Neelam Pawar

Visual prognosis, intraocular pressure control and complications in phacomorphic glaucoma following manual small incision cataract surgery

Aims: To evaluate intraocular pressure (IOP) control, visual prognosis and complications following manual small incision cataract surgery among eyes with phacomorphic glaucoma. Materials and Methods: This prospective, non-randomized interventional consecutive case series included all patients with phacomorphic glaucoma who presented to a tertiary eye care referral center in South India between March 2006 and April 2007. All patients underwent slit-lamp bio-microscopy, applanation tonometry and gonioscopy of the other eye to rule out angle closure. Small incision cataract surgery with intraocular lens implantation was performed in all affected eyes. Complete ophthalmic examination was done at each follow-up visit. Results: A total of 74 eyes with phacomorphic glaucoma were included in this study. The preoperative mean IOP was 38.4±14.3 mmHg and mean IOP at last follow-up was 12.7±2.4 mmHg. There was a statistically significant difference between IOP at presentation and IOP at last follow-up (P< 0.001). None of the eyes required long-term antiglaucoma medication. No significant intraoperative complications were noted. The final postoperative best corrected visual acuity was 20/40 or better in 51 patients. Eighteen eyes had corneal edema and 36 eyes had anterior chamber inflammation. Both conditions resolved with standard medical therapy. Conclusion: Manual small incision cataract surgery is safe and effective in controlling IOP and achieving good functional visual acuity with minimal complications in the management of phacomorphic glaucoma in developing countries.

Retinal nerve fiber layer thickness in normal Indian pediatric population measured with optical coherence tomography

Purpose: To measure the peripapillary retinal nerve fiber layer (RNFL) thickness in normal Indian pediatric population. Subjects and Methods: 120 normal Indian children ages 5-17 years presenting to the Pediatric Clinic were included in this observational cross-sectional study. RNFL thickness was measured with stratus optical coherence tomography (OCT). Children with strabismus or amblyopia, with neurological, metabolic, vascular, or other disorders and those with abnormal optic discs were excluded. One eye of each subject was randomly selected for statistical analysis. The effect of age, refraction and gender on RNFL thickness was investigated statistically. Result: OCT measurements were obtained in 120 of 130 (92.3%) subjects. Mean age was 10.8 ± 3.24 years (range 5-17). Average RNFL thickness was (± SD) 106.11 ± 9.5 μm (range 82.26-146.25). The RNFL was thickest inferiorly (134.10 ± 16.16 μm) and superiorly (133.44 ± 15.50 μm), thinner nasally (84.26 ± 16.43 μm), and thinnest temporally (70.72 ± 14.80 μm). In univariate regression analysis, age had no statistical significant effect on RNFL thickness (P =0.7249) and refraction had a significant effect on RNFL thickness (P =0.0008). Conclusion: OCT can be used to measure RNFL thickness in children. Refraction had an effect on RNFL thickness. In normal children, variation in RNFL thickness is large. The normative data provided by this study may assist in identifying changes in RNFL thickness in Indian children.

Interocular symmetry of retinal nerve fiber layer and optic nerve head parameters measured by Cirrus high-definition optical coherence tomography in a normal pediatric population

Purpose: To determine interocular differences in the retinal nerve fiber layer (RNFL) and optic nerve head (ONH) parameters in a pediatric population using Cirrus high-definition optical coherence tomography (HD-OCT). Methods: Seventy normal Indian children aged 5–17 years presenting to the Pediatric Clinic were included in this observational cross-sectional study. All subjects underwent a comprehensive ophthalmologic examination and an evaluation of the RNFL and ONH by Cirrus HD-OCT. Differences between the right and left eyes were calculated and values were compared by means of a paired t-test. Subjects were also divided into two groups based on age (under or over 10 years of age). Interocular differences in RNFL and ONH parameters together with sex and age variations for these differences were determined. Results: The mean age of studied pediatric population was 11.83 ± 3.3 years (range 5–17). Average RNFL thickness was 94.46 ± 8.7 μm (± SD) (range 77–111). Differences in the average RNFL between right and left eyes were not statistically significant (P = 0.060). Superior quadrant RNFL was thicker in the left eye and temporal quadrant was thicker in the right eye. Among ONH parameters, there were no statistically significant differences in any parameters, except vertical cup-disc (CD) ratio which was significant (P = 0.007). The 2.5%–97.5% limits of asymmetry were 9 μm for average RNFL, 0.14 for average CD ratio, and 0.22 for vertical CD ratio. Mean interocular RNFL thickness differences in superior, superior nasal, and temporal superior quadrants were 10.61 (P < 0.001), 12.57 (P < 0.001), and 4.46 (P = 0.002) μm, respectively. Interocular nerve fiber layer thickness differences were not significantly correlated with sex, while only significant differences with age were observed in 12 clock hour sector analysis, mainly in nasal inferior and inferior quadrant. Conclusions: We report the degree of interocular symmetry of RNFL and ONH parameters measured by Cirrus HD-OCT in a healthy pediatric population. The normal interocular RNFL asymmetry should not exceed 9 μm and vertical CD ratio beyond 0.22 should be considered for further investigations. The physiologic asymmetry provided by this study may assist in identifying changes in RNFL thickness and ONH parameters in pediatric glaucoma and ONH disorders.

Acute abducens nerve palsy as a presenting feature in carotid-cavernous fistula in a 6-year-old girl.

Carotid-cavernous fistulas (CCF) are abnormal communications between the internal carotid artery and the cavernous sinus. Traumatic carotid-cavernous fistulae are rare potential complications of craniofacial trauma. Typical findings of CCF are proptosis, chemosis, headache, oculomotor or abducens nerve palsy, trigeminal pain and pulsating bruit over the temporal skull and the bulb. CCF are reported very rarely in childhood. This report describes the clinical and radiological findings of a pediatric patient presented with CCF.

Unilateral optic nerve aplasia documented with optical coherence tomography—case report and literature review

Optic nerve aplasia is a rare nonhereditary developmental anomaly characterized by congenital absence of the optic nerve, retinal blood vessels, retinal ganglion cells, and optic nerve fibers in a unilaterally malformed eye of an otherwise healthy individual. We report the case of a 6-year-old girl with unilateral optic nerve aplasia documented by optical coherence tomography (OCT). She had no systemic or central nervous system anomalies. Her right eye had no light perception, total afferent pupillary defect, microcornea, variable strabismus, and enophthalmos. The fundus examination showed complete absence of the optic nerve and central retinal vessels characteristic of optic nerve aplasia in the right eye. Computerized tomography and magnetic resonance imaging showed unilateral absence of the optic nerve. Spectral domain OCT showed absence of normal foveal contour, severe atrophy of the retinal layers, extremely thin choroid, and absence of the optic nerve head.

Optic disk contractility in morning glory disk anomaly

Morning glory disk anomaly is a nonhereditary, congenital optic disk dysplasia characterized by conical excavation of the posterior fundus with a central glial tuft and radial retinal vessels. We report the case of a 4-year-old girl who presented with esotropia, enophthalmos, no light perception, and afferent pupillary defect in her left eye; fundus examination revealed morning glory disk anomaly. Ultrasound B-scan showed axial length increasing in the left eye on consensual light exposure. Magnetic resonance imaging/angiogram of the brain and orbits were within normal limits except for globe elongation posteriorly in the left eye. On examination under anesthesia with video indirect ophthalmoscopy, the left optic disk showed contraction and expansion when stimulated by strong light to the fellow eye and no spontaneous contraction on direct light stimulation. Morning glory disk contractility with increasing axial length on consensual light exposure in a child has not been reported previously.

Optic nerve aplasia: A case series

Optic nerve aplasia (ONA) is a congenital optic nerve anomaly characterized by the absence of optic nerve head, retinal blood vessels, retinal ganglion cells, and optic nerve fibers in a malformed eye. Clinically, the condition presents with the absence of perception of light, afferent pupillary defect and a fundus appearance of absent optic nerve head, and retinal vessels with associated ocular and nonocular abnormalities. Systemic anomalies have been reported with bilateral ONA, whereas unilateral ONA is seen in otherwise healthy individuals. We report three cases of ONA with varied clinical presentations.

OCT-documented optic atrophy in nonsyndromic craniosynostosis and lacunar skull

We report the case of 6-year-old boy who presented with mild redness in the left eye. On fundus examination, disk pallor was noted in both eyes. He did not complain of headache, vomiting, or blurred vision. Three-dimensional computed tomography (CT) imaging was suggestive of craniosynostosis and lacunar skull (lückenschädel). Magnetic resonance imaging findings were suggestive of intracranial hypertension. HD-OCT imaging revealed optic neuropathy in both eyes. The patient underwent sutural release and expansion cranioplasty surgery.

Reply to Pediatric optic neuritis: Points to ponder

Sir, I read with great interest this article titled, “Clinical profile and neuroimaging in pediatric optic neuritis in Indian population: A case series” by Khadse et al.[1] The article states that it is the first series of childhood optic neuritis reported in Indian literature and their contribution is impressive. However, after reading the article, I have few concerns and need some clarifications from the authors.

Clinical profile and neuroimaging in pediatric optic neuritis in Indian population: A case series

Purpose of the study: The purpose of this study was to report clinical features, neuroimaging, and visual outcome in pediatric optic neuritis (ON) in Indian population. Materials and Methods: This is a retrospective study of children up to the age of 16 years, diagnosed with ON, that presented at pediatric and neuroophthalmology clinic of a tertiary eye care center, in South India, within the period of 2010–2015. Results: We identified 62 eyes of 40 children diagnosed as ON within the study period. The mean age was 11.15 ± 3.24 years (1–15 years) with mean follow-up of 13 months. In this series, there was female preponderance (67%). Mean logarithm of the minimum angle of resolution visual acuity at presentation was 1.14 ± 0.93, which after treatment recovered to 0.10 ± 0.26 at final visit (P < 0.001). Involvement was bilateral in 22 children (55%) and recurrent in 3 eyes of 3 children. Preceding febrile illness was reported in seven cases (18%). Four (10%) cases were diagnosed as multiple sclerosis (MS), one with neuromyelitis optica , and one with acute disseminated encephalomyelitis. One case was associated with tuberculous meningitis, 1 with septicemia, and 1 with bilateral maxillary sinusitis. Neuroimaging studies of optic nerve in 14 children demonstrated isolated optic nerve enhancement. Magnetic resonance imaging brain revealed white matter T2 hyperintense lesions separate from optic nerve in ten cases, of which four cases were diagnosed as MS. Conclusions: Bilateral presentation was common, association with MS was low. Papillitis was more frequent than retrobulbar neuritis and prognosis was good in pediatric ON in Indian population.