Clinical evaluation of ophthalmic findings in active, amateur, adult, competitive male boxers in India.

Background: In the popular fighting sport of boxing, opponents strike each other above the belt line in the face, chest, and belly. The physical parts most exposed are therefore the nose and eyes. In amateur boxing, fights go only three rounds - three minutes for men and one minute for women - with a one-minute break in between. They wear gloves, but the head protection used in the men's game has been removed by AIBA due to the high likelihood of concussion when using head protection. Because chronic ocular changes may take longer than the expected short-term effects, this study included at least 3 years of competitive sports participation. Study design and setting: Institutional-based cross-sectional study. Materials and methods: To evaluate ophthalmic outcomes, 200 eyes of 100 active amateur, adult, and competitive male boxers were studied. Results: Of the 100 boxers, 51 had ophthalmic changes in at least one eye, and 49 had normal eyes. The average age of boxers was 24.98 years. The average duration of boxing training was 7.04 years. Healed eyelid scars, subconjunctival hemorrhages, conjunctival papillae, traumatic mydriasis, posterior synechiae, angulation abnormalities, traumatic cataracts, lens subluxation, increased intraocular pressure, and peripapillary atrophy were observed on the ocular side. None of these could be attributed to boxing. Conclusion: Boxing-related eye injuries are common in India and the most common vision-threatening eye abnormalities include traumatic cataracts, lens subluxation, and angle abnormalities. Surprisingly, no macular lesions were found on physical examination and OCT. Additional studies with a larger number of boxers will be needed to evaluate and prevent clinical symptoms. All boxers should have a complete eye exam regularly. Abbreviations: AIBA = Association Internationale de Boxe Amateur, OCT = Optical Coherence Tomography.

Determining the effect of climate and profession on dry eye disease: A prevalence study among young males in north, north-west and central India.

Background: Ocular tear film and the ocular surface together represent a dynamic playground of various protective factors against environmental influencers. Surrounding environment and geoclimatic milieu are the pertinent and continuous influencing factors. Prevalence study of Dry eye disease (DED) in various climatic conditions and professions provides an insight into this peculiar aspect of DED and human geography. Methods: This was a hospital based, cross-sectional, comparative, analytical observational study. 1840 young soldiers between 25 and 45 years of age were studied. Divided in five climate groups based on Köppen-Geiger climate classification system the subjects were sub-grouped into professions exposed to known aggravating environmental factors. The ocular surface was examined for signs and symptoms of DED and its prevalence and risk ratio for different climates and professions were calculated. Results: Highest prevalence of DED was found in cold desert climate and among visual display unit (VDU) users. Least prevalence was seen in highland type of climate and among people involved in professional exposed to high temperature. Prevalence of DED based upon the signs and ocular surface disease index (OSDI) was calculated and stratified with risk ratio for climatic conditions and professions. Conclusion: Different climatic conditions and professions had different prevalence of signs, symptoms of OSD and DED which indicated its influence on prevalence of the disease.

Parent's Perspective of Problems Faced during the COVID-19 Pandemic Lockdown on the Care of Children with Epilepsy: A Qualitative Study.

Background: COVID-19 has significantly impacted the care of children with chronic illness. There is a paucity of data on issues faced by parents of children with epilepsy (CWE) in an Indian setup. Objectives: The objective was to describe the parental perspective of the problems faced by them on the care of their CWE during the first wave of the COVID-19 pandemic. Materials and Methods: Parents of CWE who physically visited the clinic for their follow-up visit were asked to narrate their experiences about the problems they faced during the first lockdown due to COVID-19. The narratives were audio recorded, and transcripts were analyzed using thematic analysis to arrive at broad themes. Results: Four broad themes were identified: transport-related issues, medication-related issues, issues related to doctor consultation, and diagnostic delay. Limited transportation facilities, lack of appropriate social distancing norms in public transport and outpatient units, rigorous frisking by personnel during travel, fear of viral transmission during outpatient visits, nonavailability of antiseizure medications (ASMs) in local markets, lack of discounts by pharmacy, change of brands of ASM, and inability to undergo scheduled diagnostic investigations were some of the major issues raised by parents of CWE. Conclusion: Parents of CWE had trouble in transport to the hospital, inadequate access to ASMs, difficulties in doctor consultation, and delays in diagnostic investigations during the first COVID-19 pandemic lockdown.

Posterior keratometry changes after steep axis phacoemulsification: a prospective study.

Purpose: To measure changes in posterior corneal curvature after steep axis phacoemulsification and investigate the possibility of its effect on SIA. Methods: This was a prospective longitudinal study on 60 consecutive eyes of age-related cataract with regular astigmatism and absence of co-morbidities undergoing uneventful cataract surgeries with main incision at steep meridian. Preoperative and 4 weeks postoperative measurements of anterior and posterior corneal curvatures using Scheimpflug based corneal topographer were performed. Posterior corneal curvature was assessed at 3, 5- and 7-mm diameters. Results: The study found a statistically significant change in posterior corneal K1, K2 and mean astigmatism in all zones (3, 5 and 7 mm) at 4 weeks postoperative, when compared to preoperative readings. Conclusion: Posterior keratometry is likely to be an important determinant of Surgically Induced Astigmatism (SIA) and should be factored in for refractive cataract surgery.

Change in Apo B100/A1 Ratio in Children With Epilepsy on Monotherapy With Sodium Valproate, Oxcarbazepine or Levetiracetam.

A prospective longitudinal study was conducted to assess the Apo B100/A1 ratio as a marker of cardiovascular risk in children with epilepsy aged 5-14 years on long-term anti-seizure medication monotherapy with either sodium valproate, oxcarbazepine, or levetiracetam. Apo B100/A1 ratio showed an increase after six months of monotherapy with oxcarbazepine (P=0.05).

Modified Atkins Diet vs. Ketogenic Diet in the Management of Children with Epileptic Spasms Refractory to First Line Treatment: An Open Labelled, Randomized Controlled Trial.

OBJECTIVE: To compare the efficacy and tolerability of modified Atkins diet (mAD) and ketogenic diet (KD) among children aged 9 mo to 3 y with epileptic spasms refractory to the first line treatment. METHODS: An open labelled, randomized controlled trial with parallel group assignment was conducted among children aged 9 mo to 3 y with epileptic spasms refractory to the first line treatment. They were randomized to either receive the mAD along with conventional anti-seizure medications (n = 20) or KD with conventional anti-seizure medications (n = 20). Primary outcome measure was proportion of children who achieved "spasm freedom" at 4 wk and 12 wk. Secondary outcome measures were proportion of children who achieved >50% and >90% reduction in spasms at 4 wk and 12 wk, nature and proportion of the adverse effects as per parental reports. RESULTS: Proportion of children achieving spasm freedom [mAD {4 (20%)} vs. KD {3 (15%)}: OR (95% CI) 1.42 (0.27-7.34); P = 0.67], >50% spasm reduction [mAD {3 (15%)} vs. KD {5 (25%)}: OR (95% CI) 0.53 (0.11-2.59); P = 0.63] and >90% spasm reduction [mAD {4 (20%)} vs. KD {2 (10%)}: OR (95% CI) 2.25 (0.36-13.97); P = 0.41] was comparable between the two groups at 12 wk. The diet was well tolerated in both the groups with vomiting and constipation being the most common reported adverse effect. CONCLUSIONS: mAD is an effective alternative to KD in the management of children with epileptic spasms refractory to first line treatment. However, further studies with adequately powered sample size and longer follow-up are required. TRIAL REGISTRATION: CTRI/2020/03/023791.

Online Interactive Flipped Classroom Teaching in Pediatrics for Medical Undergraduates.

OBJECTIVES: To introduce online flipped classroom teaching for medical undergraduates in Pediatrics and to assess students' engagement and satisfaction with the students and faculty with the flipped classroom teaching method. METHODS: An interventional education study was conducted on online flipped classrooms for final-year medical undergraduates. The core team of faculty members was identified, students and faculty were sensitized, and pre-reading material and feedback forms were validated. Students were engaged using the Socrative app, and feedback from students and faculty was collected using Google Forms. RESULTS: One hundred sixty students and six faculty members participated in the study. During the scheduled class, 91.9% of students were engaged. The majority of the students strongly agreed that the flipped classroom was interesting (87.2%) and interactive (87%) and developed an interest in the subject of Pediatrics (86%). Faculty were also motivated to adopt this method. CONCLUSION: The present study revealed that introducing flipped classroom strategy in an online model improved students' engagement and increased their interest in the subject.

Pattern and distribution of neovascularization in proliferative diabetic retinopathy on fundus fluorescein angiography: A growing paradigm.

Background: The objective of this study was to evaluate pattern and distribution of neovascularization of optic disc (NVD) and elsewhere (NVE) in proliferative diabetic retinopathy (PDR). Methods: A cross-sectional study was conducted among freshly detected cases of PDR. Fundus fluorescein angiographic images of 61 eyes were assessed. Parameters studied for NVD were their number and location and for NVE were their number, location, type of leak, and distance from center of optic disc. Results: Of 61 eyes, 29 eyes (47.5%) had NVD with a total of 49 leaks. Of these 49 NVD leaks, the maximum was concentrated in the superotemporal quadrant with 21 leaks (42.9%; 95%CI 28.8-57.8%). Of 61 eyes, 50 eyes (82%) had NVE with 97 leaks. Of 97 NVE leaks, 41 were found in the superotemporal quadrant (42.3%; 95%CI 32.3-52.7%). Maximum NVE was found within the circle of radius 3-6 mm centered on optic disc (p value = 0.001) with no leaks in central macula. Of 29 eyes with NVD, only 7 eyes had >1/3 area of disc involvement. Also, of 18 eyes with concurrent NVD and NVE, only 2 eyes had >1/3 area of disc involvement which is a high-risk characteristic of PDR. Conclusion: Neovascular lesions have a predilection for superotemporal part for both NVD and NVE. NVE leaks were almost double the number of NVD leaks. Maximum NVE leaks were found at posterior pole with no central macular involvement. This study provides comprehensive data and further adds to knowledge of neovascularization for early diagnosis and management of PDR.

Association of serum vitamin D levels with clinical spectrum of central serous chorioretinopathy patients of Indian origin.

BACKGROUND: Vitamin D, a fat-soluble prohormone has been implicated in various ophthalmological diseases such as ocular inflammation, glaucoma, diabetic retinopathy and ocular angiogenesis. Many studies have shown effect of vitamin D on oxidative stress, angiogenesis and retinal circulation. However, there is definitive lack in published literature on effect of vitamin D on central serous chorioretinopathy especially in view of various epidemiological studies reporting risk of vitamin deficiency in up to 40% adult population. OBJECTIVE: To determine serum vitamin D levels in various clinical profiles of central serous chorioretinopathy and their effect on its pathophysiology in Indian population. DESIGN: Case control observational study METHODS: Study included 42 patients (group P) of central serous chorioretinopathy (CSCR) diagnosed with optic coherence tomography (OCT), fundus fluorescein angiography (FFA) which were further sub-grouped into acute(P1), chronic (P2) and recurrent (P3). A total of 44 age & sex-matched healthy control subjects (group C) were also included. The vitamin D levels of both groups were examined and analyzed. RESULTS: No significant difference between the groups P and C in respect of age, gender or baseline best corrected visual acuity (P = 0.153, P = 0.123 and P = 0.08, respectively) was noted. Vitamin D levels were determined as 16.473 ± 7.307 ng/mL in group P and 34.940 ± 8.348 ng/mL in group C and difference was statistically significant(P = 0.001). There were statistically significantly more no of patient in group P (78.57%) with deficient vitamin D levels as compared to normal serum levels (4.76%) (P = 0.04). Patients in group P1(acute CSCR) and P2(Chronic CSCR) also had significant more no of subjects with deficient vitamin D levels as compared to normal serum levels (P = 0.01 and P = 0.03). CONCLUSIONS: The low serum vitamin D levels were determined in all clinical sub-types of central serous chorioretinopathy patients which point to its possible role in the pathophysiology of the disease. There is a need for further studies to determine the changes that could occur with vitamin replacement therapy in CSCR.

Comparison of changes in blood pressure in phacoemulsification cataract surgery performed via topical and peribulbar anaesthesia: A cohort study.

Background: The purpose of study was to compare the changes in blood pressure in patients undergoing phacoemulsification cataract surgery under topical and peribulbar anaesthesia during preoperative, intraoperative and postoperative period. Methods: In this prospective cohort study, 240 patients undergoing phacoemulsification were divided into topical (Group 1) and peribulbar (Group 2) equally. Proparacaine 0.5% drops were used for topical anaesthesia, and Inj lignocaine with Inj bupivacaine were used to give peribulbar anaesthesia. Preoperative blood pressure was taken 30 min before surgery with automated sphygmomanometer. Intraoperative blood pressure was taken during phacoemulsification, and postoperative blood pressure was taken 1 h after surgery. Outcomes assessed were systolic, diastolic and mean blood pressure. Results: Systolic blood pressure in Group 1 was significantly increased in the intraoperative phase, whereas it was significantly decreased in Group 2 in the intraoperative phase. Diastolic and mean blood pressure in Group 1 showed no significant change, whereas in Group 2, both showed significant reduction in intraoperative and postoperative phases. Conclusion: The increase in intraoperative systolic blood pressure in topical group could be due to discomfort from microscope light, iris manipulation, irrigation and aspiration during surgery. The decrease in intraoperative systolic and diastolic blood pressure in peribulbar group could be due to systemic absorption of local anaesthetic. The mean preoperative systolic blood pressure was also higher in the topical group, which could be due to anxiety or stress under topical anaesthesia. The changes in blood pressure need to be observed so that timely intervention can be made to achieve favourable postoperative outcome.

Gabapentin as Add-on Therapy to Trihexyphenidyl in Children with Dyskinetic Cerebral Palsy: A Randomized, Controlled Trial.

OBJECTIVE: To compare the efficacy of gabapentin as add-on therapy to trihexyphenidyl in the treatment of children with dyskinetic cerebral palsy (CP). METHODS: An open-labelled, randomized, controlled trial was conducted among children aged 3-9 y with dyskinetic CP [Gross Motor Functional Classification System (GMFCS) 4-5]. Participants were assigned into two groups: gabapentin with trihexyphenidyl (n = 30) and trihexyphenidyl alone (n = 30). Dyskinesia Impairment Scale (DIS), Dystonia Severity Assessment Plan (DSAP), and International Classification of Functioning, Disability, and Health-Children and Youth Version (ICF-CY) were measured at baseline, 4 and 12 wk. RESULTS: There was significant reduction in baseline dystonia in both the groups (DIS: p < 0.001; DSAP: p = 0.007; ICF-CY: p < 0.001) but when data were compared between the groups, there was no significant difference in the severity of dystonia at 4 wk and at 12 wk (DIS: p = 0.09; DSAP: p = 0.49; ICF-CY: p = 0.25). Constipation was the commonest side effect observed in both the groups [3 (11.5%) vs. 4 (14.3%)]. CONCLUSION: Trihexyphenidyl alone is as effective as combination of gabapentin with trihexyphenidyl in decreasing the severity of dystonia at 12 wk. Hence, there is no added benefit of gabapentin as add-on therapy for dystonia among children with dyskinetic CP. TRIAL REGISTRATION: CTRI/2019/04/018603.

"Partial Open Sky Method" - A novel technique to avoid the open sky condition during Triple procedure or Penetrating keratoplasty.

Penetrating keratoplasty is referred to as an "open-sky" procedure because the intraocular contents are entirely exposed to atmospheric pressure after the diseased cornea has been trephined off and before the donor button is sutured. Suprachoroidal hemorrhage (SCH) is a major vision-threatening complication, associated with this open-sky procedure. While numerous factors may predispose an eye to SCH, like hypertension, myopia, trauma, glaucoma, etc., it is better to be prepared for the worst eventuality. We described a novel technical modification, denoted as the "partial open sky technique", that we used during the surgical steps of trephining and excision of host corneal tissue in seven cases of triple procedure and penetrating keratoplasty in our center over two months. We propose that the technique would be additionally helpful in managing the inadvertent suprachoroidal hemorrhage associated with keratoplasty over the available existing methods. Abbreviations: SCH = Suprachoroidal hemorrhage, ICCE = Intracapsular cataract surgery, ECCE = Extracapsular cataract surgery, WTW = White to White.