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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Echographic Optic Nerve Evaluation: A Novel Diagnostic Modality in Glaucoma
Correspondence Address :
Avik Dey Sarkar,
Room No. 214, PG Hostel, Aravind Eye Hospital, 1, Annanagar, Madurai-625020, Tamil Nadu, India.
E-mail: AvikDey.Sarkar@aravind.org
Introduction: Primary Open-Angle Glaucoma (POAG) is considered a leading cause of blindness among all others. Different technologies such as Scanning Laser Polarimetry (SLP) and Optical Coherence Tomography (OCT) closely correlate in measuring structural parameters of the Retinal Nerve Fiber Layer (RNFL) and Optic Nerve Head (ONH). Visual impairment related to glaucomatous damage is attributed to the RNFL. Earlier studies have shown that retro-bulbar optic nerve thickness is reduced in glaucoma and have suggested that this is also the result of RNFL destruction.
Aim: To investigate the correlation between the orbital and intraocular portions of the optic nerve among POAG patients.
Materials and Methods: This was a hospital-based cross-sectional study done in a tertiary care ophthalmic institute from October 2019 to February 2021. One eye of 32 volunteers with newly diagnosed POAG underwent optic disc analysis using OCT and echographic measurements of the retrobulbar optic nerve. For statistical calculations, Statistical Package for Social Sciences (SPSS) Statistics version 20.0 software (IBM Corp., Armonk, NY, USA) was used. Spearman’s rho (rs) was used as the index of correlation between retrobulbar optic nerve dimensions and ONH topographical data. A correlation between OCT-based RNFL and optic disc parameters was compared with retrobulbar optic nerve dimensions measured with the help of Ultrasonography- Brightness (USG B) Scan.
Results: Orbital Optic Nerve Diameter (OND) and Optic Nerve Cross-sectional Area (ONCSA) significantly and positively correlated with Neuro-retinal Rim (NR) area (OND: p-value=0.00001; ONCSA: p-value=0.00001) and average nerve fiber layer thickness (OND: p-value=0.0001; ONCSA: p-value=0.00002). The Retrobulbar ONCSA-to-disc area ratio (ONCSA/D) was found to have a statistically demonstrable positive correlation with Neuro-retinal Rim Area/Disc area ratio (NR/D) (p=0.00003).
Conclusion: This study showed that retrobulbar optic nerve dimensions correlate well with SD-OCT-based ONH parameters. Echographic measurements of the retrobulbar optic nerve add a new biomarker in the diagnosis of glaucoma.
Optical coherence tomography, Primary open angle glaucoma, Retinal nerve fibre layer, Ultrasound
Optic neuropathies, as an entity, constitute the second most common cause of legal blindness in the world (1). Inflammation, ischaemia, and compression are among the different causes of optic neuropathies, with POAG remaining the leading cause. Axonal loss, combined with changes in the extracellular matrix of the lamina cribrosa, results in a characteristic form of optic neuropathy. Concerning POAG, as estimated in 2010, results in thinning of the RNFL and cupping of the ONH, ultimately leads to Visual Field (VF) defects and significant blindness in an estimated 9.4 million people worldwide (2).
The role of structure-function relationships is widely evaluated for POAG, (3),(4),(5),(6),(7),(8), and in ischemic (9),(10) and compressive (11) optic neuropathy. Technologies such as SLP and OCT closely correlate in measuring structural parameters of RNFL and ONH (5),(7),(12),(13),(14). Comparing these methods with Standard Automated Perimetry (SAP) as the main procedure for assessing visual function has established that measurable structural changes precede measurable functional deficits in POAG (4),(5). Since axonal loss is irreversible and POAG progression can be decelerated by eye-pressure-lowering treatments, early identification of patients at risk is crucial (15), especially for future clinical trials aimed at neuro-protection.
As retinal ganglion cell axons ultimately propagate to the VF cortex via the optic nerve, retrobulbar optic nerve parameters may be considered a suitable surrogate marker for detecting optic atrophy. Histologic evidence has shown that optic atrophy does lead to a thinning of the retrobulbar optic nerve (16), suggesting that OND may correlate with the extent of optic atrophy. Visual impairment related to glaucomatous damage is attributed to the RNFL. Previous literature has indicated a scant number of studies regarding the correlation of retrobulbar optic nerve thickness with the population of the RNFL (17),(18). This correlation is extremely beneficial in cases with a doubtful appearance of ONH or due to the non-visualisation of ONH due to any media opacity. This study was conducted to investigate the relationship between orbital optic nerve dimensions and ONH topographical measurements.
It was a cross-sectional study that included the final diagnosis of POAG in patients attending the Ophthalmology department at a Tertiary care ophthalmic institution. The hospital-based study was performed from October 2019 to February 2021. Institutional Ethics Committee (IEC) clearance was obtained prior to the recruitment of the patients (Government of India, Institutional Ethics Committee Midnapore Medical College, Reference Number: IEC/
2019/05).
Inclusion criteria: Those patients who were atleast 18 years of age with clear optical media, characteristic Glaucomatous Optic disc findings, and a raised Intraocular Pressure (IOP) >21 mmHg and those patients who could perform automated perimetry under acceptable recorded reliability indices were included in the study.
Exclusion criteria: Patients with any associated retinal pathology, presence of other varieties of glaucomatous changes, significant media opacity, Best Corrected Visual Acuity (BCVA) below 3/60 in Snellen’s chart, and those unable to cooperate during investigations were excluded from the study.
Sample size calculation: The sample size was determined based on the prevalence of POAG patients attending the ophthalmology Outpatient Department (OPD) in the same institute during the study period. After that, patients who agreed to take part in the study were taken for calculations. A total of 32 subjects were included.
Procedure
The criteria for VF abnormalities included a corrected pattern standard deviation with p<0.05 or a glaucoma hemifield test outside normal limits, obtained with atleast two reliable and reproducible VF examinations using the Humphrey Field Analyser (HFA) 24-2 protocol. Patients with advanced glaucomatous changes and poor vision were diagnosed based solely on optic disc changes, raised IOP, and RNFL changes measured with Spectral Domain-OCT (SD-OCT). All the patients underwent SD-OCT-based ONH calculations, including cup area, rim area, vertical cup-disc ratio, cup volume, rim volume, and average RNFL thickness. Additionally, all the patients under observation underwent 2 mm retrobulbar optic nerve dimensions measurements with the help of the USG B-scan. The dimensions of the retrobulbar optic nerve considered were OND and ONCSA. For all measurements, five repeated readings were taken, and the mean was calculated. All the procedures were performed by a single experienced operator in a masked fashion to eliminate operator bias on the same instrument every time.
SD-OCT related calculations were accepted as the computer-generated automated reporting produced by the machine algorithm itself. In the case of USG B-scan retrobulbar optic nerve dimensions, measurements were taken in conjunction with A-scan echography. There is ambiguity about optic nerve thickness along the course of the intra-orbital region among investigators (19),(20). So, in the present study, the ultrasound probe was focused on the region of 2-4 mm of the retrobulbar region, resulting in greater resolution of orbital structures and minimising inter-subject variability. Within the depth of focus, the probe achieves a lateral resolution of <0.8 mm, and at the focal plane, it achieves lateral and axial resolutions of 0.3 mm and 0.12 mm, respectively (21). The technique used by us was previously described in the literature. Briefly, the patients were asked to move their eyes in all four gaze positions for three minutes to induce a redistribution of subarachnoid fluid (Table/Fig 1).
The USG probe was then placed on the temporal bulbar conjunctiva with the eye in the primary position. On the echographic screen, a transverse B-scan of the intra-orbital part of the optic nerve could be noticed and confirmed by the presence of dural echoes on a simultaneous A-scan. OND was calculated as the maximal inter-pial distance in the horizontal plane. The perimeter of the nerve was then calculated with a marker, and the area within was taken as the ONCSA.
Statistical Analysis
Statistical analyses were performed using Statistical Package for Social Sciences (SPSS) Statistics version 20.0 software (IBM Corp., Armonk, NY, USA). Categorical variables were expressed in terms of numbers and percentages, while quantitative variables were expressed as mean±standard deviation. Spearman’s rho (rs) was used as the index of correlation between ONH topographical data and retrobulbar optic nerve dimensions. Orbital optic nerve fiber count shows considerable interpersonal variability, and hence this coefficient plays a vital role in eliminating ambiguity (21). The average of the five ultrasound-based measurements of the OND and cross-sectional area were standardised for calculation. A p-value less than 0.05 was considered statistically significant.
Thirty-two patients diagnosed with POAG of different grades were enrolled in the study. The average age of the study population was 50.53±10.19 years. The gender distribution of the study population showed a slight male preponderance (n=18, 56.25%), while the laterality distribution was equal for both eyes. The BCVA on presentation ranged from 6/6 on Snellen’s chart to PL positive. On the HFA 24-2 protocol, the variation of field defects ranged from paracentral scotoma to being unable to perform the test properly due to tunnel vision in advanced cases (Table/Fig 2).
On SD-OCT, the calculation of optic disc area ranged from 2.07-4.26 mm2 with a mean±Standard Deviation (SD) of 2.799±0.636 mm2. The range for Cup-Disc (CD) Ratio was 0.56-0.97. The rest of the topographic dimensions calculated in SD-OCT are given in (Table/Fig 3).
Echographic measurements of orbital OND ranged between 1.44-3.78 mm, with a mean (±SD) of 2.468±0.621 mm. The orbital OND correlated positively and significantly with ONH dimensions calculated, namely rim area, rim volume, and average RNFL thickness, except with cup area, cup volume, and CD ratio where the correlation was negative and statistically significant (p<0.05) (Table/Fig 4).
Echographic measurements of orbital ONCSA ranged between 1.63-11.22 mm2, with a mean (±SD) of 5.316±2.544 mm2. Similar to OND, the orbital ONCSA correlated positively and significantly with all ONH dimensions calculated, namely rim area, rim volume, and average RNFL thickness, except with cup area, cup volume, and CD ratio where the correlation was significantly negative
(Table/Fig 4).
The calculation of NR/D ranged between 0.005-0.544, while the orbital ONCSA/disc area ratio (ONCSA/D) ranged from 0.415 to 4.109. The NR/D significantly correlated with average RNFL thickness (rs=0.69414, p=0.00004). The ONCSA/D was negatively correlated with disc area (rs=-0.34397, p=0.07) and significantly correlated with average RNFL thickness (rs=0.668, p=0.0001) (Table/Fig 5). Finally, correlating NR/D with ONCSA/D resulted in a significant positive result (rs=0.704, p=0.00003) (Table/Fig 6).
In this study, the authors included 32 perimetry-proven glaucomatous patients with insignificant gender and laterality distribution to compare the SD-OCT-measured ONH measurements with the USG B-scan-measured retrobulbar optic nerve dimensions. The authors showed that OND and ONCSA positively correlate statistically significantly with rim area, rim volume, and average RNFL thickness while negatively correlating with cup area, cup volume, and cup-disc ratio with statistical significance.
In the current settings, the diagnosis of POAG solely depends on the results of ONH evaluation, tonometry, and VF testing (22). Although it is a well-proven fact that raised IOP neither concludes a patient as glaucomatous nor does a normal IOP discards the chance of a patient being a case of normotensive glaucoma (22), nowadays IOP has lost its importance as a hallmark for diagnosing POAG.
In the case of ONH evaluation, OCT RNFL has brought a revolutionary change in order to objectify the subjective glaucomatous disc changes and is a brilliant tool to pick-up pre-perimetric glaucomatous disc changes. However, in the presence of dense media opacities, such as dense cataracts, central leucomatous corneal opacity, vitreous haemorrhage, etc., and in cases of ONH anatomical variations like tilted disc, myelinated nerve fiber, etc., it becomes very difficult to observe glaucomatous ONH changes. VF testing is a crucial component in diagnosing glaucomatous changes and is also a good tool to measure disease progression and Visual Field Index (VFI). However, it is seen that in cases of advanced glaucomatous changes with decreased visual acuity and in cases of physical and mental limitations, patients are usually unable to perform VF testing satisfactorily, hampering the reliability indices (2),(3),(4),(5),(6),(7),(8).
In this scenario, it is of utmost necessity to innovate a surrogate diagnostic protocol that can replace the current diagnostic criteria in challenging situations. Loss of retinal nerve fibers has been demonstrated in glaucoma (23),(24), and the disturbances in RNFL correlate well with the extent of pathological optic disc cupping (25),(26),(27),(28). Since the RNFL contains retinal ganglion cells and is part of the optic nerve, a reduction in the size of the retrobulbar optic nerve might be expected in glaucoma. This study, along with previous studies (16),(17), has confirmed this fact. However, the relationship between optic nerve dimensions and the SD-OCT-measured ONH dimensions is the unique criteria in this article.
The present study results are in sync with the study by Beatty S et al., (17). In their study, they also showed a significant correlation between OND and ONCSA with rim volume positively and with CDR negatively (17). But on the contrary, they showed no statistical correlation with other disc parameters mentioned in this study. The present findings are consistent with the study by Dichtl A and Jonas JB, who also demonstrated decreasing optic nerve thickness with decreasing NR (18). However, they used an older version of USG B-scan without A-scan tracing and morphometric disc dimension calculation for their study.
A study by Queiroz WS et al., showed, in thirty eyes of 15 glaucomatous patients with any CD ratio, a strong correlation between CD ratio results obtained by fundus Biomicroscopy (BIO) and the measurements of Cup-OND (C/OND) (ultrasound) (r=0.788, p<0.0001), and with C/D obtained by OCT (r=0.8529, p<0.0001) (29). However, the comparison of CD ratio results obtained with OCT to those obtained with C/OND (Ultrasound) showed only a moderate correlation (r=0.6727, p<0.0001). Bland-Altman analysis did not show good agreement between CD ratio (BIO) and C/OND (ultrasound). They concluded that B-mode ultrasound examination with a 20 MHz probe can be a good additional method for the evaluation of the CD ratio in glaucomatous patients and may be considered as an alternative gross tool in glaucomatous patients with optic media opacities.
According to the literature, although optic nerve fiber count shows a significant and positive correlation with the orbital ONCSA, the role of measurements of the retrobulbar optic nerve in glaucoma assessment may be limited because of the considerable inter-individual variability in its dimensions (19). Furthermore, several investigators have shown that larger, non-glaucomatous discs have larger CD ratios (30),(31), and that glaucomatous optic neuropathy is more difficult to detect in small discs (32),(33). In order to adjust for the inter-individual variability in the pattern and behaviour of different optic discs, the authors incorporated the orbital optic nerve cross-sectional area into a ratio with its corresponding ONH area and named this the ONCSA/D ratio. If the retrobulbar optic nerve does reflect the NR area, it will have a demonstrable significant and positive correlation with the NR/D and a significantly negative correlation with the CD ratio. Also, ONCSA/D and NR/D should be considered even more sensitive indicators for axonal loss, as each ratio is an indicator for present optic nerve fiber count as a fraction of the baseline count for that individual eye.
Limitation(s)
The small sample size, making it challenging to draw generalised opinion regarding the effect of glaucomatous optic neuropathy on retrobulbar optic nerve dimensions. On the other hand, this study could only establish the fact of decreased optic nerve dimensions in the setting of different stages of progression of glaucomatous optic nerve fiber loss. However, this study fails to offer any objective cut-off or algorithm to calculate the amount of glaucomatous optic nerve damage by measuring retrobulbar optic nerve dimensions.
This study concluded that with accurate choice of optic nerve dimensions in the retrobulbar region, they correlate significantly with NR, Cup-Disc Ratio, and average retinal nerve fiber layer thickness. A statistically significant correlation has been established between NR/D and orbital ONCSA/D. This indicates that USG B-scan-measured retrobulbar optic nerve dimensions correlate well with SD-OCT-based ONH parameters. Hence, echographic retrobulbar optic nerve thickness measurement can be a useful tool for detecting glaucoma suspects when traditional parameters of tonometry, optic disc morphometry, and VF assessment fail to detect glaucomatous changes. The authors hope this article will prove to be a cornerstone in the future development of a specific algorithm for the diagnosis of POAG based on echographic measurements of retrobulbar optic nerve dimensions.
DOI: 10.7860/JCDR/2024/69692.19484
Date of Submission: Jan 19, 2024
Date of Peer Review: Mar 21, 2024
Date of Acceptance: Apr 12, 2024
Date of Publishing: Jun 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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ETYMOLOGY: Author Origin
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