Ophthalmic and Vision Research

Visual impairment in kurdistan and trend of epidemiologic eye studies in Iran Per Kallestrup Journal of Ophthalmic and Vision Research 2019 14(2):123-124

Indications and surgical techniques for corneal transplantation at a tertiary referral center Hossein Jamali, Ahmad Reza Gholampour Journal of Ophthalmic and Vision Research 2019 14(2):125-130 Purpose: The study aimed to review the indications and techniques for corneal transplantation at a tertiary referral center over a 5-year period. Methods: Records of patients who underwent corneal transplantation at Khalili Medical Center, Shiraz, Iran from September, 2012 to September, 2017 were reviewed. Results: A total of 1149 eyes of 956 patients underwent corneal transplantation. The most common indication was infectious corneal ulcers (n = 296, 25.8%), followed by keratoconus (n = 243, 21.1%), bullous keratopathy (n = 219, 19.1%), failed grafts (n = 117, 10.2%), non-herpetic corneal scars (n = 113, 9.8%), corneal stromal dystrophies (n = 33, 2.9%), pellucid marginal degeneration (n = 31, 2.7%), and trauma (n = 26, 2.3%); other indications included thin descemetocele, post-herpetic corneal scar, endothelial corneal dystrophies, anterior segment dysgenesis, corneal ectasia after laser in situ keratomileusis, and corneal fibrosis. Corneal transplantation techniques included penetrating keratoplasty (PKP, n = 789, 68.7%), deep anterior lamellar keratoplasty (DALK, n = 187, 16.3%), Descemet's stripping automated endothelial keratoplasty (n = 171, 14.9%), and keratolimbal allograft (n = 2, 0.1%) in descending order. In children (aged ≤18 years), the most common indication was keratoconus (n = 32, 41.6%), and the most common technique was PKP (n = 50, 64.9%). In patients aged 19-27 years, the most common indication was keratoconus (n = 89, 64.5%), and the most common technique was PKP (n = 75, 54.4%). Conclusion: Infectious corneal ulcer was the most common indication, and PKP was the most prevalent technique in patients undergoing corneal transplantation. DALK was an emerging alternative surgical treatment in patients with corneal disorders in which corneal endothelium is spared.

Autologous platelet-rich plasma eye drops accelerate re-epithelialization of post-keratoplasty persistent corneal epithelial defects Shaban Alizadeh, Sahar Balagholi, Alireza Baradaran-Rafii, Siamak Delfaza-Baher, Sare Safi, Hamid Safi, Rasul Dabbaghi, Mozhgan Rezaei Kanavi Journal of Ophthalmic and Vision Research 2019 14(2):131-135 Purpose: To investigate whether autologous platelet-rich plasma (PRP) eye drops accelerate re-epithelialization of post-keratoplasty persistent corneal epithelial defects (PEDs). Methods: A total of 34 eyes with PEDs after keratoplasty (24 penetrating keratoplasty and 10 deep anterior lamellar keratoplasty) that were refractory to conventional medical treatments were treated with PRP eye drops every 3 hours. PRP eye drops were prepared with a low- and high-speed centrifugation method and final platelet counts were 700,000-800,000 plt/μl. The mean treatment duration for complete re-epithelialization was compared with the mean treatment duration of conventionally treated corneal defects before the PRP treatment by paired t-test. The mean treatment duration was also statistically analyzed between age groups, gender, indications for keratoplasty, and types of keratoplasty using analysis of variance (ANOVA). Results: Treatment with autologous PRP eye drops led to rapid re-epithelialization in all eyes. The mean treatment duration for complete re-epithelialization was 2.47 ± 1.21 weeks, which was significantly shorter than the mean treatment duration of conventionally treated corneal defects before PRP treatment (6.82 ± 1.24 weeks) (P = 0.0001). There was no significant correlation between re-epithelialization time and patients' age, sex, indications for keratoplasty, and techniques of corneal transplantation. Conclusion: Treatment with autologous PRP eye drops is an effective and reliable approach that accelerates re-epithelialization of post-transplantation PEDs.

Efficacy of autologous serum in fixing conjunctival autografts of various sizes in different types and grades of pterygium Shreya Thatte, Ankita B Dube, Stuti Sharma Journal of Ophthalmic and Vision Research 2019 14(2):136-143 Purpose: To evaluate the efficacy of autologous serum in fixing conjunctival autografts of various sizes in different grades and types of pterygium and to determine the largest successfully secured graft size. Methods: This prospective interventional study comprised 151 eyes of 151 patients belonging to age group of 21 to 64 years with different grades and types of primary and recurrent pterygium that underwent excision with inferior conjunctivo - limbal autograft secured with autologous serum. The autografts were measured with calipers and were grouped by size into three categories: Group A, small (5 × 5 mm); Group B, medium (5–7 × 5 mm); and Group C, large (>7 × 5 mm). The adhesive fixation power of autologous serum for the various conjunctival autograft sizes was determined for each group using the following criteria: graft stability, cosmetic appearance and complications in the immediate ( first week) and two-months postoperative follow-up visits. Descriptive statistical analysis was used to calculate the percentage frequency of the variables. Results: The groups A, B, and C included 48%, 22%, and 30% of the autografts, respectively. Overall, 93.34% of the grafts were stable with good cosmetic appearance. However, subconjunctival hemorrhage (36%), graft edema (36%) and graft retraction (13.5%) were the most common complications. The largest successfully fixed graft was 14 × 5 mm in size. Conclusion: Autologous serum is efficient in securing conjunctival autografts of various sizes with minimal complications and satisfactory results, including good cosmesis.

Modified deep sclerectomy for the surgical treatment of glaucoma Farideh Sharifipour, Shahin Yazdani, Mona Asadi, Azadeh Saki, Kouros Nouri-Mahdavi Journal of Ophthalmic and Vision Research 2019 14(2):144-150 Purpose: To report the short-term outcomes of modified deep sclerectomy (MDS) in the management of open angle glaucoma. Methods: This prospective, non-randomized, controlled study included 105 eyes (105 patients) with open angle glaucoma. Eyes were categorized as follows: trabeculectomy (30 eyes), MDS (27 eyes), phacotrabeculectomy (28 eyes), and phaco-MDS (20 eyes). The MDS technique involved removal of a third scleral flap to expose the suprachoroidal space and excision of a trabecular block. A two-site approach was used for combined surgeries. Main outcome measures included intraocular pressure (IOP), number of glaucoma medications, and complications. Treatment success was defined as an IOP of 6–15 mmHg and/or a 30% reduction in IOP. Results: All groups showed significant decrease in IOP and number of medications (both P s < 0.001). The MDS group had a higher IOP (13.9 ± 3.8 vs. 12.4 ± 2.5 mmHg, P = 0.080) and required more medications (P = 0.001) than the trabeculectomy group at 1 year. The MDS group had a higher baseline IOP than the trabeculectomy group (P = 0.004) and both the groups showed similar IOP reductions (33.3% vs. 25.7%, P = 0.391). The phaco-MDS and phacotrabeculectomy groups had comparable IOP (13.3 ± 3.1 vs. 12.4 ± 3.1 mmHg, P = 0.354), number of medications (P = 0.594), and IOP reduction (P = 0.509) at 1-year follow-up visit. The trabeculectomy and phacotrabeculectomy groups developed more wound leaks (P = 0.043) and required more bleb needling during the early postoperative period (P < 0.001). Conclusion: The MDS technique seems to be slightly inferior to trabeculectomy, but when combined with phacoemulsification, is safer and results in similar IOP outcomes.

Effect of intravitreal bevacizumab injection on corneal in vivo biomechanics: A pilot study Nasser Shoeibi, Mohammad-Reza Ansari-Astaneh, Mohammad Reza Sedaghat, Saeed Shokoohi Rad Journal of Ophthalmic and Vision Research 2019 14(2):151-156 Purpose: To evaluate the effect of intravitreal bevacizumab (IVB) injection on corneal biomechanical parameters as measured by the ocular response analyzer (ORA) and Corneal Visualization Scheimpflug Technology (CorVis). Methods: In this prospective pilot study, ORA and CorVis parameters were recorded before and after a three-month course of IVB injection therapy in 16 patients in the injected and the contralateral non-injected control eyes. The changes in the recorded parameters in each group and the differences between the two groups were evaluated and compared. Results: None of the changes in ORA parameters were statistically significant in the injected and non-injected groups before and three months after injection, except for corneal resistance factor (CRF) in injected eyes (paired t-test, P = 0.039). The differences in corneal hysteresis (CH) and CRF were not statistically significant between the two groups (P = 0.441 and 0.236, respectively), but significant differences were noted between corneal compensated IOP (IOPcc) and Goldmann-correlated IOP (IOPg) (P = 0.045 and 0.047, respectively). None of the changes in CorVis parameters were statistically significant in the groups before and at the end of study, except for the time of first corneal applanation (TAp1 ms) in the injected group (P = 0.040, paired t-test). Differences in TAp1, length of the second corneal applanation (LAp2 mm), velocity of the second corneal applanation (VAp2 m/s), intraocular pressure (IOP), and central corneal thickness (CCT) also showed borderline significance between the two groups. Conclusion: In this pilot study IVB injection could change CRF, IOPcc, IOPg, and TAP1 as measured by ORA and CorVis.

The effect of panretinal photocoagulation (PRP) versus intravitreal bevacizumab (IVB) plus prp on peripapillary retinal nerve fiber layer (RNFL) thickness analyzed by optical coherence tomography in patients with proliferative diabetic retinopathy Ramak Roohipour, Elahe Sharifian, Sasan Moghimi, Masoud Aghsaei Fard, Fariba Ghassemi, Mohammad Zarei, Samaneh Davoodi, Fatemeh Bazvand, Bobeck S Modjtahedi Journal of Ophthalmic and Vision Research 2019 14(2):157-163 Purpose: The current study aimed to evaluate changes in peripapillary retinal nerve fiber layer (RNFL) thickness in diabetic patients with bilateral proliferative diabetic retinopathy (PDR) after receiving panretinal photocoagulation (PRP) or intravitreal bevacizumab (IVB) with PRP. Methods: Ocular examination and peripapillary optical coherent tomography (OCT) were performed for each patient at baseline, 1, 3, 6, and 10 months after treatment. Both eyes of each patient were randomized into either PRP or PRP + IVB group. Results: Sixty-four eyes (32 patients) were enrolled in this randomized clinical trial. In the PRP group, global RNFL thickness initially increased and reached statistical significance in the third month (from 105.9 ± 21.4μm at baseline to 119 ± 41.6μm at 3 months, P = 0.03). Subsequent decline was observed with no significant difference from baseline at 10 months (106 ± 19.3μm, P = 0.914). There were no statistically significant changes in the PRP + IVB group (from 101.7 ± 22.2μm at baseline to 109.3 ± 26.9μm at 3 months, P = 0.996 and 101.9 ± 16.5μm at 10 months, P = 0.999). In the latter group, slight increase in RNFL thickness was observed in the first month (107.7 ± 21.1μm). RNFL thickness was similar to baseline in the two groups at month 10, with the exception of significant increase in superior-temporal sector in the PRP group (145.3 ± 13.4μm vs. 127.2 ± 17.3μm, P = 0.045). Conclusion: Compared to eyes treated with PRP, eyes treated with adjunctive IVB showed less significant post-treatment changes in RNFL thickness.

Evaluation of choroidal layer thickness in central serous chorioretinopathy Daren Hanumunthadu, Elon H C van Dijk, Sunila Dumpala, Bindu Rajesh, Ayesha Jabeen, Asiya Jabeen, Momin Ansari, Pooja Mehta, Shilpi Shah, Chintan Sarvaiya, Catherine Meyerle, Lihteh Wu, Alay Banker, Camiel J Boon, Jay Chhablani Journal of Ophthalmic and Vision Research 2019 14(2):164-170 Purpose: To evaluate medium and large choroidal vessel layer thickness (MCVT and LCVT, respectively) in eyes with acute and chronic central serous chorioretinopathy (CSC) in comparison with age-matched controls. Methods: The study included 96 eyes of 96 patients with CSC, including 53 eyes with acute CSC, 43 eyes with chronic CSC, and 30 eyes of 30 age-matched normal subjects. Manual measurements of subfoveal choroidal thickness (SFCT), MCVT, and LCVT at subfoveal and 750 μm nasal and temporal to the fovea locations were made on enhanced depth imaging optical coherence tomography (EDI-OCT) of the macula in all subjects using ImageJ software (National Institutes of Health, Bethesda, MD, USA). Results: SFCT in acute CSC was significantly larger than that in healthy eyes (P = 0.0001). SFCT in acute CSC did not differ significantly from that in chronic CSC eyes. Subfoveal LCVT and MCVT in acute CSC eyes were greater than those in healthy eyes (P = 0.02 and P = 0.03, respectively). Mean SFCT and MCVT in chronic CSC eyes were significantly larger than those in control eyes (P = 0.01 and P = 0.04, respectively). No significant difference in LCVT was observed between chronic and control eyes. Conclusion: Choroidal vasculature is altered in both acute and chronic CSC. SFCT, MCVT, and LCVT are higher in eyes with acute CSC. The thickening of medium choroidal vessels is still detectable in chronic CSC compared to control eyes.

Detection of FZD4, LRP5 and TSPAN12 genes variants in Malay premature babies with retinopathy of prematurity Siti Zulaikha Nashwa Mohd Khair, Abdul Salim Ismail, Zunaina Embong, Abdul Aziz Mohamed Yusoff Journal of Ophthalmic and Vision Research 2019 14(2):171-178 Purpose: To determine the mutational analyses of familial exudative vitreoretinopathy (FEVR)-causing genes in Malay patients with retinopathy of prematurity (ROP) to obtain preliminary data for gene alterations in the Malay community. Methods: A comparative cross-sectional study involving 86 Malay premature babies (ROP = 41 and non-ROP = 45) was performed from September 2012 to December 2014. Mutation analyses in (FEVR)-causing genes (NDP, FZD4, LRP5, and TSPAN12) were performed using DNA from premature babies using polymerase chain reaction (PCR) and direct sequencing. Sequencing results were confirmed with PCR-Restriction Fragment Length Polymorphism (RFLP). Results: We found variants of FZD4, LRP5, and TSPAN12 in this study. One patient from each group showed a non-synonymous alteration in FZD4, c.502C>T (p.P168S). A synonymous variant of LRP5 [c.3357G>A (p.V1119V)] was found in 30 ROP and 28 non-ROP patients. Two variants of TSPAN12, c.765G>T (p.P255P) and c.*39C>T (3′UTR), were also recorded (29 and 21 in ROP, 33 and 26 in non-ROP, respectively). Gestational age and birth weight were found to be significantly associated with ROP (P value < 0.001 and 0.001, respectively). Conclusion: Analysis of data obtained from the ROP Malay population will enhance our understanding of these FEVR-causing gene variants. The c.3357G>A (p.V1119V) variant of LRP5, and c.765G>T (p.P255P) and c.*39C>T variants of TSPAN12 could be common polymorphisms in the Malay ethnic group; however, this requires further elucidation. Future studies using larger groups and higher numbers of advanced cases are necessary to evaluate the relationship between FEVR-causing gene variants and the risk of ROP susceptibility in Malaysian infants.

Rapid assessment of avoidable blindness in Kurdistan, Iran Elham Ashrafi, Seyed-Farzad Mohammadi, Marzieh Katibeh, Ebrahim Ghaderi, Cyrus Alinia, Naser Nourmohammadi, Alireza Lashay, Ramin Beiranvand, Mahsa Yousefpour Marzbali, Ali Sadeghi Tari Journal of Ophthalmic and Vision Research 2019 14(2):179-184 Purpose: To determine the magnitude and causes of blindness and visual impairment (VI) in Kurdistan, using the Rapid Assessment of Avoidable Blindness methodology. Methods: In this population-based cross sectional study, 99 clusters were selected through probability proportional to size sampling. Visual acuity (VA) was measured using a standard tumbling “E” chart. Ophthalmologists examined participants with VA < 6/18 in both eyes. The cause of VI in the better eye or the most treatable cause was considered as the primary cause of VI. Results: A total of 3203 (response rate: 92.4%) individuals aged 50 years and older participated, of whom 1657 (51.7%) were female. The standardized prevalence of blindness, severe visual impairment (SVI), and moderate visual impairment (MVI) based on available correction (presenting VA) were 2.1% (1.5-2.6), 1.7% (1.2-2.2), and 9.6%(8.4-10.8), respectively. The proportion of avoidable causes of blindness, SVI, and MVI were 58.1%, 78.4%, and 83.4%, respectively. The most common cause of blindness and SVI was cataract (27.4% and 60.8% respectively), followed by age-related macular degeneration (25.8% and 13.7%, respectively). The leading causes of MVI were uncorrected refractive errors (RE) (37.2%) and cataract (33.6%). Conclusion: The prevalence of blindness in the study population seems comparable to the region. According to our results, blindness, SVI, and MVI were mostly due to avoidable causes. Cataract and refractive errors are the principal causes of blindness and VI in Kurdistan.

Dermatologie Vénéréologie

EDITORIAL
	The peer review process: Yesterday, today and tomorrow	p. 239
	Saumya Panda DOI:10.4103/ijdvl.IJDVL_296_19  PMID:30971533
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VIEW POINT
	Let's not let the guard down! – Early indications of syphilis resurgence?	p. 246
	Vinay Kulkarni, Ritu Parchure, Shrinivas Darak DOI:10.4103/ijdvl.IJDVL_728_17  PMID:30829295
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REVIEW ARTICLE
	Hidradenitis Suppurativa: A Systematic Review and Meta-analysis of Therapeutic Interventions	p. 248
	Huidi Tchero, Christian Herlin, Farid Bekara, Sergiu Fluieraru, Luc Teot DOI:10.4103/ijdvl.IJDVL_69_18  PMID:30924446 Hidradenitis suppurativa is a chronic inflammatory condition that affects skin regions bearing apocrine glands. Although hidradenitis suppurativa is difficult to treat and cure, the currently available treatments are directed toward managing the lesions and associated symptoms. This review presents an evidence-based outline of the available treatment options. We searched four electronic databases and extracted data from retrieved studies for qualitative or quantitative analysis. Meta-analysis was conducted using the comprehensive meta-analysis software to generate pooled standardized mean differences or risk ratios. Numerous medical treatments are available for hidradenitis suppurativa such as antibiotics, retinoids, antiandrogens, immunosuppressive and anti-inflammatory agents and radiotherapy for early lesions. Adalimumab, an anti-tumor necrosis factor antibody, was superior to placebo in reducing Sartorius score (standardized mean difference = −0.32, confidence interval [−0.46, −0.18], P < 0.0001) and pain (risk ratio = 1.42, confidence interval [1.07, 1.9], P = 0.02), when given weekly (not every other week). Combination therapies (such as antibiotics and hyperbaric oxygen therapy) have been tested, which have shown promising results that are yet to be confirmed. Based on the quality of evidence, the most recommended treatments for hidradenitis suppurativa include adalimumab and laser therapy. Surgery (either by simple excision or complete local excision followed by skin graft) is the first choice for intractable disease presenting in the late stages. However, the evidence on most of these treatments is deficient and further randomized trials are needed to establish the most efficient therapies for hidradenitis suppurativa management.
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ORIGINAL ARTICLES
	Melanocyte spheroids are formed by repetitive long-term trypsinization	p. 258
	Di Li, Ru-Zhi Zhang, Hai-Xia Shi, Yu-Hua Yang, Ting Tian, Li Wang DOI:10.4103/ijdvl.IJDVL_275_17  PMID:30785123 Background: Autologous melanocyte transplantation plays an important role in the treatment of vitiligo. Objective: Previous studies have indicated that, compared with melanocytes growing in monolayers, melanocyte spheroids have a better survival in growth factor- and serum-deprived conditions. Methods: Melanocyte spheroids were obtained from human epidermis by repetitive long-term trypsinization and maintained an aggregated morphology for a short period in certain conditions. Results: Melanocyte spheroids were capable of growing into normal dendritic melanocytes in monolayer when they were harvested and reinoculated in 24-well plates. Immunohistochemical analysis of the melanocyte spheroids revealed that they were positive for HMB45, a melanosome-specific marker. No melanomas occurred when melanocyte spheroids were transplanted into mice. Conclusion: Our study provides a promising approach for melanocyte transplantation to treat vitiligo.
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	Predictors of disease severity in drug reaction with eosinophilia and systemic symptoms	p. 266
	Sarita Sasidharanpillai, Anuradha Thalian Chathoth, Anza Khader, Olasseri K Reena Mariyath, Najeeba Riyaz, Manikoth Payyanadan Binitha, Kunnummal Muhammed, Biju George, Parvathy Santhosh, Sangeetha Roslind, Nina Paul, Mithun Harold Thomas DOI:10.4103/ijdvl.IJDVL_482_17  PMID:30058562 Background: Drug reaction with eosinophilia and systemic symptoms is an outcome of a complex interaction between specific drugs, certain herpesviruse types and the immune system of the affected individual and is characterized by an unpredictable course and recurrent flares even after withdrawal of the offending drug and administration of systemic steroids. Aims: To identify the predictors of disease severity in drug reaction with eosinophilia and systemic symptoms. Methods: After obtaining ethical clearance from the institutional ethics committee and a written informed consent from individual study participant, the first hundred patients who required inpatient care in Government Medical College, Kozhikode with drug reaction with eosinophilia and systemic symptoms from January 1st 2011 were included in this study aimed to identify the predictors of disease severity in drug reaction with eosinophilia and systemic symptoms. Results: Male-to-female ratio of the study group was 0.8:1. The presence of atypical cells in peripheral smear and advanced age were found to be predictors of disease severity in drug reaction with eosinophilia and systemic symptoms, whereas, sex, facial erythema and edema and absolute eosinophil count were found not to be predictors of the same. Limitations: The main limitation of this study was our inability to assess the role of human leukocyte antigen (HLA) association and herpes virus reactivation in disease severity in drug reaction with eosinophilia and systemic symptoms. This study was also not designed to evaluate the response to treatment given and the mortality caused by drug reaction with eosinophilia and systemic symptoms. Conclusions: Studies on the predictors of severity in drug reaction with eosinophilia and systemic symptoms in different population groups may enable us to identify the warning signs and help to formulate the standard therapeutic guidelines.
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	A randomized, double-blind trial of amorolfine 0.25% cream and sertaconazole 2% cream in limited dermatophytosis	p. 276
	Anirban Das, Amrita Sil, Tushar Kanti Sarkar, Arpita Sen, Sriparna Chakravorty, Manideepa Sengupta, Anupam Das, Somodyuti Chandra, Santasmita Pal, Debabrata Bandyopadhyay, Nilay Kanti Das DOI:10.4103/ijdvl.IJDVL_907_17  PMID:30409926 Background: Dermatophytosis is becoming increasingly unresponsive to conventional antifungals. Newer topical antifungals may be more effective in these patients. Aims: To evaluate and compare the efficacy and safety of amorolfine 0.25% cream and sertaconazole 2% cream in limited tinea cruris/corporis. Methods: A single-center, randomized (1:1), double-blind, parallel group, active-controlled trial (CTRI/2014/12/005246) was performed. Sixty-six untreated adults with acutely symptomatic tinea cruris/corporis were included in the study. All patients had limited cutaneous involvement and were KOH mount positive. Group A received amorolfine 0.25% cream, and group B received sertaconazole 2% cream twice daily application to the lesions for 4 weeks. After the baseline visit, four follow-up visits were carried out. The outcome measures for effectiveness were clinical and mycological cure. Safety parameters studied were treatment-emergent adverse events and changes in routine laboratory parameters. Results: Both sertaconazole and amorolfine significantly reduced symptoms (P < 0.001) in both groups. However, improvement in symptoms (pruritus, burning sensation, erythema, scaling and crusting) was significantly greater in the sertaconazole group at every follow-up visit. Sertaconazole cream was also more effective than amorolfine cream in reducing the number of lesions (P = 0.002 at 12 weeks) and improving the Dermatology Life Quality Index (P < 0.001) at all the follow-up visits. Adverse events were similar in the two groups (P = 0.117). Fungal cultures became negative in 92.3% of the sertaconazole group as compared to 80% in the amorolfine group (P = 0.010). Limitations: Antifungal susceptibility testing could not be done. Conclusion: Sertaconazole 2% is superior to amorolfine 0.25%, both in terms of effectiveness and tolerability. Improvement can be appreciated from second week onwards.
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	Does using a high sun protection factor sunscreen on face, along with physical photoprotection advice, in patients with melasma, change serum vitamin D concentration in Indian conditions? A pragmatic pretest-posttest study	p. 282
	Sanjay Singh, Bandana Jha, Narendra Kumar Tiwary, Neeraj Kumar Agrawal DOI:10.4103/ijdvl.IJDVL_575_17  PMID:30409925 Background: Use of sunscreens on the face is becoming popular, and patients with melasma are prescribed sunscreen for use on the face. Results of a few Western studies on the effect of sunscreen use on serum vitamin D concentration are not applicable to Indian conditions. Aims: To examine the effect of use of a high sun protection factor (SPF 50+, PA++++) sunscreen on face in patients with melasma on serum concentration of 25-hydroxyvitamin D. Methods: Forty-five Indian patients (Fitzpatrick skin types III and IV) with melasma were advised to use a sunscreen with SPF 50 + for 3 months, 43 (33 female, 10 male; age 32.9 ± 8 years) completed the study. Patients staying outdoor for <4 hours applied sunscreen once daily after bath. Patients staying outdoors for >4 hours reapplied sunscreen 4 hours after first application. Patients were provided a container to measure the amount of sunscreen for use, which was approximately equal to recommended thickness. Compliance was tested by weighing the used tubes and tubes in use during monthly visits. Serum concentration of 25-hydroxyvitamin D was tested before and after the study period. Results: Amount of sunscreen advised (100.5 ± 29.2 ml) and the actual amount used (96.6 ± 27.9 ml) were similar (P = 0.53, t-test). The difference between serum concentrations of 25-hydroxyvitamin D at the baseline (19.20 ± 9.06 ng/ml) and at 3 months (18.91 ± 8.39 ng/ml) was not significant (P = 0.87, paired t-test, 95% confidence interval of difference −3.33 to 3.92). No correlation was found between the amount of sunscreen used and the percentage change in serum 25-hydroxyvitamin D concentration at 3 months (rho = 0.099, P = 0.528, Spearman's rank correlation). Limitations:Longer duration of application and a larger sample size may detect minor differences in vitamin D concentration. Conclusion: Using a high SPF sunscreen on the face, along with physical photoprotection advice, in patients with melasma for 3 months does not influence serum 25-hydroxyvitamin D concentration in Indian conditions.
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CASE REPORTS
	Cutaneous inflammation as a marker of malignant transformation in a patient with linear unilateral basaloid follicular hamartoma	p. 287
	Pablo Del Barrio-Diaz, Rodrigo Meza-Romero, Sergio González, Cristián Vera-Kellet DOI:10.4103/ijdvl.IJDVL_927_16  PMID:30246704 Basaloid follicular hamartoma is a rare, benign and superficial malformation of hair follicles, characterized histologically by epithelial proliferation of basaloid cells with radial disposition. It can be mistaken for basal cell carcinoma. Even though these hamartomas are considered benign lesions, malignant transformation has rarely been reported. We report the case of a 45-year-old healthy woman, with linear, unilateral basaloid follicular hamartoma which developed inflamed papules histologically suggestive of basal cell carcinoma. We believe that identification of local inflammation could be a clinical clue to guide us towards a malignant transformation of basaloid follicular hamartoma.
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	Synovial sarcoma complicating Maffucci syndrome	p. 291
	Rima Gammoudi, Amina Aounallah, Colandane Belajouza, Rafiaa Nouira DOI:10.4103/ijdvl.IJDVL_547_17  PMID:29667613 Maffucci syndrome is a rare nonhereditary disorder comprising of lymphovascular malformations and multiple enchondromas, which may be associated with several internal malignancies. This report describes a new association of Maffucci syndrome with pedal synovial sarcoma. Our case is also remarkable as lymphangioma circumscriptum is the sole lymphovascular component, which has been rarely reported. The aim of this report is to generate awareness about this rare condition and also highlight the importance of screening for malignancies in this disorder.
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BRIEF REPORTS
	Serum and tissue angiotensin-converting enzyme in patients with alopecia areata	p. 295
	Shabnam Fahim, Fatemeh Montazer, Hamid Reza Tohidinik, Zahra Safaei Naraghi, Robabeh Abedini, Maryam Nasimi, Narges Ghandi DOI:10.4103/ijdvl.IJDVL_158_17  PMID:29582789 Background: Alopecia areata is an immune-dependent disorder characterized by the interaction of T-lymphocytes with follicular antigens. Recent studies have shown the existence of a local renin–angiotensin system in the skin, where angiotensin-converting enzyme (ACE) plays a role in autoimmunity and inflammation. Aim: The objective of this study was to evaluate serum and tissue ACE activity in patients with alopecia areata. Methods: This case–control study was conducted on patients with alopecia areata and healthy controls. Serum and tissue ACE activity were assessed and compared between the two groups. Results: Twenty-five alopecia areata patients (60% male, mean age 32.1 ± 9.9 years) and 24 controls (50% male, mean age 37.4 ± 8.8 years) were included. Mean serum ACE activity was 52.1 ± 9 U/L in cases and 55.3 ± 14.7 U/L in controls (P = 0.37). Tissue ACE activity was significantly lower in cases in all parts of the skin i.e. epidermis (P = 0.016), follicular epithelium (P = 0.004), and endothelium (P = 0.037). Among cases, serum ACE activity was significantly higher in patients with more severe disease (P = 0.030), nonpatchy alopecia areata (alopecia universalis; ophiasis, patchy and ophiasis, diffuse) (P = 0.029), and with nail involvement (P = 0.027). Limitations: The sample size was too small to draw definite conclusions. Further, most of the patients had only mild or moderate alopecia areata. Conclusion: Unlike in some other inflammatory diseases, the tissue level of ACE seems to be significantly lower in alopecia areata compared to normal controls. Serum ACE was significantly higher in patients with more severe disease.
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	Effect of low-dose acitretin treatment on pituitary hormones in psoriasis vulgaris: A retrospective study	p. 300
	Ayse Serap Karadag, Emin Ozlu, Osman Kostek, Serap Gunes Bilgili, Ragıp Balaharoglu, Derun Taner Ertugrul DOI:10.4103/ijdvl.IJDVL_628_17  PMID:29855455 Background: It has been reported that retinoids may lead to hormonal alterations. Aim: In this retrospective study, we aimed to study the effect of acitretin on pituitary hormones in psoriasis patients. Methods: Out of 50 patients intended to be studied, blood samples of 43 patients could be tested before and after 3 months of acitretin therapy (0.2 to 0.5 mg/kg/day). Results: Patients mean ± standard deviation ages and female/male ratio were 46 ± 17 years and 19/24, respectively. After treatment with acitretin, gamma-glutamyltransferase, alkaline phosphatase, total cholesterol and triglyceride levels increased significantly (P < 0.05). After treatment, total protein, free thyroxine (T4) levels decreased significantly (P < 0.05). No significant differences were observed between before–after acitretin treatment regarding pituitary hormone levels in psoriasis patients (P > 0.05). Limitations: The retrospective nature of the study, inability to retest blood samples of 7 patients at 3 months post treatment, low dose and short duration of acitretin treatment were limitations of this study.Conclusion: This study showed that pituitary hormones were not affected except free T4 (thyroid hormone) by acitretin treatment. Further experimental and clinical studies are needed to clarify the effect of acitretin on pituitary hormones.
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IMAGES IN CLINICAL PRACTICE
	Papillomatosis cutis lymphostatica	p. 305
	Sabah Bazouti, Siham Dikhaye, Nada Zizi DOI:10.4103/ijdvl.IJDVL_763_17  PMID:29697069
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QUIZ
	Erythematous eroded plaque on the left nipple in a 75-year-old woman	p. 307
	Sergio Alvarez-Veliz, Paula Majluf-Caceres, Sergio González-Bombardiére DOI:10.4103/ijdvl.IJDVL_446_17  PMID:30058561
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LETTERS TO THE EDITOR - LETTERS IN RESPONSE TO PREVIOUSLY PUBLISHED ARTICLES
	Is semen analysis necessary prior to initiation of finasteride treatment?	p. 310
	Oliver Clement Lobo, Venkataram Mysore DOI:10.4103/ijdvl.IJDVL_149_19  PMID:30971531
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	Authors' reply	p. 311
	Piyush Kumar, Anupam Das, Niharika Ranjan Lal, Sourabh Jain, Anupama Ghosh DOI:10.4103/ijdvl.IJDVL_245_19  PMID:30971532
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	Transepidermal elimination: Role in leprosy transmission	p. 313
	Naveen Kumar Kansal DOI:10.4103/ijdvl.IJDVL_877_18  PMID:30829298
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	Authors' reply	p. 314
	Hiral Shah, Anup Kumar Tiwary, Piyush Kumar DOI:10.4103/ijdvl.IJDVL_192_19  PMID:30950408
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LETTERS TO THE EDITOR - CASE LETTER
	Acral peeling skin syndrome: An underdiagnosed skin disorder	p. 316
	Eva Sticova, Martin Květoň, Monika Dubská, Andrea Kubátová DOI:10.4103/ijdvl.IJDVL_3_18  PMID:30688214
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LETTERS TO THE EDITOR - OBSERVATION LETTERS
	A case of hidroacanthoma simplex with new dermoscopic features	p. 319
	Roja Toosi, Kambiz Kamyab, Cliff Rosendahl, Soheil Tavakolpour, Maryam Daneshpazhooh, Hamidreza Mahmoudi DOI:10.4103/ijdvl.IJDVL_426_18  PMID:30860169
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	Dermoscopic features of trichilemmal carcinoma	p. 321
	Zulkuf Arslan, Z Ulaş Bali, M Kürşat Evrenos, Peyker Temiz, Aylin Türel Ermertcan DOI:10.4103/ijdvl.IJDVL_468_18  PMID:30860170
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	Dermoscopy combined with ink staining as one more method to diagnose nodular scabies	p. 324
	Yangyang Ma, Wenting Hu, Ping Wang, Ke Bian, Zehu Liu DOI:10.4103/ijdvl.IJDVL_516_18  PMID:30880719
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LETTERS TO THE EDITOR - THERAPY LETTER
	Aggressive erosive lichen planus associated with hepatitis C responding to sofosbuvir/ledipasvir treatment	p. 326
	Daniel Morgado-Carrasco, Andrea Combalia, Xavier Fustà-Novell, José Manuel Mascaró Jr, Pilar Iranzo DOI:10.4103/ijdvl.IJDVL_225_18  PMID:30860163
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LETTERS TO THE EDITOR - STUDY LETTER
	Does rapamycin induce melanin formation? An in vitro study assessing the effect of rapamycin on normal cultured melanocytes	p. 330
	Muthu Sendhil Kumaran, Niharika Srivastava, Keshavamurthy Vinay, Supriya Bhardwaj, Davinder Parsad DOI:10.4103/ijdvl.IJDVL_45_18  PMID:30829293
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IMAGES IN CLINICAL PRACTICE
	Primary follicular mucinosis in childhood	p. 333
	Parul Verma, Asha Kubba, Aditi Jha DOI:10.4103/ijdvl.IJDVL_615_17  PMID:29697068
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QUIZ
	Ringworm-like skin lesion is not always tinea	p. 335
	Ramona Zanniello, Caterina Ferreli, Federico Patta, Anna Luisa Pinna, Laura Atzori DOI:10.4103/ijdvl.IJDVL_253_17  PMID:29547137
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RESIDENTS' PAGE
	Atopy patch test	p. 338
	Varsha Vaidyanathan, Aarti Sarda, Abhishek De, Sandipan Dhar DOI:10.4103/ijdvl.IJDVL_397_17  PMID:30058560
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HISTORY
	Prof. Nékám's Corpus Iconum Morborum Cutaneorum (1938): The most elaborate historical dermatovenerological atlas of the first half of the 20th century	p. 342
	Zoltan Szep, Juraj Majtan DOI:10.4103/ijdvl.IJDVL_643_17  PMID:30924445
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BOOK REVIEW
	Dermoscopy – Text and atlas	p. 346
	Laxmisha Chandrashekar DOI:10.4103/ijdvl.IJDVL_108_19  PMID:30950410
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NET STUDY
	Profile of HIV serodiscordant couples in a tertiary care center	p. 347
	Srihari Sahana, Jayadev Betkerur DOI:10.4103/ijdvl.IJDVL_1101_16  PMID:30860165 Background: Globally, 36.7 million people are infected with Human Immunodeficiency Virus (HIV). Of these 36.7 million people, 2.1 million are in India. Integrated counseling and testing centers are the cornerstones of early access to prevention and support services. The term "serodiscordant couple" refers to a couple where one partner is HIV-positive and the other HIV-negative. Aim: To study the serodiscordance rates in a cohort of people attending integrated counseling and testing center. Materials and Methods: Aretrospective descriptive study of data from integrated counseling and testing center from January 2013 to December 2014 was done. Results: Of the 7489 persons tested, 306 persons were positive for HIV (192 males and 114 females) with a prevalence of 4 percent. Of the 126 couples tested, serodiscordance was found in 46 couples, while 80 couples were seroconcordant. The overall prevalence of HIV serodiscordance was 36.5 percent. Male positive and female negative couples (M+ F−) were 35 (76.0%) and female positive and male negative (F+ M−) were 11 (23.9%). Discordant M+ F− couples were significantly higher than discordant F+ M− couples (P < 0.001). Most participants were aged between 21 and 40 years. The average age of men was 41.91 years and that of women was 34.21 years. The average age difference between life partners was 7.7 years. Significant association was seen between age and gender, as females were found to be younger (P value = 0.001). Limitation: Information regarding years of married life, number of sex partners or sexual behavior pre- and post-detection were not collected. Thus, our data present only the magnitude of serodiscordance in a cohort but does not analyze the other predictors of serodiscordance. Conclusion: Serodiscordant relationships occur more commonly in India than is presumed. Our study highlights the profile of serodiscordant couples in this part of the country. Effective measures to prevent transmission of HIV within a serodiscordant relationship are necessary steps in halting the HIV epidemic.
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NET QUIZ
	Erythematous scaly facial plaques with overlying hair loss	p. 347
	A Narayanan, M Ramam, Neetu Bhari DOI:10.4103/ijdvl.IJDVL_501_18  PMID:30860166
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NET LETTERS
	Rapid response of Kasabach–Meritt phenomenon to a combination of oral prednisolone and sirolimus	p. 348
	Sanjay Singh, Neetu Bhari, Snehal Agrawal, Kaushal K Verma DOI:10.4103/ijdvl.IJDVL_453_17  PMID:29798936
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	A case report of buffalopox: A zoonosis of concern	p. 348
	Ritu Gujarati, Siva Rami Reddy Karumuri, T Naresh Babu, B Janardhan DOI:10.4103/ijdvl.IJDVL_222_17  PMID:29667609
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	Dermoscopic manifestations of Talaromyces (Penicillium) marneffei infection in an AIDS patient	p. 348
	Xiaoxi Xu, Xin Ran, Sushmita Pradhan, Song Lei, Yuping Ran DOI:10.4103/ijdvl.IJDVL_118_17  PMID:29873309
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ERRATUM
	Erratum: "Crusted nipple and areola: a new aetiology of secondary hyperkeratosis of the nipple and areola"	p. 349
	DOI:10.4103/0378-6323.256524
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ANNOUNCEMENT OF IADVL SCHOLARSHIPS
	Announcement of IADVL Scholarships	p. 350
	DOI:10.4103/0378-6323.256525
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