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   Table of Contents - Current issue
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April-June 2022
Volume 34 | Issue 2
Page Nos. 129-272

Online since Tuesday, July 26, 2022

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EDITORIAL  

Current and future implications of using artificial intelligence in glaucoma care p. 129
Abhimanyu S Ahuja, Sarvika Bommakanti, Isabella Wagner, Syril Dorairaj, Richard D Ten Hulzen, Leticia Checo
DOI:10.4103/joco.joco_39_22  
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REVIEW ARTICLES Top

Efficacy and safety of aflibercept therapy for diabetic macular edema: A systematic review and meta-analysis Highly accessed article p. 133
Sangeetha Santhakumaran, Ali Salimi, Vanessa C Brunetti, John Galic
DOI:10.4103/joco.joco_308_21  
Purpose: To assess the real-world efficacy and safety of aflibercept for the treatment of diabetic macular edema (DME). Methods: A systematic search was conducted across multiple databases. Articles were included if participants had DME and received aflibercept treatment for a minimum of 52 ± 4 weeks. Primary outcomes included changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT). A risk of bias assessment of studies was completed, pooled estimates were obtained, and a meta-regression was performed. Information on adverse events was collected. Results: The search yielded 2112 articles, of which 30 were included. Aflibercept was more effective than laser photocoagulation functionally (12-month BCVA-weighted mean difference [WMD] = 10.77 letters, P < 0.001; 24 months = 8.12 letters, P < 0.001) and anatomically (12-month CMT WMD = –114.12 μm, P < 0.001; 24 months = –90.4 μm, P = 0.004). Compared to bevacizumab, aflibercept was noninferior at improving BCVA at 12 months (WMD = 1.71 letters, P = 0.34) and 24 months (WMD = 1.58 letters, P = 0.083). One study found that aflibercept was more effective than bevacizumab anatomically at 1 and 2 years (P < 0.001 at 12 and 24 months). Compared to ranibizumab, aflibercept rendered a greater improvement in BCVA at 1 year (WMD = 1.76 letters, P = 0.001), but not 2 years (WMD = 1.66 letters, P = 0.072). CMT was not significantly different between both therapies at 12 months (WMD = −14.30 μm, P = 0.282) and 24 months (P = 0.08). One study reported greater functional improvement with aflibercept compared with dexamethasone (P = 0.004), but inferiority in reducing CMT (P < 0.001). Meta-regression analysis demonstrated that dosing schedule was found to impact outcomes at 12 and 24 months, while study design and sample size did not impact outcomes at 12 months. There were minimal safety concerns using aflibercept therapy. Conclusions: Aflibercept is a safe and effective therapy option for DME in the clinical setting, performing superiorly to laser photocoagulation. Evidence regarding comparisons with bevacizumab, ranibizumab, and dexamethasone is mixed and limited.
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Prevalence of Pediatric Cataract in Asia: A Systematic Review and Meta-Analysis p. 148
Muhammad Ali Tariq, Qazi Shurjeel Uddin, Bilal Ahmed, Shehryar Sheikh, Uzair Ali, Ashar Mohiuddin
DOI:10.4103/joco.joco_339_21  
Purpose: To conduct a systematic review and meta-analysis for estimating the prevalence of pediatric cataracts across Asia. Methods: A detailed literature search of PubMed, Embase, Web of Science, Cochrane Library, and Google Scholar databases, from 1990 to July 2021, was performed to include all studies reporting the prevalence of cataracts among children. Two researchers performed the literature search and screening of articles independently, and a third researcher critically reviewed the overall search and screening process to ensure the consistency. The JBI Critical Appraisal Checklist for studies reporting prevalence data was used to assess the methodological quality of the included studies. Results: Of the 496 identified articles, 35 studies with a sample size of 1,168,814 from 12 Asian countries were included in this analysis. The estimated pooled prevalence of pediatric cataracts in Asian children is 3.78 (95% confidence interval: 2.54–5.26)/10,000 individuals with high heterogeneity (I[2] = 89.5%). The pooled prevalence by each country per 10,000 was 0.60 in Indonesia, 0.92 in Bangladesh, 1.47 in Iran, 2.01 in Bhutan, 3.45 in Laos, 3.68 in China, 4.27 in Thailand, 4.47 in India, 5.33 in Malaysia, 5.42 in Nepal, 9.34 in Vietnam, and 10.86 in Cambodia. Conclusions: This study utilizes existing literature to identify the prevalence of cataracts in Asian children. Moreover, it highlights the need for more epidemiological studies with large sample sizes from other countries in Asia to accurately estimate the burden of disease.
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ORIGINAL ARTICLES Top

Early macular thickness changes after trabeculectomy and combined phaco-trabeculectomy p. 160
Naveed Nilforushan, Shima Loni, Parya Abdolalizadeh, Arezoo Miraftabi, Mohammad Banifatemi, Reza Rakhshan, Samira Jafari, Navid Abolfathzadeh
DOI:10.4103/joco.joco_333_21  
Purpose: To assess postoperative changes in central retinal thickness (RT) following trabeculectomy and combined phaco-trabeculectomy using spectral domain-optical coherence tomography. Methods: In a prospective interventional comparative study, 64 consecutive glaucoma patients who underwent trabeculectomy (32 eyes) or phaco-trabeculectomy (32 eyes) were included. A macular thickness map using the Early Treatment Diabetic Retinopathy Study circles of 1 mm, 3 mm, and 6 mm was the standard to evaluate the 9-subfield thickness preoperatively and again at 1 and 3 months after surgery. Four subfields in each of the 3 mm and 6 mm rings were considered parafoveal and perifoveal regions, respectively. Results: Preoperative measurements were similar in the two groups, except patients in the combined group which were older (P = 0.002). The mean RT in the combined phaco-trabeculectomy group at month 1 was significantly higher than baseline measurements at central subfield retinal thickness (CSRT) (P = 0.01), temporal (P = 0.001), and inferior (P = 0.04) parafoveal and temporal (P = 0.01), superior (P = 0.02), and nasal (P < 0.001) perifoveal quadrants; however, RT changes in the trabeculectomy-only group were not statistically significant at months 1 and 3 (P > 0.05). The increase in the temporal perifoveal RT of the combined phaco-trabeculectomy group persisted at month 3 (P = 0.01), while the RT in other sectors returned to preoperative values. The two treatment groups did not differ in terms of changes in the CSRT over time (P = 0.37). In addition, no difference was observed between the treatment groups regarding the parafoveal RTs at each time points (0.06 ≤ P ≤ 0.29). Conclusions: There was no significant difference in the pattern of changes of CSRT and parafoveal RT between trabeculectomy and combined phaco-trabeculectomy treatment groups up to 3 months after surgery. Some detectable increase in RT in the combined phaco-trabeculectomy will reverse to baseline values 3 months after surgery, except in the temporal perifoveal region.
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Effect of prophylactic aqueous suppression on ahmed glaucoma valve surgery success p. 167
Rini Saha, Riddhi Shah Dharia, Graham E Trope, Yvonne M Buys
DOI:10.4103/joco.joco_244_21  
Purpose: To evaluate the effect of prophylactic aqueous suppressants immediately post-Ahmed glaucoma valve (AGV) surgery on the rate of hypertensive phase and success. Methods: Retrospective case–control study of 80 eyes with refractory glaucoma undergoing AGV surgery. Forty eyes in the intervention group (preoperative aqueous suppressants continued postoperatively) and 40 in the control group (all glaucoma drops stopped after surgery and reintroduced as required) were included in this study. Patients were followed for 1 year. Data collected included intraocular pressure (IOP), number of glaucoma medications, and number of eyes requiring further IOP lowering surgery. The frequency of hypertensive phase and 1-year success was compared between the groups. Results: Hypertensive phase occurred in 22.5% of the intervention group compared to 42.5% of the control group; however, this difference was not statistically significant (P = 0.06). Success at 1 year (IOP ≤21 mmHg but ≥5 mmHg and 20% reduction from baseline without additional surgery) was similar in each group: 77.5% in the intervention group and 62.5% in the control group (P = 0.22). However, at 1 year, significantly more eyes in the intervention group had an IOP ≤17 mmHg (95% vs. 80%, P = 0.04). The mean time interval to a second IOP lowering procedure was significantly shorter in the control group (P < 0.005). Conclusions: With prophylactic preoperative aqueous suppressants, more eyes achieved an IOP of ≤17 mmHg. The time interval to repeat the glaucoma procedure was significantly shorter in the control group.
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Diagnostic accuracy and relationship between optical coherence tomography angiography vessel density and structural/functional parameters in healthy, preperimetric, and manifest glaucoma eyes p. 173
Asma Khallouli, Yassin Oueslati, Dhouha Gouider, Saker Bouchoucha, Afef Maalej, Riadh Rannen
DOI:10.4103/joco.joco_326_21  
Purpose: To evaluate circumpapillary vessel density (cpVD) in normal subjects, preperimetric glaucoma, and manifest glaucoma, assess the relationship between cpVD and both structural and functional parameters and compare the diagnostic accuracy of the structural and vascular measurements. Methods: An analytical cross-sectional study of 153 eyes of 83 individuals divided into three groups: Normal subjects, preperimetric glaucoma, and manifest glaucoma. All individuals underwent standard automated perimetry, spectral-domain optical coherence tomography (SD-OCT), and OCT angiography (OCT-A) centered on the optic nerve. We assessed structural (ganglion cell complex [GCC]/retinal nerve fiber layer [RNFL]) and functional parameters (mean deviation [MD]/loss variance [LV]). Results: Thirty-three normal subjects (66 eyes), 18 patients (30 eyes) with preperimetric glaucoma, and 32 patients (57 eyes) with manifest primary open-angle glaucoma were enrolled. The comparative study of cpVD showed a significant difference comparing glaucomatous subjects versus preperimetric glaucoma (P = 0.025) groups and normal subjects (P < 0.001). The cpVD was strongly correlated with functional parameters, MD, and LV (P < 0.001). Furthermore, cpVD was better correlated with RNFL (P < 0.001) than GCC (P < 0.001). Best regression was observed with mean RNFL (R2 = 0.752). The cpVD has a higher diagnostic value than RNFL and GCC, only between preperimetric and manifest glaucoma. Conclusions: Circumpapillary vessel damages seem to be less prominent, as it was seen only for the manifest glaucoma group. Microvascular changes appear to occur secondary to RNFL and GCC damages. They seem to be well correlated with visual function. Therefore, OCT-A is not as sensitive as SD-OCT in detecting early structural alterations.
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PreserFlo™ microshunt combined with phacoemulsification versus preserflo™ MicroShunt as a standalone procedure in patients with medically resistant open-angle glaucoma p. 180
Sofia Fili, Kalliopi Kontopoulou, Iraklis Vastardis, Georgios Perdikakis, Nikolaos Bechrakis, Markus Kohlhaas
DOI:10.4103/joco.joco_298_21  
Purpose: To compare the efficacy and safety of PreserFlo™ MicroShunt (Santen, Osaka, Japan) combined with phacoemulsification to PreserFlo™ MicroShunt as a standalone procedure in eyes with moderate to advanced open-angle glaucoma. Methods: In an observatory, prospective, clinical study, 30 patients (30 eyes) with moderate to advanced angle glaucoma were allocated to either PreserFlo MicroShunt combined with phacoemulsification (15 eyes; Group A) or PreserFlo™ MicroShunt as a standalone procedure (15 eyes; Group B). The follow-up time of the study was 12 months. Results: Average intraocular pressure (IOP) at 12 months was 11.62 ± 1.6 mmHg in Group A and 13.8 ± 3.6 mmHg in Group B, which was significantly lower than baseline IOP (Group A: 23.47 ± 8.99 mmHg, P < 0.001; Group B: 23.4 ± 8.68 mmHg, P < 0.001). The absolute reduction of IOP within the 12 postoperative months was not significantly different between the two groups (P = 0.056). The number of the topical medications that were administered 12 months after ocular surgery was 0 in Group A and 0.6 ± 0.8 in Group B, compared to 3.13 ± 1.02 in Group A (P < 0.001) and 2.4 ± 1.45 in Group B (P = 0.004) at baseline. Phacoemulsification combined with PreserFlo™ MicroShunt significantly reduced the number of antiglaucoma agents after 12 months compared to the standalone procedure (P = 0.026). One eye in Group A was referred for bleb revision due to bleb fibrosis and a consequent acute postoperative rise in IOP. One eye in Group A required transscleral cyclophotocoagulation with MicroPulse® laser. One bleb revision was also necessary in Group B at the 4th postoperative week. Endothelial cell density did not significantly change over 12 months in either group (Group A: baseline, 2017.3 ± 346.8 cells/mm[2]; 12 months, 1968.5 ± 385.6 cells/mm[2]; P = 0.38; Group B: baseline, 2134.1 ± 382.6 cells/mm[2]; 12 months, 2094.4 ± 373.3 cells/mm[2], P = 0.42). The PreserFlo™ MicroShunt combined with phacoemulsification produced higher absolute success rates after 12 months in patients with moderate to advanced open-angle glaucoma than the PreserFlo™ MicroShunt as standalone procedure (Group A: 80% and Group B: 60%, P = 0.022). Conclusions: In eyes with moderate to advanced open-angle glaucoma, PreserFlo™ MicroShunt with or without phacoemulsification is effective in reducing IOP and the number of the antiglaucoma agents with a very small incidence of complications and subsequent glaucoma surgeries. However, adding phacoemulsification to PreserFlo™ MicroShunt successfully reduces IOP without the need for ongoing topical medications as are needed after the standalone procedure.
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Clinical features and outcomes of congenital cataract surgery with primary intraocular lens implantation in a tunisian cohort p. 187
Ines Malek, Jihene Sayadi, Takwa Sammouda, Racem Choura, Manel Mekni, Imen Zghal, Moncef Khairallah, Leila Nacef
DOI:10.4103/joco.joco_273_21  
Purpose: To describe the clinical features of congenital cataract (CC) in a Tunisian cohort and to assess the surgical outcomes of primary intraocular lens implantation in two groups based on the age at surgery. Methods: This study was a prospective analysis of children under 5 years with CC that were operated between January 2015 and 2020. The surgery consisted of phacoaspiration with posterior capsulorhexis and primary implantation. Group 1 comprised children operated at <2 years of age and Group 2 comprised children operated between 2 and 5 years. Peri and postoperative surgical events as well as refractive and visual outcomes were compared between both the groups. Results: Fifty-five (84 eyes) infants were enrolled. Group 1 included 30 (48 eyes) children and Group 2 included 25 (36 eyes) patients. The mean follow-up was 27.60 ± 19.89 months. The mean delay between the diagnosis and the cataract surgery was 11.97 ± 13.84 months. Of 14 (16.7%) eyes with postoperative visual axis opacification (VAO), 9 (10.7%) eyes required pars plana membranectomy. The VAO was not statistically associated with the age at surgery (P = 0.112), but significantly correlated with sulcus implantation (P = 0.037). The final mean visual acuity was 0.51 logMAR and comparable between both the groups (P = 0.871). Poor visual outcome was significantly associated with low age at presentation (<6 months; P = 0.039), delay between the diagnosis and time of surgery (P = 0.001), preoperative nystagmus (P = 0.02), and poor parental compliance to amblyopia treatment (P = 0.009). Conclusions: Primary implantation seems to be safe and efficient. VAO appears to become an avoidable occurrence owing to better surgical techniques. Amblyopia remains the biggest barrier to final visual outcome.
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A comparison between wavefront-optimized and wavefront-guided photorefractive keratectomy in patients with moderate-to-high astigmatism: A randomized clinical trial p. 194
Hassan Razmjou, Alireza Peyman, Saeedreza Moshfeghi, Hamideh Kateb, Morteza Naderan
DOI:10.4103/joco.joco_18_21  
Purpose: To compare clinical outcomes of wavefront-optimized (WFO) and wavefront-guided (WFG) photorefractive keratectomy (PRK) in patients with moderate-to-high astigmatism. Methods: Patients with corneal cylinder above 2 diopters and myopic spherical equivalent were randomized into WFO or WFG PRK. Visual acuity (VA), refraction, contrast sensitivity, higher-order aberrations (HOAs), and astigmatic vector differences were documented and compared for 6 months after surgery. Results: The total number of 362 eyes from 181 patients was analyzed. The amount of total aberration was reduced 2.7 root mean square (RMS) and 2.9 RMS in the WFO and WFG groups, respectively (P < 0.001 in each group and between the groups). HOAs including coma, trefoil, and spherical aberrations increased in both the groups (P < 0.001) but were significantly more in the WFO group (P < 0.001). The increased spherical aberration was similar in both the groups (P = 0.12). Surgically induced astigmatism was not significantly different between the groups (P = 0.20). The magnitude of error was significantly higher in the WFO group (P < 0.001), but the absolute angle of error and the arithmetic angle of error were not significantly different between the groups (P = 0.20 and P = 0.30, respectively). Conclusion: WFO and WFG platforms of PRK appear comparable in terms of VA, refractive correction, and total aberration. Yet, HOAs may increase especially after WFO PRK.
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Comparing pentacam HR screening indices in different normal corneal thicknesses among refractive surgery candidates p. 200
Leila Ghiasian, Parya Abdolalizadeh, Ali Hadavandkhani, Acieh Eshaghi, Yasaman Hadi, Fatemeh Nadjafi-Semnani
DOI:10.4103/joco.joco_249_21  
Purpose: To compare Pentacam indices in normal eyes with different corneal thicknesses. Methods: It is a retrospective observational study. Ninety-six normal eyes of 96 patients who were referred for refractive surgery in a tertiary university-based hospital from October 2015 to April 2019 were recruited consecutively. Corneal keratometry as well as Pentacam's software Belin-Ambrósio Enhanced Ectasia Display (BAD) parameters including pachymetry progression indices (PPIs), maximum Ambrosio's relational thickness (ART-max), corneal elevations, normalized deviations, BAD total deviation value (BAD-D), and anterior surface indices were measured by Pentacam HR (Type 70900). The included were classified as thin (26 eyes), average (45 eyes), and thick (25 eyes) corneas with the thinnest point thickness of ≤496 μm, 497–595 μm, and ≥596 μm, respectively. The specificities of all parameters were calculated based on routine cut-off values. Results: The refraction, keratometry, and elevations were not different (P > 0.05). All PPIs (minimum, average, and maximum) of thick corneas were significantly lower than average and thin corneas (P < 0.001). ART-max increased by thickening of the cornea (P < 0.001). BAD-D score and normalized indices of pachymetric parameters decreased with the increase of thickness (P < 0.001), while specificities of all indices increased with corneal thickening. More than 96% of thick corneas were classified as normal PPI-max (24/25), ART-max (25/25), and BAD-D (25/25), while nearly <54% of thin corneas (14/26 for PPI-max, 9/26 for ART-max, and 12/26 for BAD-D) were normal. Conclusions: The pachymetry-related indices and BAD-D were different among normal corneas with various thicknesses. The specificities of PPIs, ART-max, and BAD-D of thin corneas were lower than in thick corneas.
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Comparison of pterygium recurrence with and without using postsurgical topical cyclosporin a 0.05%: A randomized clinical trial p. 208
Yousef Alizadeh, Mitra Akbari, Reza Soltani Moghadam, Maryam Dourandeesh, Zahra Moravej
DOI:10.4103/joco.joco_285_21  
Purpose: To evaluate the efficacy of 3-month administration of topical cyclosporin A (CsA) 0.05% on postoperative recurrence after pterygium surgery. Methods: In this randomized clinical trial, 78 patients undergoing pterygium surgery (using the rotational conjunctival flap technique with mitomycin C [MMC]) were enrolled and randomly allocated into the control (n = 39) and case (CsA) (n = 39) groups in a single-blind method. The patients were examined on postoperative days 1, 3, and 7 and months 1, 3, and 6, and their best-corrected visual acuity, intraocular pressure, clinical inflammation, postoperative complications, and recurrence were compared. Results: The mean age of patients was 53.22 ± 9.99 years; most (57.7%) of them were men. The two groups were not different in terms of demographics, pterygium size, or pterygium grade. The clinical inflammation at the first and third postoperative months was not different between the groups (P = 0.108 and 0.780, respectively). No serious complications were detected; complication rates were not different between the groups (P = 0.99). The recurrence rate was 5.1% in the case group and 7.7%% in the control group (P = 0.99). Conclusion: The present study showed no priority for 3-month administration of CsA 0.05% drops on postoperative outcomes, including prevention of pterygium recurrence, complications, and inflammation after the rotational conjunctival autograft technique with MMC.
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Distribution pattern of total corneal thickness in keratoconus versus normal eyes using an optical coherence tomography p. 216
Hassan Hashemi, Zahra Heidari, Mehrdad Mohammadpour, Hamed Momeni-Moghaddam, Mehdi Khabazkhoob
DOI:10.4103/joco.joco_198_21  
Purpose: To evaluate the total corneal thickness distribution pattern using a high-resolution spectral-domain optical coherence tomography (HR SD-OCT) for distinguishing normal eyes from keratoconus (KCN). Methods: One hundred and forty-four patients were enrolled in three groups (55 normal, 45 mild KCN, and 44 moderate-to-severe KCN eyes) in this prospective diagnostic test study. Total corneal thickness was measured in 8 semi-meridians using HR SD-OCT (Heidelberg Engineering, Heidelberg, Germany) in 5 and 7 mm zones. The central corneal thickness (CCT), corneal focal thinning (minimum thickness [Min], min minus median and maximum [Min-Med, Min-Max]), and asymmetry indices (inferior minus superior [I-S] and supranasal minus infratemporal [SN-IT]) were calculated. One-way analysis of variance and the area under the receiver operating characteristic curve (AUC) were used for the analysis. Results: Thinner CCT, lower Min thickness, more negative Min-Max, Min-Med, and greater I-S and SN-IT were found in KCN eyes compared to the control group (P < 0.001). The inferior and IT semi-meridians were the thinnest locations in KCN cases in the 5 mm central zone (P < 0.001). CCT followed by Min-Med had the highest discriminative ability for differentiating mild KCN (AUC, sensitivity and specificity: 0.822, 87.0%, 60.37% and 0.805, 82.93%, 66.0%, respectively) and moderate-to-severe KCN (0.902, 87.82%, 73.08% and 0.892, 85.37%, and 78.85%, respectively) from normal corneas. Conclusion: The inferior and IT sectors of the cornea with the largest thickness changes in the 5 mm zone are the most common thinning sites in keratoconic corneas, and CCT and Min-Med are the most sensitive indices for the diagnosis of KCN.
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Prevalence and distribution of refractive errors among ophthalmic patients in Madang Province, Papua New Guinea p. 223
Bismark Owusu-Afriyie, Moses Kombra, Theresa Gende, Anna Kia, Isabella Mou
DOI:10.4103/joco.joco_337_21  
Purpose: To assess the prevalence and distribution of refractive errors in Madang Province, Papua New Guinea (PNG). Methods: A retrospective hospital-based study was conducted at Madang Provincial Hospital Eye Clinic. It is a free eye clinic and spectacle costs are further subsidized by a nongovernmental organization. Nonprobability purposive sampling was used to retrieve patients' records at the eye clinic from January to December 2016. Only demographic and clinic data on the patients' first visit to the eye clinic were recorded and these included their age, gender, location, presenting visual acuity (VA), and refractive correction. Results: One thousand and one hundred eighty-four patients' records were retrieved, of which 622 (52.53%) had refractive error. The mean age of refractive error presentation was 49.68 ± 16.29 years with a range of 9–86 years. There were more males (55%) than females. About a quarter of the patients (21.2%) presented with moderate visual impairment. There was a statistically significant relationship between visual impairment and age group (P < 0.001). Myopia (53.1%) was the most common type of refractive error followed by hyperopia (32.5%) and astigmatism (14.4%). The uptake of spectacle correction was very high (95.3%) among the patients. More than one-tenth of the patients (12.5%) reported from other provinces. Almost one-third of the patients (31.4%) could not obtain a VA of 6/6 after refraction. About one-fifth (17.0%) of the patients were suspected of functional amblyopia. Conclusions: Uncorrected refractive error (URE) is a significant cause of visual impairment in PNG. There is a need for the integration of eye care services into primary health care for early detection, treatment, and prevention of visual impairment caused by UREs.
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Corneal cross-linking in pellucid marginal degeneration: Evaluation after five years p. 229
Matin Irajpour, Pegah Noorshargh, Alireza Peyman
DOI:10.4103/joco.joco_16_22  
Purpose: To evaluate the long-term outcome of corneal cross-linking (CXL) for pellucid marginal degeneration (PMD). Methods: In a retrospective study, forty eyes of forty patients were enrolled. All subjects had undergone CXL for PMD at least 5 years before the assessments. Visual acuity, refraction, and topography data were compared to their respective values before CXL. Results: The comparison between mean preoperative logMAR uncorrected visual acuity and 5-year postoperative evaluation revealed no significant change (1.20 ± 0.65 and 1.17 ± 0.64, P > 0.05). No statistically significant difference was noted comparing preoperative mean logMAR best-corrected visual acuity (BCVA) and postoperative mean logMAR BCVA (0.24 ± 0.19 and 0.22 ± 0.20, P > 0.05). We did not find any significant difference between pre- and postoperative spherical equivalent and spherical refractive errors (P = 0.419 and P = 0.396, respectively). Regarding the BCVA Snellen lines, 23 eyes had no significant change in pre- and postoperative examinations, 11 eyes had improvement, and 6 subjects showed worsening defined as significant when two or more lines change. The spherical equivalent refractive error improved in 4 subjects, was stable in 25, and worsened in 11 subjects, while a 0.5 diopter or more myopic change was considered significant. Furthermore, regarding steep keratometry values, 25 subjects were stable, 7 had improvements, and 8 worsened. Conclusion: CXL appears to be a safe and effective procedure to halt the progression of PMD.
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Association of Use of Statins with Progression of Diabetic Retinopathy at a Tertiary Care Hospital in Southern India p. 234
Prachi Priyadarshini, Bharti Chogtu, Sulatha V Bhandary, Kabirdev , Rahul Magazine
DOI:10.4103/joco.joco_70_21  
Purpose: To study the role of statin therapy on diabetic retinopathy (DR) progression. Methods: This retrospective study was carried out at a tertiary care hospital in southern India. Data were collected from the medical records of patients admitted from January 2013 to December 2018. Out of 1673 patients of DR enrolled in the study, 171 met the inclusion criteria. Patients' demographic data, drug history, clinical characteristics, and laboratory investigations were recorded as per the pro forma. The patients were divided into statin users and nonusers. The results were analyzed to compare the DR progression between the two groups. Results: DR progressed in 67% of nonstatin users and 37% of statin users (P < 0.001). The use of statins decreased the risk of DR progression (P < 0.001). Center-involving macular edema was seen in 8 of 79 statin users (10%) and 16 of 92 statin nonusers (16%) based on optical coherence tomography findings during the follow-up period (P = 0.17). Conclusion: In patients with type 2 diabetes, lipid-lowering therapy with statins has the potential to retard DR progression.
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Retinotomy and retinectomy in the management of rhegmatogenous retinal detachment associated with advanced proliferative vitreoretinopathy p. 241
Amin Zand, Alireza Helal Birjandi, Behrouz Saeedian, Sayyed Amirpooya Alemzadeh, Fatemeh Abdi, Ahad Sedaghat, Mohammad Mehdi Parvaresh, Khalil Ghasemi Falavarjani
DOI:10.4103/joco.joco_37_22  
Purpose: To report the anatomical and functional outcomes of retinotomy and/or retinectomy for the management of rhegmatogenous retinal detachment (RRD) complicated by advanced proliferative vitreoretinopathy (PVR). Methods: In this retrospective study, the charts of patients who underwent pars plana vitrectomy with retinotomy and/or retinectomy for the management of RRD complicated by PVR were reviewed. Primary outcome measures were final best-corrected visual acuity (BCVA) and anatomical reattachment rate. Results: Sixty-one eyes of 61 patients with a mean age of 48.56 ± 15.92 were studied. The mean follow-up time was 21.38 ± 23.08 months. The mean angle of the retinotomy was 171.31° ± 79.15°. Thirty-two (52.5%) of them needed extensive (≥180°) retinotomy. In addition, simultaneous retinectomy was performed in 36.2% of the cases. The BCVA was 2.18 ± 0.63 and 1.85 ± 0.71 logMAR before the surgery and at the last visit, respectively (P = 0.001). The initial anatomical success was achieved in 45 eyes (73.8%) after retinotomy surgery. Sixteen eyes (26.2%) had recurrent RD and needed reoperation, which was performed 5.60 ± 4.01 months after the initial retinotomy surgery. At the last examination, the retina was attached in all patients. Conclusion: Retinotomy with/without retinectomy is an effective procedure in the majority of patients with RRD associated with advanced PVR; however, additional surgeries are needed in a significant number of eyes to achieve final anatomical success.
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Outcomes of Bilateral Lateral Rectus Resection in Residual Esotropia following Bilateral Medial Rectus Recession p. 247
Reza Nabie, Vahideh Manouchehri, Sepideh Rostam Meydan
DOI:10.4103/joco.joco_320_21  
Purpose: To evaluate the success rate, dose-response ratio, and predictive factors of success in patients with residual esotropia (≥25 prism diopter [pd]) following bilateral medial rectus (BMR) recession who underwent bilateral lateral rectus (BLR) resection. Methods: In a retrospective study, medical records were reviewed for 47 patients with equal or more than 25 pd residual esotropia following 6 mm BMR recession. Sex, age at second surgery, the interval between first and second surgery in months, visual acuity, refraction, presence of amblyopia, presence of dissociated vertical deviation or inferior oblique overaction/superior oblique overaction, preoperative and postoperative angle of deviation, amount of BLR resection, and months of follow-up were evaluated. Surgical success was defined as postoperative deviation within 8 pd of orthophoria. Results: The mean age of patients at reoperation was 48.59 ± 21.46 months. The mean near and far residual esotropia before BLR resection was 34.57 ± 11.02 and 33.83 ± 10.99 pd, respectively, reduced to 8.12 ± 1.43 pd in near and 6.32 ± 2.1 pd in far postoperatively. The mean BLR resection dosage was 5.53 ± 1.22 mm and each millimeter of BLR resection (1 mm for each eye) corrected an average of 7.95 pd of deviation in near and 7.40 pd in far. The success rate was 74.5%. After analysis using multivariate logistic regression, there were no factors associated with success. Conclusions: Bilateral rectus resection in patients with a previous BMR recession has acceptable outcomes. The recommended surgical table can be used as a guide by strabismus surgeons in patients with residual esotropia.
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A case-control study to determine the microbiological spectrum and antibiotic sensitivity patterns in congenital nasolacrimal duct obstruction p. 251
Muthumeena Muthumalai, Md Shahid Alam, Neha Shrirao, B Mahalakshmi, Bipasha Mukherjee
DOI:10.4103/joco.joco_216_21  
Purpose: To analyze the microbiological spectrum and antibiotic sensitivity patterns in children with congenital nasolacrimal duct obstruction (CNLDO). Methods: One hundred thirty-four eyes of 123 children in the age group of 0–16 years with a diagnosis of CNLDO who underwent lacrimal surgical procedures were included in this prospective comparative study. Sixty-two children in the age-matched group planned for intraocular surgery with patent nasolacrimal duct were deemed controls. The conjunctival swab after performing Regurgitation on Pressure over the Lacrimal Sac in the CNLDO group and the conjunctival swab in controls were sent for microbiological analysis. Antibiotic susceptibility testing was done for commonly employed antibiotics by the Kirby Bauer disk diffusion method. Results: Of 134 samples collected in the CNLDO group, 111 (82.8%) samples were culture positive. There were 165 bacteria isolated, among which 139 (84.24% of isolates) were Gram-positive bacteria, and 26 (15.75% of isolates) were Gram-negative. Fungal isolates were obtained in 2.23% of cases. The most common Gram-positive isolate was Staphylococcus epidermidis (S. epidermidis) (n = 51, 30.9% of total isolates), and the most common Gram-negative isolate was Haemophilus influenza species (n = 9, 5.5% of total isolates). Gram-positive isolates were sensitive mostly to gentamicin and vancomycin (95.5% each), and Gram-negative isolates to amikacin (92.3%). Both Gram-positive and Gram-negative isolates were susceptible to gatifloxacin (80% each). Probing outcomes were similar among Gram-positive (success, 84.6%) and Gram-negative (success, 84.0%) organisms. Conclusions: There was a predominance of Gram-positive isolates in children with CNLDO with S. epidermidis being the most common. The microbiological profile did not have any effect on the outcomes of probing.
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CASE REPORTS Top

Descemet's stripping automated endothelial keratoplasty using donor tissue from an 83-day-old infant p. 257
Nikolaos Ziakas, Angeliki Chranioti, Argyrios Tzamalis, Dimitrios Giannoulis, Dimitrios Kapantais, Michael Tsatsos, Konstantinos T Tsaousis
DOI:10.4103/joco.joco_242_21  
Purpose: To report a case of Descemet stripping automated endothelial keratoplasty (DSAEK) combined with phacoemulsification in an adult recipient using endothelial graft from an 83-day-old infant donor. Methods: A corneoscleral button was obtained from an infant donor and a DSAEK graft was prepared using a microkeratome. In comparison to the standard technique of DSAEK graft preparation some modifications were made in order to avoid inadvertent perforation, as the donor cornea had a very spherical shape, probably due to the very young age of the donor. The DSAEK graft was transplanted to the left eye of a 68-year-old woman suffering from Fuchs' endothelial dystrophy. Her preoperative best-corrected visual acuity (BCVA) in that eye was 20/100 and central corneal thickness 831 μm. Results: An uneventful DSAEK combined with phacoemulsification was performed. The main complication noted was detachment of the peripheral part and contraction of the corneal graft, observed two months after the procedure. The implanted tissue remained centrally attached with a BCVA of 20/40, 3 years postoperatively. Conclusion: This case report highlights the difficulties emerging from preparation and implantation using an endothelial graft tissue from the youngest ever reported donor.
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Management of a bilateral post-uveitic complex glaucoma with pupillary block, rupture of the anterior lens capsule, and malignant glaucoma following laser peripheral iridotomies: Case report and literature review p. 260
Khaled El Matri, Dhouha Gouider, Rim Limaiem, Ahmed Chebil, Meher Henchiri, Yousra Falfoul, Leila El Matri
DOI:10.4103/joco.joco_3_22  
Purpose: To report a case of a bilateral complex uveitic glaucoma (UG) with pupillary block, rupture of the anterior lens capsule, and malignant glaucoma in a young high-myopic patient and to report anterior segment optical coherence tomography (AS-OCT) findings initially and following surgery. Methods: A 21-year-old high-myopic woman who had a history of anterior uveitis with extensive posterior synechiae, presented with acute bilateral ocular pain, redness, and blurred vision following bilateral Nd: YAG laser peripheral iridotomy (LPI). Results: Visual acuity was limited to light perception in both eyes (OU), with a flat anterior chamber (AC) and anterior luxation of lens fragments. Intraocular pressure (IOP) was over 60 mmHg OU. AS-OCT showed closed angles and hyperreflective heterogeneous material within the flat AC. The iris and lens fragments were plated against the corneal endothelium OU. We performed an urgent pars plana vitrectomy associated with lensectomy. It was uneventful in OU. Repeated AS-OCT revealed a deep AC, widely open angles, and aphakia. IOP was lowered to 9 mmHg and visual acuity improved to 5/10 in OU. Conclusion: Performing LPI might be harmful in the presence of UG with extensive posterior synechia, resulting in complex mechanism glaucoma with aqueous misdirection syndrome associated with a pupillary block due to anterior lens luxation, even in high-myopic eyes. Nd: YAG LPI should not be performed simultaneously in OU, especially in pathologic eyes, to prevent bilateral vision-threatening complications. AS-OCT was of great help, allowing easy and detailed ultrastructural assessment of the ACs, and iridocorneal angles before and after surgery.
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Bilateral vision loss in an adult patient with woakes' syndrome: An unprecedented case p. 264
Kaveh Abri Aghdam, Ali Aghajani, Sara Hemmati, Mostafa Soltan Sanjari
DOI:10.4103/joco.joco_302_21  
Purpose: To report a rare case of Woakes' syndrome presented with bilateral vision loss. Methods: A 28-year-old male with a 1-year history of vision loss in the left eye was referred to the neuro-ophthalmology clinic after sudden vision loss in his right eye. A detailed review of clinical findings and the presumed pathophysiological basis of vision loss was performed. Results: Neuroimaging revealed bilateral massive nasal polyps, sphenoid sinus mucocele formation, and optic nerve dehiscence inside the sphenoid sinus. The vision in the right eye was restored after pulse corticosteroid therapy; however, the left eye remained severely visually compromised even after nasal polypectomy and mucocele drainage. Conclusion: Sinonasal disorders should be sought for patients with unexplained vision loss, as prompt intervention could be vision-saving in these patients.
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Presumed Combined Brilliant Blue G and Endolight-Induced Macular Damage following Epiretinal Membrane Removal Surgery p. 267
Ramesh Venkatesh, Aditi Gupta, Naresh Kumar Yadav, Jay Chhablani
DOI:10.4103/joco.joco_46_22  
Purpose: To report a rare case of macular outer retinal and retinal pigment epithelium (RPE) damage following brilliant blue G (BBG)-assisted epiretinal membrane (ERM) removal surgery. Methods: Retrospective, observational case report. Results: An 85-year-old lady presented with decreased vision in the left eye and a best-corrected visual acuity of 20/400. The right eye examination was within normal limits. The left eye had a significant cataract, and the fundus examination through the cataractous haze showed an ERM with macular pucker, which was confirmed on an optical coherence tomography (OCT) scan. A combined cataract surgery with intraocular lens implantation and BBG-assisted ERM removal and internal limiting membrane peeling surgery was performed. Over the subsequent visits, a well-defined area of outer retinal and RPE alteration was identified on OCT and fundus autofluorescence without significant improvement in visual acuity. At the last follow-up visit, the visual acuity minimally improved to 20/200. Conclusions: Macular toxicity due to repeated usage of BBG dye and high intensity focal endo-illumination may lead to poor visual outcome following ERM removal or similar macular surgeries. Adequate precautions need to be taken to prevent vision loss.
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LETTERS TO EDITOR Top

Letter to editor: Water-Drinking test in central serous chorioretinopathy p. 271
Ludovica Reda, Margherita Di Stasi, Eleonora D'Aniello
DOI:10.4103/joco.joco_128_22  
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Reply to Letter to Editor: Water-Drinking Test in Central Serous Chorioretinopathy p. 272
Niroj Kumar Sahoo, Jay Chhablani
DOI:10.4103/joco.joco_149_22  
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