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   Table of Contents - Current issue
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April-June 2021
Volume 11 | Issue 2
Page Nos. 111-203

Online since Wednesday, June 16, 2021

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EDITORIAL  

What's new in the world of corneal treatment p. 111
Wei-Li Chen
DOI:10.4103/tjo.tjo_17_21  
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REVIEW ARTICLES Top

Advances in refractive corneal lenticule extraction p. 113
Matthias Fuest, Jodhbir S Mehta
DOI:10.4103/tjo.tjo_12_21  
Refractive errors are the leading cause of reversible visual impairment worldwide. In addition to the desired spectacle independence, refractive procedures can improve quality of life, working ability, and daily working performance. Refractive corneal lenticule extraction (RCLE) is a relatively new technique, dependent only on a femtosecond laser (FS). This leads to potential benefits over laser-assisted in situ keratomileusis (LASIK) including a quicker recovery of dry eye disease, a larger functional optical zone, and no flap-related complications. SMILE, available with the VisuMax FS (Carl Zeiss Meditec AG, Jena, Germany), is the most established RCLE application, offering visual and refractive outcomes comparable to LASIK. SmartSight (SCHWIND eye-tech-solutions GmbH, Kleinostheim, Germany) and CLEAR (Ziemer Ophthalmic Systems AG, Port, Switzerland) are two new RCLE applications that received Conformité Européenne (CE) approval in 2020. In this article, we review refractive and visual outcomes, advantages, and disadvantages of RCLE and also report on the latest advances in RCLE systems.
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Regenerative medicine in Fuchs' endothelial corneal dystrophy p. 122
Amy E Yuan, Roberto Pineda
DOI:10.4103/tjo.tjo_23_20  
The management of Fuchs' endothelial corneal dystrophy (FECD) has evolved rapidly since the introduction of endothelial keratoplasty (EK). In recent years, advances in our understanding of endothelial cell biology, in particular with respect to the regenerative capacity of endothelial cells, have opened the door to novel therapeutic options that stray from the traditional paradigm of allograft transplantation. We review the development of descemetorhexis without EK (DWEK) as a primary treatment for FECD and discuss the lessons learned to date about the mechanism of wound healing, surgical technique, patient selection, and refractive outcomes. Multiple randomized clinical trials are currently underway to evaluate the potential for pharmacological supplementation with rho-associated kinase inhibitors to increase the success rate of corneal clearance following DWEK. Biologic supplementation with intracameral endothelial cell injection and acellular Descemet's membrane transplantation are other avenues of adjuvant therapy. DWEK is a promising surgical option for management of a subset of FECD patients.
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Update on the application of amniotic membrane in immune-related ocular surface diseases p. 132
Ziyan Chen, Hubert Yuenhei Lao, Lingyi Liang
DOI:10.4103/tjo.tjo_16_21  
Immune-related ocular surface diseases, a group of diseases in which immune dysregulation damages the ocular surface, can induce uncontrolled inflammation and persistent epithelial defect, thus leading to the most severe forms of acute keratoconjunctivitis, dry eye disease, epithelial keratitis, stromal ulceration, and corneal perforation. As these diseases are often refractory to treatments, they have a threatening impact on the vision and life quality of patients. This review summarizes the current literature regarding the clinical application of sutured and self-retained cryopreserved amniotic membrane (AM) in treating Stevens–Johnson syndrome/toxic epidermal necrolysis, ocular graft-versus-host disease, Sjögren's syndrome, Mooren's ulcer, and peripheral ulcerative keratitis. Current evidence supports the safety and effectiveness of AM, especially self-retained cryopreserved AM, in decreasing ocular surface inflammation, promoting corneal epithelial and stromal healing, improving visual acuity, and preventing sight-threatening complications. Future studies are still required to validate the above findings and explore the varied application methods of AM to improve the clinical efficacy in maintaining ocular surface health.
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ORIGINAL ARTICLES Top

Corneal biomechanical properties in patients with kidney transplant p. 141
Vaibhav Kumar Jain, Rachna Agarwal, Shabari Pal, Jaya Kaushik, Kumudini Sharma, Vikas Kanaujia
DOI:10.4103/tjo.tjo_24_20  
PURPOSE: The purpose of the study was to evaluate the corneal biomechanical properties in patients post kidney transplant and to compare them with healthy age-matched control. MATERIALS AND METHODS: In this cross-sectional study, 68 patients with kidney transplant (study group) and 68 healthy individuals (control group) were analyzed with ocular response analyzer measurements. Only the right eye of each participant was assessed for corneal hysteresis (CH), corneal resistance factor (CRF), corneal-compensated intraocular pressure (IOPcc), and Goldmann-correlated intraocular pressure (IOPg). RESULTS: The mean CH in the study group was 9.70 ± 1.62 mmHg which was significantly lower than the control group with the mean CH of 10.60 ± 1.49 mmHg (P = 0.001). The mean IOPcc was 18.17 ± 4.00 mmHg and 16.00 ± 3.94 mmHg in the study and control groups, respectively (P = 0.002). CRF and IOPg were not significantly different between groups. CONCLUSION: CH and IOPcc are altered in kidney transplant patients.
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Clinical characteristics and topographic findings of corneal ectasia in patients with symptomatic Demodex blepharitis p. 146
Kuo-Hsuan Hung, Hsin-Yuan Tan, Hung-Chi Chen, Lung-Kun Yeh
DOI:10.4103/tjo.tjo_45_20  
PURPOSE: The purpose of this study is to present characteristics and topographic findings of patients with corneal ectasia and symptomatic ocular demodicosis. MATERIALS AND METHODS: A retrospective, noncomparative study. Twenty-one patients with symptomatic ocular demodicosis and corneal ectasia since 2017 to 2019 were enrolled. Patients with dry eye syndrome and meibomian gland dysfunction were identified and treated. Demographic data, topography, and clinical data were collected. All patients underwent lash sampling to confirm Demodex mite infestation by direct visualization under the microscope. RESULTS: Twenty-one ectasia patients (36 eyes) were enrolled with male preponderance (M:F =18:3). Mean age (years) was 28.6 ± 8.12. Of the 21 cases reviewed, the average number of topography taken was 6.8 within 43.8 months of follow-up. Corneal ectasia was characterized by focal thinning area beside central cornea, with corresponding mean thickness of 487.1 μm and 518 μm, respectively. All ectasia patients were combined with Demodex blepharitis and associated symptoms, proven by direct microscopic examination. After treatment with eyelid cleanser (OCuSOFT® Lid Scrub® PLUS), warm compress, and improved daily hygiene, ocular demodicosis and topographic changes were controlled and even reversed. CONCLUSION: Our results indicated that ocular demodicosis may be potentially associated with corneal ectasia. Demodex blepharitis still remains an overlooked differential diagnosis in clinic; however, it may be one of the risk factors triggering eye rubbing. Comorbidity of lid infestation with eye rubbing may lead to corneal ectasia, even in elder patients with thick cornea. Therefore, meticulous examination and intensive treatment were highly recommended in this group of patients.
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Ocular surface disorder among adult patients with type II diabetes mellitus and its correlation with tear film markers: A pilot study p. 156
Vijayakumari Manchikanti, Nirupama Kasturi, Medha Rajappa, Debasis Gochhait
DOI:10.4103/tjo.tjo_56_20  
PURPOSE: The purpose is to study the ocular surface changes among patients with diabetes mellitus (DM) and to correlate them with tear film markers such as insulin-like growth factor (IGF)-1, interleukin (IL)-1β, and tumor necrosis factor (TNF)-α levels. MATERIALS AND METHODS: The study was carried out on diabetic patients (>5 years' duration) and healthy age- and gender-matched controls with 21 individuals in each group. Schirmer's test for basal and reflex tear secretion, tear film breakup time (TBUT) for tear stability, ocular staining score (OSS) for dryness severity, ocular surface disease index (OSDI) for symptomatic assessment of dryness and conjunctival impression cytology (IC) for epithelial cell integrity, keratinization, squamous metaplasia, and goblet cell density was studied. Thirty microliters of tears were collected to test IGF-1, IL-1β, and TNF-α levels. RESULTS: Patients with DM showed significantly low Schirmer's, TBUT, and OSS values than controls. OSDI score showed moderate-severe dryness in patients with DM and only mild symptoms among controls. An abnormal IC score was seen among cases and controls. The level of TNF-α was significantly increased in patients with DM and positively correlated with Schirmer and TBUT values (P < 0.05). CONCLUSION: Dry eye is more prevalent in patients with DM compared to controls as evidenced by poor OSDI score, Schirmer, TBUT, and OSS. TNF-α in the tears of patients with DM is a useful marker that showed a good correlation with Schirmer, TBUT, and dry eye symptoms. IC could not conclusively differentiate the dry eye status in patients with DM from controls.
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Randomized controlled trial of trehalose: An efficient autophagic bioprotectant in the management of dry eye disease p. 161
Arvind Kumar Morya, Kanchan Solanki, Sujeet Prakash, Monika Samota, Arushi Gupta
DOI:10.4103/tjo.tjo_58_20  
PURPOSE: To compare the therapeutic effect of sodium hyaluronate (SH)–trehalose (Trehalube, Microlabs, Bangalore, India, SH 0.1% and trehalose 3%) or SH (0.1% Hylotears, Raymed, Chandigarh, India) alone in patients with dry eye disease (DED). MATERIALS AND METHODS: Patients were randomized into two groups: SH-trehalose (SH 0.1% and trehalose 3%) or SH (0.1% Hylotears) alone. The Ocular Surface Disease Index (OSDI) questionnaire was used to assess patient's symptoms. Patients were followed up at 4 and 8 weeks, and OSDI score, tear film break-up time (TBUT), tear film height (TFH), Schirmer's test, and conjunctival staining were evaluated at each visit. RESULTS: A total of 384 patients were included in the study, 192 patients in each arm. The mean age of participants was 37.62 + 14.4 years and 225 were women (56%). The improvement in Schirmer's test was significantly better in the SH-trehalose group at 8 weeks (5.26 + 4.3 mm, 95% confidence interval = 4.6–5.9 mm) compared to the SH group (3.71 + 3.9, 95% confidence interval = 3.15–4.28 mm). The TBUT and TFH showed slight improvement at 4 weeks in both groups, but not at 8 weeks. There were no group differences at all-time points in terms of conjunctival staining and OSDI-based grades of DED. CONCLUSION: It was found that treating dry eye with SH-trehalose leads to greater improvement in the Schirmer's values and TBUT after 8 weeks of sustained use in patients with DED, and this was more pronounced in those with severe DED.
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Investigation of the repeatability of tear osmolarity using an I-PEN osmolarity device p. 168
Raied Fagehi, Abdulkareem B Al-Bishry, Mana A Alanazi, Ali Abusharha, Gamal A El-Hiti, Ali M Masmali
DOI:10.4103/tjo.tjo_65_20  
PURPOSE: To investigate the repeatability of tear osmolarity in healthy Saudi subjects using an I-PEN osmolarity device. MATERIALS AND METHODS: Thirty typical male subjects with healthy eyes (27.4 ± 4.9 years) participated in the study. Eye abnormalities were tested with a slit lamp, and eye comfort was determined with the surface disease index. Measurements of the tear break-up time and phenol red thread tests were used for as exclusion criteria. The tear osmolarity test, using an I-PEN osmolarity system, was performed three times in the right eye of each subject with a 5 min' gap between tests. RESULTS: The average osmolarity test score was 303.8 ± 4.8 mOsm/L. Tear osmolarity measurements showed tear osmolarity of 280–299 mOsm/L, 300–309 mOsm/L, and 310–329 mOsm/L in 14 (46.7%), three (10%), and 13 (43.3%) subjects, respectively. Correlations among the three I-PEN measurements were significant (Spearman's correlation coefficient; r = 0.036, 0.501, and 0.603; P = 0.050, 0.006, and 0.001, respectively). The mean coefficient of variance among the three measurements was 4.4%. CONCLUSION: The mean measurement of an I-PEN tear osmolarity was 303.8 ± 4.8 mOsm/L which is in agreement with the range of those reported for healthy subjects. The I-PEN is reliable and has the advantage of portability (hand-held) compared to the other osmolarity systems.
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CASE REPORTS Top

Bilateral corneal edema in an alcoholic male p. 175
Peng-Yu Lee, Wei-Yi Chou, Chih-Chien Hsu, Pei-Yu Lin, Ko-Hua Chen
DOI:10.4103/tjo.tjo_50_20  
Pseudophakic bullous keratopathy and Fuchs' endothelial dystrophy are the two most common causes of corneal edema after cataract surgery. We report a 61-year-old alcoholic male with bilateral corneal edema that improved after his alcohol abstinence. He had uneventful bilateral cataract surgery 3 years ago and blurred vision in both eyes developed for weeks. As he had no history of endothelial dystrophy, the treatment for viral endotheliitis was used initially yet in vain. We asked him to stop alcohol and adjusted his psychiatric drugs, but he lied about stopping drinking. The corneal edema progressed, and finally, he underwent penetrating keratoplasty in his left eye 1 year later. During hospitalization for surgery, alcohol withdrawal syndrome was noted because he could not drink alcohol in our hospital. After he quit drinking for months, corneal edema in the right eye disappeared. Our case highlights that alcoholism can result in corneal edema, and stopping drinking is necessary in these patients.
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Toxic keratopathy related to antiseptics in nonocular surgery p. 179
Mei-Chi Tsui, Jen-Yu Liu, Hsiao-Sang Chu, Wei-Li Chen
DOI:10.4103/tjo.tjo_5_21  
Antiseptics, especially those containing ethanol, are toxic to the ocular surface. Here, we report a 5-year-old girl with antiseptic-related eye injury following an uneventful bilateral tonsillectomy under general anesthesia. Before surgery, her eyes were protected and disinfection of perioral skin with ethanol-containing chlorhexidine followed. Whitening of the lower half of her right ocular surface was found after the surgery, and this indicated severe chemical burn. Prompt irrigation with normal saline, instillation of topical medication, and application of amniotic membrane containing device were performed, which led to a satisfactory result. Toxic eye injury could happen in head and neck surgeries under general anesthesia. Causes of ocular injury include improper eye protection, head positions leading to accumulation of excessive antiseptics, and improper usage of ethanol-containing antiseptics for skin preparation. The use of ethanol-free antiseptic solutions in the peri-ocular region and proper protection of eyes may reduce the risk of severe ocular surface injury in nonocular surgeries.
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A rare case of type 3 usher syndrome with bilateral cystoid macular edema treated with topical dorzolamide p. 183
Athul Puthalath, Ramanuj Samanta, Neeraj Saraswat, Ajai Agrawal, Anupam Singh, Mahsa Jamil
DOI:10.4103/tjo.tjo_6_20  
A 30-year-old female presented with gradually progressive diminution of vision for 1 month, with night blindness for the past 5 years and difficulty in hearing for the past 10 years. Her developmental history and family history were unremarkable. Ocular examination revealed visual acuity of 6/36 in both eyes. Fundus showed features of retinitis pigmentosa with bilateral macular edema. Audiometry revealed bilateral sensorineural hearing loss; although, her vestibular functions were preserved. Clinical diagnosis of Usher syndrome type 3 was made based on normal hearing at birth, delayed presentation of progressive visual and auditory impairment with normal vestibular function, and developmental milestones. Her macular edema resolved after 3 months of treatment with topical dorzolamide therapy. The unique feature of this case is the presence of bilateral macular edema in type 3 Usher syndrome, which is rarely reported in literature.
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Bilateral maculopathy and cataracts secondary to an accidental high-voltage electrical discharge p. 187
Carlos F Penaranda, Dhariana Acon, Carlos A Valdes, Lihteh Wu
DOI:10.4103/tjo.tjo_7_20  
The aim of the study was to describe the ocular findings following an accidental high-voltage electrical discharge. A 32-year-old male suffered an accidental electric discharge of 10,000 volts of direct current. He developed cortical, nuclear, and posterior subcapsular opacities in both the eyes. The retinal examination showed bilateral macular cysts. Four months after the event, the macular cyst in the OD spontaneously regressed without visual improvement. The macular cyst in the OS remained unchanged. High-voltage electrical discharge can lead to bilateral maculopathy and cataracts. The visual prognosis is reserved. The visual acuity may not improve despite macular cyst regression.
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Alternaria chartarum sclerokeratouveitis: A new fungus cause p. 190
Luz Elena Concha del Rio, Carolina Ramirez-Dominguez, Virginia Vanzzini-Zago, Lourdes Arellanes-Garcia
DOI:10.4103/tjo.tjo_17_19  
We report a case of Alternaria chartarum sclerokeratouveitis with an unfavorable response to treatment. To the best of our knowledge, there are no previous reports of this fungus invading the sclera. A 68-year-old diabetic farmer male patient presented with a 3-week history of pain and redness and a decrease in visual acuity occurring 5 days before admittance in the right eye. Examination revealed severe mixed hyperemia and a scleral calcified plaque with a surrounding area of ischemia and lysis. The cornea showed diffuse infiltrates, stromal edema, and hypopyon. Initial scrapings were negative, and empiric antibiotics were started. After a fungus was reported, topical and systemic antifungals were initiated, but there was no clinical response. The eye was enucleated. A slow-growing fungus A. chartarum, resistant to voriconazole, was isolated. Fungal etiology must be kept in mind when dealing with infectious scleritis. Despite treatment, the outcome of this case was unfavorable due to the slow-growing nature of the fungus and this strain's resistance to voriconazole.
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Perfluorocarbon liquid-assisted inverted inner limiting membrane-flap for large macular hole after recurrent rhegmatogenous retinal detachment p. 193
Luigi Sborgia, Alfredo Niro, Francesco D'Oria, Giancarlo Sborgia, Alessandra Sborgia, Claudio Furino, Gianluigi Giuliani, Luisa Micelli Ferrari, Francesco Boscia, Nicola Recchimurzo, Giovanni Alessio
DOI:10.4103/tjo.tjo_13_20  
A 45-year-old Caucasian myopic woman with a severe vision impairment (20/320) in the left eye due to a macula-off rhegmatogenous retinal detachment (RRD) underwent vitrectomy with silicone oil tamponade followed by an inferior relaxing retinectomy with heavy silicone oil tamponade during the second procedure for recurrence of RRD due to proliferative vitreoretinopathy. Four weeks after the second surgery, visual acuity was 20/200 and the patient complained metamorphopsia in the same eye due to a large full-thickness macular hole. A perfluorocarbon liquid-assisted inverted inner limiting membrane-flap technique was performed. Visual acuity improved to 20/80 after closing of macular hole and partial recovery of outer retinal layers at 3 months from the last surgery.
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Retinal astrocytoma with exudative retinal detachment treated with photodynamic therapy in a young girl with tuberous sclerosis p. 197
Wei-Yi Chou, Fenq-Lih Lee
DOI:10.4103/tjo.tjo_15_20  
Around 50% of patients with tuberous sclerosis have the manifestation of retinal astrocytomas. Symptomatic retinal astrocytomas are very rare, with no consensus on optimal treatment. A 7-year-old patient with tuberous sclerosis presented with progressive blurred vision in the right eye for more than half a year. On examination, best-corrected visual acuity was 20/30 in the right eye and 20/20 in the left eye. Dilated fundus examination of the right eye showed a well-circumscribed, elevated, opaque lesion, with surrounding lipid exudate, and retinal detachment involving the fovea. Spectral-domain optical coherence tomography of the right eye revealed an intraretinal lesion with adjacent subretinal fluid. A diagnosis of retinal astrocytoma with exudative retinal detachment was made. The patient was treated with verteporfin photodynamic therapy (PDT) on the lesion in the right eye. After 1 month, complete resolution of subretinal fluid was observed. At 21-month follow-up, the right eye vision was stable at 20/20, without ocular or systemic adverse events. In conclusion, PDT had a good safety profile in a cooperative pediatric patient, and was able to induce regression of astrocytoma as well as resolution of exudation with excellent visual outcome.
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LETTERS TO THE EDITOR Top

Letter to the editor: Herpes zoster keratouveitis with hypopyon and hyphema p. 200
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/tjo.tjo_34_20  
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Reply: Herpes zoster keratouveitis with hypopyon and hyphema p. 201
Katherine Seng Boon Hwei
DOI:10.4103/tjo.tjo_35_20  
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Letter to the editor: PROKERA® slim corneal bandage now approved in Taiwan for treatment of corneal diseases p. 202
Scheffer C. G. Tseng
DOI:10.4103/tjo.tjo_67_20  
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