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   Table of Contents - Current issue
Coverpage
February 2017
Volume 65 | Issue 2
Page Nos. 79-171

Online since Friday, March 24, 2017

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EDITORIAL  

Celebrating excellence Highly accessed article p. 79
Sundaram Natarajan
DOI:10.4103/ijo.IJO_177_17  
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GUEST EDITORIALS Top

Dr. Rajendra Prasad Centre celebrates golden jubilee p. 80
Madan Mohan
DOI:10.4103/0301-4738.202856  
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Fifty glorious years of Dr. Rajendra Prasad Centre p. 83
Atul Kumar
DOI:10.4103/ijo.IJO_170_17  
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REVIEW ARTICLE Top

Insight into high myopia and the macula Highly accessed article p. 85
Atul Kumar, Rohan Chawla, Devesh Kumawat, Ganesh Pillay
DOI:10.4103/ijo.IJO_863_16  
The incidence of myopia is constantly on the rise. Patients of high myopia and pathological myopia are young and can lose vision due to a number of degenerative changes occurring at the macula. With the emergence of new technologies such as swept-source optical coherence tomography (OCT) and OCT angiography, our understanding of macular pathology in myopia has improved significantly. New conditions such as myopic traction maculopathy have been defined. Early, noninvasive detection of myopic choroidal neovascularization and its differentiation from lacquer cracks is possible with a greater degree of certainty. We discuss the impact of these new exciting and promising technologies and management of macular pathology in myopia. Incorporation of OCT in the microscope has also improved macular surgery. New concepts such as fovea-sparing internal limiting membrane peeling have emerged. A review of literature and our experience in managing all these conditions are discussed.
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SYMPOSIUM Top

Definition of blindness under National Programme for Control of Blindness: Do we need to revise it? p. 92
Praveen Vashist, Suraj Singh Senjam, Vivek Gupta, Noopur Gupta, Atul Kumar
DOI:10.4103/ijo.IJO_869_16  
A review appropriateness of the current definition of blindness under National Programme for Control of Blindness (NPCB), Government of India. Online search of peer-reviewed scientific published literature and guidelines using PubMed, the World Health Organization (WHO) IRIS, and Google Scholar with keywords, namely blindness and visual impairment, along with offline examination of reports of national and international organizations, as well as their cross-references was done until December 2016, to identify relevant documents on the definition of blindness. The evidence for the historical and currently adopted definition of blindness under the NPCB, the WHO, and other countries was reviewed. Differences in the NPCB and WHO definitions were analyzed to assess the impact on the epidemiological status of blindness and visual impairment in India. The differences in the criteria for blindness under the NPCB and the WHO definitions cause an overestimation of the prevalence of blindness in India. These variations are also associated with an over-representation of refractive errors as a cause of blindness and an under-representation of other causes under the NPCB definition. The targets for achieving elimination of blindness also become much more difficult to achieve under the NPCB definition. Ignoring differences in definitions when comparing the global and Indian prevalence of blindness will cause erroneous interpretations. We recommend that the appropriate modifications should be made in the NPCB definition of blindness to make it consistent with the WHO definition.
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Chlamydial eye infections: Current perspectives p. 97
Gita Satpathy, Himanshu Sekhar Behera, Nishat Hussain Ahmed
DOI:10.4103/ijo.IJO_870_16  
Chlamydia trachomatis, an obligate intraocular bacteria causing trachoma, adult and neonatal inclusion conjunctivitis, was the leading cause of blindness in the last century worldwide. Improvement in socioeconomic and living conditions, availability of antibiotics, and introduction of National Trachoma Control Programmes reduced the prevalence in developed countries, but it persisted in resource-poor settings of Africa and Asia, including India. In 2016, as per the WHO report, trachoma is restricted to 42 countries, causing blindness/visual impairment in ~1.9 million people. India is one of the five countries with nearly half of total active trachoma patients. Introduction of Global Elimination of Trachoma 2020 program by the WHO, using SAFE strategy (surgery for trachomatous trichiasis; Antibiotics for C. trachomatis; Facial cleanliness; and environmental improvement) greatly reduced the prevalence, but trachoma still persists in India. Global increase in the reproductive tract infection by C. trachomatis urogenital serotypes (D-K) has led to concurrent increase in C. trachomatis eye infections. Therefore, kerato eye infections due to chlamydial infections continue to be seen in hospitals. Over the years, there have been advances in laboratory diagnostics, in understanding the pathogenesis, tissue tropism, C. trachomatis genomics, and treatment modalities. Due attention and research is still needed for the study of C. trachomatis eye infections.
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Innovations in glaucoma surgery from Dr. Rajendra Prasad Centre for Ophthalmic Sciences p. 103
Tanuj Dada, Neha Midha, Pooja Shah, Talvir Sidhu, Dewang Angmo, Ramanjit Sihota
DOI:10.4103/ijo.IJO_865_16  
Trabeculectomy surgery is the current standard of care in glaucoma for achieving a low target intraocular pressure if medical therapy is not adequate. Augmentation of trabeculectomy with antimetabolites brought a revolutionary change in the long-term success rates of trabeculectomy, but along with it came a plethora of complications. There still is a big window for therapeutic innovations on this subject. The foremost target for these innovations is to modulate the wound healing response after glaucoma drainage surgery. Achieving the desired balance between long-term success of filtering blebs versus early failure due to scarring of blebs and hypotony due to dysfunctional filtering blebs poses a unique challenge to the ophthalmologists. Alternatives to trabeculectomy such as glaucoma drainage devices and minimally invasive glaucoma surgeries cannot solve the problem of glaucoma blindness in our country, mainly due to their unpredictable results and unfavorable cost-benefit ratio. In this article, we present a summary of our innovations in glaucoma surgery to advance patient care by making it more effective, safer, and economical.
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Upgradation and modernization of eye banking services: Integrating tradition with innovative policies and current best practices p. 109
Radhika Tandon, Archita Singh, Noopur Gupta, M Vanathi, Vivek Gupta
DOI:10.4103/ijo.IJO_862_16  
Purpose: The purpose of this study is to review the history and evolution of the National Eye Bank (NEB) and analyze the impact over the years and report the outcome of the invested resources. Methods: Review of archival material, records, project reports, policy and procedures' manuals, and publications was done. Descriptive and analytical processing of data obtained was undertaken. Parameters evaluated included total collection, transplantation, utilization rates of donor cornea, changing trends over time in terms of numbers and duration of recipients waiting, impactful research translated into changes in standard operating protocols, new facilities, and subsequent effects on numbers or quality assurance measures and overview of major achievements. Periodic situational analysis with contextual relevance and interpretation of outcomes was done pertaining to national goals and international standards. Results: The NEB and cornea services have played a key leadership role in furthering the development of eye banking and corneal transplantation services. The contribution extends beyond routine patient care to education, training, generation of resources, advocacy, and policymaking. In quantifiable terms, the overall performance has steadily increased over the years. Major contributions include training of doctors, eye bank staff and corneal surgeons, introduction of innovative techniques for corneal transplantation, setting of national standards for eye banking and provision of preservation media, customized corneal, and ocular surface cell replacement therapy in collaboration with other departments and institutes. Conclusion: The eye banking and corneal transplantation facilities have evolved with time providing quality services, modernized as appropriate with updated knowledge and incorporating technological advances supported by the systematic evidence-based approach.
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Intraoperative optical coherence tomography in anterior segment surgeries p. 116
Jeewan S Titiyal, Manpreet Kaur, Ruchita Falera
DOI:10.4103/ijo.IJO_868_16  
Intraoperative optical coherence tomography (iOCT) is a noninvasive imaging modality that provides a real-time dynamic feedback of the various surgical steps. Comprehensive literature search was performed in MEDLINE using “intraoperative optical coherence tomography” and “iOCT” as keywords. The use of iOCT as an aid to decision-making has been successfully reported in cases undergoing keratoplasty, implantable Collamer lens (ICL) implantation as well as cataract surgery. iOCT helps to assess the graft-host relationship in penetrating keratoplasty. It helps confirm the presence of a big bubble, detect subclinical big bubbles and guide layer by layer stromal dissection in cases of deep anterior lamellar keratoplasty. It acts as a guide during crucial surgical steps in endothelial keratoplasty, right from scoring of the Descemet membrane to ensuring graft apposition at the end of surgery. The morphological features of the corneal incision in phacoemulsification may be assessed. iOCT is a useful tool in assessing the status of the posterior capsule and may help identify preexisting posterior capsular defects during cataract surgery in various clinical scenarios such as posterior polar cataract, traumatic cataract, and vitrectomized eyes. It allows on-table assessment of the ICL vault and potentially facilitates exchange of ICL in the same sitting in extremes of vault. Ocular surface disorders such as ocular surface squamous neoplasia, pterygium, and dermoid may find an application for iOCT, wherein an iOCT-guided stromal dissection will ensure adequate depth of dissection. Further technological advancements may allow for automatic centration and tracking and address the present limitation of instrument-induced shadowing.
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Retina and the tubercle Bacillus: Four decades of our journey and current understanding p. 122
Pradeep Venkatesh
DOI:10.4103/ijo.IJO_864_16  
Tuberculosis continues to be a major pandemic with enormous public health implication. Involvement of ocular tissues in the form of tubercles, tuberculomas, panophthalmitis, and iris granulomas are well recognized as definitive manifestations of tuberculosis. For these lesions, confirmatory evidence is available in the form of demonstration of acid-fast Bacillus on Ziehl–Neelsen staining. For other retinochoroidal disorders such as central serous chorioretinopathy, retinal vasculitis, and presumed ocular tuberculosis, hard evidence about the role of Mycobacterium tuberculosis is lacking. In this review, work done at our center over the past four decades in the form of experimental animal studies, nucleic acid amplification assays and clinical studies regarding the above retinochoroidal pathologies and the tubercle Bacillus is presented. It is possible that revisiting experimental animal studies may be a way forward in the current scenario of ambiguity about the cause–effect relationship between M. tuberculosis and few of the retinochoroidal disorders.
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Prognosis of different glaucomas seen at a tertiary center: A 10-year overview p. 128
Ramanjit Sihota, Neha Midha, Harathy Selvan, Talvir Sidhu, Deepa R Swamy, Ajay Sharma, Amisha Gupta, Viney Gupta, Tanuj Dada, Sunil Chaudhary
DOI:10.4103/ijo.IJO_875_16  
Aim: This study aims to determine treatment patterns, long-term intraocular pressure (IOP) and perimetric control in different glaucomas seen at a tertiary eye center. Settings and Design: Hospital-based, cross-sectional chart review of patients routinely following up at an outpatient glaucoma service. Methods: Patients with a follow-up of at least 10 years were evaluated. Their mean IOP, visual field (VF) status, and medications/surgery required at final assessment were noted. Statistical Analysis: Descriptive statistics (mean, standard deviation, and range) were used for all parameters. Results: A total of 230 patients met our inclusion and exclusion criteria, 79 having ocular hypertension with open angles or primary angle closure (PAC), 35 primary open angle glaucoma (POAG), 50 PAC glaucoma (PACG), 20 primary congenital glaucoma (PCG), 46 secondary glaucoma patients. Ocular hypertensives with open angles showed progression to POAG in 3.7%, those with PAC in 5.2%, at a mean IOP of 17.3 ± 3.37 mmHg and 17.13 ± 4.41 mmHg, respectively. A progression on Humphrey Field Analyzer was seen in 11% of POAG and PACG eyes at a mean IOP of 13.50 ± 5.07 and 13.09 ± 3.95 mmHg, respectively. Fifteen percent of primary congenital glaucomas (PCGs) showed a glaucomatous VF defect after 10 years. In secondary glaucoma eyes, the mean IOP at last follow-up visit was 12.38 ± 3.74 mmHg, with progression noted in 7.69% of eyes. Conclusion: This study provides evidence that routine delivery of care can provide well controlled IOP in glaucomas, both primary and secondary, and the VF stabilized in about 90% of patients over a period of 10 years, with the currently available glaucoma medications and trabeculectomy.
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Recent advances and challenges in the management of retinoblastoma p. 133
Bhavna Chawla, Rashmi Singh
DOI:10.4103/ijo.IJO_883_16  
The treatment of retinoblastoma (Rb) has improved significantly in recent times. Worldwide, there is an increasing trend to use conservative treatment modalities that aim to preserve the globe as well as vision with minimum morbidity. Recently, the use of targeted delivery of chemotherapy to the eye in the form of selective intra-arterial and intravitreal chemotherapy has shown promising results. Radiotherapy is beneficial in selected cases, either in the form of plaque brachytherapy or as external beam radiotherapy. Orbital disease carries a poor prognosis for survival. However, a multimodal treatment protocol has improved survival in children with extraocular disease. Nevertheless, challenges remain, especially for the developing world. This review aims to highlight recent advances in the management of Rb that have contributed towards improving treatment outcomes and also discuss the challenges ahead, with special reference to the Indian scenario.
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ORIGINAL ARTICLES Top

Appraising the spectrum of firework trauma and the related laws during Diwali in North India p. 140
Ramesh Venkatesh, Prachi Gurav, Shailja Tibrewal, Manisha Agarwal, Suneeta Dubey, Umang Mathur, Suma Ganesh, Sima Das
DOI:10.4103/ijo.IJO_527_16  
Purpose: To evaluate the epidemiological characteristics and outcomes of ocular injuries resulting from the use of firecrackers during the Diwali festival in all age groups. Materials and Methods: A single-center, retrospective, hospital-based case series presenting with ocular trauma consequent to fireworks usage in a tertiary eye care center in North India during the 5 days of Diwali festival from 2011 to 2015 was conducted. Results: A total of 53 eyes of 45 patients were included in the study, out of which the vast majority (39/87%) were males. The mean age was 20.55 years. Almost an equal number of bystanders (25/55.5%) were affected as compared to people handling the fireworks (20/44.44%). Five (9.43%) eyes had open-globe injury, whereas 48 (90.56%) eyes had closed-globe injury. Eighteen (33.96%) eyes underwent surgical intervention. Thirty-three (62.26%) eyes had final vision >20/200 with eight (15.09%) eyes being vision <3/60 in the affected eye. Conclusion: Firework-related ocular trauma can lead to serious visual impairment. Mandatory legislative laws pertaining to the manufacture, sale, and use of fireworks and creating public awareness can reduce the incidence of this preventable cause of blindness in the society. Initiating new policies for retailers involved in sale of these firecrackers can also bring in decrease of such morbidities.
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Laser capsulotomy following cataract surgery: Comparing time to capsulotomy with implantation of two broadly used intraocular lenses p. 144
Yael Sharon, Eitan Livny, Michael Mimouni, Dov Weinberger, Irit Bahar
DOI:10.4103/ijo.IJO_933_16  
Purpose: The aim of this study is to compare the length of time from uneventful cataract surgery using one of two common posterior chamber intraocular lenses (IOLs) (hydrophilic versus hydrophobic acrylic) to laser capsulotomy. Materials and Methods: Retrospective analysis of all patients who underwent neodymium: yttrium-aluminum-garnet laser capsulotomy between 2011 and 2014 following uneventful phacoemulsification surgery at a tertiary university-affiliated medical center. Medical records were reviewed for demographics, ocular comorbidities, operative details, postoperative follow-up, and findings of the precapsulotomy ophthalmologic examination. Parameters, including age, sex, laterality, visual acuity, surgeon's experience, and time from cataract surgery to capsulotomy, were compared between patients who received hydrophilic (SeeLens AF, Kibbutz Hanita, Israel) or hydrophobic (AcrySof SA60AT, Alcon Laboratories, Fort Worth, TX, USA) IOLs. Results: The cohort included 222 patients (255 eyes), of which, 107 were male and 115 female, of mean age 73 ± 8 years. Mean interval from cataract surgery to laser capsulotomy was 24 months (range 2–70) and was significantly shorter in patients with SeeLens (23 ± 13 months) than AcrySof IOL implantation (28 ± 13 months, P = 0.04). Lens type remained significant in multivariate analysis after including surgeon's experience and age as potential confounders (P = 0.04). Conclusion: The hydrophilic SeeLens IOL is associated with a significantly shorter time interval from cataract surgery to laser capsulotomy than the hydrophobic AcrySof IOL.
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Late dislocation of in-the-bag intraocular lenses in uveitic eyes: An analysis of management and complications p. 148
Sudha K Ganesh, Parveen Sen, Hitesh R Sharma
DOI:10.4103/ijo.IJO_938_16  
Aim: An analysis of late in-the-bag dislocation of intraocular lenses (IOL), in uveitic eyes. Setting: Referral uveitis clinic. Design: Retrospective case series. Materials and Methods: All case records of eyes with chronic uveitis that had phacoemulsification with IOL implantation, at a referral uveitis clinic between February 1997 and January 2015 were retrieved and analyzed. Only those eyes with no documented intraoperative complication and no predisposing risks to IOL dislocation, such as pseudoexfoliation, high myopia, trauma, and prior VR surgery were included in this study. Results: A total of 581 eyes with chronic uveitis underwent phacoemulsification with IOL implantation under steroid cover from February 1997 to December 2015. Out of these 581 eyes, 10 patients (11 eyes) had experienced late in-the-bag IOL dislocation (1.89%). All 11 eyes had chronic intermediate uveitis. The mean duration from the time of cataract surgery to IOL dislocation was 11.24 years. 5 out of 11 eyes had pars plana vitrectomy (PPV) with IOL removal with 4-point sutured scleral fixated IOL. Two out of 11 eyes had PPV with in-the-bag IOL re-fixation. Out of 11, 2 eyes had PPV with IOL removal only. Remaining 2 eyes of 2 patients did not opt for surgery. Out of 11, 8 eyes had improved vision at last follow-up. Conclusions: In-the-bag dislocation of IOL is a rare late complication in uveitic eyes. With tight perioperative inflammatory control, scleral-fixated posterior chamber intraocular lens or IOL re-fixation are good options of restoring vision in these high-risk eyes.
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Clinical correlation of imaging findings in congenital cranial dysinnervation disorders involving abducens nerve p. 155
Chanchal Gupta, Pradeep Sharma, Rohit Saxena, Ajay Garg, Sanjay Sharma
DOI:10.4103/ijo.IJO_1013_15  
Purpose: High-resolution magnetic resonance imaging (MRI) of intracranial parts of sixth nerve and seventh nerve and the extraocular muscles (EOMs) in orbit to correlate the clinical characteristics in patients with two special forms of strabismus in congenital cranial dysinnervation disorders which are Duane's retraction syndrome (DRS) and Mobius syndrome. Materials and Methods: Morphological analysis by 3T MRI of orbit (using surface coils) and brain (using 32 channel head coil) was performed on 6 patients with clinical DRS (1 bilateral), 2 cases with Mobius syndrome, and 1 case with congenital sixth nerve palsy. These were compared with findings in five controls. Results: We observed absence/hypoplasia of sixth nerve in five out of seven eyes with DRS (71.42%), anomalous course in one eye, sixth and seventh nerve absence/hypoplasia in affected eyes with Mobius syndrome and bilateral absence/hypoplasia of the sixth nerve in congenital sixth nerve palsy. For EOMs we calculated maximum diameter, area, and circumference of muscles using Osirix software, and noticed significant hypoplasia of lateral rectus in comparison to controls (P < 0.001). Conclusions: MRI gives useful information regarding confirmation of clinical diagnosis and its neurological anomalies in complex cases and helps to plan tailor made surgical management.
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COMMUNITY EYE CARE Top

Differential cataract blindness by sex in India: Evidence from two large national surveys p. 160
Hira B Pant, Souvik Bandyopadhyay, Neena John, Anil Chandran, Murthy Venkata S Gudlavalleti
DOI:10.4103/ijo.IJO_28_15  
Aims: Women suffer disproportionately more from cataract blindness compared to males in low- and middle-income countries. Two large population-based surveys have been undertaken in India at an interval of 7 years and data from these surveys provided an opportunity to assess the trends in gender differentials in cataract blindness. Materials and Methods: Data were extracted from the surveys to discern sex differences in cataract blindness. Multivariate analysis was performed to adjust for confounders and their impact on gender differences in cataract blindness. Blindness was defined as presenting vision <20/400 in the better eye, and a cataract blind person was defined as a blind person where the principal cause of loss of vision was cataract. Results: Prevalence of cataract blindness was higher in females compared to males in both surveys. The odds of cataract blindness for females did not change over time as observed in the surveys (1999–2001 and 2006–2007). Adjusted odds ratio from logistic regression analysis revealed that females continued to be at a higher risk of cataract blindness. Conclusions: Sex differences continued in India in relation to cataract blindness despite the gains made by the national program.
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PHOTO ESSAY Top

Missed punctal foreign body: A cause for chronic ocular irritation p. 165
Tanie Natung, Wakaru Shullai, PK Goswami
DOI:10.4103/ijo.IJO_950_15  
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LETTERS TO THE EDITOR Top

Congenital nasolacrimal duct obstruction: Should we continue lacrimal massage till 1 year or perform an office probing at 6 months? A clinical decision analysis approach p. 167
Mihir Kothari, Vivek Rathod, Kruti Shah, Khushboo Shikhangi, Renu Singhania
DOI:10.4103/ijo.IJO_245_16  
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Comment on: Comparison of serum sodium and potassium levels in patients with senile cataract and age-matched individuals without cataract p. 170
Sujata Subbiah, Philip A Thomas
DOI:10.4103/0301-4738.202863  
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Comment on: Comparison of serum sodium and potassium levels in patients with senile cataract and age-matched individuals without cataract p. 171
Eung Suk Kim, Moosang Kim, Seung-Jun Lee, Sang Beom Han
DOI:10.4103/0301-4738.202862  
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