Chronic pancreatitis: Pediatric and adult cohorts show similarities in disease progress despite different risk factors

Objectives: To investigate the natural history of chronic pancreatitis (CP), patients in the North American Pancreatitis Study2 (NAPS2, adults) and INternational Study group of Pediatric Pancreatitis: In search for a cuRE (INSPPIRE, pediatric) were compared. Methods: Demographics, risk factors, disease duration, management and outcomes of 224 children and 1,063 adults were compared using appropriate statistical tests for categorical and continuous variables. Results: Alcohol was a risk in 53% of adults and 1% of children (p

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Similarities and Differences in Allocation Policies for Pediatric Liver Transplantation Across the World

Objectives: We aimed to investigate national allocation policies for pediatric liver transplantation. Method: A survey was prepared by the ESPGHAN hepatology committee in collaboration with the North-American SPLIT (Studies of Pediatric Liver Transplantation) consortium. The survey was sent to pediatric hepatologists and transplant surgeons worldwide. National data were obtained from centrally based registries. Results: Replies were obtained from 15 countries from five of the world continents. Overall donation rate varied between 9 and 35 per million inhabitants. The number of pediatric liver transplantations was 4–9 per million inhabitants below 18 years of age for 13 of the 15 respondents. In children below 2 years of age mortality on the waiting list varied between 0 and 20%. In the same age group, there were large differences in the ratio of living donor liver transplantation to deceased donor liver transplantation as well as in the ratio of split liver segments to whole liver. These differences were associated with possible discrepancies in waiting list mortality. Conclusion: Similarities but also differences between countries were detected. The described data may be of importance when trying to reduce waiting list mortality in the youngest children. Address correspondence and reprint requests to Björn Fischler, Dept. of Pediatrics Karolinska University Hospital, CLINTEC Karolinska Institutet, SE-14186 Stockholm, Sweden (e-mail: bjorn.fischler@sll.se). Received 4 May, 2018 Accepted 22 December, 2018 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). No conflicts of interest. © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Predisposing Conditions to Pediatric Hepatocellular Carcinoma and Association with Outcomes: Single-Center Experience

Objectives: Hepatocellular carcinoma (HCC) has been linked to chronic viral or metabolic liver disease and other conditions. The characteristics of children with HCC have not been fully elucidated and outcomes in children with predisposing liver disease are not well defined. Methods: Patients ≤ 21 years old with HCC managed at our institution and through external consultation between 1996 and 2016 were included. Demographics, clinical history, and pathology were tabulated. Fisher's exact test and Wilcoxon test were employed for sub-group comparison, and survival differences were evaluated by Kaplan-Meier method. Results: Sixty-one cases of HCC were identified. Seven of 16 patients (44%) at our institution and 18 of 45 consult patients (40%) had a predisposing condition: cryptogenic cirrhosis/steatosis (9), genetic (7), biliary pathology (4), viral hepatitis (1), other (4). Thirteen of 27 patients with de novo HCC had fibrolamellar HCC. Clinical characteristics were grouped by presence or absence of predisposing conditions: age at diagnosis (7.2 versus 10.2 years, p 4 cm (20% versus 100%, p 

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Healthy Body Weights With Corticosteroid-Free Immunosuppression Is The Best Predictor of Cardiovascular Health In Children After Liver Transplantation

Introduction: Cardio-metabolic dysregulation (CMD) influences morbidity and mortality risk in adults post-liver transplantation (LTx). CMD is reported in 10–25% of pediatric LTx recipients, but no information regarding the longitudinal expression of CMD is available. The study objective was to examine the longitudinal expression of CMD and associations with body composition and growth in children post-LTx. Methods: A retrospective review was conducted in youth (34F/30 M) who underwent LTx between 1994–2015 at the Stollery Children's Hospital. Primary outcomes included; serum markers of CMD (insulin, glucose, Hemoglobin A1C [A1C], HOMA-IR [abnormal >3], lipid panel (triglycerides [TG], total cholesterol [TC], high-density-lipoprotein-cholesterol [HDL-cholesterol], low-density-lipoprotein-cholesterol [LDL-cholesterol]) and systolic/diastolic blood pressure (BP: absolute/z-scores). Results: Mean (± SD) age, weight-z, height-z, BMI-z was 9.7 ± 3.4 years (3.5–17.9), 0.26 ± 1.03, 0.017 ± 1.2, and 0.41 ± 1.05, respectively. The majority of children had %fat mass (FM), %fat-free mass (FFM) within normal reference ranges. Systolic/diastolic BP were within healthy references ranges in 83.1% and 93.5% of children, respectively. Serum insulin (83.4%) and HDL-cholesterol (43.9%) concentrations were low, with abnormal findings of other laboratory markers found in 9.7 years) and FFM (total, arms). Insulin levels decreased significantly in the first four years post-LTx, but no changes in lipid panel, A1C and glucose were noted over 10 years. Conclusions: Pediatric LTx recipients with healthy body weights and CST-free immunosuppression have a low expression of CMD over 10 years. Address correspondence and reprint requests to Dr Diana R. Mager, PhD, MSc, RD, Associate Professor, Clinical Nutrition, 2-021D Li Ka Shing Centre for Research Innovation, Clinical Research Unit, Department of Agricultural, Food & Nutritional Sciences, University of Alberta, Edmonton, AB, Canada, T6G 0K2 (e-mail: mager@ualberta.ca). Received 3 July, 2018 Accepted 18 December, 2018 Authors Roles and Responsibilities Diana R Mager PhD RD: Responsible for study design, data collection (AH/DRM),data analysis and intellectual/scientific interpretation, wrote manuscript, approved final manuscript. PI/corresponding author. Amber Hager, Dietetic Intern. Collected data, contributed to data analysis and intellectual/scientific interpretation, wrote manuscript, approved final manuscript. Kerry Siminoski MD FRPCP. Contributed to data collection, intellectual/scientific interpretation, approved final manuscript. Jason Yap MBBS FRACP. Responsible for study design, contributed to data interpretation/data analysis, approved final manuscript. Susan Gilmour. Responsible for study design, contributed to data interpretation/data analysis, approved final manuscript. Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). The authors report no conflicts of interest. © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Microscopic / “Backwash” Ileitis and its Association with Colonic Disease in New Onset Pediatric Ulcerative Colitis

Background: Microscopic ileitis and its association with pancolitis in adults with ulcerative colitis (UC) has been described. However, the incidence of ileitis and associations with colonic disease in pediatric UC have not been thoroughly investigated. This study was undertaken to examine the prevalence of microscopic ileal inflammation at the time of initial diagnosis in a cohort of children with UC. Methods: We reviewed colonoscopy and biopsy data at time of diagnosis from 105 children and young adults with treatment naïve ulcerative colitis; ileal and colonic mucosal biopsies were available on all patients. Ileal mucosal biopsies were examined for the presence and severity of ileal inflammation, as well as other histologic features. Concurrently obtained colonic mucosal biopsies were assessed to define the severity, distribution, and extent of disease; endoscopic and clinical follow-up data were reviewed. Results: 107 ileal mucosal biopsies and 693 corresponding colonic mucosal biopsies were examined. Seventeen of 105 patients (16%) were found to have ileal inflammation (mean age = 10.4 years, 59% female), 14 (82%) of whom had histologic pancolitis. The presence of ileal inflammation was significantly associated with endoscopic pancolitis (p = 0.02). The association between histologic pancolitis, severity of active inflammation in the cecum and ascending colon suggested a possible association with ileal inflammation (p = 0.06, 0.07, and 0.08 respectively), but did not reach statistical significance. Conclusion: Patients with new onset ulcerative colitis may have microscopic ileal inflammation at time of diagnosis, even if the terminal ileum appears macroscopically normal. The presence of endoscopic pancolitis is associated with the presence of histologic ileitis. In contrast to existing studies in adults, an association between the presence of ileitis and the histologic severity or the histologic extent of colitis was not observed. Children with microscopic ileitis in the context of UC do not need to be reclassified as "indeterminate colitis" or Crohn's disease. Address correspondence and reprint requests to Jeffrey D. Goldsmith, MD, Boston Children's Hospital, Department of Pathology, BCH 3027, 300 Longwood Avenue, Boston, MA 02215, USA (e-mail: jeffrey.goldsmith@childrens.harvard.edu). Received 10 July, 2018 Accepted 6 December, 2018 Source of Funding: None. Relevant Conflicts of Interest: None. The authors report no conflicts of interest. © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Dietary Therapy in Conjunction with Immunosuppression to Treat Gastrointestinal Graft-Versus-Host Disease (GVHD)

No abstract available

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Transjugular Liver Biopsy vs Percutaneous Liver Biopsy with Tract Embolization in Children with Coagulopathy

No abstract available

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Prevalence of Gastroesophageal Reflux Disease Symptoms in Infants and Children: A Systematic Review

Objectives: Gastroesophageal reflux disease (GERD) is defined as GER causing troublesome symptoms or complications. In this study we reviewed the literature regarding the prevalence of GERD symptoms in infants and children. Methods: Databases of PubMed, EMBASE and Cochrane were systematically searched from inception to June 26, 2018. English-written studies based on birth cohort, school based or general population samples of ≥50 children aged 0–21 years were included. Convenience samples were excluded. Results: In total, 3581 unique studies were found, of which 25 studies (11 in infants and 14 in children) were included with data on the prevalence of GERD symptoms comprising a total population of 487969 children. In infants (0–18 months), GERD symptoms 1) are present in more than a quarter of infants on a daily basis and 2) show a steady decline in frequency with almost complete disappearance of symptoms at the age of 12 months. In children >18 months, GERD symptoms show large variation in prevalence between studies (range 0%-38% of study population) and overall, are present in more than 10% and in 25% on respectively a weekly and monthly basis. Of the risk factors assessed, higher BMI and the use of alcohol and tobacco were associated with higher GERD symptom prevalence. Conclusions: This systematic review demonstrates that the reported prevalence of GERD symptoms varies considerably, depending on method of data collection and criteria used to define symptoms. Nevertheless, the high reported prevalence rates support better investment of resources and educational campaigns focused on prevention. Address correspondence and reprint requests to Maartje Singendonk, MD, Emma Children's Hospital/Amsterdam UMC – location AMC, C2–312, PO Box 22700, 1100 DD Amsterdam, The Netherlands (e-mail: m.m.j.singendonk@amc.uva.nl). Received 29 October, 2018 Accepted 10 January, 2019 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). Financial disclosure: The authors have no financial relationships relevant to this article to disclose. Funding source: No external funding for this manuscript. Potential conflicts of interest: The authors have no conflicts of interest relevant to this article to disclose. © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Comparison of Transjugular Liver Biopsy and Percutaneous Liver Biopsy with Tract Embolization in Pediatric Patients

No abstract available

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Psychologic distress and anxiety in mothers of children with gastroesophageal reflux undergoing antireflux surgery

Objectives: Parents of children with a chronic illness are at risk for impaired psychosocial functioning. Gastroesophageal reflux disease (GERD) is such a disease, and no studies have investigated effects of antireflux surgery on parental psychological distress. The aims of this study were to assess psychological distress and state and trait anxiety in mothers of children with GERD, and to explore possible changes after antireflux surgery. Methods: Mothers of children referred for antireflux surgery were included in this prospective study. Standardized questionnaires were used to evaluate psychological distress and state and trait anxiety before and twelve months after antireflux surgery. Results: Of 87 eligible mothers of children with GERD, 62 (71%) agreed to participate. All children had objectively verified GERD by 24-hour pH-monitoring and/or upper gastrointestinal contrast study and unsatisfactory symptom relief of pharmacological treatment. 31 (50%) mothers returned questionnaires postoperatively. Preoperatively, mothers of children undergoing antireflux surgery reported high levels of psychological distress and state anxiety, and 54% had scores indicating clinically significant psychological distress. None of the preoperative child characteristics were found to significantly influence maternal psychological distress or state anxiety. Twelve months postoperatively, both psychological distress and state anxiety were reduced. Conclusion: Mothers of children undergoing antireflux surgery reported reduced levels of psychological distress and state anxiety twelve months after the operation. Address correspondence and reprint requests to Morten Kvello, Department of Gastrointestinal and Pediatric surgery, Oslo University Hospital, Rikshospitalet, Postboks 4950 Nydalen, 0424 Oslo, NORWAY (. e-mail: m.kvello@gmail.com) Received 6 October, 2018 Accepted 5 January, 2019 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). Trial identification: www.clinicaltrial.gov, NCT01551134 Conflict of Interest and Source of Funding: The authors declare no conflicts of interest relevant to this article. M Kvello has received financial support from the University of Oslo Financial Disclosure: The authors declare no financial relationships relevant to this article. © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Is the WHO Creating Unnecessary Confusion Over Breast Milk Substitutes?

No abstract available

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Fecal Fat Concentration and Excretion in the First 2 Years of Life: a Cross-Sectional Study

Objectives: Data on pancreatic exocrine secretion in the youngest children are scarce. The aim of the study was to determine the range of normal values for fecal fat concentration (FFC) and fecal fat excretion (FFE) in infants and toddlers up to 2 years of age. Methods: A total of 160 subjects aged 1 to 24 months (8 groups of 20: aged 1–3, 4–6 months, etc) were included in the study. In all children, FFC (%) and FFE (g/day) were assessed in 3-day stool collection. Results: FFC correlated with age (r = −0.50, P 

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Complementary and Alternative Medicine Use in Children With Inflammatory Bowel Disease

Complementary and alternative medicine (CAM) consists of products and practices that are not considered to be a part of conventional medicine. This article reviews pediatric studies on CAM in inflammatory bowel disease (IBD) along with relevant adult studies. Prevalence of CAM use ranges from 22% to 84% in children with IBD all over the world. CAM use in IBD includes diet changes, supplements, herbals, botanicals, and mind-body therapies. Common reasons for using CAM include severe disease and concern for adverse effects of conventional medicines. Despite widespread use, there are limited studies on efficacy and safety of CAM in children. Small studies suggest a favorable evidence for use of probiotics, fish oil, marijuana, and mind-body therapy in IBD. Adverse effects of CAM are reported but are rare. The article provides current state of knowledge on the topic and provides guidance to physicians to address CAM use in pediatric patients with IBD.

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Use of Breast Milk and Other Feeding Practices Following Gastrointestinal Surgery in Infants

Objectives: The aim of the study was to characterize the enteral feeding practices in infants after gastrointestinal surgery. Methods: We performed a retrospective analysis of infants who underwent intestinal surgery at age

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Should Pediatricians Be Aware of Cystic Echinococcosis? A Literature Review

Among parasitic hepatic cystic lesions, the most common disease is represented by cystic echinococcosis (CE), especially in high endemic countries. European epidemiology of CE in children is difficult to assess because of under-reporting but is increasing, because of high immigration flows from endemic countries and an increased awareness. Hydatidosis can be localized in every part of the body. The liver and lungs are the most common localizations in both children and adults. Multiorgan involvement is rarely reported in children. Different tests are available. Usually the sensitivity of serological screening tests is variable, ranging between 60% and 90%. The immunoblot assay is used as a confirmatory test because of its higher sensitivity and specificity. Radiological tests are the criterion standard for diagnosis of CE, with an ultrasound accuracy of approximately 90%. In case of inactive and uncomplicated cysts the watch-and-wait approach is recommended. Albendazole, currently used for 3 to 6 months consecutively represents the most commonly used drug in children even if there is limited experience in treating children younger than 6 years of age. Percutaneous treatment with the puncture, aspiration, injection, and reaspiration technique is a minimally invasive procedure. Surgery is indicated based on cyst characteristics in case of big cysts with multiple daughter cysts, single superficial cysts at risk of spontaneous or traumatic rupture, cysts related with the biliary tract in which the percutaneous treatment is contraindicated, and cysts compressing related structures.

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Diffuse Intestinal Ganglioneuromatosis Causing Severe Intestinal Dysmotility in a Child With a PTEN Mutation

No abstract available

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Alloimmunity and Cholestasis After Liver Transplantation in Children With Progressive Familial Intrahepatic Cholestasis

Objectives: Bile salt export pump (BSEP) deficiency is an important reason for chronic cholestasis leading to liver transplantation (LT) in early childhood. The underlying pathology is a dysfunction of BSEP due to various mutations in the ABCB11 gene. Cases of clinical recurrence after LT due to alloantibodies directed against BSEP (antibody-induced BSEP deficiency [AIBD]) have been reported. Most of these patients could be controlled by intensified immunosuppression. Methods: We here report on 3 children with BSEP-deficiency and end-stage liver disease, which developed AIBD after LT refractory to extensive immunosuppressive and immunomodulatory treatments; retransplantation was necessary in all 3 patients. In 1 patient, a stem cell transplantation was performed successfully. Results: AIBD seems to be induced by triggering factors such as initial impaired graft function or infections after LT. Conclusions: The underlying mutation may play a role in this process. Intensifying immunosuppression may be able to control AIBD, but some cases seem to be refractory to treatment and require retransplantation. Stem cell transplantation may provide a new therapeutic option for cases refractory to conservative treatment.

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Red Spot Lesions in the Duodenal Bulb Are a Highly Specific Endoscopic Sign of Celiac Disease: A Prospective Study

We have recognized red spot lesions (RSLs) in the duodenal bulb in children with celiac disease (CD) and believe they may represent an underappreciated and distinct endoscopic sign of CD. A total of 171 pediatric patients undergoing esophagogastroduodenoscopy with duodenal biopsy for symptoms consistent with CD were prospectively recruited. There were 75 patients who met criteria for CD and the remaining 96 patients served as symptomatic controls. As compared to endoscopic markers frequently mentioned in literature, RSLs had comparable sensitivity, specificity, positive predictive value, and negative predictive value of 31%, 94%, 80%, and 64%, respectively. If RSLs are noted during endoscopy in a patient with gastrointestinal symptoms that might be the result of CD, then sufficient duodenal biopsies to make the diagnosis of CD should be obtained.

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Hepatotoxicity of Statins as Determined by Serum Alanine Aminotransferase in a Pediatric Cohort With Dyslipidemia

Objective: The aim of the study was to evaluate the hepatotoxicity of statins, as determined by serum alanine aminotransferase (ALT), in children and adolescents with dyslipidemia in real-world clinical practice. Study design: Clinical and laboratory data were prospectively collected between September 2010 and March 2014. We compared ALT levels between patients prescribed versus not prescribed 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors (statins), and then compared ALT before and after initiation of statins. Results: Over the 3.5-year observation period, there were 2704 ALT measurements among 943 patients. The mean age was 14 years; 54% were boys, 47% obese, and 208 patients were treated with statins. Median follow-up after first ALT was 18 months. The mean (SD) ALT in statin and non-statin users was 23 (20) U/L and 28 (28) U/L, respectively. In models adjusted for age, sex, and race, ALT was 2.1 U/L (95% CI 0.1 to 4.4; P = 0.04) lower among statin users, which was attenuated after adjustment for weight category. Patients started on statins during the observation period did not demonstrate an increase in ALT over time (ALT 0.9 U/L [95% confidence interval −5.2 to 3.4] increase per year; P = 0.7). Conclusions: In our study population, we did not observe a higher burden of ALT elevations among pediatric patients on statins as compared to those with dyslipidemia who are not on statins, supporting the hepatic safety of statin use in childhood.

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Development and Pilot Implementation of a Nutrition Curriculum and Rotation in Pediatric Gastroenterology Fellowships

Structured nutrition rotations are rarely offered in pediatric gastroenterology fellowships. The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) Nutrition Committee developed a curriculum to serve as the basis for a rotation in clinical nutrition. We worked directly with 5 fellowship programs to tailor the experience to individual institutions. As part of our pilot study, fellows completed knowledge assessments and self-assessment of comfort level at the start and end of the experience. We saw a trend in improvement of comfort level and increase in mean score on knowledge assessments, but the differences did not meet statistical significance. Fellows who completed the rotation had an increase in comfort level in all topics with most dramatic increases in nutrition management of cystic fibrosis, refeeding syndrome, and cholestasis. Objective measures of nutrition knowledge attainment and use of programmatic feedback to continually improve the learners' experience will help expand the nutrition curriculum to a broader audience.

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Clinical Practice Approach to Nonalcoholic Fatty Liver Disease by Pediatric Gastroenterologists in the United States

Objectives: Nonalcoholic fatty liver disease (NAFLD) is common; however, no information is available on how pediatric gastroenterologists in the United States manage NAFLD. Therefore, study objectives were to understand how pediatric gastroenterologists in the US approach the management of NAFLD, and to identify barriers to care for children with NAFLD. Methods: We performed structured one-on-one interviews to ascertain each individual pediatric gastroenterologist's approach to the management of NAFLD in children. Responses were recorded from open-ended questions regarding screening for comorbidities, recommendations regarding nutrition, physical activity, medications, and perceived barriers to care. Results: Response rate was 72.0% (486/675). Mean number of patients examined per week was 3 (standard deviation [SD] 3.5). Dietary intervention was recommended by 98.4% of pediatric gastroenterologists. Notably, 18 different dietary recommendations were reported. A majority of physicians provided targets for exercise frequency (72.6%, mean 5.6 days/wk, SD 1.6) and duration (69.9%, mean 40.2 minutes/session, SD 16.4). Medications were prescribed by 50.6%. Almost one-half of physicians (47.5%) screened for type 2 diabetes, dyslipidemia, and hypertension. Providers who spent more than 25 minutes at the initial visit were more likely to screen for comorbidities (P = 0.003). Barriers to care were reported by 92.8% with 29.0% reporting ≥3 barriers. Conclusions: The majority of US pediatric gastroenterologists regularly encounter children with NAFLD. Varied recommendations regarding diet and exercise highlight the need for prospective clinical trials. NAFLD requires a multidimensional approach with adequate resources in the home, community, and clinical setting.

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Peutz-Jegher Syndrome With Endoscopic Polypectomy for Subacute Biliary Obstruction

No abstract available

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Alanyl-glutamine Protects Against Damage Induced by Enteroaggregative Escherichia coli Strains in Intestinal Cells

Background: Enteroaggregative Escherichia coli (EAEC) is an important pathogen causing enteric infections worldwide. This pathotype is linked to malnutrition in children from developing countries. Alanyl-glutamine (Ala-Gln) is an immune modulator nutrient that acts during intestinal damage and/or inflammation. This study investigated the effect of EAEC infection and Ala-Gln on cell viability, cell death, and inflammation of intestinal epithelium cells (IEC-6). Methods: Cells were infected with an EAEC prototype 042 strain, an EAEC wild-type strain isolated from a Brazilian malnourished child, and a commensal E coli HS. Gene transcription and protein levels of caspases-3, -8, and -9 and cytokine-induced neutrophil chemoattractant 1 (CINC-1/CXCL1) were evaluated using RT-qPCR, western blot analysis, and ELISA. Results: Infections with both EAEC strains decreased cell viability and induced apoptosis and necrosis after 24 hours. Ala-Gln supplementation increased cell proliferation and reduced cell death in infected cells. Likewise, EAEC strain 042 significantly increased the transcript levels of caspases-3, -8, and -9 when compared to the control group, and Ala-Gln treatment reversed this effect. Furthermore, EAEC induced CXCL1 protein levels, which were also reduced by Ala-Gln supplementation. Conclusion: These findings suggest that EAEC infection promotes apoptosis, necrosis, and intestinal inflammation with involvement of caspases. Supplementation of Ala-Gln inhibits cell death, increases cell proliferation, attenuates mediators associated with cell death, and inflammatory pathways in infected cells.

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Speckle Tracking Analysis of Left Ventricular Systolic Function Following Traumatic Brain Injury: A Pilot Prospective Observational Cohort Study

Background: Systolic dysfunction and reduction in left ventricular ejection fraction (LVEF) has been documented after traumatic brain injury (TBI). Speckle tracking is an emerging technology for myocardial strain assessment which has been utilized to identify subclinical myocardial dysfunction, and is most commonly reported as global longitudinal strain (GLS). We examined myocardial strain and regional strain patterns following moderate-severe TBI. Materials and Methods: We conducted a prospective cohort study of moderate-severe TBI patients (Glasgow Coma Scale≤12) and age/sex-matched controls. Transthoracic echocardiography was performed within the first day and 1 week following TBI. Myocardial function was assessed using both GLS and LVEF, and impaired systolic function was defined as GLS >−16% or LVEF ≤50%. Regional strain patterns and individual strain trajectories were examined. Results: Thirty subjects were included, 15 patients with TBI and 15 age/sex-matched controls. Among patients with adequate echocardiographic windows, systolic dysfunction was observed in 2 (17%) patients using LVEF and 5 (38%) patients using GLS within the first day after TBI. Mean GLS was impaired in patients with TBI compared with controls (−16.4±3.8% vs. −20.7±1.8%, P=0.001). Regional myocardial examination revealed impaired strain primarily in the basal and mid-ventricular segments. There was no improvement in GLS from day 1 to day 7 (P=0.81). Conclusions: Myocardial strain abnormalities are common and persist for at least 1 week following moderate-severe TBI. Speckle tracking may be useful for the early diagnosis and monitoring of systolic dysfunction following TBI. Supported by NIH L30 NS084420. The authors have no conflicts of interest to disclose. Address correspondence to: Vijay Krishnamoorthy, MD, PhD, Department of Anesthesiology, Duke University, 2301 Erwin Road, Durham, NC 27710 (e-mail: vijay.krishnamoorthy@duke.edu). Received August 24, 2018 Accepted December 9, 2018 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

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Abnormal Liver Enzymes in Fat or Lean Children Should Always Be a Cautionary Tale

No abstract available

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Clinical and Genetic Study of Children With Peutz-Jeghers Syndrome Identifies a High Frequency of STK11 De Novo Mutation

Objectives: The present study aims to identify the genotype-phenotype correlation in children with Peutz-Jeghers Syndrome (PJS) through the analysis of STK11 gene mutations in the context of clinical and pathological characteristics. Method: In this observational cohort study, the clinical characteristics of 18 families diagnosed with pediatric PJS were collected. Genomic DNA from the peripheral blood of affected children and their family members was collected. The coding region of STK11 was amplified by PCR and screened for mutation by Sanger sequencing. The families that were negative for STK11 mutation were further assessed by multiplex ligation-dependent probe amplification (MLPA). Result: Initial presentation in affected children was at 1.6 to 14.2 years and included anemia in 8 patients whereas 6 presented for screening by virtue of family history. All patients underwent endoscopy, colonoscopy, and polypectomy. Polyps were distributed throughout the gastrointestinal (GI) tract, including the small intestine, stomach, colon, and rectum. In the 18 pediatric PJS families, STK11 mutations were detected in 8 families by Sanger sequencing, and large deletions were detected in 3 by MLPA, respectively. Nine of the 11 STK11 mutations were de novo, 3 were novel (c.419T>C:p.L140P, c.314T>G:p.L105X), and (c.488_489insACGG p.L164fs). Conclusions: Although the main clinical features of pediatric PJS were similar to those of PJS cases in adults, a high frequency of STK11 de novo mutations were encountered in our population of patients with PJS.

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Steps Forward in the Management of Familial Cholestasis

No abstract available

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The Brussels Infant and Toddler Stool Scale: A Study on Interobserver Reliability

Objectives: The Bristol Stool Form Scale (BSFS) is inadequate for non-toilet trained children. The Brussels Infant and Toddler Stool Scale (BITSS) was developed, consisting of 7 photographs of diapers containing stools of infants and toddlers. We aimed to evaluate interobserver reliability of stool consistency assessment among parents, nurses, and medical doctors (MDs) using the BITSS. Methods: In this multicenter cross-sectional study (2016–2017), BITSS photographs were rated according to the BSFS. The reliability of the BITSS was evaluated using the overall proportion of perfect agreement and the linearly weighted κ statistic. Results: A total of 2462 observers participated: 1181 parents (48.0%), 624 nurses (25.3%), and 657 MDs (26.7%). The best-performing BITSS photographs corresponded with BSFS type 7 (87.5%) and type 4 (87.6%), followed by the BITSS photographs representing BSFS type 6 (75.0%), BSFS type 5 (68.0%), BSFS type 1 (64.8%), and BSFS type 3 (64.6%). The weakest performing BITSS photograph corresponded with BSFS type 2 (49.7%). The overall weighted κ-value was 0.72 (95% CI 0.59–0.85; good agreement). Based on these results, photographs were categorized per stool group as hard (BSFS type 1–3), formed (BSFS type 4), loose (BSFS types 5 and 6), or watery (BSFS type 7) stools. According to this new categorization system, correct allocation for each photograph ranged from 83 to 96% (average: 90%). The overall proportion of correct allocations was 72.8%. Conclusions: BITSS showed good agreement with BSFS. Using the newly categorized BITSS photographs, the BITSS is reliable for the assessment of stools of non-toilet trained children in clinical practice and research. A multilanguage translated version of the BITSS can be downloaded at http://bit.ly/2T8RuiD.

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Association of Maternal Secretor Status and Human Milk Oligosaccharides With Milk Microbiota: An Observational Pilot Study

Background and Objectives: Breast milk contains several bioactive factors including human milk oligosaccharides (HMOs) and microbes that shape the infant gut microbiota. HMO profile is determined by secretor status; however, their influence on milk microbiota is still uncovered. This study is aimed to determine the impact of the FUT2 genotype on the milk microbiota during the first month of lactation and the association with HMO. Methods: Milk microbiota from 25 healthy lactating women was determined by quantitative polymerase chain reaction and 16S gene pyrosequencing. Secretor genotype was obtained by polymerase chain reaction-random fragment length polymorphisms and by HMO identification and quantification. Results: The most abundant bacteria were Staphylococcus and Streptococcus, followed by Enterobacteriaceae-related bacteria. The predominant HMO in secretor milk samples were 2'FL and lacto-N-fucopentaose I, whereas non-secretor milk was characterized by lacto-N-fucopentaose II and lacto-N-difucohexaose II. Differences in microbiota composition and quantity were found depending on secretor/non-secretor status. Lactobacillus spp, Enterococcus spp, and Streptococcus spp were lower in non-secretor than in secretor samples. Bifidobacterium genus and species were less prevalent in non-secretor samples. Despite no differences on diversity and richness, non-secretor samples had lower Actinobacteria and higher relative abundance of Enterobacteriaceae, Lactobacillaceae, and Staphylococcaceae. Conclusions: Maternal secretor status is associated with the human milk microbiota composition and is maintained during the first 4 weeks. Specific associations between milk microbiota, HMO, and secretor status were observed, although the potential biological impact on the neonate remains elusive. Future studies are needed to reveal the early nutrition influence on the reduction of risk of disease.

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Recurrent Abdominal Pain in Children: Is Colonoscopy Indicated?

Recurrent abdominal pain (RAP) in children is common, with most functional in origin. Colonoscopy has sometimes been performed to exclude pathology but its role is unclear. Our aim therefore was to assess the diagnostic yield and role of colonoscopy in these children. Retrospective review of consecutive colonoscopies in a tertiary pediatric hospital between November 2011 and October 2015 was undertaken. Only those with RAP as an indication for procedure were included. Chart review of patients with pain was undertaken to ensure they fulfilled Rome IV criteria. Patient demographics, indication for procedure, and adjunct preprocedure tests were noted. Statistical analyses were performed with SPSS software. A total of 652 colonoscopies were performed, of which 68 (10%) had abdominal pain as one of the indications, and was the sole indication in 15 (2%) patients. All 68 patients had preprocedure serum inflammatory markers measured and 53% (36/68) had stool calprotectin. Positive histology was found in 10% (7/68) including Crohn disease (n = 3), polyps (n = 2), and microscopic colitis (n = 2). The remaining 61 patients had normal colonoscopy and ileocolonic biopsies. Of the 36 patients 5 had raised fecal calprotectin, and all had abnormal histology. Serum inflammatory markers were raised in 4 patients and all also had abnormal calprotectin. No patient with isolated abdominal pain had positive histology. Rectal bleeding was the only associated indication to predict abnormal histology (P = 0.019). Colonoscopy is likely not warranted in children with RAP without bleeding, weight loss, or altered bowel habit. Fecal calprotectin is useful in helping predict positive findings.

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Dysbiosis in Snoring Children: An Interlink to Comorbidities?

Background and Objectives: Early microbial colonization has a key impact on infant health through nutritional, immunological, and metabolic programming. The origin of child snoring is multifactorial and complex, and may thereby also generate long-term health problems. The link between child snoring and gut microbes remains unclear, although indirect evidence exists regarding this relationship. This study aimed to characterize the connection between gut microbiota and child snoring. Methods: In a prospective, observational CHILD-SLEEP birth cohort study, gut microbiota in a subcohort of 43 of these children at 2 years of life was profiled with 16S ribosomal RNA gene amplicon sequencing. Results: A higher abundance of the Proteobacteria phylum, the Enterobacteriaceae family, and Erysipelotrichaceae family, as well as a higher ratio of Firmicutes to Bacteroidetes were detected in snorers as compared to controls. Furthermore, snorers showed significantly lower microbial diversity and richness than non-snorers. Conclusions: The snoring children manifest different gut microbiota as compared with healthy children. Considering that snoring and sleep disorders can be a source of long-term consequences, including cardiovascular, metabolic, immunological, neurocognitive and behavioral consequences, our results proposes early microbiota as a new treatment target.

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A Systematic Review of the Impact of Surgical Special Care Units on Patient Outcomes and Health Care Resource Utilization

Perioperative intermediate care units (termed surgical special care units) have been widely implemented across health systems because they are believed to improve surveillance and management of high-risk surgical patients. Our objective was to conduct a systematic review to investigate the effects of a 3-level model of perioperative care delivery (ie, ward, surgical special care unit, or intensive care unit) compared to a 2-level model of care (ie, ward, intensive care unit) on postoperative outcomes. Our protocol was registered with PROSPERO, the international prospective register of systematic reviews (CRD42015025155). Randomized controlled studies and nonrandomized comparator studies were included. We performed a systematic search of Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, and the Cochrane library (inception – 11/2017). The primary outcome was mortality; secondary outcomes included length of stay and hospital costs. We identified 1995 citations with our search, and 21 studies met eligibility criteria (2 randomized controlled studies and 19 nonrandomized comparator studies; 44,134 patients in total). Surgical special care units were characterized by continuous monitoring (12 studies), the absence of mechanical ventilation (8 studies), nurse-to-patient ratios (range, 1:2–1:4), and number of beds (median: 5; range: 3–33). Thirteen studies reported on mortality. Notable findings included no observed difference in overall in-hospital mortality, but an apparent increase in intensive care unit mortality in a 3-level model of care. This may reflect a decanting of lower acuity patients from the intensive care unit to the surgical special care unit. No significant difference was found in hospital length of stay; however, 2 studies demonstrated reductions in hospital costs with the implementation of a surgical special care unit. Significant clinical and methodological heterogeneity precluded pooled analysis. Given the prevalence of surgical special care units, the results of our review suggest that additional methodologically rigorous investigations are needed to understand the effect of these units on the surgical population. Accepted for publication October 8, 2018. Funding: M.M.L. and D.I.M. are supported by the Ottawa Hospital Alternate Funds Association, Ottawa, Ontario, Canada. M.M.L. is also supported by Scholarship Protected Time Program, Department of Anesthesiology and Pain Medicine, Ottawa, Ottawa, Ontario, Canada. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://bit.ly/KegmMq). Reprints will not be available from the authors. Address correspondence to Manoj M. Lalu, MD, PhD, FRCPC, Department of Anesthesiology and Pain Medicine, Clinical Epidemiology and Regenerative Medicine Programs, Blueprint Translational Research Group, Ottawa Hospital Research Institute, 501 Smyth Rd, PO Box 201B, Ottawa, ON K1H 8L6, Canada. Address e-mail to manojlalu@gmail.com. © 2019 International Anesthesia Research Society

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Effect of Body Mass Index Category on Body Surface Area Calculation in Children Undergoing Cardiac Procedures

BACKGROUND: Many of the common equations used for body surface area determination were either introduced before the widespread prevalence of childhood obesity, contained very few children in their sample, or have not been assessed in overweight/obese children. Therefore, we compared 6 body surface area formulae to determine their performance across body mass index categories using cross-sectional anthropometric data of children who underwent elective cardiac procedures. METHODS: We selected 6 formulae from the literature that included data from pediatric subjects in their derivation. We then substituted measured height and weight into each equation to compute body surface area data for the study subjects. The average values of the 6 formulae were calculated for each patient and used as reference for comparison. Comparisons between each formula and the reference standard were made with the 1-way ANOVA, Pearson correlation coefficient (measure of precision), the Lin concordance correlation coefficient (measure of bias and precision), and the Bland-Altman limit-of-agreement. All comparisons were made across age, sex, and body mass index categories. RESULTS: Among the 1000 (mostly Caucasian: 76.1%) subjects, 16.7% were overweight, while 14.1% were obese and 51.2% were girls. All calculated body surface area data showed a strong positive correlation with each other and the derived reference body surface area values (0.99–1.00; P

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Postoperative Myocardial Injury in Middle-Aged and Elderly Patients Following Curative Resection of Esophageal Cancer With Aggressive or Standard Body Temperature Management: A Randomized Controlled Trial

BACKGROUND: Risk of intraoperative hypothermia is relatively high in middle-aged and elderly patients undergoing curative resection of esophageal cancer, which may cause myocardial ischemia during the early postoperative period. The objective of this study was to compare aggressive or standard body temperature management for lowering the incidence of postoperative myocardial injury that was assessed by troponin levels collected at a priori defined set times in these patients. METHODS: Seventy patients undergoing elective curative resection of esophageal cancer were randomly assigned to undergo aggressive body temperature management (nasopharyngeal temperature ≥36°C) or standard body temperature management (n = 35 in each arm). The primary outcome was myocardial injury, defined as the occurrence of elevated troponin I (>0.06 µg/L) or elevated high-sensitivity troponin T (≥0.065, or 0.02 µg/L≤ high-sensitivity troponin T

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Low Tidal Volume Ventilation in the Surgical Patient: Not Particularly Low and Perhaps Not Particularly Protective

No abstract available

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In Response

No abstract available

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Regional Anesthesia for Pediatric Ophthalmic Surgery: A Review of the Literature

Ophthalmic pediatric regional anesthesia has been widely described, but infrequently used. This review summarizes the available evidence supporting the use of conduction anesthesia in pediatric ophthalmic surgery. Key anatomic differences in axial length, intraocular pressure, and available orbital space between young children and adults impact conduct of ophthalmic regional anesthesia. The eye is near adult size at birth and completes its growth rapidly while the orbit does not. This results in significantly diminished extraocular orbital volumes for local anesthetic deposition. Needle-based blocks are categorized by relation of the needle to the extraocular muscle cone (ie, intraconal or extraconal) and in the cannula-based block, by description of the potential space deep to the Tenon capsule. In children, blocks are placed after induction of anesthesia by a pediatric anesthesiologist or ophthalmologist, via anatomic landmarks or under ultrasonography. Ocular conduction anesthesia confers several advantages for eye surgery including analgesia, akinesia, ablation of the oculocardiac reflex, and reduction of postoperative nausea and vomiting. Short (16 mm), blunt-tip needles are preferred because of altered globe-to-orbit ratios in children. Soft-tip cannulae of varying length have been demonstrated as safe in sub-Tenon blockade. Ultrasound technology facilitates direct, real-time visualization of needle position and local anesthetic spread and reduces inadvertent intraconal needle placement. The developing eye is vulnerable to thermal and mechanical insults, so ocular-rated transducers are mandated. The adjuvant hyaluronidase improves ocular akinesia, decreases local anesthetic dosage requirements, and improves initial block success; meanwhile, dexmedetomidine increases local anesthetic potency and prolongs duration of analgesia without an increase in adverse events. Intraconal blockade is a relative contraindication in neonates and infants, retinoblastoma surgery, and in the presence of posterior staphylomas and buphthalmos. Specific considerations include pertinent pediatric ophthalmologic topics, block placement in the syndromic child, and potential adverse effects associated with each technique. Recommendations based on our experience at a busy academic ophthalmologic tertiary referral center are provided. Accepted for publication December 7, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Alecia L. S. Stein, MD, Department of Anesthesiology, Perioperative Medicine and Pain Management, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami Health System, 1611 NW 12th Ave, Rm SW 301, Miami, FL 33136. Address e-mail to asabartinelli@med.miami.edu. © 2019 International Anesthesia Research Society

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Ophthalmology

EDITORIAL
	Driving blind - Should tests of visual function be mandatory for driving license?	p. 193
	Santosh G Honavar DOI:10.4103/ijo.IJO_150_19
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ONE MINUTE OPHTHALMOLOGY
	Just another chalazion?	p. 195
	Jonathan McLaughlin, Sara E Lally, Carol L Shields DOI:10.4103/ijo.IJO_18_19
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REVIEW ARTICLE
	Visual function assessment, ocular examination, and intervention in children with developmental delay: A systematic approach. Part 1	p. 196
	Meenakshi Swaminathan, Deiva Jayaraman, Namita Jacob DOI:10.4103/ijo.IJO_524_18   Children with special needs form a unique subset with regards to visual function and examination techniques needed to assess them. With more awareness among the general public, neurologists, and pediatricians, these children are referred for assessment to the ophthalmologist or optometrist and sometimes even to the rehabilitation professional at an early age. This clinical practice guideline and review gives a systematic approach for examining the visual functions of a child with special needs. It outlines the procedures to be followed with equipment needed in clinical practice. Functional vision assessment guidelines are also included. This is the first part in a two-part series, with the first part presenting clinical examination guidelines and the second presenting intervention and vision enhancement techniques.
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ORIGINAL ARTICLES
	Causes of visual impairment in applications for blindness certificates in a tertiary center of Bihar and its role in health planning	p. 204
	Anita Ambastha, Rakhi Kusumesh, Shalini Sinha, Bibhuti P Sinha, Gyan Bhasker DOI:10.4103/ijo.IJO_837_18   Purpose: To analyze applications for blindness certificates to find causes of visual impairment (VI), handicap, and blindness in a tertiary hospital of Bihar. Methods: Applications for blindness certificates were analyzed over a two-year period. The main cause of blindness, visual handicap, and VI in these applications was ascertained by age group and etiology. VI disability percentages and definitions proposed by Governmen of India (category 0–4; 20–100%) were used to categorize and give percentage to all applicants. Results were compared with data from studies on blindness certificates and population based studies. Results: In total, 203 applicants were reviewed. Mean age was 23.5 ± 7.9 years. Overall, most common cause of visual handicap (40–100% impairment) and blindness (75–100% impairment) was macular pathology (P <.05), while most common cause of overall VI (20–100% impairment) was amblyopia. In age group 0–15 years, most common causes of blindness/visual handicap were congenital globe and hereditary retinal or optic nerve disorders (P = 0.016). In age group 16–30 years, macular pathology was the most common cause of visual handicap [P = 0.007], while amblyopia was the most common cause of VI [P = 0.00]. Between 31 and 45 years of age group, corneal scar in one eye was the most common cause of VI, while macular scar in both eyes was the most common cause of visual handicap. Glaucoma and diabetic retinopathy were the most common causes of blindness/visual handicap between 46 and 65 years and above 65 years of age, respectively. Data about causes of VI such as amblyopia, complicated cataract surgery, and one eyed blindness could not be ascertained by analyzing blindness certificate alone. Conclusion: Data from applications for blindness certificates provide valuable information regarding different causes of VI that might otherwise not be eligible for blindness certification and provide an insight into the overall trends in disease profile and service delivery.
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	Iris and knot configuration after Single Pass Four Throw (SFT) pupilloplasty as imaged by the spectral-domain optical coherence tomography	p. 209
	Dhivya Ashok Kumar, Amar Agarwal, Radhika Chandrasekar, Nagaraj Jaganathasamy DOI:10.4103/ijo.IJO_885_18   Purpose: To analyze the morphological changes in the iris-knot complex configuration using spectral-domain optical coherence tomography (SD-OCT) following the single pass four throw (SFT) pupilloplasty. Methods: In this retrospective case series, eyes with SFT pupilloplasty were examined by SD-OCT (Optovue). Iris morphology compared to the normal iris, presence of specific patterns (single hump, double humps, peaks and valleys, tethering), prolene suture, knot complex (length and orientation), and intraocular lens (IOL) vault were evaluated. Results: Overall, 41 knots of 26 patients with a mean time duration of 3.1 ± 2 months from surgery were analyzed. Iris configurations seen were single hump (n = 28, 63.8%), double humps (n = 7, 17%), loop (n = 2, 4.8%), flat (n = 3, 7.3%), and mulberry (n = 1, 2.4%). The mean length and the height of the knot complex was 784.1 ± 433.7 μm and 317.7 ± 110.4 μm, respectively. Knot positions were at 3 clock hours in 9 eyes (21.9%), 9 in 8 eyes (19.5%), and others in 24 eyes (58.5%). Cut end of the prolene suture was detectable in 26 eyes (63.4%) as hyper-reflective line, and the mean cut length was 465.8 ± 321.1 μm. The suture was predominantly vertically oriented (80.6%) to the iris with a mean distance of 3.6 ± 0.3 mm (2.6–4 mm) away from corneal endothelium. The mean distance from the knot complex and the IOL was 289.2 ± 146 μm and the mean anterior chamber depth was 4.1 ± 0.1 mm. Conclusion: A significant change in iris configuration was noted after SFT pupilloplasty, and vertically oriented retained prolene suture was predominant with good endothelial vault.
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	Perceived difficulties and complications in learners of phacoemulsification: A principal component analysis model	p. 213
	Sagnik Sen, Mukesh Patil, Rohit Saxena, Atul Kumar, Sreelakshmi P Amar, Deepsekhar Das, Anand Singh Brar, Pragya Saini DOI:10.4103/ijo.IJO_1133_18   Purpose: To evaluate the difficulty perceived of each step of phacoemulsification and analyze the factors affecting them. Methods:Overall, 12 trainee residents were allotted 10 cases of phacoemulsification of eyes with senile cataract, under a single observer, and the steps of each surgery were rated from very easy to very difficult with a questionnaire. The completion rates of steps and complications of each surgery were noted. Principal component analysis of the responses to the difficulty level questionnaire was conducted to obtain factors resulting in the perceived difficulty. Results: The lowest difficulty scores were for initial step of incision creation (1.63 ± 0.84), followed by intraocular lens insertion (2.51 ± 0.8). The most difficult step was divide/chop of the nucleus (3.74 ± 0.97) followed by phacoemulsification (3.32 ± 0.82). Highest completion rates were seen for the initial steps of the surgery and the lowest for divide/chop. We identified two major patterns of difficulty among the trainees – one for steps involving high amount of binocularity and the other, for steps involving high precision of hand control. The rate of complication of our study was within acceptable range. Conclusion: Although trainees have practiced phacoemulsification steps on simulation, real-life situation may bring in unprecedented level of difficulty and challenges, which may be documented and used for targeted improvement of surgical skills. Stereopsis and hand control training should form a major part of training modules of cataract surgery both on simulation and real-life scenarios.
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	Retrospective study on outcomes of terminal chop technique of nuclear fragmentation in phacoemulsification and combined surgery: An observational study	p. 217
	Arvind K Morya, Sahil Bhandari, Anushree Naidu DOI:10.4103/ijo.IJO_711_18   Purpose: Terminal chop, a new technique of nuclear segmentation, has been recently described in literature. The technique is considered to be a safe and effective option. Methods: We did a retrospective study to evaluate the outcome of terminal chop. Patients operated for terminal chop (phacoemulsification with or without trabeculectomy) from October 2016 to July 2018 were included in the study. Results: In all, 933 patients were included in the study. The grade of nuclear sclerosis ranged from 2 to 5. All the patients had a significant visual improvement at 1 month postop. Around 3.4% had pseudoexfoliation and 8.89% of the eyes underwent combined surgery. Cumulative dissipated energy showed a proportionate relation with the grade of nucleus. Intraoperative complication rate was 0.08%. Postoperative complication rate was 3.50%. Conclusion: Terminal chop proved to be a safe, reproducible, and effective technique of nuclear segmentation in different grades of cataract.
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	Frequency and surgical difficulties associated with pseudoexfoliation syndrome among Indian rural population scheduled for cataract surgery: Hospital-based data	p. 221
	Rajesh S Joshi, Sonali V Singanwad DOI:10.4103/ijo.IJO_931_18   Purpose: To study the frequency and intraoperative difficulties associated with pseudoexfoliation (PXF) syndrome at a tertiary eye care center in a rural central India. Methods: This study included patients scheduled for cataract surgery who were diagnosed with PXF syndrome. All patients underwent a complete ophthalmologic evaluation, including slit-lamp examination, tonometry, gonioscopy, and ophthalmoscopy before the surgery. Cataract surgeries were performed by a single surgeon who reported the intraoperative difficulties. Results: In total, 1022 phakic eyes of 1823 patients were evaluated, 226 of whom (22.1%) were diagnosed with PXF syndrome. Most eyes (n = 81, 35.8%) with PXF syndrome were ≥81 years old. Eighty-six eyes (38.1%) had bilateral involvement, whereas 70 (30.9%) had right or left eye involvement. Further, PXF material was distributed on the iris, pupil, and lens in 70 eyes (30.9%) and on the pupillary margin in 36 eyes (15.9%). The mean pupillary dilation was 5.1 (±1.4) mm in patients with PXF syndrome compared with 7.2 (±1.6) mm in those without it (P = 0.03). Grade VI cataract was observed in 93 eyes (41.2%) and hypermature cataract was the most commonly observed cataract stage. Twenty-one eyes (9.3%) had increased intraocular pressure. Intraoperative difficulties were encountered in 62 eyes (27.4%) with poor pupillary dilation being the most common problem (32 eyes, 14.2%), followed by zonular dehiscence (18 eyes, 8%). Conclusion: This hospital-based study showed that PXF syndrome is common in Indian rural population and that the intraoperative complication rate in these patients is high.
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	Quantification of RAPD by an automated pupillometer in asymmetric glaucoma and its correlation with manual pupillary assessment	p. 227
	Manju R Pillai, Sapna Sinha, Pradeep Aggarwal, Ravilla D Ravindran, Claudio M Privitera DOI:10.4103/ijo.IJO_648_18   Purpose: The relative afferent pupillary defect (RAPD) is an important sign of asymmetrical retinal ganglion cell damage. The purpose of this study was to quantify RAPD by a pupillometer (RAPiDo, Neuroptics) and assess its correlation with asymmetric glaucoma and manual pupillary assessment. Methods: A total of 173 subjects were enrolled in the study and categorized into glaucoma, n = 130, and control, n = 43. Subjects were all recruited in the Glaucoma Clinic of the Aravind Eye Hospital in Madurai during their follow-up. They were 18 years and older, with best corrected visual acuity of 6/36 or better. Exclusion criteria included all retinal pathologies, optic atrophies, ocular injuries, severe uveitis, cloudy corneas, dense cataracts, or use of mydriatics or miotic drugs. RAPD was assessed in all subjects using an automated pupillometer and the results were compared with the swinging flash light test conducted on the same subjects by an experienced ophthalmologist. We looked at the correlation between RAPD and the intereye difference in cup-to-disc ratio (CDR), mean deviation (MD) of visual field testing, and retinal nerve fiber layer (RNFL) thickness. Sensitivity and specificity were assessed by area under the receiver operator characteristic (AUROC) analysis. Results: Glaucoma patients had significant RAPD (0.55 ± 0.05 log units) when compared with the controls (0.25 ± 0.05 log units), P < 0.001. Significant intereye differences in CDR, MD, and RNFL between glaucoma and control (P < 0.001) were seen. There was a good correlation between the magnitude and sign of RAPD and these intereye differences in CDR (r = 0.52, P < 0.001), MD (r = 0.44, P < 0.001) and RNFL thickness (r = 0.59, P < 0.001). When compared with the experienced ophthalmologist, AUROC was 0.94, with 89% sensitivity and 91.7% specificity. Conclusion: The good correlation between the magnitude of RAPD, as measured by the automated pupillometer, and intereye differences in MD, CDR, and RNFL thickness in glaucomatous, and the good sensitivity and specificity when compared with the experienced ophthalmologist, suggest that pupillometry may be useful as a screening tool to assess asymmetric glaucoma.
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	Intermediate-term outcome of Aurolab aqueous drainage implant	p. 233
	Reji Philip, Premanand Chandran, Nabeed Aboobacker, Mrunali Dhavalikar, Ganesh V Raman DOI:10.4103/ijo.IJO_675_18   Purpose: To report the intermediate-term safety and efficacy of Aurolab aqueous drainage implant (AADI) in patients with glaucoma. Methods: Retrospective review of patients who underwent AADI between January 2013 and December 2016. Patients aged >16 years and with a minimum follow-up of 6 months were included. Success was defined as complete when the intraocular pressure was ≥6 and ≤21 mmHg without antiglaucoma medication and as qualified if those requiring additional antiglaucoma medications were included. Results: The study included 55 patients (55 eyes) with a mean age ± standard deviation (SD) of 47.3 ± 18.1 years with a mean follow-up of 16.7 ± 11.4 months. Mean intraocular pressure reduced from 30.8 ± 11.1 mmHg to 13.1 ± 4.7, 14.1 ± 4.8, 15.7 ± 2.5 (P < 0.001) mmHg at 6 months, 1 year, and 2 years, respectively. The mean number of antiglaucoma medications reduced from 3.4 ± 1 to 0.8 ± 1.2, 0.7 ± 1.1, 0.8 ± 1 (P < 0.001) at 6 months, 1 year, and 2 years, respectively. The cumulative probability of complete and qualified success was 62% and 100% at 6 months, 54% and 92% at 1 year, and 43% and 88% at 2 years, respectively. Four patients failed during the follow-up period. Postoperative complication occurred in 28 eyes (51%), of which 17 eyes (31%) required intervention. Conclusion: AADI is a safe and effective treatment for the control of intraocular pressure in patients with glaucoma.
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COMMENTARY
	Commentary on: Glaucoma drainage devices: Boon or bane	p. 238
	Sushmita Kaushik DOI:10.4103/ijo.IJO_1234_18
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ORIGINAL ARTICLES
	Renewal of driving license in India and glaucoma: A study of prevalent practice and its lacunae	p. 240
	Gowri J Murthy, Ajinkya V Deshmukh, Ayyappa R Mallidi, Praveen R Murthy, Jyoti S Kattige, Vinay R Murthy DOI:10.4103/ijo.IJO_776_18   Purpose: Glaucoma affects different aspects of vision including visual field. This prospective observational study aims to collect details of driving license (DL) renewal procedure (in an urban metro in India) among patients with diagnosed glaucoma and the method of reporting of vision-related requirements during renewal. Methods: One-hundred patients with diagnosed glaucoma above 40 years, having valid DL (with at least one renewal cycle), were included. Patients with other ocular comorbidities were excluded. Driving Habits Questionnaire and a questionnaire about license renewal were administered. Driving eligibility was compared to international guidelines. Results: Study population included patients with 69% early, 29% moderate, and 2% advanced glaucoma. Sixteen percent of patients had stopped driving. Legal license renewal procedure was bypassed by 45%. Form-1 was not submitted by 43% and 49% did not submit Form-1A at the time of renewal. Only 7.01% mentioned about glaucoma in the self-declaration form. None were asked about their visual field during renewal. Among 61 patients who submitted a medical certificate, the undersigning doctor was an ophthalmologist in only six patients. Thirty percent patients with valid Indian DL would not have satisfied International College of Ophthalmologists guidelines. Driving difficulties were experienced by 44%, more so in advanced glaucoma (F (1, 82) = 22.12, P < 0.001). Conclusion: Vision-related testing at the time of renewal of DL is inadequate in India. Chronic eye diseases such as glaucoma are commonly not self-declared or detected at pre-renewal testing. Clear-cut guidelines about visual requirements and implementation are required to prevent road traffic events because of vision-related errors.
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	Clinical profile of uveitis patients developing central serous chorioretinopathy: An experience at a tertiary eye care center in India	p. 247
	Parthopratim Dutta Majumder, Nitin Menia, Sridharan Sudharshan, Chetan Rao, Sudha K Ganesh, Jyotirmay Biswas DOI:10.4103/ijo.IJO_831_18   Purpose: To evaluate clinical profile of patients with uveitis who developed central serous chorioretinopathy (CSC). Methods:Retrospective case series of consecutive patients of uveitis with CSC managed at a tertiary eye care center in India between 1994 and 2014. The data about clinical features, investigations, treatment, and outcomes were obtained from their medical records. Results: A total of 31 eyes of 26 patients with uveitis with a diagnosis of CSC between June 1994 and May 2014 were included in the study. The mean age of presentation was 42.8 ± 9.2 years, and 88.4% of the patients were male. CSC was bilateral in 19.2% of the patients, and in 38.4% patients uveitis was because of infectious etiology. CSC developed in 23 (88.5%) patients when they were on oral corticosteroid. The most common cause of uveitis in our study was choroiditis (48.4%), followed by retinal vasculitis (12.9%). The mean time for resolution of CSC was relatively less in patients with uveitis because of infectious etiology. In 10% eyes vision remained the same and deterioration of vision was noted in 19% eyes. Best corrected visual acuity of the patients at the time of presentation with CSC was 0.56 ± 0.34 and after the resolution of CSC was 0.48 ± 0.5 (P < 0.0005). Conclusion: Patients with choroidal inflammations are more prone to develop CSC compared with other subtypes of uveitis. Management of CSC in uveitis can be challenging.
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	Choroidal thickness in normal Indian eyes using swept-source optical coherence tomography	p. 252
	Amber A Bhayana, Vinod Kumar, Akshay Tayade, Mahesh Chandra, Parijat Chandra, Atul Kumar DOI:10.4103/ijo.IJO_668_18   Purpose: The purpose of this study is to provide normative database for subfoveal choroidal thickness in Indian eyes using swept-source optical coherence tomography. Methods: This is a cross-sectional study based at a tertiary eye care center in Northern India. Two hundred and thirty eight eyes of 119 healthy subjects were examined in terms of axial length, spherical equivalent, and choroidal thickness. Inclusion criteria included age 19–60 years, no retinal or choroidal disorder, and patients with clear media and good fixation. Patients with high hypermetropia (>4 D) or myopia (>6 D) or any systemic disease likely to affect choroidal thickness were excluded. Twelve radial line scans were obtained centered on the fovea that were used to calculate choroidal and retinal thickness in 9 early treatment diabetic retinopathy study (ETDRS) zones. Results: The mean age of all the subjects was 28.70 ± 11.28 years; mean axial length was 23.63 ± 1.96 mm, and mean spherical equivalent was − 0.92 ± 3.08 D. The mean subfoveal choroidal thickness was 299.10 ± 131.2 μ and mean foveal thickness was 239.92 ± 48.16 μ. A negative correlation was found between subfoveal choroidal thickness and age (r = −0.0961, P = 0.1392) and axial length (r = −0.3166, P < 0.001). A statistically significant positive correlation was found between subfoveal choroidal thickness and refractive error (r = 0.2393, P = 0.0002). Conclusion: This study provides normative database for subfoveal choroidal thickness and foveal thickness using swept-source optical coherence tomography. The choroidal thickness measured with swept-source platform is slightly higher than that reported with spectral domain platforms.
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COMMENTARY
	Commentary: Choroidal thickness in the era of swept-source optical coherence tomography	p. 256
	Aniruddha Agarwal DOI:10.4103/ijo.IJO_1893_18
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ORIGINAL ARTICLE
	Outcome of delayed adjustable strabismus surgery in children using a bow-tie optional adjustable technique	p. 258
	R Muralidhar, Lal Churawan, M Sekar, AP Chidambaram, P Mugdha, D Ramamurthy DOI:10.4103/ijo.IJO_398_18   Purpose: The aim of this article is to study the feasibility of a delayed adjustable technique of strabismus surgery in children using an optional adjustable suture technique. Methods: The retrospective study included patients <12 years of age. Recessions were done using an optional adjustable bow-tie technique and resections were done by the conventional technique. Patients were evaluated on the third postoperative day and adjustments done when needed. Statistical analysis was done using Microsoft Excel 2010®. Results: The study included 11 patients with exotropia and 16 patients with esotropia. The mean age of the patients was 5.2 years (range 1–11 years). The mean preoperative distance deviation was 46.7 ± 10.4 prism diopters (PD) for exotropic patients and 47.1 ± 16.9 PD for esotropic patients. The mean preoperative near deviation was 46.6 ± 11 PD for exotropic patients and 52.4 ± 17.1 PD for esotropia. Two patients with exotropia (18.2%) and four patients with esotropia (25%) were adjusted under intravenous ketamine in the operating room under anesthetist supervision. No difficulty was encountered in advancing/recessing the muscles. The success rate at 1 month was 100% for exotropia and 87.5% for esotropia. The success rate at the final follow-up was 81.8% for patients with exotropia and 68.7% for patients with esotropia. Conclusions: This delayed optional adjustable strabismus surgery technique provides good short-term results and lower adjustment rates.
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COMMENTARY
	Commentary: Adjustable strabismus surgery	p. 263
	Rohit Saxena, Rebika Dhiman DOI:10.4103/ijo.IJO_1000_18
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SURGICAL TECHNIQUE
	Modified Faden operation –A new surgical technique	p. 264
	Manjula Jayakumar, Suganya Vel, Amar Agarwal DOI:10.4103/ijo.IJO_952_18   Faden operation was first described in 1912. It weakens the muscle in its field of action without much slackening and alteration in the primary position. When combined with recession the weakening effect is more. It is a useful surgery in esotropia with high accommodative convergence, nystagmus blockage syndrome, dissociated vertical deviation, Duane's retraction syndrome with up or downshoots, and in sixth nerve paresis, where it is performed on the contralateral normal yoke muscle to increase the field of binocular vision. The conventional procedure is cumbersome due to small working space, entanglement of sutures, and posterior location of Faden site which is not easily accessible. We have modified the Faden operation by using a single 5-0 double-armed polyester suture, which is much easier and simpler to perform, and have done it in a series of small angle esotropias combined with recession. This paper demonstrates the surgical technique so that this surgery can be performed with ease by more surgeons.
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PHOTO ESSAY
	Ocular argyrosis: A case with silver deposits in cornea and lens	p. 267
	Lakshey Dudeja, Ishani Dudeja, Anuja Janakiraman, Manohar Babu DOI:10.4103/ijo.IJO_730_18
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	Anterior chamber migration of intravitreal dexamethasone implant in glued intraocular lens	p. 268
	Dhivya Ashok Kumar, Atul Dhawan, Soumya Narayanan, Amar Agarwal DOI:10.4103/ijo.IJO_841_18
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	Hyperpigmented torpedo maculopathy	p. 270
	PC Ranjith, Anantharaman Giridhar DOI:10.4103/ijo.IJO_886_18
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	Pigmented paravenous retinochoroidal atrophy	p. 271
	Saurabh Deshmukh, Dipankar Das, Hemalata Deka, Harsha Bhattacharjee, Awaneesh Upadhyay, Krati Gupta DOI:10.4103/ijo.IJO_1202_18
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	A rare case having hemi-retinal artery occlusion in one eye and hemi-retinal vein occlusion in the other: Diverse manifestations of retinal vascular occlusion	p. 273
	Pulak Agarwal, Vinod Agarwal, Shorya Azad DOI:10.4103/ijo.IJO_987_18
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OPHTHALMIC IMAGES
	Bilateral vitritis as an initial presentation of primary central nervous system lymphoma	p. 275
	Nitin K Menia, Ranjan Behera, Reema Bansal, Nalini Gupta, Astha Takkar, Vivek Lal DOI:10.4103/ijo.IJO_773_18
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	A complication of ischemic branch retinal vein occlusion	p. 276
	PC Ranjith, Anantharaman Giridhar DOI:10.4103/ijo.IJO_882_18
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	Congenital tortuous retinal vessels	p. 277
	Mohit Dogra, Mangat R Dogra DOI:10.4103/ijo.IJO_1281_18
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	Autofluorescence of optic disc drusens	p. 278
	Nitin K Menia, Swati Kiran, Reema Bansal DOI:10.4103/ijo.IJO_888_18
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	Endoscopic view of mascara laden lacrimal sac with canalicular involvement	p. 279
	Nishi Gupta, Smriti Bansal, Arpan Gandhi DOI:10.4103/ijo.IJO_1348_18
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CASE REPORTS
	Consecutive cyclic esotropia – A case report	p. 280
	Niranjan K Pehere, Usha B Kommineni, Ramesh Kekunnaya DOI:10.4103/ijo.IJO_1018_18   Cyclic esotropia, a rare condition of obscure etiology characterized by regularly alternating periods of esotropia and orthophoria. We present a case of a 7-year-old boy who underwent surgical correction for intermittent exotropia elsewhere and developed esotropia with cyclic pattern post-operatively. Initially the cycle was of half-day orthophoria and half-day esotropia, which later became one full day of esotropia and one day of orthophoria. During re-surgery, right lateral rectus was found to have a stretched scar which was resected and then advanced and medial rectus was recessed. Post-surgery the child was orthophoric without cyclic pattern.
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	Human ocular thelaziasis caused by gravid Thelazia callipaeda – A unique and rare case report	p. 282
	Meenakshi Sharma, Dipankar Das, Harsha Bhattacharjee, Saidul Islam, Nilutparna Deori, Gayatri Bharali, Sumegha Tomar, Priyank Bhola, Apurba Deka DOI:10.4103/ijo.IJO_1110_18   An 80-year-old male reported to the clinic with complaints of diminished vision, foreign body sensation, and occasionally some black object moving in front of the right eye. Detailed ocular examination revealed three slender creamy white live worms in the conjunctival sac of the right eye. Total three worms were retrieved and sent to the pathology department for detailed examination. The worm was identified as gravid Thelazia callipaeda. As per the search results in PubMed and Cochrane search engine, this is the first report of human case of gravid Thelazia infestation with simultaneous existence of embryonated or ensheathed eggs and primary-stage larvae in the same worm.
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	Uncontrolled neovascular glaucoma – an alarming manifestation of chronic myeloid leukemia on imatinib therapy – a case report and review of literature	p. 285
	Prakhyat Roop, Dewang Angmo, Neha Kamble, Ankit S Tomar DOI:10.4103/ijo.IJO_1288_18   A 45-year-old diabetic male, with diabetic retinopathy and medically uncontrolled neovascular glaucoma (NVG) underwent intracameral bevacizumab followed by trabeculectomy, with controlled intraocular pressures (IOP) post-operatively, OD: 12 mmHg; OS: 14 mmHg. Patient was referred to hematology, where he was diagnosed as chronic myeloid leukemia (CML) and started on imatinib mesylate. Thereafter, he presented with recurrence of neovascularization and vascularization of the bleb along with OS vitreous hemorrhage at 6 weeks follow-up. While he was planned for OS vitreo-retinal surgery, he presented with OD spontaneous hyphema with raised IOP (OD: 38 mmHg, OS: 16 mmHg). He had maintained a tight glycemic control. Following imatinib therapy, there was a rapid progression and recurrence of neovascularization, eventually leading to failure of trabeculectomy OD and bilateral severe loss of vision. Imatinib may be implicated in the worsening of NVG in CML patients, especially with co-existing diabetes and thus, such patients should receive regular thorough ophthalmic evaluation as long as imatinib continues.
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	Suprachoroidal hemorrhage after removal of releasable suture with globe massage post-trabeculectomy	p. 287
	Jyoti Shakrawal, Shreyas Temkar, Ramanjit Sihota, Pradeep Venkatesh DOI:10.4103/ijo.IJO_452_18   A 19-year-old female, having aniridia with secondary glaucoma, presented with uncontrolled intraocular pressure (IOP) in the right eye (RE) on maximal topical and systemic medications. On examination, RE had a subluxated cataractous lens with advanced cupping. She underwent trabeculectomy with mitomycin C. On postoperative day 1, as the IOP was 32 mmHg, one releasable suture was removed followed by gentle bleb massage. On postoperative day 2, suprachoroidal hemorrhage was noted, for which the patient underwent two drainage procedures. Hemorrhagic choroidals resolved completely 4 weeks after drainage.
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	Macular toxicity after short-term hydroxychloroquine therapy	p. 289
	Isil Pasaoglu, Funda E Onmez DOI:10.4103/ijo.IJO_732_18   We report an unusual case of hydroxychloroquine (HCQ) toxicity after only 2 months of starting the treatment. A 42-year-old woman presented with visual impairment. Her visual acuity was 20/20 in the right eye and 20/25 in the left eye. Ophthalmologic examination revealed a bull's eye pattern in both eyes which was more prominent in the left eye. She had received HCQ therapy (400 mg/day) for 1 month, and had been taking 200 mg/day for 1 month for the treatment of rheumatoid arthritis. HCQ macular toxicity is rarely seen in short-term use, before 5 years, and to our knowledge, there is only one other case reported in the literature.
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	Quetiapine associated Central Serous Chorioretinopathy: Implicit role of serotonin and dopamine pathways	p. 292
	Manish Jain DOI:10.4103/ijo.IJO_929_18   A 30-year-old insomniac, an off-label user of quetiapine, presented with blurring of central vision, eventually diagnosed as central serous chorioretinopathy. A potential association was suspected based on the drug's actions on the autonomic nervous system. He showed improvement on drug withdrawal; then he unwittingly resumed quetiapine and had a recurrence. Possible underlying mechanisms that include alteration in choroidal perfusion through serotonin and dopamine receptors are discussed. Although retinal vein occlusions and pigment epithelial detachment have been described with quetiapine, to the author's knowledge, this is the first case report of quetiapine-associated central serous chorioretinopathy.
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	Multicolor imaging findings in torpedo maculopathy	p. 295
	Ramesh Venkatesh, Bharathi Bavaharan, Naresh K Yadav DOI:10.4103/ijo.IJO_1317_18   We describe the multicolor imaging findings in two cases of Torpedo maculopathy (TM). Multicolor imaging can be a useful tool in identifying the level of retinal and choroidal layer involvement in TM. This imaging modality further confirms the hypothesis that TM is a localized congenital abnormality of retinal pigment epithelium pigmentation which leads to outer retinal and inner choroidal degeneration.
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	Optical coherence tomography angiography features of retinitis post-rickettsial fever	p. 297
	Mahesh Shanmugam, Vinaya Kumar Konana, Rajesh Ramanjulu, KC Divyansh Mishra, Pradeep Sagar, Dilip Kumar DOI:10.4103/ijo.IJO_799_18   The intraocular manifestations of rickettisial retinitis include retinal vasculitis, maculopathy, optic neuritis, and neurosensory detachment. Extensive leakage of dye on the fundus fluorescein angiography may obscure visualization in eyes with retinitis. We report the vascular changes in eyes with rickettsial retinitis and its response to treatment using optical coherence tomography angiography. The microvascular abnormalities we noted were, capillary drop out areas corresponding to retinitis patches, vascular loops, and pruning of vessels. The choriocapillary slabs showed signal void areas. Post-treatment there was vascular remodeling with decrease in non-perfused area, appearance of new vascular lateral branching, and appearance of collaterals.
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	In vivo diagnosis of intraocular osseous metaplasia in neovascular age-related macular degeneration	p. 300
	Hibba Quhill, Stephen Stewart, Ian G Rennie DOI:10.4103/ijo.IJO_1076_18   A 75-year-old man presented with deterioration of right eye vision for 6 months. He had no relevant medical history. Fundus examination revealed subretinal fluid, fibrosis, and subretinal hemorrhages. Ocular coherence tomography of the right macula illustrated an underlying subretinal lesion with internal lamellae, resembling trabecular bone elsewhere in the body. Bruch's membrane was clearly intact beneath the lesion, indicating an extrachoroidal location. The lesion appeared highly reflective on B-scan ultrasonography, consistent with ossification. Although initially misdiagnosed as choroidal osteoma, this lesion represents in-vivo intraocular osseous metaplasia at the site of neovascular age-related macular degeneration. The authors believe that similar lesions may have been misdiagnosed as "atypical" osteoma caused by failure to identify their extrachoroidal location.
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	Do oblate eyeballs exist? A rare case of rhegmatogenous retinal detachment in an elliptical globe	p. 302
	M Dheepak Sundar, Prakhyat Roop, Atul Kumar, Rohan Chawla, Nasiq Hasan DOI:10.4103/ijo.IJO_1150_18   A patient, being a moderate myope with an axial length of 24.71 mm, presented to us with a fresh rhegmatogenous retinal detachment and marked peripheral chorioretinal degeneration. Difficulty in maneuvering with the standard 23 gauge vitrectomy cutter, inability to identify the break due to poor peripheral contrast, inadequate laser uptake, and an unusual large silicon oil fill (7.3 ml) were a few findings raising suspicion. Postoperative ocular ultrasonography showed an oblate eyeball with a relatively longer oblique axis (26.1 mm) as compared to the axial length confirming our suspicion. Oblateness should be suspected when the chorioretinal degenerations are more marked in the periphery as compared to the posterior pole. Intraoperative difficulties should be kept in mind while operating such cases.
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LETTERS TO THE EDITOR
	Mr. Jack J. Kanski (1939-2019): A tribute	p. 306
	Suresh K Pandey, Vidushi Sharma DOI:10.4103/ijo.IJO_37_19
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	Commentary: Pseudopestalotiopsis theae keratitis	p. 307
	Prashant Garg DOI:10.4103/ijo.IJO_1490_18
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	Vitamin D supplementation in patients with xeroderma pigmentosum	p. 308
	Ashik Mohamed, Archana Bhargava, Sunita Chaurasia DOI:10.4103/ijo.IJO_1319_18
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	Changes in pattern electroretinogram after application of 0.01% atropine eye drops	p. 309
	Mihir Kothari, Deepak Bhat, Nitu Khadse, Rishika Jain, Vivek Rathod, Pallavi Aru DOI:10.4103/ijo.IJO_989_18
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	Comment on: Validating the pachychoroid disease spectrum using multimodal imaging	p. 310
	Jay U Sheth, Anantharaman Giridhar DOI:10.4103/ijo.IJO_1460_18
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	Response to comment on: Validating the pachychoroid disease spectrum using multimodal imaging	p. 312
	Guruprasad Ayachit, Apoorva Ayachit, Harsha Nadgir, Shrinivas Joshi DOI:10.4103/ijo.IJO_1870_18
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	Comment on: Bilateral combined central retinal artery and vein occlusion in a 3-year-old child with nephrotic syndrome	p. 312
	Anamika Dwivedi, Sujata Lakhtakia DOI:10.4103/ijo.IJO_1633_18
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