Horizontal gaze palsy with progressive scoliosis.

Horizontal gaze palsy with progressive scoliosis (HGPPS) is a rare autosomal recessive condition characterized by absence of abduction and adduction movements with intact vertical eye movements and progressive scoliosis. Patients usually present by mid-childhood with complaints of progressive scoliosis. The clinical diagnosis of HGPPS can be further confirmed by the ROBO3 gene mutation on chromosome number 11. We present 2 Indian siblings who were incidentally diagnosed with HGPPS with synergistic convergence on regular eye examination; diagnosis was confirmed by radiological and genetic testing.

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.

Evaluation of Peripapillary and Macular Optical Coherence Tomography Angiography Characteristics in Different Stages of Papilledema.

BACKGROUND: Prospective evaluation of optical coherence tomography (OCT) and OCT angiography (OCT-A) characteristics in different stages of papilledema in idiopathic intracranial hypertension (IIH). METHODS: In this prospective, observational study patients of IIH with papilledema were recruited and divided into 3 groups-early/established (Group 1), chronic (Group 2), and atrophic papilledema (Group 3). Peripapillary retinal nerve fiber layer (RNFL) and macular ganglion cell inner plexiform layer (GC-IPL) were recorded on OCT. Peripapillary and macular perfusion was documented at superficial retinal, deep retinal, and choriocapillary level using OCT-A. The investigations were repeated at 3 months. RESULTS: RNFL showed significant thinning in all groups on follow-up with the atrophic group showing maximum thinning ( P = 0.01-Group 3). GC-IPL was significantly reduced in all stages of papilledema at baseline compared with the controls. Thinnest GC-IPL was noted in the atrophic group (52.75 ± 7.44 µm; P = 0.00 in Group 3 vs controls) that showed further deterioration on follow-up. On Image J analysis, significant decrease was noted at various levels in the peripapillary and macular perfusion at baseline especially in the atrophic group which showed further deterioration noted on follow-up. The final visual acuity showed a statistically significant weak negative correlation with baseline RNFL (r = -0.306) and GC-IPL (r = -0.384) and moderately negative correlation with baseline superficial peripapillary retinal perfusion (r = -0.553). A significant negative correlation was seen between increasing grade of papilledema and superficial peripapillary retinal perfusion with both Image J and automated indices (r = -0.46; r = -0.61), respectively. CONCLUSIONS: GC-IPL may help identify early damage in papilledema even in the presence of thicker RNFL. Significant vascular changes can be observed on OCT-A that may help predict the final visual outcome in papilledema due to IIH.

Biomechanical properties of cornea and ocular aberrations in myopic eyes.

PURPOSE: To study the correlation of corneal topography, corneal biomechanical properties, and ocular aberrations with the magnitude of refractive error in myopic eyes. METHODS: All myopic patients attending the clinic for refractive surgery were recruited. Data recorded included visual acuity, axial length (AL), central corneal thickness (CCT), manifest refraction spherical equivalent (MRSE), topography (Pentacam - Oculus), corneal biomechanical factors [ocular response analyzer (ORA)], and optical aberrations (iTrace). They were further categorized into group 1 (suitable for femto-LASIK) and group 2 (unsuitable for femto-LASIK). RESULTS: Sixty eyes (30 myopes) of mean age 22.78 ± 2.71 years were enrolled. A negative correlation of refractive error was noted with AL (ρ = -0.9; P < 0.001), total aberrations (ρ = 0.53; P < 0.001), and lower-order aberrations (LOA) (ρ = 0.54; P < 0.001). A strongly positive correlation was noted between CCT and corneal hysteresis (CH) (ρ = 0.63; P < 0.001), CCT and CRF (ρ = 0.56; P < 0.001), CH and corneal resistance factor (CRF) (ρ = 0.83; P < 0.001), and Goldmann equivalent intraocular pressure (IOPg) and corneal compensated intraocular pressure (IOPcc) (ρ = 0.78; P < 0.001). An increase in higher-order aberrations (HOAs) as well as lower-order aberrations (LOAs) was noted with increasing sim-K [HOA (r = 0.73, P = 0.001); LOA (r = 0.601, P = 0.014)] and increasing CRF [HOA (r = 0.5, P = 0.006); LOA (r = 0.732, P = 0.001)] in group 2. The amount of refractive error, axial length, central corneal thickness, and sim-K were significantly different in the two groups. CONCLUSION: Increasing degree of myopia is associated with an increase in axial length, total aberrations, and lower-order aberrations. Corneal biomechanical parameters have a strong correlation with each other. Lower corneal biomechanics are noted in high myopes as they have weaker and thinner corneas. Corneal biomechanics and ocular aberrations do not differ significantly between cases suitable for femto-LASIK and cases unsuitable for femto-LASIK.

Evaluation of change in objective cyclotorsion after various inferior oblique-weakening procedures.

PURPOSE: To study the effect of four types of inferior oblique-weakening procedures on ocular torsion: inferior oblique recession (IOR), recession and antero-positioning (RAP), anterior transposition as practiced by Elliot and Nankin (EN), and anterior and nasal transposition (ANT). METHODS: The medical records of 72 consecutive patients >10 years of age undergoing inferior oblique weakening for primary or secondary inferior oblique overaction (IOOA) with or without horizontal rectus surgery were reviewed retrospectively. The 106 included eyes were assigned to one of the four groups according to the type of inferior oblique-weakening procedure. The severity of IOOA and the amount of V pattern guided the choice of procedure. IOOA, disk-fovea angle (DFA), and the amount of V pattern were recorded preoperatively. Measurements were repeated postoperatively at 1 week, 4 weeks, and 3 months. Change in the DFA was used to study the change in objective cyclotorsion in all four groups. RESULTS: A significant incyclotorsional shift was seen in all four groups at postoperative 3 months. The mean reduction in excyclotorsion 3 months postoperatively was 3.65° ± 4.84° for IOR, 5.31° ± 4.64° for RAP, 6.10° ± 3.89° for EN, and 16.62° ± 8.72° ANT; it was significantly higher in the ANT group compared with the other three groups. Reduction in DFA was also correlated with preoperative DFA overall, and for all procedures except IOR (P ≤ 0.005). CONCLUSIONS: All four inferior oblique-weakening procedures reduced excyclotorsion; the largest reductions in our study were seen in cases treated using ANT of the inferior oblique.

Current perspective: Cerebral visual impairment-The impending doom.

Cerebral visual impairment (CVI) has emerged as an important cause of morbidity in young children. CVI children often have a large number of visual symptoms along with motor abnormalities. It is the need of the hour to build an integrated approach towards their management. This article aimed to provide a comprehensive view of the manifestations, evaluation, and management of children with CVI.

Evaluation of the Levels of Low-dose Topical Atropine (0.01%) in Aqueous and Vitreous Humor in Human Eyes.

SIGNIFICANCE: This is the first human study that confirmed penetration of 0.01% topical atropine in aqueous and vitreous humor in live human eyes. This supports the possible mode of action of atropine via posterior ocular structures. This knowledge will help improve the outcomes in myopia management. PURPOSE: The purpose of this study was to evaluate penetration of low-dose atropine 0.01% in aqueous and vitreous humor. METHODS: In this cross-sectional interventional pilot study, 48 cataract cases were divided into four groups (12 each), and 30 epiretinal membrane/macular hole cases were divided into three groups (10 each). One drop of 0.01% atropine was put in the eye to be operated. Aqueous humor samples were taken from patients undergoing cataract surgery at 60 ± 15 minutes in group 1, 120 ± 15 minutes in group 2, 240 ± 15 minutes in group 3, and 360 ± 15 minutes in group 4. Vitreous humor samples were taken from patients undergoing vitreoretinal surgery for epiretinal membrane/macular hole at 120 ± 15 minutes in group 1, 240 ± 15 minutes in group 2, and 360 ± 15 minutes in group 3. The assay of atropine was performed using liquid chromatography-mass spectrometry. RESULTS: Median concentrations of atropine in aqueous samples were 1.33 ng/mL (min-max, 0.6 to 6.46 ng/mL; interquartile range [IQR], 3.05 ng/mL) at 60 minutes, 2.60 ng/mL (min-max, 0.63 to 4.62 ng/mL; IQR, 1.97 ng/mL) at 120 minutes, 1.615 ng/mL (min-max, 0.1 to 3.74 ng/mL; IQR, 1.62 ng/mL) at 240 minutes, and 1.46 ng/mL (min-max, 0.47 to 2.80 ng/mL; IQR, 1.73 ng/mL) at 360 minutes, and those in vitreous samples were 0.102 ng/mL (min-max, 0 to 0.369 ng/mL; IQR, 0.366 ng/mL) at 120 minutes, 0.1715 ng/mL (min-max, 0 to 0.795 ng/mL; IQR, 0.271 ng/mL) at 240 minutes, and 0.2495 ng/mL (min-max, 0 to 0.569 ng/mL; IQR, 0.402 ng/mL) at 360 minutes, respectively. CONCLUSIONS: Measurable concentration of low-dose topical atropine (0.01%) was noted in aqueous and vitreous humor after instillation of a single drop of low-dose atropine. Muscarinic receptors located in the posterior segment such as the choroid and retina could be the possible site of action of low-dose atropine in myopia.

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.

Effect of low-dose atropine (0.01%) on crystalline lens power among school-aged children with progressive myopia.

PURPOSE: To evaluate the change in crystalline lens power (LP) in a cohort of Indian children with progressive myopia receiving atropine (0.01%) compared with an untreated control group. DESIGN: Nonrandomised clinical trial. METHODS: The study included 120 children (70 in the atropine group; 50 in the control group) with progressive myopia (≥0.5 D/year) with a 1-year follow-up. The atropine group received 0.01% atropine eye drops once daily in both eyes, whereas the control group received no treatment. Changes in cycloplegic spherical equivalent, axial length (AL), keratometry (KER), anterior chamber depth (ACD) and lens thickness (LT) were recorded. LP was calculated using the formula proposed by Bennett. RESULTS: Mean myopia progression at year 1 was significantly less in the atropine group (-0.18 D [0.2]) than in the control group (-0.59 [0.21]; p < 0.001). The increase in AL was significantly different between the two groups (atropine: 0.21 mm [0.12]; control: 0.29 mm [0.11], p < 0.001). A significantly greater loss of LP was noted in the atropine group (-0.67 D [0.34]) than in the placebo group (-0.28 D [0.42]; p < 0.001). The change in LT was significantly different between the atropine and control groups (p = 0.02), whereas the change in ACD and KER was similar in the two groups. CONCLUSION: The greater loss of LP could contribute to the anti-myopia effect of atropine and should therefore be evaluated in studies reporting the efficacy of atropine on myopia to assess its actual effect on myopic progression.

Comparison of Dichoptic Therapy Versus Occlusion Therapy in Children With Anisometropic Amblyopia: A Prospective Randomized Study.

PURPOSE: To compare a smartphone-based dichoptic video game with occlusion therapy in children with anisometropic amblyopia. METHODS: In this prospective, randomized, interventional study, 55 children aged 5 to 15 years with anisometropic amblyopia were randomized into two groups: the video game group (n = 27) played a dichoptic video game with adjusted contrast for 2 hours/day and the patching group (n = 28) received occlusion therapy of the non-amblyopic eye for 6 hours/day. All patients were evaluated for best corrected visual acuity (BCVA), near vision, contrast sensitivity, and near and distance stereoacuity at baseline and 1, 2, and 3 months. RESULTS: Mean distance BCVA improved from 0.74 ± 0.19 and 0.70 ± 0.18 logarithm of the minimum angle of resolution (logMAR) in the video game and patching groups, respectively, at baseline to 0.53 ± 0.19 and 0.49 ± 0.19 logMAR, respectively, at 3 months (P < .001 for both). Mean near vision was 0.82 ± 0.19 and 0.81 ± 0.17 logMAR in the video game and patching groups, respectively, at baseline and improved to 0.60 ± 0.16 and 0.63 ± 0.17 logMAR at 3 months (P < .001 for both). There was no significant difference in distance and near vision between the two groups at baseline and final follow-up visit. Contrast sensitivity was 1.41 ± 0.20 and 1.38 ± 0.20 in the video game and patching groups, respectively, at baseline and 1.74 ± 0.18 and 1.61 ± 0.21 at 3 months (P < .001 for both). At the final follow-up visit, contrast sensitivity was significantly better in the video game group compared to the patching group (P = .01). Near stereoacuity significantly improved only in the video game group (P = .006), whereas distance stereoacuity did not improve in either group. CONCLUSIONS: Dichoptic video game therapy showed better results in terms of improvement in contrast sensitivity and near stereoacuity and similar outcomes for distance and near vision when compared to patching in children with anisometropic amblyopia. However, the availability of interesting games is essential to maintain children's interest. [J Pediatr Ophthalmol Strabismus. 2023;60(3):210-217.].

Current concepts in the management of childhood myopia.

Myopia or short-sightedness is an emerging pandemic affecting more than 50% population in South-Asian countries. It is associated with several sight-threatening complications, such as retinal detachment and choroidal neovascularization, leading to an increased burden of visual impairment and blindness. The pathophysiology of myopia involves a complex interplay of numerous environmental and genetic factors leading to progressive axial elongation. Environmental factors such as decreased outdoor activity, reduced exposure to ambient light, strenuous near work, and role of family history of myopia have been implicated with increased prevalence of this refractive error. While multiple clinical trials have been undertaken to devise appropriate treatment strategies and target the modifiable risk factors, there is no single treatment modality with ideal results; therefore, formulating a comprehensive approach is required to control the myopia epidemic. This review article summarizes the epidemiology, dynamic concepts of pathophysiology, and evolution of the treatment modalities for myopia such as pharmacological (atropine and other agents) and optical methods (spectacles, contact lenses, and orthokeratology).

A case of neuro retinitis in association with COVID-19.

A 36-year-old female presented with blurring of vision in one eye for 10 days after 1 month of an episode of COVID-19 infection. Her fundus showed disc edema with blurring of margins along with exudation around the fovea. Her C-reactive protein levels were raised. She responded well to oral steroids. A likely association with COVID-19 infection and its associated immune response was suspected.

Effect of legislation and changing trends of Diwali ocular firecracker injuries in Northern India.

OBJECTIVE: The objective of this study is to study the impact of temporary legislation implemented during Diwali on ocular firecracker injuries in Delhi-National Capital Region (NCR) region. MATERIALS AND METHODS: In this retrospective study, records of the patients presenting with ocular firecracker injury during 10 days of Diwali (prediwali, Diwali and 8 days postdiwali) from 2014 to 2019 were retreived from the medical record section. Clinico-demographic profile, relevant history pertaining to the use of firecracker, and details of eye examination, namely presenting visual acuity (VA), laterality and classification of injury based on Birmingham Eye Trauma Terminology System were noted. RESULTS: Six hundred and sixty-seven eyes of 646 patients were recruited. The median age of patients was 14 years (R = 3-65 years) and male: Female ratio was 4.9:1. Majority of patients (57.7%; n = 373) were from outside Delhi. Most of them were open globe injuries (66.8%). In 55.4% (n = 356) eyes, presenting VA was perception of light to finger counting close to face and 28% (n = 180) eyes could not perceive any light. A significant reduction was noted in the number of ocular firecrcaker injuries after regulation (preregulation [2014-2016] n = 456; postregulation [2017-2019] n = 211; [P = 0.01, t-test]). During preregulation period, presenting VA was worse than 1/60 in significantly higher number of eyes (85.5%; n = 376) than post regulation (78.8%, n = 160) (P = 0.03, Chi-square test). CONCLUSION: Although temporary legislation seems to be effective in reducing ocular firecracker injuries (52.7% reduction) in NCR, uniform implementation of stricter laws nationwide is essential to further minimize the problem.

Neuro-ophthalmic manifestations of tuberculosis.

Neuro-ophthalmic features are a known association in tuberculosis, especially common in central nervous system tuberculosis (CNS-TB). They are mostly the result of the visual pathway and/or ocular motor and other cranial nerve involvement. Furthermore, toxic optic neuropathy and paradoxical response to anti-tubercular drugs (ATT) are also not uncommon. The etiopathogenesis is by the complex interplay of various factors like exudates, vasculitis, arachnoiditis, presence of tuberculomas, hydrocephalus, brain infarcts and/or immune-mediated reaction. The entity often poses a diagnostic dilemma for the ophthalmologists/neuro-ophthalmologists and may lead to irreversible vision loss. The presence of neuro-ophthalmic features not only affect the visual outcome but are also predictors of systemic morbidity of the disease. Therefore, understanding and knowledge about this entity are necessary for the comprehensive management of the disease. While various forms of TB including CNS-TB have been well-dealt with in literature, little is discussed specifically about the neuro-ophthalmic manifestations of tuberculosis. Therefore, the purpose of this review is to highlight current understanding of the types of neuro-ophthalmic involvement in tuberculosis, its etiopathogenesis, diagnosis and management.

An Ophthalmologist's Insight Into The Viral Pandemics.

In recent past, major pandemics and epidemics have occurred due to the emergence and resurgence of the novel strains of viruses like Influenza [HINI-A "Spanish Flu", H1N1-Novel A "Swine flu"], Corona [Middle East Respiratory Syndrome (MERS), Severe acute respiratory syndrome (SARS-CoV-1, SARS-CoV-2)] and Ebola virus [Ebola virus disease]. These infectious diseases may have several ocular manifestations and rarely might be the presenting symptom of the underlying disease. The eyes can act as a portal of entry and/or route of viral transmission for these pathogens. Therefore, an ophthalmologist/optometrist needs to act with ample preparedness and responsibility. Establishing a standard of care in ophthalmic practice by modifying the conventional examination techniques and adopting tele-ophthalmology model to triage the patients can control the community spread of the disease. This article aims to elucidate the ocular manifestations in these pandemics and measures that should be adopted in ophthalmic practice to prevent the disease transmission.

Lifestyle modification in school-going children before and after COVID-19 lockdown.

Purpose: To evaluate the impact of COVID-19 lockdown restrictions on lifestyle of school-going children. Methods: This was a questionnaire-based prospective study of 1237 school children aged 9-14 years enrolled from various private and government schools across Delhi in October-December 2020. These children were being followed-up over the previous 2 years (before pandemic) with details of their lifestyle like near/outdoor/reading activities using a questionnaire as a part of another study. The data during the COVID-19 lockdown was collected by telephonic interview. This was compared to similar information collected from this cohort in the pre-Covid period in 2019 when the students had a regular physical school curriculum. Results: A significant decline was noted in time spent on outdoor activity (from 8.5 hours/week in pre-COVID-19 time to 1.6 hours/week during COVID-19 lockdown; P < 0.001) and doing homework offline (from 15.3 hour/week to 14 hours/week; P < 0.001). A significant increase was noted in screen time spent on digital devices (from 6.2 hours/week to 19.8 hours/week; P<0.001), and watching television (from 12.2 hours/week to 13.4 hours/week; P < 0.001). The rise in the digital on-screen time was significantly more in boys (P < 0.001) and in students from private schools (P < 0.001). The rise in the duration of watching television was significantly more in girls than boys (P < 0.05). Conclusion: COVID-19 lockdown has markedly impacted the lifestyle of school children by significantly decreasing the outdoor activity and increasing the screen time, thereby pre-disposing them to ocular ill-health and myopia. This necessitates the adoption of guidelines for promoting healthy digital habits in children.

Treatment outcome with interferon alpha 2b in ocular surface squamous neoplasia: Recommendation as primary treatment by peripheral ophthalmologists.

BACKGROUND: To evaluate the role of interferon alpha 2b (IFNα2b) in the management of primary/recurrent cases of ocular surface squamous neoplasia (OSSN). METHODOLOGY: Medical records of 27 OSSN cases managed with IFNα2b (topical drops and/or perilesional injection) in 1 year were retrospectively reviewed. RESULTS: The median age of presentation was 60 years with a male: female ratio of 3.5:1. American Joint Commission on Cancer tumor grading was T1 in 1 eye (3.7%) and T3 in 26 eyes (96.3%). Eighteen cases were treated with topical drops (1 million IU/ml), 4 cases with perilesional subconjunctival injection (3-6 million IU/ml), and 5 cases with combined therapy. Overall, treatment response was seen in 88% cases. Complete regression was achieved in 80% cases. Median time to complete regression of tumor was 3 months (range 1-11 months) in cases treated with topical interferon therapy and 2.5 months (range 0.7-3 months) in cases managed with injections or a combination of the two. The mean duration of follow-up was 24 months. All cases with partial/no response showed complete regression on subsequent management with topical mitomycin C. None of the patients required surgery. Acute ocular surface congestion was seen in two patients necessitating discontinuation of therapy. CONCLUSION: In view of excellent treatment outcome and few side-effects, interferons can be considered as a primary, safe, and cost-effective treatment option for OSSN not only in tertiary centers but also by peripheral ophthalmologists.

Systemic neoadjuvant chemotherapy in non-resectable invasive squamous cell carcinoma of ocular surface.

BACKGROUND/OBJECTIVES: The conventional modality for management of advanced invasive ocular surface squamous neoplasia (OSSN) (AJCC grade T4 and T3 with fornicial involvement) is surgical excision which is not only challenging in terms of ability to achieve tumor free margins and tissue reconstruction but also has high morbidity. We describe the use of systemic neoadjuvant chemotherapy (NAC) in cases of advanced invasive OSSN. SUBJECTS/METHODS: This is a retrospective case series. Five cases of histopathologically proven advanced OSSN that were challenging to manage with surgical excision or required exenteration were treated with NAC. Demographic details, previous treatment history, location and extent of tumor, imaging findings, number of cycles and duration of NAC, response to treatment, and final outcome on follow-up were noted. RESULTS: A remarkable response to NAC was seen in 4/5(80%) cases. Complete regression was seen in 2/5, partial regression in 2/5, and no response in 1/5 cases. In 75% (3/4) cases who showed response to NAC, minimal or no surgery was required. Exenteration was avoided in 2/3 cases with orbital extension. CONCLUSION: NAC appears to be an exciting option for management of surgically challenging cases of invasive OSSN and may be helpful in avoiding orbital exenteration. However, more studies are required to explore this treatment option.