March 2014
Brief communications
Annular elastolytic giant cell granuloma of conjunctiva: A case report Karabi Konar, Saurabh Sanyal1, Arindam Rakshit Annular elastolytic giant cell granuloma is a condition characterized histologically by damaged elastic fibers associated with preponderance of giant cells along with absence of necrobiosis, lipid, mucin, and pallisading granuloma. It usually occurs on sun‑damaged skin and hence the previous name actinic granuloma. A similar process occurs on the conjunctiva. Over the past three decades only four cases of conjunctival actinic granuloma have been documented. All the previous patients were females with lesions in nasal or temporal bulbar conjunctiva varying 2-3 mm in size. We report a male patient aged 70 years presenting with a 14 mm × 7 mm fleshy mass on right lower bulbar conjunctiva. Clinical differential diagnoses were lymphoma, squamous cell carcinoma in situ and amyloidosis. Surgical excision followed by histopathology confirmed it to be a case of actinic granuloma. This is the first case of isolated conjunctival actinic granuloma of such a large size reported from India. Key words: Actinic granuloma, conjunctiva, granuloma annulare, necrobiosis lipoidica
Annular elastolytic giant cell granuloma, as the name implies, is a giant cell rich granulomatous inflammation in response to elastolysis or damage to elastic tissue fibers. It almost always occurs as cutaneous lesions in patients with sun damaged skin. Though a possibly related process can occur in the conjunctiva, very few cases have been reported so far. Over the past three decades only four cases of conjunctival actinic granuloma have been documented.
Case Report A 70‑year‑old male patient presented with painless, gradually increasing swelling in the right lower bulbar conjunctiva for
361
6 months followed by redness and watering for last 3 weeks. Ocular examination revealed a 14 mm × 7 mm red fleshy mass in the lower bulbar conjunctiva in the right eye [Fig. 1]. Vision in the right eye was 20/100 with early cataractous change. The left eye was pseudophakic and had a total retinal detachment with only PL. The patient had no significant past medical history. The conjunctival mass was clinically diagnosed to be a squamous cell carcinoma in situ, lymphoma or amyloidosis. Excision biopsy followed by histopathological examination was done. Histopathology revealed a localized granulomatous inflammation with histiocytes around a homogeneous material along with giant cells and chronic inflammatory cells [Figs. 2 and 3]. Van Gieson and Congo red stains were performed. Congo red stain was negative. Van Gieson stain demonstrated the complete absence of elastic tissue at the center of the granuloma [Fig. 4]. The patient was followed up for 2 years. There was no further recurrence of the disease.
Discussion Annular elastolytic giant cell granuloma is a condition characterized histologically by damaged elastic fibers surrounded by numerous giant cells and absence of necrobiosis, lipid, mucin, and pallisading of the granuloma.[1] It almost always occurs on sun exposed skin, such as face, neck, dorsum of hand, forearm, and arm and hence the previous name actinic granuloma; however there are few reports occurring in sun‑protected sites. A possibly related process occurs on the conjunctiva.[2] The term actinic granuloma was coined by O Brien in 1975, who described similar histological features in cutaneous lesions of patients with sun‑damaged skin.[3] He described the pathogenesis as an attempt to repair the damaged connective tissue. Subsequently this concept was disputed by Ragaz and Ackerman,[4] who believed that actinic granuloma was a variant of granuloma annulare.[5,6] McGrae postulated that actinic granuloma represented a cell‑mediated immune response to actinically altered elastotic fibers with a preponderance of helper T cells in the lymphocytic infiltrate.[1] The occurrence of conjunctival actinic granuloma in isolation is a rare entity. In the past four decades only four cases have been
Access this article online Quick Response Code:
Website: www.ijo.in DOI: 10.4103/0301-4738.121142 PMID: ***
Department of Pathology, Burdwan Medical College, Burdwan, 1 Ophthalmology, Consultant, Disha Eye Hospital, Hooghly, West Bengal, India Correspondence to: Dr. Karabi Konar, 53/30, J. N. Lahiri Road, Lahiri Park, Serampore, Hooghly - 712 201, West Bengal, India. E‑mail: [email protected] Manuscript received: 24.06.11; Revision accepted: 23.04.12
Figure 1: Clinical photograph showing 14 mm × 7 mm red fleshy mass in right lower bulbar conjunctiva
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Indian Journal of Ophthalmology
Vol. 62 No. 3
in nasal or temporal bulbar conjunctiva. In those cases the clinical differential diagnoses were pinguicula, pinguiculitis, Bowens disease, and conjunctival nevus. In our case the size of the lesion was much larger. 14 mm × 7 mm, a fleshy mass involving the whole of the lower bulbar conjunctiva. The clinical differential diagnoses were squamous cell carcinoma in situ, mucosa associated lymphoid tumor (MALTOMA), amyloidosis, and leukemic deposit. The hematological investigations of the patient were within normal limits.
Figure 2: Microphotograph showing subepithelial granulomatous reaction in right conjunctiva. H and E stain ×100
Surgical biopsy followed by histopathology demonstrated a granulomatous reaction in the subepithelial lamina propria. A large number of giant cells along with lymphoplasmacytic infiltration were seen. There was elastotic degeneration of the connective tissue. There was no evidence of any neoplastic change or amyloid deposition. Histological differential diagnoses were infectious and noninfectious granulomatous reaction. Among the infectious agents mycobacterial, fungal, and parasitic lesions can occur. The absence of caseous necrosis excludes tuberculosis and the prominent eosinophilic response invited by fungal and parasitic lesions was not present in this case. The noninfectious granulomatous inflammation includes foreign‑body giant cell reaction, granuloma annulare or pseudoheumatoid nodule, and necrobiosis lipoidica. No foreign body could be detected in the lesion. Granuloma annulare presents with abundant mucin, partial loss of elastic fibers and radial arrangement of epithelioid histiocytes (pallisading granuloma). In Necrobiosis lipoidica central elastolysis is absent.
Figure 3: Microphotograph showing giant cells, inflammatory cells, and histiocytes in the granuloma. [H and E stain ×400]
The complete loss of elastic tissue in the central zone as documented by connective tissue stain is used as the primary basis for separating annular elastolytic giant cell granuloma from granuloma annulare and necrobiosis lipoidica. Thus actinic granuloma of conjunctiva is a distinct clinical, histological, and immunological lesion. Though rare, the clinician should consider the possibility of actinic granuloma presenting as a fish flesh mass in the conjunctiva and pathologist should consider the possibility of granulomatous inflammation in association with elastolysis and does not necessarily imply the presence of foreign bodies or infection. Regarding medical treatment Hydroxychloroquine, Clofazimine, Dapsone, intralesional, and systemic steroid has been used in annular elastolytic giant cell granuloma (AEGG) of skin.[8,9] No trial has been documented for conjunctival lesion. Topical steroid had little effect.[7] Surgical excision is considered to be the treatment of choice.
References 1. McGrae JD Jr. Actinic granuloma: A clinical, histopathologic, and immunocytochemical study. Arch Dermatol 1986;122:43‑7. Figure 4: Microphotograph showing the absence of elastic tissue in the centre of granuloma. Van Geison stain ×400
documented.[7] All the previous cases were females, our case being the first such lesion occurring in a male patient. The size of all the previous lesions varied between 2 and 3 mm occurring
2. Steffen C. Actinic granuloma of the conjunctiva. Am J Dermatopathol 1992;14:253. 3. O’Brien JP. Actinic granuloma: An annular connective tissue disorder affecting sun and heat damaged (elastotic) skin. Arch Dermatol 1975;111:460‑6. 4. Ragaz A, Ackerman AB. Is actinic granuloma a specific condition? Am J Dermatopathol 1979;1:43‑50.
March 2014
363
Brief communications
5. Rao NA, Font RL. Pseudorheumatoid nodules of the ocular adnexae. Am J Ophthalmol 1975;79:471‑8. 6. Ferry AP. Subcutaneous granuloma annulare(“pseudorheumatoid nodules”) of the eyebrow.J Pediatr Ophthalmol 1997;14:154‑7.
9. Babuna G, Buyukbabani N, Yazganoglu KD, Baykal C. Effective treatment with hydroxychloroquine in a case of annular Elastolytic Giant cell granuloma. Indian J Dermatol Venereal Leprol 2011;77:110‑1.
7. Gallagher MJ, Roberts F, Osborne S, Kirkness CM. Actinic granuloma of the conjunctiva. Br J Ophthalmol 2003;87:1044‑5. 8. Ozkaya‑Bayazit E, Büyükbabani N, Baykal C, Oztürk A, Okçu M, Soyer HP. Annular Elastolytic Giant cell granuloma: Sparing of a burn scar and successful treatment with choloroquin. Br J Dermatol 1999;140:525‑30.
Cite this article as: Konar K, Sanyal S, Rakshit A. Annular elastolytic giant cell granuloma of conjunctiva: A case report. Indian J Ophthalmol 2014;62:361-3.
Repeat gas insufflation for successful closure of idiopathic macular hole following failed primary surgery
technique to improve the functional and anatomical outcomes. Currently, the standard technique consists of pars plana vitrectomy, internal limiting membrane (ILM) peeling and gas tamponade. The current success rate of primary surgery is 80-100%.[2,3,‑4] There can be several reasons for failure of hole closure viz duration of hole, size of hole, incomplete ILM peeling, traction from the residual epiretinal membrane and difficulties in postoperative positioning.[1,5,6,7,‑8] In the cases of failed primary surgery, pre‑ and post-operative configuration of the macular hole visualized by optical coherence tomography (OCT) could probably help in correlating anatomical and functional outcome and also help in selection of cases for re‑surgery. We present a case report in which a persistent idiopathic macular hole was successfully closed two weeks following re‑surgery after the failure of primary surgery, twelve weeks before. To the best of our knowledge, this is the first report of its kind from India.
Pukhraj Rishi, Sumanth Reddy, Ekta Rishi A 65‑year‑old lady presented with decreased vision in left eye since seven months. Vision was 6/9 in right eye and 6/36 in left. Examination revealed idiopathic, full‑thickness macular hole in left eye; confirmed by optical coherence tomography (OCT). Patient underwent phacoemulsification with intraocular lens (IOL) implantation, vitrectomy, internal limiting membrane (ILM) peeling and 14% C3F8 gas injection. OCT repeated after six weeks revealed type II closure with cuff of subretinal fluid. Four weeks later, patient underwent fluid–gas exchange with 14% C3F8 gas and postoperative positioning. OCT was repeated after two weeks, which showed complete closure of the macular hole. OCT can help in selection of eyes for re‑surgery that stand a better chance for hole closure. Macular holes with cuff of subretinal fluid are probably more likely to close on re‑surgery than those without. However, larger studies with longer follow‑up are required to validate this finding. Key words: Internal limiting membrane, macular hole, optical coherence tomography, re‑surgery, vitrectomy
Surgical treatment of idiopathic, full‑thickness macular hole by vitreous surgery was first described by Kelly and Wendel in 1991.[1] Since then there has been a refinement in the surgical
Source of Support: Nil. Conflict of Interest: None declared.
Case Report A 65‑year‑old lady presented with diminution of vision associated with distortion of images in the right eye since the past seven months. On examination, her best corrected visual acuity (BCVA) was 6/9, N6 in the right eye and 6/36, N36 in the left eye. Biomicroscopic examination revealed nuclear sclerosis grade 2 with posterior subcapsular cataract in both eyes. Left fundus revealed an idiopathic, full‑thickness macular hole in the left eye [Fig. 1a] confirmed on OCT [Fig. 1b]. Hole formation factor (HFF) was noted to be 0.80 and the basal diameter was 949 microns. Right eye fundus was normal. The patient underwent phacoemulsification with intraocular lens (IOL)
Access this article online Quick Response Code:
Website: www.ijo.in DOI: 10.4103/0301-4738.116452
a
PMID: ***
Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralya, 18 College, Chennai, Tamil Nadu, India Correspondence to: Dr. Pukhraj Rishi, Senior Consultant, Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, 18 College Road, Chennai - 600 006, Tamil Nadu, India. E‑mail: [email protected] Manuscript received: 15.09.11; Revision accepted: 27.04.12
b Figure 1: Baseline (a) Color fundus photo of the left eye showing a full‑thickness macular hole (b) OCT scan is confirmatory of macular hole
Copyright of Indian Journal of Ophthalmology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Brief communications
Annular elastolytic giant cell granuloma of conjunctiva: A case report Karabi Konar, Saurabh Sanyal1, Arindam Rakshit Annular elastolytic giant cell granuloma is a condition characterized histologically by damaged elastic fibers associated with preponderance of giant cells along with absence of necrobiosis, lipid, mucin, and pallisading granuloma. It usually occurs on sun‑damaged skin and hence the previous name actinic granuloma. A similar process occurs on the conjunctiva. Over the past three decades only four cases of conjunctival actinic granuloma have been documented. All the previous patients were females with lesions in nasal or temporal bulbar conjunctiva varying 2-3 mm in size. We report a male patient aged 70 years presenting with a 14 mm × 7 mm fleshy mass on right lower bulbar conjunctiva. Clinical differential diagnoses were lymphoma, squamous cell carcinoma in situ and amyloidosis. Surgical excision followed by histopathology confirmed it to be a case of actinic granuloma. This is the first case of isolated conjunctival actinic granuloma of such a large size reported from India. Key words: Actinic granuloma, conjunctiva, granuloma annulare, necrobiosis lipoidica
Annular elastolytic giant cell granuloma, as the name implies, is a giant cell rich granulomatous inflammation in response to elastolysis or damage to elastic tissue fibers. It almost always occurs as cutaneous lesions in patients with sun damaged skin. Though a possibly related process can occur in the conjunctiva, very few cases have been reported so far. Over the past three decades only four cases of conjunctival actinic granuloma have been documented.
Case Report A 70‑year‑old male patient presented with painless, gradually increasing swelling in the right lower bulbar conjunctiva for
361
6 months followed by redness and watering for last 3 weeks. Ocular examination revealed a 14 mm × 7 mm red fleshy mass in the lower bulbar conjunctiva in the right eye [Fig. 1]. Vision in the right eye was 20/100 with early cataractous change. The left eye was pseudophakic and had a total retinal detachment with only PL. The patient had no significant past medical history. The conjunctival mass was clinically diagnosed to be a squamous cell carcinoma in situ, lymphoma or amyloidosis. Excision biopsy followed by histopathological examination was done. Histopathology revealed a localized granulomatous inflammation with histiocytes around a homogeneous material along with giant cells and chronic inflammatory cells [Figs. 2 and 3]. Van Gieson and Congo red stains were performed. Congo red stain was negative. Van Gieson stain demonstrated the complete absence of elastic tissue at the center of the granuloma [Fig. 4]. The patient was followed up for 2 years. There was no further recurrence of the disease.
Discussion Annular elastolytic giant cell granuloma is a condition characterized histologically by damaged elastic fibers surrounded by numerous giant cells and absence of necrobiosis, lipid, mucin, and pallisading of the granuloma.[1] It almost always occurs on sun exposed skin, such as face, neck, dorsum of hand, forearm, and arm and hence the previous name actinic granuloma; however there are few reports occurring in sun‑protected sites. A possibly related process occurs on the conjunctiva.[2] The term actinic granuloma was coined by O Brien in 1975, who described similar histological features in cutaneous lesions of patients with sun‑damaged skin.[3] He described the pathogenesis as an attempt to repair the damaged connective tissue. Subsequently this concept was disputed by Ragaz and Ackerman,[4] who believed that actinic granuloma was a variant of granuloma annulare.[5,6] McGrae postulated that actinic granuloma represented a cell‑mediated immune response to actinically altered elastotic fibers with a preponderance of helper T cells in the lymphocytic infiltrate.[1] The occurrence of conjunctival actinic granuloma in isolation is a rare entity. In the past four decades only four cases have been
Access this article online Quick Response Code:
Website: www.ijo.in DOI: 10.4103/0301-4738.121142 PMID: ***
Department of Pathology, Burdwan Medical College, Burdwan, 1 Ophthalmology, Consultant, Disha Eye Hospital, Hooghly, West Bengal, India Correspondence to: Dr. Karabi Konar, 53/30, J. N. Lahiri Road, Lahiri Park, Serampore, Hooghly - 712 201, West Bengal, India. E‑mail: [email protected] Manuscript received: 24.06.11; Revision accepted: 23.04.12
Figure 1: Clinical photograph showing 14 mm × 7 mm red fleshy mass in right lower bulbar conjunctiva
362
Indian Journal of Ophthalmology
Vol. 62 No. 3
in nasal or temporal bulbar conjunctiva. In those cases the clinical differential diagnoses were pinguicula, pinguiculitis, Bowens disease, and conjunctival nevus. In our case the size of the lesion was much larger. 14 mm × 7 mm, a fleshy mass involving the whole of the lower bulbar conjunctiva. The clinical differential diagnoses were squamous cell carcinoma in situ, mucosa associated lymphoid tumor (MALTOMA), amyloidosis, and leukemic deposit. The hematological investigations of the patient were within normal limits.
Figure 2: Microphotograph showing subepithelial granulomatous reaction in right conjunctiva. H and E stain ×100
Surgical biopsy followed by histopathology demonstrated a granulomatous reaction in the subepithelial lamina propria. A large number of giant cells along with lymphoplasmacytic infiltration were seen. There was elastotic degeneration of the connective tissue. There was no evidence of any neoplastic change or amyloid deposition. Histological differential diagnoses were infectious and noninfectious granulomatous reaction. Among the infectious agents mycobacterial, fungal, and parasitic lesions can occur. The absence of caseous necrosis excludes tuberculosis and the prominent eosinophilic response invited by fungal and parasitic lesions was not present in this case. The noninfectious granulomatous inflammation includes foreign‑body giant cell reaction, granuloma annulare or pseudoheumatoid nodule, and necrobiosis lipoidica. No foreign body could be detected in the lesion. Granuloma annulare presents with abundant mucin, partial loss of elastic fibers and radial arrangement of epithelioid histiocytes (pallisading granuloma). In Necrobiosis lipoidica central elastolysis is absent.
Figure 3: Microphotograph showing giant cells, inflammatory cells, and histiocytes in the granuloma. [H and E stain ×400]
The complete loss of elastic tissue in the central zone as documented by connective tissue stain is used as the primary basis for separating annular elastolytic giant cell granuloma from granuloma annulare and necrobiosis lipoidica. Thus actinic granuloma of conjunctiva is a distinct clinical, histological, and immunological lesion. Though rare, the clinician should consider the possibility of actinic granuloma presenting as a fish flesh mass in the conjunctiva and pathologist should consider the possibility of granulomatous inflammation in association with elastolysis and does not necessarily imply the presence of foreign bodies or infection. Regarding medical treatment Hydroxychloroquine, Clofazimine, Dapsone, intralesional, and systemic steroid has been used in annular elastolytic giant cell granuloma (AEGG) of skin.[8,9] No trial has been documented for conjunctival lesion. Topical steroid had little effect.[7] Surgical excision is considered to be the treatment of choice.
References 1. McGrae JD Jr. Actinic granuloma: A clinical, histopathologic, and immunocytochemical study. Arch Dermatol 1986;122:43‑7. Figure 4: Microphotograph showing the absence of elastic tissue in the centre of granuloma. Van Geison stain ×400
documented.[7] All the previous cases were females, our case being the first such lesion occurring in a male patient. The size of all the previous lesions varied between 2 and 3 mm occurring
2. Steffen C. Actinic granuloma of the conjunctiva. Am J Dermatopathol 1992;14:253. 3. O’Brien JP. Actinic granuloma: An annular connective tissue disorder affecting sun and heat damaged (elastotic) skin. Arch Dermatol 1975;111:460‑6. 4. Ragaz A, Ackerman AB. Is actinic granuloma a specific condition? Am J Dermatopathol 1979;1:43‑50.
March 2014
363
Brief communications
5. Rao NA, Font RL. Pseudorheumatoid nodules of the ocular adnexae. Am J Ophthalmol 1975;79:471‑8. 6. Ferry AP. Subcutaneous granuloma annulare(“pseudorheumatoid nodules”) of the eyebrow.J Pediatr Ophthalmol 1997;14:154‑7.
9. Babuna G, Buyukbabani N, Yazganoglu KD, Baykal C. Effective treatment with hydroxychloroquine in a case of annular Elastolytic Giant cell granuloma. Indian J Dermatol Venereal Leprol 2011;77:110‑1.
7. Gallagher MJ, Roberts F, Osborne S, Kirkness CM. Actinic granuloma of the conjunctiva. Br J Ophthalmol 2003;87:1044‑5. 8. Ozkaya‑Bayazit E, Büyükbabani N, Baykal C, Oztürk A, Okçu M, Soyer HP. Annular Elastolytic Giant cell granuloma: Sparing of a burn scar and successful treatment with choloroquin. Br J Dermatol 1999;140:525‑30.
Cite this article as: Konar K, Sanyal S, Rakshit A. Annular elastolytic giant cell granuloma of conjunctiva: A case report. Indian J Ophthalmol 2014;62:361-3.
Repeat gas insufflation for successful closure of idiopathic macular hole following failed primary surgery
technique to improve the functional and anatomical outcomes. Currently, the standard technique consists of pars plana vitrectomy, internal limiting membrane (ILM) peeling and gas tamponade. The current success rate of primary surgery is 80-100%.[2,3,‑4] There can be several reasons for failure of hole closure viz duration of hole, size of hole, incomplete ILM peeling, traction from the residual epiretinal membrane and difficulties in postoperative positioning.[1,5,6,7,‑8] In the cases of failed primary surgery, pre‑ and post-operative configuration of the macular hole visualized by optical coherence tomography (OCT) could probably help in correlating anatomical and functional outcome and also help in selection of cases for re‑surgery. We present a case report in which a persistent idiopathic macular hole was successfully closed two weeks following re‑surgery after the failure of primary surgery, twelve weeks before. To the best of our knowledge, this is the first report of its kind from India.
Pukhraj Rishi, Sumanth Reddy, Ekta Rishi A 65‑year‑old lady presented with decreased vision in left eye since seven months. Vision was 6/9 in right eye and 6/36 in left. Examination revealed idiopathic, full‑thickness macular hole in left eye; confirmed by optical coherence tomography (OCT). Patient underwent phacoemulsification with intraocular lens (IOL) implantation, vitrectomy, internal limiting membrane (ILM) peeling and 14% C3F8 gas injection. OCT repeated after six weeks revealed type II closure with cuff of subretinal fluid. Four weeks later, patient underwent fluid–gas exchange with 14% C3F8 gas and postoperative positioning. OCT was repeated after two weeks, which showed complete closure of the macular hole. OCT can help in selection of eyes for re‑surgery that stand a better chance for hole closure. Macular holes with cuff of subretinal fluid are probably more likely to close on re‑surgery than those without. However, larger studies with longer follow‑up are required to validate this finding. Key words: Internal limiting membrane, macular hole, optical coherence tomography, re‑surgery, vitrectomy
Surgical treatment of idiopathic, full‑thickness macular hole by vitreous surgery was first described by Kelly and Wendel in 1991.[1] Since then there has been a refinement in the surgical
Source of Support: Nil. Conflict of Interest: None declared.
Case Report A 65‑year‑old lady presented with diminution of vision associated with distortion of images in the right eye since the past seven months. On examination, her best corrected visual acuity (BCVA) was 6/9, N6 in the right eye and 6/36, N36 in the left eye. Biomicroscopic examination revealed nuclear sclerosis grade 2 with posterior subcapsular cataract in both eyes. Left fundus revealed an idiopathic, full‑thickness macular hole in the left eye [Fig. 1a] confirmed on OCT [Fig. 1b]. Hole formation factor (HFF) was noted to be 0.80 and the basal diameter was 949 microns. Right eye fundus was normal. The patient underwent phacoemulsification with intraocular lens (IOL)
Access this article online Quick Response Code:
Website: www.ijo.in DOI: 10.4103/0301-4738.116452
a
PMID: ***
Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralya, 18 College, Chennai, Tamil Nadu, India Correspondence to: Dr. Pukhraj Rishi, Senior Consultant, Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, 18 College Road, Chennai - 600 006, Tamil Nadu, India. E‑mail: [email protected] Manuscript received: 15.09.11; Revision accepted: 27.04.12
b Figure 1: Baseline (a) Color fundus photo of the left eye showing a full‑thickness macular hole (b) OCT scan is confirmatory of macular hole
Copyright of Indian Journal of Ophthalmology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
