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   Table of Contents - Current issue
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October-December 2020
Volume 32 | Issue 4
Page Nos. 307-428

Online since Saturday, December 12, 2020

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EDITORIAL  

Ophthalmology education in the post-coronavirus disease 2019 era p. 307
Mehran Zarei-Ghanavati, George P T-H Liu, Hasan Naveed, Rawya A Diab, Christopher Liu
DOI:10.1016/j.joco.2019.08.006  
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REVIEW ARTICLES Top

Vogt–Koyanagi–Harada is a curable autoimmune disease: Early diagnosis and immediate dual steroidal and non-steroidal immunosuppression are crucial prerequisites p. 310
Ioannis Papasavvas, Ilknur Tugal-Tutkun, Carl P Herbort
DOI:10.4103/JOCO.JOCO_190_20  
Purpose: It is crucial to subdivide Vogt–Koyanagi–Harada (VKH) disease into two subentities, initial-onset disease versus chronically evolving disease. For early diagnosis and precise follow-up of VKH choroiditis, the “Revised criteria for VKH” are no more sufficient for the appraisal of VKH and new biomarkers for disease activity are needed. It has been shown that, if initial-onset disease is treated promptly within the “therapeutic window of opportunity” and long enough with dual steroidal and non-steroidal immunosuppression, the disease can be cured in a large proportion of cases, an approach still contested. The proportion of chronic evolution and/or sunset-glow fundus (SGF) following steroidal monotherapy versus dual steroidal and non-steroidal immunosuppression was compared. Methods: A literature search was performed, identifying studies on initial-onset VKH treated either by steroidal monotherapy or dual immunosuppression. Evolution toward chronicity and/or SGF was compared in both groups. Results: Twenty studies were identified with reported long-term outcomes. In 16 studies, 802 patients received steroidal monotherapy, while in 4 studies, 172 patients received dual steroidal and non-steroidal immunosuppression. Chronic evolution and SGF occurred, respectively, in 44% and 59% in the corticosteroid-alone group versus 2.3% and 17.5% in the dual therapy group with no chronic evolution in three studies and no SGF in two studies. Conclusions: Chronic evolution and SGF are significantly less frequent in initial-onset VKH when treated with immediate dual steroidal and non-steroidal immunosuppression with a high proportion of healed cases. This combined approach seems recommended in the management of initial-onset VKH disease.
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An ophthalmic insight into novel coronavirus 2019 disease: A comprehensive review of the ocular manifestations and clinical hazards Highly accessed article p. 315
Amani E Badawi, Sara S Elsheikh, Sarah Zaher Addeen, Mostafa A Soliman, Rami Abd-Rabu, Walid Shaban Abdella, Elham A Gad
DOI:10.4103/JOCO.JOCO_255_20  
Purpose: To discuss the ocular manifestations provoked by novel coronavirus 2019 (COVID-19) disease in humans, the natural history of the disease in the eye, and its treatment. Methods: We designed a narrative review of the ocular manifestations of COVID-19 based on the literature published till July 30, 2020. The databases were PubMed, Scopus, Cochrane Library, Google Scholar, and ScienceDirect. The inclusion criteria were (1) all types of clinical studies and (2) the topic was COVID-19 and its association to the eye regarding the current guidelines. Results: From 168 abstracts screened, 61 papers fully filled the inclusion criteria after the full-text screening. The 61 records include 13 case reports, 17 prospective (case series or cross-sectional) studies, 8 retrospective studies, 12 literature reviews (one systematic review), and 11 letters to the editor. The majority of the papers agreed that ophthalmic manifestations due to COVID-19 were few and rarely encountered. The main ocular pathology seemed to be conjunctivitis, where the viral polymerase chain reaction also happened to be most detectable. Posterior segment or neuro-ophthalmic manifestations were scarce. Viral genome detection in the eye as well as viral portal of entry to the globe is still vague. Conclusion: The exact incidence of ocular manifestations in COVID-19 disease is uncertain. Conjunctivitis is the most prevalent ocular manifestation. It is still a debate whether the eye is a portal of entry for infection.
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ORIGINAL ARTICLES Top

Comparison of the surgical outcomes of single-site, mitomycin C-augmented trabeculectomy combined with phacoemulsification versus manual small-incision cataract surgery p. 329
Tarannum Mansoori, Nagalla Balakrishna
DOI:10.4103/JOCO.JOCO_4_20  
Purpose: To compare the safety, efficacy, and outcome measures of a single-site, mitomycin C (MMC)-augmented trabeculectomy combined with phacoemulsification (PT) versus manual small-incision cataract surgery (MSICS) with the posterior chamber intraocular lens (PCIOL) implantation as a primary surgery in the patients with primary glaucoma coexistent with cataract. Methods: From April 2015 to August 2017, medical records of all the patients who underwent combined cataract surgery with PCIOL and MMC augmented trabeculectomy were reviewed. One hundred and thirty-seven eyes met the inclusion criteria. Ninety-seven eyes which underwent PT with MMC were compared with forty eyes that underwent MSICS combined with trabeculectomy (MSICST) MMC. Outcome measures were best corrected visual acuity (BCVA), intraocular pressure (IOP), and number of anti-glaucoma medications (AGM). Complications, if any, were noted in both the groups. Results: The mean follow-up period after surgery was 18.6 ± 7.7 months (range, 12–40 months). At the last follow-up visit, there was no statistically significant difference between the groups, in terms of mean logMAR BCVA (PT: 0.22 ± 0.31, MSICST: 0.21 ± 0.33, P = 0.8), mean IOP reduction (PT: 13.9 ± 2.98 mmHg, MSICST: 14.1 ± 4.12 mmHg, P = 0.8), and mean number of AGM (PT: 0.03 ± 0.8, MSICST: 0.025 ± 0.7, P = 0.8). Complications were few and transient. One eye in the PT group was considered as a failure and had to undergo needling, repeat trabeculectomy, and later, cyclodestructive procedure. None of the eyes in the MSICST group required an additional procedure for IOP reduction. Conclusion: There was no difference in the mean IOP reduction, BCVA, and mean number of AGM between the two procedures, and both appeared to be safe and effective techniques as a primary surgery in the patients with coexistent cataract and glaucoma.
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Long-term intraocular pressure changes after pars plana vitrectomy: An 8-year study p. 335
Arash Omidtabrizi, Vahid Ghavami, Masoud Shafiee, Razieh Bayani, Touka Banaee
DOI:10.4103/JOCO.JOCO_85_20  
Purpose: To investigate the long-term changes of intraocular pressure (IOP) after pars plana vitrectomy (PPV). Methods: This was a retrospective historical cohort study. Patients with a history of vitrectomy in one eye by a single surgeon were enrolled. IOP of the operated eye was compared to the fellow eye. Previous scleral buckling, IOP rise due to surgical/anatomic complications, silicone oil (SO) emulsification, and contralateral ocular hypertension/glaucoma at recruitment were exclusion criteria. “Significant IOP rise” (>6.0 mmHg) and development of open angle glaucoma (OAG) were the main outcome measures. Results: Two hundred and twenty-five eyes were included. Mean and median follow-up duration were 20.6 and 9.0 months, respectively. Mean baseline IOP and mean final IOP were 13.53 ± 3.75 mmHg and 16.52 ± 6.95 mmHg, respectively (P < 0.001). Forty-three patients developed “significant IOP rise” with no statistically significant relation to the indication of vitrectomy, the postoperative lens status, and number of vitrectomies (P = 0.410, P = 0.900, and P = 0.160, respectively). SO injection raised the probability of IOP rise in the long-term (P = 0.028). OAG occurred in 17 patients (7.5%) with no association to SO tamponade (P = 0.840). “Significant IOP rise” and OAG occurred in 3 and 1 control eyes, respectively, significantly lower than the rates in study eyes (P < 0.001). Conclusion: Mean IOP slightly rose in the long-term after PPV. SO tamponade was associated with IOP rise in the long-term but not with the incidence of OAG. Both IOP rise and OAG were more probable after vitrectomy.
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Keratoconus indices and their determinants in healthy eyes of a rural population p. 343
Hassan Hashemi, Reza Pakzad, Samira Heydarian, AbbasAli Yekta, Hadi Ostadimoghaddam, Mahdi Mortazavi, Shahroukh Ramin, Mehdi Khabazkhoob
DOI:10.4103/JOCO.JOCO_31_20  
Purpose: To determine the distribution of keratoconus indices in a 5-93-year-old healthy eyes of a rural population in Iran. Methods: In this cross-sectional study, multi-stage cluster sampling was applied to select subjects from two villages in the north and southwest of Iran. After obtaining informed consent, all subjects underwent ophthalmologic and optometric examinations. Corneal imaging by the Pentacam was done in subjects above 5 years between 9 a.m. and 2 p.m., at least 3 h after wakeup. All subjects who had abnormal keratoconus indices were excluded. Our main outcome was keratometry-flat (Kf), keratometry-steep (Ks), keratoconus index (KI), and central keratoconus index (CKI). Results: The mean ± standard deviation of Kf, Ks, KI, and CKI was 43.12 ± 1.74, 44.25 ± 1.65, 1.02 ± 0.02, and 1.01 ± 0.01, respectively. According to multiple linear regression analysis, the mean index surface variance (ISV) (b: -1.367, P < 0.001), index vertical asymmetry (IVA) (b: -0.012, P < 0.001), KI (b: -0.011, P < 0.001), CKI (b: -0.001, P < 0.001), index height asymmetry (IHA) (b: -0.491, P: 0.005), and index height decentration (IHD) (b: -0.001, P < 0.001) were lower in men compared to women. Moreover, age had an indirect association with ISV (b: -0.030, P < 0.001) and average pachymetric progression index (RPI_avg) (b: -0.001, P < 0.001), and a direct association with KI, CKI, and IHA. Spherical equivalence had an indirect association with KI (b: -0.001, P < 0.001) and RPI_avg (b: -0.004, P < 0.001) and a direct association with CKI (b: 0.001, P < 0.001). Among all variables, sex had the greatest impact on ISV, IVA, KI, IHA, IHD, and minimum sagittal curvature. Conclusions: The Keratoconus indices of our study were similar to other studies. Although age, living place, and type of refractive error were associated with some indices, sex was the strongest determinant of Keratoconus indices in a population of healthy eyes.
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Correlation between corneal topographic patterns and refractive status of the eye in an adult Iranian population: Tehran study p. 349
Fateme Alipour, Fateme Bazvand, Fateme Jafari, Parisa Abdi, Behnaz Samet, Ali Kabir, Hosein Poustchi
DOI:10.4103/JOCO.JOCO_130_20  
Purpose: To evaluate the corneal topographic patterns in an adult Iranian population and investigate its correlation with the refractive status of the eye. Methods: In a cross-sectional study named “Tehran Study,” 1023 samples were selected by the cluster sampling method from the downtown area of Tehran. Eight hundred and forty-nine adults aged over 15 years participated. All selected participants were refracted and underwent topography imaging. Results: The patients' ages ranged from 15 to 91 years with a mean of 40.33 ± 16 years. The most frequent topographic patterns were symmetric bowtie (SB) (34%), SB with inferior steepening (SB-IS) (14.1%), and round (10.5%). The orders changed in categorization by refractive status: The most frequent pattern in all subgroups (emmetropia, myopia, and hyperopia) was SB with frequencies 32.7%, 35.8%, and 22.5%, respectively. Although the second order was asymmetric bowtie (AB) with AB-IS in the emmetropic and myopic subgroups, in the hyperopic subgroup, round pattern had the second place. The third place was different in all groups. The rarest patterns in the whole were SB with skewed radial axis (SRAX) and AB with SRAX. The first prevalent topographic pattern was SB in all age groups and in both genders. The prevalence of round pattern, irregular pattern, and SRAX significantly increased in older ages, and the prevalence of SB decreased in older ages. The first observed prevalent pattern was SB in both sexes, but the second most prevalent pattern was AB-IS and round in females and males, respectively. Conclusions: Corneal topographic pattern might be related to the refractive status of the eye. The information about normal topographic patterns provides a reference for comparison with diseased corneas.
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Corneal and ocular residual astigmatism in school-age children p. 355
Samira Heydarian, Sara Sardari, Zahra Heidari, Abbas Ali Yekta, Hadi Ostadimoghaddam, Mehdi Khabazkhoob
DOI:10.4103/JOCO.JOCO_8_20  
Purpose: To determine the distribution of residual and corneal astigmatism (CA) in children aged 6–18 years and their relationship with age, sex, spherical equivalent, and biometric parameters. Methods: In this cross-sectional study, multi-stage stratified cluster sampling was done to select students from Dezful, a city in Southwestern Iran. Examinations included the measurement of visual acuity with and without optical correction, refraction with and without cycloplegia, and biometry using the Biograph (Lenstar, Germany). The main outcomes in this report were corneal and residual astigmatism. The CA was measured by Biograph (difference between k1 and k2), and residual astigmatism was calculated using Alpine method. The power vector method was applied to analyze the data of astigmatism. Results: Of 864 students that were selected, 683 (79.1%) participated in the study. The mean residual and CA were -0.84 diopter (D) and -0.85 D, respectively. According to the results of J0 and J45 vectors, residual astigmatism was -0.33 D and 0.04 D, and CA was 0.38 D and 0.01 D, respectively. With-the-rule (WTR), against-the-rule (ATR), and oblique astigmatism were seen in 3.4%, 66.8%, and 4.5% of the children with residual astigmatism and 67.94%, 1.3%, and 1.5% of the children with CA. Residual astigmatism decreased with an increase in spherical refractive error, whereas CA increased with an increase in spherical refractive error. Conclusion: The results of the present study showed a high prevalence and amount of residual astigmatism with ATR pattern among the 6–18-year-old population and the compensatory effect of this type of astigmatism on CA that mostly followed a WTR pattern.
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Novel method of plugging the hole: Anatomical and functional outcomes of human amniotic membrane-assisted macular hole surgery p. 361
Naresh Kumar Yadav, Ramesh Venkatesh, Sherina Thomas, Arpitha Pereira, K Bhujang Shetty
DOI:10.4103/JOCO.JOCO_189_20  
Purpose: To describe the surgical outcomes of macular holes (MHs) by inserting a human amniotic membrane (hAM) plug. Methods: In this retrospective, interventional, comparative case series, 10 patients who had undergone hAM plugging for a MH were included in the study. Seven patients had idiopathic full-thickness MHs, 1 patient had traumatic MH, and 1 patient each had a MH-induced retinal detachment and combined retinal detachment. The control group included 10 cases with similar configuration and duration of MHs treated with the inverted peeling of the internal limiting membrane technique. All patients underwent a standard 3-port, 25-gauge transconjunctival pars plana vitrectomy and hAM plug transplantation in the subretinal space under the MH. The anatomic and functional outcomes were assessed at 4 weeks postsurgery. Results: At the 4-week follow-up visit, all the MHs in the hAM plug group achieved hole closure, whereas 80% of the eyes in the control group were able to achieve hole closure. Improvement of 0.1 logMAR vision was noted in 8 of the 10 patients. At the 4-week follow-up visit, the external limiting membrane and ellipsoid zone layer continuity over the hAM was defined only in one case. No significant difference was found between the hAM plug group and controls in visual and anatomical responses. No complications following hAM transplantation such as rejection, endophthalmitis, or hypotony were noted following surgery. Conclusion: Subretinal hAM graft transplantation can be a useful option in the repair of primary or refractory MHs not only for achieving anatomic closure but also for the accompanying visual improvement.
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Performance of deep transfer learning for detecting abnormal fundus images p. 368
Yan Yu, Xiao Chen, XiangBing Zhu, PengFei Zhang, YinFen Hou, RongRong Zhang, ChangFan Wu
DOI:10.4103/JOCO.JOCO_123_20  
Purpose: To develop and validate a deep transfer learning (DTL) algorithm for detecting abnormalities in fundus images from non-mydriatic fundus photography examinations. Methods: A total of 1295 fundus images were collected to develop and validate a DTL algorithm for detecting abnormal fundus images. After removing 366 poor images, the DTL model was developed using 929 (370 normal and 559 abnormal) fundus images. Data preprocessing was performed to normalize the images. The inception-ResNet-v2 architecture was applied to achieve transfer learning. We tested our model using a subset of the publicly available Messidor dataset (using 366 images) and evaluated the testing performance of the DTL model for detecting abnormal fundus images. Results: In the internal validation dataset (n = 273 images), the area under the curve (AUC), sensitivity, accuracy, and specificity of DTL for correctly classified fundus images were 0.997%, 97.41%, 97.07%, and 96.82%, respectively. For the test dataset (n = 273 images), the AUC, sensitivity, accuracy, and specificity of the DTL for correctly classifying fundus images were 0.926%, 88.17%, 87.18%, and 86.67%, respectively. Conclusion: DTL showed high sensitivity and specificity for detecting abnormal fundus-related diseases. Further research is necessary to improve this method and evaluate the applicability of DTL in community health-care centers.
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Relevance of multicolor imaging in type 2 macular telangiectasia p. 375
Ramesh Venkatesh, Arpitha Pereira, Bharathi Bavaharan, Kushagra Jain, Aditya Aseem, Sajjan Sangai, Naresh Kumar Yadav
DOI:10.4103/JOCO.JOCO_96_20  
Purpose: To report the imaging characteristics of various clinical features in idiopathic macular telangiectasia (MacTel 2) on multicolor imaging (MCI) and compare its accuracy vis-à-vis color fundus photograph (CFP) and fluorescein angiography (FA). Methods: In this retrospective observational study, 54 eyes of 27 patients with MacTel 2 were included after institutional review board approval. Multimodal imaging with CFP, optical coherence tomography (OCT), MCI, and FA was done. Images were analyzed to identify and describe the clinical findings in MacTel 2. Sensitivity, specificity, and positive and negative predictive values were computed for the various imaging modalities in MacTel 2. Results: In this study, the MCI identified all the different clinical features of MacTel 2 in 100% of cases. The confocal blue reflectance (BR) image was more sensitive than CFP (100% vs. 96.3%) in identifying the loss of retinal transparency in MacTel 2. For other clinical features such as right-angled vessels, superficial retinal crystals, and retinal pigment epithelial hyperplasia/plaques, the sensitivity of BR, and green reflectance (GR) image, was comparable to that of CFP. Confocal infrared reflectance (IR) images showed poor sensitivity in identifying the non-proliferative features in MacTel 2 (P < 0.001). Loss of retinal transparency was not picked up on IR image. Other features such as right-angled vessels, superficial retinal crystals, and pigment plaques were seen in 20%, 4.6%, and 26.3% of cases, respectively. However, confocal IR images were superior to FA (100% vs. 47%) and CFP (100% vs. 15%) in identifying the extent and location of subretinal neovascular membrane. The confocal BR and GR images were unable to identify the choroidal neovascular membrane (P < 0.001). Conclusion: MCI is a useful and non-invasive imaging modality to identify the clinical features in MacTel 2. MCI can be used as a complementary imaging tool to CFP, FA, and OCT.
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Choriocapillaris involvement in acute syphilis posterior placoid chorioretinitis is responsible for functional impairment and points towards an immunologic mechanism: A comprehensive clinicopathological approach p. 381
Carl P Herbort, Ioannis Papasavvas, Alessandro Mantovani
DOI:10.4103/JOCO.JOCO_184_20  
Purpose: To evaluate the multimodal imaging of acute syphilitic posterior placoid chorioretinitis (ASPPC) lesions in order to elucidate their pathophysiology which seems to resemble choriocapillaritis as in primary inflammatory choriocapillaropathies such as multifocal choroiditis (MFC) and acute posterior multifocal placoid pigment epitheliopathy (APMPPE). Methods: Charts of patients with ASPPC seen in the Centre for Ophthalmic Specialised Care, Lausanne, Switzerland, were retrieved. Fundus autofluorescence (FAF), spectral domain optical coherence tomography (SD-OCT), fluorescein angiography (FA), indocyanine green angiography (ICGA), and when available, OCT angiography were analyzed and compared to a case of MFC. Results: One woman aged 58 and 2 men aged 50 and 31 with unilateral ASPPC were analyzed. All had positive syphilis serologies (venereal disease research laboratory [VDRL] and treponema Pallidum hemagglutination assay [TPHA]). Two were human immunodeficiency virus (HIV) positive. Mean best corrected visual acuity was 0.2 ± 0.1 at presentation and 1.0 for all patients 6 weeks later, after antibiotic treatment for neurosyphilis. All had central scotomata with a mean defect (MD) of 12.2 ± 2.6. Six weeks later, MD values were 3.9 ± 1.7. Microperimetry had a mean score of 25/560 at presentation and recovered to a mean of 444/560 6 weeks later. Multimodal imaging features consisted of FA tissue staining, ICGA hypofluorescent choriocapillaris non-perfusion, FAF hyperautofluorescence, and loss of the ellipsoid line in the diseased areas. The findings were consistent and identical in ASPPC and a case of MFC and pointed toward the involvement of the choriocapillaris. Conclusions: Similarities seen in multimodal imaging features in ASPPC and choriocapillaritis highlight the role of the choriocapillaris in the pathophysiologic mechanism of both conditions. Inflammatory choriocapillaris non-perfusion triggered by infectious agents seems to be the common pathway through which the eye is reacting.
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Clinical findings in four siblings with genetically proven oguchi disease p. 390
Cagri Ilhan, Mehmet Citirik, Mehmet Yasin Teke, Selda Celik Dulger
DOI:10.4103/JOCO.JOCO_155_20  
Purpose: To assess the clinical findings in normal daylight status and 3 h of dark-adapted status in family members with Oguchi disease (OD). Methods: Four siblings with OD and their parents were included in this case series. The presence of disease was confirmed with genetic analysis and comprehensive clinical evaluation. Corrected distant visual acuity (CDVA), automated visual field analysis (VFA), optical coherence tomography (OCT), OCT angiography (OCTA), colored fundus photography, fundus autofluorescence (FAF), fundus fluorescein angiography (FFA), electroretinography (ERG), and dark adaptation test (DAT) results were obtained in normal daylight status. On the next day, after 3 h of dark adaptation, the patients were re-evaluated. The findings obtained in normal daylight status and 3 h dark-adapted status were compared. Results: The mean age of the four sibling subjects was 15.25 ± 2.2 years. All subjects had 20/20 CDVA and normal VFA. There was no abnormality in OCT and OCTA in normal daylight status and 3 h of dark-adapted status. Colored fundus photographs showed characteristic golden-yellow colored reflex in the mid-peripheral retina in normal daylight status, and discoloration in 3 h of dark-adapted status. In FAF and FFA, no abnormal pattern was observed in normal daylight status and 3 h of dark-adapted status. ERG showed rod function alterations and normal cone function. DAT showed delayed rod adaptation and normal cone adaptation. ERG and DAT findings remained unchanged after 3 h of dark adaptation. Conclusion: After 3 h of dark adaptation, golden-yellow fundus color returns to normal in patients with OD; however, rod function alterations and normal cone function in ERG, as well as delayed rod adaptation and normal cone adaptation in DAT remain unchanged.
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Psychometric assessment of the persian version of the revised convergence insufficiency symptom survey in young adults with convergence insufficiency p. 395
Payam Nabovati, Mohammad Kamali, Mehdi Khabazkhoob, Ali Mirzajani, Ebrahim Jafarzadehpur
DOI:10.4103/JOCO.JOCO_194_20  
Purpose: To translate the Convergence Insufficiency Symptom Survey (CISS) to Persian and to assess its validity and reliability in a group of young adult Iranian patients with convergence insufficiency (CI). Methods: The questionnaire was translated in backward and forward phases. Face validity was measured using a 6-point scale (very weak, weak, moderate, good, very good, best), and a score of =4 for each item indicated an acceptable face validity. The content validity was assessed using three indices of relevancy, clarity, and comprehensiveness. Relevancy and clarity were checked for each item and for the whole scale using a 4-point scale (1-undesirable, 2-relatively desirable, 3-desirable, 4-completely desirable), and Item Content Validity Index (I-CVI) and Scale Content Validity Index (S-CVI) were calculated for the above indices. Comprehensiveness was measured at the scale level using a 4-point scale (1-incomprehensive, 2-relatively comprehensive, 3-comprehensive, 4-totally comprehensive), and S-CVI was calculated. The internal consistency and test-retest reliability were assessed using Cronbach's alpha coefficient and interclass correlation coefficient (ICC), respectively. To evaluate discriminant validity, CI was categorized into mild, moderate, and severe stages, and the mean overall CISS score was compared between these groups. Results: Thirty CI patients aged 18–34 years participated in this study. On face validity assessment, all items finally had a score of ≥4. As for relevancy and clarity, I-CVI was above 80% for all items, and S-CVI was 98.8% and 96.6%, respectively. The S-CVI was 100% for comprehensiveness. The overall Cronbach's coefficient and ICC were 0.77 and 0.95, respectively. There was a significant difference in the overall score between the three severity groups. Conclusion: The Persian CISS is a valid and reliable tool for clinical and research applications.
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Prevalence of refractive error and visual impairment among rural dwellers in mashonaland Central Province, Zimbabwe p. 402
Selassie Tagoh, Samuel Kyei, Michael Agyemang Kwarteng, Evans Aboagye
DOI:10.4103/JOCO.JOCO_224_20  
Purpose: To determine the prevalence of refractive error and visual impairment in a rural population of Zimbabwe. Methods: This community-based, cross-sectional study used a multi-stage sampling to select the participants from households in four communities within three rural districts in Mashonaland Central Province. Participants' demographic data were collated, and their presenting visual acuity (VA) was measured using the logMAR E chart. Clinical refraction was preceded by an anterior segment and posterior segment eye examinations. Visual impairment was defined as presenting VA worse than 6/12 (0.3 logMAR) in the better eye. Descriptive statistics were presented as frequencies. Results: A total of 519 participants were involved in this study. Their ages ranged from 5 to 100 years (mean age = 50.94; standard deviation ± 21.12 years). Out of the 519 participants, 233 (44.9%) were male, and 286 (55.1%) were female. The prevalence of visual impairment was 56.8% (95% confidence interval [CI]: 55.7–67.2), and blindness was 13.1% (95% CI: 11.2–17.6). The prevalence of near visual impairment based on presenting near VA (N = 408) was 78.6% (95% CI: 78.1–85.4). The two most common causes of visual impairment were uncorrected refractive errors (UREs) (54.2%) and cataract (24.8%). The most common cause of blindness was cataract (41.2%). Hypermetropia (56.9%) was the most common refractive error. Conclusions: A high burden of visual impairment due to UREs and cataracts was observed among the rural dwellers of Zimbabwe. Public health education, access to refractive error services, and cataract surgery are necessary to mitigate this high burden of visual impairment.
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Comparison of the effectiveness of onion extract, topical steroid, and petrolatum emollient in cosmetic appearance of upper blepharoplasty scar p. 408
Naser Owji, Mohammad Reza Khalili, Behzad Khademi, Mohammad Shirvani, Maryam Sadat Sadati
DOI:10.4103/JOCO.JOCO_39_20  
Purpose: To compare the effectiveness of onion extract, topical steroid, and petrolatum emollient in the prevention of scars in cases who underwent bilateral upper eyelid blepharoplasty. Methods: A prospective, interventional, comparative, double-blinded case series was designed on cases who underwent upper lid blepharoplasty. After suture removal (1 week following the surgery), the eyelids of participants were randomly allocated into the three groups: The first group used onion extract on the right eyelids (n = 18), and the second group used topical steroid on the right eyelids (n = 19). In the third group, the control group, petrolatum emollient was used on the left eyelids (n = 37) of the first and second group's cases. They used drugs for 2 months and were evaluated by the Manchester Scar Scale (MSS) objectively by two graders who were blinded to the type of medication. MSS evaluates five different characteristics of the scar in addition to the Visual Analog Scale (VAS). These characteristics include color, distortion, contour, texture, and transparency. VAS scores the overall scar appearance which ranged among 0–10. The sum of the scores for the five different parameters, and VAS was calculated, analyzed, and compared among the groups. Results: A total of 37 cases (74 eyelids) who underwent bilateral upper blepharoplasty were included. The mean ± standard deviation (SD) of age was 51.94 ± 9.26 years, 49.40 ± 9.37 years, and 47.00 ± 9.06 years in the onion extract, topical steroid, and petrolatum emollient groups, respectively (P = 0.275). There were no statistically significant differences in the mean ± SD of the sum of the MSS scores among the three groups (P = 0.924) or between the onion extract and topical steroid groups (P = 0.951). Furthermore, the color, distortion, contour, texture, transparency, and VAS scores were not statistically significantly different among the three groups or between the onion extract and topical steroid groups (P > 0.05). Conclusion: There were no significant differences among these three groups of drugs regarding the appearance of the upper blepharoplasty scar.
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CASE REPORTS Top

Giant cell tumor: Changing behavior from intraorbital to intraosseous mass p. 414
Mohammad Taher Rajabi, Seyedeh Zahra Poursayed Lazarjani, S Saeed Mohammadi, Mohammad Veshagh, Farideh Hosseinzadeh, Seyed Mohsen Rafizadeh, Fahimeh Asadi Amoli, Simindokht Hosseini
DOI:10.4103/JOCO.JOCO_63_20  
Purpose: To present a patient with giant cell tumor (GCT) of the orbit by changing behavior from an intraorbital mass to an intraosseous tumor. Methods: A 16-year-old boy presented with pain, swelling, erythematous of the left upper and lower eyelids, proptosis, and diplopia. Ophthalmic examination revealed chemosis, conjunctival injection, limited elevation, depression as well as abduction in the left eye. Results: Multislice computed tomography scan (CT scan) of the orbit and paranasal sinuses showed a hyperdense, oval, extraconal mass with bone erosion. Magnetic resonance imaging of the orbit showed an inferior lateral isointense, oval, extraconal mass that had indented the globe. The patient underwent superior lateral orbitotomy, and the orbital mass was excised. Two months later, the patient developed proptosis, severe chemosis, and eyelid erythema in the same eye. CT scan showed an intraosseous mass in the lateral wall of the orbit that had pushed the globe anteromedially. Intraosseous tumor was resected, and the lateral orbital wall was drilled during the second surgery. GCT was diagnosed based on pathological survey. Conclusion: Following the resection of the orbital GCT, the tumor behavior may change to an intraosseous lesion.
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Recurrent periorbital cellulitis secondary to cyclic neutropenia p. 417
Nasim Raad, Abbas Bagheri, Yousef Eskandari, Mehdi Tavakoli
DOI:10.4103/JOCO.JOCO_16_20  
Purpose: To present a 1-year-old boy with cyclic neutropenia who presented with multiple episodes of periorbital cellulitis (POC). Methods: The child presented with three episodes of POC. In the second episode, the cellulitis was associated with nasolacrimal duct obstruction, and in the third episode, a pansinusitis was noted. He underwent a thorough systemic evaluation. Results: Patient's evaluation revealed the diagnosis of cyclic neutropenia. Conclusion: This report emphasizes the possibility of an underlying immunodeficiency with recurrent POC, even in an apparently healthy child.
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Intravitreal bevacizumab (Avastin) as an adjuvant therapy for choroidal carcinoid metastasis p. 420
Saeed Karimi, Amir Arabi, Toktam Shahraki
DOI:10.4103/JOCO.JOCO_54_20  
Purpose: To report a case of choroidal carcinoid metastasis with neovascularization of the optic disc and macular edema that was treated with three sessions of intravitreal anti-vascular endothelial growth factor (anti-VEGF) as an adjuvant therapy with photodynamic therapy (PDT). Methods: A 16-year-old patient with a diagnosis of lung carcinoid tumor presented to an ophthalmology clinic with a complaint of decreased vision in his right eye. Fundus examination revealed choroidal carcinoid metastasis in addition to neovascularization of the optic disc. Macular optical coherence tomography revealed cystoid macular edema and subretinal fluid. The patient was treated with PDT in addition to three sessions of intravitreal anti-VEGF injections. Results: Following the treatment, the new vessels regressed, and visual acuity improved. Furthermore, central retinal thickness reduced significantly. The tumor size reduced significantly over a follow-up period of 6 weeks. Conclusion: Choroidal carcinoid metastasis may be complicated by neovascularization of optic disc, which responds favorably to intravitreal injections of bevacizumab.
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Re-endothelialization of bare stroma after descemet's detachment due to macroperforation during deep anterior lamellar keratoplasty p. 423
Zahra Ashena, Mayank A Nanavaty
DOI:10.4103/JOCO.JOCO_79_20  
Purpose: To report a case with spontaneous re-endothelialization of bare stroma after subtotal detachment of Descemet's membrane (DM) due to macroperforation during deep anterior lamellar keratoplasty (DALK). Methods: Case report. Results: A 64-year-old patient underwent DALK for deep stromal scarring secondary to herpetic keratitis. During manual dissection, DM macroperforation occurred, and this was successfully managed intraoperatively and postoperatively. The DM with host posterior stroma remained attached for 10 months when it detached from the bare donor stroma. The cornea remained clear, with uncorrected distance visual acuity (UCVA) of 0.17 logMAR. After graft suture removal 30 months later, he was noted to have regular astigmatism and cataract for which he underwent phacoemulsification with toric intraocular lens implantation. Twenty-four months following his cataract surgery and 58 months following his DALK, his UCVA remains 0.17 logMAR and the cornea remains clear with no evidence of edema. His average specular count at 58 months was 1296 cell/mm[2]. Conclusion: This case shows a very good visual outcome with clear cornea at 58 months despite of large DM detachment which happened 10 months following manual DALK with intraoperative macroperforation.
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LETTER TO EDITOR Top

Comment on the article: Management of upside-down descemet membrane endothelial keratoplasty: A case series p. 427
Arjun Srirampur
DOI:10.4103/JOCO.JOCO_173_20  
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REPLY Top

Reply to letter - Management of upside-down descemet membrane endothelial keratoplasty: A case series p. 428
Ahmed Shalaby Bardan, Mohamed Bahgat Goweida, Hesham Fouad El Goweini, CS Christopher Liu
DOI:10.4103/JOCO.JOCO_230_20  
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