Indian Journal of Clinical and Experimental Ophthalmology

Page No. 1

Authors: Rajendra P Maurya

It is my humble privilege to present the special issue of IJCEO after successful journey of two years. This issue of IJCEO has several interesting articles on vision threatening morbidity , Glaucoma particularly on diagnosis and awareness of primary glaucoma. Primary open angle glaucoma (POAG) is a chronic, progressive, multifactorial neuro-degenerative disorder characterized by loss of retinal ganglion cells and their axon leading to optic nerve cupping and visual field defect. It is the second most common cause of blindness worldwide. Approximately 45 million people have open angle glaucoma and morbidity is expected to be 59 million by 2020.

Page No. 3-10

Authors: Pankaj Soni, Ashwani Srivastava, Akash Srivastava, Deepti Yadav

Objective: To correlate the cup/disc ratio with visual field defect in primary open angle glaucoma patient using magnified photograph of optic disc and Humphrey field analyzer. Method: Cross sectional study includes 114 eyes of 60 patients suffering from primary open angle glaucoma. All patients were 40 years age having IOP 21 mmHg and gonioscopically open angle of anterior chamber. The things assessed includes IOP, angle of anterior chamber, optic disc and visual field. Results: Total 114 eyes of 60 patients with primary open angle glaucoma included in study. Mean age of patient in our study was 58.7±10.26 year. Out of 60 patients, 31 (51.66%) were male and 29 (48.33%) were female. 12 eyes (10.52%) had IOP in the range of 21-24 mmHg, 52 eyes (45.61%) had IOP in the range of 25-29 mmHg, 48 eyes (42.10%) had IOP in the range of 30-34 while only 2 eyes (1.75%) had IOP > 35 mmHg. Mean IOP of 114 eyes was 27.9±3.23 mmHg. 32 patient (28.07%) had C:D ratio of 0.6 whereas 30 patient (26.31s%) had C:D ratio 0.7. Mean C:D ratio of POAG was 0.64±0.07. Considering other parameter of the optic nerve head it was seen that Bayonetting sign was present in 60 eyes. Meanwhile baring of vessels was seen in 46 eyes. Laminar dot sign, on the other hand was seen in 72 eyes. Beta zone peripapillary atrophy was seen in 78 eyes. Another important parameter of the optic disc is notching. In 53 eyes notching was seen. Out of these, 35 eyes show superior notching, of which 33 eyes (94.3%) correlated with inferior field defects. 18 eyes show inferior notching, and all of them showed superior field defect. Inferior neuroretinal thinning is found in 55 eyes, out of which 50 eyes (90.9%) had correlating visual field defect while 32 eyes (86.5%) with superior neuroretinal thinning correlate visual field defect. Maximum number of eyes show superior zone defect i.e. 54 eyes (47.36%) followed by inferior zone defect in 25 eyes (22.0%). The least common visual field defect in our study is baring of blind spot in 3 eyes (3.0%). Finally, the patients were divided into 2 group depending on their cup disc ratio, and their association with the field defects was evaluated. Group 1- patients with c:d ratio < 0.7;Group 2- patients with c:d ratio 0.7. The pattern defects signifying the localized defects were then compared between the two group. The average pattern defect in group- 1 was found to be 6.16 db, while the average pattern deviation in group- 2 was 9.62 db. The association of c:d ratio 0.7 with PD was seen to be significant with a p <0.001. Conclusions: This was a cross sectional study done over a period of 1 year to correlate the optic disc changes with the visual field defects by using optic disc evaluation and Humphrey visual field analyzer done. The correlation between cup disc ratio and intra.

Page No. 15-19

Authors: Sundip Shenoy, Dinesh P, Pavan Kumar Reddy, Pranessh Ravi

Background: PACS (primary angle closure suspects) continue to pose a diagnostic and therapeutic dilemma. PACS being converted to PACG as the disease evolves in the long run leads to irreversible blindness; hence the importance of screening with gonioscope to see which patients will improve with laser peripheral iridotomy (LPI). Objective: To assess the effectiveness of routine manipulative gonioscopy as a tool in order to predict angle opening after NdYAG laser iridotomy in PACS patients. Methods: Fifty patients having PACS were enrolled in the prospective observational interventional study. Main outcome measure were effect on IOP, effectiveness of manipulative gonioscopy with regard to angle opening and Van Hericksin predicting angle changes. Manipulative gonioscopy and Peripheral laser iridotomy was done. Wilcoxon signed rank was used to find the significance of study parameters. Results: Seventy four percent were females with males forming 26% of the study. Mean age was 65 ± 5.16 years. Comparison of Shaffers grading pre and post intervention in superior quadrant showed P value 0.020(suggestive of significance), inferior quadrant showed p<0.001 which was significant. Van Herick’s grading pre and post intervention in the temporal quadrant showed P value 0.005 and in the nasal quadrant showed P value of 0.001 which is strongly significant and correlates with gonioscopic findings. Conclusion: Study confirms that laser peripheral iridotomy increases peripheral chamber angle as predicted by manipulative gonioscopy in majority of cases prior to the intervention which correlates with schaffer/Van Herick’s grading. Laser peripheral iridotomy to all patients with PACS requiresproper evaluation as some cases have no effect on peripheral anterior chamber depth post LPI.

Page No. 24-27

Authors: Anitha S. Maiya, Ravindra B., Manjunath BH, Meghana Patil

Purpose: To evaluate the characteristics of Lens Induced Glaucoma among the rural population and to determine if cataract surgery in one eye plays a role in causing Lens Induced Glaucoma in the other eye. Methods: This prospective study included 43 eye of 43 patients who were clinically detected to have lens induced glaucoma and operated by one surgeon. A comprehensive ophthalmic evaluation was done and medical management instituted. All patients underwent Manual Small Incision Cataract Surgery and were followed up for 6 weeks. Results: Majority of the patients were in the age group of more than 60 years. The incidence of lens induced glaucoma was more among females (65.12%). Phacomorphic glaucoma was more common (30 cases; 69.77%) than phacolytic glaucoma (13 cases; 30.23%). Following cataract surgery, 26 eyes (60.47%) had visual acuity 6/18 or better. Majority of our patients(69.77%) presented within 7 days of onset of symptoms; among the 13 patients who presented after 7 days of onset of symptoms, the postoperative visual acuity tended to be poorer than in those who presented early. A majority of them (34 patients; 79.07%) mentioned having good vision in the fellow eye as the reason for delaying cataract surgery in the affected eye. Conclusions: Since LIG is a preventable condition, Ophthalmologists should stress the importance of undergoing cataract surgery when the cataract is still immature and in bilateral cases advice early surgery for the fellow eye. With advances in surgical techniques, good preoperative control of IOP and postoperative treatment, it is possible to restore good vision in patients with LIG who present early.

Page No. 31-33

Authors: MB Dongre, Khaire BS, Bhalerao Ravindra

Introduction: Pseudoexfoliation syndrome (PEX) is a common and clinically important systemic condition characterized by the pathological production and accumulation of an abnormal fibrillar extracellular material in many intraocular and extraocular tissues. Patients with PEX syndrome have a significantly higher risk for a variety of complications during cataract surgery. Aim and Objective: To study the clinical profile of cataract patients with co-existent pseudoexfoliation syndrome. Methodology: 85 patients with Cataract patients diagnosed with pseudoexfoliation on the basis of slit lamp examination. Data includes demographic profile of patient, detailed ophthalmological history and ocular Examination. Visual acuity testing, Slit lamp examination, Gonioscopy, Indirect ophthalmoscopy and Intra Ocular Pressure (IOP) was taken with the help of Schiotz tonometer. Keratometry and A scan was done to calculate IOL power. Results: Males for.med a majority of cases. Majority of the cases were in their sixth decade. In this PEX material was most commonly deposited on Anterior lens capsule 84.7%. Poor pupillary dilatation (<5mm) was seen in as many as 63% cases. 86% eyes had intra-ocular pressure in the range of 14mmHg- 21 mm Hg. Discussion and Conclusion: PEX material most commonly deposited on anterior lens capsule. Mixed cataract were more common in pseudoexfoliation syndrome.

Page No. 38-41

Authors: K. Kalaivani

Purpose: To find out the spatial distribution and to assess the severity of visual field defects in Primary Open Angle Glaucoma (POAG) and Primary Angle Closure Glaucoma (PACG) patients and also to compare among the two groups. Materials and Methods: 45 eyes of 28 patients with Primary Open angle Glaucoma and 39 eyes of 28 patients with Primary Angle Closure Glaucoma who were clinically diagnosed and monitored in the Glaucoma Service of our hospital for a period of 16 months were recruited into the study. Main outcome measures were 1) distribution of visual field defects, 2) severity of visual field defects and 3) comparison among the two groups. Results: There was no significant statistical difference in Mean Deviation and Pattern Standard Deviation between the two groups. Superior Field was more depressed in both groups. Glaucoma Hemifield Test also shows that all the zones of superior field were depressed in both the groups but the severity is more in open angle group. Conclusion: My study shows that superior field is more severely affected than the inferior in both groups. However, trans meridional variation in field loss is less pronounced in subjects with angle closure glaucoma.

Page No. 45-49

Authors: Kavitha Chikkanayakanahalli Venugopal, Lakshmi Bomalapura Ramamurthy, Pavana Acharya, Sahana Raviraj

Aim: To evaluate the effect of 6mm sutureless clear corneal incision on pre-existing astigmatism of 1D-2D and to compare outcome of superior and temporal incisions, in manual small incision cataract surgery (SICS). Methods: A prospective interventional study was conducted from January 2015 to July 2015 on 80 patients who underwent manual SICS, with pre-existing astigmatism of 1D-2D on keratometry. A 6mm superior or temporal sutureless clear corneal incision was made along the steep axis. Postoperative follow up was done on 1 st , 3 rd and 6 th week and keratometry values noted in each visit. Final refraction and correction noted at the end of 6 weeks Results: Out of 80 patients, 71 had 1D-1.5 D and 9 had 1.5D-2D astigmatism. The mean pre-operative astigmatism was 1.228D±0.32D. Among 62 cases of with-the rule astigmatism, full correction after surgery was noted in 37 patients (59.67%), partial correction in 19 (30.64%), no change in 6(10%). Among 18 cases of against-the rule astigmatism, 11 had full correction (61.11%) and 6 had partial correction (33.33%) and remained unchanged in 1(5.5%). So the mean post-operative astigmatism was found to be 0.43D±0.35. The astigmatic difference between pre-operative and post-operative astigmatism was found to be statistically significant. (P-value 0.0001). Peaking of pupil was noted in 3 patients and iris prolapse in two patients, accounting for minor complications in 6.7%. No other complications were observed till 6 weeks. Conclusion: A 6mm sutureless clear corneal incision on steep axis is an economical and effective way of reducing pre-existing astigmatism of 1D-2D in manual SICS.

Page No. 53-56

Authors: Shweta Tripathi, Shakun Gupta, Varun Arora

Introduction: To investigate the level of compliance with glaucoma medications in a clinical setting of a tertiary north Indian hospital amongst both rural and urban patients and the factors associated with failed compliance. Thus to improve patient care and reducing visual deterioration and loss from glaucoma. Method: This was a Cross sectional study done at the Glaucoma Clinic, Indira Gandhi eye hospital and research centre Lucknow, between October 2014 and March 2015. 198 patients in the clinic were administered a questionnaire by the doctor. All patients were examined to make sure they met the inclusion and exclusion criteria and then a standard questionnaire was filled for each patient by direct questioning and also form case records Impact of age, gender, place of residence, religion, education, social status, knowledge about disease, systemic illness, other medical treatment, duration of treatment and number of anti-glaucoma medication on compliance was evaluated.. Data was analyzed using SPSS version 15.0. Data has been represented as numbers and percentages. Associations were evaluated in terms of odds ratio and tested using chi-square test. Results: Out of 198 patients enrolled - 30.8% were females, 30.8% were in the age group of 61-70 years age group, 60.1% had an urban background, 73.3% were aware that they had glaucoma and 66.7% were under treatment for more than 2 years. Although rate of compliance varied among different age groups ranging from 0 to 34.4% yet this difference was not significant statistically (p=0.072.) The odds of compliance were higher (OR>1) among females as compared to males, urban as compared to rural, Hindus as compared to Muslims, 12th Class/ Graduates as compared to Uneducated/Primary educated, Higher socioeconomic strata as compared to other socioeconomic strata, those having knowledge about disease as compared to those not having knowledge about disease, having shorter duration (<2 years) of disease and those taking single AGM as compared to those taking multiple, however, this difference was significant statistically only for place of residence, education, social status, duration of treatment and number of AGMs only (p<0.05). The commonest reason cited for non-compliance was side effects (26.3%) of anti-glaucoma medications. Other causes included cost factor (19.2%), forgetting schedule (17.7%), depletion of medication before next appointment (14.6%), inability to understand instructions (12.2%) and loss of prescription (4%). Conclusion: Compliance rates were quite poor and were mainly associated with demographic factors, duration and number of drugs.

Page No. 61-65

Authors: Bindu S, Jyothi PT, Padma B. Prabhu, Sandh S

Background: Age related maculopathy causes irreversible central visual loss in elderly population. Photo stress recovery time and Amsler grid evaluation are the tests used to assess the functional integrity of macula. Aim of Study: 1. To determine the Photo stress recovery time (PSRT) in patients with asymmetrical age-related macular maculopathy (ARM) 2. To find out the prevalence and the relation between risk factors, visual acuity, Amsler evaluation and photo stress recovery time. Settings and Design: Hospital based Case series study. Materials and Methods: Out of the 2104 participants above 50years, 37 patients presented with features of age related maculopathy. The systemic and ocular risk factors of ARM was observed. Relevant clinical examination, photo stress test and amsler grid monitoring was done in all patients. Statistical analysis was done using SPSS Version 18. Results: The overall prevalence of age related maculopathy in the study population was 1.76%, and it increases with age. Mean age was 62.84 years ± 7.97. Males were more affected by the disease. Smoking, dyslipidemia, cortical cataract and hyperopia were the most common risk factors. Photo stress recovery time was prolonged in all patients with reduced visual acuity. Even in eyes with good vision it was abnormal in the early stage of the disease before visible change occurred in the macula. Abnormal recovery time was also noted in patients with normal Amsler grid. Conclusion: PSRT helps in early detection of macular dysfunction in better eye, as well as progression in worse eye in patients with asymmetrical age related maculopathy.

Page No. 69-73

Authors: Jayashree S Shah, Satya Swapnika Y, MS Padma Jothi

Background: This study was conducted to isolate the common fungi from the corneal ulcer of the patients and to treat fungal keratitis with appropriate antifungal drugs. Methods: All the patients with corneal ulcer who visited the Ophthalmology OPD at SSMCH, Tumkur were evaluated. Further, all the cases of corneal ulcer were examined with slit lamp biomicroscopy and corneal scrapings taken are subjected to KOH preparation and those with fungal etiology were identified and taken up for the study. The patients were taken into the study irrespective of the previous disease and previous medication. Results: Out of 20 patients recognised as fungal corneal ulcer, most of the patients belong to the age of 11 to 50 years as they are the working population. The patients with fungal corneal ulcer showed minimal symptoms than signs we lead to delayed avail to treatment. The earliest time the patient visited the hospital after the onset of the disease, was 2 days and the longest duration was 2 months. Those patients with a history of agricultural trauma had either remained negligent in early stage or tried all possible remedies within their easy reach in their initial conditions and come only when the pain became intractable with loss of vision. Conclusion: A high index of suspicion should be raised in cases with history of trauma and clinical features highly suggestive of fungal corneal ulcer (dry elevated surface, stromal infiltration with hyphate margins). 10% KOH smear is a rapid and sensitive method of diagnosis which is confirmed by SDA cultures that is the most sensitive and specific test available. Aspergillus and Fusarium are the most common isolates. Fluconazole and Natamycin are the drugs of choice in most filamentous keratitis. Most of the cases heal with some grade of opacity, ultimately requiring a therapeutic Penetrating Keratoplasty to regain useful vision.

Page No. 80-84

Authors: Neha R. Chandak, Sachin V. Daigavane, Surabhi R. Sharma

Introduction: Colour vision in humans is trichromatic. Colour vision deficiency (CVD) occurs when one or more of cone types are absent, or present but defective. It is a common X-linked genetic disorder. However, most colour blind children remain undetected due to absence of proper screening. Therefore, this cross-sectional study was carried out to determine the prevalence of CVD, type of CVD and prevalence of each type among school children of Wardha District. Materials and Methods: 850 school children in the age of 10-15 years were screened for CVD using Ishihara’s pseudoisochromatic test 38 plate edition. Results: Of 850 school children, 18 children (2.1%) (95% confidence interval: 1.35-3.33) suffered from CVD. Prevalence rate for CVD was found to be higher in males (3.7%) than in females (0.4%). The overall trend of defects was: deuteranomaly > deuteranopia > protanomaly > protanopia. The prevalence of congenital dyschromatopsia in school children of Wardha District was comparable to prevalence rates across India. Conclusion: Early diagnosis of congenital dyschromatopsia would allow for minimization of these problems, improvement of adaptation of children to their dysfunction, and, most importantly, for better planning of their professional future.

Page No. 91-95

Authors: Shakeen Singh, Pawan Prasher, Mandeep Kaur, Arushi Kakkar, Manish Chhabra

Purpose: To study the indications for penetrating keratoplasty(PKP) in Punjab. Design: Retrospective study. Methods: Retrospective analysis of medical records of patients who underwent PKP at Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar from January 1, 2015 to January 1, 2017 was conducted to study the indications of PKP. Results: A total of 102 eyes of 94 patients were included in the current study, of which 75 (79.78%) were males. The mean age of the patients was 53.1 ± 17.2 (range 15 to 85) years. The most common indication for PKP was corneal opacity in 43 (42.15%) cases, followed by active infectious keratitis in 16 (15.69%), adherent leucoma in 12 (11.76%), bullous keratopathy in 10 (9.8%), failed graft in 9 (8.82%), staphyloma in 6 (5.88%), keratoconus in 1 (0.98%), and miscellaneous causes in 5 (4.9%) cases. Post infectious cause was the most common subcategory in the corneal opacity group, followed by post-trauma and post chemical burns. Conclusions: Corneal opacity, most commonly as a result of post-infectious scarring, is the most common indication for PKP in Punjab. Patient education, preventive measures, and improvement in primary eye health care services are required to reduce the burden of corneal blindness in this region.

Page No. 107-111

Authors: R N Kothari, Dipak B. Patel, Nirali Patel, Anjashi Patel, Toral Rajput

Introduction: “Meibomian gland dysfunction (MGD) is thought to be the leading cause of dry eye disease”. (1) The pathophysiology of MGD is complex and bacterial infection is a cause of MGD remains controversial. “Doxycycline is a long acting analogue of tetracycline which has been used to treat MGD through its antimicrobial, anti-inflammatory and anti metalloproteinase properties, with fewer side effects than tetracycline”. (2,3) This comparative and clinical study is being done to evaluate efficacy and compliance of oral doxycycline and oral azithromycin in meibomian gland dysfunction who were not responding to conservative management. Methods: The study was carried out from April 2016 to September 2016 in our institute. 100 patients were enrolled in the study. Thorough ophthalmic examination was done. Schirmer tests 1 and 2 and TBUT (tear film break up time) were performed to check for dry eye. Patients were called for 3 follow-up and whole ophthalmic examinations were repeated each time. Results: Total 100 patients were included in the study. Of these 59 males and 41 were females. In both group signs and symptoms improvement from pretreatment to last follow up was statistically significant (p=0.000). Improvement of symptoms and signs in both group was almost equal, so p-value is insignificant, when comparing between both groups (p=0.714). The side effects in doxycycline group was more as compared to azithromycin group at all follow up (p=0.012). Conclusion: This study demonstrated that both oral doxycycline and azithromycin are effective in patients with MGD. The side effects observed in doxycycline group were significantly higher in all follow up visits as compared to azithromycin group. Therefore, a five day course of oral azithromycin is suggested based on better clinical improvement, shorter treatment duration, less side effects and low cost.

Page No. 115-116

Authors: Ashok Madan, Mona Deshmukh, Bhushan A. Chaukhe

Electrical insults to the human body range from death to damage to various parts of the body. It can result in a wide range of ocular injuries with resultant ocular complications. Of these, electrical cataract can occur after a latent period and then can progress with starting rapidly. The clinical picture of electrical injury is influenced by numerous factors including voltage, tissue sensitivity, type of current (direct or alternating), length of contact, place and area of contact, and route traveled in the body. The majority of cases respond well to surgery, but final visual acuity will depend on the other ocular damage due to electrical current. However proper surgical management can result in good and stable visual acuity as is seen in this case. The need for awareness of the possibility of this complication and screening of all cases of electrical injuries is stressed. The majority of cases respond well to surgery. We report a rare case of a 15 years young boy having bilateral anterior sub-capsular cataracts caused by high-voltage electrocution in a young man who regained normal vision after surgery in both eyes. Bilateral Phacoemulsifiation with foldable hydrophobic lens [PCIOL] in capsular bag was done.