Ophthalmology

EDITORIAL
	Indian Journal of Ophthalmology – The journey so far	p. 317
	Santosh G Honavar DOI:10.4103/ijo.IJO_303_19
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GUEST EDITORIAL
	Current management options in primary angle closure disease	p. 321
	Ramasamy Krishnadas DOI:10.4103/ijo.IJO_1932_18
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ONE MINUTE OPHTHALMOLOGY
	To prick or to poke?	p. 324
	Md. Shahid Alam, Vathsalya Vijay DOI:10.4103/ijo.IJO_763_18
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REVIEW ARTICLE
	Enigma of serpiginous choroiditis	p. 325
	Parthopratim Dutta Majumder, Jyotirmay Biswas, Amod Gupta DOI:10.4103/ijo.IJO_822_18   Serpiginous choroiditis (SC) is an asymmetrically bilateral inflammation of the choroid that leads to loss of choriocapillaris atrophy or loss of overlying retinal pigment epithelium. Over the last few decades, SC has passed through a long evolution of nomenclature, etiologies and morphological variations. Initially diagnosed in patients with tuberculosis and syphilis, SC was predominantly considered as autoimmune process. With the advancement of molecular diagnosis, a new aspect of infectious subtypes of SC has emerged out. The terminologies such as serpiginous-like choroiditis (SLC) and multifocal serpiginoid choroiditis are now used to denote the subtypes of SC which are associated with infectious etiologies especially tuberculosis. In a country endemic for tuberculosis such as India, it is very important to differentiate between classic SC and SLC before initiating aggressive immunomodulatory therapy. Also, management of paradoxical worsening of the clinical condition with antitubercular treatment is another challenge in SLC and ophthalmologists should be aware of such situations. With advent of newer imaging modalities, monitoring the patient with choroiditis and identification of complications such as choroidal neovascular membrane have become much easier. This article aims to review the existing literature on SC with a special emphasis on management of SC and SLC.
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COMMENTARY
	Commentary: Serpiginous choroiditis—so near yet so far	p. 333
	Soumyava Basu DOI:10.4103/ijo.IJO_1686_18
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ORIGINAL ARTICLE
	Practice pattern of cataract surgeons when operating on seropositive patients	p. 335
	Parveen Rewri, Madhavi Sharma, Aprajita Lohan, Deepika Singh, Vibha Yadav, Aparna Singhal DOI:10.4103/ijo.IJO_1437_18   Purpose: The aim of this study is to know practice pattern of cataract surgeons when operating on patients, positive for blood-borne viral infections (BBVIs), namely, hepatitis B virus, hepatitis C virus, and human immunodeficiency virus. We also studied their awareness, knowledge, and attitude toward universal precautions and guidelines. Methods: The telephonic survey enrolled practicing cataract surgeons, who were interviewed to record responses pertaining to their practice using an open-ended questionnaire. We studied statistical significance of difference of frequency of prick injuries in topical versus peribulbar anesthesia, and phacoemulsification versus manual small incision cataract surgery by employing Chi-square test. Significance of proportion was calculated using z-test. For all statistical calculations, significance level was set at 0.05%. Results: Of 623 ophthalmologists contacted, responses of 479 (79%) ophthalmologists were analyzed. Maximum participants were in private practice (48%). During whole practicing carrier, 313 (65%; 95% confidence interval [CI]: 61–70) participants admitted having suffered injury with needle or sharp instruments; of these, 204 (65%; 95% CI: 60–70) participants did not report their injury. Wearing "double gloves" during cataract surgery was the most common barrier adopted by participants. Conclusion: We found high prevalence of occupational-related sharp injuries among ophthalmologists in this survey. Majority of them were aware of universal precautions, but adherence to postexposure prophylaxis was lacking.
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COMMENTARY
	Commentary on: Practice pattern of cataract surgeons when operating on seropositive patients	p. 339
	Mahipal Sachdev, Rashmi Deshmukh DOI:10.4103/ijo.IJO_46_19
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ORIGINAL ARTICLES
	Three-dimensional digital visualization of phacoemulsification and intraocular lens implantation	p. 341
	Zhuyun Qian, Hongxia Wang, Hua Fan, Dong Lin, Wensheng Li DOI:10.4103/ijo.IJO_1012_18   Purpose: To evaluate the feasibility and safety of heads-up three-dimensional (3D) vision system for phacoemulsification and intraocular lens (IOL) implantation surgery. Methods: In this prospective, randomized controlled study, 20 eyes with age-related cataract received phacoemulsification and IOL implantation and were randomly divided into "heads-up" 3D vision group and conventional surgery group. Ocular and surgical parameters such as surgery time, pre and postoperative best-corrected visual acuity (BCVA), and corneal endothelial cells density were recorded and statistically analyzed. Results: The result showed significant postoperative improvement of BCVA in both groups. There was no difference in either mean surgery time or postoperative mean endothelial cell density between the 3D group and the conventional group. No major complication occurred during surgery in either group. Conclusion: The heads-up 3D vision system is suitable and safe for cataract phacoemulsification and IOL implantation. This technique can be of widespread use.
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	Confounding sizing in posterior chamber phakic lens selection due to white-to-white measurement bias	p. 344
	Joaquín Fernández, Manuel Rodríguez-Vallejo, Javier Martínez, Ana Tauste, Elisa Hueso, David P Piñero DOI:10.4103/ijo.IJO_613_18   Purpose: To assess the agreement in the white-to-white (WTW) measurement with two different devices, the reproducibility and the probability of confusing sizing (PCS) in selecting a different implantable collamer lens (ICL). Study Design: Retrospective observational case series. Methods: Images of 192 eyes were captured with both devices. The WTW was measured automatically (OA) and manually (OM) with the Orbscan and Keratograph (KA and KM) by one examiner who repeated a total of four measures. A second examiner conducted a single manual measure for each device over the same image. The ICL sizing was computed for each measure of WTW and the PCS was calculated as the percentage of cases for which the confronted or repeated measure resulted in a different size of the ICL. The critical WTWs with highest PCS were identified. Results: KM overestimated the WTW versus OM in 0.13 ± 0.18 mm (P < 0.001) but not in the automated method comparison, 0.01 ± 0.19 mm (P = 0.58). Inter-examiner reproducibility (R) was higher with OM than with KM, and the intra-examiner R decreased with the average of two measures in both cases. The PCS was higher with the increase of mean differences, the limits of agreement (LoAs), and R. WTWs from 11.1 to 11.2 mm, 11.6 to 11.7 mm, and 12.3 to 12.4 mm resulted in higher PCS. Conclusion: The mean difference is not enough to apply conversions between devices and the LoAs and R should be considered. Special attention should be taken for WTWs with higher PCS.
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	Iris varix: 10-year experience with 28 eyes	p. 350
	Puneet Jain, Paul T Finger DOI:10.4103/ijo.IJO_1253_18   Purpose: The purpose of this study is to describe the clinical characteristics, multimodality imaging findings, and clinical course of iris varices. Methods: Retrospective, noncomparative, observational case series of 28 eyes of 26 patients with iris varices, diagnosed between 2007 and 2017, has been used. Results: The mean (±SD) age was 58.3 ± 12.5 years (median 57.5, range 37–81). Patients were 57.7% male and 27% hypertensive. Varices were bilateral in two patients. The mean and median visual acuities were both 20/20 (range 20/16–20/40). Intraocular pressures were 16 mmHg (10–23 mmHg). Secondary glaucoma did not occur. The inferotemporal iris quadrant was affected in 75%. A single varix was seen in 64% and 36% appeared multiple. Varix orientation was radial in 57% and circumferential in 21%. Combined radial and circumferential varix orientation was noted in 18%. One had independent radial and circumferential varices in separate quadrants. A single episcleral sentinel blood vessel directed to the varix was present in 36%. Ultrasound biomicroscopy (UBM) showed a slightly increased mean iris thickness of 0.8 mm and multiple echolucent iris stromal vascular channels. Iris angiography showed no leakage of dye. Managed by observation over a mean follow-up of 37.7 months (range, 3–129), 96.4% eyes were stable and one (3.6%) regressed. No corectopia, ectropion uveae, hyphema, or metachronous anterior segment benign or malignant tumors occurred. Conclusion: Iris varix is primarily located in the inferotemporal quadrant and not associated with dysmorphic pupillary findings, progression, secondary glaucoma, or malignancy. Iris varices were benign vasculopathies with no associated ocular or vision-related morbidity.
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	Profile of childhood glaucoma at a tertiary center in South India	p. 358
	Sirisha Senthil, Swathi Badakere, Jonnadula Ganesh, Rashmi Krishnamurthy, Siddharth Dikshit, Nikhil Choudhari, Chandrasekhar Garudadri, Anil K Mandal DOI:10.4103/ijo.IJO_786_18   Purpose: To describe the prevalence of various types of childhood glaucomas, their clinical features and treatment methods. Methods:We prospectively included consecutive children with glaucoma presenting to glaucoma clinic for the first time between March 2013 and May 2014. We classified childhood glaucomas as per the classification proposed by Congenital Glaucoma Research Network. Results:Of the 275 children (449 eyes) with glaucoma during this period, primary glaucomas constituted 56% (n = 252 eyes of 145 children), including 169 eyes (37.64%) of 97 children with primary congenital glaucoma (PCG), 16 eyes (3.56%) of 10 children with infantile glaucoma, and 67 eyes (14.9%) of 38 children with juvenile open angle glaucoma. Among these, 85% (214 eyes of 107 children) had bilateral involvement. Secondary glaucomas constituted 44%; they were glaucoma associated with ocular anomalies 18% (n = 80 eyes), glaucoma associated with acquired conditions (steroid induced and traumatic glaucoma) 14% (n = 61 eyes), glaucoma following congenital cataract surgery 7.6% (n = 34 eyes), and glaucoma associated with systemic or syndromic conditions 5% (n = 22 eyes). In primary glaucomas, boys and girls were equally affected (1:1), and more boys (3.8:1) had acquired glaucomas. Close to 80% PCG eyes were managed surgically with combined trabeculotomy and trabeculectomy (CTT). Majority of secondary glaucomas were managed medically. Conclusion: In our cohort, PCG was the most common childhood glaucoma and CTT was the most common surgery performed in these eyes. Steroid-induced and traumatic glaucomas were the most common acquired glaucomas; appropriate measures should be taken to avert these preventable glaucomas in children.
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	Surgical outcomes of phacoemulsification/goniosynechialysis with and without endocyclophotocoagulation in patients with chronic angle closure glaucoma	p. 366
	Ketaki Panse, Crystal Le, Margaret Hubbell, Ramesh S Ayyala DOI:10.4103/ijo.IJO_895_18   Purpose: To compare surgical outcomes of patients after phacoemulsification with goniosynechialysis (phaco/GSL) versus phaco with GSL and endocyclophotocoagulation (phaco/GSL/ECP) in patients with chronic angle closure glaucoma (CACG) through 12-month follow-up. Methods: A retrospective, nonrandomized, comparative case series was performed. Patients with CACG who underwent phaco in combination with either GSL alone (group 1) or GSL with ECP with intracameral injection of kenalog (group 2) from 2011 to 2018 were included. Group 1 included 6 eyes of 6 patients and group 2 included 11 eyes of 10 patients. All surgeries were performed by a single surgeon (RSA). Primary outcome measures included changes in intraocular pressure (IOP), visual acuity (VA), failure based on IOP (>18 or <6 mmHg at 1 year), and secondary operative procedures and complication rates. Data were analyzed using a paired two-tailed T-test. Results: The mean preoperative IOP decreased from 23.5 ± 11.2 to 14.2 ± 2.4 mmHg (P < 0.0073) in group 1 and 24.4 ± 8.2 to 14.5 ± 2.7 mmHg (P < 0.0001) in group 2. The mean % IOP reduction was 33.7% in group 1 and 34.2% in group 2. The mean improvement in VA (logMAR units) was 0.24 (P = 0.085) in group 1 and 0.13 (P = 0.657) in group 2. The mean number of topical meds decreased from 2.50 ± 1.76 to 1.80 ± 1.64 in group 1 (P = 0.513) and from 2.82 ± 1.25 to 1.17 ± 0.98 in group 2 (P = 0.014). Conclusion: Phaco/GSL and phaco/GSL/ECP both achieve a significant reduction in IOP without the complications associated with traditional glaucoma filtration surgeries.
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	Pachydrusen in Indian population: A hospital-based study	p. 371
	Sumit Randhir Singh, Avadhesh Oli, Sashwanthi Mohan, Abhilash Goud, Mohammed A Rasheed, Kiran K Vupparaboina, Jay K Chhablani DOI:10.4103/ijo.IJO_1173_18   Purpose: To report the prevalence of pachydrusen in Indian population and their characteristics in relation to subfoveal choroidal thickness (SFCT), choroidal vascularity index (CVI) in comparison to eyes with soft drusen and subretinal drusenoid deposits (SDD) in age-related macular degeneration (AMD). Methods: The study was a retrospective, cross-sectional study involving patients with a diagnosis of dry AMD in at least one eye. The diagnosis of soft drusen, SDD, and pachydrusen was made on the basis of color fundus photograph and optical coherence tomography (OCT). SFCT and CVI was calculated and compared among the different subtypes of drusen. Results: A total of 169 eyes (143 dry and 26 wet AMD) of 85 patients with a mean age of 67.67 ± 9.57 years were included. In eyes with dry AMD, pachydrusen were seen in 12 eyes (8.4%) with a mean (±SD) SFCT of 289.66 ± 91.01 μ. The difference in SFCT was statistically significant (P = 0.001) using analysis of variance (ANOVA) test. The eyes with pachydrusen had significantly thickened choroid compared to the eyes with SDD (30 eyes; 21.0%) or combination of soft drusen and SDD (29 eyes; 20.3%) but not soft drusen (72 eyes; 50.3%). The difference of CVI in different subgroups was significant (P = 0.03). One eye in wet AMD group had concurrent pachydrusen. Comparison of SFCT and CVI in wet AMD and fellow dry AMD eyes were not significant. Conclusion: In Indian eyes with dry AMD, prevalence of pachydrusen (8.4%) is slightly lower compared to western literature (11.7%) and is associated with thicker choroid and higher CVI.
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	Epiretinal membrane profile on spectral domain optical coherence tomography in patients with uveitis	p. 376
	Puja Maitra, Dhivya Ashok Kumar, Amar Agarwal DOI:10.4103/ijo.IJO_650_18   Purpose: To study the epiretinal membrane (ERM) profile on the spectral-domain optical coherence tomography (SDOCT) in eyes with uveitis. Methods: In this prospective observational study, macula of uveitic eyes were evaluated by SDOCT (Cirrus, model 5000) for ERM. ERM was quantified (in microns) and were followed up along with the best-corrected visual acuity (BCVA) and treatment profile for 1 year. ERM morphology (focal, global, or mixed) and characteristics (thickness at fovea, maximum thickness, and location of maximum thickness in relation to fovea) were documented. Changes in altered foveal contour, cystoid macular edema (CME), and central foveal thickness were also noted. BCVA was noted when the inflammation subsided and it was correlated to specific ERM characteristics. SDOCT characteristics were compared in three treatment groups (no oral steroids, oral steroids with, and without immunomodulators). Results: Thirty-four eyes of 25 patients were evaluated. Mean logMAR BCVA decreased from 0.25 to 0.35 (P = 0.005). Foveal involvement with ERM (P = 0.011), lost foveal contour (P = 0.043), and ellipsoid layer disruption (P = 0.017) were associated significantly with reduced BCVA. Focal attachment of ERM was more commonly associated with CME (P = 0.03). Median ERM thickness showed significant increase (P < 0.001). Significant ERM progression from parafoveal to foveal (P = 0.02), significant progression of the thickest area of ERM closer to fovea (P = 0.0006) indicated a strong tendency of foveal involvement and this was correlated with worse BCVA (P= 0.009, r = −0.44) Oral steroids/immunomodulators showed no significant benefit on ERM progression. Conclusion: ERM progression in uveitis has a tendency to involve the fovea and is associated with significant vision loss, particularly in foveal ERM, focal attachment, and IS-OS disruption. Oral steroids and immunomodulators have no role in halting progression.
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	Oral versus single intravenous bolus dose antibiotic prophylaxis against postoperative surgical site infection in external dacryocystorhinostomy for primary acquired nasolacrimal duct obstruction – A randomized study	p. 382
	Jenil Sheth, Suryasnata Rath, Devjyoti Tripathy DOI:10.4103/ijo.IJO_616_18   Purpose: To compare the efficacy of a single perioperative bolus dose of intravenous antibiotic versus postoperative oral antibiotic prophylaxis for prevention of surgical site infection (SSI) in external dacryocystorhinostomy (DCR) for primary acquired nasolacrimal duct obstruction (PANDO). Methods: This was a prospective randomized controlled study with a noninferiority design. Patients undergoing external DCR surgery were randomized into two groups A and B. Patients in group A received a single bolus dose of intravenous cefazolin 1 g at surgery, whereas those in group B received oral cephalexin 500 mg postoperatively twice a day for 5 days. Allocation concealment was ensured by sequentially numbered opaque sealed envelopes (SNOSEs). Both groups were advised identical postoperative local wound care regimens. Any clinical evidence of SSI at 4 weeks of follow-up in either group was the main outcome measure. Results: In all, 338 patients randomized into two groups of 169 patients each participated in this study. At follow-up of 4 weeks, only one patient in group B developed postoperative SSI. None in group A developed postoperative SSI. Other potential risk factors for postoperative SSI were also analyzed by univariate and multivariate analyses but none achieved statistical significance in either group. Conclusion: Our results demonstrate that a single bolus dose of perioperative intravenous antibiotic offers adequate prophylaxis against postoperative SSI and compares favorably with the more commonly used oral antibiotic prophylaxis in external DCR for PANDO in our population and our practice scenario.
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	Prevalence of ocular morbidity among tribal children in Jawadhi hills, southern India: A cross-sectional study	p. 386
	KM Mahesh, Deepa John, Anuradha Rose, Padma Paul DOI:10.4103/ijo.IJO_795_18   Purpose: Childhood blindness is second to cataract in terms of blind person years; population-based prevalence of ocular morbidity among tribal children has not been studied. We conducted this study to determine the prevalence of ocular morbidity in tribal children age 15 years or younger in Jawadhi hills, southern India. Methods: A population-based cross-sectional study was conducted in four tribal villages where all children below 15 years of age were invited to participate in the study. After appropriate consent/assent, an optometrist assessed uncorrected vision refraction and best-corrected visual acuity using suitable techniques. A comprehensive ophthalmic examination was also done by an ophthalmologist to determine the presence of ocular morbidity. Children requiring cycloplegic refraction or further treatment were referred to the base hospital. Results: Among 260 children examined, the prevalence of ocular morbidity was 10.8% [95% confidence interval (CI): 6.3–13.7]. Vitamin A deficiency (VAD) was the foremost morbidity: 4.6% (95% CI 1.6–6.3) followed by refractive error (2.7%). Three (10.7%) children had more than one ocular morbidity. Nearly 1 in 10 tribal children suffer from ocular morbidity and 1 in 57 had low vision. Conclusion: VAD is a public health problem in this tribal region which requires immediate intervention with prophylaxis and treatment. Uncorrected refractive errors in school-age children also need to be attended.
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PHOTO ESSAY
	Wire lid retractor – A new use of wire eye speculum	p. 391
	Ankita Aishwarya, Prabha Gupta, Uma S Tiwari DOI:10.4103/ijo.IJO_1119_18
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	A case of posterior ciliary artery occlusion following pneumatic reposition of the Descemet membrane	p. 392
	Alok C Sen, Gaurav M Kohli, Ashish Mitra, Pawan P Malhotra DOI:10.4103/ijo.IJO_1273_18
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	Double trouble: Microspherophakia with Axenfeld-Rieger anomaly	p. 394
	Jyoti Shakrawal, Harathy Selvan, Arpit Sharma, Dewang Angmo DOI:10.4103/ijo.IJO_978_18
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	Intracameral migration of collagen matrix implant	p. 395
	Jitender Phogat, Manisha Rathi, Sumit Sachdeva, Brijesh Takkar, Sumeet Khanduja DOI:10.4103/ijo.IJO_754_18
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	Ocular albinism with bilateral ocular coloboma – A rare association	p. 397
	Vishal Raval, Srinivas Rao, Taraprasad Das DOI:10.4103/ijo.IJO_1182_18
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	Presumed tubercular choroidal nodule following adalimumab therapy for juvenile idiopathic arthritis	p. 399
	Harshit Vaidya, Parthopratim Dutta Majumder, Jyotirmay Biswas DOI:10.4103/ijo.IJO_1149_18
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	Juxtapapillary Focal Choroidal Excavation	p. 400
	Pulak Agarwal, Shayeri Roy, Shorya Vardhan Azad, Vinod Kumar DOI:10.4103/ijo.IJO_1299_18
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	Juxtapillary choroidal excavation with polypoidal choroidal vasculopathy: An unusual association	p. 401
	Maitreyi Chowdhury, Pukhraj Rishi DOI:10.4103/ijo.IJO_1307_18
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	Multimodal imaging characteristics of acute macular neuroretinopathy	p. 403
	Kumar Saurabh, Rupak Roy, Dhaivat Shah, Sugandha Goel, Samarth Mishra, Deepak Senger DOI:10.4103/ijo.IJO_969_18
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	External ophthalmomyiasis due to Oestrus ovis	p. 404
	Parthopratim Dutta Majumder, Pankaj Jeswani, Narayanaperumal Jeyathilakan, Jyotirmay Biswas DOI:10.4103/ijo.IJO_1391_18
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OPHTHALMIC IMAGES
	Bilateral spontaneous lens capsule rupture in Alport's syndrome	p. 406
	Monica Lohchab, Ritu Arora DOI:10.4103/ijo.IJO_1089_18
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	Ultra-wide field imaging of giant circumferential chorioretinal fold following post-operative hypotony	p. 407
	Brijesh Takkar, Sudarshan Khokhar, Divya Agarwal, Pradeep Venkatesh DOI:10.4103/ijo.IJO_1483_18
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	Multicolor imaging in neovascularization of disc	p. 408
	Sugandha Goel, Barun Garg, Ankit V Shah, Samarth Mishra, Kumar Saurabh, Rupak Roy DOI:10.4103/ijo.IJO_1522_18
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CASE REPORTS
	Successful treatment of conjunctival lymphangiectasia accompanied by corneal dellen using a high-frequency radiowave electrosurgical device	p. 409
	Shin-Myeong Choi, Kyung Hyun Jin, Tae Gi Kim DOI:10.4103/ijo.IJO_1109_18   A 62-year-old man presented with a 1-month history of right eye pain unresponsive to artificial tears and topical steroids. At presentation, bullous yellowish fluid collection was noted in the nasal conjunctiva. Corneal thinning and opacity were observed at the 3 o'clock position of the cornea. High-frequency radiowave ablation and biopsy were performed at the affected area. Conjunctival lymphangiectasia was confirmed by excisional biopsy. An improvement in the degree of corneal dellen and chemosis was evident 1 week after ablation. Use of a high-frequency radiowave electrosurgical device may be a simple and effective treatment option for symptomatic conjunctival lymphangiectasia.
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	Utility of multicolor optic disc photography in evaluation of glaucomatous optic disc in myopic eyes: A novel approach	p. 412
	Tamonash Basu, Barun Garg, Samarth Mishra, Sugandha Goel, Rupak Roy, Kumar Saurabh DOI:10.4103/ijo.IJO_1385_18   Interpretation of optic disc cupping and neuroretinal rim is challenging in myopic eyes because of large, shallow, and tilted disc, myopic crescent, and macular degeneration. Color and red-free optic disc photographs do not reveal the cup/disc ratio often in myopic eyes. We report characteristics of multicolor optic disc photography in three myopic eyes. All eyes underwent multicolor imaging Spectralis SDOCT system (Heidelberg Engineering, Germany). Owing to use of three laser lights in a confocal design, multicolor optic disc photography was able to delineate the neuroretinal rim and optic cup more clearly than color and red-free optic disc photographs.
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	Curious case of retrolental mass: An unusual tele-screening artifact	p. 415
	Ratnesh Ranjan, Parag K Shah, Venkatapathy Narendran DOI:10.4103/ijo.IJO_1318_18   We are presenting a case of premature baby born at 32 weeks of gestation who was under regular follow-up with our retinopathy of prematurity (ROP) tele-screening team. During final follow-up at 41 weeks of postconceptional age, anterior segment image captured with RetCam showed a retrolental mass lesion in right eye resembling retinoblastoma or medulloepithelioma. The baby was referred to our base hospital for further evaluation, where a detailed examination showed no retrolental lesion or intraocular mass. This is the first case where imaging artifact, despite use of high-quality imaging system by well-trained staff, during ROP tele-screening appeared like a retrolental mass lesion and resulted in false-positive referral.
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	OCT angiography features of paracentral acute middle maculopathy	p. 417
	Amravi Shah, Pukhraj Rishi, Charanya Chendilnathan, Soni Kumari DOI:10.4103/ijo.IJO_1249_18   Paracentral acute middle maculopathy (PAMM) refers to retinal lesions with changes in the inner nuclear layer on spectral domain optical coherence tomography (OCT). PAMM is associated with retinal vascular pathology involving the deep capillary plexus. We report two cases of PAMM in Indian subjects using multimodal imaging highlighting the OCT angiography (OCTA) findings. The first case is of a middle-aged female with a paracentral scotoma with SS-OCT (swept-source optical coherence tomography) and OCTA findings suggestive of "chronic" PAMM. The second case presented with sudden decreased vision, and multiple creamy white lesions suggestive of "acute" PAMM, imaging features depicting a possible venular obstruction. These cases demonstrate the importance of considering PAMM as a differential diagnosis in patient presenting with nonspecific visual complains and apparently normal ophthalmic examination. The recognition of PAMM should prompt an appropriate evaluation and investigation.
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	Vitreous hemorrhage as the presenting feature of peripheral exudative hemorrhagic chorioretinopathy in Indian eyes	p. 419
	Neha Goel DOI:10.4103/ijo.IJO_714_18   Five Indian patients presenting with unilateral vitreous hemorrhage (VH) underwent pars plana vitrectomy (PPV) and were found to have lesions suggestive of peripheral exudative hemorrhagic chorioretinopathy (PEHCR). All eyes had extensive sub-retinal hemorrhage; three also showed an elevated mass lesion. The temporal retina anterior to the equator was the most commonly affected site. Exudative manifestations were absent in all. No recurrences occurred over a mean follow-up of 17.5 months. Although PEHCR is reported to be rare in Asians, this series demonstrates that it can present as VH in Indians as well. Unless the macula has irreversible damage, a favorable outcome can be obtained with PPV alone.
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	Staphylococcus lugdunensis endophthalmitis following dexamethasone intravitreal implant	p. 424
	Silvia Olivia Salceanu, Dina Hamada, Ramona Gabriela Ursu, Ahmed Abdelwahab Saad DOI:10.4103/ijo.IJO_720_18   We present a unique case of endophthalmitis with Staphylococcus lugdunensis following dexamethasone intravitreal implant for branch retinal vein occlusion associated with cystoid macular edema. Patient did not show favorable clinical response after vitrectomy and intravitreal antibiotics; so, we decided to repeat vitrectomy, remove the steroid implant and fill the eye with silicon oil, and repeat intravitreal vancomycin. Vision has improved from hand movements at presentation to counting fingers at 1.5 m after second vitrectomy and final visual acuity 3 months later after silicon oil removal was 6/36.
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	Commentary: Endophthalmitis following intravitreal injection of dexamethasone implant	p. 426
	Ekta Rishi, Pradeep T Manchegowda DOI:10.4103/ijo.IJO_1809_18
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	Chandelier-assisted scleral buckling in an eye with longstanding inert foreign body with fresh rhegmatogenous retinal detachment	p. 429
	Madhu Kumar, Vinaya Kumar Konana, Ashok Kanakamedla, Dilip Kumar, Jayamadhury Gudimetla DOI:10.4103/ijo.IJO_1361_18   Intraocular foreign bodies (IOFBs) present in varied manners which in turn necessitate their removal in majority of the cases. A stone foreign body can remain inert inside the eye for years. Retinal detachment in eyes following penetrating trauma with an IOFB is common, but a combination of fresh rhegmatogenous retinal detachment in an eye with a longstanding inert stone foreign body is extremely rare. We report a case of a 50-year-old male with rhegmatogenous retinal detachment with a longstanding stone foreign body, where we managed such a scenario with a chandelier-assisted, sutureless, scleral buckle without removing the stone foreign body.
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	Commentary: Revival of scleral buckling technique with Chandelier illumination	p. 431
	Ekta Rishi, Pradeep T Manchegowda DOI:10.4103/ijo.IJO_1964_18
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	Primary ocular presentation of tuberous sclerosis – A case report	p. 433
	Nancy M Rajasekaran, Saban Horo, Thomas Kuriakose DOI:10.4103/ijo.IJO_925_18   A 25-year-old man presented with decreased vision in the left eye with hypopigmented elevated subretinal lesion over the optic disk with abnormal vasculature, subretinal and retinal hemorrhages, and fluid in the macula. An area of high spike over the disk with corresponding orbital shadowing was seen on B scan ultrasonography. Fundus fluorescein angiography revealed abnormal vasculature. Systemic examination revealed facial angiofibroma, ashleaf spot, and dental pits with multiple cortical tubers on CT brain. Intravitreal injection of bevacizumab led to visual and tomographic improvement. Abnormal retinal vascularization and exudation in young individuals may be a presenting feature in tuberous sclerosis.
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	Retinoblastoma discordance in families with twins	p. 436
	Aloysius Abraham, Kannan Thirumalairaj, Namrata Gaikwad, Veerappan Muthukkaruppan, Alla G Reddy, Kumarasamy Thangaraj, Usha Kim, Ayyasamy Vanniarajan DOI:10.4103/ijo.IJO_1245_18   Retinoblastoma has an increased inheritance risk of germline RB1 mutations in offspring and siblings, especially twins. Three families, each having one retinoblastoma-affected twin, were selected for genetic analysis and DNA profiling. Germline RB1 mutations were found in all probands. DNA profiling carried on similar-looking twins of families I and II, proved them to be fraternal. This study demonstrates the importance of genetic analysis of RB1 gene for risk prediction in retinoblastoma families. It also emphasizes that DNA profiling is a mandate for genetic screening of families with twins, thus adding a new dimension in counseling of retinoblastoma.
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LETTERS TO THE EDITOR
	Are ophthalmic conferences losing their relevance and how to reverse this trend?	p. 440
	Suresh K Pandey, Vidushi Sharma DOI:10.4103/ijo.IJO_1898_18
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	Unilateral corneal edema in young: A diagnostic dilemma	p. 442
	Manisha Singh, Neha Kapoor, Virender S Sangwan DOI:10.4103/ijo.IJO_1895_18
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	Response to comment on 'Unilateral corneal edema in young: A diagnostic dilemma'	p. 442
	Dewang Angmo, Harathy Selvan, Aswini K Behera, Pramod K Suman DOI:10.4103/ijo.IJO_2079_18
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Indian Journal of Ophthalmology – The journey so far Santosh G Honavar Indian Journal of Ophthalmology 2019 67(3):317-320

Current management options in primary angle closure disease Ramasamy Krishnadas Indian Journal of Ophthalmology 2019 67(3):321-323

To prick or to poke? Md. Shahid Alam, Vathsalya Vijay Indian Journal of Ophthalmology 2019 67(3):324-324

Enigma of serpiginous choroiditis Parthopratim Dutta Majumder, Jyotirmay Biswas, Amod Gupta Indian Journal of Ophthalmology 2019 67(3):325-333 Serpiginous choroiditis (SC) is an asymmetrically bilateral inflammation of the choroid that leads to loss of choriocapillaris atrophy or loss of overlying retinal pigment epithelium. Over the last few decades, SC has passed through a long evolution of nomenclature, etiologies and morphological variations. Initially diagnosed in patients with tuberculosis and syphilis, SC was predominantly considered as autoimmune process. With the advancement of molecular diagnosis, a new aspect of infectious subtypes of SC has emerged out. The terminologies such as serpiginous-like choroiditis (SLC) and multifocal serpiginoid choroiditis are now used to denote the subtypes of SC which are associated with infectious etiologies especially tuberculosis. In a country endemic for tuberculosis such as India, it is very important to differentiate between classic SC and SLC before initiating aggressive immunomodulatory therapy. Also, management of paradoxical worsening of the clinical condition with antitubercular treatment is another challenge in SLC and ophthalmologists should be aware of such situations. With advent of newer imaging modalities, monitoring the patient with choroiditis and identification of complications such as choroidal neovascular membrane have become much easier. This article aims to review the existing literature on SC with a special emphasis on management of SC and SLC.

Commentary: Serpiginous choroiditis—so near yet so far Soumyava Basu Indian Journal of Ophthalmology 2019 67(3):333-334

Practice pattern of cataract surgeons when operating on seropositive patients Parveen Rewri, Madhavi Sharma, Aprajita Lohan, Deepika Singh, Vibha Yadav, Aparna Singhal Indian Journal of Ophthalmology 2019 67(3):335-339 Purpose: The aim of this study is to know practice pattern of cataract surgeons when operating on patients, positive for blood-borne viral infections (BBVIs), namely, hepatitis B virus, hepatitis C virus, and human immunodeficiency virus. We also studied their awareness, knowledge, and attitude toward universal precautions and guidelines. Methods: The telephonic survey enrolled practicing cataract surgeons, who were interviewed to record responses pertaining to their practice using an open-ended questionnaire. We studied statistical significance of difference of frequency of prick injuries in topical versus peribulbar anesthesia, and phacoemulsification versus manual small incision cataract surgery by employing Chi-square test. Significance of proportion was calculated using z-test. For all statistical calculations, significance level was set at 0.05%. Results: Of 623 ophthalmologists contacted, responses of 479 (79%) ophthalmologists were analyzed. Maximum participants were in private practice (48%). During whole practicing carrier, 313 (65%; 95% confidence interval [CI]: 61–70) participants admitted having suffered injury with needle or sharp instruments; of these, 204 (65%; 95% CI: 60–70) participants did not report their injury. Wearing “double gloves” during cataract surgery was the most common barrier adopted by participants. Conclusion: We found high prevalence of occupational-related sharp injuries among ophthalmologists in this survey. Majority of them were aware of universal precautions, but adherence to postexposure prophylaxis was lacking.

Commentary on: Practice pattern of cataract surgeons when operating on seropositive patients Mahipal Sachdev, Rashmi Deshmukh Indian Journal of Ophthalmology 2019 67(3):339-340

Three-dimensional digital visualization of phacoemulsification and intraocular lens implantation Zhuyun Qian, Hongxia Wang, Hua Fan, Dong Lin, Wensheng Li Indian Journal of Ophthalmology 2019 67(3):341-343 Purpose: To evaluate the feasibility and safety of heads-up three-dimensional (3D) vision system for phacoemulsification and intraocular lens (IOL) implantation surgery. Methods: In this prospective, randomized controlled study, 20 eyes with age-related cataract received phacoemulsification and IOL implantation and were randomly divided into “heads-up” 3D vision group and conventional surgery group. Ocular and surgical parameters such as surgery time, pre and postoperative best-corrected visual acuity (BCVA), and corneal endothelial cells density were recorded and statistically analyzed. Results: The result showed significant postoperative improvement of BCVA in both groups. There was no difference in either mean surgery time or postoperative mean endothelial cell density between the 3D group and the conventional group. No major complication occurred during surgery in either group. Conclusion: The heads-up 3D vision system is suitable and safe for cataract phacoemulsification and IOL implantation. This technique can be of widespread use.

Confounding sizing in posterior chamber phakic lens selection due to white-to-white measurement bias Joaquín Fernández, Manuel Rodríguez-Vallejo, Javier Martínez, Ana Tauste, Elisa Hueso, David P Piñero Indian Journal of Ophthalmology 2019 67(3):344-349 Purpose: To assess the agreement in the white-to-white (WTW) measurement with two different devices, the reproducibility and the probability of confusing sizing (PCS) in selecting a different implantable collamer lens (ICL). Study Design: Retrospective observational case series. Methods: Images of 192 eyes were captured with both devices. The WTW was measured automatically (OA) and manually (OM) with the Orbscan and Keratograph (KA and KM) by one examiner who repeated a total of four measures. A second examiner conducted a single manual measure for each device over the same image. The ICL sizing was computed for each measure of WTW and the PCS was calculated as the percentage of cases for which the confronted or repeated measure resulted in a different size of the ICL. The critical WTWs with highest PCS were identified. Results: KM overestimated the WTW versus OM in 0.13 ± 0.18 mm (P < 0.001) but not in the automated method comparison, 0.01 ± 0.19 mm (P = 0.58). Inter-examiner reproducibility (R) was higher with OM than with KM, and the intra-examiner R decreased with the average of two measures in both cases. The PCS was higher with the increase of mean differences, the limits of agreement (LoAs), and R. WTWs from 11.1 to 11.2 mm, 11.6 to 11.7 mm, and 12.3 to 12.4 mm resulted in higher PCS. Conclusion: The mean difference is not enough to apply conversions between devices and the LoAs and R should be considered. Special attention should be taken for WTWs with higher PCS.

Iris varix: 10-year experience with 28 eyes Puneet Jain, Paul T Finger Indian Journal of Ophthalmology 2019 67(3):350-357 Purpose: The purpose of this study is to describe the clinical characteristics, multimodality imaging findings, and clinical course of iris varices. Methods: Retrospective, noncomparative, observational case series of 28 eyes of 26 patients with iris varices, diagnosed between 2007 and 2017, has been used. Results: The mean (±SD) age was 58.3 ± 12.5 years (median 57.5, range 37–81). Patients were 57.7% male and 27% hypertensive. Varices were bilateral in two patients. The mean and median visual acuities were both 20/20 (range 20/16–20/40). Intraocular pressures were 16 mmHg (10–23 mmHg). Secondary glaucoma did not occur. The inferotemporal iris quadrant was affected in 75%. A single varix was seen in 64% and 36% appeared multiple. Varix orientation was radial in 57% and circumferential in 21%. Combined radial and circumferential varix orientation was noted in 18%. One had independent radial and circumferential varices in separate quadrants. A single episcleral sentinel blood vessel directed to the varix was present in 36%. Ultrasound biomicroscopy (UBM) showed a slightly increased mean iris thickness of 0.8 mm and multiple echolucent iris stromal vascular channels. Iris angiography showed no leakage of dye. Managed by observation over a mean follow-up of 37.7 months (range, 3–129), 96.4% eyes were stable and one (3.6%) regressed. No corectopia, ectropion uveae, hyphema, or metachronous anterior segment benign or malignant tumors occurred. Conclusion: Iris varix is primarily located in the inferotemporal quadrant and not associated with dysmorphic pupillary findings, progression, secondary glaucoma, or malignancy. Iris varices were benign vasculopathies with no associated ocular or vision-related morbidity.