In this article, we have discussed the basic knowledge to calculate sensitivity, specificity, positive predictive value and negative predictive value. We have discussed the advantage and limitations of these measures and have provided how we should use these measures in our day-to-day clinical practice. We also have illustrated how to calculate sensitivity and specificity while combining two tests and how to use these results for our patients in day-to-day practice.

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Diabetic retinopathy (DR), a major microvascular complication of diabetes, has a significant impact on the world's health systems. Globally, the number of people with DR will grow from 126.6 million in 2010 to 191.0 million by 2030, and we estimate that the number with vision-threatening diabetic retinopathy (VTDR) will increase from 37.3 million to 56.3 million, if prompt action is not taken. Despite growing evidence documenting the effectiveness of routine DR screening and early treatment, DR frequently leads to poor visual functioning and represents the leading cause of blindness in working-age populations. DR has been neglected in health-care research and planning in many low-income countries, where access to trained eye-care professionals and tertiary eye-care services may be inadequate. Demand for, as well as, supply of services may be a problem. Rates of compliance with diabetes medications and annual eye examinations may be low, the reasons for which are multifactorial. Innovative and comprehensive approaches are needed to reduce the risk of vision loss by prompt diagnosis and early treatment of VTDR.

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Purpose: COVID-19 infection, its treatment, resultant immunosuppression, and pre-existing comorbidities have made patients vulnerable to secondary infections including mucormycosis. It is important to understand the presentation, temporal sequence, risk factors, and outcomes to undertake measures for prevention and treatment. Methods: We conducted a retrospective, interventional study on six consecutive patients with COVID-19 who developed rhino-orbital mucormycosis and were managed at two tertiary ophthalmic referral centers in India between August 1 and December 15, 2020. Diagnosis of mucormycosis was based on clinical features, culture, and histopathology from sinus biopsy. Patients were treated with intravenous liposomal amphotericin B with addition of posaconazole and surgical debridement of necrotic tissue. Results: All patients were male, mean age 60.5 ± 12 (46.2–73.9) years, type 2 diabetics with mean blood glucose level of 222.5 ± 144.4 (86–404) mg/dL. Except for one patient who was diagnosed with mucormycosis concurrently with COVID-19, all patients received systemic corticosteroids for the treatment of COVID-19. The mean duration between diagnosis of COVID-19 and development of symptoms of mucor was 15.6 ± 9.6 (3–42) days. All patients underwent endoscopic sinus debridement, whereas two patients required orbital exenteration. At the last follow-up, all six patients were alive, on antifungal therapy. Conclusion: Mucormycosis is a life-threatening, opportunistic infection, and patients with moderate to severe COVID-19 are more susceptible to it. Uncontrolled diabetes mellitus and use of corticosteroids increase the risk of invasive fungal infection with mucormycosis which can develop during the course of the illness or as a sequelae. High index of suspicion, early diagnosis, and appropriate management can improve survival.

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Uveitis, a complex intraocular inflammatory disease results from several etiological entities. Causes of uveitis are known to vary in different populations depending upon the ecological, racial and socioeconomic variations of the population studied. Tropical countries are unique in their climate, prevailing pathogens and in the existing diseases, which further influence the epidemiological and geographical distribution of specific entities. We provide an overview of the pattern of uveitis of 15221 cases in 24 case series reported from several countries over 35 years (1972-2007) and we integrate it with our experience of an additional 8759 cases seen over six years (1996-2001) at a large community-based eye hospital. Uveitis accounted for 0.8% of our hospital-based outpatient visits. The uveitis was idiopathic in 44.6%, the most commonly identified entities in the cohort included leptospiral uveitis (9.7%), tuberculous uveitis (5.6%) and herpetic uveitis (4.9%). The most common uveitis in children below 16 years (616 patients; 7.0% of the total cohort) was pediatric parasitic anterior uveitis, (182 children, 29.5% of the pediatric cohort), whereas the most common uveitis in patients above 60 years (642 patients; 7.3% of the total cohort) was herpetic anterior uveitis, (78 patients, 12.1% of the elderly cohort). Etiologies varied with the age group of the patients. As in other tropical countries, a high prevalence of infectious uveitis was seen in this population.

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Purpose : To review the epidemiological characteristics, microbiological profile, and treatment outcome of patients with suspected microbial keratitis. Materials and Methods : Retrospective analysis of a non-comparative series from the database was done. All the patients presenting with corneal stromal infiltrate underwent standard microbiologic evaluation of their corneal scrapings, and smear and culture-guided antimicrobial therapy. Results : Out of 5897 suspected cases of microbial keratitis 3563 (60.4%) were culture-proven (bacterial - 1849, 51.9%; fungal - 1360, 38.2%; Acanthamoeba - 86, 2.4%; mixed - 268, 7.5%). Patients with agriculture-based activities were at 1.33 times (CI 1.16-1.51) greater risk of developing microbial keratitis and patients with ocular trauma were 5.33 times (CI 6.41-6.44) more likely to develop microbial keratitis. Potassium hydroxide with calcofluor white was most sensitive for detecting fungi (90.6%) and Acanthamoeba (84.0%) in corneal scrapings, however, Gram stain had a low sensitivity of 56.6% in detection of bacteria. Majority of the bacterial infections were caused by Staphylococcus epidermidis (42.3%) and Fusarium species (36.6%) was the leading cause of fungal infections. A significantly larger number of patients (691/1360, 50.8%) with fungal keratitis required surgical intervention compared to bacterial (799/1849, 43.2%) and Acanthamoeba (15/86, 17.4%) keratitis. Corneal healed scar was achieved in 75.5%, 64.8%, and 90.0% of patients with bacterial, fungal, and Acanthamoeba keratitis respectively. Conclusions : While diagnostic and treatment modalities are well in place the final outcome is suboptimal in fungal keratitis. With more effective treatment available for bacterial and Acanthamoeba keratitis, the treatment of fungal keratitis is truly a challenge.

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Important functions of cornea in the eye include protecting the structures inside the eye, contributing to the refractive power of the eye, and focusing light rays on the retina with minimum scatter and optical degradation. Considerable advances have taken place in understanding the organization of collagen in the corneal stroma and its clinical significance. In this review, the structure and function of various components of cornea and ocular surface are presented.

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Emerging pandemics show that humans are not infallible and communities need to be prepared. Coronavirus outbreak was first reported towards the end of 2019 and has now been declared a pandemic by the World Health Organization. Worldwide countries are responding differently to the virus outbreak. A delay in detection and response has been recorded in China, as well as in other major countries, which led to an overburdening of the local health systems. On the other hand, some other nations have put in place effective strategies to contain the infection and have recorded a very low number of cases since the beginning of the pandemics. Restrictive measures like social distancing, lockdown, case detection, isolation, contact tracing, and quarantine of exposed had revealed the most efficient actions to control the disease spreading. This review will help the readers to understand the difference in response by different countries and their outcomes. Based on the experience of these countries, India responded to the pandemic accordingly. Only time will tell how well India has faced the outbreak. We also suggest the future directions that the global community should take to manage and mitigate the emergency.

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Purpose: In early 2020, the World Health Organization declared the outbreak of the disease COVID-19, caused by a new variant of coronavirus 2019-nCoV as a global pandemic. The government of India ordered a nationwide lockdown for 21 days, limiting movement of people as a preventive measure. This survey was designed and conducted during the lockdown period to assess its effect on ophthalmic practice and patient care in India. Methods: An online survey was sent across to practicing Indian ophthalmologists across through various social media platforms. All valid responses were tabulated and analyzed. Results: A total of 1260 ophthalmologists responded to the survey. Most of the respondents (775/1260; 61.5%) were in private practice and 14.8% (187/1260) were affiliated to ophthalmic institutes. At the time of taking the survey, 72.5% of the respondents (913/1260) were not seeing any patients due to the lockdown. Of those who were still examining patients, 82.9% (287/347) were only seeing emergency cases, based on their own clinical judgement. The proportion of ophthalmologists in ophthalmic institutes, government and municipal hospitals (126/253;49.8%) who were still seeing patients was significantly higher (P < 0.0001) than those in private practice (174/775;22.4%). Apart from emergencies such as trauma, retinal detachment, and endophthalmitis (81.8%), other surgeries that were still being performed included intravitreal injections (9.1%) and cataract surgeries (5.9%). Approximately, 77.5% (976/1260) of the respondents had begun telephonic/e-mail/video consultations or consultations over social media applications since the lockdown began. In addition, 59.1% (745/1260) felt that ophthalmologists were potentially at a higher risk of contracting COVID-19 compared to other specialties while examining patients. When asked about the resumption of practice upon easing off of the restrictions, 57.8% (728/1260) of the respondents said they were unsure of when to resume elective surgeries; furthermore, 62.8% (791/1260) were unsure about the preferred screening strategy or precautionary approach prior to resuming surgeries and were awaiting guidelines. Conclusion: Our survey shows that majority of ophthalmologists in India were not seeing patients during the COVID-19 lockdown, with near-total cessation of elective surgeries. Emergency services were still being attended to by 27.5% of ophthalmologists who responded. A large proportions of ophthalmologists had switched over to telephonic advice or other forms of telemedicine to assist patients. Most of the responding ophthalmologists were unclear about when and how to resume surgeries upon easing off of the COVID-19 related restrictions. Regulatory bodies should take note of this and issue appropriate guidelines regarding the same.

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Corneal diseases represent the second leading cause of blindness in most developing world countries. Worldwide, major investments in public health infrastructure and primary eye care services have built a strong foundation for preventing future corneal blindness. However, there are an estimated 4.9 million bilaterally corneal blind persons worldwide who could potentially have their sight restored through corneal transplantation. Traditionally, barriers to increased corneal transplantation have been daunting, with limited tissue availability and lack of trained corneal surgeons making widespread keratoplasty services cost prohibitive and logistically unfeasible. The ascendancy of cataract surgical rates and more robust eye care infrastructure of several Asian and African countries now provide a solid base from which to dramatically expand corneal transplantation rates. India emerges as a clear global priority as it has the world's largest corneal blind population and strong infrastructural readiness to rapidly scale its keratoplasty numbers. Technological modernization of the eye bank infrastructure must follow suit. Two key factors are the development of professional eye bank managers and the establishment of Hospital Cornea Recovery Programs. Recent adaptation of these modern eye banking models in India have led to corresponding high growth rates in the procurement of transplantable tissues, improved utilization rates, operating efficiency realization, and increased financial sustainability. The widespread adaptation of lamellar keratoplasty techniques also holds promise to improve corneal transplant success rates. The global ophthalmic community is now poised to scale up widespread access to corneal transplantation to meet the needs of the millions who are currently blind.

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Uveal melanoma is the most common primary malignant tumor of the eye in adults, predominantly found in Caucasians. Local tumor control of uveal melanoma is excellent, yet this malignancy is associated with relatively high mortality secondary to metastasis. Various clinical, histopathological, cytogenetic features and gene expression features help in estimating the prognosis of uveal melanoma. The clinical features associated with poor prognosis in patients with uveal melanoma include older age at presentation, male gender, larger tumor basal diameter and thickness, ciliary body location, diffuse tumor configuration, association with ocular/oculodermal melanocytosis, extraocular tumor extension, and advanced tumor staging by American Joint Committee on Cancer classification. Histopathological features suggestive of poor prognosis include epithelioid cell type, high mitotic activity, higher values of mean diameter of ten largest nucleoli, higher microvascular density, extravascular matrix patterns, tumor-infiltrating lymphocytes, tumor-infiltrating macrophages, higher expression of insulin-like growth factor-1 receptor, and higher expression of human leukocyte antigen Class I and II. Monosomy 3, 1p loss, 6q loss, and 8q and those classified as Class II by gene expression are predictive of poor prognosis of uveal melanoma. In this review, we discuss the prognostic factors of uveal melanoma. A database search was performed on PubMed, using the terms "uvea," "iris," "ciliary body," "choroid," "melanoma," "uveal melanoma" and "prognosis," "metastasis," "genetic testing," "gene expression profiling." Relevant English language articles were extracted, reviewed, and referenced appropriately.

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The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had health implications of unprecedented magnitude. The infection can range from asymptomatic, mild to life threatening respiratory distress. It can affect almost every organ of the body. Ophthalmologists world over are reporting various manifestations of the infection in the eye. This review was undertaken to help ophthalmologists recognize the possible manifestations and the stage of the viral disease when they commonly appear. Literature search was performed for the publications on ophthalmic manifestations of coronavirus disease-19 (COVID-19) between January 1, 2020 and January 31, 2021. 46 case reports, 8 case series, 11 cross sectional/cohort observational studies, 5 prospective interventional studies, 3 animal models/autopsy studies and 6 reviews/meta-analysis were included. Conjunctivitis is the most common manifestation and can develop at any stage of the disease. Direct effect due to virus, immune mediated tissue damage, activation of the coagulation cascade and prothrombotic state induced by the viral infection, the associated comorbidities and drugs used in the management are responsible for the findings in the eye. The viral ribonucleic acid (RNA) has been isolated from ocular tissues but the role of eye as a route for infection is yet to be substantiated. Ophthalmic manifestations may be the presenting feature of COVID-19 infection or they may develop several weeks after recovery. Ophthalmologists should be aware of the possible associations of ocular diseases with SARS-CoV-2 in order to ask relevant history, look for specific signs, advise appropriate tests and thereby mitigate the spread of infection as well as diagnose and initiate early treatment for life and vision threatening complications.

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Blindness is a major global public health problem and recent estimates from World Health Organization (WHO) showed that in India there were 62 million visually impaired, of whom 8 million are blind. The Andhra Pradesh Eye Disease Study (APEDS) provided a comprehensive estimate for prevalence and causes of blindness for the state of Andhra Pradesh (AP). It also highlighted that uptake of services was also an issue, predominantly among lower socio-economic groups, women, and rural populations. On the basis of this analysis, L V Prasad Eye Institute (LVPEI) developed a pyramidal model of eye care delivery. This article describes the LVPEI eye care delivery model. The article discusses infrastructure development, human resource development, and service delivery (including prevention and promotion) in the context of primary and secondary care service delivery in rural areas. The article also alludes to opportunities for research at these levels of service delivery and the amenability of the evidence generated at these levels of the LVPEI eye health pyramid for advocacy and policy planning. In addition, management issues related to the sustainability of service delivery in rural areas are discussed. The article highlights the key factors required for the success of the LVPEI rural service delivery model and discusses challenges that need to be overcome to replicate the model. The article concludes by noting the potential to convert these challenges into opportunities by integrating certain aspects of the existing healthcare system into the model. Examples include screening of diabetes and diabetic retinopathy in order to promote higher community participation. The results of such integration can serve as evidence for advocacy and policy.

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Purpose: To report the clinical outcome of autologous cultivated limbal epithelial transplantation. Methods: Eighty-six patients' records and their clinical photographs were reviewed for demographics, primary etiology, type of limbal transplantation, ocular surface stability, visual acuity, final outcome, and possible factors affecting outcome and complications. Results: Eighty-eight eyes of 86 patients with limbal stem cell deficiency (LSCD) underwent autologous cultivated limbal epithelium transplantation between March 2001 and May 2003, with a mean follow-up of 18.3 months. The etiology of LSCD was alkali burns in 64% patients. Sixty-one eyes had total LSCD. Thirty-two of the 88 eyes had undergone amniotic membrane transplantation and 10 eyes had previously undergone limbal transplantation with unfavorable outcome. Nineteen eyes underwent penetrating keratoplasty, of which 11 grafts survived at the final follow-up. Finally, 57 eyes (73.1%, 95% CI: 63.3-82.9) had a successful outcome with a stable ocular surface without conjunctivalization, 21 eyes (26.9%, 95%CI: 17.1-36.7) were considered failures, and 10 patients were lost to follow-up. Conclusion: LSCD can be successfully treated by autologous cultivated limbal epithelium transplantation in majority of the cases.

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Suturing is a time consuming task in ophthalmology and suture induced irritation and redness are frequent problems. Postoperative wound infection and corneal graft rejection are examples of possible suture related complications. To prevent these complications, ophthalmic surgeons are switching to sutureless surgery. A number of recent developments have established tissue adhesives like cyanoacrylate glue and fibrin glue as attractive alternatives to sutures. A possible and promising new application for tissue adhesives is to provide a platform for tissue engineering. Currently, tissue glue is being used for conjunctival closure following pterygium and strabismus surgery, forniceal reconstruction surgery, amniotic membrane transplantation, lamellar corneal grafting, closure of corneal perforations and descematoceles, management of conjunctival wound leaks after trabeculectomy, lid surgery, adnexal surgery and as a hemostat to minimise bleeding. The purpose of this review is to discuss the currently available information on fibrin glue.

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Background: Retinopathy of prematurity (ROP) is an important cause of childhood blindness in developing countries. Aim: To report the spectrum of ROP and associated risk factors in babies weighing > 1250 g at birth in a developing country. Setting and Design: Institutional, retrospective, non-randomized, observational clinical case series. Materials and Methods : Retrospective analysis (10 years) of 275 eyes (138 babies) with ROP. Statistical Analysis: Qualitative data with the Chi-square test. Quantitative data using the unpaired t test or the ANOVA and further tested using multivariate logistic regression. Results: The mean birth weight was 1533.9 g (range 1251 to 2750 g) and the mean period of gestation was 30.9 weeks (range 26 to 35). One hundred and twenty-four of 275 eyes (45.1%) had threshold or worse ROP. Risk factors for threshold or worse disease were, 'outborn babies' ( P < 0.001), respiratory distress syndrome ( P = 0.007) and exchange transfusion ( P = 0.003). The sensitivity of the American and British screening guidelines to pick up threshold or worse ROP in our study group was 82.4% and 77.4% respectively. Conclusions : Severe ROP is often encountered in babies weighing greater than 1250 g at birth in developing countries. Western screening guidelines may require modifications before application in developing countries.

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Purpose: To study the prevalence of dry eye in a hospital-based population and to evaluate the various risk factors attributable to dry eye. Materials and Methods: In this cross-sectional study, 500 patients above 20 years of age were screened randomly for dry eye. A 13-point questionnaire, Lissamine Green test, Tear film break-up time (TBUT), Schirmer's test and presence of strands/filaments were used to diagnose dry eye. The diagnosis was made when at least three of the tests were positive. The role of air pollution, sunlight, excessive winds, smoking, drugs and refractive status as dry eye risk factors was assessed. Results: Ninety-two (18.4%) patients had dry eye. Dry eye prevalence was maximum in those above 70 years of age (36.1%) followed by the age group 31-40 years (20%). It was significantly higher ( P = 0.024) in females (22.8%) than in males (14.9%), more common in rural residents (19.6%) than in urban (17.5%) and highest among farmers/labourers (25.3%). A 2.15 fold increase was found in the odds for dry eye in those exposed to excessive wind, 1.91 fold to sunlight exposure, 1.42 to smoking, 1.38 to air pollution and 2.04 for persons on drugs. Dry eye prevalence was 14% in emmetropes, 16.8% in myopes and 22.9% in hypermetropes. It was 15.6% in those with corrected and 25.3% in those with uncorrected refractive errors. Conclusion: Dry eye is an under-diagnosed ocular disorder. Reduction in the modifiable risk factors of dry eye is essential to reduce its prevalence

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Coronavirus disease 2019 (COVID-19) is a form of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that has been declared a pandemic by the World Health Organization (WHO). Ocular manifestations related to COVID-19 are uncommon with conjunctivitis being reported in a few cases. We report a unique case of vasculitic retinal vein occlusion (RVO) secondary to COVID-19 in a 52-year-old patient who presented with the diminution of vision in the left eye 10 days after he tested positive for SARS-CoV-2. All investigations for vasculitis were negative. This case supports the mechanism of thrombo-inflammatory state secondary to the “cytokine-storm” as the pathogenesis for systemic manifestations of COVID-19.

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PURPOSE: To determine the epidemiologcial pattern and risk factors involved in suppurative corneal ulceration in Gangetic West Bengal, eastern India, and to identify the specific microbial agents responsible for corneal infections. METHODS: All patients with suspected microbial keratitis presenting to the corneal clinic at Disha Eye Hospital, Barrackpore, West Bengal, India, from January 2001 to December 2003 were evaluated. Sociodemographic data and information pertaining to the risk factors were recorded. After diagnosing infective corneal ulcer clinically, corneal scraping and cultures were performed. RESULTS: Over a three-year period, 1198 patients with suppurative keratitis were evaluated. Ocular trauma was the most common predisposing factor in 994 (82.9%) patients (P< 0.0001), followed by use of topical corticosteroids in 231 (19.28%) patients. Cultures were positive in 811 (67.7%) patients. Among these culture positive cases, 509 (62.7%) patients had pure fungal infections (P< 0.001), 184 (22.7%) patients had pure bacterial infections and 114 (14.1%) had mixed fungal with bacterial infections. Acanthamoeba was detected in 4 (0.49%) patients. The most common fungal pathogen was Aspergillus spp representing 373 (59.8%) of all positive fungal cultures (P< 0.0001), followed by Fusarium spp in 132 (21.2%) instances. Most common bacterial isolate was Staphylococcus aureus, representing 127 (42.6%) of all the bacterial culture (P< 0.0001) followed by Pseudomonas spp 63 (21.1%). CONCLUSION: Suppurative keratitis in Gangetic West Bengal, most often occurs after a superficial corneal trauma with vegetative or organic materials. Fungal ulcers are more common than bacterial ulcers. Aspergillus spp and Staphylococcus aureus were the most common fungus and bacteria respectively. These ′regional′ findings have important public health implications for the treatment and prevention of suppurative corneal ulceration in this region of India.

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Aim: The aim of this study is to ascertain the prevalence of diabetic retinopathy (DR) in diabetic patients across the nation and attempt to establish history-based risk factors. Materials and Methods: A cross-sectional study of diabetic patients was conducted as an initiative of the All India Ophthalmological Society from 14^th November to 21^st November 2014. Known diabetics were evaluated voluntarily by members of the society at 194 centers using a structured protocol provided by the society for examination. The results were evaluated to ascertain the prevalence of DR in the population studied and to establish relation with gender, age, and history-based risk factors such as duration of diabetes, insulin use, and other end-organ disease using the Chi-square test. Results: A total of 6218 known diabetics were screened. Totally, 5130 data entry forms were considered suitable for further evaluation. About 61.2% were males, 88.6% were between 40 and 80 years of age, almost two-thirds of the patients were from the west and south zones, and over half had diabetes more than 5 years. The data set was predominantly urban 84.7% and 46.1% had no family history. DR prevalence in the entire data set was 21.7%. Prevalence was more in males (P = 0.007), diabetics more than 5 years (P = 0.001), those above 40 years (P = 0.01), insulin users (P = 0.001), and history of vascular accidents (P = 0.0014). Significantly 22.18% of patients detected with DR had a vision of 6/18 or better in the worse eye. Conclusion: The study reiterated the findings of earlier regional studies on a pan Indian scale and put data in perspective.

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Aggressive posterior retinopathy of prematurity (formerly known as fulminate/type II/rush disease) occurs in zone 1 or posterior zone 2. Treatment involves extensive near confluent laser ablation of a large area of avascular retina. Anterior segment ischemia is a rare complication that can occur due to injury to the long posterior ciliary arteries in the horizontal meridians during aggressive posterior laser treatment. The outcome of this rare complication is very poor. This case describes a favorable outcome of intravitreal injection of bevacizumab (Avastin) in a case of anterior segment ischemia.

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Purpose: To evaluate the psychological impact of the COVID 19 crisis on ophthalmologists-in-training and practising ophthalmologists during lockdown in India. Methods: An online survey was completed by ophthalmologists and ophthalmology trainees during the lockdown. The information collected included demographics (age, gender), domicile (state, union territory), current professional status (in training or practising), type of practice (solo, group, institutional, governmental, non-governmental), marital status (married, single), impact of COVID-19 on their training or practice, and impact on income and ability to meet living expenses. Psychological distress was assessed using the Patient Health Questionnaire-9 (PHQ-9). Results: In all, 2,355 ophthalmologists responded. Mean age was 42.5 (range, 25-82 years; SD, 12.05) years. Of these, 1,332 (56.7%) were males; 475 (20.2%) were still not in practice; 366 (15.5%) were single; 1,244 (52.8%) felt that COVID-19 would impact on their training or professional work; and 869 (37%) had difficulty in meeting their living expenses. The mean PHQ-9 score was 3.98 (range, 0-27; SD, 4.65). In terms of psychological impact, 768 (32.6%) had some degree of depression; mild in 504 (21.4%), moderate in 163 (6.9%), and severe in 101 (4.3%). Multivariable analysis showed that depression was significantly higher at younger age. The odds of depression decreased by 3% with 1 year increase in age. It was higher in non-practicing ophthalmologists, especially those who were considerably worried about their training or professional growth, and those with difficulty in meeting living expenses. Conclusion: A strikingly high proportion of ophthalmologists are psychologically affected and may require personalized mental health care.

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Purpose: The aim of this study was to determine prevalence, symptoms frequency and associated risk factors of digital eye strain (DES) among children attending online classes during COVID-19 pandemic. Methods: The online electronic survey form was prepared on the Google app. Children/parents were asked to indicate the total duration of digital device use before and during COVID era. The symptoms of DES, its severity and frequency were recorded & measured with the Computer Vision Syndrome Questionnaire. Results: Two hundred and sixty one parents responded to the questionnaire, of these 217 were complete. Mean age of children was 13 ± 2.45 years. Mean duration of digital device used during COVID era was 3.9 ± 1.9 h which is more than pre COVID era (1.9 ± 1.1 h, P = <0.0001). 36.9% (n = 80) were using digital devices >5 h in COVID era as compared to 1.8% (n = 4) before COVID era. The most common digital device used were smartphones (n = 134, 61.7%). One hundred and eight children (49.8%) were attending online classes for >2 h per day. Prevalence of DES in our cohort is 50.23% (109/217). Of these 26.3% were mild, 12.9% moderate and 11.1% of severe grade. Most common symptoms were itching and headache (n = 117, 53.9%). Multivariate analysis revealed age >14 years (P = 0.04), male gender (P = 0.0004), smartphone use (P = 0.003), use of device >5 h (P = 0.0007) and mobile games >1 h/day (P = 0.0001) as independent risk factors for DES in children. Conclusion: There is an increased prevalence of DES among children in COVID era. Parents should be considerate about duration, type and distance of digital device use to avoid DES symptoms in children.

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