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   Table of Contents - Current issue
October-December 2020
Volume 10 | Issue 4
Page Nos. 241-317

Online since Friday, November 20, 2020

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Is intraocular pressure reduction the key treatment for normal-tension glaucoma? p. 241
Mei-Ju Chen
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Controversies in the association of parapapillary atrophy with glaucoma Highly accessed article p. 243
Syed Shoeb Ahmad, Yusra Tanveer, Musab Siddique, Zeba Saleem
Parapapillary atrophy is a condition which is seen in around 70% of normal individuals. Classically divided into zone alpha and beta, recently, it has been further categorized into zone gamma and delta. Some of these zones of parapapillary atrophy are more prevalent and larger in size in glaucoma patients. Studies have also found the rate of progression of glaucomatous change to be faster in patients with this anomaly. This condition is of clinical significance in glaucoma suspects, as it could be another pointer indicating potential risk of converting to glaucoma. On the contrary, there are other studies which question the relevance of these clinical features in glaucoma patients. In the light of these conflicting reports, it becomes an interesting exercise to explore this controversial area further. This review attempts to determine the role of parapapillary atrophy and its relevance with glaucoma. With this purpose, an online search for this term was conducted on search engines such as PubMed, Google Scholar, and others.
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Normal tension glaucoma in Asia: Epidemiology, pathogenesis, diagnosis, and management p. 250
Mei-Ju Chen
Normal tension glaucoma (NTG) has similar optic neuropathy as primary open-angle glaucoma (POAG), but intraocular pressure (IOP) is within the normal range. Compared with high-pressure POAG, the development of NTG is possibly a consequence of a complex interaction of several ocular and systemic factors. Recent data have shown higher translaminar pressure gradient due to impaired cerebrospinal fluid dynamics may account for the pathogenic mechanism. Insufficient blood supply and vascular dysregulation may also be the cause of the disease. In clinical evaluation, NTG is a diagnosis by excluding other nonglaucomatous optic neuropathies. NTG is characterized by larger and deeper optic-disc cupping, more central visual field defects and a higher incidence of disc hemorrhage compared with POAG. In clinical practice, controlling IOP as low as possible (with medication, laser trabeculoplasty, or surgery) is the key to manage NTG patients. In addition to IOP reduction, the control of systemic risk factors or improving ocular perfusion may be beneficial therapies. NTG is more prevalent in Asia than in the Western countries. Due to increasing old population and underdiagnoses in the clinical settings, NTG became a great challenge for ophthalmologist in Asia. Therefore, the aim of this article is to focus on the epidemiology, to update pathogenesis, diagnosis, and management for NTG.
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Intraocular pressure reduction in glaucoma: Does every mmHg count? p. 255
Hari Jayaram
The reduction of intraocular pressure is currently the only known modifiable risk factor for the treatment of Glaucoma, which is the leading cause of irreversible worldwide blindness. This concise review discusses the evidence underpinning the reduction of intraocular pressure in the treatment of glaucoma, the role of target intraocular pressure in clinical practice and appraises clinical data supporting the concept that every mmHg of intraocular pressure reduction is important in reducing the risk of developing glaucoma and the progression of existing disease. Every mmHg in IOP reduction is important, with evidence showing an impact on both functional and structural progression but does not however explain all glaucoma risk.
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Couching in pediatric patients in Nigeria: Report of a medical socioeconomic dilemma in a developing country p. 259
DS Ademola-Popoola, IA Yusuf
Couching in Nigeria is a well-documented treatment for cataracts among adult population, especially in the northern part of the country. Couching option among the pediatric age group is extremely rare, and its evolvement may be a pointer to deteriorating eye care in the country.
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Results of laser enhancement for residual myopia after primary laser in situ keratomileusis p. 264
Mahfouth A Bamashmus, Hisham A Al-Akhlee, Yasmin A Al-Azani, Najeeb A Al-Kershy
PURPOSE: The purpose of the study is to evaluate and analyze the results and outcomes after laser enhancement for residual myopia after primary laser in situ keratomileusis (LASIK). MATERIALS AND METHODS: This retrospective interventional consecutive case series clinical study was performed on 112 consecutive eyes (82 patients) that had undergone primary LASIK before the enhancement procedure. The study was done in the Refractive Surgery Unit in Yemen Magrabi Hospital between 2006 and 2014. The retreatment was for residual myopia with or without astigmatism. Either the original flap was lifted or surface ablation was performed. Parameters evaluated were uncorrected visual acuity (UCVA) and best spectacle-corrected visual acuity (VA), spherical equivalent (SE) refraction, corneal topography, and pachymetry. Complications after laser enhancement were also evaluated. RESULTS: Mean age of the study group was 26.72 ± 6.89 years (range from 18 to 44 years). Males accounted for 37/82 (45.1%) and females for 45/82 (54.9%). The right eye was treated in 67/112 (59.8%) and the left eye in 45/112 (40.2%). Before primary LASIK, the mean SE (MSE) was −5.78 ± 1.89 D. Before enhancement, the MSE was −1.32 ± 0.61 D (range −3.25 D to −0.50 D), and none of the eyes had an UCVA of 20/40 or better. Twelve months after retreatment, the percentage of eyes having UCVA of 20/40 or better increased to 67.9% (76 of 112). There were no vision-threatening complications seen. CONCLUSION: Retreatment or enhancement after LASIK surgery by lifting the original flap or surface ablation is a safe and effective method for the treatment of regressed or undercorrected myopia. The risk of postoperative complications is very minimal.
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A treatment protocol for minimizing duration and complications of adenoviral epidemic keratoconjunctivitis p. 269
Chidanand Kulkarni, Kirthinath Ballal
PURPOSE: The purpose of the study was to assess the treatment protocol of topical 2.5% Povidone-Iodine (PovI) and 0.1% fluorometholone (FluM) for Adenoviral Epidemic keratoconjunctivitis (EKC) in reducing the duration and severity of the disease as compared to conventional treatment. This was a retrospective case–control study. MATERIALS AND METHODS: Cases were defined as patients with EKC receiving the treatment protocol and conjunctival swab taken for polymerase chain reaction. Controls were defined as similar patients receiving conventional treatment protocol. Forty-one cases and 35 controls were identified for analysis. Cases were treated with a protocol using 2.5% povidone-iodine eye drops and 0.1% FluM eye drops. Controls received conventional treatment until resolution of signs and symptoms. Both the groups were followed up for 1 month. Data collected were analyzed for effect of the two treatment protocols on the duration of EKC, rate of recovery, and incidence of complications. RESULTS: The treatment protocol was significantly better than conventional treatment protocol in achieving cure (P = 0.002) with large effect size. The proportion of cases achieving cure was significantly higher with treatment protocol (64% vs. 11% at 5 days, P < 0.001) by 5 days. There was a significant reduction of the subepithelial infiltrates (SEI) incidence group (10% vs. 57%, P < 0.001). There were no SEI at 1 month in the treatment group (0% vs. 31%). CONCLUSION: Treatment protocol used in our study can significantly reduce the severity and duration of EKC. It can prevent chronic keratitis in majority of cases. Since povidone-iodine is nonspecific and virucidal for adenovirus, this therapy can be used for other types of adenoviral conjunctivitis.
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Visual outcome and factors influencing surgical outcome of horizontal strabismus surgery in a teaching hospital in Malaysia: A 5-year experience p. 278
Hussein Waheeda-Azwa, Ibrahim Norihan, Evelyn Li Min Tai, Yee Cheng Kueh, Ismail Shatriah
PURPOSE: The available data on strabismus surgery in South East Asian countries are scarce. This study aimed to identify visual outcome and factors influencing surgical outcome of horizontal strabismus surgery in a Southeast Asian cohort. MATERIALS AND METHODS: A retrospective review of patients who underwent horizontal strabismus surgery between 2013 and 2017 in Hospital Universiti Sains Malaysia was conducted. Surgery was considered successful if the post-operative deviation was within 10 prism diopters at 6 months' postoperative period. Factors influencing the outcome of surgery at 6 months were identified. Chi-square and Fisher's exact tests were used in data analysis. RESULTS: Ninety-eight patients were included. Both genders were equally affected. Exotropia (58.2%) was the most common type. About 65.3% of patients had alternating strabismus, while 51% had an angle of deviation of more than 45 prism diopters. Amblyopia was documented in 14.3% of patients. Those operated on below 10 years of age comprised 64.3%. Ninety-four patients completed follow-ups at 6 months after the surgery. The success rate was 81.6%. Approximately 92% of the patients had best-corrected visual acuities of 6/12 and better at 6 months' postoperative period. There was no significant association between age of onset, gender, presence of amblyopia, type of deviation, amount of deviation, and postoperative best-corrected visual acuity with surgical outcome at 6 months' postoperative period (P > 0.05). CONCLUSION: The success rate was good. Postoperative best-corrected visual acuity was promising. Age of onset, gender, presence of amblyopia, type of deviation, amount of deviation, and postoperative best-corrected visual acuity did not influence the outcome of horizontal strabismus surgery in our review.
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Factors impacting gas fill after microincision vitrectomy surgery combined with fluid–gas exchange p. 284
Meng-Syuan Li, Yu-Harn Horng, Huey-Shyan Lin, Shwu-Jiuan Sheu
PURPOSE: The objective of the study was to investigate possible factors influencing gas fill after microincision vitrectomy surgery (MIVS) combined with fluid–gas exchange. MATERIALS AND METHODS: This was a retrospective chart review of patients who underwent MIVS combined with fluid–gas exchange (20% C3F8) from February 2017 to December 2017. RESULTS: Sixty-one eyes of 58 patients were identified. The mean age was 59.97 ± 9.65 years. The mean gas fill percentage was 76.28% ± 14.29% on day 1, 65.49% ±13.65% on day 3, 60.03% ± 14.53% on day 4, and 43.9% ± 20.88% on day 7 postoperatively. Compared to phakic eyes, eyes that were pseudophakic prior to surgery had a lower gas fill on days 1–3, but the difference did not reach significance on day 3. Eyes that underwent phacovitrectomy had a significantly lower gas fill on days 1–3 than eyes that did not. CONCLUSION: Postoperative pseudophakic status is associated with lower gas fill after MIVS. Adjusted gas fill should be considered in these cases.
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Ziv-aflibercept and bevacizumab for exudative age-related macular degeneration: A retrospective comparison of clinical outcomes and cost at 1 year p. 289
Sumit Randhir Singh, Ravi Parikh, Yoichi Sakurada, Bhushan Uplanchiwar, Ahmad Mansour, Abhilash Goud, Yasha S Modi, Jay Chhablani
PURPOSE: The purpose of this study was to compare intravitreal ziv-aflibercept (IVZ) monotherapy to intravitreal bevacizumab (IVB) monotherapy in patients with exudative age-related macular degeneration (eAMD). MATERIALS AND METHODS: Patients with treatment-naïve eAMD treated with pro re nata (PRN) monotherapy of IVZ (1.25 mg/0.05 ml) or IVB (1.25 mg/0.05 ml) with a minimum follow-up of 12 months were retrospectively analyzed. Study outcomes included change in best-corrected visual acuity (BCVA), central macular thickness, mean number of injections, and total medication cost in both the groups at 12 months. RESULTS: Forty-seven eyes (IVZ, 18/47 [38.3%] and IVB, 29/47 [61.7%]) from 47 treatment-naive patients were included. The change in BCVA for patients receiving IVZ was from 0.61 ± 0.33 logarithm of the minimum angle of resolution (Snellen 20/81; range: 20/38–20/174) to 0.45 ± 0.31 (Snellen 20/56; range: 20/27–20/115) at 1 year (P = 0.02). The total number of injections needed to achieve the resolution of intraretinal or subretinal fluid was 2.6 ± 1.4 and 3.5 ± 1.3 for IVZ and IVB, respectively (P = 0.029). Direct medication cost of IVZ and IVB in our cohort on PRN basis was an average of US$78 (2.6 × US$30) and US$175 (3.5 × US$50), respectively, through 1 year. CONCLUSION: IVZ-PRN monotherapy resulted in improved visual acuity, reduced treatment burden, and reduced direct medication cost in comparison to IVB-PRN monotherapy through 1 year.
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A novel G26A variation in 5′ half of TGIF1 gene associates with high myopia in ethnic Kashmiri population from India p. 294
Shabhat Rasool, Rubiya Dar, Arif Akbar Bhat, Shiekh Gazalla Ayub, Muneeb U Rehman, Sabia Rashid, Tariq Jan, Khursheed Iqbal Andrabi
This study aims to look at novel variations in TGIF1 gene and explores their potential association with high myopia in an ethnic population from Kashmir (India). Genomic DNA was genotyped for polymorphic variations, and allele frequencies were tested for the Hardy–Weinberg disequilibrium in 240 ethnic Kashmiri cases with high myopia with a spherical equivalent of >−6 diopters (D) and compared with emmetropic controls with spherical equivalent within −0.5D in one or both eyes represented by a sample size of 228. In this study, we found a novel sequence variation G26A (GAT to AAT) in 5′ half of TGIF1 gene (p. aspartic acid >asparagine) at a frequency of 62% (148/240, P ≤ 0.0001). Variation appears to associate with high myopia significantly (P ≤ 0.001) as it happens to be present only in high myopia affected individuals. Further, it shows statistical significance for its association with gender and the degree of myopia (P ≤ 0.05). In addition, in silico predictions show that variation likely has an impact on the structure and functional properties of the protein. The assessment of the I-TASSER protein structure showed higher energy for a wild-type protein (−5820.186 kJ/mol) as compared to mutant protein (−6595.593 kJ/mol).
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Intraoperative capsular marking for toric intraocular lens placement p. 298
Harinder Singh Sethi, Mayuresh P Naik
Preoperatively, the surgeon instills two drops of 0.5% proparacaine and then marks the 0° and 180° points at the limbus using a Gentian violet marker and 26G needle edge. Intraoperatively, after phacoemulsification and irrigation and aspiration of the cortex are complete, the surgeon inspects the previously marked 0°–180° points on the limbus. In case the steeper astigmatic meridian needs to be marked, a Mendez Ring is used and the meridian is marked using a Gentian violet marker and 26G needle edge. The desired markings (2 mm in length only) on the anterior lens capsule can be made using 26G needle bent at the bevel or using micro-vitreoretinal scissors. The toric intraocular lens (IOL) is then rotated in the bag in the desired meridian (customized-toric IOL in 0°–180° meridian and noncustomized toric IOL in steeper marked meridian), viscoelastic substance is aspirated and corneal wounds are hydrated.
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A refractory malignant glaucoma posttrabeculectomy in vitrectomized eye: A case report and review of the literature p. 302
Hung-Chi Lai, Kwou-Yeung Wu, Han-Yi Tseng
The objective of this study is to report a case of refractory malignant glaucoma post trabeculectomy in vitrectomized eye and review of previous literature in PubMed database. A 63-year-old male encountered malignant glaucoma after trabeculectomy in vitrectomized eye. We had tried vitreous tapping with peripheral iridectomy and vitreous tapping with intracameral injection of room air (Chandler procedure). All of previous procedures were in vain. Finally, the yttrium–aluminum–garnet laser membranectomy with zonulectomy was done. The intraocular pressure is within normal range without any topical glaucoma eye drops during 3-year outpatient department regular follow-up. Complete vitrectomy with a patent tunnel from posterior chamber to anterior chamber (iridectomy-zonulectomy) is the effective procedure to manage of malignant-like glaucoma.
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Isolated abducens nerve palsy following temporal bone fracture in a child p. 306
Vibha Baldev, Shailja Tibrewal, Soveeta Rath, Suma Ganesh
Temporal bone fractures are often associated with damage to middle or inner ear structures, facial nerve, and cerebrospinal fluid (CSF) leak, and rarely with abducens nerve palsy. Isolated abducens nerve palsy is not known to occur following temporal bone fracture and is most commonly associated with concurrent facial nerve injury. We report a case of an 11-year-old girl who presented with isolated right abducens nerve palsy following head trauma. The child had incurred injury following a fall from a bicycle. The presence of postauricular ecchymosis was suggestive of possible temporal bone fracture. High-resolution computed tomography scan revealed undisplaced fracture of the right temporal bone at the petrous apex. Identification of temporal bone fracture prompted toward complete neurological and otological evaluation to detect life-threatening complications like CSF otorrhea. The child was managed conservatively with occlusion therapy to alleviate diplopia and showed complete resolution of the nerve palsy after 4 months. Isolated abducens nerve palsy following the temporal bone fracture is a rare finding. Additional clinical findings like postauricular ecchymosis should be looked for, and appropriate otological evaluation sought in such cases.
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Cyclosporine 0.1%(Ikervis®) as a corticoid-sparing agent in Lyell syndrome with KeraKlear® keratoprosthesis p. 309
Miriam Rahhal-Ortuno, Alex-Samir Fernández-Santodomingo, Carla Villena-Alvarado, Emma Marín-Payá, Marina Aguilar-González, Salvador García-Delpech
Cyclosporine 0.1% was used in a patient with Lyell syndrome, which had undergone a KeraKlear® keratoprosthesis implant due to the severe ocular involvement to avoid overuse of corticoid agents. To the best of our knowledge, this is the first reported case of cyclosporine 0.1% eye drops to use in Lyell syndrome previously treated with keratoprosthesis implant.
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Surgical management of complications in a case of progressive outer retinal necrosis p. 312
Navneet Mehrotra, Jayesh Khandelwal, Manish Nagpal
We report a case of bilateral progressive outer retinal necrosis (PORN) in a patient with acquired immune deficiency syndrome with CD4 count 50 cells/μL. He was treated with standard intravenous and intravitreal antivirals but ultimately developed complications such as retinal detachment and epiretinal membrane. His vision was preserved with early pars plana vitrectomy. This case demonstrates that prompt clinical diagnosis of PORN with its successful medical and surgical management can help prevent progression of this frightening disease.
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Anti-N-methyl-D-aspartate receptor optic neuritis in a patient without history of encephalopathy p. 315
Seyed Mohammad Baghbanian, Abdorreza Naser Moghadasi
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Corrigendum: Optical coherence tomography features in a case of Type I sialidosis p. 317

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