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   2014| July-December  | Volume 6 | Issue 2  
    Online since February 6, 2015

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Formative assessment using direct observation of single-patient encounters in ophthalmology residency
Kavita Bhatnagar, OK Radhakrishnan, Abhay Lune, K Sandhya
July-December 2014, 6(2):49-53
Background: There has been a growing concern that trainees are infrequently observed, assessed, and given feedback during their workplace-based education. This has led to an increasing interest in a variety of formative assessment methods that require observation and offer the opportunity for feed. Mini-clinical evaluation exercise (mini-CEX) is an observation tool that facilitates the assessment of skills that are essential for good clinical care and provision of immediate feedback. The aim of this article is to sensitize academician-clinician in developing countries to mini-CEX. Materials and Methods: This observational study was conducted on 10 postgraduate students who were assessed on clinical skills, communication skills, professionalism and ethics in different clinical settings using a validated mini-CEX global rating scale. Data analysis was done. Student's scores in the first encounter and last encounter were compared to see an improvement in their performance. Results: A total of 216 encounters was observed and rated on a nine-point Likert scale. Mean score and maximum improvement were seen for Humanistic qualities/professionalism. About 100% residents found mini-CEX exercise useful. Faculty feedback was more useful than multiple encounters being observed. Over 90% patients were highly satisfied with resident behavior. The mean score for faculty satisfaction with mini-CEX was 5.33, and for the students, it was 5.48. Conclusion: Mini-CEX is an examination tool which permits evaluation based on a much broader set of clinical settings and patients. It also gives an opportunity to observe and communicate with the students in real life settings. It can be used as a tool to identify and highlight deficient areas in individual performance for further improvement.
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Ocular problems in diabetes mellitus
Galal Mohamed Ismail
July-December 2014, 6(2):43-48
Diabetes Mellitus (DM) is an important health problem affecting wide population band globally. According to the World Health Organization (WHO) considerable numbers of individuals were diagnosed with DM, however, notable numbers are still undiagnosed due to diverse reasons. All diabetics are at risk of developing pathological complications in particular ocular complications seemed to appear early and might lead to blindness at late stages. The screening and routine medical eye care programs helped in detecting early the ocular problems allowing best possible remedy. Monitoring of such ocular problems has significant role in reducing advance stages that might lead to blindness. In an attempt of listing possible ocular problems due to DM, the author reviewed what would be most seen in practice across the ocular and visual components structurally and functionally. Assuming the article might be used as a quick reference by the clinicians involved in seeing diabetic patients.
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Determination of post-operative toric IOL alignment - Analyzed by two different methods: Slit-lamp versus Adobe Photoshop
Javed Hussain Farooqui, Archana Koul, Ranjan Dutta, Noshir Minoo Shroff
July-December 2014, 6(2):57-61
Purpose: To compare two different methods of determining the post-operative position of the toric IOL and to calculate the alignment error with each method. Setting/Venue: Cataract and Intraocular Lens Implantation Service, Shroff Eye Center, New Delhi, India. Design: Case series Materials and Methods: Eighty-nine eyes of 61 patients with cataract and co-existing corneal astigmatism ranging from 1 to 4 diopters planned for toric IOL implantation were included. All eyes underwent pre-operative automated keratometry and biometry. Toric IOL cylindrical power, axis of implantation, and anticipated residual astigmatism were calculated using the web-based Acrysof Toric calculator. All eyes underwent pre-operative reference marking to denote the 0° and the 180° positions (using bubble marker) followed by digital slit-lamp photography. All eyes were operated by the same surgeon, at the same incision location. At 3 months, the achieved IOL alignment was analyzed by aligning the slit-beam of the slit-lamp with the pair of marks denoting the axis of the IOL after pupillary dilation. Additionally, the IOL position was determined after capturing a digital retro-illuminated slit-lamp photograph, which was superimposed on the pre-operative photograph using single prominent major episcleral vessel around the limbus as landmark. The axis of orientation of the toric IOL was determined using tools in Adobe Photoshop (version 7.0) by aligning a line through the marks denoting the IOL axis. The amount of alignment error (in degrees) by both methods induced with respect to the desired axis of alignment was calculated and statistically analyzed. Results: The mean pre-operative keratometry was 44.19 ± 1.51 D, and the mean corneal cylinder was 2.54 ± 0.90 D. The mean post-operative absolute cylinder was 0.57 ± 0.28 D. Toric IOL models used were T3(1.03 D): 28 eyes (31.5%), T4(1.55 D): 21 eyes (23.6%), T5(2.06 D): 18 eyes (20.2%), T6(2.57 D): 11 eyes (12.4%), T7(3.08 D): 4 eyes (4.5%), T8(3.60 D): 4 eyes (4.5%), and T9(4.11 D): 3 eyes (3.4%). Mean post-operative alignment error was 3.44 ± 2.60 D by the slit-lamp method and 3.89 ± 2.86 D by the Photoshop method with no significant difference seen between the two methods (P = 0.384). Fifty-six eyes (62.9%) by the slit-lamp method and 52 eyes (58.4%) by the Photoshop method had rotation error ≤ 5 degrees (P = 0.526), and 78 eyes (87.6%) by the slit-lamp method and 75 eyes (84.3%) by the Photoshop method had rotation error ≤ 10 degrees (P = 0.422). Conclusions: Both Adobe Photoshop method and slit-lamp observation were reliable and predictable methods of assessing IOL alignment. Although the sensitivity is more with the Photoshop method, the slit-lamp method is more accessible in an outpatient setup. The clinical outcome following toric IOL implantation can be refined by reducing the alignment error, which is dependent on an accurate keratometry and biometry, surgeon-specific SIA, reference and intra-operative marking, and finally, placement of IOL in the bag.
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Causes of poor visual outcome of extracapsular cataract extraction with posterior chamber intraocular lens implantation
Khalil Ali Ibraheim, Kamal Hashim, Mustafa Alsaraj
July-December 2014, 6(2):54-56
Aims: To detect the causes of poor visual outcome among patients who had extracapsular cataract extraction and intraocular lens (IOL) implantation. Materials and Methods: All patients who had ECCE and IOL implantation 6 weeks or more following surgery and who come for regular follow-up were picked from the Statistical Department and assessed for visual acuity, and for those with poor vision uncorrectable with glasses or any other mean of correction, complete ophthalmic examination including pupillary reactions measurement of intraocular presser (IOP) and direct and indirect ophthalmoscopy was performed. Results: Most of the patients were elderly (74%) and females were slightly more than males. The predominant type of cataract was senile cataract, 89% of patients complained of poor vision, 35% with visual acuity after operation less than 6/60 represent the biggest group with poor vision. Concerning intraocular pressure, the majority of pseudophakic eyes had normal range of IOP (75%), while 25% of the study group had raised intraocular pressure, although some of the patients with normal tension showed signs of advanced glaucomatous optic neuropathy. The most common causes of poor vision in the anterior segment were: Posterior capsule opacification (24%), corneal edema, opacity, pannus and bullous keratopathy (23%), amblyopia (6%), IOL decentration (5%), squint (4%), intraocular scarring (3%), nystagmus (2%), shrunken eyes (2%) and epithelial down-growth (1%). The most common causes of low vision in the media and posterior segment were glaucomatous optic neuropathy (28%), vitreous opacities (23%), macular edema (19%) and optic atrophy non-glaucomatous (19%), age-related macular degeneration (11%), toxoplasmic choroidoretinitis (6%), retinal detachment (6%), vitro-retinal bands (2%) and organized macular hemorrhage (1%); in some eyes, more than one cause was detected. Conclusion: The most common contributory factors for poor vision were incomplete ophthalmic examination before surgery, poor case selection and incomplete and irregular follow-up besides the above-mentioned causes.
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Unusual presentation of metastatic neuroendocrine (carcinoid) tumor in the orbit
Manju Meena, Ian C Reddie, Georgina Kourt, Peter A Martin
July-December 2014, 6(2):66-68
Purpose: To report a rare presentation of metastatic neuroendocrine tumor in the orbit. Case report: A 43-year-old female presented with a left painful proptosis of 4 days duration associated with nausea and vomiting. There was a history of multiple liver metastases from an unknown primary carcinoid tumor for 7 years. Ocular examination revealed severe eyelid swelling associated with conjunctival injection, chemosis and complete external ophthalmoplegia. The visual acuity was 20/20 in right eye and no light perception in left eye. The initial clinical diagnosis was orbital cellulitis with optic nerve compression. Orbital imaging showed gross enlargement of left lateral rectus muscle with optic nerve compression consistent with a carcinoid metastasis. Surgical resection of the tumor mass along with the involved muscle was performed. Histopathology confirmed the diagnosis of neuroendocrine (carcinoid) tumor infiltrating fibro fatty tissue and skeletal muscle with widespread necrosis. On Immunohistochemical staining the tumor cells were positive for chromogranin A, synaptophysin and cytokeratin. Post-operative external beam radiotherapy (EBRT) and systemic chemotherapy were given. Conclusion: Acute necrosis in metastatic orbital carcinoid tumor can lead to orbital inflammation which could mimic orbital cellulitis. Systemic history and orbital imaging play an important role in differentiating the infective etiology from metastasis.
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The effect of fasting on intra ocular parameters
Salem Musa Alameen, Ahmed Alsiddig A Albagi
July-December 2014, 6(2):62-65
Objectives: The objective was to assess the effect of fasting on the intraocular parameters. Materials and Methods: A total of 114 subjects enrolled in this study. The method included was the measurements of the keratometry readings, axial length, anterior chamber depth, lens thickness, vitreous thickness, and calculation of intraocular lens (IOL) power. These measurements were done twice at first while the patient is in the fasting state and second while the patient is in the fed state. Result: No change occurred in keratometry readings, lens thickness or vitreous thickness. The axial length decreased by 0.251 mm in the fasting state while the anterior chamber depth was 0.165 mm shorter. Furthermore, the power of IOL calculated by Sanders, Retzlaff, and Kraft formula was found to be increased by 1 D in the fasting state which was found to be statistically significant. Conclusion: Measuring the intraocular parameters for a patient who is in the fasting state will result in a shorter axial length and higher IOL power so care should be taken when measuring the intraocular parameters for a patient who is in the fasting state.
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Orbital roof leptomeningeal cyst presenting as proptosis
Ishan Kumar, Ashish Verma
July-December 2014, 6(2):69-69
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Strategies to reduce the magnitude of avoidable blindness in developing nations
R Shrivastava Saurabh, S Shrivastava Prateek, Ramasamy Jegadeesh
July-December 2014, 6(2):70-70
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