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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Keratoconus is an ectatic corneal disease characterized by progressive stromal thinning, irregular astigmatism, and defective vision. It can be unilateral or bilateral with asymmetric presentation. It starts at puberty and either progresses rapidly to an advanced stage of the disease or stops in case of delayed onset and slow progression. Pediatric keratoconus is more aggressive than in adults and the management protocols differ because of various rationales such as accelerated progression, advanced stage of disease at the time of diagnosis and co-morbidities. It poses a burden to the society as it affects the quality of life, social, and educational development in children. Hence early diagnosis, recognition of progression, and timely intervention with collagen crosslinking is imperative to arrest the worsening. Association with systemic syndromes and ocular comorbidities can be of concern in pediatric keratoconus. Severe ocular allergy when associated hastens progress and complicates timely intervention of crosslinking treatment and compliance to contact lens wear. Keratoplasty in pediatric keratoconus has good outcomes but can encounter frequent suture-related concerns. This article discusses the epidemiology, etiopathogenesis, clinical challenges, and current perspectives of management of pediatric keratoconus.

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Purpose: The objective of this study was to identify and validate smartphone-based visual acuity (VA) apps that can be used in a teleophthalmology portal. Methods: The study was conducted in three phases: A survey to investigate if the SmartOptometry App was easy to download, understand and test (phase I), an in-clinic comparison of VA measured in a random testing order with four tools namely COMPlog, Reduced Snellen near vision, Peek Acuity (Distance VA) and SmartOptometry (Near VA) (phase II) and a repeatability study on these 4 tools by measuring VA again (phase III). The study recruited the employees of our institute and adhered to the strict COVID-19 protocols of testing. Results: Phase I Survey (n = 40) showed 90% of participants used android phones, 60% reported that instructions were clear, and all users were able to self-assess their near VA with SmartOptometry App. Phase II (n = 68) revealed that Peek Acuity was comparable to COMPlog VA (P = 0.31), however SmartOptometry was statistically significantly different (within 2 log MAR lines) from Reduced Snellen near vision test, particularly for young (n = 44, P = 0.004) and emmetropic (n = 16, P = 0.04) participants. All the 4 tests were found to be repeatable in phase III (n = 10) with a coefficient of repeatability ≤0.14. Conclusion: Smartphone-based apps were easy to download and can be used for checking patient's distance and near visual acuity. An effect of age and refractive error should be considered when interpreting the results. Further studies with real-time patients are required to identify potential benefits and challenges to solve.

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Purpose: To compare the efficacy and safety of Alcaftadine 0.25%, Olopatadine hydrochloride 0.2%, and Bepotastine besilate 1.5% ophthalmic solutions in the treatment of allergic conjunctivitis. Methods: This is a prospective, observer-masked, comparative study of 180 patients with mild to moderate allergic conjunctivitis, randomized into three groups of 60 patients each. Each group was assigned to be treated with one of the three treatment options namely Alcaftadine 0.25%, Olopatadine hydrochloride 0.2% and Bepotastine besilate 1.5% ophthalmic solutions. Patients were followed-up at regular intervals with relief and resolution of symptoms and signs noted using Total Ocular Scoring System (TOSS) and hyperaemia scale. Results: All three topical medications were effective in resolving symptoms of the patients with mild to moderate allergic conjunctivitis. Baseline mean TOSS scores for Alcaftadine group, Olopatadine group and Bepotastine besilate group were (7.68±2.32), (7.65±2.32) and (7.45±2.27) respectively as compared to the corresponding TOSS scores on 14^th Day (4^th visit) which were (0.2 ± 0.43), (0.4 ± 0.56) and (0.1 ± 0.36) respectively. The resolution of symptoms in the Bepotastine and Alcaftadine groups was significantly profound as compared to the Olopatadine group (p = 0.008). Bepotastine and Alcaftadine groups significantly reduced allergic conjunctivitis symptoms compared to Olopatadine group (p = 0.008). Conclusion: All three topical ophthalmic medications used in the study are safe and effective in the treatment of allergic conjunctivitis. However, Bepotastine and Alcaftadine appear to outweigh Olopatadine in resolving the symptoms of allergic conjunctivitis.

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Purpose: The aim of this study was to evaluate the efficacy and safety of Razumab (the biosimilar Ranibizumab by Intas Pharmaceuticals Ltd.) for the treatment of chorioretinal vascular diseases such as diabetic macular edema (DME), choroidal neovascular membrane (CNVM), and macular edema secondary to retinal vein occlusion (RVO). Methods: We conducted a single-center, retrospective study, including patients with DME, CNVM, and RVO, who had received treatment with Razumab® between October 2018 and September 2019. Primary outcome measures were the changes in corrected distance visual acuity (CDVA) and central foveal thickness (CFT) from baseline to 1 month and 3 months. Secondary outcome measures included intraocular pressure (IOP) at day 1, any signs of ocular inflammation or systemic adverse events during the follow-up. Results: One hundred and fifty-three eyes of 141 patients were analyzed. The indications included DME in 70 (45.8%) eyes, CNVM in 70 (45.8%) eyes, and RVO in 13 (8.4%) eyes. Mean CDVA improved from baseline (0.62 ± 0.44) to month 1 (0.45 ± 0.42) and maintained till 3 months (0.42 ± 0.44; P < 0.001). Mean CFT showed significant reduction from baseline (405.68 ± 192.422 μm) to month 1 (286.08 ± 118.36 μm) and month 3 (271 ± 104.24 μm; P < 0.001). None of the eyes recorded IOP >20 mmHg on day 1. No evidence of ocular toxicity or systemic adverse event was noted. Conclusion: Razumab® showed a rapid improvement in CDVA and CFT in most of the eyes with efficacy observed as early as 1 month and maintained till 3 months. The biosimilar Ranibizumab can be a safe and effective low-cost drug for treating macular diseases.

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Giant cell arteritis (GCA) is the most important medical emergency in ophthalmology, because its most dreaded complication is visual loss, which is preventable if these patients are diagnosed early and treated immediately and aggressively. This is a brief review of GCA, its ophthalmic manifestations, and how to diagnose and manage them.

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Purpose: The aim of this study was to assess the impact of an audio visual (AV) teaching module on basic torchlight examination of the eye and direct ophthalmoscopy for undergraduate medical students. Methods: This observational longitudinal study was done on 33 consecutive medical interns during their Ophthalmology posting from December 2019 to March 2020 at a medical college in South-India. An AV-module was created using animation graphics, narratives, demonstrations on normal individuals and on patients with positive signs. All interns had a pretest consisting of Multiple-choice questions, (MCQs) and an Objective Structured Clinical Examination (OSCE) on torchlight examination and direct ophthalmoscopy (DO). They were then shown the 20-minute AV-module. A posttest was performed immediately and after one week. Results: The mean pretest MCQ score was 5.84 ± 1.98. It improved to 8.81 ± 1.15 in the immediate posttest and 8.87 ± 1.66 in the one-week posttest. The mean pretest OSCE score was 12.21 ± 3.39. It improved to 23.21 ± 3.39 in the immediate posttest and 23.90 ± 3.7 in the one-week posttest. Using Generalized Estimating Equation, MCQ score improved by 2.97 units and 3.03 units and the OSCE score improved by 11 units and 11.69 units in the immediate posttest and one-week posttest respectively when compared to the pretest corresponding to the MCQ score and OSCE score (p < 0.001). Conclusion: AV teaching modules-for torchlight examination and DO has a significant benefit in improving knowledge and skill in undergraduate medical students. These significant results have the great translatory capacity in the current COVID-19 pandemic, where physical demonstrations involving close proximity and groups of students are highly risk prone.

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Purpose: The study aimed to investigate the changes in choroidal thickness (CT), retinal nerve fiber layer thickness (RNFL), and visual field parameters in morbidly obese patients following bariatric surgery. Methods: The study included 40 morbidly obese patients with body mass indexes (BMI) ≥40 who had undergone bariatric surgery (Group 1) and 40 age-and sex-matched healthy subjects with normal BMI values (Group 2). RNFL and CT measurements by optical coherence tomography (OCT) and visual field test were performed preoperatively and the 1^st, 6^th, and 12th months postoperatively. CT measurements were obtained from the subfoveal, nasal (N), and temporal (T) regions at distances of 500 μm and 1,000 μm from the fovea. Results: No significant pathology was detected during ophthalmological examinations following bariatric surgery. The BMIs were found to be significantly lower in all of the periods after bariatric surgery (P < 0.0001). The CT measurements decreased significantly in all periods after bariatric surgery (P < 0.0001). No differences were found in terms of the mean RNFL thicknesses in all postoperative periods (P = 0.125). Visual field tests showed no significant changes during scheduled visits. (P = 0.877). No visual field defect was detected in any patient during the follow-up periods after bariatric surgery. Conclusion: These results have suggested that CT is positively correlated with BMI and decreased with a reduction in BMI progressively. Nutritional disorders resulting from malabsorption have not caused any nutritional optic neuropathy and visual field defect for at least the first postoperative year after bariatric surgery.

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A 36-year-old male underwent uneventful small incision lenticule extraction (SMILE) for the correction of his high residual refractive error 12 years after photorefractive keratectomy (PRK). Preoperatively, uncorrected distance visual acuity (UDVA) was counting fingers in both eyes. Corrected distance visual acuity was 20/20 in the right and 20/30 in the left eye due to amblyopia. One month after SMILE, UDVA was 20/20 and 20/30 in the right and left eye, respectively; post-PRK corneal haze had reduced. During the 4-year follow-up, UDVA remained stable and there were no complications. SMILE could be a good alternative approach for retreatment in post-PRK patient.

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Wet labs are an extremely important training tool, especially in times of a global COVID-19 pandemic, where surgical training can be minimal. They help the trainee learn and practice in a risk-free environment, without an imminent of a complication or failure, also allowing them the chance to execute the steps of a surgery repeatedly. We summarize all the key ingredients required from setting up a wet lab to improve the surgical skill of the trainees. The review also discusses various eyeball fixating devices, preparation of the eye for various types of ocular surgeries, and the role of simulation-based training in today's scenario.

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To determine the effect of commonly used intravitreal agents on immediate and long-term IOP elevations and their association, if any, with glaucoma. Literature searches in PubMed and the Cochrane databased in January 2020 yielded 407 individual articles. Of these, 87 were selected for review based on our inclusion criteria. Based on the evidence provided, 20 were assigned level I, 27 level II, and 22 level III. Eight articles were rejected because of poor quality, insufficient clarity, or irrelevance based on standardized protocols set out by the American Academy of Ophthalmology. The studies that reported on short-term IOP elevation (i.e., between 0 and 60 min) showed that an immediate increase in IOP is seen in all patients who receive anti-VEGF agents or triamcinolone acetonide when measured between 0 and 30 min of intravitreal injection and that the IOP elevation decreases over time. The data on long-term IOP elevation were mixed; Pretreatment with glaucoma medications, anterior chamber tap, vitreous reflux, longer intervals between injections, and longer axial lengths were associated with lower IOP elevations after injection of anti-VEGF agents, while the position of the implant vis-à-vis, the anterior chamber was important for steroid therapy. Data were mixed on the relationship between IOP increase and the type of intravitreal injection, number of intravitreal injections, preexisting glaucoma, and globe decompression before injection. There were no data on the onset or progression of glaucoma in the studies reviewed in this assessment. However, some studies demonstrated RNFL thinning in patients receiving chronic anti-VEGF therapy. Most, if not all, intravitreal agents cause ocular hypertension, both in the short term and long term. The functional consequences of these observations are not very clear.

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Purpose: The aim of this study was to describe a poly-vinyl chloride air condition (PVC AC) curtain shield placed at the intervening space between the chin rest and the illuminating and optical arm of the slit lamp microscope (distal barrier) instead of the present position at the oculars (proximal barrier) to guard against severe acute respiratory syndrome Coronavirus 2. This experimental study was done to validate and compare the protection offered by the conventional breath shields and the one described by us in a simulated environment. Methods: In this experimental study, 12 puffs of fine mist were sprayed over a period of 1 minute using “magenta-colored dye” and “cyan-colored dye” for analyzing proximal barrier and distal barrier respectively. To access the amount of contamination of the slit lamp, caused by sprayed “magenta” and “cyan” colored dye, we covered the entire slit lamp with appropriately sized white-colored cotton sheet. The stained sheets were individually photographed and then the images were first cropped, then color threshold adjusted and then converted to binary and finally fraction of surface area stained was calculated using the ImageJ software. (P_n Surface Area _{magenta fraction} (%) during analysis of “proximal barrier” and P_n Surface Area _{cyan fraction} (%) during the analysis of “distal barrier”, where P_n refers to various parts of slit lamp. Results: The entire surface area of the cloth covering the slit lamp was 9912.45 cm². The surface area of the cloth which was stained when using the “proximal barrier” was 567.50 cm² whereas when using the “distal barrier” was 222.93 cm². When using proximal barrier, 97.71% of the staining was present on the slit lamp base, viewing arm, illumination arm and the pivot of the slit lamp. While using the distal breath shield no parts of the viewing arm, illumination arm, the pivot or the mechanical base with joystick were stained. Conclusion: The novel PVC AC curtain shield provides better barrier against the simulated contaminated stream of patient's breath directed towards the working parts of the slit lamp as compared to conventional slit lamp oculars mounted breath shields.

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Purpose: Health care workers are susceptible to contracting infection with COVID-19 by aerosol transmission. This is a risk while examining and/or treating an un-sedated neonate in retinopathy of prematurity (ROP) screening and treatment. But screening for neonates for ROP and treating with laser, when required, should not be delayed to avoid the blindness. We describe a cost-effective method of containing aerosols generated during such a procedure in an un-sedated baby. Methods: An acrylic transparent containment box was prepared to accommodate an average-sized infant. The box had four walls and a roof. The floor was open to place the container box over the baby. The walls have two types of openings, large ones to allow passage of hands to examine the baby, small ones to enable passage of oxygen tubing when required. A simulation was created to examine the impact of aerosol spray on examining healthcare personnel. Results: The cost of the acrylic box was negligible. It could be assembled locally with available acrylic sheets and craftsmen. It was not difficult to examine the baby inside the box, and the simulation demonstrated that it protected the health personnel from the aerosol contamination. Conclusion: The described method is likely to increase healthcare personnel's confidence not to delay or deny ROP screening and laser treatment and save the babies from blindness.

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Purpose: The aim of this study was to formulate a methodological approach for resuming eye bank services during COVID-19 pandemic. Methods: Eye bank operations were temporarily halted in March after the government-mandated “Lockdown” in response to COVID-19 pandemic. Before restarting eye bank operations in May, we studied sources of exposure, performed risk assessment, instituted additional process validations and redefined the Standard Operating Procedures (SOPs) in consultation with the guidelines published by the Eye bank Association of India and All India Ophthalmological Society. The eye bank staff were rigorously trained before and after operations were restarted. We conducted a survey at the end of July to gauge staff attitude and reaction. Results: Eye banks services resumed on 20^th May 2020. Since reopening till the end of July total 41 keratoplasties have been done. 91.75% of all keratoplasties done were therapeutic surgeries and 17% of the surgeries were done using glycerine preserved tissues. No staff had COVID-19 symptoms when the operations restarted and none developed symptoms up to the end of July. All eye bank staff were aware of COVID-19 pandemic and 86% said they felt safe working at the eye bank. 86% of the staff said that they received adequate training and 66% of the staff expressed that they always received proper PPE and kits. Overall, 93% of the staff expressed that the measures taken by the eye bank ensured their safety. Conclusion: Based on our experience we suggest the following activities for planned resumption of eye bank services during the pandemic: Exposure Risk Analysis, Personal Protective Equipment usage training, SOP Revision and staff training on modified SOPs. Criteria based selection of donor sources, participatory planning involving the staff and double-checking at critical process junctions helped us in managing a smooth transition.

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Purpose: The aim of this study was to present the outcomes of the 2018 and 2020 Vitreo-retinal Society of India (VRSI) biosimilars of anti-vascular endothelial growth factor (VEGF) (VIBE) surveys. Methods: An online survey of members of VRSI was conducted in July 2018 and January 2020 regarding their practice-patterns on anti-VEGF biosimilars pertaining to safety, efficacy, pricing, and need for enhanced clinical trials before regulatory approval. Results: In 2018, 112 VRSI members participated, whereas in 2020, 98 society members participated. In both surveys, majority of respondents were aware of biosimilars (96%, 2018 vs. 100%, 2020; P = 0.9) and felt that approval of biosimilar drugs should be made more stringent with larger clinical trials (89%, 2018 vs. 91%, 2020; P = 0.93). An increase in use of ranibizumab-biosimilar (41%, 2018 to 56%, 2020; P = 0.2) and a simultaneous significant decline in use of bevacizumab-biosimilar (9%, 2018 to 2%, 2020; P = 0.04) was noted from 2018 to 2020. From 2018 to 2020, the proportion of respondents satisfied with safety (61% to 68%; P = 0.59) and efficacy (65% to 81%; P = 0.32) of ranibizumab-biosimilar increased. However, during the same period, we noted in reduction in satisfaction levels with safety of bevacizumab-biosimilar (30% to 25%; P = 0.54), whereas satisfaction with its efficacy was stable (29% vs 30%; P = 0.99). A substantial proportion of retina specialists considered that current cost of ranibizumab-biosimilar ($130) was sufficiently low for it to be used as a substitute for Avastin (37%, 2018 and 40%, 2020; P = 0.82). Conclusion: The VRSI surveys reveal that Indian vitreoretinal specialists are familiar with anti-VEGF biosimilars. There was a progressive trend favoring ranibizumab-biosimilar over bevacizumab-biosimilar. One-third of the participants deem the current price of ranibizumab-biosimilar as appropriate to replace Avastin. Simultaneously, the need for enhanced pharmacovigilance and larger clinical trials are warranted for regulatory approval of these agents.

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Purpose: A sub-population of patients with diabetic macular edema (DME) responds less effectively to off-label use of Bevacizumab. Approval of Aflibercept for DME has offered Bevacizumab nonresponders an alternative therapeutic option. Herein, we investigate the anatomical and functional changes associated with Aflibercept treatment in Bevacizumab nonresponders with chronic DME in a Canadian setting. Methods: A retrospective study of eyes with persistent DME that were switched to Aflibercept due to nonresponse following ≥6 consecutive monthly Bevacizumab injections was performed. Anatomical and functional changes and the predictors of response were assessed using patients' characteristics prior to receiving their first (baseline) and seventh consecutive Aflibercept injections (follow-up). Results: Twenty-four eyes were included, with a mean age of 63.9 ± 10.7 years, an average of 16.8 ± 8.5 Bevacizumab injections prior to switching to Aflibercept, and mean follow-up duration of 11.8 ± 1.7 months following switching to Aflibercept. Best-corrected visual acuity (BCVA) improved significantly from 0.49 ± 0.13 to 0.41 ± 0.11 logMAR (P < 0.001) and central subfield thickness (CST) decreased by 119.4 μm from 409.4 ± 85.8 μm to 290.0 ± 64.5 μm (P < 0.001), with 50% of eyes showing complete anatomical response. Worse BCVA and higher CST at baseline predicted greater vision improvements (P = 0.001 and P = 0.035, respectively) while a larger decrease in CST was associated with greater baseline CST (P = 0.001) and better glycemic control (P = 0.039). Conclusion: Our data from a real-world clinical setting highlight the efficacy of Aflibercept as an alternative therapeutic option for DME recalcitrant to Bevacizumab, with potential additional benefit to those with worse vision, greater CST, and better glycemic control at baseline.

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Purpose: The current pandemic of COVID-19 has made airway procedures like intubation and extubation, potential sources of virus transmission among health care workers. The aim of this work was to study the safety profile of combined ketamine and regional anesthesia in pediatric ocular surgeries during the COVID-19 pandemic. Methods: This prospective study included pediatric patients undergoing ocular surgery under general anesthesia from April to October 2020. Children were premedicated with oral midazolam (0.25–0.50 mg/kg) or intramuscular ketamine (7-10 mg/kg), ondensetron (0.1 mg/kg) and atropine (0.02 mg/kg). Anesthesia was achieved with intravenous ketamine (4–5 mg/kg) and local anesthesia (peribulbar block or local infiltration). The patient's vital signs were monitored. Serious complications and postoperative adverse reactions related to anesthesia were documented. Results: A total of 55 children (62 eyes) were operated. Lid tear was the most common surgical procedure performed [n = 18 (32.7%)]. Dose of ketamine needed ranged from 30 to 120 mg (66.67 ± 30.45). No intubation or resuscitation was needed. Four children complained of nausea and two needed an additional dose of intravenous ondansetron due to vomiting in the post-operative period. Incidence of postoperative nausea and vomiting was not affected by age, duration of surgery or dose of ketamine used (P > 0.05). There was no correlation between increase in pulse and dose of ketamine. Conclusion: Combined ketamine and regional anesthesia is a safe and effective alternative to administer anesthesia in a child during ocular surgeries.

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Purpose: Multiple-choice questions (MCQs) are useful in assessing student performance, covering a wide range of topics in an objective way. Its reliability and validity depend upon how well it is constructed. Defective Item detected by item analysis must be looked for item writing flaws and optimized. The aim of this study was to evaluate the MCQs for difficulty levels, discriminating power with functional distractors by item analysis, analyze poor items for writing flaws, and optimize. Methods: This was a prospective cross-sectional study involving 120 MBBS students writing formative assessment in Ophthalmology. It comprised 40 single response MCQs as a part of 3-h paper for 20 marks. Items were categorized according to their difficulty index, discrimination index, and distractor efficiency with simple proportions, mean, standard deviation, and correlation. The defective items were analyzed for proper construction and optimized. Results: The mean score of the study group was 13.525 ± 2.617. Mean difficulty index, discrimination index, and distractor efficiency were 53.22, 0.26, and 78.32, respectively. Among 40 MCQs, twenty-five MCQs did not have non-functioning distractor; 7 had one, 5 had two, and 3 had three. Of the 20 defective items, 17 were optimized and added to the question bank, two were added without modification, and one was dropped. Conclusion: Item analysis is a valuable tool in detecting poor MCQs, and optimizing them is a critical step. The defective items identified should be optimized and not dropped so that the content area covered by the defective item is not kept of the assessment.

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Purpose: The objective of this study was to analyze the role of neuroimaging and documenting various intracranial pathologies in primary and secondary hemifacial spasm. Methods: This retrospective study included patients with HFS who had undergone neuroimaging. The demographic profile, onset, progression, neuroimaging findings, and types of HFS were documented and analyzed. Results: A total of 202 patients (male = 110, female = 92) were included. The mean age of the study population was 51.81 ± 11.76 years. The right side was involved in 104 patients, the left side was involved in 97 patients and bilateral involvement was observed in one patient. Primary HFS: secondary HFS was 9.6:1. The mean age of onset of the spasms in the primary HFS group was 49.26 ± 8.35 years and in secondary HFS was 43.13 ± 12.12 years respectively. The anterior inferior cerebellar artery was the major vessel causing neurovascular conflict in primary HFS (n = 55). Facial nerve palsy was the most common cause (n = 13) of secondary HFS followed by cerebellopontine angle (CPA) tumors. Conclusion: The hemifacial spasm occurs mostly in the fifth decade of life. Primary HFS is more prevalent than secondary HFS. Clinical distinction between them is difficult. Neuroimaging is essential to detect the conflicting vasculature in cases of primary HFS and pathologies like CPA tumor, cyst, and aneurysms in cases of secondary HFS.

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Purpose: Congenital corneal anesthesia (CCA) is a rare clinical entity that poses a diagnostic dilemma, particularly in the pediatric age group with very little literature on this. Accurate initial diagnosis, evaluation, early identification of risk factors, aggressive systemic workup, and appropriate therapy are paramount to prevent visual loss due to long-term complications of corneal anesthesia. The purpose of the study was to estimate and compare the corneal neural architecture using real time, in vivo confocal microscopy (IVCM) in patients with CCA as against a control population. Methods: This was a retrospective nonconsecutive, comparative clinical case series in a tertiary hospital in South India from June 2015 to December 2018. Methods: IVCM was accomplished in cooperative children in whom central cornea was relatively clear. The clearest three to five images from each eye were selected, and the nerves were analyzed for length, thickness, density, dichotomous pattern, and beading. Statistical analysis was done using Origin v7.0 (Origin Lab Corporation, Northampton, MA, USA). Results: In total, 15 eyes of 11 cases and 20 eyes of 10 controls were imaged. Measurements on corneal nerve density showed a significant difference (P = 0.0005), cases having a lower mean (3.85 ± 1.38 mm per mm²) compared to the controls (6.74 ± 1.75 mm per mm²). Measurements on corneal nerve length (P = 0.28), thickness (P = 0.45), and presence of beading (P = 0.97) and dichotomous pattern (P = 0.07) did not reveal a significant difference between cases and controls. Conclusion: There is a strong relationship between the functional loss (absent corneal sensation) and anatomical decrease (reduced subbasal nerve density) of corneal nerves in congenital corneal anaesthesia.

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The current practice for low vision management in India exclusively focuses on clinical aspects without much of the rehabilitation components. While making all efforts to improve independent living skills, daily living activities, and quality of life as a whole for people living visual disabilities, vision rehabilitation is an indispensable component. There is no single appropriate low vision and rehabilitation model implementable at health care institutions in the country to cover these fundamental aspects of a visually impaired individual. We did a literature review to know the existing practices of low vision and various disability models. The purpose of the review is to discern any pitfalls and shortcomings in managing visually disabled in India and to underpin the credibility and feasibility as well as suitability of the developed model. The review was done using search key terms low vision, current practices, visual disability, disability models, vision rehabilitation, and service delivery. Therefore, the article discusses the development of an inclusive low vision management model name as “Clinico-Social Model”, which we consider the most appropriate for the best management of people with vision loss. The primary aim of this model is to provide both clinical and vision rehabilitation components of management for people with visual disabilities. Such an approach is likely to have the potential to improve the quality of life of people with vision loss and can provide practical guide to eye care managers across India. Given the specific context in the current practices of low vision in India, it is desirable to design a similar model to care for the visually disabled.

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Purpose: Perioperative inadvertent hypothermia (PIH) is the decrease in core temperature below 36°C. We aimed to assess whether PIH develops in patients operated under local anesthesia (ULA) for vitreoretinal surgery in the operating room and investigate active warming efficacy. Methods: Seventy-two patients were divided into two groups: Group 1 contained unwarmed patients (n = 36), and Group 2, warmed patients (n = 36). The core temperatures, heart rate (HR), and mean arterial pressure (MAP) of the patients were measured at the beginning of surgery, after 20 min, 40 min, 1 h, at the end of the operation, and during the postoperative period. Results: PIH incidence was 44.6% in Group 1, whereas no hypothermia was observed in Group 2. Patient temperatures at 20 min (P = 0.001), 40 min (P < 0.001), 1 h (P < 0.001), the end of the operation (P < 0.001), and the postoperative period (P < 0.001) were significantly higher in Group 2 than in Group 1. Patient HRs at the end of the operation and during the postoperative period were significantly lower in Group 2 (P = 0.005) than in Group 1 (P < 0.001). The intraoperative 40^th (P = 0.044) and 60^th (P < 0.001) minutes, end of operation (P < 0.001), and postoperative MAP (P < 0.001) values of Group 1 were significantly higher than those of Group 2. Conclusion: PIH may develop in patients operated ULA, especially with a low ambient temperature. Actively warming may help prevent the harmful effects of PIH.

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Purpose: The purpose of this study is to study single surgery reattachment rate, refractive shift, surgical time, cost, and complications of pneumoretinopexy (PR) compared to scleral buckling (SB) in rhegmatogenous retinal detachments (RRDs) with superior breaks. Methods: Data of RRD with superior breaks, from 2013 through 2016, treated either with PR or SB surgery at a tertiary eye-care center were retrospectively reviewed. Treatment outcomes, procedural costs, refractive shift, surgical time, and complications, namely, cataract and glaucoma, were analyzed. Results: Thirty-two cases treated by PR (n = 15) and SB surgery (n = 17) fulfilled the selection criteria. Macula off RRD (91%) was the commonest presentation. Baseline parameters like duration of vision loss, presenting vision, and ocular characteristics were comparable. Single surgery retinal reattachment (66.7% PR vs. 76.5% SB) was analogous (P = 0.698). Retinal reattachment with secondary intervention was achieved in all cases at the last follow-up. Average vision gain in logMAR of 0.8 in PR and 0.6 in SB was not significantly different (P = 0.645) between the two groups, with SB group having a 1.9 Dioptre myopic shift and PR group none. Surgical time was shorter in PR versus SB at 15 versus 85 min and surgical cost (including additional surgery) was 50% less in PR. Complications like cataract progression (P > 0.99) and glaucoma (P = 0.71) were analogous among the groups. Horse-shoe tears were associated with failed primary surgery in 60% of PR and 75% of SB procedures. Conclusion: In RRDs secondary to superior breaks, PR proved to be faster, more economical, and less tissue manipulative than scleral buckle surgery, with equivalent efficacy and safety profile.

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Purpose: The aim of this study was to evaluate the efficacy and safety of intravitreal moxifloxacin injections in the treatment of acute post-cataract surgery endophthalmitis with visual acuity equal to or greater than hand movements. Methods: Fifty two patients with post-cataract surgery endophthalmitis who presented within 6 weeks with visual acuity equal to or greater than hand movements received two intravitreal moxifloxacin injections 48 h apart. Patients with prior history of ocular disease or treatment were excluded. Patients were followed up to 3 months either for resolution of endophthalmitis or worsening of disease. Number of patients who achieved visual acuity equal to or better than 20/40 and 20/200 at the third-month follow-up visit were compared with the number of patients at presentation, using Chi-square test. In addition, pretreatment LogMAR visual acuity at the time of presentation was compared with posttreatment visual acuity at end of third month using paired t test. Results: Fifty (96.15%) patients showed complete resolution of endophthalmitis while three patients required vitrectomy. Forty-one (78.85%) and 49 (94.23%) patients achieved visual acuity equal to or better than 20/40 and 20/200, respectively, at the third-month follow-up visit as compared to eight (15.38%) and 13 (25%) patients, respectively, at presentation (P < 0.05). In addition, mean LogMAR visual acuity at the time of presentation was 0.755 which improved to 0.307 at the third-month follow-up visit (P < 0.05). None of the patients developed hypersensitivity reactions to intravitreal moxifloxacin. Conclusion: Intravitreal moxifloxacin injections showed promising results in acute post-cataract surgery endophthalmitis.

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Scleral-fixated intraocular lens implantation in an important tool in the armamentarium of an ophthalmologist for managing aphakia. Various techniques have been described in the literature with variable learning curves. Herein, we describe an easy, fast, reproducible technique; the “MYX” technique, which utilizes the advantages of both the Yamane and the X-NIT technique, where the handshaking of the prolene haptic of a 3-piece PMMA IOL into the lumen of a 26-gauge needle is done externally (like in X-NIT technique), and the exteriorized haptic is cauterized to form a flange transconjunctivally, thereby avoiding the scleral pocket tucking (like Yamane technique), to achieve excellent surgical outcomes.

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Purpose: The objective of this study was to evaluate an OPD-based Lying down looking down (LDLD) test for the assessment of patient suitability for assisted topical anesthesia (ATA) during manual small incision cataract surgery (MSICS), and to compare it with assisted local anesthesia (ALA). Methods: The LDLD test was carried out during preoperative assessment of 250 consecutive patients. A standard LED torch was shined in patient's eye after pupil dilation, with the patient in lying down position, while simultaneously elevating the upper eyelid digitally. A positive test was indicated by the ability to maintain downward gaze and the lack of squeezing of eyes or withdrawal. Chi-square and Fisher's exact tests were used to assess the association between LDLD results and suitability for ATA. The positive predictive value and specificity of the test as an indicator of patient suitability for ATA were calculated. Complications (intra- and post-operative) and postoperative inflammation at day 1 and week 6 were compared between the ATA and ALA groups. Results: A total of 250 patients were included in the study, 138 in ALA group and 112 in ATA group. There were 109 males (43.6%) and 141 females (56.4%). Around 7.4% of LDLD- positive patients were converted to ALA during the surgery. Chi-square and Fisher's exact tests demonstrated a significant association of a positive LDLD test with successful ATA (P value 0.002). The positive predictive value and specificity of the test were 92.56% (95% CI86.87-95.9%) and 93.48% (95% CI87.98-96.97%), respectively. Intraoperative complications were similar in both the groups. Congestion and visually significant corneal edema were significantly less in ATA group. Conclusion: The LDLD is a simple, highly specific, OPD-based test to determine patient suitability for MSICS under ATA

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Purpose: The aims of this study were to evaluate the effects of decorin (DCN) in rat oxygen-induced retinopathy (OIR) model and to compare the results with those of bevacizumab. Methods: Twenty-eight newborn Sprague–Dawley rats were randomly divided into four groups. Group I (control): normoxia plus intraperitoneal (ip) normal saline (NS), Group II (sham): OIR plus ip NS, Group III (DCN): OIR plus ip 0.1 mg/kg DCN, and Group IV (bevacizumab): OIR plus ip 2.5 mg/kg bevacizumab. The OIR model was induced by cycling the oxygen concentration between 50% and 10% every 24 h for 14 days following their birth. In all groups, injections were administered on postnatal day (PD) 15. All animals were sacrificed and their right eyes were enucleated on PD 18. The nuclei of neovascular endothelial cells on the vitreal side of the inner limiting membrane were counted, and vascular endothelial growth factor (VEGF) and tumor necrosis factor-alpha (TNF)-α immunoreactivity were detected in histopathological and immunohistochemical examinations. One-way analysis of variance and post hoc Tukey tests were used for statistical analyses of the data. Results: In Groups II, III, and IV, the mean neovascular cell nuclei counts were 13.14 ± 1.34, 6.57 ± 1.51, and 6.71 ± 1.49, respectively. The mean neovascular cell nuclei count was significantly reduced in treatment groups compared with sham group (P < 0.001). In immunohistochemical staining, the immunoreactivity of VEGF was 0.07 ± 0.02, 0.97 ± 0.21, 0.37 ± 0.12, and 0.23 ± 0.17, respectively. Likewise, immunoreactivity of TNF-α was 0.02 ± 0.02, 1.11 ± 0.36, 0.37 ± 0.13, and 0.62 ± 0.21, respectively. VEGF and TNF-α immunoreactivity increased markedly in the sham group compared with those in the control group (P < 0.001). VEGF and TNF-α immunoreactivity of treatment groups decreased significantly compared to sham group (P < 0.001). Conclusion: The beneficial effects obtained by DCN administration in OIR model were comparable to the effects of bevacizumab.

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Purpose: To compare the outcomes of vitreoretinal surgery in patients with primary and recurrent rhegmatogenous retinal detachment (RRD) with proliferative vitreoretinopathy (PVR) on 3 dimensional digitally assisted visualization system (3D-DAVS) and conventional analogue microscope (CAM). Methods: 68 patients with primary (50) and recurrent (18) RRD with PVR > C1 were included. One group underwent surgery on 3D-DAVS while the other on CAM. The parameters studied included detachment rate, best-corrected visual acuity (BCVA), duration of surgery, mean endo-illumination levels of 23 G (Gauge) micro incision vitrectomy system (MIVS) and microscope and satisfaction of surgeon and observers based on a framed questionnaire. The mean duration of follow up was three months. Results: 68 eyes of 68 patients with median age 52.5 (range 18–68) years were included. 50 had primary RRD and 18 had recurrent RRD. Detachment rate at the end of three months was comparable in both groups of primary (P > 0.99) and recurrent (P = 0.21) RRD. Mean duration of surgery in minutes for 3D DAVS and CAM group was 61.8 (±22.07) and 58.04 (±12.33), respectively, in primary RRD and 37.22 (±10.27) and 36.55 (±5.92), respectively, in recurrent RRD group. Mean endo-illumination in 3D DAVS (14.5%) group was half of that in CAM (34.17%) group. Surgeon and observer satisfaction scores were significantly higher for 3D DAVS group. Conclusion: 3D DAVS is a safe and effective modality or performing VR surgery in RRD with PVR. 3D DAVS allows lower endo-illumination levels provides superior surgeon ergonomics and offers better learning opportunities to the trainees.

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Purpose: Deeply embedded corneal foreign bodies and intrastromal foreign body removal can often be a challenge. The aim of this report was to describe the utility of endoscopy in visualization and removal of an embedded corneal bee stinger. Methods: A 44-year-old male patient developed toxic keratopathy after injury from a bee stinger. On examination, the bee stinger was noted to be deeply embedded in the corneal stroma. A superficial keratectomy was initially attempted; however, the stinger was noted to be intrastromal and protruding into the anterior chamber and could not be removed. An Endoscopy-assisted visualization was used to remove the stinger. Results: The bee stinger was successfully removed and the patient's vision improved to 20/100 from an initial CFCF (counting fingers close to face) at time of presentation. At the end of 3 months follow-up, there was residual corneal edema along with cataractous changes in the lens as a sequelae of the initial bee sting injury. The patient subsequently underwent an endothelial keratoplasty along with phacoemulsification with intraocular lens implantation and the final BCVA improved to 20/40. Conclusion: Endoscopyassisted visualisation of anterior chamber and angle structures can be valuable in removal of retained and deeply embedded corneal or intracameral foreign bodies.

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Purpose: The aim of this study was to estimate and compare the differences in ocular biometric measurements (OBMs), central macular thickness (CMT), and retinal nerve fiber layer thickness (RNFLT) between children with refractive errors and those with emmetropia. Methods: A cross-sectional observational study of 205 children (334 eyes) aged between six and 18 years consisting of four groups (emmetropia, hypermetropia, myopia, and astigmatism) was carried out. Best-corrected visual acuity (BCVA), a detailed ocular examination, OBMs, spectral-domain optical coherence tomography (SD OCT) for RNFLT and CMT in both eyes were evaluated for each child. Results: Mean age of 205 children was 12.4 ± 3.2 years. 55.6% (n = 114) were girls and 44.4% (n = 91) were boys. There was a significant difference between the four groups for the parameters spherical equivalent (SE), keratometer readings K1and K2, axial length (AL), anterior chamber depth (ACD), vitreous chamber depth (VCD) and lens thickness (LT) (P < 0.0001). The mean central corneal thickness (CCT) was not significantly different between the four groups (P = 0.076). The mean RNFLT was thinner in the myopic group compared with the emmetropic group (P = 0.0048) There was no significant difference in the mean CMT across the four groups (P = 0.458). Conclusion: The data obtained are helpful in providing the normative as well as a comparative database on OBMs, RNFLT and CMT of the pediatric population. This also facilitates evaluation of RNFLT and CMT measurements in children with amblyopia, optic neuropathies, glaucoma, macular and retinal diseases.

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Purpose: The objective of this study was to identify the diagnostic features of optic nerve head melanocytoma (ONH-MCT) on spectral domain optical coherence tomography (SD OCT) and OCT angiography (OCT-A). Methods: Retrospective study of 11 patients for their demographic, clinical features and imaging including SD OCT (tumour location, extent and interface) and OCT-A (surface and intrinsic vascularity) were reviewed. Flow rate percentage (FR %) was calculated over the lesion and compared to fellow eye and similar pigmented lesions. Results: The average age was 52.8 ± 10.9 years. ONH-MCT tumors occupied 3-tissue spaces- optic disc (n = 2), retinal layer (n = 5) and retina-choroidal layers (n = 4). SD OCT (11 eyes) showed elevated hyper reflective disorganized retinal layers with posterior shadowing (9 eyes) and hyper reflective dots within the tumor (all eyes). Microvascular features on OCT-A (8 eyes) in radial peripapillary capillary slab showed surface vascularization (7 eyes) and intrinsic vascularity in choroidal slab (8 eyes) with surrounding hypo reflective boundary. The mean FR % was higher at 65.1 ± 3.77% (CI: 61.9-68.2) compared to mean FR at 60.4 ± 1.06% (CI: 59.5-61.2) in the fellow eye (p = 0.01). Comparison with nevus and melanoma SD OCT showed a high reflective choroidal layer with normal or irregular outer retinal layers respectively; OCT-A showed hypo reflective area at the center with hyper reflective boundary and iso reflective area at center with hyper reflective boundary respectively. Conclusion: SD OCT and OCT-A features may help to differentiate ONH-MCT from clinically similar looking pigmented lesions like nevus and melanoma.

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A 23-year-old man presented with congestion, peripheral corneal vascularization, an elevated ridge-like epithelial line and cellular infiltration around limbal transplants, 15 months after undergoing living-related simple limbal epithelial transplantation (SLET) for total limbal stem cell deficiency. A diagnosis of acute allograft rejection was made and he was treated with intravenous methylprednisolone, topical and oral prednisolone as well as systemic cyclosporine and azathioprine, leading to reversal of the signs. Similar findings were noted during a later rejection episode. An epithelial rejection line and cellular infiltration of limbal transplants are easily identifiable clinical signs of allograft rejection post SLET.

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Purpose: The purpose of this study is to compare the endothelial cell loss (ECL) in nanophthalmic eyes and age-matched controls undergoing cataract surgery by phacoemulsification and also to identify the risk factors influencing the endothelial cell density (ECD). This was a prospective comparative interventional case series. Methods: We enrolled 19 nanophthalmic eyes (study group) and 42 age-matched cataract controls (control group) undergoing phacoemulsification after meeting the inclusion criteria. Ocular parameters like best-corrected visual acuity, intraocular pressure, pachymetry, specular microscopy, and slit lamp findings were noted preoperatively and at month 1 and 3 postsurgery. All nanophthalmic eyes underwent cataract surgery with concomitant prophylactic posterior sclerostomy. Results: The median percentage endothelial loss in nanophthalmic eyes was 4.0 (IQR 0–23.5), 7.4 (IQR 1.0–-22.4) at 1 and 3 months postoperatively compared to 6.3 (IQR 1.7–14.1) and 6.4 (IQR 2.6–-12.1) in age controlled normal eyes (P = 0.94, P = 0.46, respectively). Linear regression analysis showed increasing age as the only variable influencing the percentage decrease in corneal ECD in the study group (P = 0.001). Nanophthalmic eyes with ACD <2.5 mm had a significantly greater reduction in ECD at 3 months postcataract surgery compared to baseline (P = 0.039). Visual outcomes and IOP reduction in the study group with ACD >2.5 mm were significantly better postcataract surgery (P = 0.02 and P = 0.002, respectively). Conclusion: The percentage of ECL in nanophthalmic eyes undergoing phacoemulsification is equivalent to normal eyes. However, in the nanophthamic eyes with AC depth <2.5 mm, the percentage cell loss was significantly higher warranting the need for extensive intraoperative care. Increasing age was found to be the only significant risk factor influencing the ECD in short eyes.

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A 78.year.old male underwent ultra.thin DSAEK for PBK (OS) and achieved BCVA 6/12 at 9 months. The patient developed allograft rejection 10 months postoperatively and was treated with IV methyl prednisolone, systemic, and topical steroids. The patient then improved and achieved 6/18 BCVA at 8 weeks. Topical prednisolone 1% twice daily was continued. Six weeks later, the patient developed fever and diminished vision and had high IOP, corneal edema, and keratic precipitates on endothelium. Considering it to as second episode of graft rejection, IV methyl prednisolone and topical steroids were given. Seeing no response, presumed HSV endotheliitis was considered as diagnosis and treated with steroids, oral acyclovir. The patient improved and achieved BCVA 6/24 with no subsequent recurrence during 11 months follow.up.

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Purpose: National Accreditation Board for Hospitals and Healthcare Providers operates the health-care accreditation program in India. Research on impact of accreditation on eye-care centers is scarce. This article was conceptualized to scientifically evaluate the changes in documentation brought about by accreditation and its effects on staff in the Ophthalmology Department of an Indian Medical College. Methods: This was conducted as a quasi-experimental study in four steps. First, a point-based evaluation of case sheets in both pre-accreditation and postaccreditation phase, along with statistical analysis of the results, was done. Step two involved analysis of quality indicators and patient safety indices in successive years from inception of data to post-accreditation phase. Step three comprised a survey of staff employing a validated tool, and finally, face-to-face semistructured interviews with designated authorities, including finance departmental head, completed the study. Results: A statistically significant difference was seen in scores achieved by the pre and postaccreditation case sheets, with the postphase case sheets achieving 15% increased scores over the prephase case sheets. Quality indicator indices displayed improvements post-accreditation. There was an accompanying increase in quantity of documentation. Financial data analysis showed increased expenditure for accreditation under multiple heads. Staff believed that accreditation led to increased workload but did not express decreased satisfaction and felt that accreditation was eventually beneficial. However, staff believed rewards for improving quality can be enhanced. Conclusion: Accreditation increases quality and quantity of documentation, and staff workload. Increased financial costs also ensue.Staff believe that accreditation improves quality, is beneficial, but desire enhanced rewards.

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Purpose: To assess ocular morbidity attributable to kites (patang) with emphasis on the cause, type and severity of the injury, complications, and final visual outcome. Methods: All the patients with a history of kite injury during months of Makar Sankranti for consecutive 6 years (2014–2019) were included in this study. A B-scan, orbital X-ray, and CT scan were performed for extensive ocular evaluation. Results: Out of 68 patients with kite-related injury, 58 were male and 10 were female. Globe rupture (20), lid laceration (18), penetrating injury (9), wooden foreign body in the anterior or posterior chamber (7), superficial foreign body (4), hyphema (7), and vitreous hemorrhage (3) due to falling from height were noted. Factors associated with a poor final visual outcome in our study were poor initial visual acuity, globe rupture, intraocular foreign body, and development of endophthalmitis. Conclusion: Kites can cause serious preventable injuries mostly among pediatric males. The use of protective eyewear and public awareness can decrease ocular injury significantly.

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Purpose: The purpose of this study is to evaluate the factors affecting the success of needling surgery for early filtering bleb failure after trabeculectomy. Methods: Patients who underwent a single needling surgery within 3 months after trabeculectomy were retrospectively evaluated. Glaucoma type, intraocular pressure (IOP), and medical treatments before trabeculectomy; the presence of hypotony after trabeculectomy; bleb type; IOP before needling; lens status; complications; IOP after 1, 6, and 12 months; and medical treatments after needling were recorded. Risk factors were evaluated for complete success at 1, 6, and 12 months after needling. Results: Thirty-three eyes of 33 patients were analyzed. The mean IOP after needling at 1, 6, and 12 months was 16.09 ± 3.70, 15.64 ± 2.68, and 15.79 ± 2.61 mmHg, respectively. The mean age of the patients was 53.97 (25–79) years. The mean IOP after needling at 1, 6, and 12 months was 16.09 ± 3.70, 15.64 ± 2.68, and 15.79 ± 2.61 mmHg, respectively. The pre-needling IOP and IOP decrease on the first day affected the complete and qualified success at 1, 6, and 12 months, but the glaucoma type, presence of hypotony after trabeculectomy, lens status, interval between trabeculectomy and needling, and bleb type were not found to affect success. In the receiver operating curve analysis, the pre-needling IOP value was found to be significant in determining complete success. Complete success at 1 month was more likely when the pre-needling IOP cutoff value was <24.5 mmHg. Conclusion: According to the results of single needling surgery performed within 3 months after trabeculectomy, the pre-needling IOP and IOP decrease with needling were found to be factors affecting success. Regardless of the time between the primary trabeculectomy and needling, effective needling will be successful before the IOP rises to high levels. Keeping the IOP at low values with medical treatment until the needling process is performed will have a positive effect on success.

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Purpose: To compare the visual outcome in terms of multifocality in Manual Small Incision Cataract Surgery (MSICS) with and without intraoperative manipulation of corneal curvature. Methods: This was a prospective study on 80 subjects (80 eyes) who underwent MSICS with monofocal posterior chamber intraocular lens (PCIOL) implantation between January 2018 and October 2019. Intraoperative manipulation of corneal curvature using viscoelastics was performed during MSICS in 40 subjects (cases) while this intraoperative manipulation was not performed in the remaining 40 subjects (controls). Uncorrected distance visual acuity (UDVA) and uncorrected near visual acuity (UNVA) were compared at day 1, 7, 30 and 180postoperatively. Results: At 1 month and 6 months of follow up, UDVA was comparable in the 2 groups. UNVA was better in cases than controls at 1 month and6 months (P < 0.001). At 6 months of follow up,76% of cases with UDVA of 6/9 or better had UNVA of N8 while only 15% of controls with UDVA of 6/9 or better had UNVA of N8 (P <0.001). Mean near add requirement to achieve a best corrected near vision (BCNV)of N6 at 6 months was significantly lesser (P =0.002) in cases (+2.05 D) compared to controls (+2.43D). Conclusion: MSICS with intra operative manipulation of corneal curvature resulted in better unaided near visual acuity compared to that without intra operative manipulation of corneal curvature, without compromising unaided distant visual acuity.

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