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   Table of Contents - Current issue
July-September 2020
Volume 10 | Issue 3
Page Nos. 151-240

Online since Wednesday, September 16, 2020

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Keep an eye on acute optic neuropathy p. 151
Tzu-Lun Huang
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Ocular manifestation, comorbidities, and detection of severe acute respiratory syndrome-coronavirus 2 from conjunctiva in coronavirus disease 2019: A systematic review and meta-analysis p. 153
Xiao Chun Ling, Eugene Yu-Chuan Kang, Jui-Yen Lin, Hung-Chi Chen, Chi-Chun Lai, David Hui-Kang Ma, Wei-Chi Wu
The coronavirus disease 2019 (COVID 19) pandemic has presented major challenges to ophthalmologists. Reports have shown that ocular manifestations can be the first presenting symptoms of COVID 19 infection and conjunctiva may be a portal of entry for the severe acute respiratory syndrome (SARS) associated coronavirus 2 (SARS CoV 2). The purpose of this article is to provide general guidance for ophthalmologists to understand the prevalence of ocular presentation in COVID 19 patients and to reduce the risk of transmission during practice. Relevant studies published in the period of November 1, 2019, and July 15, 2020, regarding ocular manifestations of COVID 19 and detection of SARS CoV 2 in the eye were included in this systematic review and meta analysis. The pooled prevalence of the ocular manifestations has been estimated at 7% (95% confidence interval [CI]: 0.03–0.10) among COVID 19 patients. The pooled detection rate of SARS CoV 2 from conjunctiva was low (1%, 95% CI: 0.00–0.03). Conjunctival symptoms were the most common ocular manifestations in COVID 19, but the positive detection rate of the SARS CoV 2 virus by reverse transcription–polymerase chain reaction of conjunctival tears or secretions remained low. No study has shown a definite transmission of COVID 19 through ocular mucosa or secretions. In summary, ocular manifestations in COVID 19 patients commonly comprise ocular surface symptoms. Although a low prevalence of ocular symptoms was encountered among patients infected by SARS CoV 2, it is imperative for all ophthalmologists to understand the full spectrum of COVID 19 symptoms or signs including those of the eyes as well as to adopt appropriate protective measures during clinical practice.
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Posterior ischemic optic neuropathy: Perioperative risk factors p. 167
Michelle Y Wang, Ryan Brewer, Alfredo A Sadun
Perioperative posterior ischemic optic neuropathy (PION) is a rare but devastating condition. Visual impairment is commonly bilateral, profound, and irreversible. The most frequently associated triggering events are spine surgeries, other orthopedic surgeries, cardiac bypass surgeries, and radical neck dissection. The etiology is multifactorial. The most commonly reported risk factors are severe and prolonged hypotension, anemia, hemodilution, orbital and periorbital edema, direct orbital compression by prone position, and abnormal autoregulation. This review discusses the current literature on perioperative PION and includes a study conducted by our group to investigate the perioperative risk factors of PION in order to better understand the pathogenesis and help identify high-risk patients. Our results provide further corroborating evidence that PION is associated with spinal, cardiovascular, and abdominal surgeries, longer duration of procedure, and facial edema. Anemia and chronic hypertension are frequent risk factors. Treatment for perioperative PION is uncertain and depends largely on the immediate reversal of hemodynamic alterations. Hence, it is important to identify patients at risk and accordingly take prophylactic measures to prevent its occurrence. Optimizing hemoglobin levels, hemodynamic status, and tissue oxygenation is crucial.
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Progress in the pathogenesis of thyroid-associated ophthalmopathy and new drug development p. 174
Yazhuo Huang, Sijie Fang, Shuo Zhang, Huifang Zhou
Thyroid-associated ophthalmopathy (TAO) is the most common extrathyroidal manifestation of toxic diffuse goiter (Graves' disease), also known as Graves' ophthalmopathy/orbitopathy. As an organ-specific autoimmune disease, the pathogenesis of TAO is still unclear. In recent years, great progress has been made in revealing the mechanism of TAO. Various biological and immunosuppressive agents have emerged in an endless stream, showing encouraging results. Strengthening the basic research, establishing ideal animal models, deeply understanding the pathogenesis, and developing novel targeted drugs are of great significance to guide the clinical diagnosis and management of TAO and improve the prognosis of patients.
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Orbital hybrid peripheral nerve sheath tumors p. 181
Kai Ching Peter Leung, Tak Chuen Simon Ko
Hybrid peripheral nerve sheath tumors (HPNST) are recently classified tumors from the World Health Organization Classification of soft tissue tumors that display combined features of more than one peripheral nerve sheath tumor. Acknowledgment is important because of its association with the development of neurofibromatosis type 1, type 2, and schwannomatosis. Orbital involvement is rare and only six cases of HPNST have been documented on literature. This article serves to review the pathophysiology, clinical manifestation, diagnosis, treatment, and prognosis of this infrequent but important orbital tumor.
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Peripapillary and macular choroidal thickness in both eyes of patients with acute unilateral retrobulbar optic neuritis p. 184
Alireza Dehghani, Heshmatollah Ghanbari, Mohammadreza Akhlaghi, Farzan Kianersi, Mohammad-Hasan Alemzadeh-Ansari
PURPOSE: The purpose of this study was to examine macular and peripapillary choroidal thickness (CT) in patients with acute unilateral retrobulbar optic neuritis. MATERIALS AND METHODS: In this cross-sectional study, 19 patients with acute unilateral retrobulbar optic neuritis were examined. A control group was matched with patients for sex and age. Enhanced depth imaging optical coherence tomography in macula and peripapillary areas in both eyes was performed for evaluation of CT. The CT was measured in subfoveal and other six points of macula and four points of peripapillary areas with a 3.4-mm scan circle centered on the optic nerve head. RESULTS: The mean subfoveal CT was 384.7 ± 101.6 μm, 380.5 ± 109 μm, and 401.2 ± 84.6 μm for affected eye, unaffected fellow eye, and healthy control, respectively. All measurements of macular CT were thinner in the patient group compared with healthy controls. Global peripapillary CT in affected eyes, unaffected fellow eyes, and healthy controls were 202 ± 43.3, 195.1 ± 42.9, and 234 ± 71.2, respectively. The difference between the three groups was statistically significant in the nasal point of peripapillary area (P = 0.023). No correlation was seen between CT and initial visual acuity or duration from symptom onset to medical survey in acute phase of retrobulbar optic neuritis. CONCLUSION: Patients with acute retrobulbar optic neuritis showed no significantly thinner macular and peripapillary CT in both eyes compared with healthy controls.
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Evaluation of retinal nerve fiber layer thickness and optic nerve functions in fellow eye of neuromyelitis optica with unilateral optic neuritis p. 189
Wendy Ong Chin Feng, Wan Hazabbah Wan Hitam
Purpose: Peripapillary retinal nerve fibre layer (RNFL) thickness might be useful in monitoring ongoing subclinical structural damage especially in eyes with no history of optic neuritis (ON) in neuromyelitis optica (NMO). Objective: To evaluate the peripapillary RNFL thickness and optic nerve functions in fellow eye of NMO with unilateral optic neuritis. Materials and Methods: A comparative cross-sectional study was conducted in 2 tertiary hospitals from August 2017 to May 2019. RNFL thickness and optic nerve functions were evaluated. Statistical analysis was performed using Statistical Package for Social Science version 24. Results: A total of 26 NMO patients and 26 controls were involved in this study. The median age (IQR) of NMO patients was 32.5 (12) years old. The RNFL thickness was significantly reduced in NMO patients with non-ON eyes as compared to control group. Best corrected visual acuity between the 2 groups were comparable (0.20 vs 0.00, p=0.071). Contrast sensitivity was also reduced in NMO patients (non-ON eyes) at all 5 spatial frequencies. In NMO group, 34.6% have normal colour vision. The mean deviation (MD) of Humphrey visual field (HVF) was higher in NMO group (p<0.001). There was a moderate correlation between RNFL thickness and contrast sensitivity. Weak correlation was found between the RNFL thickness with visual acuity and mean deviation of visual field test. Conclusion: Our study showed that the fellow eye of NMO patients with unilateral ON revealed a significant reduction in RNFL thickness and all the optic nerve functions have subtle early changes that signify a subclinical retinal damage.
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Factors associated with severity of orbitopathy in patients with Graves' disease p. 197
Tauseef Nabi, Nadeema Rafiq
PURPOSE: Graves' orbitopathy (GO) is one of the most frequent orbital disorders and is the most common cause of proptosis in adults. GO is described as chronic inflammation of orbital and periorbital tissues. This study aimed to evaluate the risk factors for severe GO in patients with Graves' disease (GD). MATERIALS AND METHODS: This was a prospective cross-sectional study done on 52 newly diagnosed patients of GD with GO documented by thyroid99mTechnetium-pertechnetate scan at our center between May 2016 and May 2019. All patients underwent a comprehensive ophthalmological examination and laboratory and hormonal analysis. Clinical Activity Score (CAS) and severity were estimated as per the European Group on Graves Orbitopathy. Thirty-four patients with mild GO were compared with 18 patients with moderate-to-severe GO (severe) for baseline risk parameters. RESULTS: Majority of the patients had mild orbitopathy (34 [65.4%]) followed by moderate to severe (18 [34.6%]). CAS was active in 13.5% of the study group. There was a statistically significant male preponderance in severe GO. Current smoking increased the risk of severe GO (P = 0.003). Duration of GD symptoms at presentation was statistically significantly longer in severe GO patients than mild GO (P = 0.004). Thyrotropin receptor antibody (TRAb) titer significantly increased in severe GO group (6.2 ± 2.4 IU/L) when compared to mild GO (3.2 ± 1.6 IU/L) (P < 0.001). TRAb positivity was similar between groups. Braley's sign, i.e., the differential intraocular pressure (IOP) of >6 mmHg, was statistically significantly higher in severe GO (P < 0.001). Male gender, current smoking, TRAb >2 upper limit of normal (ULN), and differential IOP >6 mmHg were found to be associated with severe GO. CONCLUSION: Approximately 35% of the patients with GO have severe disease, with a higher risk in men. This study identified male gender, current smoking, TRAb >2 ULN, and differential IOP >6 mmHg to be associated with severe GO.
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Quality of life in children with low vision following use of low vision aids Highly accessed article p. 203
V Kavitha, Mallikarjun M Heralgi, Mubashir Parkar, Sneha Harogoppa
CONTEXT: Vision loss early in life has profound functional and psychological implications. Functional vision, defined as vision that can be used to perform a task(s) requiring vision, can be assessed by a number of tools. Questionnaires are a popular tool. AIMS: This study aimed at assessing the vision-related quality of life (QOL) with the help of LV Prasad-Functional Vision Questionnaire (LVP-FVQ) and also to analyze the outcome of baseline best-corrected visual acuity (BCVA) 3 months after the introduction of low vision aids (LVAs) in children with low vision (LV). SETTINGS AND DESIGN: This was a prospective, longitudinal study. SUBJECTS AND METHODS: Thirty children aged between 8 and 18 years with LV were recruited and prescribed LVAs for distance and/or near based on their needs. The QOL and BCVA for distance and near were assessed before and 3 months after the introduction of LVAs. STATISTICAL ANALYSIS USED: Descriptive and inferential statistical analyses. Student's t-test was used to calculate the P value. RESULTS: There was a significant improvement in the vision-related QOL (P < 0.001) as well as the baseline BCVA (P = 0.002), 3 months after use of LVAs. CONCLUSION: LVAs are effective in improving the vision-related QOL and can also act as vision stimulator.
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A novel technique for closed-chamber iridodialysis repair p. 208
Jen-Yu Huang, Yu-Ling Liu, Ya-Chi Huang, Chang-Ping Lin
PURPOSE: We introduce a novel technique for closed chamber iridodialysis repair. MATERIALS AND METHODS: We use a 2.8-mm paracentesis knife to penetrate into the anterior chamber and create interrupted incisions in the sclera. The wounds are 1.5 mm distant from the limbus, at consistent 2.8-mm intervals along the dialysis area. After injecting viscocohesive ophthalmic viscosurgical device through a side port to relieve the synechia and to push the iris toward the incisions, the iris is then grasped by Kelman forceps through the sclera, dragged carefully, and incarcerated. After adjusting the tension of the iris according to the pupil shape, the sclera and the incarcerated iris tissue were sutured together with 10-0 nylon. RESULTS: The technique was effective in six patients with traumatic iridodialysis. CONCLUSION: Our surgical technique repairs the iris, restores the shape of pupil, as well as avoids creating a large incision in the limbus in patients suffering from iridodialysis.
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Comparison of endpoint of subjective cycloplegic refraction with artificial aperture and post-mydriatic test among adults with refractive error p. 212
Nagarajan Theruveethi, Ramesh S Ve, Krithica Srinivasan
PURPOSE: There is a need to understand the requirement for the post-mydriatic test (PMT) among adults for the final prescription of spectacles as this test increases the cost of eye care and causes inconvenience to the patient because of the additional visit to an eye care practitioner. We aim to compare the cycloplegic subjective refraction using apertures of various sizes and PMT in an adult population. METHODS: This prospective crossover study was conducted under standard settings in an eye clinic. Adult individuals between 18 and 35 years of with emmetropia and various degrees of ametropia participated in this study. Individuals with known ocular pathology were excluded. Non-cycloplegic objective refraction was performed followed by subjective refraction. Cycloplegic objective refraction was performed followed by subjective refraction with custom designed artificial apertures. After a washout period of cycloplegic, PMT was performed. The distribution of data was tested using the Kolmogorov–Smirnov test. Depending on the distribution of the data, either parametric or nonparametric test was done. RESULTS: Fifty-nine eyes of thirty individuals with a mean (±SD) age of 23(±4) years with a male: female ratio of 1:4 participated in this study. A comparison of measures of PMT and subjective refraction with 2, 3, 4, 5, and 6 mm aperture under cycloplegic effect using the Friedman test rendered a Chi square value (df = 5) of 1.92 which was not statistically different (P = 0.86). CONCLUSION: Performing subjective refraction with an appropriate spherical and cylindrical endpoint under cycloplegic effect with appropriate aperture overcomes the necessity of PMT.
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Sanjaa-Uyen-Tumur ophthalmometer: An introduction of the objective ophthalmometer p. 217
Uyen Bold, S Tumur, Otgonchimeg Kh, E Sanjaa
PURPOSE: The purpose is to present the objective of the Sanjaa-Uyen-Tumur (SUT) ophthalmometer and compare its measurements with the standard Hertel exophthalmometer. METHODS: Eyeball position of 88 healthy eyes of the patients was measured using both the SUT ophthalmometer and Hertel exophthalmometer. Both methods were performed in one session by the same experienced ophthalmologist. Data were analyzed using Bland–Altman method. RESULTS: Mean age of the participants was 41.11 ± 14.08, further, 59% (26) were male and 41% (18) were female, respectively. The mean difference was 0.1420455 and the standard deviation of the difference was 0.9221067, 95% confidence interval, respectively. Based on the Bland–Altman analysis, lower limit of agreement in our study was from −2.284538 to −1.614211 and upper limit of agreement was from 1.33012 to 2.000447. According to the results of our studies, there is no relationship between the difference and the level of measurement in either plot. CONCLUSION: This SUT ophthalmometer can be used same as the Hertel exophthalmometer in ophthalmology practice as can be accurate, affordable, and objective.
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Acute zonal occult outer retinopathy presenting as optic neuritis p. 222
Pai-Huei Peng, Tong-Sheng Lee, Cheng-Kuo Cheng, Chi-Hsien Peng, Wei-Chun Chan
Acute zonal occult outer retinopathy (AZOOR) is an outer retinal disorder characterized by the acute loss of visual functions. Herein, we report a case of AZOOR presenting features mimicking optic neuritis. A 17-year-old healthy male reported fogginess in the right eye for 2 weeks. His best-corrected visual acuity was 20/20 in both eyes. Results of a color vision test and pupillary reaction were unremarkable. Funduscopic examination revealed a subtle hyperemic disc surrounded by hyperpigmentation in the right eye. Visual field examination confirmed an enlarged blind spot in the affected eye. Fundus autofluorescence imaging revealed zonal hyperautofluorescence around the optic disc. Fluorescein angiography showed optic disc staining and a window defect in the retinal pigment epithelium. Optical coherence tomography demonstrated loss of the ellipsoid line at the corresponding hyperautofluorescent region. All these characteristics indicated a diagnosis of AZOOR. However, the prolonged P100 wave observed through visual-evoked potential examination, hyperintensity T2 signal at the retrobulbar optic nerve through magnetic resonance imaging, and mild hyperemic optic disc along with optic disc staining through fluorescein angiography resemble the characteristics of optic neuritis. Because the clinical features of AZOOR are similar to those of optic neuritis, ophthalmologists should be able to differentiate between these two diseases to achieve a timely and correct diagnosis.
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Sarcoidosis presenting as lacrimal gland enlargement: Eyes speak the truth p. 227
Arjit Agarwal, Shruti Chandak
Bilateral lacrimal gland enlargement is uncommon; however, its presence induces brainstorming process and intensive discussion between a clinician and an imaging specialist, leading to exploration of multiple systemic disease patterns such as lymphoproliferative disorders, sarcoidosis, Sjögren's syndrome, and tuberculosis. Thoughtful analysis and diagnostic work-up are required to confirm the diagnosis. Sarcoidosis is a rare systemic disease, with ocular involvement being still rarer. Here, we report a case of a young male presenting with nodular swelling over lateral aspects of both the eyes. The imaging study revealed bilateral lacrimal gland enlargement. Further work-up revealed mediastinal and hilar lymphadenopathy with pulmonary nodules which along with biochemical tests lead to the diagnosis of sarcoidosis. The case highlights the ocular symptoms in sarcoidosis and clinicoradiological approach to bilateral lacrimal gland enlargement.
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Combined superior oblique palsy and ipsilateral Brown's syndrome after a closed-head trauma: A case report and brief review p. 231
Yao-Lin Liu
Closed-head trauma is a well-recognized etiology of acquired superior oblique (SO) palsy. However, combined SO palsy and ipsilateral Brown's syndrome after a closed-head trauma is rare. We describe a patient with this ocular motility disorder and conduct a brief review of the literature.
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Concomitant abducens and facial nerve palsies: A rare presentation in anti-aquaporin-4 antibody-positive neuromyelitis optica p. 235
Kok-Tian Oo, Kim-Siang Tay, Wan-Chung Law, Ismail Shatriah
Over the past decade, the discovery of disease-specific aquaporin-4 antibodies has led to a better understanding of the diverse spectrum of disorders that are associated with neuromyelitis optica. Brainstem manifestations have been increasingly recognized in this disease. However, multiple cranial nerve palsies as an initial presentation of neuromyelitis optica are uncommon. We report a rare case of anti-aquaporin-4 antibody-positive neuromyelitis optica that presented with unilateral abducens and facial nerve palsies. Notably, this case did not involve the optic nerve or the spinal cord. Diagnosing neuromyelitis optica that presents as an isolated acute brainstem syndrome is challenging, but the outcome may be devastating if the diagnosis is delayed.
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Rapid visual loss associated with fulminant idiopathic intracranial hypertension p. 239
Neeraj Saraswat, Ramanuj Samanta, Gitanjli Sood, Sandhya Yadav, Ajai Agrawal
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