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   Table of Contents - Current issue
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April-June 2022
Volume 12 | Issue 2
Page Nos. 121-245

Online since Wednesday, June 1, 2022

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EDITORIAL  

Current status of artificial intelligence for medicine p. 121
Hitoshi Tabuchi
DOI:10.4103/tjo.tjo_23_22  
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REVIEW ARTICLES Top

Understanding required to consider AI applications to the field of ophthalmology p. 123
Hitoshi Tabuchi
DOI:10.4103/tjo.tjo_8_22  
Applications of artificial intelligence technology, especially deep learning, in ophthalmology research have started with the diagnosis of diabetic retinopathy and have now expanded to all areas of ophthalmology, mainly in the identification of fundus diseases such as glaucoma and age-related macular degeneration. In addition to fundus photography, optical coherence tomography is often used as an imaging device. In addition to simple binary classification, region identification (segmentation model) is used as an identification method for interpretability. Furthermore, there have been AI applications in the area of regression estimation, which is different from diagnostic identification. While expectations for deep learning AI are rising, regulatory agencies have begun issuing guidance on the medical applications of AI. The reason behind this trend is that there are a number of existing issues regarding the application of AI that need to be considered, including, but not limited to, the handling of personal information by large technology companies, the black-box issue, the flaming issue, the theory of responsibility, and issues related to improving the performance of commercially available AI. Furthermore, researchers have reported that there are a plethora of issues that simply cannot be solved by the high performance of artificial intelligence models, such as educating users and securing the communication environment, which are just a few of the necessary steps toward the actual implementation process of an AI society. Multifaceted perspectives and efforts are needed to create better ophthalmology care through AI.
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Lightning injuries of the posterior segment of the eye p. 130
Ekta Rishi, VP Indu, Unnati Sharma
DOI:10.4103/tjo.tjo_27_20  
Lightning causes serious injuries and deaths worldwide every year. Ophthalmic injuries due to lightning are due to direct or indirect transmission of electric current, resistance-induced heat, and heat-induced shock wave. PubMed search of articles related to posterior segment injuries caused by lightning using keywords (lightning injury, ophthalmic manifestations, ocular injuries, and posterior segment) was conducted, and 19 case reports in 17 articles including 29 eyes with lightning injury to the posterior segment of the eye from 1984 to 2019 were reviewed. The majority of case reports (n = 10, 53%) were from North America. Eleven patients (58%) were in the age group of 10–30 years. Most patients (n = 10, 53%) had bilateral injury. The macula was the most common site of involvement with retinal pigment epithelial changes (n = 14, 48%) being the most common manifestation. A variety of other retinal, vitreous, and electrophysiological abnormalities have also been reported. We conclude that although lightning injuries are usually mild injuries, with vision remaining, either stable or showing some improvement in the majority of cases, severe visual loss due to optic atrophy and maculopathy may occur in long term.
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Subretinal drusenoid deposits: An update p. 138
Manuel Monge, Adriana Araya, Lihteh Wu
DOI:10.4103/tjo.tjo_18_22  
A wide spectrum of phenotypic manifestations characterizes age-related macular degeneration (AMD). Drusen is considered the hallmark of AMD and is located underneath the retinal pigment epithelium (RPE). In contrast, subretinal drusenoid deposits (SDDs), also known as reticular pseudodrusens, are located in the subretinal space, on top of the RPE. SDDs are poorly detected by clinical examination and color fundus photography. Multimodal imaging is required for their proper diagnosis. SDDs are topographically and functionally related to rods. SDDs cause a deep impairment in retinal sensitivity and dark adaptation. SDDs are dynamic structures that may grow, fuse with each other, or regress over time. An intermediate step in some eyes is the development of an acquired vitelliform lesion. The presence of SDD confers an eye a high risk for the development of late AMD. SDD leads to macular neovascularization, particularly type 3, geographic atrophy, and outer retinal atrophy.
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ORIGINAL ARTICLES Top

Real-time artificial intelligence evaluation of cataract surgery: A preliminary study on demonstration experiment p. 147
Hitoshi Tabuchi, Shoji Morita, Masayuki Miki, Hodaka Deguchi, Naotake Kamiura
DOI:10.4103/tjo.tjo_5_22  
PURPOSE: We demonstrated real-time evaluation technology for cataract surgery using artificial intelligence (AI) to residents and supervising doctors (doctors), and performed a comparison between the two groups in terms of risk indicators and duration for two of the important processes of surgery, continuous curvilinear capsulorhexis (CCC) and phacoemulsification (Phaco). MATERIALS AND METHODS: Each of three residents with operative experience of fewer than 100 cases, and three supervising doctors with operative experience of 1000 or more cases, performed cataract surgeries on three cases, respectably, a total of 18 cases. The mean values of the risk indicators in the CCC and Phaco processes measured in real-time during the surgery were statistically compared between the residents' group and the doctors' group. RESULTS: The mean values (standard deviation) of the risk indicator (the safest, 0 to most risky, 1) for CCC were 0.556 (0.384) in the residents and 0.433 (0.421) in the doctors, those for Phaco were 0.511 (0.423) in the residents and 0.377 (0.406) in the doctors. The doctors' risk indicators were significantly better in both processes (P = 0.0003, P < 0.0001 by Wilcoxon test). CONCLUSION: We successfully implemented a real-time surgical technique evaluation system for cataract surgery and collected data. The risk indicators were significantly better in the doctors than in the resident's group, suggesting that AI can objectively serve as a new indicator to intraoperatively identify surgical risks.
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Comparison of smartphone application-based visual acuity with traditional visual acuity chart for use in tele-ophthalmology p. 155
Aparna Bhaskaran, Mahesh Babu, B Abhilash, NA Sudhakar, V Dixitha
DOI:10.4103/tjo.tjo_7_22  
PURPOSE: The aim of this study was to compare the visual acuity (VA) by smartphone-based applications – EyeChart and the Peek Acuity to the standard Snellen chart to explore the possibility of using them as an alternative in tele-ophthalmology in the current COVID-19 pandemic. MATERIALS AND METHODS: An analytical type of observational study was done on 360 eyes of 184 patients above 18 years of age. Patients with VA <6/60 and gross ocular pathology were excluded from the study. VA measured by these three methods was converted to logMAR scale for ease of statistical analysis. One-way analysis of variance with post Tukey HSD was used to compare the VA measured by these three methods. RESULTS: There was no statistically significant difference between VA measured using the smartphone-based apps (EyeChart and Peek Acuity) and the Snellen chart (F = 2.5411, P = 0.7925) in 360 eyes assessed. VA measured by Peek Acuity (P = 0.5225) was more comparable to Snellen chart than EyeChart (P = 0.4730). Intraclass correlation coefficient (ICC) demonstrated a strong positive correlation for EyeChart (ICC: 0.982, P < 0.001) and Peek Acuity (ICC: 0.980, P < 0.001) with Snellen chart. A Bland–Altman difference plot showed good limits of agreement for both EyeChart and Peek Acuity with Snellen chart. In subgroup analysis, VA measured by Peek Acuity was not statistically different from Snellen in any subgroups, but in EyeChart, it was statistically different in emmetropes. CONCLUSION: VA measured by smartphone apps (EyeChart and Peek Acuity) was comparable with traditional Snellen chart and can be used as an effective, reliable, and feasible alternative to assess VA in tele-ophthalmology.
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Accuracy of different lens power calculation formulas in patients with phacomorphic glaucoma p. 164
Seyed Ali Tabatabaei, Melika Samadi, Mohammad Soleimani, Hosein Fonoodi, Sepideh Ghods, Bahman Inanloo
DOI:10.4103/tjo.tjo_1_22  
PURPOSE: The purpose of the study was to determine the most accurate formula for intraocular lens (IOL) power calculation among five currently used formulas in eyes with phacomorphic glaucoma (PG) undergoing cataract extraction surgery. MATERIALS AND METHODS: In this prospective interventional case series Patients diagnosed with PG were undergone uneventful phacoemulsification and IOL implantation. After 3 months, the refractive outcome for each formula was evaluated with mean prediction error (PE), mean absolute error (MAE), and the percentages of eyes within 0.25 D and 0.5 D of predicted error. RESULTS: Twenty-three patients completed the study. PEs were significantly different among the 5 formulas (P = 0.019), and Holladay I had the least error (−0.02 ± 1.11). Haigis formula had the highest hyperopic shift (0.37 ± 1.22), highest MAE (0.99 ± 0.78) and the lowest percentages of desired PEs, while the SRK II produced the greatest percentages. The overall differences in MAE between the 5 formulas were statistically insignificant (P = 0.547). CONCLUSION: In some extreme situations like patients with PG, lower generation of IOL power calculation formulas may still produce more acceptable refractive outcomes.
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Point-wise variability of threshold sensitivity of 24-2 and 10-2 visual fields p. 170
Aparna Rao, Harsha L Rao, Debananda Padhy
DOI:10.4103/tjo.tjo_10_22  
PURPOSE: To evaluate point-wise variability of threshold sensitivity at different test locations on 24-2 and 10-2 visual field (VF). MATERIALS AND METHODS: Electronic medical records of patients seen at a tertiary eye care center were screened to include those with at least 3 reliable VF with glaucomatous defects involving fixation on 24-2 and confirmed on 10-2 test strategy. Ninety eyes of 90 patients were categorized into 3 severity groups based on mean deviation (MD on 24-2) test strategy; MD<-6 dB and >-12 dB, <-12 dB and >-20 dB and <-20 dB and >-30 dB. Variability of threshold sensitivity at all topographical test locations in central (ring 1), mid-peripheral (ring 2), peripheral rings on 24-2 VF test strategy (ring 3), and central (ring 4) and paracentral (ring 5) on 10-2 VF test along with variability of visual field index and central field index were calculated by multilevel mixed effects model. RESULTS: Central ring1 on 24-2 and ring 4 on 10-2 showed higher variability (>10 dB) than peripheral ring 2, 3, and 5. Seventy-three eyes were adjudged as stable and 17 as progressing in this cohort. The average ring and point-wise variability was higher in stable eyes (2-6 dB) across all glaucoma severities. Across severity, variability was seen to decrease with increasing severity with minimal variability in point-wise threshold sensitivity beyond MD <-20 dB. CONCLUSION: Central test points/ring on 24-2 and 10-2 with greater threshold variability suggests that status of the eye, severity and topographical location of test points should be incorporated into conventional progression algorithms to predict true glaucoma progression.
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The relation between the severity of reading disorder and visual functions among children with dyslexia p. 178
Azam Darvishi, Davood Sobhani Rad, Somayyeh Boomi Quchan Atigh, Aghdas Hamidi, Javad Heravian Shandiz, Ahmad Shojaei Baghini
DOI:10.4103/tjo.tjo_33_21  
PURPOSE: The purpose of the study was to investigate the relation between the severity of reading disorder and visual functions among children with dyslexia. MATERIALS AND METHODS: The present study included 32 dyslexic children selected from two centers for learning disabilities in Mashhad, Iran. Dyslexics were then classified as mild, moderate, and severe based on an instrument used to determine the severity of their reading disorder. Complete optometric examinations to measure visual acuity, refractive errors, latent and manifest deviations, stereoacuity, and amplitude of accommodation were performed for all participants. The correlation between visual functions among dyslexics and their reading disorder severity was investigated. RESULTS: The mean age of the participants in this study was 8.1 ± 0.8 years. Among participants, 40.6%, 31.3%, and 28.1% presented with severe, moderate, and mild levels of reading difficulties, respectively. Only exophoria significantly correlated with the severity of reading disorders. No significant correlation was found between other visual functions and the severity of reading disorders in dyslexic children. CONCLUSION: We found that higher exophoria at near has a significant correlation with the severity of dyslexia. A complete and detailed eye examination of patients with dyslexia and correcting their visual impairments might be helpful.
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Ocular manifestations in acute stage Stevens-Johnson syndrome/toxic epidermal necrolysis - A retrospective study in a tertiary hospital in south India p. 184
Thanuja Gopal Pradeep, Samyakta A Shetti
DOI:10.4103/tjo.tjo_13_21  
PURPOSE: To describe the ocular manifestations in the acute stage of Stevens-Johnson syndrome/ toxic epidermal necrolysis. MATERIALS AND METHODS: We reviewed all the medical records of patients diagnosed with Stevens-Johnson syndrome/ toxic epidermal necrolysis and erythema multiforme between 2012 and 2019. Demographics, ophthalmic manifestations, and the treatment given systemically and locally were reviewed and analyzed. RESULTS: We had forty-five patients admitted to our hospital between Jan 2012 to Dec 2019 with SJS/TEN as a diagnosis.Twenty-six (57.5%) of them were females, and 19(42.2%) were males. The mean age was 27.5 years.Forty (88.9%) of our cases were diagnosed as Stevens-Johnson syndrome, and five (11.9%) as toxic epidermal necrolysis.We found antiepileptics as a triggering agent in thirteen cases (28.8%).Fever (84.4%) and mucosal lesions (86.7%) were the most common presenting symptom.We found ocular symptoms in only 22 (48.9%) patients.The treating physicians referred only thirty-one cases to the ophthalmologist, out of which 22 cases were referred within three days of admission.The most common ocular involvement was conjunctival congestion (69%).Ocular grading showed that mild grade included 42.9%, moderate grade 28.6%, and severe grade 28.6% of the cases.The ocular treatment involved medical management with lubricating drops (100%), topical steroids (58.6%), and topical antibiotics (68.9%). Five individuals with a severe grade of ocular involvement underwent amniotic membrane transplantation. CONCLUSION: Ocular examination and grading are essential in the acute stage of SJS/TEN. It helps the ophthalmologist recognize the sentinel findings and institute appropriate treatment in the acute stage as early as possible.
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Low ambient temperature correlates with the severity of dry eye symptoms p. 191
Wei-Ting Ho, Chiung-Yi Chiu, Shu-Wen Chang
DOI:10.4103/tjo.tjo_25_21  
PURPOSE: The symptoms of dry eye disease (DED) are influenced by environmental factors, but the effect of ambient temperature is less certain. Our purpose was to investigate the relationship between the severity of DED symptoms and the ambient temperature. MATERIALS AND METHODS: This retrospective study reviewed the symptom scores, including ocular surface disease index (OSDI) and standardized patient evaluation of eye dryness (SPEED), as well as tear film parameters of first-time DED patients between June 2018 and June 2019. The contribution of tear film parameters and environmental factors, including ambient temperature, humidity, wind speed, and the concentration of air pollutants, to the severity of dry eye symptoms was evaluated by univariate and multivariate linear regression analyses. RESULTS: There were 351 patients included aged 52.8 ± 13.6 years, and 257 (73.2%) were female. The average tear film break-up time, Schirmer test value, and lipid layer thickness were 2.6 ± 0.7 s, 5.5 ± 4.3 mm, and 64.1 ± 6.0 μm, respectively. The average OSDI and SPEED were 41.8 ± 19.8 and 12.1 ± 5.1, respectively. In winter, the patients reported higher OSDI and SPEED. Both scores were significantly correlated with low ambient temperature. Regression analysis showed that low ambient temperature and Schirmer test value contributed to higher OSDI, while low ambient temperature and younger age contributed to higher SPEED. CONCLUSION: Low ambient temperature plays a significant role in DED symptom severity.
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BRIEF COMMUNICATION Top

Can lacrimal punctum size link to the severity of dry eye disease? p. 198
Ming Chen, Jerris R Hedges, So Yung Choi, Keke Liu, Szu Yuan Lin
DOI:10.4103/tjo.tjo_15_21  
To investigate if larger punctum size links to the severity of dry eye disease (DED) and perhaps, punctum size inspection can be adopted to become one of the DED evaluations for practitioners. The records of 200 eyes of 114 patients that had temporary collagen punctum plugs due to severe DED (Level 2 to Level 4) from January 1, 2017, to July 31, 2018, were reviewed for the size of the plugs. Lacrimal punctum size of those eyes was approximated according to the size of vertical canalicular soft collagen plug (from 0.3 to 0.5 mm diameter, Oasis, Lacrimedics, Glendora, CA, USA). The dry eye severity grading from the International Dry Eye WorkShop was used to grade the level of the severity of DED. Those eyes classified as Level 2 and above were considered as severe due to the presentation of moderate-to-diffuse corneal staining and symptomatic. To assess if there is a correlation between punctum size and the severity of DED, the Spearman's rank correlation coefficient was calculated. Of the 200 Level 2 and above eyes, 131 (66%) eyes had a large punctum (≥0.5 mm). Punctum size larger than 0.4 mm was 95%. The estimated Spearman's ρ was 0.16. This indicates a statistical significant positive correlation (P = 0.02) between larger punctum size and higher level of DED. The larger size of lacrimal punctum may link to the severity of DED. Punctum inspection may be adopted to become one parameter for DED evaluation for practitioners.
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CASE REPORTS Top

Branch retinal vein occlusion post severe acute respiratory syndrome coronavirus 2 vaccination p. 202
Hayato Tanaka, Daisuke Nagasato, Shunsuke Nakakura, Toshihiko Nagasawa, Hiroyuki Wakuda, Akihiro Kurusu, Yoshinori Mitamura, Hitoshi Tabuchi
DOI:10.4103/tjo.tjo_24_22  
In this article, we report two patients who experienced the first onset of branch retinal vein occlusion (BRVO) 3 days after the administration of the BNT162b2 (Pfizer–BioNTech) severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. Case 1: A 50-year-old woman without any history of retinal disease developed vision loss in her right eye 3 days after receiving the first dose of the SARS-CoV-2 mRNA vaccine. Case 2: A 56-year-old woman without any history of retinal disease developed vision loss in her right eye 3 days after receiving the first dose of the SARS-CoV-2 mRNA vaccine. Case 1: Temporal superior BRVO and secondary macular edema (ME) were observed in the patient's right eye. Her best-corrected visual acuity (BCVA) was 20/25. Case 2: Temporal inferior BRVO and secondary ME were observed in the patient's right eye. Her BCVA was 13/20. Case 1: Three doses of intravitreal ranibizumab (IVR) were administered. Case 2: Three doses of IVR were administered. Case 1: ME resolved and BCVA improved to 20/20. Case 2: ME resolved and BCVA improved to 20/20. Both the cases showed a possible association between the SARS-CoV-2 vaccination and the first onset of BRVO.
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Visual outcome after endovascular intervention in Takayasu arteritis p. 206
Vaibhav Kumar Jain, Shabari Pal, Vivek Singh, Rini Saha, Kumudini Sharma
DOI:10.4103/tjo.tjo_53_21  
Takayasu arteritis is a chronic multisystem vasculitis which has been known to be associated with myriad of ophthalmological manifestations. Steroids and immunomodulators are the mainstay of medical management in early stages of disease. We report the case of a 15-year-old girl with complaints of diminution of vision in both the eyes. Her ophthalmic examination suggested a diagnosis of Takayasu retinopathy with posterior ischemic optic neuropathy in her left eye and ocular ischemic syndrome in the right eye. Digital subtraction angiography revealed a significant narrowing of major vessels originating from the arch of aorta and the left vertebral artery. She underwent left subclavian artery and left vertebral artery balloon angioplasty followed by left vertebral artery stenting. Her vision improved significantly postprocedure, suggesting that endovascular intervention in the later stages of disease is a promising treatment modality for Takayasu retinopathy.
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Simultaneous existence of three intraocular lens inside one eye p. 209
Fan Mei, Tzu-Yun Kao, Cheng-Kuo Cheng
DOI:10.4103/tjo.tjo_29_21  
The purpose of the study was to report an unusual case of recurrent pseudophakic cystoid macular edema (PCME) in an eye with three simultaneous intraocular lenses (IOLs) inside. A 57-year-old female with diabetes mellitus (DM) and a history of complicated cataract surgery was diagnosed with cystoid macular edema (CME). Upon examination, an anterior chamber intraocular lens (ACIOL) with vitreous strand in her right eye was noted. The fluorescence angiography revealed CME of the right eye and microaneurysms in both eyes. Pars plana vitrectomy was performed to release the vitreous prolapse and traction around the ACIOL. During the surgery, two sunken posterior chamber IOLs in the vitreous were incidentally found and removed. The vitreous traction strand around the inappropriately placed anterior chamber ACIOL was also released. It was rarely reported that two dislocated IOL and ACIOL simultaneously existed in the same eye. Chronic recurrent PCME in this patient was possibly associated with posteriorly dislocated IOL, DM, and vitreous traction.
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Use of anterior segment imaging and direct cyclopexy repair of cyclodialysis cleft p. 213
Chin Sheng Teoh, Maria Cecilia Aquino, Dawn K Lim, Paul Chew, Victor Koh
DOI:10.4103/tjo.tjo_24_21  
We aim to describe different imaging modalities to localize cyclodialysis clefts and direct cyclopexy repair of cyclodialysis clefts. We reviewed the record of a patient with traumatic cyclodialysis cleft who underwent direct cyclopexy retrospectively. Preoperative and postoperative visual acuity and intraocular pressure (IOP) were recorded. Gonioscopy, ultrasound biomicroscopy (UBM) and 360° swept-source anterior segment optical coherence tomography (SS-ASOCT) were used to localize the cyclodialysis cleft. We concluded that UBM is the current gold standard imaging modality in localization of cyclodialysis clefts, and that SS-ASOCT is potentially useful as alternative imaging modality. Direct cyclopexy is an effective treatment for large cyclodialysis cleft with good IOP control and visual outcomes.
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Fabrication of a facial prosthesis for a 13-year-old child by using a point-and-shoot three-dimensional scanner and CAD/CAM technology p. 219
Ming-Hui Sun, Chieh-Hung Yen, Yueh-Ju Tsai, Yi-Lin Liao, Shu-Ya Wu
DOI:10.4103/tjo.tjo_49_21  
Patients cannot wear ocular prostheses after undergoing orbital exenteration. They require a facial prosthesis to obtain a more favorable appearance, which greatly affects their social life and psychological health. In addition, conventional prosthesis-making processes require substantial time and expense. The economic burden is particularly heavy on children, who may require many prosthesis replacements as they mature. We report a method of fabricating a facial prosthesis by three-dimensional (3D) facial scanning and 3D printed for a 13-year-old girl who underwent partial orbital exenteration for malignant ciliary body medulloepithelioma 2 years ago. The patient's facial contour was captured with a hand-held, point-and-shoot 3D scanner. A facial prosthesis was designed using a mirror image technique with 3D modeling software and 3D printed. The prosthesis was then postprocessed and cast in silicone rubber. An ocular prosthesis was integrated into the facial prosthesis. The prosthesis was retained by prosthetic adhesives. This digitally assisted, impression-free method may lower the cost and effort of making facial prostheses and improve patient comfort, especially for children.
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Psychosis resulting from trimethoprim-sulfamethoxazole treatment for preseptal cellulitis Highly accessed article p. 223
Kashif M Iqbal, Priscilla K Luke, Michael T Ingram
DOI:10.4103/tjo.tjo_66_20  
Trimethoprim-sulfamethoxazole (TMP-SMX) is a commonly used antimicrobial agent because of its low cost, diverse antimicrobial profile, and minimal severe adverse effects. A rare side effect is psychosis, a complication that has not been published in the ophthalmology literature. A 53-year-old female presented to the ophthalmology office with left upper eyelid erythema, focal tenderness, and discharge. She was diagnosed with preseptal cellulitis of the left upper lid and started on TMP-SMX. The next day, the patient's condition improved with reduced swelling and no discharge. However, 2 days later, she experienced visual hallucinations whereby worms were growing out of her left eye accompanied by theme-congruent tactile hallucinations. TMP-SMX was discontinued and substituted for clindamycin, and she reported resolution of her symptoms 8 h later. TMP-SMX has extensive cerebrospinal fluid penetration and causes a folic acid deficiency, which may explain the rare occurrence of neuropsychiatric side effects. This patient had a substance-induced psychosis, in which visual and tactile hallucinations began 3 days after taking TMP-SMX and resolved 8 h after discontinuation, a timeline consistent with the literature. Central nervous system toxicity is rare in nonelderly immunocompetent patients, with only three such cases reported in the literature. While visual and auditory hallucinations have been described previously, this is the first reported case of TMP-SMX-induced tactile hallucinations and unilateral visual hallucinations. Moreover, because TMP-SMX is a first-line agent commonly used to treat orbital and preseptal cellulitis, it is important for ophthalmologists to be aware of this atypical side effect, as it can be life threatening.
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Branch retinal artery occlusion as an initial ocular manifestation of severe iron deficiency anemia: A rare case report p. 227
Amit Kumar Deb, Swathi Subramaniam, Sandip Sarkar, Sangaraju Suneel, Vignesh Elamurgan, Subashini Kaliaperumal
DOI:10.4103/tjo.tjo_70_20  
Ocular manifestations of anemia include conjunctival pallor, retinal hemorrhages, cotton wool spots, Roth spots, subhyaloid hemorrhage, venous dilatation, disc edema, and anterior ischemic optic neuropathy (AION). Retinal arterial occlusion is a very rare complication of iron deficiency anemia. We, hereby, report such a rare case of branch retinal artery occlusion (BRAO) occurring as a complication of iron deficiency anemia. A 49-year-old female presented with sudden painless diminution of vision in her right eye (RE) for 2 weeks with visual acuity of 20/120 in the affected eye and 20/20 in the left eye. Fundus examination of RE showed disc pallor, arteriolar attenuation, and retinal whitening at macula. Fluorescein angiography study demonstrated delayed filling of superotemporal branch of retinal artery, suggesting BRAO as the cause of vision loss. Thorough evaluation for underlying etiology revealed severe iron deficiency anemia (hemoglobin 3.9 g/dl). Her blood pressure, blood sugar profile, lipid profile, carotid Doppler, echocardiogram, coagulation profile, and immunological workup were all unremarkable. She was treated with packed cell transfusion and oral iron supplementation, and her vision improved to 20/40 at 1-month follow-up. Retinal vascular occlusions can occur rarely in iron deficiency anemia, and therefore anemia should be considered, while evaluation of vascular occlusion – specially in those with associated conjunctival pallor as in our case.
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Two young patients with extranodal natural killer/T-cell non-Hodgkin lymphoma, nasal-type (ENKTL-NT) masquerading inflammatory processes: A case series p. 231
Neni Anggraini, Mutmainah Mahyuddin, Nurjati Chairani Siregar
DOI:10.4103/tjo.tjo_80_20  
Extranodal natural-killer/T-cell lymphoma (ENKTL) is a rare type of non-Hodgkin lymphoma. However, it is common in Asia and South America. ENKTL, nasal type (ENKTL-NT), predominantly presents initial unspecific clinical manifestations involving the nasal cavity and its adjacent structures. We present two cases to increase the awareness of the ENKTL-NT cases masquerading inflammatory processes. Although the main clinical feature is a rapidly progressive facial destruction, none of these patients experienced the mentioned complaint. Its various manifestations frequently lead to misdiagnosis and delayed treatment, particularly in those with marked ocular, not nasal symptoms. Our patients were previously diagnosed with inflammatory conditions, namely sinusitis, idiopathic orbital inflammation, dacryocystitis, and orbital cellulitis. The combined approach of chemotherapy and radiotherapy has been proposed as the treatment of choice. Both cases showed young adults treated with combined therapy, yet showing poor outcomes. Clinicians should be aware of its existence and have to consider ENKTL-NT as one of the differential diagnoses in sinonasal or orbital inflammatory cases with unusually rapid progression or unresponsive to treatment.
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Ocular sporotrichosis from a tertiary referral center in Malaysia and review of literature in Southeast Asia p. 237
Shazana Ahmad-Fauzi, Noranida Abd-Manan, Nor-Sharina Yusof, Mohtar Ibrahim, Shahidatul-Adha Mohamad, Julieana Muhammed
DOI:10.4103/tjo.tjo_93_20  
Ocular sporotrichosis is rare in Malaysia and Southeast Asia and is increasingly reported in endemic areas of Brazil and Peru. We describe six cases of ocular sporotrichosis involving the bulbar conjunctiva and lid with a literature review on ocular sporotrichosis in Southeast Asia. In these series, four patients presented with similar findings of granulomatous lesion at the palpebral conjunctiva within 1–3 weeks. There was one case mistakenly diagnosed as conjunctival concretion due to its multiple yellowish nodules on the palpebral conjunctiva and another case as chalazion due to swelling of the lower lid. All patients showed immunocompetence. Four patients had an immediate contact with sick cats, one patient had a history of skin scratched by a healthy cat, and another patient had a history of gardening without direct contact with cat. Culture from conjunctival biopsy obtained from five patients and from ruptured lower lid nodules of one patient yielded Sporothrix schenckii. The patients were successfully treated with oral itraconazole 200 mg twice daily. Two patients developed symblepharon after completing treatment, while four patients showed good results without any sequelae.
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Management strategies in vision-threatening sclerokeratouveitis p. 242
Bharat Gurnani, Kirandeep Kaur
DOI:10.4103/tjo.tjo_39_21  
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Reply to editor comment on Alternaria chartarum sclerokeratouveitis: A new fungus cause p. 244
Luz Elena Concha del Rio, Carolina Ramirez-Dominguez, Virginia Vanzzini-Zago, Lourdes Arellanes-Garcia
DOI:10.4103/tjo.tjo_36_21  
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