Purpose: The current classification of ocular trauma does not incorporate adnexal trauma, injuries that are attributable to a nonmechanical cause and destructive globe injuries. This study proposes a new classification system of ocular trauma which is broader-based to allow for the classification of a wider range of ocular injuries not covered by the current classification. Methods: A clinic-based cross-sectional study to validate the proposed classification. We analyzed 535 cases of ocular injury from January 1, 2012 to February 28, 2012 over a 4-year period in an eye hospital in central India using our proposed classification system and compared it with conventional classification. Results: The new classification system allowed for classification of all 535 cases of ocular injury. The conventional classification was only able to classify 364 of the 535 trauma cases. Injuries involving the adnexa, nonmechanical injuries and destructive globe injuries could not be classified by the conventional classification, thus missing about 33% of cases. Conclusions: Our classification system shows an improvement over existing ocular trauma classification as it allows for the classification of all type of ocular injuries and will allow for better and specific prognostication. This system has the potential to aid communication between physicians and result in better patient care. It can also provide a more authentic, wide spectrum of ocular injuries in correlation with etiology. By including adnexal injuries and nonmechanical injuries, we have been able to classify all 535 cases of trauma. Otherwise, about 30% of cases would have been excluded from the study.

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Several decades ago, penetrating keratoplasty was a challenge to corneal surgeons. Constant effort by the corneal surgeon to improve the outcomes as well as utilization of the available resources has led to a revolutionary change in the field of keratoplasty. All these efforts have led to the evolution of techniques that allow a corneal surgeon to disease-specific transplant of individual layers of corneal “so-called component corneal surgery” depending on the layer of cornea affected. This has led to an improvement in corneal graft survival as well as a better utilization of corneal tissues. This article reviews the currently available literature on component corneal surgeries and provides an update on the available techniques.

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Purpose: The purpose of this study was to review the incidence and microbiology of acute postcataract surgery endophthalmitis in India. Methods: Systematic review of English-language PubMed referenced articles on endophthalmitis in India published in the past 21 years (January 1992–December 2012), and retrospective chart review of 2 major eye care facilities in India in the past 5 years (January 2010–December 2014) were done. The incidence data were collected from articles that described “in-house” endophthalmitis and the microbiology data were collected from all articles. Both incidence and microbiological data of endophthalmitis were collected from two large eye care facilities. Case reports were excluded, except for the articles on cluster infection. Results: Six of 99 published articles reported the incidence of “in-house” acute postcataract surgery endophthalmitis, 8 articles reported the microbiology spectrum, and 11 articles described cluster infection. The clinical endophthalmitis incidence was between 0.04% and 0.15%. In two large eye care facilities, the clinical endophthalmitis incidence was 0.08% and 0.16%; the culture proven endophthalmitis was 0.02% and 0.08%. Gram-positive cocci (44%-64.8%; commonly, Staphylococcus species), and Gram-negative bacilli (26.2%–43%; commonly Pseudomonas species) were common bacteria in south India. Fungi (16.7%-70%; commonly Aspergillus flavus) were the common organisms in north India. Pseudomonas aeruginosa (73.3%) was the major organism in cluster infections. Conclusions: The incidence of postcataract surgery clinical endophthalmitis in India is nearly similar to the world literature. There is a regional difference in microbiological spectrum. A registry with regular and uniform national reporting will help formulate region specific management guidelines.

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Purpose: The purpose of this study was to evaluate the incidence and outcome of surgically treated superior oblique palsy (SOP) and the factors involved in its resolution. Methods: We performed a retrospective study of 76 patients who underwent surgery for SOP. We recorded data from the physical examination and the number and type of procedures performed. Favorable outcome was defined as resolution of or improvement in torticollis (≤5°) and diplopia in primary position (PP) and downgaze or as vertical deviation (VD) <5 prism diopters (pd) in PP and 10 pd in the oblique diagnostic position. Results: Mean age was 33.12 years. Congenital SOP was the most frequent type (65.8%). Mean preoperative VD was 15.89 ± 9.94 pd, decreasing to 3.07 ± 4.36 pd after surgery. Associated horizontal deviation was recorded in 51.32% of cases. The mean number of procedures was 1.37 ± 0.62 (range 1–4), with 69.7% of patients requiring only one procedure. The mean number of muscles operated on was 1.96 ± 1.01 (inferior oblique being the most frequent). A greater reduction in VD after surgery was observed in patients with congenital SOP (P = 0.04). Although none of the factors evaluated influenced surgical outcome, amblyopic patients had a greater risk of reoperation (P = 0.04). A favorable outcome was achieved in 75% of cases. Mean follow-up was 37.08 months. Conclusion: Congenital SOP was twice as frequent as acquired SOP and although surgery was successful in most cases, a greater reduction in VD was obtained in congenital cases. Amblyopia was identified as a risk factor for reoperation.

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Purpose: The aim of this study is to describe a modified technique of vertically split-conjunctival autograft (CAG) for primary double-head pterygium and evaluate its postoperative outcome. Methods: In this retrospective, noncomparative, interventional case series, 87 eyes of 87 patients of double-head pterygium from June 2009 to June 2015 were included. They underwent vertical split CAG. A limbus-limbus orientation was not strictly maintained. Primary outcome measure was recurrence rate. Other outcome measures studied were graft retraction, Tenon's granuloma, dellen, and so on. Results: Mean age was 54.54 ± 11.51 years; M:F was 41:46. Mean follow-up was 17.28 ± 10.28 months. The only significant complication was recurrence rate of 3.45% (3 eyes out of 87). Other most common secondary outcome was graft edema, 42.52% (37 eyes out of 87) which resolved without any intervention. Other outcomes such as graft retraction (31.03%), dellen (1.15%), Tenon's granuloma (3.45%), and subconjunctival hemorrhage (36.78%) were recorded. Conclusion: Modified vertical split CAG without maintaining limbus-limbus orientation, just large enough to cover the bare scleral defect, appears to be a successful technique with lower recurrence rate in treating double-head pterygium.

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Purpose: Comparison of conventional trabeculectomy (CT) and viscoelastic-augmented trabeculectomy (VAT) in primary open-angle glaucoma. Methods: A total of 65 primary open-angle glaucoma cases were taken for each of the two groups, i.e., CT and VAT. Viscoelastic-augmented trabeculectomy constituted lamellar scleral flap, deep scleral flap, penetrating trabeculectomy, peripheral iridectomy, filling of the anterior chamber with viscoelastic (sodium hyaluronate) and balanced salt solution, movement of visco in bleb, and tight flap closure. Success criteria included intraocular pressure (IOP) <14 mmHg with no devastating complications. P < 0.05 was considered statistically significant. Results: Mean IOP was significantly lower after VAT compared to CT at 6 weeks, 12 weeks, and 6 months postoperatively. Target IOP was achieved in 60% cases in VAT group compared to 36.92% in CT group. Conclusion: VAT is effective in reducing IOP to the target level for advanced glaucoma with lower postoperative complications.

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The most challenging step in sutureless scleral fixation of intraocular lens (SFIOL) is exteriorization of haptics. The conventional handshake technique has a learning curve since it involves intraocular handing over of haptics from one forceps to another. Here, we describe “extraocular needle-guided haptic insertion technique” (X-NIT), a novel technique of exteriorizing haptics that totally eliminates intraocular manipulations. This method involves sequential introduction of two bent 26-gauge needles through the sclera (pars plicata zone) into the eye which are brought out through a sclerocorneal wound. The intraocular lens haptics are threaded through these needles and exteriorized. Nineteen consecutive patients underwent surgery by this technique. There were no intraoperative complications. The mean best-corrected visual acuity (BCVA) of these patients at 1-month follow-up was 0.5 ± 0.3 (logarithm of the minimum angle of resolution) with 18 of 19 eyes showing one or more lines of improvement in BCVA. X-NIT is a safe, easy, cost-effective, and highly reproducible technique, especially for beginners.

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Purpose: The aim is to assess the prevalence, severity, and associations of back pain among Indian ophthalmologists. Methods: A self-reporting questionnaire was sent to ophthalmologists with valid e-mail addresses registered with the All India Ophthalmological Society. The survey was open for responses for 2 months. Results: A total of 651 (5.96%) responses were obtained; 394 (61%) males and 257 (39%) females. Half (50%) of responses were obtained from doctors belonging to 31–40 years' age group. Two hundred and thirty (35%) of the ophthalmologists had height ranging from 161 to 170 cm and 443 (68%) had weight ranging from 51 to 75 kg. Four hundred and eighty-one (73.8%) of the respondents had <15 years of ophthalmic experience. Cataract (346; 53.1%) and general ophthalmology (342; 52.5%) were commonly practised by the ophthalmologists. Time spent in the outpatient department (OPD) was 39.37 ± 16.32 h/week and in the operating theater 13.64 ± 9.89 h/week, respectively. Self-reported prevalence of back pain was 70.5%. Fully 49% of respondents had low back pain, followed by neck pain (33%) and upper extremity symptoms (16%). Age <50 years (odds ratio [OR] = 2.4485), female gender (OR = 2.0265), long working hours in OPD (OR = 1.6524), and performing retinal lasers and indirect ophthalmoscopy (OR = 3.3251) showed positive association with back pain. The intolerable back pain was noted in <7% of the respondents. Around 398 (61%) respondents felt that their back pain was exacerbated while doing work and 86.6% felt that up to 5 h/week was lost due to persistent backache. Yoga and some form of exercise (74.3%) was practised to alleviate back pain. Conclusion: Back pain symptoms appear to be common among ophthalmologists. Awkward posture and prolonged working hours are responsible for developing back pain among ophthalmologists. Performing yoga and regular exercises, modifications in instrumentation and creating a larger workforce of eye care practitioners are needed to prevent ophthalmologists from developing back pain.

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Traumatic globe dislocation into the maxillary sinus is a rare event and usually associated with a poor visual outcome if not managed appropriately. We report a 45-year-old female patient who presented to the emergency after blunt injury to her face with a door. Initial evaluation revealed nil perception of light and an apparently anophthalmic socket. Neuroimaging revealed large floor and medial wall fracture with dislocation of the globe into the maxillary sinus. The patient underwent exploration with repositioning of the globe and fracture repair. She was also administered 1 g intravenous methylprednisolone along with tapering course of oral steroids for 3 days. Patient's final visual acuity at 18 months of follow-up improved to counting fingers at 1 m. A thorough review of the literature suggests immediate surgery might improve the final visual outcome in such cases.

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Purpose: To identify the morbidity patterns causing blindness in children attending schools for the blind in Chennai and comparing our data with similar studies done previously. Methods: A cross-sectional prevalence study was carried out in two schools for the blind in Chennai. Blind schools were visited by a team of ophthalmologists and optometrists. Students with best-corrected visual acuity (BCVA) worse than 3/60 in the better eye were included and relevant history was noted. Every student underwent anterior segment evaluation and detailed fundus examination. Morbidity of the better eye was taken as cause of blindness. Health records maintained by the school were referred to wherever available. Results: The anatomical causes of blindness include optic nerve disorders in 75 (24.8%) cases, retinal disorders in 55 (18.2%), corneal disorders in 47 (15.6%), lens-related disorders in 39 (12.9%), congenital anomalies in 11 (3.6%), and congenital glaucoma in 20 (6.6%) cases. The whole globe was involved in six cases (1.99%). Among conditions causing blindness, optic atrophy seen in 73 (24.17%) cases was the most common, followed by retinal dystrophy in 44 (14.56%), corneal scarring in 35 (11.59%), cataract in 22 (7.28%), and congenital glaucoma in 20 (6.6%) cases. Conclusion: It was found that avoidable causes of blindness were seen in 31% of cases and incurable causes in 45%. Optic nerve atrophy and retinal dystrophy are the emerging causes of blindness, underlining the need for genetic counseling and low vision rehabilitation centers, along with a targeted approach for avoidable causes of blindness.

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Purpose: The purpose of this study is to assess the learning curve in the initial 100 cases of cataract surgery performed using femtosecond laser-assisted cataract surgery (FLACS) by experienced cataract surgeons without prior experience in femtosecond laser platform. Methods: This study was conducted at tertiary care eye hospital, South India. This was a prospective interventional study. The first 100 consecutive eyes undergoing FLACS were studied to understand docking time, number of docking attempts, problems encountered during docking, and complications attributable to docking. Phacoemulsification performed after femtosecond laser was also studied for complications, need for additional instrumentation, and total time required for surgery. Comparison was also made between two operating surgeons. Results: Successful docking was recorded in 70% eyes at the first attempt. Mean time taken for successful docking was 9.3 ± 6.4 min (median = 6 min, interquartile range (IQR) = 5–10 min, range = 4–35 min). When surgeries were divided into quartiles, docking time reduced significantly from 16.2 ± 7.9 min in the first quartile to 6.2 ± 2.7 min in the fourth quartile (P < 0.001). Phacoemulsification postdocking required 12.9 ± 6.2 min (median = 10 min, IQR = 9–17.5 min). Six eyes showed anterior capsular tags, one had radial extension of capsulorhexis, and two eyes showed pupillary miosis after femtosecond laser application. At 6 weeks, 79% eyes attained uncorrected vision of 20/20, and all eyes had best-corrected vision of 20/20. Conclusion: Approximately 25–30 cases were required before obtaining reproducible results with FLACS, irrespective of cataract surgical experience, suggesting that training programs must offer a minimum 25 surgeries. Very few complications occurred during the learning curve, making it patient friendly.

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Purpose: To evaluate the incidence, outcomes, and risk factors for hemorrhagic complications in eyes with polypoidal choroidal vasculopathy (PCV) following photodynamic therapy (PDT). Methods: Medical records of 94 eyes of 86 consecutive patients with PCV who underwent PDT between January 2007 and December 2014 were retrospectively reviewed. The diagnosis of PCV was based on clinical features and indocyanine green angiography. Eyes were treated with PDT monotherapy or a combination of PDT plus anti-vascular endothelial growth factor. PDT was performed at (standard [SFPDT] or reduced fluence RFPDT). Results: Ninety-four eyes had 119 PDT treatment sessions (mean: 1.3 sessions). Mean presenting vision was 0.46 ± 0.44 logarithm of the minimum angle of resolution (logMAR). Following PDT, ten eyes (11%) of nine patients had hemorrhagic complications such as subretinal hemorrhage (SRH; n = 5), subretinal pigment epithelium (RPE) hemorrhage (n = 1), breakthrough vitreous hemorrhage (BVH; n = 3), and SRH with sub-RPE hemorrhage and BVH (n = 1). Median interval to hemorrhage following PDT was 2 months. Age (P = 0.842), duration of symptoms (P = 0.352), number of laser spots (P = 0.219), and laser spot size (LSS) (P = 0.096) were not significantly associated with increased risk of hemorrhagic complications. Female gender was associated with reduced risk of hemorrhage (P = 0.045). SFPDT was significantly associated with increased risk of hemorrhage (P = 0.026). The probability of developing hemorrhagic complications in SFPDT group was 0.24 compared to 0.07 in RFPDT group (P = 0.039). Multivariate logistic regression analysis showed SFPDT as the only significant risk factor for hemorrhage following PDT (odds ratio 5.3, 95% confidence interval 1.1–24.8, P = 0.03). Mean final vision was 0.61 ± 0.53 logMAR at mean follow-up of 33 months (median = 22 months; range = 2–157 months). Conclusion: Age, LSS, number of laser spots, preexisting hemorrhages, or use of anticoagulants were not associated with increased risk of hemorrhagic complications. SFPDT was significantly associated with increased risk of hemorrhagic complications in such eyes.

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Purpose: The aim of this study was to explore the possibilities of acceptance of a ready-to-dispense spherical equivalent (SE) of spherocylindrical (SC) correction spectacles in rural India. Methods: Snellen visual acuity with SE power of refracted SC lenses was prospectively collected from all individuals visiting vision centers in Phase 1 (vision correction accuracy) of the study conducted in two South Indian districts. The satisfaction level was recorded by asking one standard question. The SE spectacles were dispensed in vision centers of one district in Phase 2 (SE acceptance) with a suggestion to return, if unsatisfied, for free exchange of spectacles within a month of dispensing. Results: In Phase 1, 929 of 3529 patients were refracted and it was found that 320 patients and one eye of one patient (641 eyes) had astigmatism. The average age was 41 (±16; range: 7–84) years. There was no reduction of visual acuity in SE of 0.25 Dcyl (100% satisfaction) and progressive decrease in satisfaction to 43%, 26%, and 19% with SE correction of 0.50, 0.75, and 1.00 Dcyl, respectively. In Phase 2, 988 of 6168 patients needed refraction and 240 had astigmatism. A total of 103 patients (206 eyes) accepted SE equivalent spectacles. No client returned for the free exchange of spectacles. Conclusion: Dispensing SE power up to 1 Dcyl in ready - made spectacles could be considered in remote rural populations in resource-poor economic conditions.

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Newly described retinoblastoma (RB) rosettes have various kinds of pathological significance. Some of their characteristics have been revealed in this immunohistochemistry study. Five paraffin-embedded eyeballs with RB and new rosettes were studied for neuron-specific enolase (NSE), p53, p16, BAX, c-Myc, glial fibrillary acidic protein, synaptophysin, and chromogranin. They were compared and interpreted using control specimens. NSE, P53, and P16 were significantly expressed in the cells of the new rosettes. The presence of new RB rosettes that mostly have histopathological high-risk factors and p53 positivity may be a strong marker of poor prognosis of RB.

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Purpose: This study aimed to evaluate the theoretical influence on intraocular lens power (P_IOL) calculation of the use of keratometric approach for corneal power (P_c) calculation in keratoconus and to develop and validate an algorithm preliminarily to minimize this influence. Methods: P_cwas calculated theoretically with the classical keratometric approach, the Gaussian equation, and the keratometric approach using a variable keratometric index (n_kadj) dependent on r_1c(P_kadj). Differences in P_IOLcalculations (ΔP_IOL) using keratometric and Gaussian P_cvalues were evaluated. Preliminary clinical validation of a P_IOLalgorithm using P_kadjwas performed in 13 keratoconus eyes. Results: P_IOLunderestimation was present if P_cwas overestimated, and vice versa. Theoretical P_IOLoverestimation up to −5.6 D and −6.2 D using Le Grand and Gullstrand eye models was found for a keratometric index of 1.3375. If n_kadjwas used, maximal Δ P_IOLwas ±1.1 D, with most of the values ≤±0.6 D. Clinically, P_IOLunder- and over-estimations ranged from −1.1 to − 0.4 D. No statistically significant differences were found between P_IOLobtained with P_kadjand Gaussian equation (P > 0.05). Conclusion: The use of the keratometric P_cfor P_IOLcalculations in keratoconus can lead to significant errors that may be minimized using a P_kadjapproach.

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We describe a case of a 13-year-old male patient of Coats' disease who developed sympathetic ophthalmia (SO) following contact diode laser cyclophotocoagulation. There was no history of invasive surgery or any perforating injuries preceding cyclodestructive therapy. The eye had neovascular glaucoma secondary to Coats' disease, which was treated once with contact cyclophotocoagulation. Subsequently, the intraocular pressure slowly decreased, and the eye became phthisical. Intraocular inflammation developed in the fellow eye and SO was suspected, which was confirmed by characteristic findings seen on fluorescein angiography. The case was successfully managed with the help of topical and systemic immunosuppression. Enucleation with silicone ball implantation was performed in the right phthisical eye and specimen was sent for histopathological examination. Histopathology and immunostaining supported the diagnosis of SO.

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A 37-year-old immunocompetent male patient presented with the blurring of vision, both eyes for the past1 year. Fundus examination revealed bilateral multiple subretinal abscesses with areas of healed serpiginous-like choroiditis. Laboratory investigations showed positive tuberculin skin test, positive QuantiFERON TB-Gold Test, and high resolution computed tomography chest showed enlarged mediastinal lymph nodes. The aqueous sample revealed polymerase chain reaction (PCR) positive for Mycobacterium tuberculosis (MTB) (MPB64 genome). He was treated antitubercular therapy (ATT) along with oral steroids. Although he responded well initially, he had recurrent inflammation and paradoxical worsening. This was managed with a high dose of intravenous corticosteroids, immune suppressive and ATT. He also had a diagnostic vitreous biopsy which was also PCR positive for MTB (IS6110 gene). He subsequently continued ATT along with corticosteroids and immune suppressive and responded well. We present this case report for its unusual presentation.

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Swept source optical coherence tomography-angiography (OCT-angiography) gives us a unique opportunity to study the vasculature of choroidal lesions in vivo. We describe the OCT angiographic characteristics of circumscribed choroidal hemangioma before and after laser photocoagulation. Medium-sized choroidal vessels/vessels on the tumor surface become predominantly visible after laser photocoagulation due to laser-induced damage to the overlying choriocapillaris. OCT-angiography adds a new dimension to in vivo analysis of vascular changes in choroid due to choroidal tumors and their response to therapy.

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Treatment guidelines for symptomatic polypoidal choroidal vasculopathy (PCV) have been described, but the management of recurrent or recalcitrant PCV is a challenge. The newer anti-vascular endothelial growth factor: aflibercept has shown promise in the treatment of both treatment naive and recalcitrant PCV in studies outside India. We present the minimum 6 months results of intravitreal aflibercept in recurrent and recalcitrant PCV in Indian eyes after multiple injections of bevacizumab/ranibizumab with or without photodynamic therapy. Of 10 eyes, 7 resolved of which 4 recurred needing continued aflibercept. Three of the ten eyes did not show a response. To the best of our knowledge, this is the first report from India in this challenging situation.

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Sympathetic ophthalmia (SO) is a rare, diffuse, bilateral, and granulomatous nonnecrotizing panuveitis that may follow intraocular penetrating trauma. Our aim is to report a rare case of SO following orbital exenteration. Orbital exenteration was performed on a 48-year-old african female due to conjunctival keratinizing squamous cell carcinoma with intraocular involvement of the left eye. Five days after the uneventful procedure, the patient presented signs and symptoms compatible with SO. Key differential diagnoses were excluded, and prompt and aggressive immunosuppression was started with a favourable but slow clinical response. This case highlights the fact that SO can also be induced by a neoplasm with intraocular invasion or by aggressive nonpenetrating surgery. While the underlying pathogenesis of SO is still not fully elucidated, we hereby contribute with a novel potential mechanism leading to its development.

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Purpose: To report the response of cavernous haemangioma of the disc to PDT. Methods and Patients: A 32 years old lady presented to us with complaints of sudden onset of blurry vision in her right eye. What seemed initially as polypoidal choroidal vasculopathy turned out as cavernous haemangioma of the disc after pneumatic displacement of the sub-retinal haeme. She was treated with PDT as she was prone to recurrent haemorrhage from the lesion due to her low platelet count. Results: Complete regression of the cavernous haemangioma was noted as early as the second week itself and remained regressed for 4 months. Conclusion: PDT can be safe option for patients presenting with symptomatic cavernous haemangioma of the disc or retina.

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