Uttaranchal Journal of Ophthalmology 2020

Fig 1 - Clinical image of the patient showing right Fig 4 - Clinical image of the patient at 6 weeks
eye proptosis. follow-up post-operatively.

Fig 2 - Fundus photo of the right eye showing DISCUSSION
blurring of disc margins with hyperemia of the
disc and left eye was normal. Cavernous haemangioma is benign primary
intraorbital tumour in middle age adult with
Fig 3 - MRI T2w image – Axial section showing higher predisposition in female and peak
well defined homogenous intraconal hyperintense incidence noted in fifth decade.1-2
mass causing compression on posterior surface of Progesterone receptor expression in
globe, medial rectus and lateral rectus. epithelial cells of orbital cavernous
hemangioma was postulated as the cause of
higher proportion of cases in female.3

Painless progressive proptosis of slow onset
is the most frequent clinical sign. Delayed
presentation occurs in some cases due to
delayed observation of symptoms mainly
decreased vision and limitation of eye
movement.

Diagnosis is usually made with magnetic
resonance imaging (MRI) in which they
appear as well defined, oval to round,
homogenous masses with density somewhat
greater than that of muscle. Most common
location of the tumour is within intraconal
space and may extend outside the muscle
cone when enlarged. Long standing cases are
associated with surrounding bone
remodelling and small foci of calcification

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 65

within the tumour. On MRI, the lesion is tumours in deep medial compartment and
hypointense on T1 and hyperintense on T2. lateral approach for tumours in superior,
lateral and inferior compartment.5
In our case, an age of female was 37years,
with asymptomatic gradual progressive In our case we have done right lateral
protrusion of eyeball for 1 year and orbitotomy while preserving the lateral
diminution of vision in right eye for 2 year orbital rim. After periorbital incision, lateral
which was insidious in onset and gradually rectus was retracted inferiorly, and lesion
progressive. On CE-MRI, a well-defined approached through a superior window.
homogenously enhancing oval mass lesion Lesion was globular, circumscribed, highly
was present in intraconal compartment of the vascular and of size about 2×2 cm.
orbit. Lesion had multiple hyperintense foci
in it suggestive of calcification. On T1 lesion The most serious complication of the surgery
was hypointense and T2 it was hyperintense. in irreversible blindness due to damage to
Lesion was displacing and stretching the optic nerve. Blindness can be due to direct
infraorbital part of optic nerve although optic damage to optic nerve and optic nerve
nerve signals were normal. compression and optic nerve traction.

Management of intraconal cavernous In our case, tumour was shrunk with surface
haemangioma include periodic observation bipolar coagulation on low setting and
and surgical excision. The incidental dissected by developing planes around the
diagnosis without any symptoms and non- lesions while protecting surrounding
progressive cases with mild proptosis are structures through moist cottons and
kept under periodic observation. Surgical excised. Deficient lateral orbital wall was
removal is reserved for the patients with reconstructed using an orbital mesh and
large symptomatic tumours causing orbital rim was fixed using manipulates. The
diminution of vision, progressive proptosis postoperative outcome was satisfactory and
and limitation of ocular movements.4 right eye proptosis reduced by 6 mm on
Hertel’s Exophthalmometry.
Surgical approaches for orbital tumours
depend on the location and extent of the We hereby report a rare case of right eye
tumour. Three major types of approaches are
anterior approach for tumour in anterior intra-orbital, intra-conal cavernous
orbital space; transcranial approach for
tumours with intracranial extensions, at haemangioma with hypothyroidism occurring
orbital apex or invading optic canal and
in a female presenting with proptosis and

diminution of vision. The tumour was

diagnosed on CT and MRI and was removed

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 66

using lateral orbitotomy approach by REFERENCES

multidisciplinary team including 1. Alfred PR, Char DH. Cavernous
hemangiomas of the orbit. Orbit
ophthalmology, neurosurgery and burn and 1996;15:59-66.

plastics. Patient had significant improvement 2. Henderson JW. Orbital Tumors.
2 nd ed. New York: Thieme
in symptoms with a mild deterioration of Stratton; 1980. p. 115-76.

vision. Visual outcome in the surgical 3. Di Tommaso L, Scarpellini F, Salvi
F, Ragazzini T, Foschini MP.
treatment of orbital cavernous Progesterone receptor expression
in orbital cavernous
haemangiomas is affected by the choice of hemangiomas. Virchows Arch
2000;436:284-8.
the proper surgical approach according to the
4. Boari N, Gagliardi F, Castellazzi P,
location of the lesion and by the tumour Mortini P. Surgical treatment of
orbital cavernomas: Clinical and
dissection technique. Visual function and functional outcome in a series of
20 patients. Acta Neurochir (Wien)
cosmetic result are the main parameters to 2011;153:491-8.

evaluate the clinical and functional outcome 5. Maroon JC, Kennerdell JS. Surgical
approaches to the orbit.
and play an important role in the Indications and techniques. J
Neurosurg1984;60:1226-35.
determination of patients' quality of life after

surgery.

CONFLICTS OF INTEREST: None

FINANCIAL INTERESTS: None

Correspondence Address

Dr. Anupam Singh
Additional Professor
Department of Ophthalmology,
AIIMS Rishikesh,
Uttrakhand-249203
E-mail ID: [email protected]
Contact no.: +91-8475000188, +91-9997580044

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 67

Case Report

A CASE OF ENDOGENOUS ENDOPHTHALMITIS IN A YOUNG WOMAN
FOLLOWING TYPHOID FEVER

Dr Achala Ramawat, Dr Prateek Nishant, Dr Himanshi Aggarwal, Dr Gitanjali Sood, Dr Anupam Singh,
Dr Ramanuj Samanta

ABSTRACT pars plana vitrectomy with lensectomy and
was given repeat intravitreal vancomycin,
We hereby discuss a case of endogenous ceftazidime, amphotericin B and
endophthalmitis following typhoid fever. A dexamethasone. Although vitreous sample
29-year-old female presented with did not reveal any microorganism even after
complaints of painless, sudden diminution of 5 days, empirical oral Voriconazole was
vision in the right eye for last four days started based on clinical picture. Her
associated with fever since two weeks. She inflammation settled gradually over four
was diagnosed as typhoid fever with positive weeks thereafter, but visual acuity remained
Widal test elsewhere and received poor due to formation of scar at posterior
intravenous fluid and medication during the pole. Physicians must be aware of
febrile episode. Visual acuity at presentation endogenous endophthalmitis in the setting of
was counting finger close to face in the right proper risk factors e.g. systemic diseases,
eye (RE) and 6/6 in the left eye (LE). RE intravenous medications etc. in the absence
showed cells 4+, hypopyon, dense vitreous of trauma or surgical interventions. Early
membranes, subretinal creamy yellowish diagnosis and management is required,
deposits in peripapillary region and at the although it may not be possible to salvage
centre of posterior pole. LE was normal. vision in all cases.
Ultrasound of RE revealed posterior vitreal
exudates and large subretinal posterior pole Key Words: Endogenous Endophthalmitis,
abscess. A presumptive diagnosis of
endogenous endophthalmitis was made. Parsplana Vitrectomy, Typhoid, Intravitreal
Patient was admitted and internist evaluation antibiotics, Endophthalmitis
was sought. Complete haemogram, blood
culture, urine culture and chest x-ray was INTRODUCTION
normal. She was administered intravitreal
vancomycin and ceftazidime and was started Endogenous endophthalmitis is caused by
on intravenous ciprofloxacin, topical haematogenous dissemination from a remote
antibiotic, topical steroid and cycloplegic. As primary source. It accounts for 2-8% of all
no improvement was noted, she underwent cases of endophthalmitis.1 Various Asian

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 68

studies have documented fungi as a prime during this febrile period although detailed
documents were not available. She also gave
causative agent in 11.1-17.5% of all cases of a history of amenorrhea for two months but
she did not undergo any gynaecological
endogenous endophthalmitis.2,3 evaluation for same.

Immunodeficient patients and intravenous

drug abusers are known to be at increased

risk. Most commonly, fungal endogenous

endophthalmitis is caused by Candida, On our examination, the patient was found to
have low-grade fever, but rest of the
followed by Aspergillus spp.4 It was reported systemic evaluation was unremarkable. The
best-corrected visual acuity was counting
in few studies that invasion of vitreous fingers close to face in the right eye (RE) and
6/6 in the left eye. Extraocular movements
occurs in Candida, while Aspergillus invades were full and free in both eyes.
Circumcorneal congestion was present in RE,
the retina and choroid.5,6 and the anterior chamber showed 4+ cells
and hypopyon while posterior segment
The purpose of this case report is to discuss showed posterior vitreous exudates and sub-
the clinical presentation and management of retinal creamy yellowish deposits in
a case of unilateral endogenous peripapillary region and at the centre of
endophthalmitis in a young female following posterior pole (figure 1A). Anterior and
typhoid fever. posterior segment of left eye was normal
(figure 1B). USG B-Scan of RE showed few
CASE DESCRIPTION moderately reflective dot-echoes in posterior
vitreous suggestive of exudates, with a
A 29-year old female from Dehradun hyperechoic shadow within the retinochoroid
presented with complaints of sudden, at posterior pole, suggestive of posterior pole
painless, progressive diminution of vision in abscess. OCT Macula of RE also showed
the right eye for last four days, which was subretinal hyperreflective material suggestive
not associated with pain on extraocular of abscess at the posterior pole (figure 2).
movements, flashes or floaters. There was
no history of similar episodes in the past, A presumptive diagnosis of endogenous
prior ocular trauma or surgery. At this point
of time, the patient denied any major endophthalmitis from contaminated
systemic illness. However, on further
questioning, she gave a history of fever since intravenous fluid/line was made and the
last two weeks, for which she had consulted
another hospital and was diagnosed with patient was admitted in our ward and
typhoid fever with positive Widal test. She
received intravenous fluid and medication evaluated by an internist.

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 69

AB was advised abortion as per recommendation
of obstetrician.
Fig 1 - At the time of presentation. A. OD fundus
photograph showing vitreous exudates with dense Patient was started on intravenous
vitreous membranes and sub-retinal creamy ceftriaxone, topical moxifloxacin, topical
yellowish deposits in peripapillary region and at prednisolone acetate and topical cycloplegic.
centre of posterior pole. B. OS fundus photograph A vitreous tap was taken from the RE and
at the time of presentation showing normal sent for microbiological examination, and
appearance. intravitreal vancomycin (1mg/0.1ml) and
ceftazidime (2.25mg/0.1ml) was given.
Fig 2 - OD OCT macula at the time of presentation Patient’s clinical findings worsened after 2
showing subretinal hyperreflective deposits days of commencing treatment (figure 3A),
so RE 25-gauge pars-plana vitrectomy with
Complete hemogram, renal function test, pars-plana lensectomy was done, and
liver function test, random blood sugar, intravitreal antibacterial and antifungal
routine urine microscopy, blood culture, agents [vancomycin (1mg/0.1ml) +
urine culture and chest x-ray were normal. ceftazidime (2.25mg/0.1ml) + amphotericin
Viral markers and Rapid Plasma Reagin test (5µg/0.1ml)] + dexamethasone
were non-reactive. She was started on (0.4mg/0.1ml) were given under local
injection ceftriaxone 1g twice a day for a anaesthesia under guarded visual prognosis.
week. A gynaecological opinion was also Lensectomy was performed because of
sought, wherein USG pelvis of the patient significant fibrin and dense membrane was
showed empty sac with no foetal pole. She adherent to posterior lens surface, which
precluded adequate visualization of fundus
during vitrectomy.

Bacterial and fungal culture of the vitreous
sample did not reveal any organism at this
point, but based on intra-operative features,
tab. Voriconazole 200mg BD followed by
100mg BD was started. Intraocular
inflammation settled gradually over a period
of four weeks (figures 3B, 3C) but her visual
acuity remained poor due to formation of
scar at the posterior pole. The cultures

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 70

remained negative at the end of six weeks of caused by Candida and Aspergillus spp.
incubation. At 6 months of follow-up she had
a BCVA of counting fingers at half-metre in Candida infection primarily involves the
the RE with a scar at the centre of posterior
pole. There was no evidence of residual vitreous whereas Aspergillus has a
inflammation.
predilection to infect the retinal pigment
AB
epithelium and subretinal area. Another
C
Fig 3 - OD fundus photo A. before pars plana characteristic of Aspergillus is vascular
vitrectomy, B. one week after pars plana
vitrectomy, C. at four weeks of follow-up showing invasion which often leads to retinal necrosis
scar at the posterior pole.
followed by scar formation at the posterior
DISCUSSION
pole.[1-7] Endogenous bacterial
Various bacterial and fungal infections are
linked with endogenous endophthalmitis. endophthalmitis, caused by a variety of
There are notable differences in clinical
characteristics of fungal endophthalmitis bacteria, is responsive to intravenous

antibiotics; third-generation cephalosporins

are known to have better ocular tissue

penetration. However, the outcome of

endogenous endophthalmitis is often

disappointing in terms of visual gain. The

main poor prognostic factors are delayed

diagnosis, highly virulent organisms,

immunocompromised status, worse initial

visual acuity and centrally located lesions at

posterior pole.8,9

Systemic antibiotic and antifungal therapy
should be given to treat remote focus of
infection which causes metastatic spread to
eye. However, in severe cases, pars-plana
vitrectomy and intravitreal injections remain
the mainstay.10 In sight-threatening
conditions, vitrectomy has given better
results in many cases than systemic therapy
alone.3,11-13 A systematic review also
concluded that vitrectomy and intravitreal
antibiotics yield a higher probability of
achieving a final visual acuity better than
20/200, with three-fold lesser chance of

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 71

evisceration or enucleation when compared management is required, although the visual
with intravitreal antibiotics alone.14
prognosis may be guarded due to scar
About 40% of clinically diagnosed
endophthalmitis cases in India are eventually formation.
found to be culture negative. This could be
attributed to the fastidious nature of the Correspondence Address
inciting organism that may be difficult to
grow in culture. Despite the limitation of low Dr. Ramanuj Samanta
yield and inability of certain pathogens to Assistant Professor; Department of Ophthalmology
grow on routine media, microbiological All India Institute of Medical Sciences,
culture remains the current gold standard. Rishikesh, Uttarakhand, India, 249203.
Advanced molecular methods such as E-mail: [email protected]
polymerase chain reaction (PCR) and next- Phone Number: +9188722932345
generation sequencing (NGS) have
considerably better yield in terms of REFERENCES
microbiological diagnosis but are limited in
availability.15,16 In our case, no 1. Okada AA, Johnson RP, Liles WC,
microorganisms were found on culture, still D’Amico DJ, Baker AS. Endogenous
we started empirical treatment based on bacterial endophthalmitis. Report of a
clinical characteristics. As our patient did not ten-year retrospective study.
improve with initial intravitreal antibiotics Ophthalmology 1994; 101:832-838.
and systemic antibiotics, pars-plana
vitrectomy and lensectomy were done and 2. Sharma S, Padhi TR, Basu S, Kar S, Roy
ultimately improvement in inflammation was A, Das T. Endophthalmitis patients seen
noted. in tertiary care centre in Odisha: a
clinico-microbiological analysis. Indian J
CONCLUSIONS Med Res.2014; 139(1):91-98

Physicians must be aware of endogenous 3. Lim HW, Shin JW, Cho HY, et al.
endophthalmitis as a complication of Endogenous endophthalmitis in the
systemic infections in setting of risk factors Korean population: a six-year
e.g. systemic diseases, intravenous retrospective study. Retina. 2014;
medications etc. in the absence of trauma or 34(3):592-602.
surgical interventions. Early diagnosis and
4. Essman TF, Flynn HW Jr, Smiddy WE.
Treatment outcomes in a 10-year study
of endogenous fungal endophthalmitis.
Ophthalmic Surg Lasers 1997; 28:185-
194.

5. Jampol LM, Dyekman S, Maniates V.
Retinal and choroidal infarction from
Aspergillus: Clinical diagnosis and
clinicopathologic correlation. Trans Am
Ophthalmol Soc 1988; 86:422-440.

6. McDonnell PJ, McDonnell JM, Brown RH.
Ocular involvement in patients with

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 72

fungal infections. Ophthalmology 1985; 12. Shen X, Xu G. Vitrectomy for
92:706-709. endogenous fungal endophthalmitis. Ocul
7. Rao NA, Hidayat AA. Endogenous Immunol Inflamm. 2009; 17(3):148-
mycotic endophthalmitis: Variations in 152.
clinical and histopathologic changes in
candidiasis compared with aspergillosis. 13. Takebayashi H, Mizota A, Tanaka M.
Am J Ophthalmol 2001; 132:244-251. Relation between stage of endogenous
8. Endogenous Vitrectomy Study Group. fungal endophthalmitis and prognosis.
Results of the Endophthalmitis Graefes Arch Clin Exp Ophthalmol. 2006;
Vitrectomy Study. A randomised trial of 244(7): 816-820.
immediate vitrectomy and of intravenous
antibiotics for the treatment of 14. Jackson, TL, Eykyn SJ, Graham EM.
postoperative bacterial endophthalmitis. Endogenous bacterial endophthalmitis: a
Arch Ophthalmol. 1995; 113:1479-1496. 17-year prospective series and review of
9. Sallam A, Taylor SR, Khan A. Factors 267 reported cases. Surv Ophthalmol.
determining visual outcome in 2003; 48:403-423.
endogenous candida endophthalmitis.
Retina. 2012; 32(6):1129-1134. 15. Anand AR, Therese KL, Madhavan HN.
10. Sadiq MA, Hassan M, Agrawal A. Spectrum of aetiological agents of
Endogenous endophthalmitis: diagnosis, postoperative endophthalmitis and
management and prognosis. J antibiotic susceptibility of bacterial
Ophthalmic Inflamm Infect. 2015; 5:32. isolates. Indian J Ophthalmol. 2000;
11. Sridhar J, Flynn HW, Jr, Kurian AE, Miller 48(2):123-128.
D, Albini T. Endogenous fungal
endophthalmitis: risk factors, clinical 16. Deshmukh D, Joseph J, Chakrabarti M,
features, and treatment outcomes in et al. New insights into culture negative
mold and yeast infections. J Ophthalmic endophthalmitis by unbiased next
Inflamm Infect. 2013; 3(1):60. generation sequencing. Sci rep.
2019;9(1), 844.

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Case Report

TRAUMATIC OPTIC NERVE HEAD AVULSION FOLLOWING BLUNT
OCULAR TRUAMA

Dr Preeti Yadav, Dr Rupal Verma, Dr Neeraj Saraswat, Dr Kavya Subramaniam, Dr Saneev Kumar Mittal

ABSTRACT INTRODUCTION

Although a rare entity, optic nerve head Avulsion of the optic nerve head is a rare but
avulsion is a catastrophic complication of catastrophic complication of ocular trauma. It
ocular trauma. It is a type of traumatic is an indirect traumatic optic neuropathy.1
anterior optic neuropathy. Visual loss is Damage to the optic nerve can be caused by
generally profound in cases of total optic a number of mechanisms, usually involving
nerve head avulsion, but visual prognosis damage in the canal or in the orbit at the
may be better in patients with partial moment of impact.2 It may occur due to
avulsion of optic nerve. Damage to the optic extension of bony fracture, direct penetration
nerve can be caused by various mechanisms of a foreign body, laceration of the optic
such as extension of bony fracture, direct nerve or by shearing forces of deceleration
penetration by foreign body, laceration of the that are transferred to the nerve particularly
optic nerve or by shearing forces of within the optic canal where the nerve is
deceleration that are transferred to the nerve tightly bound.
particularly within the optic canal where the
nerve is tightly bound. In the current report, CASE REPORT
we present a case of 11-year-old male child,
who presented to our emergency services An eleven-year-old male child presented to
with chief complaint of sudden loss of vision the emergency services with chief complaint
following blunt trauma to the left eye with of sudden loss of vision following blunt
iron rod while travelling on the backseat of a trauma to his left eye with iron rod while
motor bike. sitting on the backseat of a motor bike. His
initial examination revealed periorbital
Key words oedema, severe ptosis in the left eye and a
5cm ×0.5 cm bruise below the left lower lid
Optic nerve head avulsion, Anterior optic at the junction of medial 1/3rd and lateral
neuropathy, Traumatic optic neuropathy, 2/3rd (Figure 1). Visual acuity was 6/6 in the
Blunt trauma. right eye and there was no perception of
light in the left (PL –VE). The left eye had

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 74

relative afferent pupillary defect (RAPD). Fig 1 - Clinical photograph showing abrasion
Extraocular movements were full and free in below left lower lid (black arrow) and severe
all directions in both eyes. X-ray orbit (AP & ptosis of left eye.
Lateral view) did not reveal any bony
fracture. Intraocular pressures were 15 Fig 2 - Excavation at the area of optic nerve head
mmHg and 10 mm Hg in right and left eye, (blue arrow) with large peripapillarypre-retinal
respectively. The right eye showed a normal haemorrhage extending into the vitreous cavity
anterior segment and fundus. Slit-lamp suggestive of optic nerve head avulsion.
examination of left eye revealed that the
cornea and lens were intact and clear with no
signs of globe rupture. Fundus examination
showed an excavation at the area of optic
nerve head with large peripapillary preretinal
haemorrhage extending into the vitreous
cavity suggestive of optic nerve head
avulsion (Figure 2). Ultrasonography of left
eye also showed vitreous haemorrhage with
no evidence of any intraocular foreign body
(Figure 3). High resolution computed
tomography (HRCT) scans of brain and orbit
revealed mild enlargement of retrobulbar
part of the left optic nerve with dependent
hyperdense contents in globe suggestive of
vitreous haemorrhage (Figure 4a & 4b). No
bony injury was seen. MRI was advised and
patient was referred to neurosurgeon and
started on systemic steroids. MRI revealed
tortuous intraorbital part of left optic nerve
head with indistinct outline at the site of
globe attachment suggestive of optic nerve
head avulsion (Figure 5a & 5b). Trial of high
dose of intravenous methyl prednisolone was
given.

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 75

Fig 3 - Moderately reflective echoes in posterior On follow up, one week after the injury there
vitreous cavity suggestive of pre retinal was spontaneous dispersion of haemorrhage
haemorrhage and incomplete posterior vitreous in vitreous cavity. The ptosis had improved
detachment. but there was lack of visual recovery in the
left eye. He was monitored regularly for
Fig 4 - HRCT scan of brain and orbit showing long-term complications like phthisis bulbi,
thickening of retro bulbar part of optic nerve (a) fibroglial scarring in the disc, epiretinal
and vitreous haemorrhage (b) membrane, retinal detachment and
secondary neovascular glaucoma till six
Fig 5 - T1-weighted MRI showing tortuous intra- months before he was lost to follow-up.
orbital part of left optic nerve head (a) and T2-
weighted MRI showing indistinct outline of optic DISCUSSION
nerve head at the site of globe attachment
suggestive of optic nerve head avulsion. Avulsion of the optic nerve is a rare
traumatic entity.3,4 A decelerating injury of
significant momentum causes the vitreous
and the retina to separate from the optic disc
and lamina cribrosa is ripped from its
attachment to the choroid and sclera.5 Optic
nerve avulsion must be considered in cases
of trauma with forced rotation of the eye.
Several mechanisms have been postulated
involving anterior luxation of the globe,
retropulsion of the nerve, forced globe
rotation, or a sudden marked rise in
intraocular pressure causing disinsertion of
the nerve off the sclera.6 The loss of myelin
and absence of supportive connective tissue
septae make the axons at lamina cribrosa
particularly vulnerable.7

Complete optic nerve avulsion results in a
blind eye, while partial avulsions cause

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 76

variable degrees of visual loss. Conscious easily avoided with basic safety precautions
patients are usually aware of the visual loss like helmet use even while travelling in the
immediately after the injury. If the media is backseat of a motor bike. According to
clear, the appearance of the fundus is Pirouzmand, motorized vehicle accidents
markedly evident at the time of presentation, remain the main aetiology of traumatic optic
with a hole or cavity where the optic disc has neuropathy (63%).12 This case highlights the
retracted into its dural sheath. The possibility and mechanism of serious
mechanism of optic nerve avulsion depends posterior segment injury in eyes with
on the type of injury. Most cases result from minimal or no anterior segment injuries and
blunt injury typically when an object intrudes the potential for serious ocular trauma, if
between the globe and the orbital wall and adequate road safety measures are not
causes displacement of the globe resulting in adhered. Strict law enforcement and
shearing force on optic nerve fibres.3 The awareness among public regarding road
axons at lamina cribrosa are more traffic safety measures can prevent such
susceptible to damage because of absence of accidents and associated visual morbidity.
supportive connective tissue septae.3,4
Correspondence Address
Our patient had optic nerve avulsion
following blunt trauma to his left eye with Dr. Preeti Yadav
iron rod while sitting on the backseat of a Junior Resident
motor bike. It has been hypothesized that All India Institute of Medical Sciences, Rishikesh,
when the eye suffers relatively minor non- Uttarakhand, India, 249203.
penetrating injury from pointed objects such E-mail: [email protected].
as fingers, rods, etc., these may cause Phone Number: +919643348447
creation of a wedge effect in the orbit.8,9 This
pushes the eye against the angled lateral References
wall of the orbit forcing the eye anteriorly
resulting in a sudden rotation of the globe in 1.Foster BS, March GA,Lucarelli MJ, et al
the direction of the object.10,11 Our patient Optic nerve avulsion.ArchOphthalmol
had a left lower lid bruising inferiorly towards 1997;115:623-30.
the nasal side. Considering this as the line of
impact (Figure 1), it might have led to 2. Mackiewicz J, Tomaszewska J, Jasielska M.
inferior rotation of the anterior aspect of the Optic nerve avulsion after blunt ocular
globe with stretching and tearing of the trauma – Case report. Ann Agric Environ
superior optic nerve. This could have been Med. 2016; 23(2): 382–383.

3. Roberts SP, Schaumberg DA, Thompson P.
Traumatic avulsion of the optic nerve. Optom
Vis Sci 1992; 69: 721–727.

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 77

4. Temel A, Sener AB. Complete evulsion of 9. Arkin MS, Rubin PA, Bilyk JR, et al.
the optic nerve. Acta Opthalmol 1988; 66: Anterior chiasmal optic nerve avulsion. Am J
117–119. Nucl Res. 1996;17:1777–18.

5. Steinsapir KD, Goldberg RA. Traumatic 10. Mackiewicz J, Tomaszewska J, Jasielska
optic neuropathy. Surv Ophthalmol 1994; M. Optic nerve avulsion after blunt ocular
38: 487–518. trauma – Case report. Ann Agric Environ
Med. 2016; 23(2): 382–383.
6. Hillman J, et al. Complete avulsion of the
optic nerve Brit J Ophthal. 1975; 59: 503. 11. De Vries-Knoppert WA. Evulsion of the
optic nerve. Documentaophthalmologica.
7. Anand S, Harvey R, Sandramouli S. 1989 Aug 1;72(3-4):241-5.
Accidental self-inflicted optic nerve head
avulsion. Eye (Lond). 2003 Jul; 17(5): 646– 12. Pirouzmand F. Epidemiological trends of
7. traumatic optic nerve injuries in the largest
Canadian adult trauma centre. J Craniofac
8. Sawhney R, Kochhar S, Gupta R, et al. Surg. 2012 Mar; 23(2): 516–20.
Traumatic optic nerve avulsion: role of
ultrasonography. Eye. 2003;17:667–70.

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Photo Essay
MANAGEMENT OF A CASE OF VASCULITIC COMBINED RETINAL
DETACHMENT

Dr Himanshi Aggrawal, Dr Neeraj Kumar Saraswat, Dr Achala Ramawat, Dr Ramanuj Samanta

A 44-year-old male presented with gradual tamponade in the RE. Strict prone position
painless diminution of vision in the right eye was followed for two weeks post-operatively.
(RE) for last six months. There was no A short course of oral steroids, topical
history of prior ocular trauma or any major steroids, cycloplegics and lubricating eye
systemic illnesses. Best-corrected visual drops were also administered. Follow-up of
acuity (BCVA) was counting finger at 1-meter RE at six months showed BCVA of 6/60 and
distance in RE and 6/6 in left eye (LE) at an attached retina with silicone oil-filled
presentation. Intraocular pressure and globe (figure 1C). Optical coherence
anterior segment were normal in both eyes. tomography (OCT) revealed presence of thick
Fundus of RE revealed subtotal hyperreflective membrane suggestive of
rhegmatogenous retinal detachment (RD) epiretinal membrane (ERM; figure 1D) in RE.
involving macula associated with a sheathed He underwent silicone oil removal (SOR) with
vessel and a slit-shaped retinal break along ERM peeling subsequently. At final follow up
the inferotemporal arcade (figure 1A). Left of one year, he had BCVA of 6/24 in RE and
eye had clear media with normal optic disc 6/6 in LE. RE showed attached retina with
and retinal vessels (figure 1B). Systemic lasered retinal break and peripheral laser
examination was non-contributory. A scars. No recurrence of vascultic was seen in
presumptive diagnosis of vasculitic combined either eye.
RD in RE was considered. A panel of
investigations including complete hemogram, Retinal vasculitis is a potentially vision
erythrocyte sedimentation rate, fasting blood threatening inflammatory eye disease which
sugar level, renal function test, liver function is characterized by perivascular white or
test, venereal disease research laboratory, creamy colored infiltrates and sheathing of
serum angiotensin converting enzyme, urine the retinal blood vessels. These changes
routine microscopy, viral markers and chest primarily involve peripheral retinal venules,
X-ray were unremarkable. Tuberculin skin less commonly retinal arterioles. It may
test was also normal. He underwent 25- occur as an isolated idiopathic phenomenon
gauge pars plana vitrectomy (PPV), or secondary to various etiologies including
peripheral scatter laser and silicone oil infective, neoplastic or inflammatory

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 79

disorders. Various complications of retinal those cases without underlying systemic
vasculitis include nonresolving vitreous
hemorrhage(VH), tractional RD, combined pathologies to avoid systemic side effects.
rhegmatogenous and tractional RD, ERM,
neovascular glaucoma and others.1,2 PPV is usually considered for non-resolving
Corticosteroids are the main stay of
treatment in primary retinal vasculitis or VH, ERM, tractional RD threatening the
those with underlying systemic vascular
disease. In the absence of a specific macula, combined tractional and
infection, administration of corticosteroids
helps to control the inflammation. rhegmatogenous RD and a densely opacified
Administration of periocular long standing
corticosteroids should be considered in vitreous.3 A meticulous physical

examination, tailored laboratory

investigations and optimized treatment

approach can provide good visual outcome

in most case.

Figure - (A) Montage fundus photograph of the right eye at presentation showing subtotal rhegmatogenous
retinal detachment involving macula associated with a sheathed vessel (green arrow) and a slit-shaped
retinal break along the infero-temporal arcade (black arrow); (B) Normal fundus of left eye; (C) Follow-up at
6 months showing attached retina with oil-filled globe in the right eye; (D) Corresponding OCT image of the
right eye showing a hyperreflective membrane suggestive of epiretinal membrane (yellow membrane)

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 80

REFERENCES

Correspondence Address 1. Ali A, Ku JH, Suhler EB, Choi D,

Dr. Neeraj Kumar Saraswat Rosenbaum JT. The course of retinal
Senior Resident
Department of Ophthalmology vasculitis. British Journal of
All India Institute of Medical Sciences,
Rishikesh, Uttarakhand, India, 249203. Ophthalmology 2014;98(6):785-789.
E-mail: [email protected]
Phone Number: +918864920132 2. George RK, Walton RC, Whitcup SM,

Nussenblatt RB. Primary retinal vasculitis.

Systemic associations and diagnostic

evaluation. Ophthalmology 1996; 103(3):

384-389.

3. Walton RC, Ashmore ED. Retinal

vasculitis. Curr Opin Ophthalmol.

2003;14(6):413-419.

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Residents Corner

QUIZ

Q1. Which website predominantly uses blue A. Supplement with Vit B12 and monitor
colour platform because it’s founder platelet count 6 monthly
is red green blind? B. Supplement with Iron and monitor by CT
chest monthly
a. Facebook C. Supplement with folic acid and monitor by
b. Whatsapp monthly blood count and liver function tests
c. Twitter D. Supplement with folic acid and monitor by
d. Instagram monthly blood counts and renal function
tests
Q2. Following is the pictorial representation
of histological examination of a specimen Q4. A 30-year-old obese female presented
taken from intraocular malignancy from a with history of headache and bilateral
child with leukocoria. What is this blurring of vision since 1 month. She gave
characteristic of? history of transient ischemic attacks during
this one month. On examination, herBody
Mass Index (BMI) is 35. Routine
haematological and blood pressure was
normal. The anterior segment examination
was essentially normal with bilateral
sluggishly reacting pupil. Her colour vision
was moderately impaired (13/20 on the right
and 11/20 on the left using the Ishihara
chart). Dilated fundus examination picture is
shown below. She underwent MRI brain with
orbit which was essentially normal.

a. Homer Right Rosette The most probable diagnosis is
b. Fleurettes a) Idiopathic Intracranial Hypertension
c. Flexner Wintersteiner rosette b) Optic neuritis
d. Target cells c) Anterior ischemic optic neuropathy
d) Compressive optic neuropathy.
Q3. A patient of recurrent intermediate
uveitis is developing side effects of systemic Q5. A 12-year-old boy is undergoing squint
steroids. The patient was started on systemic surgery under general anaesthesia. As soon
methotrexate therapy. What additional test as the surgeon hooks the medial rectus
will you recommend the patient to monitor muscle, there is continuous beep in the
systemic side effect of drug?

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monitors.The heart rate is 40/min (40% following features: pendular, disconjugate
drop) from baseline, saturation is normal, movement of eyes in which one
and electrocardiogram shows sinus elevates/intorts while the fellow eye
bradycardia. The anaesthetist tells the depresses/extorts. This is known as
surgeon to stop the surgery at once and
injects atropine. Once the patient is stable, a) Spasmus nutans
the surgery is resumed. What is the most b) Down beat nystagmus
likely rationale for stopping the surgery and c) Up beat nystagmus
giving atropine? d) See saw nystagmus

a) To stimulate a reflex to counter the Q 10. The presence of Scheie’s line/
effect of the reflex responsible Zentmayer’s Ring on the zonules and lens
equator are characteristic of which kind of
b) To avoid the afferent limb of the secondary open angle glaucoma
reflex only
a) Steroid induced glaucoma
c) To block the efferent limb of the reflex b) Pseudoexfoliation glaucoma
d) To avoid the stimulus in the afferent c) Pigment dispersion syndrome
d) Post-traumatic glaucoma
limb of the reflex and block the
efferent limb of reflex as well Q 11. A 40-year-old male presented with
neurotrophic keratopathy in left eye,
Q6. In a patient with Sturge Webers unresponsive to convential treatment. Which
syndrome, there is facial hemangioma of the following newer drugs can be usedthat
involving right side of face and upper lid. works on the principle of increasing blood
This predisposes the patient to develop flow to brain?
ipsilateral right eye intraocular involvement.
This rule is known as a) Nicergoline
b) Neuromodulators like substance P
a) Knapps Rule c) Insulin growth factor
b) Anderson Rule d) Regenerating agents(RGTAs)
c) Kollner rule
d) Prince rule Q 12. Chemo-tarsorrhaphy is achieved by
injecting which of the following drugs?
Q7. All of the following syndromes are due to
involvement of chromosome 11 that have a) Botox
ocular involvement except. b) Edrophonium
c) Pyridostigmine
a) Congenital stationary night blindness d) Neostigmine
b) Best Macular Dystrophy
c) Familial exudative vitreoretinopathy Q13. A 60 year old male presented with
d) Oculo Cutaneous Albinism slowly progressive dimunition of vision in left
eye. On examination BCVA was 3/60 with in
Q8. Which of the following Uveitic disorders the affected eye and examination revealed a
has highest HLA association? choroidal mass lesion. Ultrasound
examination picture is given below. All are
a) Bird Shot Chorioretinopathy: HLA A29 the features of the lesion except:
b) HLAB27 aasociated anterior uveitis
c) Behcte’s Disease: HLAB5
d) Posner-Schlossman syndrome:

HLAB51Bw54:

Q9. A patient was diagnosed as having
craniopharyngioma. On ocular examination
there is presence of nystagmus with

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 83

a) High surface reflectivity enlargement and proptosis andbilateral
b) High internal reflectivity parotid gland enlargement with bilateral
c) Choroidal excavation infraorbital nerve enlargement. Orbitalbiopsy
d) No back shadowing showing dense storiform fibrosis with hyaline
or sclerotic appearance in abackground of
Q14. Which of the following newer drugs dense lymphoplasmacytic inflammation. The
used in glaucoma management increase the most likely diagnosis is
outflow to lower IOP?
a) IgG4 disease
a) Ripasudil, a ROCK Inhibitor b) Idiopathic orbital inflammatory
b) Netasurdil, a ROCK Inhibitor disease
c) Trabodenoson (INO 8875), an c) Thyroid eye disease
d) Lymphoma
adenosine receptor agonist
d) Bamosiran, a siRNA Q 18. A 32-year-old woman presents with
insidious onset of diplopia. On alternate
Q 15. Luxturna is FDA approved gene cover testing, the patient has a right
therapy for which of the following condition? hypertropia, worse on right head tilt and left
gaze. A palsy of which muscle might cause
a) Retinitis Pigmentosa her symptoms?
b) Fuchs endothelial dystrophy
c) Retinoblastoma a) Right superior oblique
d) Melanoma b) Left superior rectus
c) Left inferior oblique
Q 16. All of the following are exception to d) Right inferior rectus
Kollners rule for colour vision defect except
Q 19. Lesion at which site along the optic
a) Lebers hereditary optic neuropathy pathway will produce the following field
b) Autosomal dominant optic atrophy defect
c) Glaucoma
d) Stargardts Disease. a) Left temporal lobe
b) Left parietal lobe
Q 17. A 50 year old male presented with c) Right parietal lobe
bilateral upper eyelid fullness and d) Right temporal lobe
preauricular swelling.Computed tomography
scan shows bilateral lacrimal gland Q 20. A patient with the preoperative
refraction OD of −3.00 + 2.00 × 90 has a
visually significant cataract in this eye.
Keratometry is 40.00 at 180 and 42.00 at
90. Which length and location of the cataract
scleral tunnel might help decrease the
amount of late postoperative astigmatism for
the patient?

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 84

a) 3.5-mm scleral incision superiorly a) associates a unilaterally myopic
b) 6.0-mm scleral incision superiorly eye with hypotropia.
c) 3.5-mm scleral incision temporally b) is caused by an abnormally high
d) 6.0-mm scleral incision temporally muscle path of the lateral rectus
muscle in the involved eye.
Q 21. Heavy eye syndrome is associated c) may exhibit limited elevation of the
with which of the following? affected eye.
d) may exhibit a head turn toward the
side of the affected eye.

CROSSWORDS

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ACROSS DOWN

2. Cataract in Diabetics 1.Congenital melanocytic naevus of upper
4. Appearance in Thiel Behnke corneal and lower lid
dystrophy
7. Corneal topography pattern in pellucid 3. Appearance of Cogan’s epithelial
marginal degeneration basement membrane dystrophy
8. Cytomegalovirus Retinitis
9. MRI finding in Optic nerve sheath 5. Appearance of sessile squamous cell
meningioma papilloma
10. Pattern in PVR Grade C with localized 6. Retinal Astrocytoma
contracture of retina

ANSWERS

1. (A). Facebook uses blue platform as owner Mark Zuckerberg is red green colour blind. Red
green colour blindness is the commonest form of colour blindness. Its inheritance is X linked
recessive, thus the features are manifested in males.

2. (C). Flexner-Wintersteiner rosettes consist of columnar cells arranged around a central lumen.
This is highly characteristic of retinoblastoma and is also seen in medulloepithelioma. Homer
Wright rosettes consist of cells arranged around a central neuromuscular tangle. This is also
found in neuroblastomas, medulloblastomas and medulloepitheliomas. Pseudorosette refers to
the arrangement of tumor cells around blood vessels. They are not signs of good
differentiation. Fleurettes are eosinophilic structures composed of tumor cells with pear
shaped eosinophilic processes projecting through a fenestrated membrane.

3. (C). Methotrexate is an folate antagonist that inhibits dihydrofolate reductase. Side effects are
pancytopenia, hepatotoxicity and pneumonia. Folic acid is given along with methotrexate to
avoid pancytopenia.

4. (A). Idiopathic intracranial hypertension (IIH) or Pseudotumor cerebri is a disorder
characterized by increased intracranial pressure (ICP) of unknown cause that predominantly
affects obese women of childbearing age. Papilledema is the primary ocular finding and may
progressively lead to optic atrophy and blindness if no treatment is provided. The modified
Dandys Criteria for diagnosis is as follows:

• Signs and symptoms of increased ICP (headaches, nausea, vomiting, transient visual
obscurations, papilledema)

• No localizing neurologic signs, except for unilateral or bilateral sixth cranial nerve palsy.

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• C SF opening pressure >25 cm H2O with normal CSF composition
• No evidence of hydrocephalus, mass, structural, or vascular lesion (including venous sinus

thrombosis) on imaging
• No other cause of increased ICP identified

5. (D). The child developed oculocardiac reflex on pulling the muscle. Hooking the muscle puts a
stretch on the receptors that carry afferent to the ciliary ganglion through the long and short
ciliary nerves. Atropine blocks the peripheral muscarinic receptors of the heart, and there is
increased firing at the sinoatrial node as well as conduction through the AV node. This opposes
the vagal response, or the efferent limb, of the oculocardiac reflex. Sometimes even withdrawal of
stimulus is sufficient to stop the reflex. But as this patient had a 40% drop in heart rate and
electrocardiogram changes, thus atropine was injected.

6. (B). Anderson's rule says that when a hemangioma involves the upper lid, there is ipsilateral
intraocular involvement. Sturge-Weber syndrome is a disorder of neural crest cells, also known as
encephalotrigeminal angiomatosis. The facial cutaneous angioma is usually unilateral, present at
birth, and distributed over the first and second divisions of the trigeminal nerve. The onset of
glaucoma in SWS ranges from early childhood to adulthood.

7. (A). The following disorders/syndromes have association with chromosome 11

11p13: Aniridia (PAX6)
11p13: Peter’s anomaly (PAX6)
11q: Oculocutaneous albinism (tyrosinase -)
11q: FEVR
11q: Best’s
11q: Ataxia-telangiectasia (Louis Bar)

8. (A). Bird shot chorioretinopathy (BSCR) is an autoimmune condition, but its pathogenesis
remains unknown. BSCR is strongly associated with HLA-A29, and at least 96% of BSCR patients
are HLA-A29 carriers [14]. The prevalence of HLA-A29 is about 7% in the general population

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HLA Type Associated disease
HLA B-27 Recurrent acute anterior uveitis
HLA A-29 Birdshot chorioretinopathy
HLA-b51 and HLA-B5 Behcet syndrome
HLA-B7 and HLA-DR2 Presumed ocular histoplasmosis syndrome
HLA-DR4 Sympathetic ophthalmia
HLA-DR4 Vogt-Koyanagi-Harada syndrome

9. (D). See-saw nystagmus is a subtype of torsional nystagmus. There is pendular, disconjugate
movement of eyes in which one elevates/intorts while the fellow eye depresses/extorts. Hemi-
seesaw nystagmus is similar but with jerk waveform rather than pendular. The common causes of
see-saw nystagmus are arge parasellar tumor (craniopharyngioma, pituitary adenoma),
congential achiasma and rarely associated with retinitis pigmentosa and albinism.

10. (C). Pigment on lens equator and posterior capsule in pigment dispersion syndrome(PDS) is
pathognomic of pigment dispersion syndrome known as "Scheie's line"/ Zentmayers line.

Whereas hyperpigmentation of Schwalbes line is known as Sampaolesi line is found in PDS ,
pseudoexfoliation syndrome, trauma and iris melanoma.

11.(A). Nicergoline facilitates healing of epithelial defects in patients with neurotrophic ulcers by
increasing Nerve growth factor (NGF) levels or increasing the reduced acetylcholine. It is usually
prescribed in a dose of 10mg twice a day for 2 weeks.

12. (A). Chemodenervation of levator muscle is a quick and easy procedure for induction of
temporary ptosis for corneal protection. There by avoiding surgical tarsorrhaphy and subsequent
scarring of eyelid margin. It is often associated with paresis of superior rectus muscle.
Intramuscular administration of botulinum toxin acts at the neuromuscular junction to cause
muscle paralysis by inhibiting the release of Ach from presynaptic motor neurons. Type A toxin is
mostly used and commercially availbale.

13. (B). Ultrasound features of choroidal melanoma are: high surface reflectivity, low internal
reflectivity or acoustic hollowness and choroidal excavation. High surface reflectivity followed by
wave attenuation on A scan is known as “Kappa Sign”.

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14. (D). Bamosiran is a naked double-stranded small-interfering RNA. It acts through specific
gene silencing and causes beta-2 adrenergic receptor blockade, thereby decreasing aqueous
production by the ciliary body. After topical administration, the drug is rapidly distributed in the
anterior chamber. It is preferentially taken up by the ciliary body cells; hence, undesirable beta-
receptor blockade in bronchioles and alveoli is limited.

15. (A). Voretigene neparvovec (Luxturna) is the world’s first approved gene therapy for an eye
disease. Luxturna is a treatment for people who have Leber congenital amaurosis (LCA) or
retinitis pigmentosa (RP) caused by mutations in both copies of the RPE65 gene. Luxturna
provides a working RPE65 gene to act in place of the mutated version of the same gene. This
new, functioning gene produces a protein that improves the visual cycle and helps the
photoreceptor cells in the retina sense light.

16. (A). Kollner rule stated that macular disorders usually cause blue yellow colour blindness and
optic nerve disorders lead to red green colour blindness. Exceptions to this rule are glaucoma,
autosomal dominant optic atrophy and stargardts disease.

17. (A). IgG4-related ophthalmic disease (IgG4-ROD), most commonly causes painless swelling of
the lacrimal gland(s). Other structures involved are extraocular muscles, orbital fat, infraorbital
nerve, eyelid, and the nasolacrimal duct system. Diagnostic criteria combine physical
examination, imaging, and histopathologic findings detailing the number of IgG4+ cells/HPF and
the ratio of IgG4+ to IgG+ cells/HPF. There are 3 major pathologic features of IgG4-RD: dense
lymphoplasmacytic infiltrate, focally storiform fibrosis, and obliterative phlebitis.

18. (A). The Parks three-step test,helps to identify a vertical muscle palsy.
1. Determine which eye is hypertropic. This tells you that the involved muscle is one of the two
depressors in the hypertropic eye, or one of the two elevators in the other eye. With this first step
complete, choices are narrowed from eight muscles down to four muscles.
2. Decide in which gaze the hypertropia is worse. Example, the right hypertropia, which is worse
on left gaze, indicates either the right superior oblique (the depressor of the right eye in left gaze)
or the left superior rectus (the elevator of the left eye in left gaze)
3. Determine if right or left head tilt worsens the hypertropia. When a normal patient tilts his
head, one eye intorts and the other eye extorts. The intorters are the superior muscles (superior
rectus and superior oblique) and the extortors are the inferior muscles (inferior rectus and inferior
oblique). When the head tilts to the right, the right eye intorts and the left eye extorts. If the

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 89

right superior oblique is paretic the inferior oblique will be overacting and thus the hypertropia will
increase.

19.(C). A lesion affecting one side of the temporal lobe may cause damage to the inferior optic
radiations (known as the temporal pathway or Meyer's loop) which can lead to superior
quadrantanopia on the contralateral side of both eyes (colloquially referred to as "pie in the sky");
if the superior optic radiations (parietal pathway) are lesioned, the visual loss occurs on the
inferior contralateral side of both eyes and is referred to as an inferior quadrantanopia.

20.(B) The patient has with-the-rule astigmatism that has no obvious lenticular component. A
6.0-mm scleral incision placed superiorly may help decrease the patient’s preoperative
astigmatism 1.5 ± 0.5 D. A 3.5-mm incision would be more astigmatically neutral with 0.5 ± 0.3
D drift against the rule.
21. (B). Strabismus fixus convergence or ‘Heavy Eye’ syndrome (HES) is a cause of acquired
esotropia in the setting of high myopia. It is hypothesized that HES is the result of LR and SR
shifts caused by the elongated posterior portion of the eyeball due to high myopia. Inferior shift
of LR causes reduced abduction and increased infraduction. Nasal shift of SR causes reduced
supraduction and increased adduction. Consequently, HES shows esodeviation and hypodeviation
due to increased adduction, reduced abduction, reduced supraduction with an increased
infraduction.

CROSSWORD

1. Congenital melanocytic naevus of upper and lower lid: KISSING naevus
2. Cataract in Diabetics: SNOWFLAKE
3. Appearance of Cogan’s epithelial basement membrane dystrophy: FINGERPRINT
4. Appearance in Thiel Behnke corneal dystrophy: HONEYCOMB
5. Appearance of sessile squamous cell papilloma: RASPBERRY
6. Retinal Astrocytoma: MULBERRY
7. Corneal topography pattern in pellucid marginal degeneration: BUTTERFLY
8. Cytomegalovirus Retinitis: BRUSHFIRE
9. MRI finding in Optic nerve sheath meningioma: TRAMTRACK
10. Pattern in PVR Grade C with localised contracture of retina: STARFOLD

Correspondence Address

Dr. Gitanjali Sood
Senior Resident
Department of Ophthalmology
All India Institute of Medical Sciences,
Rishikesh, Uttarakhand, India, 249203.
E-mail: [email protected]

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 90

INSTRUCTIONS TO AUTHORS
UTTARANCHAL JOURNAL OF OPHTHALMOLOGY

UJO 2020 Volume 14, Issue 1 | November 2020 | Page 91

Articles can be mailed directly to - Design and Typesetting of UJO 2020 for UKSOS by

Dr. Anupam, MS Dr. Athul S Puthalath, MD
Chief Editor, Senior Resident, Ophthalmology,
Uttaranchal Journal of Ophthalmology, All India Institute of Medical Sciences, Rishikesh,
Additional Professor, Ophthalmology,
AIIMS Rishikesh. Uttarakhand, India, 249203.
Email - [email protected] E-mail: [email protected]
Phone Number: +91 9400308820

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