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.

A Clinical study of Hansen抯 Disease and Histopathological Correlation from a Tertiary Care Centre in East India

Background: Leprosy or Hansen抯 disease caused by Mycobacterium leprae is a chronic granulomatous disease characterized by hypoesthetic skin lesions and nerve involvement. The objective of the study was to find clinicohistopathological correlation of Hansen抯 disease diagnosed at a tertiary care centre of eastern India. Material and Methods: Hospital based retrospective study was conducted that included cases of leprosy diagnosed clinically and examined for histopathology at Indira Gandhi Institute of Medical Sciences, Patna from January 2021 to December 2021. Clinical diagnosis was correlated with that of histopathological diagnosis. Result: From this study, it was observed that, the commonest age group affected by leprosy was 20 to 40 years, males were more commonly affected than females (M:F = 1.83: 1) and commonest clinically diagnosed spectrum was Tuberculoid leprosy (TT) ( 48.03%). It was observed that there was complete agreement between clinical diagnosis and histopathological diagnosis in 84.3% cases and disagreement was observed in 15.7% cases. Conclusion: Combining clinical, and histopathological finding of leprosy is essential for accurate diagnosis and thus proper treatment of the patient and prevention of complications.

Serum Vitamin D Level in Psoriasis: A Prospective Study in a Tertiary Care Centre of Eastern India

Background: Psoriasis is a systemic, inflammatory, chronic autoimmune disease characterized by multiple discoid plaques over body with silvery scales associated with cardiovascular diseases, obesity, diabetes mellitus, hypertension, and hyperlipidemia. Recently, association between psoriasis and Vitamin D level has also been reported. Our aim of study was to evaluate the association of vitamin D and its association with the severity of Psoriasis Materials and methods: 60 patients diagnosed with psoriasis, in our outpatient department from January 2021 to December 2021, were included the study. 58 age, gender- and skin phototype- matched healthy controls were included in the study. Results: The serum vitamin D level in patients and in the control group ranged from 7 to 24 ng/ml (mean: 13.04 �32 ng/ml) and from 16 to 65 ng/ml (mean: 23.91�08 ng/ml), respectively. The circulating vit D levels were less in patients compared to control. The analysis showed statistical significance (P< 0.05) between the two groups. Conclusion: Our results showed decreased level of vitamin D in patients suffering from psoriasis when compared to healthy controls. Vitamin D supplementation can be useful in psoriasis management.

Cataract surgery outcomes in pediatric patients with systemic comorbidities

Purpose: The aim of the study was to evaluate the outcomes of cataract surgery in patients of the pediatric age group with systemic comorbidities. Methods: Medical records of 54 eyes (30 patients) of the pediatric age group with systemic comorbidities who had undergone cataract surgery in a tertiary?care center were reviewed. The following parameters were recorded: systemic comorbidity; toxoplasmosis, rubella, cytomegalovirus, herpes simplex, HIV (TORCH) profile, best spectacle?corrected visual acuity (BSCVA), strabismus, nystagmus, and cataract morphology. Results: Thirty patients with a mean age of 55 months (9 months–14 years) were included. On average, every child was seen by three physicians, and the mean duration between the first visit to a physician and presentation to our center was 2.23 ± 0.67 years. The various causes for delay in referral include multiple referrals due to a lack of general anesthesia services in 78% of cases, a long waiting list at the referral hospital in 35% of cases, and a lack of awareness at the primary?care physician level in 50% of cases. The mean BSCVA at presentation was 1.4 logMAR (0.3 to 3 logMAR). The most common cataract morphology was that of zonular cataract (31.48%; 17/54). Strabismus and abnormal eye movements were observed in 27.7% (15/54) and 33.3% (18/54) of eyes, respectively. Various systemic associations were periventricular leukomalacia (12/30), Down’s syndrome (6/30), seizure disorder (6/30), cardiac valvular anomalies (6/30), Marfan’s syndrome (4/30), hypothyroidism (4/30), rubella (3/20), cytomegalovirus (3/20), cerebral palsy (2/30), nephrotic syndrome (2/30), Type 1 diabetes mellitus (1/30), microcephaly (1/30), cryptogenic West syndrome (1/30), congenital rubella syndrome (1/30), and Tourette syndrome (1/30). The mean postoperative corrected distance visual acuity (CDVA) at 2?year follow?up improved to 1.0 logMAR (0 to 3 logMAR). No postoperative complications were reported at the final follow?up. Around 70% of the parents reported improvement in their child’s psychomotor skills. Conclusion: Intellectually impaired pediatric patients with cataract should be operated upon whenever there is a presence of infrastructure, and unnecessary delay in surgery should be avoided by referring the patient to higher centers. Even though objective improvement in visual acuity was suboptimal, there was definitely an improvement in the psychomotor skills of the patients.

Outcomes of surgical intervention in cases of ectopia lentis

Purpose: To evaluate the outcomes of surgical intervention in cases of ectopia lentis. Methods: This retrospective study included all cases of ectopia lentis that presented between June 2015 and March 2019 in a tertiary care center. They were reviewed retrospectively. The corrected distance visual acuity (CDVA), severity of lens subluxation, type of surgery, intra?operative and post?operative complication, and specular count were recorded. Results: Seventy?eight eyes of 57 cases with a mean age at surgery of 14.73 years were analyzed. Intra?lenticular lens aspiration was the most common (n?62/78; 79.5%) surgical procedure followed by lens aspiration, intra?capsular cataract extraction, phaco?aspiration, and pars?plana lensectomy. Simultaneous intra?ocular lens (IOL) implantation was performed in 46.2% (n?32/78) of the eyes. The mean CDVA improved from 0.85 ± 0.55 logMAR to 0.44 ± 0.29 logMAR at 6 weeks follow?up. The post?operative CDVA was significantly better in the pseudo?phakic group compared to the aphakic group (p?0.02). The patient’s age at the time of surgery and the degree of subluxation did not impact the final visual outcome. Intra?operative complication included vitreous hemorrhage (n?1) and lens matter drop (n?1). Post?operative complications were noted in 26.9% of the eyes (n?21/78) with a higher complication rate in the pseudo?phakic group (p?0.00). A second intervention was required in 7.7% of the eyes (n?6/78). Conclusion: Age and degree of subluxation at the time of surgery do not influence the final visual outcome in cases of ectopia lentis undergoing lens extraction surgery. IOL implantation results in better visual outcomes but is associated with a high complication rate.

Spectrum of bacterial keratitis in North India: A retrospective analysis of six years at a tertiary care eye center

Purpose: To analyze the pattern of bacterial pathogens causing infective keratitis and their resistance to the recommended antibiotics over six years. Methods: It was a retrospective study of 9,357 cases of bacterial keratitis from January 2015 to December 2020, at a tertiary care ophthalmic center. A total of 9,547 corneal specimens were obtained from the study subjects. Demographic details of the patients, pathogenic bacteria isolated, and their antimicrobial susceptibility were noted and analyzed. Results: Bacterial pathogens were identified in 23.52% of the specimens. The most common isolates were coagulase?negative Staphylococci (60.75%), followed by Pseudomonas aeruginosa (14.23%), Staphylococcus aureus (13.92%), gram negative bacilli of the family Enterobacterales (8.64%), Streptococcus spp. (1.72%), Acinetobacter spp. (0.13%), and other non?fermenting gram?negative bacilli (0.57%). In Staphylococci, 55–80% of isolates were resistant to erythromycin, and 40–70% to fluoroquinolones, while no resistance was observed against vancomycin. 40–60% of isolates of P. aeruginosa were resistant to cephalosporins, 40–55% to fluoroquinolones, and 30–60% to aminoglycosides. Also, 40–80% of isolates of Enterobacterales were resistant to cephalosporins, and 50–60% to fluoroquinolones. Most gram?negative isolates were susceptible to carbapenems and polymyxin B. Conclusion: To the best of our knowledge, our study is the largest compilation of microbiological profile of bacterial keratitis from North India. It highlights the current trend of the bacterial pathogens that cause infectious keratitis. Staphylococci and Pseudomonas were found to be the most common pathogens. Increased resistance was seen against some of the commonly prescribed empirical antibiotics. Such evidence is useful for restructuring the empirical prescription practices from time to time.

Management of descemetocele: Our experience and a simplified treatment algorithm

Purpose: To formulate a treatment algorithm for the management of descemetocele. Methods: This was a prospective interventional study that was conducted at a tertiary eye?care center. All consecutive cases of descemetocele during the study period (April 1, 2017–March 31, 2018) were evaluated for the following parameters: age, sex, previous medical or surgical therapy, risk factors, preexisting ocular diseases, location, site and size of descemetocele, interventions undertaken, visual acuity, and the fellow eye status. The surgical modalities and fellow eye status were correlated individually with therapeutic and functional outcomes, based on which a treatment algorithm was formulated. Results: The study included 24 eyes of 24 patients (19M, 5F) with a median age of presentation of 45 years. The mean follow?up duration was 6.79 ± 3.97 months (3–12 months). The most common cause of descemetocele was microbial keratitis (66.66%), and most cases were central (50%), small (58.33%), and non?perforated (79.16%). The surgical interventions undertaken were cyanoacrylate glue (CG, 37.5%), penetrating keratoplasty (PKP, 33.33%), patch graft (16.66%), and deep anterior lamellar keratoplasty (DALK, 12.5%). Therapeutic success was noted in 13/24 eyes (54.16%). Final visual acuity > 3/60 was seen in 25% cases. Suboptimal therapeutic (P = 0.07) and visual (P = 0.34) outcomes were noted in subjects with non?functional fellow eye. Conclusion: PKP was preferred for descemetoceles with active microbial keratitis and extensive infiltrates, while CG and DALK were undertaken for healed microbial keratitis, neurotrophic keratitis, and ocular surface disorders with partial limbal stem cell deficiency (LSCD). For total LSCD, amniotic membrane graft was preferred.

Determinants of Out-of-Pocket and Catastrophic Health Expenditure: A Cross-sectional Study.

Background: In India, Out of Pocket Health Expenditures (OOPHE) is as high as 70-80% of total health expenditures, borne by the families of ailing persons. In most cases such high OOPHE is catastrophic in nature, in the backdrop of high poverty level in the country. High OOPHE and Catastrophic Health Expenditures (CHE) have a potential to impoverish people. It is therefore important to identify the predictors of OOPHE and CHE, to formulate an equitable and efficient financial protection measure from health expenditure. Methods: The study tried to understand the factors of out-of-pocket health expenditure and catastrophic health expenditure using the cross-sectional data from 986 sampled households in Koderma district of the state of Jharkhand in India. A multi-staged sampling method was followed to select households with incidences of in-patient care in the last one and child birth in the last two years and of out-patient care in the last one month. Alongside health expenditure data of the sampled households, their socio-demographic and socio-economic information were also collected using survey questionnaire. Findings: Male headed households, families with more than five members, household head who were unemployed or were engaged in agriculture or labour works as compared to those in service; household head aged above 60 years, households from higher expenditure quintiles, households with any member suffering from chronic illness, households reporting any episode of hospitalisation, in-patient or delivery services availed from private providers in the reference periods, families living closer to service providers especially private providers were significant predictors of high OOPHE. Residence in rural area (aOR: 1.65, 95% CI 1.10 - 2.49), families living in ‘kutcha’ (mud house) houses (aOR: 1.46, 95% CI 1.06 - 2.0), families with lower social status like Schedule Tribe (aOR: 1.76, 95% CI 1.0 – 3.13), Scheduled Caste (aOR: 1.73, 95% CI 1.02 - 2.92) and Other Backward Classes (aOR: 1.42, 95% CI 1.02 - 2.01) compared to General castes, families where any member suffering from chronic illness (aOR: 2.33, 99% CI 1.48 – 3.67), families where any member had received in-patient care in the last one year irrespective of type of providers (aOR: 2.18, 99% CI 1.60 - 2.97), longer distance from health service providers, had higher likelihood of CHE. Conclusion: The study tried to identify different predictors of Out of Pocket Health Expenditure (OOPHE) and Catastrophic Health Expenditure (CHE), incurred by families seeking medical care for various ailments. OOPHE was found higher among families from higher expenditure quintile; however, people from disadvantaged socio economic profile had higher likelihood of CHE. Apparently, even smaller OOPHE is proving to be catastrophic for families from lower socio-economic segments. Families with any member suffering from chronic illness were at a higher risk of CHE. OOPHE was considerably higher when services have been sought from private providers compared to public health providers, however, for in-patient care, expenditure incurred in both situations were found to be catastrophic. Urgent action is needed for designing healthcare finance policies that is more equitable and efficient and has a potential to reduce OOPHE and incidences of CHE.

Attitude of Ayurveda doctors toward the impact of health information technology.

Background: Health information technology (HIT) equips healthcare professionals with the required information and tools for making quality decisions in patient care, but it is always advisable to assess their attitude before its actual implementation. Objectives: To assess the attitude of Ayurvedic doctors toward the impact of HIT. Materials and Methods: A cross‑sectional survey was carried out among 140 doctors of an Ayurvedic center of Southern India. A validated questionnaire consisting of 18 questions based on a 5‑point Likert scale was administered to the participants after receiving their due consent. Results: About 75–80% of the respondents concurred that the HIT application, such as electronic health record, has the potentials to reduce the duplication of documentation work, is easy and has an instant processing and real‑time access to patient information. They also felt the need of such application to report the patient data to local and national health institutions. A total of 85% of them mentioned that these applications can make the collection and accessibility of patient data much easier compared with paper‑based records, whereas 87.4% of them claimed telemedicine as a platform for multidisciplinary collaborative research and patient care. Conclusion: Even though most of the respondents agreed about the role of HIT in improving the quality of health care, there were many who held no opinion about HIT, including privacy and security of patient data. The need of proper awareness and training program is identified to make them aware about the HIT and its application in patient care, education and research.

Laser in-situ keratomileusis for refractive error following radial keratotomy.

Aim: To evaluate the safety and efficacy of laser in-situ keratomileusis (LASIK) in eyes with residual/induced refractive error following radial keratotomy (RK). Design: Retrospective study. Materials and Methods: A retrospective analysis of data of 18 eyes of 10 patients, who had undergone LASIK for refractive error following RK, was performed. All the patients had undergone RK in both eyes at least one year before LASIK. Parameters like uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), contrast sensitivity, glare acuity and corneal parameters were evaluated both preoperatively and postoperatively. Statistical Software: STATA-9.0. Results: The mean UCVA before LASIK was 0.16±0.16 which improved to 0.64 ± 0.22 (P < 0.001) after one year following LASIK. Fourteen eyes (out of 18) had UCVA of ≥ 20/30 on Snellen's acuity chart at one year following LASIK. The mean BCVA before LASIK was 0.75 ± 0.18. This improved to 0.87 ± 0.16 at one year following LASIK. The mean spherical refractive error at the time of LASIK and at one year after the procedure was –5.37 ± 4.83 diopters (D) and –0.22 ± 1.45D, respectively. Only three eyes had a residual spherical refractive error of ≥ 1.0D at one year follow-up. In two eyes, we noted opening up of the RK incisions. No eye developed epithelial in-growth till 1 year after LASIK. Conclusion: LASIK is effective in treating refractive error following RK. However, it carries the risk of flap-related complications like opening up of the previously placed RK incisions and splitting of the corneal flap.

Recurrent Salzmann's nodular degeneration: report of two cases and review of literature.

Recurrence of Salzmann's nodular degeneration following corneal transplantation is uncommon. The earlier reports of recurrence of Salzmann's degeneration were based on clinical evidence. We report two histopathologically proven cases of recurrence of Salzmann's nodular degeneration following keratoplasty; one recurring after lamellar keratoplasty and the other following penetrating keratoplasty. Two male patients (40 yrs and 24 yrs) presented to us with a clinical picture of Salzmann's nodular degeneration. One patient had undergone lamellar keratoplasty in both eyes for Salzmann's degeneration, 22 years ago. A repeat lamellar keratoplasty was performed in the right eye (7.5 mm/8 mm). In the other patient, penetrating keratoplasty was performed in the left eye, 6 years ago for the same. Lamellar keratoplasty was performed in the left eye (8 mm/8 mm). The histopathologic evaluation of the host button in both the cases, showed features very much suggestive of a recurrence of Salzmann's nodular degeneration.

Complications of laser-in-situ-keratomileusis.

Laser-in-situ-keratomileusis (LASIK) has become a popular technique of refractive surgery because of lower postoperative discomfort, early visual rehabilitation and decreased postoperative haze. Compared to photorefractive keratectomy (PRK), LASIK involves an additional procedure of creating a corneal flap. This may result in complications related to the flap, interface and underlying stromal bed. The common flap-related complications include thin flap, button holing, free caps, flap dislocation and flap striae. The interface complications of diffuse lamellar keratitis, epithelial ingrowth and microbial keratitis are potentially sight threatening. Compared to PRK, there is less inflammation and faster healing after LASIK, but there is a longer period of sensory denervation leading to the complication of dry eyes. The refractive complications include undercorrection, regression, irregular astigmatism, decentration and visual aberrations. Honest and unbiased reporting is important to understand the aetiology and redefine the management.

Pattern of pediatric ocular trauma in India.

OBJECTIVE: The aim of the study is to identify the causes, demographic and clinical profile and evaluate final visual outcome of pediatric ocular injuries. METHODS: Two hundred and four children aged fourteen years or less presenting to the emergency services of a tertiary care centre with ocular injury were included. Demographic data, nature and cause of injury, duration between injury and presentation to an ophthalmologist and the diagnosis were recorded. Evaluation of visual acuity, anterior segment and fundus were done. All patients were appropriately managed and followed up on days 1, 7, 1 month, 3 and 6 months. RESULT: Majority of injuries occurred in children of 5 years and older (87.7%). There were 133 (65.1%) boys and 71 (34.9%) girls. Forty-nine (24%) cases presented within 6 hours of injury while 70 (34.3%) presented after more than 24 hours after trauma. Most common cause of injury was bow and arrow (15.2%) followed by household appliances(14.3%). Closed globe injuries accounted for 42.2% injuries, open globe for 53.9% and 3.9% were chemical injuries. Best corrected visual acuity of 6/12 or better was achieved in 79 eyes (91.86%) in closed globe group. However, only 17 eyes (15.45%) in open globe group could achieve this. CONCLUSION: Most ocular injuries in children are preventable and occur from unsupervised games like bow and arrow and firecracker, which can lead to significant visual loss.