Ocular Biometry Percentile Curves and Their Relation to Myopia Development in Indian Children.

Background: The aim of the present study was to provide ocular biometry percentile values for Indian children between the ages of 6 and 12 and to validate the usefulness of centiles in predicting myopia development. Methods: The study was part of a longitudinal study-the Sankara Nethralaya Tamil Nadu Essilor Myopia Study (STEM), where objective refraction and ocular biometry were measured for children studying in grades 1, 4, and 6 at baseline (2019-2020). These data were used to generate ocular biometry percentile curves (both for axial length (AL) and AL/corneal curvature (AL/CR) ratios). The usefulness of percentile values in predicting myopia development was estimated from follow-up data (2022). Results: The total number of children in the three grades at baseline was 4514 (age range 6 to 12). Boys represented 54% (n = 2442) of the overall sample. The prevalence of myopia at baseline was 11.7% (95% CI from 10.8 to 12.7%) in these three grades. Both the AL and AL/CR ratio centiles showed a linear trend with an increase in AL and AL/CR with increasing grades (p < 0.001) for all percentiles (2, 5, 10, 25, 50, 75, 90, 95, 98, and 99) when stratified by sex. In the follow-up data (n = 377), the 75th and 50th percentiles of the AL/CR ratio had an area under the curve (AUC) of 0.79 and 0.72 to predict myopia onset for grade 4 and 6 children at baseline. Combining baseline AL with the centile shift in follow-up as a predictor increased the AUC to 0.83. Conclusions: The present study has provided centile values specific for Indian children between the ages of 6 and 12 to monitor and intervene where children are at a higher risk of myopia development.

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.

Development of an integrated telerehabilitation model in children with cerebral visual impairment in South India during the COVID-19 pandemic - A pilot study.

Purpose: Coronavirus disease 2019 (COVID-19) pandemic affected the in-person rehabilitation/habilitation services in families with children with cerebral visual impairment (CVI) in India. This study aimed to develop a structured and family-centered telerehabilitation model alongside conventional in-person intervention in children with CVI to observe its feasibility in the Indian population. Methods: This pilot study included 22 participants with a median age of 2.5 years (range: 1-6) who underwent a detailed comprehensive eye examination followed by functional vision assessment. The visual function classification system (VFCS) was administered to the children and the structured clinical question inventory (SCQI) to the parents. Every participant underwent 3 months of telerehabilitation including planning, training, and monitoring by experts. At 1 month, the parental care and ability (PCA) rubric was administered to the parents. After 3 months, in an in-person follow-up, all the measures were reassessed for 15 children. Results: After 3 months of Tele-rehabilitation there were significant improvements noted in PCA rubric scores (P<0.05). Also, statistically significant improvements were noted in functional vision measured using SCQI and VFCS scores (P<0.05) compared to baseline. Conclusion: The outcomes of the study provide the first steps towards understanding the use of a novel tele-rehabilitation model in childhood CVI along-side conventional face-to-face intervention. The added role of parental involvement in such a model is highly essential.

Visual outcome in pediatric uveitis: A retrospective data review in 277 children.

Purpose: This study aimed to describe visual outcomes in cases of pediatric uveitis in an Indian population and to analyze various factors affecting these outcomes. Methods: Single-center, retrospective chart review of 277 cases of uveitis in patients under the age of 18 years. Variables assessed included age and sex distribution, anatomical location of uveitis, systemic associations, complications, and various treatment strategies used, including long-term immunomodulation and surgical management of complications if required. The main outcome was the final visual acuity. Results: At the final visit, 51.5% of the eyes showed improvement in the final visual acuity, while vision remained stable in 28.7% and 19.7% of the eyes showed worsening of vision at the final follow-up. A total of 19.4% of patients were blind in at least one eye at the final visit, and 16 patients (5.77%) remained bilaterally blind at the final follow-up. The presence of cataract (p = 0), posterior uveitis (p = 0.005), and retinal detachment (p = 0.014) were the most significant risk factors for predicting worse visual outcomes. More than half (65.7%) of patients reported a complication at some point in their follow-up, and the most common complication was cataract. In total, 50.9% of patients required long-term immunomodulatory therapy. Conclusion: Pediatric uveitis remains a challenging condition to treat and follow-up, and the visual outcome remains guarded for most patients.

Parental perception of facilitators and barriers to activity and participation in an integrated tele-rehabilitation model for children with cerebral visual impairment in South India - A virtual focus group discussion study.

Purpose: This study utilized virtual focus group discussions to document the facilitators and barriers reported by the parents as part of the tele-rehabilitation service delivery model in India. Methods: This study included 17 participants who were enrolled into the Tele-rehabilitation program (16 mothers, 1 father) and the virtual focus group discussion (V-FGD) were conducted through a WhatsApp video call. Three V-FGDs were conducted involving two moderators and a note taker. The V-FGD, focused at extracting the perceptions of parents pertaining to facilitators, barriers and coping mechanisms to barriers related to the tele-rehabilitation model. Results: Thematic analysis resulted in four themes for barriers that included: family and support, time, parent and care taker, child and place of living related; facilitators reported included: continuous monitoring, accessibility to professional services, provision of resource materials and parental empowerment. Themes "family and support" and "child" were most reported by parents with children >3 years and ≤3 years respectively. Finally, the barriers and facilitators were aligned with the chapters and codes of International Classification of Functioning, children and youth version (ICF-CY) environment and personal factors. Conclusion: This V-FGD highlights the importance of parental-centred and structured Tele-rehabilitation among children with CVI in India. The outcome of this study opens avenues for creating effective intervention.

Myopia and Its Association with Near Work, Outdoor Time, and Housing Type among Schoolchildren in South India.

SIGNIFICANCE: In this comprehensive assessment of environmental associations with refractive status among schoolchildren in India, outdoor time was the key modifiable risk factor associated with myopia rather than time spent on near work. PURPOSE: This study aimed to investigate the environmental risk factors associated with myopia among adolescent schoolchildren in South India. METHODS: Children in grades 8 to 10 from 11 schools in Tamil Nadu, South India, underwent eye examination and risk factor assessments through a modified version of the Sydney myopia questionnaire. Time spent on near work and outdoors was analyzed after division into three groups based on tertiles. Mixed-effects logistic regression was performed to assess the factors associated with myopia. RESULTS: A total of 3429 children (response rate, 78.4%) provided both questionnaire and refraction data. The mean (standard deviation) age was 14 (0.93) years with an equal distribution of sexes. Myopia was present among 867 children (noncycloplegic spherical equivalent refraction, ≤-0.75 D). Refraction was not associated with near work tertiles ( P = .22), whereas less time outdoors was associated with higher myopic refractions ( P = .01). Refraction shifted toward increased myopia with an increase in the near-work/outdoor time ratio ( P = .005). Children living in apartment housing had a higher prevalence of myopia compared with other types of housing ( P < .001). In multivariate analysis, increased time outdoors was a protective factor against myopia (odds ratio, 0.79; 95% confidence interval, 0.63 to 0.99; P = .04), whereas living in apartment housing (odds ratio, 1.27; 95% confidence interval, 1.04 to 1.55; P = .02) was a significant risk factor. CONCLUSIONS: In this cohort of Indian children, outdoor time, increased near-work/outdoor time ratio, and type of housing were the factors associated with myopia. Policies should target implementing a balance between near-work and outdoor time among children.

Embracing technology in cataract surgical training - The way forward.

While ophthalmology as a surgical branch itself has evolved technologically with newer instruments, techniques and procedures; ophthalmic surgical training appears to have stagnated in terms of how it is delivered and how trainees' learning and performance are assessed. This collaborative editorial attempts to identify the lacunae in ophthalmic residency training and highlight how technological tools such as surgical simulators can be incorporated into ophthalmic training even in limited-resource settings with good results.

Prevalence of myopia among urban and suburban school children in Tamil Nadu, South India: findings from the Sankara Nethralaya Tamil Nadu Essilor Myopia (STEM) Study.

PURPOSE: To report the baseline prevalence of myopia among school children in Tamil Nadu, South India from a prospective cohort study. METHODS: Children between the ages of 5 and 16 years from 11 schools in two districts of Tamil Nadu underwent vision screening. All children underwent visual acuity assessment using a Pocket Vision Screener followed by non-cycloplegic open-field autorefraction (Grand Seiko WAM-5500). Myopia was defined as a spherical equivalent (SE) refraction of ≤-0.75 D and high myopia was defined as SE ≤ -6.00 D. Distribution of refraction, biometry and factors associated with prevalence of myopia were the outcome measures. RESULTS: A total of 14,699 children completed vision screening, with 2% (357) of them having ocular abnormalities other than refractive errors or poor vision despite spectacle correction. The remaining 14,342 children (7557 boys; 52.69%) had a mean age of 10.2 (Standard Deviation [SD] 2.8) years. A total of 2502 had myopia in at least one eye, a prevalence of 17.5% (95% CI: 14.7-20.5%), and 74 (0.5%; 95% CI: 0.3-0.9%) had high myopia. Myopia prevalence increased with age (p < 0.001), but sex was not associated with myopia prevalence (p = 0.24). Mean axial length (AL; 23.08 (SD = 0.91) mm) and mean anterior chamber depth (ACD; 3.45 (SD = 0.27) mm) positively correlated with age (p < 0.001). The mean flat (K1; 43.37 (SD = 1.49) D) and steep (K2; 44.50 (SD = 1.58) D) corneal curvatures showed negative correlation with age (p = 0.02 and p < 0.001, respectively). In the multivariable logistic regression, older age and urban school location had higher odds for prevalence of myopia. CONCLUSION: The baseline prevalence of myopia among 5- to 16-year-old children in South India is larger than that found in previous studies, indicating that myopia is becoming a major public health problem in this country.

Visual function assessment, ocular examination, and intervention in children with developmental delay: A systematic approach - Part 2.

In India, there is increasing number of children with development delay and vision impairment with or without additional disabilities due to prematurity, brain damage, cerebral palsy, or genetic syndromes. Despite initiatives from Government of India, early intervention for these children remains a challenge across the country due to lack of trained professionals and appropriate resources. This paper describes the developmental screening tools, intervention aspects including Individualized Education Plan, procedures for handling children with cerebral visual impairment, team approach, and guidelines derived from the inputs of experts in vision rehabilitation centers of premier eye institutes in India.

The Sankara Nethralaya Tamil Nadu Essilor Myopia (STEM) Study-Defining a Threshold for Non-Cycloplegic Myopia Prevalence in Children.

The aim of this study was to investigate the agreement between cycloplegic and non-cycloplegic autorefraction with an open-field auto refractor in a school vision screening set up, and to define a threshold for myopia that agrees with the standard cycloplegic refraction threshold. The study was conducted as part of the Sankara Nethralaya Tamil Nadu Essilor Myopia (STEM) study, which investigated the prevalence, incidence, and risk factors for myopia among children in South India. Children from two schools aged 5 to 15 years, with no ocular abnormalities and whose parents gave informed consent for cycloplegic refraction were included in the study. All the children underwent visual acuity assessment (Pocket Vision Screener, Elite school of Optometry, India), followed by non-cycloplegic and cycloplegic (1% tropicamide) open-field autorefraction (Grand Seiko, WAM-5500). A total of 387 children were included in the study, of whom 201 were boys. The mean (SD) age of the children was 12.2 (±2.1) years. Overall, the mean difference between cycloplegic and non-cycloplegic spherical equivalent (SE) open-field autorefraction measures was 0.34 D (limits of agreement (LOA), 1.06 D to -0.38 D). For myopes, the mean difference between cycloplegic and non-cycloplegic SE was 0.13 D (LOA, 0.63D to -0.36D). The prevalence of myopia was 12% (95% CI, 8% to 15%) using the threshold of cycloplegic SE ≤ -0.50 D, and was 14% (95% CI, 11% to 17%) with SE ≤ -0.50 D using non-cycloplegic refraction. When myopia was defined as SE of ≤-0.75 D under non-cycloplegic conditions, there was no difference between cycloplegic and non-cycloplegic open-field autorefraction prevalence estimates (12%; 95% CI, 8% to 15%; p = 1.00). Overall, non-cycloplegic refraction underestimates hyperopia and overestimates myopia; but for subjects with myopia, this difference is minimal and not clinically significant. A threshold of SE ≤ -0.75 D agrees well for the estimation of myopia prevalence among children when using non-cycloplegic refraction and is comparable with the standard definition of cycloplegic myopic refraction of SE ≤ -0.50 D.

The International Council of Ophthalmology Ophthalmic clinical evaluation exercise.

Purpose: Fifteen years after the publication of the Ophthalmic Clinical Evaluation Exercise (OCEX), it was deemed necessary to review and revise it, and to validate it for an international audience of ophthalmologists. This study to revise the OCEX and validate it for international use. Methods: The OCEX rubric was changed to a modified Dreyfus scale; a behavioral descriptor was created for each category. An international panel of ophthalmic educators reviewed the international applicability and appropriateness of the tool. Results: A tool for assessing and giving feedback on four aspects of clinical competence during the ophthalmic consultation (interview skills, examination, interpersonal and communication skills, and case presentation) was revised. The original scoring tool was improved to a new behavioral one, and relevant comments and suggestions from international reviewers were incorporated. The new tool has face and content validity for an international audience. Conclusion: The OCEX is the only tool for workplace assessment and feedback specifically for ophthalmology residents and the ophthalmic consultation. This improved and simplified version will facilitate its use and implementation to diverse programs around the world.

The painless eye: Neurotrophic keratitis in a child suffering from hereditary sensory autonomic neuropathy type IV.

Hereditary sensory autonomic neuropathy (HSAN) is a group of inherited disorders (total 5 types) that are associated with sensory dysfunction and varying degrees of autonomic dysfunction. HSAN type IV (HSAN-IV) or congenital insensitivity to pain and anhidrosis (CIPA) is a rare genetic disorder inherited in an autosomal recessive manner. We report a case of this very rare genetic disease in a 3-year-old girl child, born to a family in north India with ocular features of neurotrophic keratitis. The diagnosis was made clinically based on the hallmark features of insensitivity to pain and temperature, anhidrosis, self-mutilating behavior with multiple recurrent oral ulcers, nasal bleeds, multiple trophic ulcers over joints, and decreased intellect.

Frequency of undetected binocular vision anomalies among ophthalmology trainees / Frecuencia de anomalías de visión binocular no detectadas entre los estudiantes de Oftalmología

PURPOSE: The use of ophthalmic instruments requires increased effort on the accommodation and vergence system. This study aimed to understand the prevalence of binocular vision anomalies among ophthalmology trainees attending a surgical training program at a tertiary eye care center. METHODS: This prospective cohort study was carried out between April and November 2017 at a tertiary eye care center in South India. All the ophthalmology trainees inducted for the training programs at the institution underwent a comprehensive ophthalmic and binocular vision assessment. Subjects with previous diagnosis of binocular vision dysfunction and vision therapy were excluded. RESULTS: The mean (SD) age of the subjects was 29 (3) among which 48 were females. Out of the total 75 subjects, 66 had prior surgical experience [range: 1 to 17 years]. Thirty-eight subjects were asymptomatic and 37 were symptomatic. The most common asthenopic symptom was the presence of headache. Forty-one (55%) out of the 75 had a diagnosis of a non-strabismic binocular vision dysfunction. The range of phoria at distance was orthophoria to 14 Prism Diopter (PD) exophoria (mean +/− SD: −1 +/− 3), and at near 4PD esophoria to 25PD exophoria (mean +/− SD: −4 +/− 5). Based on standard diagnostic criteria, 15 subjects (20%) had convergence insufficiency, 14 (19%) had accommodative infacility, 9 (12%) had intermittent divergent squint (IDS), while 3 subjects (4%) had convergence excess. CONCLUSIONS: This study shows the high frequency of binocular vision dysfunctions among ophthalmology trainees joining a tertiary eye care center

OBJETIVO: El uso de instrumentos oftálmicos requiere un esfuerzo incrementado de los sistemas de acomodación y vergencia. El objetivo de este estudio fue comprender la prevalencia de anomalías de visión binocular entre los alumnos de oftalmología que asistían a un programa de formación quirúrgica en un centro terciario de cuidados oculares. MÉTODOS: Este estudio de cohorte prospectivo fue realizado entre abril y noviembre de 2017 en un centro terciario de cuidados oculares en el sur de India. Todos los estudiantes de oftalmología inscritos en los programas de formación en el centro fueron sometidos a un amplio examen oftálmico y binocular. Se excluyó a los sujetos con diagnóstico previo de disfunción de visión binocular y terapia ocular. RESULTADOS: La edad media (DE) de los sujetos fue de 29 años (3), de los cuales 48 eran mujeres. Del total de 75 sujetos, 66 tenían experiencia quirúrgica previa [rango: de 1 a 17 años]. Treinta y ocho sujetos eran asintomáticos y 37 sintomáticos. El síntoma de astenopía más común fue la presencia de cefalea. Cuarenta y uno (55%) de los 75 sujetos fueron diagnosticados de disfunción visual binocular no estrábica. El rango de foria de lejos fue de ortoforia a 14 dioptrías prismáticas (DP) a exoforia (media +/− DE: −1 +/− 3) y, de cerca, de esoforia a 4DP a esoforia a 25DP (media +/− DE: −4 +/− 5). Basándonos en criterios diagnósticos estándar, 15 sujetos (20%) tenían insuficiencia de convergencia, 14 (19%) falta de facilidad acomodativa, 9 (12%) tenían estrabismo divergente intermitente (EDI), y 3 sujetos (4%) tenían exceso de convergencia. CONCLUSIONES: Este estudio muestra la alta frecuencia de disfunciones de visión binocular entre los estudiantes de oftalmología que acudierona un centro terciario de cuidados oculares

Frequency of undetected binocular vision anomalies among ophthalmology trainees.

PURPOSE: The use of ophthalmic instruments requires increased effort on the accommodation and vergence system. This study aimed to understand the prevalence of binocular vision anomalies among ophthalmology trainees attending a surgical training program at a tertiary eye care center. METHODS: This prospective cohort study was carried out between April and November 2017 at a tertiary eye care center in South India. All the ophthalmology trainees inducted for the training programs at the institution underwent a comprehensive ophthalmic and binocular vision assessment. Subjects with previous diagnosis of binocular vision dysfunction and vision therapy were excluded. RESULTS: The mean (SD) age of the subjects was 29 (3) among which 48 were females. Out of the total 75 subjects, 66 had prior surgical experience [range: 1 to 17 years]. Thirty-eight subjects were asymptomatic and 37 were symptomatic. The most common asthenopic symptom was the presence of headache. Forty-one (55%) out of the 75 had a diagnosis of a non-strabismic binocular vision dysfunction. The range of phoria at distance was orthophoria to 14 Prism Diopter (PD) exophoria (mean +/- SD: -1 +/- 3), and at near 4PD esophoria to 25PD exophoria (mean +/- SD: -4 +/- 5). Based on standard diagnostic criteria, 15 subjects (20%) had convergence insufficiency, 14 (19%) had accommodative infacility, 9 (12%) had intermittent divergent squint (IDS), while 3 subjects (4%) had convergence excess. CONCLUSIONS: This study shows the high frequency of binocular vision dysfunctions among ophthalmology trainees joining a tertiary eye care center.

The rare phenomenon of Marcus-Gunn jaw winking without ptosis: Report of 14 cases and review of the literature.

Purpose: To report a rare case series of 14 patients of the Marcus-Gunn jaw-winking phenomenon (MGJWP) without ptosis. Methods: This was a retrospective noninterventional case series. The medical records of all patients diagnosed with MGJWP over the past 10 years were retrieved. Patients with documented evidence of absence of ptosis were segregated and analyzed for visual acuity, the severity of Marcus-Gunn, the presence of squint and amblyopia, and the presence of other aberrant regenerations. Results: A total of 207 patients were diagnosed with MGJWP, out of which 14 (6.76%) patients had isolated MGJWP without blepharoptosis. The mean age of presentation was 9.5 years and males and females were equally affected. The left eye was involved more commonly (57.2%) than the right eye. Twelve patients were congenital and two were presumed to be of traumatic origin. The most common refractive error in this cohort was astigmatism (10, 71.42%), followed by hyperopia (5, 35.71%). One patient had anisometropic amblyopia. Marcus-Gunn was found to be mild (≤2 mm of lid excursion) in all cases. None of the patients had strabismus or any other aberrant innervations. None of the patients underwent surgery and did not develop ptosis or worsening or improvement of Marcus-Gunn after a mean follow-up period of 2.3 years. Conclusion: Isolated MGJWP in the absence of ptosis is a very rare entity and this is the largest series to date to report such an occurrence. All patients had a mild form of MGJWP with no intervention required in any of the cases.