Prevention and management of childhood progressive myopia: National consensus guidelines.

Myopia is a major public health problem worldwide, including India, with the global prevalence of myopia increasing rapidly over decades. The clinical and socioeconomic impact of myopia is also expected to rise with rising prevalence. Therefore, the focus has now been shifted to prevent the incidence and progression of myopia. However, there is lack of any standardized guidelines for myopia management. This document aims to generate a national-level expert consensus statement on the management of childhood myopia in the Indian scenario. The expert panel of pediatric ophthalmologists consisted of 63 members who met in a hybrid meeting. A list of topics deliberating discussion in the meeting was provided to the experts in advance and they were instructed to provide their opinions on the matter during the meet. The panel of experts then gave their views on each of the items presented, deliberated on different aspects of childhood myopia, and reached a consensus regarding the practice patterns in the Indian scenario. In case of opposing views or lack of a clear consensus, we undertook further discussion and evaluated literature to help arrive at a consensus. A written document is prepared based on recommendations explaining definition of myopia, refraction techniques, components and methods of workup, initiation of anti-myopia treatment, type and timing of interventions, follow-up schedule, and indications for revised or combination treatment. This article formulates evidence-based guidelines for progressing myopes and pre-myopes and also establishes uniformity in the management of childhood myopia in the country.

Consensus statement and guidelines for use of dilute atropine sulphate in myopia control.

Purpose: To develop a consensus statement for use of dilute atropine in control of myopia progression in children based on review of existing literature, opinions and suggestions of the members of the Group of Paediatric Ophthalmologist and Strabismologists, Mumbai (GPOS). Methods: Literature review, group discussions, questionnaire study and consensus building by supermajority voting. Results: About 65% of paediatric ophthalmologists in Mumbai have started prescribing atropine sulphate 0.01% as routine in their patients showing myopia progression. Majority of the respondents who have used it for >1 year in their patient population are extremely happy with the results. About 47% respondents expressed concerns regarding some yet unknown side effects of long-term use in our patient population. Majority of the respondents agree that it is safe and have rarely encountered side effects with its use. Conclusion: Atropine sulphate 0.01% is a safe and effective treatment for myopia control. Most trained paediatric ophthalmologists recommend its use in children with progressive simple myopia.

Macular cherry-red spot helps diagnose rare storage disorder in an infant with repeated respiratory tract infections: case report.

A seven-month-old male child was brought in for an eye test for poor vision and nystagmus noticed from four months of age. The child had delayed milestones of development and multiple (six times) episodes of unexplained lower respiratory tract infection (from two months of age) treated by pediatricians at different centers without complete cure. Fundus examination showed bilateral cherry-red spots at the macula. There were diffusely distributed hyper-pigmented patches (Mongolian spots) on the back and extensor aspect of the extremities. The case was sent back to the pediatricians for a re-evaluation to rule out storage disorder. Lysosomal enzyme assay in the leucocytes showed a significantly reduced ß-galactosidase level (15.6 nmol/hr/mg protein in contrast to a normal range of 79.6 to 480.0). This confirmed the patient to be a case of lysosomal storage disease, the GM1 gangliosidosis (type I).

Acute idiopathic frosted branch angiitis in an 11-month-old infant treated with intravitreal triamcinolone acetonide.

An 11-month-old boy presented with bilateral vision loss following upper respiratory tract infection. Extensive perivascular sheathing resembling frosted branch angiitis and severe macular edema was noted in both eyes. All tests for etiological diagnosis were negative. Treatment with systemic corticosteroids and antibiotics caused resolution of perivascular infiltrates. Macular edema resolved with improvement in visual acuity following consecutive bilateral intravitreal triamcinolone acetonide injections. To our knowledge, this is the youngest reported case of frosted branch angiitis.

Optic disc doubling.

Many developmental defects can simulate the optic disc (optic disc pseudodoubling). True optic disc duplication with 2 independent retinal vasculatures is rare. Associated optic nerve duplication is rarer still and seen in lower vertebrates. We report a rare case of unilateral double optic discs with a single optic nerve in the left eye of a 41-year-old man, otherwise asymptomatic in the affected eye.

Spectral domain optical coherence tomography finding in posterior microphthalmos.

An eight-year-old boy presented with decreased vision in both eyes. At presentation, the visual acuity was 6/60 in both eyes with high plus spheres. Anterior segment examination was normal. Fundus examination and spectral domain optical coherence tomography were consistent with posterior microphthalmos and showed an elevated foveal contour and fold in the outer plexiform layer. External limiting membrane, photoreceptor and retinal pigment epithelium were not involved in the fold. To the best of our knowledge this is the first such case report with optical coherence tomography imaging of the retinal layer involved in a case of posterior microphthalmos.

Macular folds: an unusual association in topiramate toxicity.

We report two uncommon cases of acute onset myopia with macular folds following use of topiramate. A 25-year-old woman, with no prior history of glasses, taking topiramate for recurrent headaches, presented with decreased vision. On examination, she was found to have a refractive error of -5.00 DS in both eyes and intraocular pressure of 10 mmHg and 6 mmHg in the right and left eyes, respectively. She had closed angles on gonioscopy, ciliary effusion on ultrasonic biomicroscopy with inner limiting membrane folds in the macula in both eyes. She was on anti-glaucoma medication when she presented to us. A 20-year-old woman presented with acute headache and decreased vision following use of topiramate for treatment of migraine. On examination, her intraocular pressure was 25 mmHg in both eyes with closed angles on gonioscopy, a refractive error of -4.50 DS and prominent macular folds with no fluid in both eyes. There was complete resolution of macular folds and angle-closure attack after discontinuation of topiramate and conservative treatment with topical steroids and cycloplegics in both eyes. Topiramate toxicity may present with macular folds associated with angle-closure glaucoma. Folds in the inner limiting membrane might give a clue to choroidal effusion as the cause for this presentation. The symptoms resolved on the discontinuation of topiramate.

Bilateral response after unilateral subconjunctival bevacizumab injection in a child with Stevens-Johnson syndrome.

Bevacizumab is widely used for several ocular conditions, including age-related macular degeneration, diabetic retinopathy, corneal neovascularization, neovascular glaucoma, and retinopathy of prematurity. We describe a 14-year-old patient with Stevens-Johnson syndrome in whom subconjunctival injection of bevacizumab in one eye caused bilateral regression of corneal neovascularization.

Push-pull technique of capsulorhexis for fibrous plaques on anterior capsules in pediatric cataract surgery.

We describe the adaptation of two-incision push-pull technique for performing continuous capsulorhexis in children's eyes with anterior capsules having large fibrous plaque in the center. This technique uses the fibrous plaque as a template for directing the force vectors to achieve a controlled tear and a continuous capsulorhexis. We used the technique in 12 eyes of six children with successful capsulorhexis in 10 eyes and peripheral extension of rhexis in 2 eyes.

Bietti crystalline retinal dystrophy with subfoveal neurosensory detachment and congenital tortuosity of retinal vessels: case report.

A 34-year-old man presented with reduction and distortion of vision in both the eyes. The best-corrected vision was 20/20 parts, N6 in either eye. The external and slit lamp examination of both the eyes was unremarkable. The fundus examination showed multiple intraretinal crystalline deposits at the posterior pole, extending up to midperiphery, tortuous retinal blood vessels with S-shaped deflections, and absent foveal reflex in both the eyes. There were no corneal crystals, and the color vision was defective in both the eyes. Fundus autofluorescence and fundus fluorescein angiogram (FFA) were suggestive of geographic areas of retinal pigment epithelium (RPE) and choriocapillary (CC) loss. OCT revealed subfoveal neurosensory detachment. Flash ERG and EOG were normal except for a slight decrease in amplitude and delay in latency of pattern ERG waveforms. The Humphrey's visual field showed paracentral scotoma with reduction in the amplitude of waveforms from the corresponding area in the multifocal ERG in both the eyes. Systemic evaluation for crystalline retinopathy was unremarkable. He was diagnosed to be a case of Bietti crystalline retinopathy (local/regional variant). The subfoveal neurosensory detachment could represent early RPE dysfunction caused by these crystals and could account for the mild visual disturbance in both the eyes. Retinal vascular tortuosity and neurosensory detachment seen in this case is the first time to be reported in literature.

Outcomes of a protocol-based management for zone 1 retinopathy of prematurity: the Indian Twin Cities ROP Screening Program report number 2.

PURPOSE: To report the outcomes of zone 1 aggressive posterior retinopathy of prematurity (ROP) treated with aggressive laser photocoagulation by a protocol-based approach over a 10-year period. DESIGN: Prospective, interventional case series. SETTING: Tertiary eye institute and neonatal intensive care units in the twin cities of Hyderabad and Secunderabad in South India. STUDY POPULATION: Babies screened under the Indian Twin Cities Retinopathy of Prematurity Screening (ITCROPS) program between January 1, 1997 and March 31, 2007. INTERVENTION: Multiple sessions of laser photocoagulation at any sign of plus disease with abnormal shunt vessels with or without neovascularization in zone 1. OUTCOME MEASURE: Based on the anatomic status of the retina at the final follow-up, the outcome was classified into good (completely regressed with no vitreoretinal changes), fair (regression with vitreoretinal distortion), or poor (progression into partial or total retinal detachment involving macula). Descriptive statistics (mean and range) were used for gestational age at birth, birth weight, and post-conceptional age at first presentation and at the first intervention. Trends in incidence of zone 1 ROP over 1 decade were analyzed. Outcomes were expressed in terms of proportions and 95% confidence interval (CI). RESULTS: Of the 3654 babies screened, 227 eyes of 115 babies were detected to have zone 1 aggressive disease, defined as zone 1 retinal vessels having abnormal closed-loop shunts, dilation and tortuosity, flat new vessels, or rapid progression. Laser was performed in 169 eyes. Disease regressed with good outcome in 142 eyes (84%) (95% CI, 77.6-89.2) and progressed to poor outcome in 13 eyes (7.69%) (95% CI, 4.1-12.8), while fair outcome was seen in 6 eyes (3.55%) (95% CI, 1.3-7.5). Thus 148 babies (87.5%) (95% CI, 81.6-92.14) had a favorable outcome. The outcomes in 8 treated eyes (4.7%) lost to follow-up were unknown. CONCLUSIONS: Zone 1 aggressive ROP has a good outcome if the screening is done early; intervention is prompt and adequate, with frequent follow-up until complete regression is achieved.

Surgical technique for removing congenital fibrovascular pupillary membrane, with clinicopathological correlation.

Congenital fibrovascular pupillary membrane, rare in newborns, poses challenges for the ophthalmic surgeon. Predicting its clinical course is difficult, as is removing the membrane surgically without inducing a cataract. We describe a 22-day-old girl who presented with a pupillary membrane causing progressive decrease in the size of the dilated pupil, necessitating removal at 4 months of age. Histopathology demonstrated tissue of embryonic muscle origin, suggesting that the membrane was more likely a remnant of fetal iris than of fetal vasculature. The smooth muscle or fibroblastic elements in the tissue explains progressive contracture of the membrane.

Botulinum toxin in the management of acquired motor fusion deficiency.

Acquired disruption of motor fusion is a rare condition characterized by intractable diplopia. Management of these patients is extremely difficult. Prisms in any combination or even surgery may not help relieve their symptoms. We describe a longstanding case of acquired motor fusion disruption which was managed successfully with botulinum toxin injection.