Publications by authors named "Swati Phuljhele"

51 Publications

Ethambutol toxicity: Expert panel consensus for the primary prevention, diagnosis and management of ethambutol-induced optic neuropathy.

Indian J Ophthalmol 2021 Dec;69(12):3734-3739

Directorate General of Health Services, Government of India, New Delhi, India.

Ethambutol use may lead to permanent vision loss by inducing a dose- and duration-dependent optic neuropathy. This has been of concern to ophthalmologists and physicians both; however, ethambutol continues to be used because of its anti-mycobacterial action with relative systemic safety. Recently, the guidelines of the Revised National Tuberculosis Control Programme of India have been revised to allow for fixed dose and longer duration of ethambutol use; this is likely to result in an increase in vision-threatening adverse effects. Taking cognizance of this, neuro-ophthalmologists, infectious disease specialists, and scientists met under the aegis of the Indian Neuro-Ophthalmology Society to deliberate on prevention, early diagnosis, and management of ethambutol-related toxic optic neuropathy. The recommendations made by the expert group focus on early suspicion of ethambutol toxicity through screening at the physician's office and opportunistic screening by the ophthalmologist. Further, they focus on an early diagnosis through identification of specific clinical biomarkers and on management in way of early stoppage of the drug and supportive therapy. This statement also describes the mechanism of reporting a case of toxic optic neuropathy through the Pharmacovigilance Programme of India and emphasizes the need for spreading awareness regarding vision-threatening adverse effects among patients and healthcare workers.
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http://dx.doi.org/10.4103/ijo.IJO_3746_20DOI Listing
December 2021

Simulation of complex strabismus surgical procedures on goat eyes.

Eur J Ophthalmol 2021 Sep 8:11206721211045190. Epub 2021 Sep 8.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, Delhi, India.

Purpose: To describe the possibility of complex strabismus surgical simulation on goat eyes.

Methods: The goat eyes were procured from local slaughterhouse with retained extra ocular muscle tissues. The obtained eyes were inspected for globe integrity, muscle quality, muscle length, and the surrounding teno-conjunctival layers. The included eyes were then segregated for surgical simulation based on their insertion and orientation (as oblique or recti), and they were mounted on a mannequin head, with a fixation suture at free end to simulate the resting tension. Additionally, as per necessary, extra muscles were also transplanted along desired sites to simulate human extra ocular muscle anatomy.

Results: The inferior oblique, superior oblique, and all other four recti were successfully simulated in varying proportions in more than 50 eyes. Primarily, by simulating the lateral rectus, inferior rectus, and the inferior oblique muscle, staged weakening procedures of inferior oblique were successfully practiced (Fink's recession, Park's recession, Elliot and Nankin procedure, total anterior positioning, and antero-nasal trans-position or Stager's procedure). Similarly, by simulating superior rectus, inferior rectus, lateral rectus, and the medial rectus muscles, half width transposition, full width transposition, and other complex procedures were practiced (Knapp's procedure, augmented Knapp's, Nishida's procedure, Faden operation, and Y splitting procedure). Furthermore, by simulating superior oblique and the superior rectus muscles, superior oblique tuck, posterior tenectomy, loop tenotomy, and Harada Ito procedures were successfully practiced.

Conclusions: On goat eyes, the complex strabismus surgical procedures can be successfully simulated and practiced after re-organizing the existing muscles in different patterns.
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http://dx.doi.org/10.1177/11206721211045190DOI Listing
September 2021

Optical coherence tomography angiography in amblyopia: A critical update on current understandings and future perspectives.

Eur J Ophthalmol 2021 Sep 2:11206721211042554. Epub 2021 Sep 2.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Optical coherence tomography angiography (OCTA) is a non-invasive tool to assess the retino-choroidal vasculature in vivo. It tracks the red blood cell movement and maps the vasculature in quick succession. In routine, diabetic retinopathy, age related macular degeneration, central serous chorioretinopathy, and others are commonly being studied to unveil its clinic role. On the other hand, amblyopia is a condition where the visual acuity is subnormal due to non-organic causes in the eye. But the OCTA studies till now have shown variable changes along retino-choroidal vasculature. Hence, to comprehend the existing literature knowledge, a systematic literature search was carried out and the original works describing novel findings in amblyopic eyes on OCTA were included. Upon detailed assessment, firstly, the disturbed vasculature along superficial retinal plexus, deeper retinal plexus, and choroidal plexus were evident in most untreated amblyopic eyes. However, such changes were not uniform, which is due to noted heterogenic patient profile, small sample size, biometric biases, non-uniform algorithms, and other factors. And to note, even in presence of such diverse changes, almost all the authors stated a plausible explanation for their notable changes. Secondly, the utility of OCTA in identifying vascular changes with standard treatments and segregation of visual beneficiaries from non-beneficiaries were possible. Hence, to conclude, OCTA is a valuable tool which can provide valuable useful insights into the amblyopic eyes during pre and post treatment periods. However, to gather more concrete evidence for clinical benefits, systematic, homogenous, and better structured clinical studies are mandated.
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http://dx.doi.org/10.1177/11206721211042554DOI Listing
September 2021

Clinical Role of Swept Source Anterior Segment Optical Coherence Tomography in Strabismus Re-Operation with Lost Surgical Details.

Clin Ophthalmol 2021 25;15:3581-3591. Epub 2021 Aug 25.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Background: To characterize the diagnostic role of swept source anterior segment optical coherence tomography (SS-ASOCT) in strabismus re-operations with lost surgical details.

Methods: Patients presenting to our outpatient services for strabismus care from February 2020 to March 15th 2021 were systematically evaluated. Those willing to undergo re-operation were included in the study. A total of 30 patients were identified and out of this a total of 10 eyes of 10 patients with lost surgical details were finally included in the study. Demographic details, preoperative deviation, ocular findings, orthoptic measurements, detailed SS-ASOCT findings, intraoperative measurements, and post-operative outcomes were recorded.

Results: The mean age of 10 patients was 23.7±5.75 years. Seven were male and three were female. The mean pre-operative SS-ASOCT measured distance from angle to insertion was 8.90±1.85 mm and the mean intraoperative distance was 9.12±2.14 mm. A mean difference of 0.21±1.31 mm was noted, and this difference was statistically insignificant (paired test, p = 0.57). In addition, SS-ASOCT unraveled novel signs to differentiate operated eyes from the un-operated eyes, and recessed muscle from the resected muscle.

Conclusion: In strabismus re-operation with lost surgical details, the pre-operative SS-ASOCT can provide reliable muscle details with respect to its type of surgery and amount surgery.
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http://dx.doi.org/10.2147/OPTH.S328215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8403674PMC
August 2021

Reply.

Ophthalmology 2021 12 23;128(12):e215-e217. Epub 2021 Aug 23.

Pediatric Ophthalmology and Strabismus Services, Dr. R. P. Centre for Ophthalmic Sciences, AIIMS, New Delhi, India.

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http://dx.doi.org/10.1016/j.ophtha.2021.07.011DOI Listing
December 2021

Role of spectral domain optical coherence tomography in the diagnosis and prognosis of papilledema.

Indian J Ophthalmol 2021 Sep;69(9):2372-2377

Department of Ophthalmology, All India Institute of Medical Sciences, New Delhi, India.

Purpose: The study of papilledema with a novel noninvasive technique such as spectral domain-optical coherence tomography (SD-OCT) provides minute and detailed cross-sectional changes thus giving an insight into the application of biomechanical principles and pathophysiology of disc edema.

Methods: We measured average retinal nerve fiber layer (RNFL) thickness and the retinal pigment epithelium/Bruch's membrane (RPE/BM) angle at the temporal and nasal borders of the neural canal opening (NCO) in 30 eyes with papilledema, 30 eyes with papillitis, and 80 control eyes. The inward angulation was considered as positive and the outward as negative. Follow-up was done at 1, 2, 3, and 6 months. The main outcome measures are the average RNFL thickness and the RPE/BM angle.

Results: 29 eyes (96.6%) with papilledema had a positive RPE/BM angle (+8.11 ± 3.13). 29 eyes (96.6%) with papillitis had a negative RPE/BM angle (-1.04 ± 3.27). On follow-up at 1 month, both RNFL thickness (P = 0.01) and RPE-BM angle (P = 0.001) reduced significantly in eyes with papilledema; in eyes with papillitis, there was a significant reduction in the RNFL thickness (P = 0.02), but not in the RPE-BM angle (P > 0.05). RNFL thickness in papilledema cases normalized at 3 months whereas RPE/BM normalized at 6 months of follow-up. To detect papilledema, OCT has a sensitivity of 96.66% and specificity of 99.09% on both nasal and temporal sides.

Conclusion: After appropriate treatment, the RPE/BM angle in papilledema decreased much later than the RNFL thickness. Hence, the RPE/BM angle in papilledema (positive) can be used to differentiate it from papillitis (negative) and also to monitor the activity of the disease.
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http://dx.doi.org/10.4103/ijo.IJO_3269_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8544041PMC
September 2021

Approach to optic neuritis: An update.

Indian J Ophthalmol 2021 Sep;69(9):2266-2276

Neuro-ophthalmology and Strabismus Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Over the past few years, there has been remarkable development in the area of optic neuritis. The discovery of new antibodies has improved our understanding of the pathology of the disease. Antiaquaporin4 antibodies and antimyelin oligodendrocytes antibodies are now considered as distinct entities of optic neuritis with their specific clinical presentation, neuroimaging characteristics, treatment options, and course of the disease. Similarly, there has been a substantial change in the treatment of optic neuritis which was earlier limited to steroids and interferons. The development of new immunosuppressant drugs and monoclonal antibodies has reduced the relapses and improved the prognosis of optic neuritis as well as an associated systemic disease. This review article tends to provide an update on the approach and management of optic neuritis.
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http://dx.doi.org/10.4103/ijo.IJO_3415_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8544067PMC
September 2021

Cyclic oculomotor palsy in a young male.

Natl Med J India 2020 Sep-Oct;33(5):313

Dr R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/0970-258X.317463DOI Listing
October 2021

Comparative evaluation of Octopus semi-automated kinetic perimeter with Humphrey and Goldmann perimeters in neuro-ophthalmic disorders.

Indian J Ophthalmol 2021 04;69(4):918-922

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Purpose: The aim of this study was to compare the performance of Octopus 900(OVF) kinetic module with Goldmann perimeter (GVF) and Humphrey 750i (HVF) perimeters in neuro-ophthalmic disorders.

Methods: During this prospective observational cross-sectional study, 17 patients (26 eyes) with neuro-ophthalmic disorders underwent visual field examination on the three perimeters. Field defects on OVF were matched with HVF and GVF for the number of quadrants involved. An unmasked observer, and a masked observer (unaware of the clinical diagnosis) were made to separately diagnose the type of field defects on all three fields for the same patient. The pattern of field defect on OVF was compared with GVF and HVF field defects for both observers.

Results: When OVF was compared with HVF and GVF, 88% eyes correctly matched for normal or abnormal visual fields, while quadrant-matching was 80% and 89% respectively. For the unmasked observer, the pattern of field defects on OVF was similar to HVF and GVF in 58% and 65% eyes respectively while for a masked observer, it was 54% and 62%. Central and paracentral scotomas showed unmatched fields when OVF was compared with HVF and GVF. When these patients were excluded, sensitivity of OVF increased to 95%.

Conclusion: Clinical correlation aids in better characterisation of a field defect. All 3 perimeters are concurrent in the pattern of field defects for non-central defects. However, the default protocol on OVF may not be enough to demarcate the central and para-central scotomas. Development of a customised protocol for the assessment of central and centrocecal field defects increases the accuracy of OVF.
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http://dx.doi.org/10.4103/ijo.IJO_1266_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8012927PMC
April 2021

Functional evaluation of the macular area in early glaucoma using microperimetry.

Indian J Ophthalmol 2021 04;69(4):876-881

Glaucoma Research Facility and Clinical Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Purpose: To evaluate the central visual field by microperimetry (MP), in early glaucoma.

Methods: Consecutive perimetrically experienced patients with a single nasal step or arcuate scotoma and 14 control eyes underwent MP. Retinal sensitivity on MP was mapped for frequency and depth of loss in the central 10° around fixation.

Results: Twenty-one eyes had a single nasal step and 19 eyes with single arcuate scotoma on standard automated perimetry (SAP), with central 10° being normal on 30-2 and 10-2 perimetry. The average mean sensitivity on MP, in glaucomatous and control eyes was 11.8 ± 3.9 dB and 16.6 ± 1.2 dB, respectively, P = 0.0004. The average mean defect on MP-1, in glaucomatous and control eyes was -6.5 ± 2.0 dB and -3.0 ± 1.2 Db, respectively, P = 0.05. The corresponding retinal hemisphere showed significant defects in MP. In eyes with single nasal steps, an absolute scotoma was seen in 14-28% of eyes 8-10° off fixation, moderate to mild defects were seen in 10-52% eyes, and 10% eyes showed involvement up to 4° from the fixation. Eyes with arcuate scotoma had an absolute scotoma on MP in 95% of eyes, 6-10° from fixation, with extension up to 2° from fixation in 21%. In glaucomatous eyes, the normal hemisphere on SAP showed a mild defect on MP in 43%. Control eyes did not show any defect in SAP or MP.

Conclusion: A significant loss of central retinal sensitivity is recorded on MP in early glaucomatous neuropathy as compared to SAP. Paramacular absolute defects were seen at 6-10° from fixation.
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http://dx.doi.org/10.4103/ijo.IJO_1199_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8012941PMC
April 2021

Effect of induced anisometropia on stereopsis and surgical tasks in a simulated environment.

Indian J Ophthalmol 2021 03;69(3):568-572

Department of Ophthalmology, Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Purpose: To quantitatively correlate the loss of stereopsis by induced anisometropia with its effect on tasks that require binocular vision and stereopsis, such as ophthalmic surgery in a simulated environment.

Methods: Thirty-nine ophthalmic residents with best-corrected visual acuity of 20/20 or better OU, with normal binocular vision and stereopsis, were recruited for the study. Anisometropia was induced using spherical and cylindrical trial lenses from +1D to +5D in a trial frame. The residents performed an anterior chamber navigation exercise on the EYESi simulator and the surgical score at baseline and for each level of induced anisometropia was noted. Near stereopsis was assessed by the Randot test and TNO test at baseline and for each level of induced anisometropia.

Results: Stereoacuity on the Randot test and TNO test were 30 (95% CI, 25.9-34.1) and 44.4 (95% CI, 28.5-60.3) arcseconds, respectively which reduced to 65.5 (95% CI, 48.7-82.3) and 75.9 (95% CI, 15.5-136.3) arcseconds at anisometropia of +1D Sph (P < 0.001) and 380 (95% CI, 309.9-450.1) and 1922.1 (95% CI, 1582.5-2261.7) arcseconds for +5D Sph, respectively for the two tests, (P < 0.001). The corresponding surgical score reduced from 93.8 (95% CI, 91.1-96.7) to 87.5 (95% CI, 79.2-95.8, P < 0.001) for 1 DSph and 55.97 (95% CI, 38.3-73.7, P < 0.001) for 5DSph. There was a strong negative correlation between stereopsis scores and surgical task scores (Spearman's rho -0.86, P value <0.001) Similar changes were seen for anisometropia induced with cylindrical powers.

Conclusion: Induced anisometropia is associated with a significant diminution in surgical task scores in a simulated environment and this is correlated with the deterioration in stereoacuity. Assessment of stereopsis may be included as a regular part of the screening procedure for ophthalmic trainee residents.
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http://dx.doi.org/10.4103/ijo.IJO_1540_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7942079PMC
March 2021

Atropine for the Treatment of Childhood Myopia in India: Multicentric Randomized Trial.

Ophthalmology 2021 09 2;128(9):1367-1369. Epub 2021 Feb 2.

Pediatric Ophthalmology and Strabismus Services, Dr. R. P. Centre for Ophthalmic Sciences, AIIMS, New Delhi, India.

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http://dx.doi.org/10.1016/j.ophtha.2021.01.026DOI Listing
September 2021

Ethambutol Optic Neuropathy: Vigilance and Screening, the Keys to Prevent Blindness with the Revised Anti-tuberculous Therapy Regimen.

J Assoc Physicians India 2021 Feb;69(2):54-57

Indian Neuro-Ophthalmology Society Research Group (INOSRG): Ambika Selvakumar, Ankur Sinha, Digvijay Singh, Hemalini Sawant, Jaspreet Sukhija, Jawahar Lal Goyal, Jenil Seth, Jitendra Jethani, Jyoti Matalia, Kumudini Sharma, Mahesh Kumar, Meenakshi Dhar, Murlidhar R, Naveen Jaikumar, Nishant Kumar, Padmavathy Maharajan, Pradeep Agarwal, Rashmin Gandhi, Ravinder Battu, Rohit Saxena, Satya Karna, Shikha Bassi, Soveetha Rath, Sujata Guha, Sumit Monga, Swati Phuljhele, V Krishna, Varshini Shankar, Vimal Fudnawala, Vimla Menon, Virender Sachdeva.

There has been change in the guidelines for the management of tuberculosis in India. The new guidelines advocate the daily use of Ethambutol for both intensive and continuation phase of the treatment. This may be a matter of concern as increased cumulative dose may lead to increase in incidence of toxic optic neuropathy due to ethambutol. Indian Neuro-Ophthalmology Society has taken cognizance of the issue and has come-up with guidelines for prevention and early detection of the toxic optic neuropathy.
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February 2021

Optical coherence tomography angiography in neuro-ophthalmology: Current clinical role and future perspectives.

Surv Ophthalmol 2021 May-Jun;66(3):471-481. Epub 2020 Nov 3.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Optical coherence tomography angiography (OCTA) is a noninvasive, depth-resolved imaging tool for the appraisement of retinal vascular changes. Since its introduction, the understanding of diabetic retinopathy, age-related macular degeneration, central serous retinopathy, and other diseases has been enriched on many fronts. Its dyeless imaging property maps retinal as well as deeper choroidal vasculature in quick succession with good reproducibility. Hence, it can play an important role in the diagnosis and management of optic nerve-related diseases as well. A detailed literature review for its role in nonarteritic anterior ischemic optic neuropathy, papilledema, optic disc drusen, papillitis, hereditary optic neuropathies, central nervous system diseases, and others highlights its role. The whole spectrum of neuro-ophthalmological diseases shows consistent peripapillary and macular capillary changes with structural and functional correlation. The superficial and deeper retinal and choroidal vasculatures are affected depending on the nature of the disease process. Hence, OCTA positions itself as a useful, noninvasive tool in the armamentarium of a neuro-ophthalmologist in future; however, there are several limitations of the OCTA with respect to its technical abilities in challenging neuro-ophthalmic cases. Therefore, future research should be directed to enhance the technical capabilities of OCTA and to determine the more precise role of it in the prognosis of neuro-ophthalmic diseases.
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http://dx.doi.org/10.1016/j.survophthal.2020.10.009DOI Listing
November 2020

Prospective study to evaluate incidence and indicators for early detection of ethambutol toxicity.

Br J Ophthalmol 2021 07 26;105(7):1024-1028. Epub 2020 Jul 26.

Department of Pulmonary Critical Care and Sleep Medicine, AIIMS, New Delhi, India.

Aims: To evaluate incidence of toxic optic neuropathy in patients receiving ethambutol (EMB) for 6 months and to identify its early indicators.

Methods: We included 50 patients on anti-tubercular therapy (ATT) including EMB (HRE regimen) based on total body weight for 6 months. Best-corrected visual acuity (ETDRS), colour vision (Ishihara pseudo-isochromatic plates), contrast sensitivity (Pelli-Robson chart), Humphrey visual field analysis (HVF 30-2 SITA FAST), pattern visual evoked response (VER) and spectral-domain optical coherence tomography (SDOCT) for ganglion cell inner plexiform layer (GCIPL) and retinal nerve fibre layer (RNFL) analysis were assessed at baseline and at 2, 4 and 6 months after starting ATT.

Results: Mean age of the patients was 36.5±14.7 years with male:female ratio of 2.5:1. Mean daily dosage of EMB was 17.5±1.3 mg/kg/day. No significant change was observed in visual acuity, contrast sensitivity, color vision and mean or pattern SD on HVF at 6 months. Significant increase in VER latency of >2 SD (>125 ms) was observed in 46% eyes on follow-up indicating subclinical toxicity. Significant loss of mean RNFL (from 100.79±16.05 μm to 89.96±13.79 μm) and GCIPL thickness (from 83.1±5.60 μm to 79.85±6.45 μm) was observed at 6 months (p=0.001 for both). Patients with subclinical toxicity had significantly greater damage in temporal RNFL quadrant, supero-nasal and infero-nasal GCIPL sectors compared with others.

Conclusion: The incidence of clinical EMB optic neuropathy was <2%, though subclinical damage in the form of increase in VER latency, and decrease in RNFL and GCIPL on OCT was seen in 46% eyes.
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http://dx.doi.org/10.1136/bjophthalmol-2020-316897DOI Listing
July 2021

Perineuritis or infiltration of optic nerve sheath? A presentation of diffuse large B cell Gastric lymphoma.

Indian J Ophthalmol 2020 06;68(6):1212-1214

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi, India.

Optic perineuritis is an inflammatory disorder involving the optic nerve sheath. It is currently considered as a part of idiopathic orbital inflammatory disease which also includes dacryoadenitis, orbital myositis, superior orbital fissure, and cavernous sinus syndrome (Tolosa hunt syndrome). As it is idiopathic, it is considered a diagnosis of exclusion. Another important differential is optic nerve lymphoma. Isolated optic nerve lymphoma associated with systemic involvement has been described in literature. We report a case that presented as third nerve palsy but later on developed central retinal vein occlusion and was ultimately diagnosed as primary gastric lymphoma of diffuse large B cell type.
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http://dx.doi.org/10.4103/ijo.IJO_711_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508084PMC
June 2020

Surprise of Behcet's disease in a patient with bilateral disc oedema and the role of OCT.

BMJ Case Rep 2020 May 21;13(5). Epub 2020 May 21.

Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Behcet's disease is a multisystem vasculitis which can be associated with cerebral venous thrombosis (CVT) leading to increased intracranial tension and papilloedema. We report a case of a 17-year-old boy who presented to us with inward deviation of right eye with bilateral disc oedema and on further investigations was found to be Human Leukocyte Antigen (HLA) B5 positive, along with CVT on magnetic resonance venography which further led us to the diagnosis of non-parenchymal neuro-Behcet's.
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http://dx.doi.org/10.1136/bcr-2020-234693DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7247373PMC
May 2020

Detection of structural and electrical disturbances in macula and optic nerve in Alzheimer's patients and their correlation with disease severity.

Semin Ophthalmol 2020 Feb 18;35(2):116-125. Epub 2020 Apr 18.

Department of Ophthalmology, AIIMS, New Delhi, India.

: To evaluate and compare structural and functional changes in macula and optic nerve in Alzheimer disease (AD) patients and healthy subjects.: Both eyes of 20 AD patients and 40 age-matched healthy controls were evaluated. All subjects were evaluated by cognitive testing and comprehensive ophthalmological examination, including visual acuity, visual fields, color vision, contrast sensitivity, anterior, and posterior segment examination, optical coherence tomography, multifocal electroretinography (mfERG), and pattern-reversal visual evoked potential (pVEP).: AD patients showed significantly reduced contrast sensitivity, thinner nerve fiber layer, ganglion cell layer andmacular volume. Multifocal ERG wave amplitudes were significantly reduced with delayed implicit times, which correlated significantly with the inner retinal layer thinning and poorer disease severity scores. The correlation with structural changes and disease severity was highest for pVEP, which showed significant derangement in AD patients.: Subclinical visual dysfunction may be present in AD patients, which may be detected as inner retinal thinning. A probable photoreceptor abnormality may also form a part of the AD disease process.
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http://dx.doi.org/10.1080/08820538.2020.1748203DOI Listing
February 2020

Acquired Ocular Motor Palsy: Current Demographic and Etiological Profile.

Asia Pac J Ophthalmol (Phila) 2020 Jan-Feb;9(1):25-28

Strabismus and Neuro-Ophthalmology Services, Dr. R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi 110029, India.

Purpose: To describe the clinical, demographic, and etiological profile of patients of acquired ocular motor palsy presenting in a tertiary eye care center.

Design: A retrospective hospital record-based study was conducted in patients of paralytic strabismus presenting from April 2016 to December 2017.

Methods: Data included demographic and clinical details, diagnosis, underlying etiology, imaging, laboratory reports, and the outcome.

Results: Mean age of presentation of 345 patients included in the study was 38.2 ± 19.5 years (range = 365 years). Pediatric patients (age: ≤16 years) constituted 9.5% of the entire cohort. Mean duration of complaints was 5.87 ± 2 months. Of the 372 eyes of 345 cases, 42.7% were sixth nerve palsy, 34.7% were third nerve palsy, 17.7% were fourth nerve palsy, and 4.8% had multiple ocular motor nerve involvement. Third and sixth nerve palsies were mostly due to ischemic event (58.1% and 69.8% cases, respectively), whereas fourth nerve palsies were commonly caused by trauma (63.6%). Amongst traumatic cases, road traffic accident was the most common mode of trauma. Systemic risk factors were preexistent in 18.2% cases (n = 63); in the remaining (40.8%; n = 141), they were diagnosed after presentation. Complete or partial recovery was noted in 69.7% cases in third nerve palsy, 67.9% cases in sixth nerve palsy, and 45% cases in fourth nerve palsy.

Conclusions: Acquired cranial nerve palsy has younger onset in Indian scenario. Ischemia is the most common etiology raising concerns about the health issues of young Indians. Sixth nerve is most commonly involved in all age groups. Low recovery rate in fourth nerve palsy can be attributed to traumatic etiology.
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http://dx.doi.org/10.1097/01.APO.0000617940.70112.beDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7004473PMC
October 2020

Sympathetic ophthalmitis after scleral perforation during strabismus surgery.

J AAPOS 2020 04 15;24(2):104-106. Epub 2020 Jan 15.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

We report the case of a 24-year-old woman who experienced sympathetic ophthalmitis after scleral perforation during strabismus surgery. She presented postoperatively with distorted vision and was successfully treated with intravenous and oral steroids.
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http://dx.doi.org/10.1016/j.jaapos.2019.12.002DOI Listing
April 2020

Vertical rectus transposition procedures for lateral rectus palsy: A systematic review.

Indian J Ophthalmol 2019 11;67(11):1793-1799

Squint and Neuro-Ophthalmology Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Multiple transposition procedures have been described for management of lateral rectus palsy. However, relative effect and indications of each procedure are unclear. This systematic review was planned to evaluate functional and anatomical outcomes of vertical rectus transposition (VRT) surgery in patients with lateral rectus palsy. We searched databases in English language, namely, MEDLINE, PubMed Central, EMBASE, Google Scholar, Scopus, and Index Copernicus without any date restrictions in electronic searches, using the search words 'vertical rectus transposition for lateral rectus palsy," "vertical rectus transposition for abducens palsy," "superior rectus transposition," "inferior rectus transposition," and "Hummelsheim procedure." References of the selected publications were also searched to find any relevant studies. We searched for studies that provided data on single VRT and double VRT surgeries for lateral rectus palsies. Three authors independently assessed the related studies gathered from electronic and manual searches. We found 27 studies which were relevant to the review question. As there were no randomized control trials (RCTs) available related to our study question, nonrandomized studies were used to arrive at summarization of outcomes of different transposition procedures. There is a need for prospective RCTs to investigate the different types of transposition procedures for lateral rectus palsy.
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http://dx.doi.org/10.4103/ijo.IJO_1841_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6836582PMC
November 2019

Extraocular muscle surgery on goats' eye: An inexpensive technique to enhance residents' surgical skills.

Indian J Ophthalmol 2019 10;67(10):1688-1689

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Hands-on resident surgical training for various ocular procedures is essential to impart good surgical skills to the budding ophthalmologists. Here in this report, we demonstrate a simple and inexpensive technique of performing extraocular muscle surgery on goats' eye. These animal eyes possess soft tissue resemblance to that of human eyes to a greater extent in terms of scleral rigidity, muscle elasticity, its width, thickness, and its insertion onto the sclera. Therefore, rectus muscle recession, resection, and plication surgeries can be performed repeatedly to improve an individual's orientation and practical experience before performing the procedure on human eyes.
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http://dx.doi.org/10.4103/ijo.IJO_89_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6786173PMC
October 2019

Combined resection-recession in true divergence excess sensory exotropia.

J AAPOS 2019 10 16;23(5):258.e1-258.e4. Epub 2019 Sep 16.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Purpose: To assess the effect of combined resection and recession on the same lateral rectus muscle in patients with true divergence excess sensory exotropia.

Methods: Patients were divided into two groups. One group of patients underwent combined resection-recession of the lateral rectus muscle in one eye (LR group); the other group, with exodeviation of >40 for distance underwent additional ipsilateral medial rectus resection (LR + MR group). Postoperative measurements were taken at 1 week, 1 month, and 3 months.

Results: Eleven patients were included in the study (mean age, 23.5 ± 6.7 years): 7 in the LR group and 4 in the LR + MR group. For the LR group, mean preoperative deviation was 35.7 ± 3.5 at distance and 16.3 ± 3.9 at near. The mean near-distance disparity (NDD) was 11.4 ± 2.7. The mean lateral rectus recession was 8.6 ± 1.1 mm: the mean resection, 4.3 ± 0.5 mm. At 3 months, mean deviation at distance was 8.3 ± 2.1; at near, 3.1 ± 1.6 (P = 0.01). The NDD was 5.7 ± 2.7 (P = 0.01). For the LR + MR group, mean preoperative deviations at distance was 65.0 ± 12.9; at near, 35.0 ± 12.2. The mean NDD was 30.0 ± 4.0. Mean lateral rectus recession was 9.5 ± 1.8 mm; the mean resection, 4.8 ± 0.8 mm. The mean medial rectus resection was 5.5 ± 0.6 mm. At 3 months, mean deviation at distance was 8.3 ± 2.1; at near, 3.1 ± 1.6 (P = 0.06). The NDD was 5.7 ± 2.7 (P = 0.06).

Conclusions: In our study combined resection and recession of the same lateral rectus muscle in patients with divergence excess sensory exotropia significantly reduced the NDD, with no adverse outcomes.
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http://dx.doi.org/10.1016/j.jaapos.2019.06.009DOI Listing
October 2019

Pulled into two syndrome (PITS) in a case of congenital fibrosis of the extraocular muscle.

Indian J Ophthalmol 2019 07;67(7):1229-1230

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India.

A four-year-old child with a clinical diagnosis of unilateral congenital fibrosis of extraocular muscles (CFEOM) was planned for inferior and medial rectus muscle recession surgery, adjusted with the status of forced duction test. Due to pathological changes within the muscles subsequent to innervational abnormality, intraoperatively the inferior rectus muscle was pulled into two following the insertion of muscle hook. Moreover, the snapped muscle fibers could not be identified, thus further surgery was abandoned and an observation was commenced. At the end of 6 weeks, there was a significant reduction in the amount of hypotropia but clinically significant perverted convergence with esotropia necessitated further surgical intervention. A second surgical intervention consisting of medial rectus transposition to superior rectus with 3 mm recession was performed to achieve acceptable results in the primary gaze.
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http://dx.doi.org/10.4103/ijo.IJO_1542_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6611247PMC
July 2019

Quantification of Retinal Torsion in Strabismus Using a Smartphone.

Ophthalmol Retina 2019 04;3(4):379

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1016/j.oret.2018.12.007DOI Listing
April 2019

Pathomechanism of optic nerve avulsion.

Med Hypotheses 2019 Apr 11;125:28-30. Epub 2019 Feb 11.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi 110029, India.

Optic nerve avulsion following peri-orbital trauma is an enigmatic clinical entity. Several mechanisms and ideas have been put forward to derive a logical conclusion, however, each factor independently does not appear to explain the mechanism in a logical way, therefore, here we elaborate the probable chain of events responsible for this complication. During isolated blunt trauma to the orbital framework, the globe continues to move anteriorly without any active resistance, in contrast to the globe, the optic nerve with more delicate bony and soft tissue relations, likely to remain relatively static. Thus the junction between the optic nerve and ocular coat suffers the maximum distractive injury due to anteroposterior tractional forces. In addition to this, physiological Bell's phenomenon may induce torsional tension at this junction leading to further worsening of distractive forces and violent separation of optic nerve from the globe.
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http://dx.doi.org/10.1016/j.mehy.2019.02.031DOI Listing
April 2019

Assessment of macular vascular plexus density using optical coherence tomography angiography in cases of strabismic amblyopia.

Indian J Ophthalmol 2019 Apr;67(4):520-521

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Purpose: To evaluate the superficial retinal vascular plexus density using optical coherence tomography angiography (OCTA) in cases of strabismic amblyopia.

Methods: Ten eyes of 10 patients with purely strabismic amblyopia underwent detailed ocular evaluation followed by the assessment of the superficial retinal plexus vascular density using OCTA (Topcon DRI OCT Triton, Swept Source OCT, Topcon, Japan). Ten contralateral normal eyes of the same patients were considered as control. All these 20 eyes underwent a 4.5 × 4.5 mm cube scan OCTA centered at the fovea. Using the Topcon propriety software all 20 eyes were assessed for the capillary plexus density of the superficial retinal vascular plexus along the superior, inferior, nasal, and temporal quadrants centered at the fovea. The numerical values were statistically assessed using a paired t-test with respect to each quadrant between the normal and the pathological eyes.

Results: The average age of patients was 16 years and eight patients were males. The mean superficial retinal vascular plexus density along the superior, inferior, nasal, and temporal quadrants in normal and pathological eyes were 49.25 ± 30.34 and 48.93 ± 2.85, 47.22 ± 4.11 and 47.37 ± 4.8, 45.54 ± 1.55 and 43.81 ± 4.21, and 46.26 ± 4.63 and 46.38 ± 5.40, respectively. Similarly, the capillary densities along the central were 17.84 ± 3.49 and 17.24 ± 2.44 in normal and pathological eyes. The differences among all these four quadrants and central area were not statistically significant (P-values > 0.05 for all four quadrants and central area) as compared with the normal eyes.

Conclusion: The superficial retinal vascular plexus density of a 4.5 × 4.5 mm cube centered at the fovea of eyes of cases of strabismic amblyopia is similar to that of normal eyes.
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http://dx.doi.org/10.4103/ijo.IJO_1069_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6446633PMC
April 2019

Atypical presentation of primary Sjögren's syndrome as optic neuritis.

Can J Ophthalmol 2019 02 22;54(1):e30-e32. Epub 2018 Jun 22.

Professor of Neuro-ophthalmology.

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http://dx.doi.org/10.1016/j.jcjo.2018.04.013DOI Listing
February 2019

Cervical carcinoma leading to orbital apex syndrome and blindness.

BMJ Case Rep 2019 Mar 1;12(3). Epub 2019 Mar 1.

Department of Strabismus and Neuroophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Delhi, India.

Orbit is an unusual and rare site for metastases from cancer. The most frequent site of a primary malignancy to metastasise to the orbit is the breast, followed by the lung. The malignant mixed mullerian tumour is a rare uterine and cervical carcinoma and accounts for <5% of uterine cancers. It is the primary tumour of the uterus, and de novo involvement of the cervix itself is extremely rare. We report the first case of cervical carcinoma with mixed mullerian aetiology to be associated with orbital metastasis and eventually leading to blindness and death.
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http://dx.doi.org/10.1136/bcr-2018-226587DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6398740PMC
March 2019

What decides the nature of extraocular muscle injury? The probable mechanism of flap tear and rupture.

Med Hypotheses 2019 Feb 16;123:115-117. Epub 2019 Jan 16.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, India.

The assessment of nature and the extent of extraocular muscle injuries during initial visit in ocular emergencies is of paramount importance to avoid/minimize the subsequent need for strabismus surgery. Based on our experience in managing acute globe and orbital injuries and cases of strabismus, we propose the probable mechanism involved in the occurrence of extraocular muscle flap tear and a complete rupture of the muscle. During high-velocity injuries when the forces are equally transmitted along the orbital bony framework and the globe, then due to differential shearing forces created between the global and the orbital fibres leads to a flap tear. In the second scenario, if the forces are only directed along the bony framework, then the globe continues to be in continuous motion leading to increased tension between the muscles and the globe. Thus the weaker portions between these two structures are at risk of complete separation, that is along the insertion of muscle onto the globe or the musculotendinous portion.
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http://dx.doi.org/10.1016/j.mehy.2019.01.011DOI Listing
February 2019
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