Effect of defocus incorporated multiple segments lenses on halting myopia progression not responding to low-concentration atropine (0.01%) eye drops.

To assess the effect of defocus incorporated multiple segments (DIMS) (Miyosmart) lenses on myopic progression in children not responding to low-concentration atropine (LCA) (0.01%) eye drops. A total of 10 children not responding to LCA (0.01%) eye drops were advised to start using the DIMS lens to halt the progression of myopia. The children were followed for a period of 1 year. Eight out of 10 children showed a reduction in the progression of myopia. Pre DIMS, the progression was -0.68 D ± 0.3 D sph, which reduced to -0.24 ± 0.2 diopter progression post DIMS lens in the eight children. The remaining two children still progressed by -0.57 ± 0.4 D sph over a year. The axial length growth reduced from 0.28 ± 0.3 mm to 0.16 ± 0.2 mm after using the DIMS lens in these non-responders. The DIMS lens shows initial promise in reducing the progression of myopia even in children not responding to LCA 0.01% eye drops.

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.

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.

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.

Efficacy of supplemental Occlu-pad therapy with partial occlusion in children with refractive anisometropic amblyopia.

Purpose: To study the efficacy of supplemental occlu-pad therapy with partial occlusion in children with refractive anisometropic amblyopia. Methods: Thirty-one children who did not improve after partial occlusion of 6 h for 6 months were supplemented with the use of occlu-pad for 1 h per day and three such sessions in a week. Results: The mean age was 6.8+/-1.4 years (range 5-9 years). A significant improvement of 3.2+/-1.3 lines in visual acuity was noticed at the end of 3 months of starting this supplemental therapy in children. Out of 31 children, 26 children improved at least 2 lines or more at the end of 3 months. All children (n = 9) having anisohyperopic amblyopia improved at the end of 3 months. Conclusion: Occlu-pad is useful in supplementing occlusion therapy in cases of refractive amblyopia and is more effective in anisohyperopic amblyopia.

Efficacy of low-concentration atropine (0.01%) eye drops for prevention of axial myopic progression in premyopes.

PURPOSE: Low-concentration atropine (LCA; 0.01%) is known to reduce the progression of myopia in axial myopes. The purpose of this study was to understand the role of LCA in premyopic children in preventing progression. METHODS: A randomized case-control study of known premyopes was done between the use of LCA and no intervention. A total of 30 children were included in both groups. RESULTS: The mean age in the LCA group was 7.7 ± 2.1 years (5-12 years), and in the control group, it was 7.2 ± 1.9 years (4-12 years). The mean baseline progression per year in the LCA group (before starting the eye drops) was - 0.72 ± 0.3 D, and in the control group, it was - 0.69 ± 0.4 D. At the end of the first year, the mean progression in the LCA group was - 0.31 ± 0.3 D versus - 0.76 ± 0.4 D, and the axial length increase was 0.12 ± 0.1 mm in the LCA group and 0.21 ± 0.2 mm in the control group. At the end of the second year, the mean progression compared with the baseline in the LCA group was - 0.6 ± 0.3 D versus - 1.75 ± 0.4 D, and the axial length showed an increase from baseline in the LCA group by 0.21 ± 0.2 mm, and in the control group, the increase was 0.48 ± 0.2 mm in 2 years. CONCLUSION: Low-concentration eye drops (0.01%) work in preventing the progression of axial myopia in premyopic children.

Understanding the changes in practice patterns in ophthalmology following COVID-19 lockdown.

PURPOSE: Severe acute respiratory syndrome-Coronavirus 2 pandemic has brought the world to a halt. We performed a questionnaire-based survey to know more about these issues which affected them due to this pandemic and resultant lockdown. METHODS: A questionnaire-based survey (53 questions) was conducted online among Indian ophthalmologists with a 2-week response time. The invitation to participate was also circulated widely among various ophthalmologists as members on different social media platforms and emails. It was mandatory to answer all the questions in the questionnaire to make it a valid response. RESULTS: A total of 903 responses were received across the country. A majority of these responses, 403 (44.6%), were from private practitioners. Almost 876 (97%) of the responders had either kept the daily working hours as same as pre-COVID-19 era or had reduced the actual working hours. Overall, 547 (60.6%) responders did not downsize their staff and 569 (63%) did not reduce the staff salary. Consultation charges were not revised by a majority (659, 73%) of responders. Total of 663 (73.4%) were following the appointment system and 702 (77.7%) responders had reduced the number of patients to less than 6 an hour. Only 106 (11.7%) were doing a mandatory RT-PCR test before surgery, whereas 567 (62.8%) did on the basis of suspicious symptoms. CONCLUSION: Our survey gives valuable inputs regarding the changes made by different ophthalmologist groups during the times of COVID-19 and lockdown.

Role of Preoperative Nd:YAG Laser Anterior Capsulotomy in Mature Intumescent Cataracts.

PURPOSE: The aim of this study was to examine the role of preoperative Nd:YAG laser anterior capsulotomy in preventing intraoperative complications in mature intumescent cataracts. DESIGN: A prospective, interventional, observational study. METHODS: A total of 52 eyes of 52 patients were selected in this prospective study. Preoperative Nd:YAG laser anterior capsulotomy was performed in all eyes with 1 shot of 1.2 mJ and a gush of the liquified cortex was noted. Anterior chamber depth was measured using anterior segment optical coherence tomography and intraocular pressure using Goldmann applanation tonometer were measured pre- and post-laser. Intraoperative complications and surgeon's operative comfort were noted. RESULTS: There was a mean increase in anterior chamber depth by 0.24 mm and a mean decrease in intraocular pressure by 1.61 mm Hg postlaser. No intraoperative complications were noted except for capsulorhexis extension in 1 eye (1.92%). The surgeon experienced a good control while performing the capsulorhexis and overall an uneventful surgery. CONCLUSIONS: Preoperative Nd:YAG laser anterior capsulotomy is a safe and effective technique in reducing intralenticular pressure and avoiding intraoperative complications in mature intumescent cataracts.

Comparing keratometry readings with manual separation of lids and wire speculum in children under general anesthesia.

Purpose: Keratometry (K) readings are crucial for intraocular lens power calculation in cataract surgery. In children who do not cooperate, the keratometry is done under general anesthesia with a handheld autokeratometer. However, there is little consensus regarding the method for the measurement of K readings. The lids can be separated either by fingers or a wire speculum may be placed to separate the lids for measurement. Methods: The children selected for the study were patients cooperative for keratometry reading. Nidek KM-500 handheld keratometer was used first in the awake period. Then under general anesthesia, readings were taken first by separating the lids manually with fingers and then after putting a wire speculum in both the eyes. Results: The average keratometry reading for participants in the OPD, anesthetized with lids manually opened and with lids separated with speculum was 44.7 ± 1.7 D, 44.4 ± 1.9 D, and 44.7 ± 1.7 D, respectively. Conclusion: No significant change was observed in keratometry values in children with manual separation of eyelids or with wire speculum.

Integrating binocular vision assessment in refractive surgery work-up: Proposition and protocol.

Refractive surgeries are one of most commonly performed surgeries for correcting visual impairment due to refractive errors. With the increase in demand for refractive surgeries, there is an enormous strain on the operating surgeon for delivering ideal outcomes i.e 20/20 visual acuity. Regression, under-correction and ectasia are the most dreaded complications post-refractive correction, for the surgeon as well as the patient. They have significant effects on the quantity of the vision and most importantly on the quality of life of the patient. With the advent of digital era and jobs requiring the eyes being glued to the screen for hours there has been a surge in the patients presenting with complaints of asthenopia, glare, halos, and difficulty in focusing; pointing towards diagnosis of non-strabismic binocular vision anomalies (NSBVA). NSBVA in a postrefractive surgery patient may masquerade as regression or under-correction. However, timely diagnosis of NSBVA in such patients would prevent the greater harm caused by wrongful re-correction. Home- and office-based vision therapy results in improvement in visual acuity in a large majority of these patients. This preferred practice pattern intends to guide the refractive surgeons to diagnose and treat the postrefractive surgery NSBVA following a case-based and algorithmic approach. It also emphasizes the inclusion of the binocular vision assessment as a part of the pre-operative workup for patients undergoing refractive procedures.

Pediatric ophthalmology, strabismus and neuro-ophthalmology practice in the COVID-19 era: All India Ophthalmological Society guidelines.

The COVID-19 Pandemic has prompted substantial changes in the way ophthalmology is practiced globally. General guidelines on safe ophthalmic practice have been issued by various bodies across the globe including the All India Ophthalmological Society. While these are suitable to ophthalmology overall, they are not entirely suitable to a subspecialty practice, particularly pediatric ophthalmology, strabismus and neuro-ophthalmology, which entails dealing with children, surgery under general anesthesia and managing possible life threatening situations. A group of sub-specialists and anesthetists met virtually and arrived at a consensus with regard to practice and general anesthesia protocols pertaining to these subspecialties of ophthalmology. The recommendations made by the expert group are specific yet can be universally followed to ensure the best and safest outcome for the practitioner and patient alike. The recommendations pertain to listing conditions which need emergency or urgent care in the fields of pediatric ophthalmology and neuro-ophthalmology, precautions and technique of pediatric and neuro-ophthalmic eye examination and a protocol for delivering a safe general anesthesia for a pediatriceye surgery.

The subjectivity of objective evaluation of torsion on fundus photographs by practicing strabismologists.

Purpose: To assess the variability of assessing the ocular torsion on fundus photographs among strabismus surgeons. Methods: This was a prospective, noninterventional, clinical trial involving 16 trained and experienced squint surgeons participated in the study. Two videos were prepared of a total of 10 fundus pictures with or without lines for disc foveal angle. The first video had a 4 s viewing time for each fundus image. The second video had the disc foveal lines drawn and a similar 4 s viewing time for each image. The participants were asked to grade the torsion. The primary outcome measure was to assess the agreement between the raters for ocular torsion measurement. Difference in the response of observers from the standard response was the secondary outcome measure. Results: A 4 s viewing time was given to mimic the exposure time in the clinic while assessing torsion in a patient. Large variability was found among the responses. The kappa test was done for comparing the agreement between various observers which ranged from slight to fair (<0.40). There was no difference in torsion grading in 30.6% and 26.3% responses in the first and second video from the standard response, respectively. When a limit of ±1 grade was taken as acceptable for the responses, 66.2% for the first and 68.7% for the second video respectively were similar to standard response. Conclusion: There is wide variability in assessing ocular torsion by fundus photography. The level of accuracy does increase with marking the line on photographs but still remains unreliable.

Stability and effects of muscle transplantation for very large angle esotropia: A study of 22 patients.

PURPOSE: A very large angle esotropia is characterized by an angle more than 80 prism diopters (pd). A single eye surgery would not correct such a large angle. Supramaximal recessions and resection would lead to restriction of ocular motility. We present a series of 22 patients with large angle esotropia treated with muscle transplantation. METHODS: A total of 22 patients (14 males and 8 females) were included in the study. All the patients had a minimum of 80 base out deviation in primary position. All patients underwent thorough preoperative orthoptic checkup and refraction. The patients were followed up on day 1, day 30, at 6 months, at 1 year, and 2 years. All the patients underwent standard muscle transplantation, where the resected extra stump of lateral rectus was transplanted to the medial rectus using 6-0 prolene which was recessed by a standard recession technique. RESULTS: The mean age of the 22 patients was 32.21 ± 13.1 years. The mean preoperative angle was 92.4 ± 13.5 pd base out. The mean postoperative angle at 2-year follow-up was 12.3 ± 9.9 pd. The average correction achieved per mm was 4.1 ± 0.3 pd. The adduction restriction was <1 in all the patients at the end of 2 years except one patient. The abduction was normal in all the patients. CONCLUSION: The true muscle transplantation is a safe alternate option for large angle esotropia when uniocular surgery is desired. The surgical results are stable in long-term and therefore a viable option.