Low-dose atropine 0.01% for the treatment of childhood myopia: a pan-India multicentric retrospective study.

OBJECTIVE: The objective of this study was to assess the efficacy of low-dose atropine 0.01% in controlling myopia progression among Indian children over a 2-year period. METHODS: This retrospective study, conducted across 20 centres in India, monitored the progression of myopia over 2 years after initiating treatment with 0.01% atropine eye drops. This included children between 6 and 14 years with baseline myopia ranging from -0.5 D to -6 D, astigmatism≤-1.5 D, anisometropia ≤ -1 D and documented myopia progression of ≥0.5 D in the year prior to starting atropine. Subjects with any other ocular pathologies were excluded. RESULTS: A total of 732 children were included in the data analysis. The mean age of the subjects was 9.3±2.7 years. The mean myopia progression at baseline (1 year before starting atropine) was -0.75±0.31 D. The rate of myopia progression was higher in younger subjects and those with higher baseline myopic error. After initiating atropine, myopia progression significantly decreased to -0.27±0.14 D at the end of the first year and -0.24±0.15 D at the end of the second year (p<0.001). Younger children (p<0.001) and higher baseline myopia (p<0.001) was associated with greater myopia progression and poor treatment response (p<0.001 for both). CONCLUSION: Low-dose atropine (0.01%) effectively reduces myopia progression over 2 years in Indian children.

Impact of Covid-19 on Pediatric Ophthalmology Care: Lessons Learned.

The COVID-19 pandemic came with many new challenges that forced personal and professional lifestyle modifications. Medical facilities were in scarcity against this new unknown enemy and were challenged with the overloaded patient flow, scarcity of healthcare staff, and evolving treatment modalities with a better understanding of the virus each day. Ophthalmology as a "branch of medicine" suffered challenges initially because of a lack of guidelines for patient management, close working distance during routine examinations, and halt of major surgeries, including cataracts. Pediatric ophthalmology had major implications, as reduced outpatient visits would mean deeper amblyopia, and changed lifestyles, including online classes and home refinement, predisposing children to myopia, digital eye strain, and worsening of strabismus. COVID-19 also unveiled underlying accommodation and convergence anomalies that predisposed pediatric and adolescent patients to an increased prevalence of headache and acute onset esotropia. Teleophthalmology and other innovative solutions, including the use of prism glasses, safe slit-lamp shields, alternative ways of school screening with the use of photoscreeners, performing retinoscopy only when needed, and using autorefractors were among the few guidelines or modifications adopted which helped in the efficient and safe management of pediatric patients. Many pediatric ophthalmologists also suffered in terms of financial constraints due to loss of salary or even closure of private practices. School screening and retinopathy of prematurity screening suffered a great setback and costed a lot of vision years, data of which remains under-reported. Important implications and learnings from the pandemic to mitigate future similar situations include using teleophthalmology and virtual platforms for the triage of patients, managing non-emergency conditions without physical consultations, and utilizing home-based vision assessment techniques customized for different age groups. Though this pandemic had a lot of negative implications, the innovations, modifications, and other important learnings helped pediatric ophthalmologists in navigating safely.

Health economics and manual small-incision cataract surgery: An illustrative mini review.

Cataract extraction is one of the most common surgical procedures performed worldwide. Manual small-incision cataract surgery (MSICS) is a popular technique of cataract extraction. Full economic evaluation of different techniques is of value to policy makers. This was a systematic review of published literature to present a brief overview of evidence available in respect of economic evaluation measures like cost effectiveness, cost utility, and cost parameters in cataract patients regarding MSICS. The data on these was sparse and heterogeneous. Direct costs of MSICS were lower than phacoemulsification (PE): $25.55 (PE) to $17.03 (MSICS) in India, $15 (MSICS) to $70 (PE) in Nepal, and $62.25 (MSICS) to $104.15 (PE) in Thailand. The cost utility analysis for MSICS demonstrated savings of $79.57 (INR6175) per gain in LogMAR BCVA, $8.91 (INR691) per QALY gained and $1.42 (INR110) per VF 14 score increment in India. Incremental cost-effectiveness ratio (ICER) $368.20 (13,215.50 Baht) for MSICS was better than $489.30 (17,561.70 Baht) for PE in Thailand. ICER for femto laser-assisted cataract surgery (FLACS) compared to was €10,703 in femtosecond laser-assisted versus phacoemulsification cataract surgery (FEMCAT) study. The corrected ICER for PE against MSICS is €146.50. The limited data available demonstrates that MSICS is the most cost-effective technique among FLACS, PE, and MSICS. MSICS scores over other existing alternatives of cataract extraction from cost-effectiveness and cost-minimization approaches. Further research is required in this area.

State of the nation survey on cataract surgery in India.

Purpose: To study the knowledge, attitudes, and practices of the ophthalmologists in India regarding cataract extraction practices. Methods: A prospective, online, descriptive study was conducted from January 2022 to April 2022 using a self-developed validated questionnaire attached which was administered through a generated link. Results: The mean age of these 153 respondents was 47.02 (SD = 11.53) years with a male preponderance (70.59%). The majority (52.9%) had completed a fellowship after their post-graduation, and 56.20% provided sub-specialty services. Comprehensive ophthalmology (69.93%) and anterior segment (50.32%) practice were the most popular. Although 76.47% of respondents used a mix of techniques, 11.11% surgeons used only phaco-emulsification and 9.8% used only manual small-incision cataract surgery (MSICS) as the lone cataract treatment modality. Roughly 38% felt that outcomes were comparable for phaco-emulsification and MSICS, whereas about 44% opined that the outcomes of phaco-emulsification were better. MSICS outcomes were reported to be better by approximately 15%. The frown incision (53.59%), the straight incision (19.60%), and the straight incision with back cuts (10.45%) were popular. The majority (71.24%) of the respondents were willing to train fellow ophthalmologists and youngsters in MSICS. Standalone practices and family practices (42.48%), private eye institutes (10.45%), medical colleges (12.41%), and government non-teaching hospitals (11.11%) were the major service providers. 4% were working in rural hinterland. Conclusion: The majority of the surgeons use a mix of cataract extraction operative techniques. A large, willing talent pool of manual small-incision cataract surgeons exists. India can be a global hub for MSICS delivery and training.

Two-mm chord manual small-incision cataract surgery with phacofracture: A brief exposition of the surgical technique.

We describe a surgical technique for manual small-incision cataract extraction with 2-mm chord incision with phacofracture. The authors describe a curvilinear 2-mm chord incision 1.5 mm behind the limbus and antiparallel to the limbus with back cuts of variable length; 1.5 mm for foldable lenses and 2.5-3 mm for the rigid nonfoldable lenses. Continuous curvilinear capsulorhexis with a 26-G bent needle cystitome (or Utrata forceps) is followed by cortical cleaving hydrodissection and cartwheeling of the nucleus into the anterior chamber. A specially designed Sahu modified vectis (SMV) and a flattened visco cannula are used for the phacofracture. The heminuclei are removed along their longitudinal axis and direct implantation of the pseudophakos. Surgically induced astigmatism was found to be a mean change in astigmatism of 0.14 DCyl when the axis was ignored. Corneal endothelial counts were not vastly different from the routine manual small-incision and phacoemulsification at 3 months of follow-up. The technique used here by the surgeon for cataracts of any C (1-5) or any P (1-5) to grade NC4 NO4 as graded by the LOCS III. Case selection is of paramount importance. Two-millimeter chord MSICS with phacofracture can deliver low astigmatism and good visual recovery in cataract surgery.

Digital Eye Strain- A Comprehensive Review.

Digital eye strain (DES) is an entity encompassing visual and ocular symptoms arising due to the prolonged use of digital electronic devices. It is characterized by dry eyes, itching, foreign body sensation, watering, blurring of vision, and headache. Non-ocular symptoms associated with eye strain include stiff neck, general fatigue, headache, and backache. A variable prevalence ranging from 5 to 65% has been reported in the pre-COVID-19 era. With lockdown restrictions during the pandemic, outdoor activities were restricted for all age groups, and digital learning became the norm for almost 2 years. While the DES prevalence amongst children alone rose to 50-60%, the symptoms expanded to include recent onset esotropia and vergence abnormalities as part of the DES spectrum. New-onset myopia and increased progression of existing myopia became one of the most significant ocular health complications. Management options for DES include following correct ergonomics like reducing average daily screen time, frequent blinking, improving lighting, minimizing glare, taking regular breaks from the screen, changing focus to distance object intermittently, and following the 20-20-20 rule to reduce eye strain. Innovations in this field include high-resolution screens, inbuilt antireflective coating, matte-finished glass, edge-to-edge displays, and image smoothening graphic effects. Further explorations should focus on recommendations for digital screen optimization, novel spectacle lens technologies, and inbuilt filters to optimize visual comfort. A paradigm shift is required in our understanding of looking at DES from an etiological perspective, so that customized solutions can be explored accordingly. The aim of this review article is to understand the pathophysiology of varied manifestations, predisposing risk factors, varied management options, along with changing patterns of DES prevalence post COVID-19.

Early postoperative astigmatism in 2-mm manual small incision cataract surgery with phacofracture.

Purpose: India's cataract surgery rate has been hovering around a creditable 6000 per million population but the coverage is variable across the geography and demography with sharp urban rural divide. Smaller incisions in manual small incision cataract surgery (MSICS) with phacofracture have been credited with lower astigmatism and faster recovery, which is especially useful for patients traveling for surgeries. Methods: In this retrospective chart analysis based observational study of 66 eyes, we describe the early postoperative results with 2 mm MSICS with phacofracture. Results: The mean spherical equivalent of the autorefractor measured astigmatic error changed marginally to -0.51 diopters (SD = 0.58) from -0.44 diopters (SD = 0.42) (t = -8.410, P = 0.0) translating to mean change in astigmatism of 0.14 DCyl when the axis was ignored. The keratometric difference between steepest and flattest axis of the anterior surface of the central 3 mm zone of the cornea changed from a mean of 0.89 diopters (SD = 0.55) to 1.39 diopters (SD = 1.03). The visual acuity improved to mean logarithm of the minimum angle of resolution (logMAR) score of 0.27 (SD = 0.33) at 1 week and 0.007 (SD = 0.04) which corresponds to 6/6P on Snellen's acuity at 1 month or more. Conclusion: A 2 mm MSICS with phacofracture can deliver low astigmatism and good visual recovery in cataract surgery. The study underlines the need for considering the refraction at anterior and posterior corneal interfaces when the triplanar incision with separate interfaces is used.

Neuromyelitis optica spectrum disorder post-COVID-19 infection: A rare case report from Northeast India.

Multiple sclerosis and neuromyelitis optica spectrum disorder may be seen in the acute setting of coronavirus disease 2019 (COVID-19) infection or even post-recovery. Such patients may present with optic neuropathy along with weakness in the back and lower limbs. Ascending paralysis can present with respiratory distress in acute COVID-19 infection and may even prove to be fatal. We report a unique case of a 16-year-old female with past history of COVID-19 infection having optic neuropathy, and radioimaging showing demyelinating plaques in the central nervous system with spinal cord edema. Serology showed positivity for rheumatoid arthritis, and the patient was managed with steroids and rituximab.

Transient myopia due to choroidal effusion: A novel ocular complication of COVID-19 infection.

COVID-19 was declared as a global pandemic by the WHO in 2020. Although it is a respiratory virus, ocular complications and manifestations of the infection have been reported in different forms. We report a case of transient myopia and narrow angles due to choroidal effusion following infection by the SARS-COV-2 virus. We propose that the ability of the virus to incite an inflammatory response in the host body may be the mechanism behind the disease entity. This is a novel, previously undocumented ocular complication in case of a COVID-19 infection.

Long-term changes in contrast-sensitivity, corneal topography and higher-order aberrations after upper eyelid blepharoplasty: A prospective interventional study.

PURPOSE: The aim of this study was to analyze the long-term changes in visual parameters, that is, contrast sensitivity (CS) and higher-order aberrations (HOAs), and corneal topography in the patients undergoing upper eyelid blepharoplasty (UEB) for dermatochalasis. METHODS: This was a prospective, single surgeon, intervention study including patients (≥40 years age) having severe dermatochalasis with a minimum post-UEB follow-up of 12 months. The preoperative readings of CS (using Pelli-Robson chart), HOAs (using WaveLight ALLEGRO analyzer), and corneal topography (using topographic modeling system-4, Tomey corporation) were noted and compared at 3, 6, and 12 postoperative months. RESULTS: We studied 30 patients (60 eyes) who underwent bilateral UEB. The majority of patients were females (n = 21,70%), and the mean age of patients was 56.53 ± 9.06 years. The preoperative and postoperative values of LogMAR visual acuity, log CS value, corneal topography measurements (K1, K2, cylinder value, and the axis), optical aberrations (total HOAs; third-order--trefoil & coma; four-order--spherical aberrations and secondary astigmatism, and tetrafoil) were compared. At 12 months, the mean CS value, the majority of HOAs, and corneal topography (only cylinder values) showed a stable, statistically significant difference in the postoperative period. CONCLUSION: The UEB may produce long-term, visually-beneficial, optical, and corneal changes. The patients undergoing cataract surgery aiming for spectacle independence may gain additional visual benefits with UEB.

Idiopathic inflammatory diseases of orbit and ocular adnexa: Histopathological and immunochemical analysis.

Purpose: : To present histopathological and immunohistochemical analysis of idiopathic inflammatory diseases of orbit and ocular adnexa. Methods: Design- A retrospective laboratory-based study. The study was carried out in an ocular pathology laboratory in a tertiary institute of northeast India where analysis of 93 cases was done in 5 years, during the period from 2011 to 2016. Hematoxylin--eosin and special stains were done for the diagnoses. Immunohistochemistry (IHC) panel was also carried out. For infectious pathology, Grocott's methenamine silver (GMS) stain for fungus, tissue Gram's stain for bacteria's, and acid-fast stains for tubercular bacilli were done. IHC panels were done for CD 20 (B-cells), CD-3 (T-cells), CD-45 (Leukocyte common antigen, LCA), BCL-2, CD-138 (Plasma cells), Kappa, Lambda, IgG-4 in tissue, IgG-4 in serum, etc. IHCs were done using kit methods (standardized) and adequate controls were taken for each sample. Results: 93 cases of nonspecific orbital inflammation were reported out of 1,467 specimens. Orbital pseudotumors (idiopathic orbital inflammatory disease, IOID) were seen in 27 cases (sclerosing variety-6); benign lymphoid hyperplasia in two cases; reactive lymphoid hyperplasia in 10 cases; atypical plasma lymphoproliferative reactive (polyclonal immunophenotypically, IgG4 negative) lesions in four cases; IgG-4 related disease in one case; nonspecific inflammatory reactions (conjunctiva, sclera, and lid) in 49 cases. In all the diagnoses, infections and lymphomas were excluded. Conclusion: Biopsy supported study on nonspecific orbital inflammation was important to know the pattern.

Human orbital adipose tissue-derived mesenchymal stem cells possess neuroectodermal differentiation and repair ability.

Mesenchymal stem cells (MSCs) are used extensively in cell therapy for repair and regeneration of several organs and tissues. Cell therapy is a valuable option to treat neurodegenerative diseases and MSCs have been shown to improve neuronal function through direct differentiation or secretion of neurotrophic factors. In the present study, we isolated and characterized stem cells from medial and central orbital adipose tissue and found that they could be grown in a monolayer culture. The orbital adipose tissue-derived cells were identical to bone marrow-derived MSCs in their cell surface marker expression, gene expression and multilineage differentiation abilities. The orbital adipose-derived MSCs (OAMSCs) express several neurotrophic factors, possess neuroectodermal differentiation ability and secreted factors from OAMSCs abrogated neuronal cell damage induced by oxidative stress. Thus, OAMSCs might be a valuable cell source for treatment of neurological diseases and to reverse oxidative damage in the neuronal cells.

Hyperacute spontaneous closure of a traumatic macular hole in a colobomatous eye.

A 12 year old boy presented to us with complaints of diminution of vision following blunt injury to his left eye. Examination revealed a grade 5 retina-choroidal coloboma in left eye with haemorrhage at its inferior border. A macular hole was seen clinically which was confirmed on ocular coherence tomography (OCT). Repeat fundus examination & OCT after 10 days revealed spontaneous closure of the macular hole with improvement in the visual acuity.

Human ocular thelaziasis caused by gravid Thelazia callipaeda - A unique and rare case report.

An 80-year-old male reported to the clinic with complaints of diminished vision, foreign body sensation, and occasionally some black object moving in front of the right eye. Detailed ocular examination revealed three slender creamy white live worms in the conjunctival sac of the right eye. Total three worms were retrieved and sent to the pathology department for detailed examination. The worm was identified as gravid Thelazia callipaeda. As per the search results in PubMed and Cochrane search engine, this is the first report of human case of gravid Thelazia infestation with simultaneous existence of embryonated or ensheathed eggs and primary-stage larvae in the same worm.

Systemic diffuse large B-cell lymphoma masquerading as neovascular glaucoma.

We describe a case of spontaneous hyphema associated with anterior uveitis presents in a 69-year old female as the prominent sign of the intraocular spread of systemic diffuse large B-cell lymphoma (DLBCL). She had a history of diabetes and initially misdiagnosed as neovascular glaucoma. Clinical history of systemic lymphoma, characteristic findings on B-scan ultrasonography and magnetic resonance imaging scan, and identification of atypical lymphoid cells in aqueous sample established the diagnosis of intraocular metastasis of systemic DLBCL. Therefore, this report highlights that life-threatening malignant systemic lymphoma may masquerade as anterior segment ocular inflammation or neovascular glaucoma.

Updates on upper eyelid blepharoplasty.

The human face is composed of small functional and cosmetic units, of which the eyes and periocular region constitute the main point of focus in routine face-to-face interactions. This dynamic region plays a pivotal role in the expression of mood, emotion, and character, thus making it the most relevant component of the facial esthetic and functional unit. Any change in the periocular unit leads to facial imbalance and functional disharmony, leading both the young and the elderly to seek consultation, thus making blepharoplasty the surgical procedure of choice for both cosmetic and functional amelioration. The applied anatomy, indications of upper eyelid blepharoplasty, preoperative workup, surgical procedure, postoperative care, and complications would be discussed in detail in this review article.

Single stage surgery for Blepharophimosis syndrome.

PURPOSE: The purpose of this study was to report the functional and cosmetic outcome of single stage surgical procedure for correction of the classic components of Blepharophimosis syndrome. MATERIALS AND METHODS: We report a retrospective case file review of 11 patients with Blepharophimosis syndrome operated between July 2004 and April 2008. Each patient had undergone the correction of epicanthus inversus, telecanthus, palpebral phimosis, and bilateral ptosis as a single-stage surgical procedure. Patients were examined and photographed before and after surgery. The mean follow-up was 3 years (range 2-6 years). RESULTS: A total of 11 patients (8 males, 3 females) with a mean age of 9 years (range 6--22 years) were reviewed. The surgical outcome was assessed both functionally and cosmetically. The mean preoperative visual acuity was 0.729 ± 0.316 SD and the mean postoperative visual acuity was 0.856 ± 0.277 SD (P <0.0428). There was a statistically significant decrease of astigmatism following ptosis correction (P<0.05), improvement of telecanthus (P<0.0001) in terms of IICD (inner intercanthal distance), and HPFL (horizontal palpebral fissure length) (P=0.019) along with improvement of the superior visual field. The mean preoperative and postoperative IICD was 3±0.33 SD and 2.418 ± 0.189 SD, respectively. There was also a significant postoperative improvement of ptosis (P< 0.01), as measured by IPFH (vertical interpalpebral fissure height). All the patients had a stable functional and cosmetic result after a mean follow-up period of 3 years. CONCLUSION: Single-stage surgical correction of the classic anomalies of Blepharophimosis syndrome provides stable and successful long-term results.

Sphenoethmoidal mucocele presenting with unilateral visual loss.

BACKGROUND: Sphenoethmoidal sinus mucocele causing uniocular progressive vision loss is a rare entity and was first described by Bery in 1985. It is generally diagnosed in its advanced stage when the patients develop subjective ophthalmic symptoms. CASE: A 43-year-old male presented to our institute for further evaluation and treatment of progressive visual deterioration in his left eye. The patient complained of visual impairment in his left eye for the past three months, in the form of a dark area in his left side of the visual field. OBSERVATIONS: Magnetic resonance imaging (MRI) revealed a large expansile lesion in the left sided posterior ethmoidal air cells, abutting on the left optic nerve and displacing it in the region of the orbital apex. The patient underwent an urgent endoscopic sinus surgery by an Ear-Nose-Throat surgeon which resulted in stable visual acuity in the sixth postoperative month. CONCLUSIONS: Sphenoethmoidal mucocele can cause irreversible blindness. Progressive vision loss with a neurological visual field defect should raise a high index of suspicion and computed tomography and MRI are to be performed to confirm the diagnosis. Collaboration between radiologists, ENT specialists, and ophthalmologists is essential for treating such cases.