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Purpose: To study the risk factors, clinical features, and treatment outcomes of patients with culture-negative keratitis (CNK). Methods: A retrospective data review of 933 patients with CNK was performed from January 2018 to December 2020. The variables such as the history of injury, visual acuity, slit-lamp findings with measurements of size and depth of ulcer, microbiological evaluation, duct patency, blood glucose levels, and treatment were considered, and clinical outcome was analyzed. Results: Of the 933 patients with CNK, 763 (81.8%) were medically managed, with a mean treatment duration of 2.08 ± 1.7 weeks. Among them, 622 (66.7%) were both smear and culture-negative, and 311 (33.3%) showed only smear positivity. Smear-positive patients showed a positive correlation with the history of injury. A higher incidence of fungal growth on repeat culture was observed. Surgical interventions were done only in 18.2% of the patients; the rest were treated with topical medications alone. Conclusion: High clinical suspicion, differentiation of causative organisms based on clinical findings, and initiating empirical therapy with broad-spectrum antibiotics and antifungals improve the ultimate prognosis in patients with CNK, even though a standard protocol for empirical medical treatment may differ among institutions and surgeons based on their clinical experience and geographical variations.

Multiple evanescent white dot syndrome (MEWDS) is a rare form of posterior uveitis characterized by involvement in the posterior pole and mid-periphery. A viral etiology that provokes an immune-mediated response has been hypothesized to be the inciting factor of the pathology. Recently, there has been an increase in the literature regarding new-onset uveitis and reactivation of previously diagnosed cases of uveitis following COVID-19 vaccinations. The COVID-19 vaccination has been speculated to trigger an immunomodulatory shift in recipients, resulting in an autoimmune event. MEWDS following COVID-19 vaccination was reported in 31 patients. It was most commonly observed following the first dose, affecting 15 patients, and least commonly after the booster dose, in only one patient. MEWDS-like disease following anti-SARS-CoV-2 vaccinations was reported the most in 16 cases after the Pfizer–BioNTech vaccination (BNT162b2 mRNA). Most of these cases had Primary MEWDS without any previous history of a similar event in the past.

Purpose: This study sought to identify the sources of differential performance and misclassification error among local (Indian) and external (non-Indian) corneal specialists in identifying bacterial and fungal keratitis based on corneal photography. Methods: This study is a secondary analysis of survey data assessing the ability of corneal specialists to identify acute bacterial versus fungal keratitis by using corneal photography. One-hundred images of 100 eyes from 100 patients with acute bacterial or fungal keratitis in South India were previously presented to an international cohort of cornea specialists for interpretation over the span of April to July 2021. Each expert provided a predicted probability that the ulcer was either bacterial or fungal. Using these data, we performed multivariable linear regression to identify factors predictive of expert performance, accounting for primary practice location and surrogate measures to infer local fungal ulcer prevalence, including locality, latitude, and dew point. In addition, Brier score decomposition was used to determine experts' reliability (“calibration”) and resolution (“boldness”) and were compared between local (Indian) and external (non-Indian) experts. Results: Sixty-six experts from 16 countries participated. Indian practice location was the only independently significant predictor of performance in multivariable linear regression. Resolution among Indian experts was significantly better (0.08) than among non-Indian experts (0.01; P < 0.001), indicating greater confidence in their predictions. There was no significant difference in reliability between the two groups (P = 0.40). Conclusion: Local cornea experts outperformed their international counterparts independent of regional variability in tropical risk factors for fungal keratitis. This may be explained by regional characteristics of infectious ulcers with which local corneal specialists are familiar.

Purpose: To report the uveitic manifestations of patients with systemic lupus erythematosus (SLE). Methods: This was a retrospective analysis of all SLE cases with ocular manifestations seen by a single ophthalmologist between 2015 and December 2021. Results: In total, seven patients with a median age of 40 (range 18–50) years were included in the study. Female (85.7%) predominance was noted. Ocular findings were bilateral in 71% (five patients) of cases. Majority (10 eyes, 83%) of the patients had retinal vasculitis as the common finding. Antinuclear antibodies were positive in all the patients. The vision improved in two (16.6%) eyes, was stable in eight (66%) eyes, and worsened in one (8%) eye. All the patients were treated with oral steroids along with immunosuppressive agents. Conclusion: Though SLE is rare cause of uveitis, it can be associated with significant ocular morbidity. Hence, early diagnosis and treatment can salvage vision in many cases.

Aim: The aim of the study was to correlate axial length (AL) and anterior chamber depth (ACD) with stature. Materials and Methods: The study was conducted among 100 patients attending the ophthalmology outpatient department, including both males and females aged between 20 and 40 years, with clear media and without any systemic or ocular pathology. The first comprehensive ophthalmic examination was done on each subject, including vision assessment, refraction, slit lamp examination, and fundus examination. Then subjects were enrolled in this cross-sectional and purposive study depending on the inclusion and exclusion criteria and were divided into four groups depending on their heights (in cm). Data analysis was performed using SPSS to correlate AL and ACD with stature in young adults in tertiary care hospitals. Results: Although the mean values of the height group 179–189 cm are found to be higher, the P value was found to be insignificant (P = 0.343). There was a positive correlation with P being 0.019 and 0.001 in height groups 159–169 and 169–179 cm, respectively, indicating that there is statistical significance in these groups with the ALs. The correlation was significant with P = 0.026 in the group 159–169 cm. Therefore, the height group 159–169 cm has statistical significance with ACD. Conclusion: In the present study, we found that there was a statistical correlation between the stature of an individual with their ALs and the anterior chamber of the eyeball. We found that taller young adults tend to have longer AL and ACD.

Abstract A 47-year-old woman with hypertension and rheumatoid arthritis presented with non-necrotizing scleritis in both eyes. Despite a course of oral corticosteroids, she continued to experience persistent symptoms. A rheumatologist was consulted and initiated treatment with tofacitinib, a JAK/STAT inhibitor. Treatment with tofacitinib and oral corticosteroids resulted in an improvement in the scleritis in both eyes. However, a fundus examination of her left eye revealed a superior-temporal branch retinal vein occlusion. Given the growing concern regarding the increased risk of thromboembolic events with tofacitinib therapy, it is essential to consider the risk of retinal vascular occlusions when starting tofacitinib therapy, particularly in patients with underlying systemic comorbidities.

Purpose: To assess the quality of life and contrast sensitivity (CS) pre- and post-laser assisted in situ keratomileusis (LASIK) among subjects with low, moderate and high myopia. Materials: A total of 95 ubjects undergoing myopic LASIK during the study period from 2018 to 2019 among different grades of myopia were included. It was a prospective, non-randomised study. Quality of life was measured by NEI-RQL 42 (national eye institute refractive error quality of life) questionnaire. The Pelli-Robson chart measured contrast sensitivity and the visual outcomes before LASIK and at one week, one month and six months after LASIK. Results: One hundred and ninety eyes of 95 subjects were included in the study. Out of these, 93.5% of low myopia (n = 29/31), 85.7% of moderate myopia (n = 36/42) and 72.7% of high myopia (n = 16/22) improved to 6/6 at six month follow up. All 13 subscales of the NEI-RQL 42 questionnaire observed an increasing trend except glare (GL) which showed a decreasing trend over time, and the results were statistically significant at a 5% level. Concerning contrast sensitivity, low myopias had a better postoperative CS when compared to high myopia, and this finding was statistically significant (P = 0.012). Conclusion: Despite being a safe and effective procedure of refractive correction, LASIK has its setbacks, especially when compared with the quality of vision, and this can be minimized by careful preoperative assessment and in-depth patient counseling by the treating physicians.

Purpose: To study the clinical outcomes, time span of healing of various ocular surface disorders with amniotic membrane graft. Methods: A total of 41 patients, presenting to cornea clinic were included in the study and divided into five groups depending on the type of diagnosis: Group 1, with either >2 weeks of Persistent epithelial defect following cataract/retinal/glaucoma surgeries or Shield ulcers, Group 2 with >4 weeks of Non healing corneal ulcers, Group 3 with chemical injuries, Group 4 with Epithelial defects following keratoplasty, and Group 5 is the miscellaneous group. Results: The mean age of the study subjects was 50.0 years. Overall mean duration between clinical presentation and AMT was 23.59 (30.7) days, a median 16 days (IQR; 2-26 days). Failure rate was high in Group 5 (n = 3: 30.0%) and Group 2 (n = 3: 27.3%). Time taken for epithelial closure was slower in groups 1 and 5 patients. The average time taken for reabsorption of AMG was 14.98 days. The complications included repeat AMG was in four eyes (9.75%), and graft displacement was noted in four eyes (9.75%) required resuturing, three eyes required TPK (7.31%), and one eye underwent evisceration (2.43%) following severe corneal melt secondary to neurotropic ulcer. The mean log MAR visual acuity improved from 1.52 to 1.26 at the 3 months. Conclusion: Understanding on timespan for healing of ocular surface disorders with AMG is needed to assess the prognosis of the disease, preoperative counselling for repeat procedures, and the compliance with regard to follow up.

Corneal blindness (CB) is one of the leading causes of blindness in India and globally, affecting around 8 million population worldwide. Many of these corneal blind patients may be visually rehabilitated by corneal transplantation (CT). Eye banking plays a crucial role in facilitating CT and ocular research. Many countries have adopted regulatory frameworks, quality assurance programs, and technological advancements to enhance the efficacy and safety of CT. Various infrastructural and organizational frameworks of eye banks (EBs) in India, according to the Eye Bank Association of India (EBAI), aid in establishing guidelines and standards for EB practices. Initiatives such as the National Programme for Control of Blindness (NPCB) have significantly contributed to eye donation rates and improved access to donor corneas. This review article discusses the established eye banking networks in countries such as India, the United States (USA), and Europe, where dedicated EB organizations work collaboratively to ensure efficient procurement, processing, and distribution of corneal tissue. It also highlights specific strategies employed in India and global countries to address EBs' challenges. These challenges include the shortage of donor corneas, improving donor screening and tissue processing techniques, ensuring timely distribution of corneal tissue, and maintaining high-quality standards. Interestingly, the comparative analysis between India and other developed countries highlights the similarities and differences in eye banking strategies. By understanding the strategies employed by different regions, EBs can learn from each other's experiences and work toward achieving optimal outcomes in CT and ocular research worldwide. It underscores the importance of knowledge sharing and collaborative efforts in addressing common challenges and implementing best practices in eye banking.

Purpose: The purpose of this study is to study the patient's awareness of the proper method of eye drop (ED) opening and usage among patients attending the outpatient and specialty clinics of a tertiary eye care center in South India. Methods: A questionnaire-based cross-sectional survey was conducted among 514 patients attending outpatient departments of general units and specialty clinics by seven study coordinators. The questionnaire consists of 10 simple questions to assess the awareness of these patients on ED opening, usage methods, and from whom they received the information. Immediately, at the end of the questionnaire, all the patients participating in the survey were properly instructed on the right method of ED usage. In addition, they were inquired about the right mode of communication on the topic of interest. Results: Total number of participants included was 514. Mean age was (standard deviation) 50.58 (20.8) years; only 3.3% (17) were not informed about the proper usage of ED method by any of the staff or the counselors or doctors from the hospital, and 96.7% (497) were counseled for the proper method of ED usage. Among them, the information was properly explained to 82.7% (412) of the respondents by the counselors in each department; only 7.4% (37) were explained by the doctors. Most of them, 80.2% (412), preferred direct oral conversation methods of counseling on ED usage, 9.9% (51) preferred through posters, 7% (36) through video displays, and only 9% (10) through public address systems. Conclusion: A separate, precise ED counseling system is necessary for delivering proper instructions on ED usage and opening. The patient's education with eye-to-eye contact from the counselors is the patient's preferred route of obtaining information on ED usage.

Introduction: On 11 March, 2020, World Health Organisation (WHO) declared coronavirus disease 2019 (COVID- 19) a pandemic disease, and by 26 March, 2020, COVID-19 had spread to nearly 199 countries and homes worldwide. Cases substantially present with fever, dry cough and breathing difficulty. As a result of the pandemic, a number of cases visiting the hospital for non-COVID-19 diseases was drastically reduced and only emergencies were seen in our hospital. Inpatient admissions were also reduced and surgical procedures were reduced. The cost of ocular surgeries was escalated to adhere to the guidelines issued by authorities, for the safety of patients and staff. Majority of ocular surgeries are elective, and national programmes conducting cataract camps were completely stopped since cataract surgeries are elective. Objectives: To assess the knowledge, attitude and practice (KAP) of the patients visiting ophthalmology OPD towards COVID-19 and ocular surgery. Materials and Methods: A cross-sectional non-interventional questionnaire-based study was conducted among patients visiting ophthalmology OPD. Results: The study included 100 patients of which 54% were males and 46% were females. A total of 38% were above the age of 50 years and literates consisted of 60%. The main ocular symptom was defective vision (43%). Furthermore, 98% were aware of COVID-19. Internet/media (48%) was the major source of knowledge. In addition, 80% were aware of the cause and mode of spread, 40% were willing to undergo eye surgery and 75% agreed with government lockdown measures and were ready to take the vaccine to prevent COVID-19 infection. Conclusion: The study suggests that the population demonstrated decent knowledge, appropriate practice and a positive attitude towards COVID-19 at the time of its outbreak.

Context: The use of smartphone-based peek acuity application to test the visual acuity will improve the time efficacy, availability, and utility of subjective results collections for the healthcare providers. Aims: To assess and compare the VA by Smartphone visual acuity chart and LogMAR visual acuity chart and to determine the significance of the peek acuity chart over the LogMAR chart. Settings and Design: Prospective study. Methods and Material: We analysed 50 subjects with their approval and informed consent, evaluated their visual acuity using a LogMAR chart at three metres, and performed subjective refraction, silt lamp examination, and fundus examination. VA measures were taken with a smartphone software called Peek acuity and subjective refraction was done with a smartphone-based visual acuity program. The results were then compared between the two techniques. Sample Size: Convenient sampling. Statistical Analysis Used: The data were entered in MS excel and the results were calculated using statistical software SPSS, version 20. The results were expressed in the form of descriptive statistics like mean, standard deviation, graphs, frequency, and percentage was performed and inferential statistics like corelation and paired t-test were performed wherever necessary to compare unaided visual acuity, visual acuity with pinhole, and with glasses in both the eyes using smartphone-based PEEK visual acuity app and LogMAR visual acuity chart. If P

Purpose: To analyze the impact on eye donation and corneal transplantation during the COVID-19 pandemic in a tertiary eye hospital in south India. Methods: A retrospective analysis of the donor and recipient records during the study period from January 2020 to May 2021 was conducted and tabulated in Microsoft Excel 2013. Demographic details of the donor, utility rate, cause of death, culture characteristics, storage methods, wet lab usage, and the surgical donor outcomes were evaluated. Additionally, the postoperative workup of the recipients, diagnosis, graft infection and rejection episodes, development of COVID-19 postoperatively, and outcome in terms of visual acuity at one, three, and six months were also noted. Results: A total of 466 eyes from 249 donors were received during the study period. The mean age of the donor population was 62.43 years (20.9). The corneal transplantation utility rate was 36.4% (n = 170). Fifty-one percent of the total transplant surgeries were for therapeutic purposes. This was followed by penetrating optical keratoplasty (34%), Descemet's stripping endothelial keratoplasty (9%), and patch grafts (3%). Seventeen (10%) graft rejection episodes were noted and nine (53%) had complete resolution after medical treatment. Conclusion: Proper preventive measures are key to carrying out safe and efficient eye banking activities even during a deadly pandemic, as COVID-19 transmission via transplantation is rare.

Purpose: Lid wiper epithliopathy (LWE) was stuided in symptomatic and asymptomatic dry eye subjects. This is the first such study to be conducted in the Indian population. LWE is a clinical condition associated with vital staining in the lower and upper eyelids on increased friction of the lid margin over to the cornea. Our aim was to study LWE in symptomatic and asymptomatic (control) dry eye subjects. Methods: Out of 96 subjects screened, 60 subjects were enrolled in the study and were divided into two groups, symptomatic and asymptomatic dry eye subjects, based on the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire and the Ocular Surface Disease Index (OSDI) scores. The subjects were examined to rule out clinical dry eye findings and assessed for LWE with two different dyes (fluorescein and lissamine green). Descriptive analysis was done and Chi-square test was used for statistical analysis. Results: A total of 60 subjects were enrolled in a study with a mean age of 21.33 ± 1.88 years, out of which the majority of LWE patients (99.8%) was seen in the symptomatic group than the asymptomatic group (73.3%); the difference was statistically significant (p = 0.00) and also clinically significant. LWE was found to be significantly higher in symptomatic dry eye subjects (99.8%) compared to asymptomatic dry eye subjects (73.3%). LWE severity was also found to be more (56.6% of grade 3) among symptomatic dry eye subjects compared to asymptomatic subjects (40% of grade 2). Conclusion: It is important to assess the lid wiper region (LWR) and treat LWE in routine clinical practice.

Purpose: The aim of this study was to determine the predisposing risk factors, clinical characteristics, microbiological profile, and visual and functional treatment outcome of microbial keratitis including viral keratitis in children. Methods: A prospective study was carried out in a tertiary care institute over a period of 18 months on 73 pediatric patients. Data collected was analyzed for demographics of the patient population, causative organisms, and management outcome in terms of visual and functional outcome. Results: Patients in the age group from 1 month to 16 years were included, with a mean age of 10.81 years. Trauma was the commonest risk factor (40.9%), with unidentified foreign body fall being the most common (32.3%). No predisposing factors were identified in 50% of cases. Also, 36.8% of eyes were culture positive, with bacterial isolates in 17.9% and fungus in 82.1%. Moreover, 7.1% eyes were culture positive for Streptococcus pneumoniae and Pseudomonas aeruginosa each. Fusarium species (67.8%) was the commonest fungal pathogen, followed by Aspergillus species (10.7%). Also, 11.8% were clinically diagnosed as viral keratitis. No growth was found in 63.2% of patients. Treatment with broad-spectrum antibiotics/antifungals was administered in all cases. At the final follow-up, 87.8% achieved a best corrected visual acuity (BCVA) of 6/12 or better. Therapeutic penetrating keratoplasty (TPK) was required by 2.6% of eyes. Conclusion: Trauma was the major cause for pediatric keratitis. Majority of the eyes responded well to medical treatment, with only two eyes needing TPK. Early diagnosis and prompt management helped majority of the eyes to achieve a good visual acuity after the resolution of keratitis.

To report a unique case of spontaneous resolution of momentary, non-inflammatory phakic intraocular lens implantation (pIOL) deposits, in a 24-year-old female underwent phakic IOL implantation in both eyes for high myopia. Surprisingly, multiple, whitish, refractile, non-inflammatory deposits were noted in the immediate postoperative period on the posterior surface of the pIOL in the right eye. A quick recap of surgical steps identified the rationale for the lens deposits, circumventing similar incident in the fellow eye.

Small traumatic iridodialysis (ID) may be asymptomatic, but large ones usually cause polycoria and corectopia, leading to symptoms like diplopia, glare, and photophobia. The management of ID, including medical and surgical methods, depends upon the patient's symptoms. Mild glare and diplopia can be treated either with atropine, antiglaucoma medications, tinted spectacles, colored contact lens, or corneal tattooing, but extensive IDs require surgical options. The surgical techniques are challenging due to the iris texture and the damage encountered during the primary surgery, the narrow anatomical workspace for repair, and the associated surgical complications. Numerous techniques have been described by several authors in the literature; each has its advantages and disadvantages. All the procedures described previously involve conjunctival peritomy, scleral incisions, and suture knots and are time consuming. Here, we report a novel transconjunctival, intrascleral, knotless, and ab-externo, double-flanged technique for repair of large ID with a 1-year follow-up.

Purpose: To determine the most preferred method of operating brown cataracts among ophthalmologists in India. Methods: A cross-sectional, questionnaire-based study was conducted among ophthalmologists all over India through electronic and social media from May 1 to June 15, 2022. All single, voluntary entries within the stipulated time period were accepted for analysis. Results: A total of 230 ophthalmologists participated in the study among which 198 (86%) preferred Manual small-incision cataract surgery (mSICS) as the first option. This was preferred due to the high risk of complications associated (40, 33.6%) as well as endothelial damage due to increased Phaco power (53, 47.9%). The majority of the surgeons (162, 70.4%) preferred a superior tunnel for SICS, and 51.7% (119) performed continuous curvilinear capsulorhexis in 100% of their cases. The most common complication encountered was posterior capsular rupture (PCR) (66%), followed by zonular dialysis (ZD) (18.7%), whole bag removal (8.3%), and Descemet's membrane detachment (7%). Conclusion: Despite diverse recent new modalities of Femto Laser assisted cataract surgery (FLACS). Phakonit, and Smart Intraocular Lens (IOLs), the majority of ophthalmologists still find the manual small-incision cataract surgery (mSICS) procedure a safe surgery for mature brown cataracts.

Purpose: To analyze the hesitancy and motivational factors related to coronavirus disease 2019 (COVID-19) vaccination among patients visiting for eye care. Methods: A telephonic survey was conducted using validated questionnaires consisting of 36 questions in five sections from July 1 to July 31, 2021. Patients visiting six tertiary centers and one secondary center of our eye hospitals were interviewed over their phones, and their responses were entered onto the Google forms. The responses were recorded as demographics, health status, awareness about vaccination, factors contributing to hesitancy or acceptance to vaccinate, and general perception about the vaccine. Results: A total of 5033 patients were surveyed. The mean age was 49.0 ± 14.2 years. A total of 563 (11.2%) patients gave a history of symptoms or were tested positive for COVID-19; 2225 (44.2%) patients were already COVID-19 vaccinated. Around 2883 (56%) patients were aware of getting infection despite vaccination, and 4092 (81.3%) perceived vaccination should be compulsory. The main reason for vaccination hesitancy was the fear of side effects (n = 487, 17.3%). The fear of getting infected was the most common reason for vaccination (n = 911, 40.9%). Factors associated with a lower proportion of vaccinated individuals included younger age (P < 0.001), female gender (P < 0.001), lower education (P < 0.001), lower income (P < 0.001), and rural residence (P = 0.33). Conclusion: Creating awareness about the minor side effects and reassurance can allay an individual's fears. The fear associated with the rapid spread of infection and associated mortality needs to be utilized to increase vaccination acceptance. A targeted approach toward groups with poor uptake of vaccination is necessary.

This study aimed to report the graft sequelae of retained host Descemet's membrane (DM) following Penetrating Keratoplasty (PKP). A 75-year-old male diagnosed with retained host DM with Anterior segment optical coherence tomography (ASOCT). Nd:YAG membranotomy resulted in graft failure. Later, DM stripping endothelial keratoplasty with removal of the host DM was done. Review of literature was done to discuss the best treatment modality.

Purpose: Develop computer vision models for image-based differentiation of bacterial and fungal corneal ulcers and compare their performance against human experts. Design: Cross-sectional comparison of diagnostic performance. Participants: Patients with acute, culture-proven bacterial or fungal keratitis from 4 centers in South India. Methods: Five convolutional neural networks (CNNs) were trained using images from handheld cameras collected from patients with culture-proven corneal ulcers in South India recruited as part of clinical trials conducted between 2006 and 2015. Their performance was evaluated on 2 hold-out test sets (1 single center and 1 multicenter) from South India. Twelve local expert cornea specialists performed remote interpretation of the images in the multicenter test set to enable direct comparison against CNN performance. Main Outcome Measures: Area under the receiver operating characteristic curve (AUC) individually and for each group collectively (i.e., CNN ensemble and human ensemble). Results: The best-performing CNN architecture was MobileNet, which attained an AUC of 0.86 on the single-center test set (other CNNs range, 0.68–0.84) and 0.83 on the multicenter test set (other CNNs range, 0.75–0.83). Expert human AUCs on the multicenter test set ranged from 0.42 to 0.79. The CNN ensemble achieved a statistically significantly higher AUC (0.84) than the human ensemble (0.76; P < 0.01). CNNs showed relatively higher accuracy for fungal (81%) versus bacterial (75%) ulcers, whereas humans showed relatively higher accuracy for bacterial (88%) versus fungal (56%) ulcers. An ensemble of the best-performing CNN and best-performing human achieved the highest AUC of 0.87, although this was not statistically significantly higher than the best CNN (0.83; P = 0.17) or best human (0.79; P = 0.09). Conclusions: Computer vision models achieved superhuman performance in identifying the underlying infectious cause of corneal ulcers compared with cornea specialists. The best-performing model, MobileNet, attained an AUC of 0.83 to 0.86 without any additional clinical or historical information. These findings suggest the potential for future implementation of these models to enable earlier directed antimicrobial therapy in the management of infectious keratitis, which may improve visual outcomes. Additional studies are ongoing to incorporate clinical history and expert opinion into predictive models.

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.

Purpose: The aim is to evaluate the safety and efficacy of neodymium-doped: yttrium–aluminum–garnet laser peripheral iridotomy (LPI) in the superior versus inferior quadrant in the treatment of primary angle-closure (PAC) disease. Design: Randomized, prospective, single-masked, comparative clinical study. Materials and Methods: Patients with PAC or PAC suspects were recruited and randomized to receive LPI in the superior or inferior quadrant in both eyes. Patients were masked to the location of treatment in each eye. The main outcome measures assessed were patency of iridotomy, laser parameters, complications, and visual symptoms between the two groups at 1 week and 1 month after the laser intervention. Results: A total of 100 patients were recruited, 50 into each group. The mean age was 51.46 ± 7.91 years. Average intraocular pressure (IOP) measurements before LPI was 18.24 ± 5.37 mm Hg and 18.6 ± 5.63 mm Hg in superior LPI and inferior LPI eyes, respectively. After LPI, average IOP was 17.4 ± 3.31 mm Hg and 17.1 ± 3.13 mmHg in superior LPI and inferior LPI eyes, respectively. Inferior LPIs required less use of mean total laser energy (P = 0.001) and less number of laser shots (P = 0.016) to perforate the iris tissue. There was a lower incidence of iris bleeding and focal corneal damage at the time of treatment; a lower postlaser iritis and lower need for PI enlargement in the inferior LPI group. All the iridotomies were patent at 1 month follow-up. There was no statistically significant difference between the two groups in terms of the dysphotopsias and visual symptoms experienced after the LPI (P = 0.122). Conclusions: LPI in the inferior quadrant appears to be a safe and efficient alternative to superior LPI with fewer complications in the treatment of PAC disease. Dysphotopsias and visual symptoms following inferior LPI are similar to superior LPI.

Purpose: Covid-19 has profoundly affected the day-to-day lives of individual citizens. It has strained all aspects of health care including eye banking and corneal transplantation. Although elective procedures like optical Keratoplasty can be postponed, management of perforating ulcers needs tectonic Keratoplasty to avoid permanent ocular morbidities. It has become inevitable for corneal surgeons to innovate newer methods of treatment for such corneal diseases. The large corneal perforations if left untreated may lead to permanent visual loss. An alternative method of managing a large peripheral corneal perforation of size 5 × 5.5 mm was done using Tenons patch graft with Gore-tex in a 50-year-old female patient, during the lockdown. Observations: Tenons graft with Gore-tex, effectively sealed the large corneal perforation in our case without iris incarceration, favourable for future visual rehabilitation. Conclusions and Importance: Tenons and Gore-tex are readily available. It is not necessary to rely on the donor corneas or the distributing eye banks during this pandemic situation. In the future, this procedure can reduce the burden of the pre-existing increase in the gap between the need and supply of donor corneas in developing countries.

Objective: The objective was to study the epidemiology, clinical features, and treatment outcomes of dematiaceous fungal keratitis. Design: This was a retrospective, noncomparative, observational study. Materials and Methods: Fifty-nine cases of dematiaceous fungal keratitis seen at tertiary care hospital from January 2017 to June 2018 were analyzed for demographic features, predisposing factors, clinical characteristics, microbiological profile, and treatment outcomes. Statistical Analysis: Mean (standard deviation) and frequency (percentage) were used to represent continuous and categorical variables, respectively. Wilcoxon signed rank test was used for comparative analysis. Results: Of 236 cases of fungal keratitis seen during the study period, dematiaceous fungi were the third most common isolates in 59 cases (25%) after Fusarium (n = 101; 43%) and Aspergillus species (n = 76; 32%). Majority of the patients were adult males (male: female = 2:1) from rural areas (51%) with agricultural occupation (51%). Trauma with vegetable matter was the most common predisposing factor in 27 cases (45.8%). The characteristic macroscopic pigmentation was seen in only eight eyes (13.6%). In our study, 24 (40.7%) patients revealed Curvularia species, followed by Bipolaris and Exserohilum species in 20 cases (33.9%) and 10 cases (17%), respectively. The median time of antifungal therapy was 21 days (interquartile range: 21–41 days). Fifty-four (91.5%) responded to medical therapy, whereas five eyes required surgical intervention. Conclusions: This study signifies the importance of dematiaceous fungi as the important causative agent of fungal keratitis. Medical therapy along with debridement of ulcer alone can be effective in treating patients with superficial infiltrate who seek treatment early.

Aim: This clinical study was undertaken to evaluate the profile, mechanisms, and course of traumatic glaucoma (TG) in patients who have sustained blunt ocular trauma. Methods: One hundred consecutive patients who sustained ocular blunt trauma (OBT) during the 1-year were enrolled in the study. All the patients underwent a comprehensive ophthalmic evaluation of the anterior and posterior segments along with relevant investigations. Patients who were found to have an intraocular pressure (IOP) ≥21 mm Hg with or without glaucomatous optic neuropathy were considered to have TG and started on appropriate treatment. Results: Eleven of the 100 consecutive patients who sustained OBT developed TG. The age of patients ranged between 8 and 65 years, 8 were male and 3 female; 6 patients were

Aims: The aim of this study is to analyze the outcomes of air descemetopexy with/without suture augmentation (AD) for Descemet's membrane detachment (DMD) post-cataract surgery. Materials and Methods: This prospective study included 51 eyes that underwent AD at a tertiary hospital. The outcome measures were successful Descemet's membrane (DM) reattachment and improvement in visual acuity by at least two Snellen lines. Statistical Analysis: Mean, standard deviation, and percentage were used to summarize the data. Wilcoxon signed-rank test, Chi-square test, and Fischer's exact test were used to calculate statistical significance. P < 0.05 was considered statistically significant. Results: Out of 52,396 cataract surgeries, 51 patients required surgical intervention for DMD, postoperatively. The mean age of the participants was 66.67 ± 9.8 years with a male: female ratio of 6:11. A nonplanar DMD was found in 56.87% (n = 29). The most common surgery preceding DMD was small incision cataract surgery (68.6%; n = 35). The mean interval between cataract surgery and descemetopexy was 9.3 ± 7.9 days. The mean pre- and post-descemetopexy visual acuities were 1.01 ± 0.6 and 0.44 ± 0.49, respectively (P < 0.00001). After an air tamponade, an additional suture (s) had to be placed in 62.8% (n = 32) cases, out of which 23 required a single suture, seven needed two sutures, and two needed three sutures. A successful DM reattachment was seen in 92.2% (n = 47) with the first attempt. There was a statistically significant improvement in visual acuity post-descemetopexy irrespective of the timing of surgery (P < 0.001 for all surgeries performed within 2 weeks and P = 0.03 for surgeries performed later). Conclusion: AD is a safe and effective procedure for the treatment of post-cataract surgery DMD.

Purpose: The aim of this study was to assess the knowledge, attitude, and practice (KAP) pattern towards COVID-19, among patients presenting to eye care hospitals during the last phase of lockdown period. Methods: A multicenter cross-sectional survey was conducted from May 15 to June 15, 2020 in five tertiary eye care hospitals in South India to assess the KAP towards COVID-19. Each of the hospitals belonged to one of the three different zones assigned in India based on number of infections. Red zones represent hotspots and orange/green zones represent regions with medium and lower caseloads, respectively. A validated questionnaire was administered through telephone and responses were recorded on a Google form. Results: Out of the total (n = 6119) participants, 3081 were from hospitals in green zone, 2110 from the orange zone, and 928 from red zone. Majority of participants were above 50 years of age (42%) and 15.54% were illiterate. The mean (percentage) scores of knowledge, attitude, and practice were 21.26 (82%), 9.37 (92%), and 10.32 (86%), respectively. KAP among patients more than 50 years of age and in illiterate individuals was significantly less (P < 0.01) when compared with all other groups. Participants from red zone had a significantly better attitude (P < 0.01) compared to other centers. Conclusion: Although the overall KAP regarding COVID-19 disease was robust (above 80% in all categories) in our participants, the high risk elderly population (>50 years) and illiterate individuals had a significantly lower KAP. These are populations in which education should be emphasized and appropriately delivered as a way to reduce COVID-19 risk.

Background: LASIK for refractive error correction has become a universal surgery. Despite its popularity, the estimated prevalence of traumatic flap dislocations in post-LASIK patients is 3.9%, and it is sometimes associated with epithelial ingrowth. The prognosis in such cases depends on the rapid surgical revision of the flap with the removal of the EI and perioperative steps to prevent Epithelial ingrowth (EI) recurrence in the future. Purpose: The video aims to display the steps involved in revising the flap, removing EI, and tips to prevent its recurrence. Synopsis: A 33-year-old post-LASIK patient presented with decreased vision, photophobia, and glare during the COVID pandemic in the right eye for 2 months. The best-corrected visual acuity was reduced to 6/60. The anterior segment revealed traumatic flap dislocation along with macro fold temporally and epithelial ingrowth. She underwent a successful flap revision surgery with no recurrence of epithelial ingrowth postoperatively. Highlights: A successful revision of a 2-month-old traumatic folded flap was performed along with the complete removal of EI. It explains the step-by-step approach to avoid the recurrence of EI in each step of the surgical revision of the flap. The video is self-explanatory and guides novice surgeons too. Video link: https://youtu.be/JuOSjhrfw0g

Background: Optometrists with different levels of optometric education in India provide eye care services under various capacities to the public. Aim: The study evaluated the status of optometrists in terms of their knowledge, skills and frequency of skill utilisation in public and private sectors. Setting: A quantitative study design was adopted using a survey questionnaire that was distributed to optometrists providing eye care services in public and private sectors. Methods: A structured and validated questionnaire with closed-ended questions was administered to 650 participants. Results: A total of 400 completed questionnaires were received (response rate = 62%) of which 207 respondents were males (52%) and 193 females (48%). Most (57%) of the respondents were bachelor’s degree holders with 86% of the respondents in the private sector and 14% in the public sector. The knowledge level of ancillary and diagnostic tests (69%) was the least amongst public sector optometrists whilst it was binocular indirect ophthalmoscopy (66%) for private sector optometrists. The skill levels in indirect ophthalmoscopy was least amongst the public sector (56%) and private sector (44%) optometrists. Indirect ophthalmoscopy showed the least frequency of skill utilisation amongst public sector (13%) and private sector (34%) optometrists. Conclusion: The study highlighted the need for mandating best practice standards, and expanding the scope of defined practice, as optometrists are better suited for diagnostic roles and comprehensive eye examinations, and can contribute effectively towards averting preventable blindness.

To report a case of, atypical pellucid marginal degeneration (PMD) with hydrops and to describe the inverted bell sign as the diagnostic feature in topography. A 40-year-old male presented to us with acute pain, redness, and loss of vision. On examination, hydrops was noted in the superior cornea in the right eye and advanced PMD in the left eye. The typical topographic signs of PMD have been described. The conservative management of hydrops in our case resulted in improvement in visual acuity. Early diagnosis and treatment of this condition with regular follow-up are essential for a good visual prognosis in these patients.

Lattice corneal dystrophy (LCD) is rare, bilateral, slowly progressive, inherited condition characterized by amyloid deposition in the corneal stroma. Recurrent corneal erosions most commonly occur with LCD due to abnormal basement membrane complexes incapable of providing normal structural integrity to the epithelial layer predisposing the cornea to microbial infections such as bacterial and fungal keratitis. Amyloid fibrils have also been postulated to cause tissue damage by stimulating local and nonlocal immune cell infiltration into the tissues and producing pro-inflammatory cytokines leading to sterile inflammation. This case is one of the few rare case reports of sterile infiltrates in LCD Type 1, patients identified after multiple treatment failures to the best of our knowledge.

Background: Manual Small Incision Cataract Surgery (MSICS) is the basic of cataract surgery with a short learning curve, less time-consuming, and can be performed in high-volume setups at low cost. Hence, it is imperative for every surgeon to know in detail the perfect way of wound construction and nucleus delivery methods. Purpose: A teaching video prepared for the postgraduates to understand the importance of creating a proper side port wound construction in MSICS. Synopsis: In MSICS, the side port is made for the intraocular manipulation, to fill the anterior chamber (AC) with viscoelastic and Balanced salt solutions, for easier rhexis in fluid tight maintained AC, for easy aspiration of cortex with deep AC, for cutting the extended rhexis margin with the vannas and for dialling the IOL into the bag complex (Video clip 1). In this video, a limbal stab incision for the side port is created with the 15 degree side port blade made of polycarbonate handle with maximum width of a 20G needle (1.5mm) made parallel to the iris plane of 1.5mm and the 90-110 degree distance from the superior main scleral incision to avoid astigmatic change in axis and power (Video clip 2). It is constructed with the pushing force applied along the cutting edge of the blade through the cornea to create an internal and external ostium, 0.5mm to 1mm thickness into the corneal stroma. The incision produced this way is considered astigmatically neutral (Video clip 3&4). Apart from the astigmatism, the side port is very important to avoid intra and postoperative wound leakage, iris prolapse, and DM detachment. The wound leakage favours bacterial contamination and endophthalmitis (Video clip 5). Ensure good quality of blade while entering the AC (Video clip 6). Hence, albeit small, the side port incision is as important as the main incision. Highlights: The video explains the importance of creating a proper sideport, the benefits and the complications involved were clearly explained. Video link: https://youtu.be/nljn8c6XaHY

Background: Symblepharon occurs as chronic sequelae of severe chemical injuries. The risk of recurrence is high due to unpredictable wound healing of conjunctiva and tenons following excision in young patients. Gore-tex aids in prevention of the recurrence of pterygium 1. Purpose: To present a surgical video on role of Gore-tex in grade 4 Symblepharon lysis. Synopsis: A 28-year-old male with a previous history of Grade 4 chemical injury presented with symblepharon and total obliteration of both upper and lower fornices after one year in the right eye. He underwent symblepharon lysis, Living related conjunctival allograft, Amniotic membrane graft and Gore-tex. The video explains the surgical steps in detail. A 360-degree complete peritomy was done, Symblepharon was released from the corneal surface, and the fibrotic tissue was extensively dissected away from the corneal surface and released into the fornix. Further, cryopreserved AMG was placed over the entire raw ocular surface and sutured to the episclera with glue. Prepared Gore-tex was placed on the superior and inferior fornix and sutured with 10-0 nylon suture. Again, AMG was placed over the Gore-tex in the fornices and covered with glue. A small 2x2mm biopsy of limbal stem cells from the superior limbus was already excised from the fellow eye (CLAG) and then Lr-CLAL was prepared from the patient's mother. These two grafts were placed on the nasal and temporal bulbar surface over the AMG and sutured to the underlying AMG and the episclera with glue. The entire surface was then covered with the AMG to promote epithelisation. At one month postoperative period, patient had stable ocular surface with intact Limbal conjunctival graft with mild conjunctival recurrence of fibrosis superiorly. Highlights: The video clearly explains the surgical steps of Symblepharon and the benefits of using Gore-tex. Online Video Link: https://youtu.be/aFfq2x9QBwA

Background: This video demonstrates a useful technique of keratoplasty which can be routinely undertaken by all surgeons when imaging modalities such as anterior segment optical coherence tomography are not available and prior patient history is not forthcoming. Purpose: To demonstrate a technique of lamellar separation and layer by layer removal of host cornea when dealing with keratoplasty in perforated corneal ulcers, adherent leucomas, dense corneal opacities, which obscure visualization of the iris and anterior chamber details. Synopsis: In this video, we demonstrate penetrating keratoplasty in a failed opacified graft with iridocorneal adhesions, with no visualization of anterior chamber details. Lamellar dissection of the host cornea is done starting at its periphery and moving centrally, with gentle peeling of the superficial layers, the epithelium and bulk of stroma, following which, the deeper portion of the cornea is dissected and separated from underlying adherent iris tissue. Layer by layer separation allows better visualization through the remaining thin layers of the cornea. This permits fine dissection and layered removal of the cornea, thereby avoiding injury to iris and lens. Debulking of the host cornea decreases the force that is needed to be applied to separate adherent iris tissue from the host cornea, and reduces the chances of sudden entry into the anterior chamber and subsequent damage to the iris or lens. This also reduces the chance of iris tears, iridodialysis and bleeding from the iris and helps maintain iris integrity, which is essential intraoperatively for protection of lens and anterior chamber formation, and to avoid glare and photophobia postoperatively. Preventing iris damage also reduces the chances of formation of peripheral anterior synechiae (PAS), which can predispose to graft rejection, graft failure and secondary glaucoma. Highlights: Layer by layer corneal separation beginning inside the graft host junction, careful separation of iridocorneal adhesions and PAS is a helpful technique to optimally preserve the anterior segment anatomy during difficult cases of penetrating keratoplasty. Online Video Link: https://youtu.be/ZmQQhuOnAh4

Context: Ocular trauma is the cause of one-third of monocular blindness. The inherent risk factors for ocular injuries among the rural population, and lack of surveys conducted in the rural areas stresses the need for a descriptive study that identifies the cause and pattern of ocular injuries and visual outcome among the rural population. Aims: To analyze blunt ocular trauma with respect to (i) demographic profile, (ii) mode of injury, and (iii) the ocular structures involved. Settings and Design: Prospective study. Subjects and Methods: This study included 95 cases of blunt ocular trauma who attended the casualty and the outpatient Department of Ophthalmology of our institution. All patients underwent a comprehensive ocular examination along with relevant radiological tests. All the cases were appropriately treated and followed at regular intervals to assess the visual outcome and complications. Statistical Analysis Used: Not applicable. Results: The male to female ratio was 4.5:1; majority of the patients (42 patients, 44.2%) belonged to the 21–40 years age group. About fifty patients (52.6%) were from agricultural class. In 46 patients (48.4%) the injuries were agricultural in nature. Subconjunctival hemorrhage was the most common finding (36 patients, 37.89%) followed by traumatic uveitis (27 patients, 28.42%) and lid and adnexal injuries (21 patients, 22.10%). Conclusions: Ocular blunt trauma in the rural population is common in males and mostly agriculture-related with involvement of multiple ocular structures in the same eye. The spectrum of ocular complications can range from trivial to severe sight-threatening injuries. It is recommended that health education highlighting early diagnosis and prompt treatment of ocular injuries can help to reduce the ocular morbidity.