean keratometry [Kmean] and maximum keratometry [Kmax]) were recorded at 1, 3, 6, 12, 18, 24, and 30 months. Eyes were compared in terms of subjective pain scores after the procedures. Furthermore, anterior segment optical coherence tomography and confocal microscopy were performed at 1 month. RESULTS: Kmeanand Kmaxwere less than baseline in both the groups; however, the reduction was significantly higher in epi-off CXL than epi-on CXL eyes at 18 and 30 months. The UCVA and BCVA increased approximately 1 Snellen line at the end of mean follow-up in epi-off CXL and in epi-on CXL. Stromal demarcation line for epi-off CXL is 276.4 ± 58.9 while 148.3 ± 24.8 for epi-on CXL (P = 0.001). Furthermore, subepithelial nerves were observed in any eye in epi-off CXL; however, subepithelial nerves were observed in 12 eyes (80%), in epi-on CXL (P = 0.01). CONCLUSION: Both techniques were able to stop progression; however, in contrast to expectations, the pain was felt more in epi-on CXL than epi-off CXL.
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Association between corneal biomechanical parameters and myopic refractive errors in young Indian individuals p. 45
Vaishal P Kenia, Raj V Kenia, Onkar H Pirdanka
DOI:10.4103/tjo.tjo_15_19  
PURPOSE: To report corneal biomechanical parameters in young myopic Indian individuals. METHODS: It is a retrospective study where young myopic individuals aged between 19 and 36 years who have undergone corneal biomechanics assessment using Corvis ST between January 2017 and December 2017 were enrolled. Individuals with central corneal thickness (CCT) <500 microns, intraocular pressure (IOP) >21 mmHg, history of any systemic and ocular disease, any previous ocular surgery, high astigmatism, corneal disease such as keratoconus, poor scans quality, and individuals with any missing data were also excluded. Corneal biomechanical parameters were noted in mild to moderate and high myopia. RESULTS: We analyzed the 266 eyes of 266 myopic individuals, of which 167 and 99 eyes had mild to moderate and high myopia, respectively. All the individuals were matched for age, IOP, and CCT (P > 0.05). Twenty-three of 32 parameters were similar in different degrees of myopia whereas 9 parameters were significantly different in high myopes as compared to low to moderate myopes. First applanation (A1) parameters and Vinciguerra screening parameters were similar in both the groups (P > 0.05). Second applanation (A2) parameters were similar in both the groups (P > 0.05) except A2 time, A2 deformation, amplitude (DA) (P < 0.05). Highest concavity (HC) parameters were significantly different in both the groups (P < 0.05) except HCDA, HC deflection length, and HC delta arc length (P > 0.05). CONCLUSIONS: High myopic eyes showed a significantly higher maximum deflection amplitude, lesser A2 time and HC time, less A2DA, smaller HC radius than mild to moderate myopia indicating softer, more deformable corneas. However, better predictor of corneal biomechanics such as Stiffness parameters at A1 (SPA1), DA ratio max, integrated radius, and Corvis Biomechanical Index were similar among both the groups of myopia.
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CASE REPORTS Top

Herpes zoster keratouveitis with hypopyon and hyphema Highly accessed article p. 54
Seng Boon Hwei Katherine, You Siang Ngim, Jalaluddin Juliana, Norlina Ramli
DOI:10.4103/tjo.tjo_20_18  
This study aims to report two cases with an uncommon, early manifestation of herpes zoster ophthalmicus which is keratouveitis. The first patient is a 61-year-old female who had presented with painful facial skin eruption and right eye redness without impairment of vision. She was treated initially as herpes zoster blepharoconjunctivitis; however, the disease had progressed to neurotrophic keratitis with severe anterior chamber reaction manifested by a mixture of hypopyon and hyphema. The second patient is a 74-year-old female who had presented after 2 weeks of facial skin eruption with blurring of vision and similar keratouveitic manifestations. Both patients had poor visual outcome due to severe ocular inflammation.
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Bilateral corneal keloids after eyelid compression p. 58
Ming-Chieh Hsieh, Jen-Yu Huang, Yu-Ling Liu, Chang-Ping Lin
DOI:10.4103/tjo.tjo_120_18  
The purpose of this study is to present a case of bilateral corneal keloids after performing eyelid compression for half a year. This study was a retrospective case report. Visual acuity, as well as detailed high-resolution images of external eye photography, anterior segment optical coherence tomography (ASOCT), and topography were documented. Initially, the best-corrected visual acuities were 20/20 (OD) and 20/32 (OS). ASOCT revealed a characteristic irregular hyperplastic epithelium, a disrupted Bowman's layer, and an edematous stroma for both eyes. Topography exposed an irregular astigmatism of 2.1 diopters for the left eye, while the right eye had a relatively smooth surface. After 1 year of conservative treatment, the best-corrected visual acuity improved to 20/20 (OU), and astigmatism also decreased. Corneal keloid may be induced after long-term eyelid compression. ASOCT and topography are useful for detecting and monitoring disease progression. Conservative treatments are suggested as the first line of therapy, while the size, depth, and location of the lesions are tolerable.
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Central retinal artery occlusion as the presenting manifestation of invasive rhino-orbital-cerebral mucormycosis p. 62
Pritam Bawankar, Sayalee Lahane, Pooja Pathak, Payal Gonde, Anjali Singh
DOI:10.4103/tjo.tjo_72_18  
Rhino-orbital-cerebral mucormycosis (ROCM) is a rare but devastating fungal infection caused by filamentous fungi of the family Mucoraceae. We report a rare case of unilateral ROCM in a diabetic patient where central retinal artery occlusion (CRAO) was the first manifestation of the disease. Magnetic resonance imaging scan revealed orbital and intracranial spread of the disease. Definitive diagnosis was established by culture of the biopsy specimen which showed Rhizopus oryzae on Sabouraud's dextrose agar. The patient was successfully treated with extensive debridement of sinuses and intravenous liposomal amphotericin B; however, the left eye remained blind following the CRAO.
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A case of adult-onset tubulointerstitial nephritis and uveitis syndrome presenting with granulomatous panuveitis p. 66
Kemal Tekin, Yasemin Ozdamar Erol, Olcay Kurtulan, Dilek Ertoy Baydar
DOI:10.4103/tjo.tjo_33_18  
The tubulointerstitial nephritis and uveitis (TINU) syndrome is a rare disorder that is probably underdiagnosed in clinical practice. Ocular involvement in TINU syndrome not only presents with the nongranulomatous anterior uveitis in 80% of patients but also manifests as intermediate, posterior, or panuveitis. This case report mentions an adult male patient who presented with granulomatous iridocyclitis with panuveitis and mild renal insufficiency. Workup for connective tissue and infectious diseases was negative for the patient. He was diagnosed with TINU syndrome based on the findings of renal biopsy. Both the uveitis and nephritis promptly responded well to steroid treatment, and there was no recurrence during the follow-up of 24 months.
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Megaloblastic anemia and bilateral disc edema: An enigma… Have we figured it out yet? p. 71
Harinder Singh Sethi, Mayuresh Naik, Aastha Gandhi
DOI:10.4103/tjo.tjo_27_18  
A 28-year-old male presented with insidious-onset, painless, progressive diminution of vision in both eyes. He denied any other ocular symptoms. On examination, visual acuity in both eyes was 6/60. Color vision and contrast sensitivity were maintained in both eyes. Direct ophthalmoscopy revealed that the optic discs were bilaterally hyperemic and congested, with blurring of all the disc margins and loss of spontaneous venous pulsations. Besides this bilateral disc edema, rest of the clinical examination was normal. Primary intensive search for any intracranial space-occupying lesions returned negative on computed tomography scan imaging. Blood investigations revealed a hemoglobin level of 9.2 g/dl, leukocyte count of 7000 cells/mm3, and serum Vitamin B12 level of 155 pg/ml (200–835 pg/ml). Serum homocysteine and methylmalonic acid levels were done and were found to be elevated. After 4 weeks, visual acuity improved to 6/6 in both the eyes, and laboratory investigations showed no signs of Vitamin B12 deficiency. Nonsurgical causes for papilledema should be considered in the differential diagnosis. Early diagnosis and prompt treatment is the key to a good prognosis in Vitamin B12-deficient optic neuropathy, which has shown to have a good prognosis if treatment is initiated in the first few months after the onset of symptoms.
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