Haryana Journal of Ophthalmology Jan-April 2024 Vol.XVI (No.1)

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 46 RETROSPECTIVE STUDY TO OBSERVE UTILITY OF HOUSEHOLD ITEM FOR VISUAL REHABILITATION ON THE PATIENTSWHO HAD NO HOPES OF GETTING THEIR VISION BACK Dr.Ashwini Kumar1 ARTICLE INFORMATION AFFILIATION OF ALL AUTHORS: ABSTRACT 1. Mahavir Netralaya kankarbagh Patna Corresponding author Dr. Ashwini Kumar Consultant – Ophthalmologist& Low vision aid specialist , Mahavir Netralaya kankarbagh Patna Email - kumarashwini816@gmail.com NA Article received Article accepted Article on line Keywords Presented at January 2024 January 2024 February 2024 Low vision, visual rehabilitation, household objects NA A retrospective study was done on 55 patients in the month of November 2021 at Mahavir Netralayakankarbagh Patna to access the utility of household items in visual rehabilitation. Majority of the patients were of poor social economic background. Consent for the research was taken before study, no invasive technique was used. Majority of the patients express satisfaction and availability to perform simple day to day task. The researcher recommended COMMENTARY | JAN-APR 2024 aids as needle threader, torch light and most importantly individual counseling as per their profession. There was a bell shaped distribution of patients who participated in the research , with majority of the subjects were in the 2nd to 5th decade of life. Only 1/5th of subject were female an 4/5th are male, before coming the visual acuity of the subjects were overwhelmingly poor and had limited scope of correction using lens or glasses.

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 47 COMMENTARY | JAN-APR 2024 Retrospective Study to Observe utility of household item for visual rehabilitation on the patients who had no hoops of getting their vision back

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 48 COMMENTARY | JAN-APR 2024 Retrospective Study to Observe utility of household item for visual rehabilitation on the patients who had no hoops of getting their vision back

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 49 COMMENTARY | JAN-APR 2024 Retrospective Study to Observe utility of household item for visual rehabilitation on the patients who had no hoops of getting their vision back

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 50 COMMENTARY | JAN-APR 2024 Retrospective Study to Observe utility of household item for visual rehabilitation on the patients who had no hoops of getting their vision back

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 51 COMMENTARY | JAN-APR 2024 Retrospective Study to Observe utility of household item for visual rehabilitation on the patients who had no hoops of getting their vision back The author concludes that humble counseling and individual training can do miracles in patients who had no hoops of normal lifestyle with household items which are very convenient.

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 52 COMMENTARY | JAN-APR 2024 Retrospective Study to Observe utility of household item for visual rehabilitation on the patients who had no hoops of getting their vision back REFERENCES David Turbert and Dan Gudgel .What Is Low Vision? American Acadamy of Ophthalmology-Feb, 2019. Mitchell Scheiman, Maxine Scheiman., Stephen G. Whittaker . Low Vision Rehabilitation: A Practical Guide for Occupational Therapists . Slack Incorporated.15 Dec 2006 Rebika Dhiman, Itika Garg, Sneha Aggarwal, Rohit Saxena, Ra d h i k a Ta n d o n . Low Visi o n Ass e ssme n t a n d Rehabilitation. DJO [serial online] 2017;28:7-12. Dandona R, Dandona L, Srinivas M, Giridhar P, Nutheti R, Prasad MN. Planning Low Vision Services in India: A population - based perspective. Ophthalmology 2002;109:1871-78. Dandona L, Dandona R, Naduvilath TJ, McCarty CA, Srinivas M, Mandal P, et al. Burden of moderate visual impairment in an urban population in southern India. Ophthalmology 1999;106:497-504. Lovie – Kitchin JE. Low vision services in Australia. J Vis Impairment Blindness 1990;84:298-304. Gresset J, Baumgarten M. A survey of the utilization of rehabilitation services by the visually impaired elderly . In: Kooijman AC, Looijestijn PL, Welling JA, Van der Wildt GJ, editdors. Low Vision Research and New Developments in Rehabilitation. Amsterdam: IOS Press, 1994;481-84. Rosenbloom AA, Goodrich G. Visual rehabilitation historical perspectives – future challenges. In: Johnston AW, Lawrence M, editors. Low vision ahead II: Proceedings of the International Conference on Low Vision. Melbourne Association for the Blind, 1990; 286-91. 1. 2. 3. 4. 5. 6. 7. 8. Financial disclosure Conflict of Interest Acknowledgements Copyright Transfer None None Nil Copyright transfer form signed by corresponding author on behalf of all co-authors FOOTNOTES AND DISCLOSURES

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 53 COMMENTARY | JAN-APR 2024 Retrospective Study to Observe utility of household item for visual rehabilitation on the patients who had no hoops of getting their vision back Hoppe E, Bowyer NK, Evans S. Access to vision rehabilitation services for older adults. Optom Vis Sci 1993;70:164. World Health Organization. The Management of Low Vision in Children. Report of a WHO Consultation: Bangkok, July 1992. Geneva: World Health Organization, 1993. WHO/PBL/93.27. Dandona R, Dandona L, Naduvilath TJ, McCarty CA, Rao GN. Awareness of eye donation in an urban population in India. NZJ Ophthalmol 1999;27:166-69 Pal N, Titiyal JS, Tandon R, Vajpayee RB, Gupta S, Murthy GV. Need for optical and low vision services for children in schools for the blind in North India. Indian J Ophthalmol. 2006;54:189–93. Khan SA, Shamanna B, Nuthethi R. Perceived barriers to the provision of low vision services among ophthalmologists in India. Indian J Ophthalmol. 2005;53:69–75. 9. 10. 11. 12. 13.

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 54 OUR EXPERIENCE WITH AURO-KPRO (BOSTON TYPE 1) Dr V.SHANKAR NAG MBBS.MS1 , Dr.Siva rama Krishna MBBS,DNB2 , Dr Madhu Uddaraju MBBS,MS3 ARTICLE INFORMATION AFFILIATION OF ALL AUTHORS: ABSTRACT 1. -- 2. -- 3. -- Corresponding author Dr. Madhu Uddaraju MBBS,MS Consultant – Email - eyedrmadhu@gmail.com Keratoprosthesis is usually the last option for end stage corneal blindness and is also commonly performed in eyes with multiple failed grafts or in cases with high risk of rejection where a regular corneal transplant is more likely to fail (1,2). Boston type1 is the most commonly performed of all types of Keratoprosthesis. In Indian subcontinent it is available as AURO KPRO for our patients. There is a growing need in our country among ophthalmologists to be aware of indications of Kpro to facilitate appropriate referral and also of procedure to enable basic evaluation during follow up. AIM: To elaborate the indications, procedure, clinical and visual outcomes, complications and postoperative regimen of Boston type 1 (AURO KPRO). Our experience with Auro Kpro and lessons learnt after performing 30 cases. Article received Article accepted Article on line Keywords Presented at November 2023 January 2024 February 2024 Boston keratoprosthesis, Keratoprostheis, ocular surface disease. NA INTRODUCTION: The choice of Kpro depends on the underlying etiology, status of ocular surface, tear film. Broadly categorized into type1 and type2 Kpros. Eyes with normal lids, blink and tear film without any immunological etiology are considered as candidates in type1 the protype of which is Boston Type 1Kpro (Auro Kpro). However, in eyes with severely dry or keratinised ocular surface with underlying immunological disorder, associated with lid abnormalities, the type 2 Kpros are considered as treatment of choice. Design of Kpro: Kpro is a semiartifical prosthesis and has four components (Figure1)- 1. Optical cyclinder- made of Polymethyl methacrylate(PMMA) 2. Donor tissue- corneal rim 3. Fenestrated backplate – for passage of aqueous flow 4. Titanium Ring- for locking The assembly of above components form the KPRO Complex. In the recent designs of Boston Type1 Kpro the titanium locking ring is eliminated and locking system is incorporated in the back plate design. Figure 1: ORIGINAL ARTICLE | JAN-APR 2024 METHODOLOGY: Retrospective Analysis - 24 months All the eligible cases underwent Keratoprothesis implantation, Aphakic or Phakic depending upon the lens status of the recipient. INCLUSION CRETERIA: With improved outcomes, the indications for Type 1 Kpro have been expanding over the past decade. However, it is best to categorize these based on prognostic criteria since eyes with guarded prognosis have an increased risk to develop complications [2,3]. Good prognosis • Multiple failed grafts • Aniridia • Herpetic keratitis

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 55 • Silicon oil filled eyes Guarded prognosis • Pediatric corneal conditions • Chemical injuries Very guarded prognosis • Underlying immune conditions such as Stevens– Johnson syndrome (SJS)/ocular cicatricial pemphigoid (OCP) • Severe chemical injuries with severe forniceal shortening and lid abnormalities Paediatric Kpro forms a separate entity and the Type 1 Kpro is performed in paediatric population to visually rehabilitate children with congenital bilateral corneal disorders not amenable to penetrating keratoplasty. Type 2 Kpros are usually not performed in the paediatric population. Exclusion criteria: • Unrealistic expectations • Nil perception of light • Advanced glaucoma and retinal conditions • Unwilling or unable to come for regular follow-ups • Unwilling to accept cosmetic outcome • Unwilling to follow postoperative care and restrictions • Dense amblyopia Patient evaluation: 1. A detailed history taking to determine cause and previous intraocular surgeries is of paramount importance 2. Accuracy of Perception of light and projection of rays is assessed 3. Digital Intraocular pressure 4. Evaluation of blink mechanism, Ocular surface & tear secretion 5. Schrimmer’s above 10mm Hg 6. Ultrasound B-scan- look for Optic nerve cupping & Macula pathology 7. Lens status A-Scan – Axial length – Optical cylinder power (Table 1) 8. Look for Signs of chronic inflammation 9. Patency of nasolacrimal duct is confirmed by means of syringing to rule out focus of infection. 10. Counseling the patient and family with respect to realistic expectations, the need for compliance with postoperative care and regimen. Table 1: Axial length in mm Diopter 15 97.5 16 85.1 17 79.9 ORIGINAL ARTICLE | JAN-APR 2024 OUR EXPERIENCE WITH AURO-KPRO (BOSTON TYPE 1) 18 75.5 19 71.5 20 67.8 21 64.5 22 61.5 23 58.9 24 56.4 25 54.0 26 52.0 27 50.1 28 48.2 29 46.6 30 45.0 Selection of refractive power of optic cyclinder In Pseudophakic eyes: Retain the IOL,use the p-phakic kpro 45D In Phakic eyes: Remove the lens,implant the aphakic kpro In Aphakic eyes: Perform Core vitrectomy. SURGICAL TECHNIQUE: • Decide on the type of Kpro to be ordered: pseudophakic/ aphakic; adult (8.5mm backplate)/ pediatric (7.0mm backplate) • Axial length to be specified for aphakic Kpro • Kpro to be ordered for depending upon the lens status. • Local or general anesthesia as indicated • The recipient cornea is marked with the trephine as required with Kpro to be assembled before trephining the recipient. Backplate of the Kpro measures 8.5 mm and hence the minimum donor graft size to be 8.5 mm. The donor cornea is usually oversized by 0.5 mm. • The central 3 mm opening in the donor cornea is subsequently trephined • Fresh therapeutic grade donor cornea is preferred to assemble the Kpro • The optic is placed on teflon block. The donor graft is

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 56 ORIGINAL ARTICLE | JAN-APR 2024 OUR EXPERIENCE WITH AURO-KPRO (BOSTON TYPE 1) slided down the stem of the optic cyclinder into its slot and the back plate is slid in place. The assembly is then locked with the titanium ring and the locking of the ring is indicated by a click sound • The recipient cornea is further trephined and removed. Any intraocular procedure as planned to be performed. • If we have planned for an aphakic KPRO we should try to save the posterior capsule and in case of posterior capsular rupture,we should perform core vitrectomy before KPRO Implantation. • The assembled Kpro is then sutured like in a penetrating keratoplasty using 16 interrupted 10 o nylon sutures. In each quadrant 1 suture knot is left exposed on the conjuctival side (to attract vascularization and aid in early fusion of the graft) • A bandage contact lens is placed on the Kpro(Figure 2). Figure 2: Showing preop and post op pictures Post-operative regimen: A. Topical: i. Steroid: Prenisolone acetate 2Hourly tapered 3 monthsLoteprednol BD ii. Antibiotics: Moxifloxacin & Chloramphenicol, Polymyxin Combination with BAK iii. Anti Glaucoma agents – Timolol and Brimonidine Combination BD iv. Pulsed anti-fungal – Voricanozole/Fluconazole eye drops QID for 1 week or 10 days in every post-operative visit. v. BCL should be cleaned every month and replaced. The ocular cul de sacs and surface should be cleaned with 5 % povodine iodine in every post-operative visit and we should also look for any potential wound or prosthesis leaks before we replace the BCL. B. Systemic: i. Injection Gentamycin 2cc for 3 days. ii. Injection Dexamethasone 2cc-for 3 days. Examination during each follow-up visit: • Change in refraction. A hyperopic shift could indicate an early leak, a myopic shift could be indicative of raised intraocular pressure • Deposits on BCL, if any, to preferably be submitted for microbiological evaluation. • To assess for air bubbles under the optic flange as well as immobile bubbles beneath the BCL that could indicate early thinning of the carrier graft • The graft around the optic should be inspected for the presence of any infiltration • Slit beam examination to assess for any irregularity in the carrier graft • Presence of retroprosthetic membrane (RPM), if any • Presence of loose sutures, if any, should be removed • Intraocular pressure is monitored by digital tonometry • 90D lens examination to document the optic disc and posterior pole findings • Following removal of the BCL for replacement, the graft should be stained with sterile fluorescein to look for the presence of any epithelial defect or leak • Use of 5% povidone iodine in the eye is recommended at the time of BCL replacement. • Slit lamp photographic documentation of the eye • Humphrey visual field 24-2 analysis once in 6 months. • ASOCT to identify early graft thinning, periprosthetic tissue loss, retroprosthetic membrane, and angle details once in 6 months • B Scan ultrasonography once in a year. RESULTS:

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 57 Complications in our 30 cases DISCUSSION: Out of 30 cases, the most common indication was multiple failed grafts in 23 cases (76%). 16(53%) of them had visual improvement of better than 2/200. 5 Patients had useful ambulatory vision CF 6feet and above.9 cases had vision less than CF 6 feet with a Mean follow up period of 14.2 months. Retroprosthetic membrane (RPM) (Figure 4) has been reported as the most common complication in various series published so far with majority of the studies quoting an occurrence in more than 50% of the eyes (5). However, in our series in 2 out of 30 cases had ORIGINAL ARTICLE | JAN-APR 2024 OUR EXPERIENCE WITH AURO-KPRO (BOSTON TYPE 1) • Most common indication was multiple failed grafts 23 (76%) followed by Vascularised corneas 5 (16.6%) cases • Majority of them were one eyed – 19 (63 %). • All the 16(53%) of them had visual improvement of better than 6/60. 5 (16.6%) Patients had useful ambulatory vision CF 6ft and above. • Mean follow up period was 14.2 months. • 2 Cases had Thick RPMs (Non amenable to Yag laser) • 4 Cases had Extrusion of KPRO (2 were repeated) • 2 cases had Endophthalmitis -1 salvaged by core vitrectomy • 2 cases were effected with fungal infiltrate –Managed medically along with collagen cross linking • 20 cases had optic disc cupping of more than 0.5, Glaucoma drainage device was implanted in 7 cases Indications in our 30 cases Visual outcomes in our 30 cases

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 58 with CXL (Fig 5) CONCLUSIONS (LESSONS LEARNT): Antibiotics with BAK and prophylactic topical pulsed anti fungals every 3 months for a few weeks has a role in prevention of endophthalmitis & Infiltrates. Monthly follow-up with meticulous examination for leaks are mandatory. Selective suture knots exposure on the conjunctival side will attract vascularization and aid in early fusion of the graft. This will also prompt the patient to visit us when BCL is displaced due to irritation. To avoid angle crowding, we prefer to use 7.0mm back plate Auro KPRO can be used be used as a last resort in cases where we know graft failure is inevitable Considering the tropical region, in which we live with a primarily agrarian population, the risk of infection is probably bound to be more compared to the results quoted in the Western literature [10]. The indication profile in the developing countries also varies with the guarded and very guarded prognosis categories forming a major proportion of cases that undergo Type 1 Kpro. Hence, direct comparisons with outcomes and complications and applying them to different geographical zones might not be appropriate. With a holistic understanding of Kpro and its implications, the need to follow strict postoperative compliance with medications, follow ups and restrictions cannot therefore be overemphasized. Herein, decision making and counseling plays the most crucial aspect of Kpro surgery, knowing when to operate and when not. ORIGINAL ARTICLE | JAN-APR 2024 OUR EXPERIENCE WITH AURO-KPRO (BOSTON TYPE 1) RPM. It has also been implicated as one of the causes for sterile corneal melts by virtue of preventing access of aqueous to the carrier graft [6]. A recent study has shown no benefit of titanium back plate over a PMMA back plate in the formation of RPM, with similar rates of RPM noted in both [7]. Performing a total pars plana vitrectomy appears to reduce the rate of RPM formation [8]. Visually insignificant RPM’s can be observed and monitored, visually significant RPM’s can be addressed by means of neodymium: yttrium aluminum garnet laser membranotomy or a surgical membranectomy. Glaucoma is very common sequel in Kpro surgery. An eventual drainage procedure would also be required in most of the cases. To avoid angle crowding we prefer to use 7.0 mm back plate. 20 cases had optic disc cupping of more than 0.5 and Glaucoma drainage devices was implanted in 7 cases. In our study, 2 out of 30 cases went in to endophthalmitis. One eye salvaged with core vitrectomy. endophthalmitis was reported in 11.9% at a mean follow up of 64.9 months in a single center series from Thailand (9). In our study, 2 out of 30 cases were effected with fungal infiltrate managed medically along with collagen cross-linking (Fig 5). Lekhanont etal. reported infective keratitis in 21.4% of the eyes (9). Out of 30 cases, 4 Kpros were extruded (figure3). In 2 cases, Kpro was repeated COMPLICATIONS OF KPRO Extrusion of Kpro(fig3) RPM (Fig4) Fungal infections before and after medical management along Financial disclosure Conflict of Interest Acknowledgements Copyright Transfer None None Nil Copyright transfer form signed by corresponding author on behalf of all co-authors FOOTNOTES AND DISCLOSURES

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 59 ORIGINAL ARTICLE | JAN-APR 2024 OUR EXPERIENCE WITH AURO-KPRO (BOSTON TYPE 1) REFERENCES Khan B, Dudenhoefer EJ, Dohlman CH. Keratoprosthesis: An update. Curr Opin Ophthalmol 2001;12:2827. Saeed HN, Shanbhag S, Chodosh J. The Boston keratoprosthesis. Curr Opin Ophthalmol 2017;28:3906. Yaghouti F, Nouri M, Abad JC, Power WJ, Doane MG, Dohlman CH, et al. Keratoprosthesis: Preoperative prognostic categories. Cornea 2001;20:1923. Dohlman CH, Mona HD, Graney J. The Boston keratoprosthesis: A new threadless design. Digit J Ophthalmol 2007;13:3. Lee R, Khoueir Z, Tsikata E, Chodosh J, Dohlman CH, Chen TC, et al. Longterm visual outcomes and complications of Boston keratoprosthesis type II implantation. Ophthalmology 2017;124:2735 Chan CC, LoVerde L, Qiang J, Nordlund ML, Holland EJ. Incidence, risk factors, and surgical management of Boston type 1 keratoprothesis corneal melts, leaks, and extrusions. Cornea 2016;35:104956. Talati RK, Hallak JA, Karas FI, de la Cruz J, Cortina MS. Retroprosthetic membrane formation in Boston keratoprosthesis: A Casecontrolmatched comparison of titanium versus PMMA backplate. Cornea 2018;37:14550 Perez VL, Leung EH, Berrocal AM, Albini TA, Parel JM, Amescua G, et al. Impact of total pars plana vitrectomy on postoperative complications in aphakic, snapon, type 1 Boston keratoprosthesis. Ophthalmology 2017;124:15049. Lekhanont K, Thaweesit P, Muntham D, Chuckpaiwong V, Vongthongsri A. Mediumterm outcomes of Boston type 1 keratoprosthesis implantation in Bangkok, Thailand. Cornea 2014;33:13129. Iyer G, Srinivasan B, Gupta N, Padmanabhan P. Outcome of Boston keratoprosthesis in a developing countryimportance of patient selection, education, and perioperative care: The Indian experience. Asia Pac J Ophthalmol (Phila) 2012;1:2027. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 60 ASSESSING KNOWLEDGE, ATTITUDE AND PRACTICE REGARDING CONJUNCTIVITIS AMONG PRIMARY HEALTH CARE PROFESSIONALS Dr Bhailume Prajakta V1 , Dr. Maxwell Silva2 , Dr. Pargaonkar Nachiket3, Dr. Malcolm Silva4 ARTICLE INFORMATION AFFILIATION OF ALL AUTHORS: ABSTRACT 1. Assistant professor Department of OPhthalmology B.J.Govt medicalcollege ,Pune 2. Junior Resident in Department of Ophthalmology B.J.Govt Medical College Pune 3. Senior Resident Department of Ophthalmology B.J.Govt Medical College Pune 4. Assistant Professor Department of Pharmacology, Goa Medical College Corresponding author Dr. Prajakta Bhailume Consultant – Glaucoma Services, Shroff Eye Centre Phone number-8007789051 Email - praj232@gmail.com Introduction: Conjunctivitis also referred to as pink eyes is a common eye disease encountered by primary health care professionals.India witnessed an epidemic of conjunctivitis in month of August 2023.The primary Health care professionals play a crucial role in early diagnosis ,referral and appropriate management of conjunctivitis.Assessing knowledge,attitude and practices among primary health care givers regarding conjunctivitis will help us to find out the lacunae in treatment and avoid further complications. Mehods: This was a cross sectional questionnaire based study conducted in a tertiary care centre of Maharashtra during 2nd to 4th week of August 2023 which saw a peak in conjunctivitis epidemic in India.The questionare were distributed to 500 primary health care providers in the hospitals which included interns,resident doctors of other departments and nursing staff.The data was computed and analyzed by using statistical package for social science version 20 (SPSS version 20) descriptive analyses were conducted. The result for each item on the questionnaire were reported as frequencies and percentages. Results: The statistical analysis showed that the primary health care givers(99.4%) had adequate knowledge regarding itiology, diagnosis and treatment of conjunctivitis . Maximum respondents were Interns (58%) illustrating their role in primary health care. 62.8% health care workers were not aware about self limiting nature of conjunctiivitis and unnecessary use of antibiotics eye drops. Hospital education and awareness programes play an important role (70.4%) in spreading knowledge was seen in our study. Conclusion:Primary health care workers play a crucial role in diagnosis and prevention of spread of conjunctivitis.They should be educated regarding conjunctivitis through various media and prevent complications and reduce the healthcare burden. Article received Article accepted Article on line Keywords Presented at November 2023 January 2024 Feburary 2024 Conjunctivitis, primary health care professionals, knowledge, attitude, practice NA INTRODUCTION Conjunctivitis is inflammation of conjunctiva i.e. palpebral, bulbar and marginal conjunctiva (the thin transparent layer of tissue that lines the inner surface of the eyelid and covers the white part of the eye), often called “pink eye”. Conjunctivitis can present as unilateral or bilateral disease of eye and can affect all age groups,gender and economic strata of the society. Generally, considered as a minor eye infection it can sometimes advance into serious complications . (1) A healthy conjunctiva is required to maintain corneal transparency and eventually maintaining clear vision . Typically, conjunctivitis is caused by viruses, bacteria and allergy (Morrow and Abbott 1998). Hands and URTI are the source to transmit bacterial and viral conjunctivitis. It is a contagious disease where mild disease is self-resolving however needs proper care and treatment. But severe disease needs immediate treatment to avoid further corneal complications. When diagnosed, ophthalmologists treat conjunctivitis with suitable medications ORIGINAL ARTICLE | JAN-APR 2024 as per the presentation of the patients. Good personal hygiene can prevent the spread of conjunctivitis. Sanitization of hand, face, clothes and towel is necessary to control the spread of conjunctivitis .(2) Conjunctivitis is commonly seen in wards,emergency departments and in general practice of a hospital .80 % of cases are diagnosed by non ophthalmologist like Primary health care givers including Interns,Resident doctors and nurses .(3)

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 61 Assessing Knowledge, Attitude and Practice Regarding Conjunctivitis Among Primary Health Care Professionals A study of knowledge, attitudes and practices (KAP) among the population has been widely used in clinical areas to educate the masses regarding prevention and treatment of infective diseases. (4,5) It is a common and low budget tool to assess the knowledge of population regarding a disease and thus implement appropriate measure to reduce the burden of diseases especially in contagious diseases.(4,5) Nurses, Interns and Resident doctors play an important part concerning prevention of conjunctivitis through providing health education for the patients about meaning, causes, sign & symptoms, contributing factors, preventive measures and management of acute infective conjunctivitis. They help aid in decreasing the effect of the disease that has already developed through early detection and prompt treatment of the disease to steady it’s progress, encouraging personal strategies to prevent recurrence, and to return patients to their original health and function to prevent long- term problems, also should support in identifying family with community resources that will promote health maintenance.(6) Therefore knowledge, attitudes and practices are important to guide the Health care professionals regarding prevention and treatment so as to avoid further complications and improve the visual prognosis of patients. The motive of our study is to give knowledge and to teach proper Attitude and practice about conjunctivitis regarding – cause, risk factors, treatment and prevention. Health care workers are primary care giver and they can assess the patient on initial signs and symptoms, and advice appropriate treatment reference and counselling. AIMS AND OBJECTIVES: a) To assess the Knowledge, Attitude and Practice about Conjunctivitis among Health care Professionals. b) To make Health care workers aware of early treatment and prevention of spread of conjunctivitis. METHODOLOGY Study design A Cross – sectional study was conducted among Health Care Professionals to assess the knowledge, attitude and practice of conjunctivitis in a tertiary healthcare centre of Maharashtra. The Study was conducted from 2nd week of August 2023 to 4th week of August 2023. Questionnaires were distributed to 500 Health care Professionals who were willing to participate and collected back from them. Study tool A structured questionnaire was used which contained close ended question to assess the knowledge, attitude and practice regarding conjunctivitis. Self-developed questionnaire was used which was approved by expert of faculty ophthalmology and faculty of community medicine. A questionnaire-based study which contain Demographic part: It contain question regarding age, gender and qualification. Questionnaire: 24 knowledge-based questions about conjunctivitis which gave emphasis on causes, differential sign and symptom, diagnosis, treatment, prevention of conjunctivitis. Source of information for Health care professionals: It contain different source of information where they get knowledge about conjunctivitis Validity and Translation The questionnaire of the study went through a face and content validation. The questionnaire is reliable and the reliability Chronbach’s alpha value is 0.771. Cronbach alpha value is done on 30 patients. Questions were in a language familiar to the responden English,Hindi or Marathi. Study procedure The data was collected from Health care Professionals of a a tertiary health care Hospital in Maharshtra where they could be approached. After explaining purpose of study, questionnaire was distributed along with consent form. Appropriate time was given to each participant for completion of questionnaire. When they completed answering the questions, questionnaire was collected on the spot. Each question was given +1 mark.Score below 13 showed the health care professional had poor knowledge above 13 had adequate knowledge. Ethical consideration The study has been approved by ethical committee of the hospital. According to standards, consent form was taken from the participant before data collection Participants were ensured that confidentiality of the information will be maintained. Health Care Professionals participate voluntary and had right to with draw from study at any point. Statistical analysis The data was computed and analyzed by using statistical package for social science version 20 (SPSS version 20) and descriptive analyses was conducted. The result for each item on the questionnaire was reported as frequencies and percentages. Comparative mean was done on demographics. RESULTS Demographic Characteristics ORIGINAL ARTICLE | JAN-APR 2024

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 62 According to the table no 1 description of demography of characteristics shows that Majority of respondents are female by making frequency and percentage of 309 (61.8%) who were in greater number as compared to male. 256 (60.07%) respondents were of age range below 25 years. We also found that majority of the Health care professionals who answered the questionnaire were Interns 290(58.0%) illustrating their role in primary health. Table no 1. Demographic characteristics QUESTION RESPONSE According to the table no 2 it showed that 497 (99.4%) respondents known about disease conjunctivitis. It was statistically seen that 500 (100.0%) know that conjunctivitis is a contagious disease (spread through person to person) and 477 (95.4%) were aware that conjunctivitis spread via Air, contact with contaminated surfaces. 452(90.4%) respondent knew that conjunctivitis spreads through sharing of eye makeup, towel or eye drops. Majority of respondent 492(98.4%) knew that conjunctivitis can be caused because of viral, bacterial infection and allergy. 500 (100%) respondents knew that redness, pain, discharge in eye are common symptoms of conjunctivitis. In addition, Irritation, burning sensation, sensitivity to light and blurring of vision are also symptoms of conjunctivitis was known to 487 (97.4%) respondents. 398 (79.6%) knew that contact lens has possibility to cause conjunctivitis, and 431 (86.2%) knew that contact Lens which is being used should be discarded when symptoms of conjunctivitis appear. 406 (81.2%) knew that Purulent discharge formation in eye, crust over eye lashes, inflamed eye are also symptoms of conjunctivitis. 495(99.0%) knew that it is important to show to a health care facility when encountered with such symptoms and 413 (82.6%) knew that conjunctivitis can be visually threatening, if not treated. 396(79.2%) respondents knew that Mild conjunctivitis is diagnosed through signs and symptoms. For further evaluation of conjunctivitis, sampling is done through eye swab and culture was known to 298(59.60%) respondents, and for diagnoses of conjunctivitis slit lamp (bio microscopy) examination to be done, is known to 303(60.6%).It was seen that 314 (62.8%) were unaware to the fact that conjunctivitis can resolve on its own without taking any treatment which is a concern in health care system. Majority of respondent 395 (79.0%) know that clean cloth soaked in warm water and put on eye for few minutes 3-4 time per day provide relief. Artificial tear Give relief from conjunctivitis symptoms is known to 283(56.6%). For treatment of bacterial conjunctivitis antibiotics can be used is known to 487 (97.4%) respondents. 497(99.4%) respondents know that hand and eye hygiene is important preventive mode to reduce transmission. It was observed that 472 (94.4%) respondent know that touching or rubbing your eyes spread conjunctivitis. 466 (93.2%) knew that maintaining social distance from infected individual prevent spread of conjunctivitis. 337(67.4%) respondents knew that conjunctivitis is associated with FLU. Majority of respondent 469 (93.8%) knew that covering your mouth and nose while coughing and sneezing prevent germ spread. Demographics Frequency Percentage Gender Male 191 38.2% Female 309 61.8% Age <25 256 51.2% 25-60 244 48.8% Qualification Intern 290 58.0% Nursing Staff 112 22.4% Resident 98 19.6% Question Yes N (%) No N (%) Don’t know N (%) Are you aware of the disease named Conjunctivitis? 497(99.4) 3(0.6) 0(0) Is Conjunctivitis a contagious disease (spread through person to person)? 500(100) 0(0) 0(0) Does Conjunctivitis spread via 477(95.4) 20(4.0) 3(0.6) Air, contact with contaminated surfaces? Table no 2. Question Yes N (%) No N (%) Don’t know N (%) ORIGINAL ARTICLE | JAN-APR 2024 Assessing Knowledge, Attitude and Practice Regarding Conjunctivitis Among Primary Health Care Professionals

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 63 Conjunctivitis can be caused because of viral, bacterial infection and allergy? 492(98.4) 3(0.6) 5(1.0) Are Redness, pain, discharge in eye common symptoms of conjunctivitis? 500(100) 0(0) 0(0) Irritation, burning sensation, sensitivity to light and blurring of vision are also symptoms of conjunctivitis? 487(97.4) 3(0.6) 10(2.0) Contact lens has possibility to cause conjunctivitis? 398(79.6) 71(14.2) 31(6.2) Purulent (pus) formation in eye, crust over eye lashes, inflamed eye are symptoms of conjunctivitis? 406(81.2) 72(14.4) 22(4.4) Is it important to show to a health care facility when encountered with such symptoms? 495(99.0) 0(0) 5(1.0) Can Conjunctivitis be visual threatening, if not treated? 413(82.6) 69(13.8) 18(3.6) It is spread through sharing of eye makeup, towel or eye 452(90.4) 33(6.6) 15(3.0) Is Mild conjunctivitis diagnosed through signs and symptoms? 396(79.2) 63(12.6) 41(8.2) For further evaluation Sampling is done through eye swab and culture? 298(59.6) 84(16.8) 118(23.6) For diagnoses of conjunctivitis slit lamp (bio microscopy) examination is done? 303(60.6) 143(28.6) 54(10.8) Conjunctivitis is resolves on its own without taking any treatment. 186(37.2) 288(57.6) 26(5.2) Washed cloth soaked in warm water and put on eye for few mins 3-4 time per day provide relief 395(79.0) 82(16.4) 23(4.6) Artificial tear Give relief? 283(56.6) 183(36.6) 34(6.8) Antibiotics are used for bacterial conjunctivitis treatment? 487(97.4) 7(1.4) 6(1.2) Hand and eye hygiene are important preventive mode to reduce transmission? 497(99.4) 0(0) 3(0.6) Lens should be Discarded that you were using when symptoms of conjunctivitis appeared 431(86.2) 54(10.8) 15(3.0) Does touching or rubbing your eyes spread conjunctivitis? 472(94.4) 17(3.4) 11(2.2) Does maintaining social distance from infected individual prevent you from getting conjunctivitis? 466(93.2) 22(4.4) 12(2.4) Is conjunctivitis associated with FLU? 337(67.4) 115(23.0) 48(9.6) Does covering your mouth and nose while coughing and sneezing prevent germ spread? 469(93.8) 23(4.6) 8(1.6) ORIGINAL ARTICLE | JAN-APR 2024 Assessing Knowledge, Attitude and Practice Regarding Conjunctivitis Among Primary Health Care Professionals

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 64 Knowledge level According to table no 3-knowledge level was assessed, there were 24 questions, every correct answer given one mark, so respondents scored 13 or more than 13 were considered as adequate knowledge. majority of respondent have adequate knowledge 497 (99.4%) Table no 3. Assesment of knowledge level Source of information According to table no 4 Majority of respondent get information about conjunctivitis from hospital education system. Second source of information Internet, third source of information is television and the source of information which give least information about conjunctivitis is newspaper. Table no 4. Source of information DISCUSSION As per the results of our study it is seen that though majority of Primary Health care workers were aware about the causes, spread, prevention and treatment of conjunctivitis, emphasis should be given on educating the masses on the same to prevent further complications. Similar findings were noted in a study conducted Media Frequency Percentage Hospital education system 352 70.4 Internet 169 33.8 Television 118 23.6 Newspaper 74 14.8 by Prabhu, P.B., et al., on Attitude and Practices of Subjects with Recent History of Conjunctivitis, Regarding Treatment and Prevention of The Disease in 2015 .(7) Health care professionals should be made aware of the symptoms of conjunctivitis for early diagnosis and referral to ophthalmologist. The role of interns in primary eye health care is very important as they are in constant contact with patients at all levels. The present study shows that the majority of health care professionals didn’t know that conjunctivitis is self-limiting disease and antibiotics should be avoided which was also observed in a study conducted in Hampshire and Wiltshire.[8] We should emphasis on spreading knowledge regarding this judicious use of antibiotic eye-drops to prevent drug resistance. Participants knew about various etiologies and prevention of spread of conjunctivitis which will be helpful in reducing the healthcare load of conjunctivitis . Serious efforts to enlighten the population will therefore help to reduce blindness/visual impairment in our community. These awareness and education programs at the level of hospitals help in imparting better strategies and protocol treatment which will be suitable for the class of patients attending the hospital.Education can also be done through the TV program, social media, newspapers and interpersonal communication which will be helpful. CONCLUSION Health care professionals have sufficient knowledge and awareness about conjunctivitis, yet efforts should be made to bring change about knowledge regarding treatment of conjunctivitis. Imparting knowledge of avoiding unnecessary use of antibiotics and other ocular drugs in conjunctivitis will prevent the problem of drug resistance. Proper eye health teaching should be involved in institute and health services to primary healthcare professionals which will help early diagnosis, appropriate treatment ,referral and prevention of spread of epidemic . Early presentation to eye care centers for its treatment should be encouraged to prevent complications and maintain population eye health. Knowledge Count % Adequate 497 99.4 Poor 3 0.6 Financial disclosure Conflict of Interest Acknowledgements Copyright Transfer None None Nil Copyright transfer form signed by corresponding author on behalf of all co-authors FOOTNOTES AND DISCLOSURES ORIGINAL ARTICLE | JAN-APR 2024 Assessing Knowledge, Attitude and Practice Regarding Conjunctivitis Among Primary Health Care Professionals

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 65 REFERENCES Hashmi MF, Gurnani B, Benson S. Conjunctivitis. [Updated 2022 Dec 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541034/ Wood, M., Conjunctivitis: diagnosis and management. Community Eye Health Journal, 1999. 4: p. 7-8. Shekhawat NS, Shtein RM, Blachley TS, Stein JD. Antibiotic Prescription Fills for Acute Conjunctivitis among Enrollees in a Large United States Managed Care Network. Ophthalmology. 2017 Aug;124(8):1099-1107. Kaliyaperumal K. Guideline for Conducting a Knowledge, Attitude and Practice (KAP) Study. AECS Illumination. 2004;4(1):7-9. Andrade C, Menon V, Ameen S, Kumar Praharaj S. Designing and Conducting Knowledge, Attitude, and Practice Surveys in Psychiatry: Practical Guidance. Indian J Psychol Med. 2020 Aug 27;42(5):478-481. doi: 10.1177/0253717620946111. PMID: 33414597; PMCID: PMC7750837. Liang Q., Lu X., Wang M., Tian L., Labbé A., and Hu A. (2016): Study of infectious conjunctivitis among children in rural areas of Qinghai province Science China Life, 59 (6), P. 548. Prabhu, P.B., et al., Attitude and Practices of Subjects with Recent History of Conjunctivitis, Regarding Treatment and Prevention of The Disease. BMH Medical Journal, 2015. 2(4). Everitt, H., S. Kumar, and P. Little, A qualitative study of patients’ perceptions of acute infective conjunctivitis. Br J Gen Pract, 2003. 53(486): p. 36-41. 1. 2. 3. 4. 5. 6. 7. 8. ORIGINAL ARTICLE | JAN-APR 2024 Assessing Knowledge, Attitude and Practice Regarding Conjunctivitis Among Primary Health Care Professionals

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 66 Surgeon’s view point: MIGS – ‘Where we stand today’ SURGEON’S VIEW POINT | JAN-APR 2024 Dr Mainak Bhattacharyya (MB) Head – Glaucoma Services EyeQ Superspeciality Eye Hospitals Dr Ankush Mahajan (AM) Consultant – Cornea, Glaucoma & Oculoplasty Mahajan Eye Hospital, Jalandhar, Punjab Dr. Suneeta Dubey(SD) Medical Director, Director - Glaucoma Services & Quality Assurance - SCEH Network Dr. Shroff's Charity Eye Hospital Tanuj Dada (TD) Dr Vanita Pathak-Ray (VPR) Head – Glaucoma Services RP Centre of Ophthalmic Sciences, AIIMS, Delhi Glaucoma Fellowship, University of Toronto, Canada Director Glaucoma and Senior Consultant Glaucoma and Cataract Specialist Centre for Sight, SURGEON’S VIEW POINT Haryana Journal of Ophthalmology is pleased to bring a new section This section would be following invitation and will involve a panel discussion in Q&A format on subjects and topics on which surgeons have different approaches or viewpoints. This would involve discussions on adopting a new device or technique. This will also include less conventional approaches.

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 67 SURGEON’S VIEW POINT | JAN-APR 2024 SURGEON’S VIEW POINT: MIGS – ‘WHERE WE STAND TODAY’ MB. I do GATT, ABiC, AB INTERNO TRABECULECTOMY and iSTENT as my MIGS procedures but there is no one single preferred technique for me. My indications for MIGS procedure include: 1 Mild to moderate (open or closed angle) glaucoma requiring cataract surgery 2 Mild to moderate (phakic) open angle glaucoma not compliant with medication or progressing despite medical management 3 Mild to moderate (pseudophakic) open or closed angle patients interested in decreasing the number of eye drops being used to control IOP 4 Any glaucoma patient who is at high risk of failure or complications with traditional surgery - high myopes, one eyed, uveitic glaucoma 5 Pseudophakic patients with previous failed trabeculectomy with open or closed angles 6 Phakic patients with previous failed trabeculectomy but with completely open angles 7 Congenital or juvenile glaucoma requiring surgery 8 Steroid induced glaucoma 9 Neo vascular glaucoma that has received full PRP treatment and Anti VEGF also given within last 30 days The selection of a specific procedure involves meticulous consideration of variables such as the targeted Intraocular Pressure, financial implications, and the surgeon's proficiency. MIGS can either involve surgical devices that incise, excise, or ablate the trabecular meshwork or function as implants. In India, available procedures encompass Kahook Dual Blade (KDB) goniectomy, Bang (Bent ab interno needle goniotomy), Gonioscopy-Assisted Transluminal Trabeculotomy (GATT), and iStent. Within our institute, KDB is favored for its ease, cost-effectiveness, and notable IOP-lowering effects. GATT is a preferred option when cost considerations are paramount. The iStent is exclusively recommended for open-angle glaucoma, while GATT, BANG, and KDB find utility in angle-closure glaucoma following peripheral iridotomy, with or without synechiolysis. AM: SD: What is your preferred MIGS device/technique and how do you choose which MIGS is best suited depending on the type and stage of glaucoma? What procedure to choose depends most importantly on perimetry and on GONIOSCOPY and also other factors like -- lens status, silicon oil, vitreous haemorrhage, anticoagulant use and steroid use, number of antiglaucoma medication, neovascularisation of iris , cornea clarity. In short, I do MIGS in mild to moderate glaucoma on 24-2 fields where I can clearly see the angle on gonioscopy. My indications for GATT are: a) Chronic synechial narrow angle glaucoma b) lasered neovascular glaucoma (PRP completed and no vessels on iris) c) congenital and juvenile open angle glaucoma d) uveitic glaucoma e) Steroid induced glaucoma f) POAG (but here expect high failure rate after 1 year) f) after a previous failed trabeculectomy /deep sclerectomy/ canaloplasty g) angle recession glaucoma h) post keratoplasty synechial angle closure glaucoma Indications for iSTENT inject are: > Open angle glaucoma > Preferably only early perimetric loss on 24-2 field > Narrow angle glaucoma opening on indentation gonioscopy, combined planned, mild perimetric field loss, controlled IOP with max 2 drugs (not including pilocarpine) Indications for AB INTERNO TRABECULECTOMY: A) EARLY to MODERATE POAG either along with cataract surgery or as standalone procedure Indications for AB INTERNO CANALOPLASTY (ABiC): a) early open angle glaucoma b) enhancement in a post canaloplasty case after 4 to 5 years c) aphakic POAG where other MIGS procedures could lead to blood trickling into vitreous.

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 68 SURGEON’S VIEW POINT | JAN-APR 2024 SURGEON’S VIEW POINT: MIGS – ‘WHERE WE STAND TODAY’ Ultimately, the decision-making process for MIGS mandates a thorough evaluation of patient characteristics and surgical considerations, emphasizing a commitment to tailoring interventions for optimal outcomes. Based on efficacy, safety and cost effectiveness- Bent needle Ab interno Goniectomy (BANG) is best suited for earlymoderate POAG. I have modified the technique and now use a 30 G needle with viscoelastic to first dilate and then incise the trabecular meshwork (visco BANG) The availability of MIGS is still quite limited in India – this is both a bane and a boon! However, I do not have a preferred procedure – this introduces bias. Each eye is evaluated wrt type, stage and severity of glaucoma, number of glaucoma medication/s, purchasing power of the patient, and the procedures are agreed upon after informed consent. Angle closure glaucoma with extensive angle synaechiae/ Plateau Iris Syndrome and refractory glaucoma Therefore, procedures that are discussed are - Open angle glaucoma or if angle opens post LPI (+cataract surgery or in pseudophakic eyes JS: TD: VPR: Segmental trabeculotomy or excisional gioniotomy (Bent Needle Angle Goniectomy - BANG / Kahook Dual Blade - KDB) iStent inject Endocyclophotocoagulation (ECP) MIT (Minimally invasive Trabeculotomy) ECP • • • • • MB. No profile for MIGS. MIGS are most suitable for managing mild to moderate open-angle glaucoma, requiring functional distal collector channels for effectiveness, limiting their application in advanced cases. Typically performed in conjunction with cataract surgery, MIGS can also be considered post-iridectomy in angle-closure glaucoma cases. In my clinical practice, MIGS is applied in recent onset open-angle secondary glaucomas with uncontrolled intraocular pressure, assuming patent collector channels. Pre-procedural counseling is paramount, ensuring patients comprehend MIGS intricacies, benefits, and realistic outcomes, including pressure reduction objectives and potential medication decrease. Despite no assured discontinuation of medication, potential risks like infection, bleeding, inflammation, or vision changes are communicated for informed decision-making. Discussing alternative treatments enhances patient awareness, while ensuring a collaborative decisionmaking process aligned with individual characteristics and treatment goals. Ocular hypertension and early POAG - counsel patient about continuing medications, loss of MIGS effectiveness over time I tell all patients personally that since we are planning cataract surgery and patient already has glaucoma I would like to do a MIGS procedure also. Only COUNSELLING that is done is to explain to patient the difference between iStent and AB INTERNO TRABECULECTOMY My advice for counselling – BE BRUTALLY HONEST. I tell patients clearly that this may not make them drop free and DEFINITELY will not cure their glaucoma. For iStent we clearly explain that one stent is maximally equivalent to one Anti-glaucoma medication and in case of failure of surgery we will do a deep sclerectomy surgery for the patient free of charge if the patient so desires. AM: SD: What profile of patient do you generally have in mind while choosing MIGS? Also, what should be counselled to any patient prior to the surgery?

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 69 SURGEON’S VIEW POINT | JAN-APR 2024 SURGEON’S VIEW POINT: MIGS – ‘WHERE WE STAND TODAY’ VPR: AM: and need for second surgery. Visually significant cataract + mild-to-moderate glaucoma (as determined by visual fields) or even OHT, on 2 or more antiglaucoma medications is the usual profile. However, those that have severe intolerance / allergy to AGM or have significant ocular surface disease (OSD) are also prime candidates. In fact I have done MIGS for patients who have expressed their inability to do even one AGM. Presence of an open angle is desirable; however, I routinely do goniosynaechiolysis, if PAS is not very extensive) and then proceed with angle surgery if the angle is closed. ECP, on the other hand, is extremely versatile and is not dependent on the angle status. I give options to all such above-mentioned profile of patients - to be able to control their IOP a little better with MIGS along with either elimination or significant reduction of AGM. If they are on multiple drugs, I suggest that doing MIGS along with cataract surgery helps to ‘reset’ their AGM clock, so that the need for additional AGM can be delayed further and possibility of any invasive surgery is in the distant future, if at all. Such a patient is given the option of the entire spectrum of MIGS available in my practice across the cost spectrum – from BANG to MIT to KDB goniectomy to ECP to iStent. I counsel them that the first 3 procedures help to clear the drainage of the eye, whereas ECP helps to decrease the flow from the ‘tap’ of the eye. Further, I explain that the iStent is akin to the cardiac stent, where early disease can be treated in a minimally invasive manner, rather than open heart surgery, which is reserved for advanced disease, similar to trabeculectomy. Patient makes an informed choice based on their affordability and insurance cover. This is particularly important for iStent Inject; so far the majority of my patients who have undergone istent/ inject have been re-imbursed fully by insurance. I also give the option of cataract surgery alone; I stress the need for lifelong continuation of eyedrops in such a scenario. I counsel them that all these MIGS procedures and devices are relatively very safe (vs. traditional bleb forming surgery) and do not carry any additional risk when undertaken with cataract surgery, except perhaps a mild increased risk of transient bleeding. After discussion on the glaucoma aspect, IOLs are also discussed – I avoid trifocals unless patient has very mild early disease or OHT. Even then, they are warned that should they not be regular with follow-ups, then the risk of glaucoma becoming uncontrolled is high, leading to a decrease in contrast sensitivity. Rest are counselled for monofocal IOL, even EDOF IOL. All such surgeries are possible under topical anaesthesia except ECP, which can be mildly painful. My preferred technique in such cases is sub-tenons anaesthesia – 3 to 4 ml of Lignocaine 2%. Patient can choose either topical or sub-tenons anaesthesia, as per their comfort level in all other surgeries. Most importantly when MIGS is combined with phaco, from the patient viewpoint – post-operative visual recovery is like phaco with fewer visits to the hospital and zero manipulations (vs Trab – massage, suturelysis, Yag synaechiolysis, needling etc). Results – ISTENT MB. What has been your success rate with MIGS? How many of your patients could be weaned off anti-glaucoma medications post MIGS? TOTAL CASES WITH 6 MONTHS DATA – 5 IOP DECREASE OVER 6 MONTHS FROM AVERAGE OF 19.6 ⏈6.7 MM HG TO 18.4 ⏈ 8.4 MM HG THE ANTI GLAUCOMA MEDICATION USE DECREASED FROM 3.6 ⏈1.8 TO 1.2 ⏈ 0.8 • • •

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 70 SURGEON’S VIEW POINT | JAN-APR 2024 SURGEON’S VIEW POINT: MIGS – ‘WHERE WE STAND TODAY’ GATT – 3 years data for 52 cases in chronic synechial narrow angle glaucoma For AB INTERNO TRABECULECTOMY – 1 year data The pre op IOP was 24.88 ± 9.1 mm of Hg. The post op IOP at 1 year , 2 years and 3 years was 14.71 ± 3.28 (n=48), 15.14 ± 3.05 (n= 42), 14.16 ± 2.39 (n= 51) (p= 0.0001) respectively . The medication use decreased from 2.62 ± 1.29 preoperatively to 0.86 ± 1.06 at 1 year. Hyphema occurred in 98.7 % cases but resolved spontaneously in 98.07% cases. The pre op IOP was 22.78 ± 5.95 mm of Hg. The post op IOP at day 1 , 1 week , 1 month, 6 month and 1 year was 15.9 ± 5.3 (n=38), 15.65 ± 4.59 (n=38), 15.61 ± 3.42 (n= 34) , 16.14 ± 3.07 (n= 27) , 16.10 ± 2.73(n= 37) (p=0.0001) respectively. The anti-glaucoma medication use decreased from 2.0 ± 0.83 preoperatively to 0.2 ± 0.6 at 1 year. • • • • • • • The success of MIGS is multifaceted, influenced by factors like glaucoma type, severity, and the specific MIGS procedure. Success, often gauged by reduced intraocular pressure and decreased reliance on medications, is a common goal. Numerous studies, including our study published in IJO on Ab interno Goniectomy with Trabectome in 58 eyes, affirm positive outcomes. Our data indicates a noteworthy 76% overall success rate at one year, with the trabectome + phaco group achieving a significantly higher 88%, compared to 67% for trabectome-only.1 Similar success is observed in over 100 eyes with KDB goniectomy (unpublished). The observed reduction encompasses both IOP levels and the number of required medications. Success in MIGS is basically about reducing medications; 1-2 medicines can be reduced but patients are rarely medication free if target IOP of <15-18mm Hg required over long term. Definition of success rate varies from person to person and study to study. However, in MIGS, approximately 20% reduction in IOP and at least 50% reduction in AGM along with preservation of vision and avoidance of sight threatening complications, is reasonable. Any increase in post-op AGM should be considered a failure. As per the table below (Table 1), >90% success was achieved in the short term (approx.1 year) for all MIGS types. None of the eyes lost vision and nil had serious sight threatening complications (whereas malignant glaucoma occurred in phaco alone group). SD: TD: VPR:

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 71 SURGEON’S VIEW POINT | JAN-APR 2024 SURGEON’S VIEW POINT: MIGS – ‘WHERE WE STAND TODAY’ MB. MB. While doing MIGS combined with cataract surgery, which procedure you prefer to do first and why? What has been the major challenge in your experience with MIGS? Also, most common complication(s) encountered intra- or early post operatively? AGM could be discontinued in 40-77% eyes as per the table; hence in approximately 1-in-2 to 3-in-4 eyes, AGM could be stopped completely. * ECP has a much better effect in PACG in terms of complete success (vs. POAG) and so has been analysed separately. It has also been compared with phaco-alone. Publications are pending for all (except ECP in PACG) AM: AM: SD: SD: TD: VPR: You can do it either before or after cataract surgery. I prefer doing cataract surgery first except where I am implanting a toric IOL (then its reverse). Reason being that I prefer the slightly deeper chamber that you get after removing cataract. MIGS is not very difficult to learn. I had a few challenges in learning GATT, particularly when early in learning curve the procedure could not be completed 360 degrees. Rest of the MIGS are very easy. The widespread adoption of MIGS faces notable hurdles, with financial considerations, procedural efficacy, and the necessity for well-trained medical personnel emerging as key challenges. The distinctive nature of MIGS mandates a specialized learning curve for surgeons, involving the mastery of techniques, judicious procedure selection, and an understanding of Only 3 complications encountered till date 1) Hyphema (97% incidence) had to do a few AC wash also since patients were on anti-coagulants but it’s not a big problem 2) 2 cases of ciliary cleft (less than 1 clock hour) in AB INTERNO TRABECULECTOMY 3) Blood behind IOL post op – needs YAG CAP at 3 weeks postop (very rare complication). The sequential order of performing MIGS or cataract surgery demands careful clinical consideration, each approach bearing distinct advantages and disadvantages. Opting for cataract surgery prior to MIGS affords superior visibility of the angle, especially in eyes with narrow angles. However, this strategy may predispose patients to hypotony, resulting in blood accumulation in the Schlemm canal, thereby obstructing the view of the angle. Additionally, there is a potential compromise to corneal clarity, particularly notable in cases involving hard cataracts. Conversely, performing MIGS before cataract surgery is grounded in the rationale that the eye maintains a firm state, mitigating the risk of hypotony with unaltered angle. This sequencing enhances the visibility of the angle, a crucial factor in the procedural success of MIGS. As a clinical preference, I advocate for the performance of MIGS preceding cataract surgery. MIGS first. I usually do MIGS after cataract surgery, unless the grade of nuclear sclerosis is high and some degree of corneal oedema is anticipated, compromising view of the angle via an intra-operative gonioscope. View of the angle is much better if phaco is performed first, as it deepens the anterior chamber. However, I have done all of the stated MIGS procedures in phakic eyes also, without any problems. Cornea may become hazy later and bleeding is better controlled if MIGS done first rather than after Phaco.

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 72 SURGEON’S VIEW POINT | JAN-APR 2024 SURGEON’S VIEW POINT: MIGS – ‘WHERE WE STAND TODAY’ MB. Have you considered proceeding with MIGS in angle closure disease post iridotomy? Considering the high prevalence of angle closure in Indian patients, any modifications suggested to use MIGS in these patients? the procedural costs especially the devices. The limited understanding of long-term outcomes in MIGS further complicates these challenges. Concerning complications, though infrequent and generally transient, canal-based MIGS procedures introduce potential issues such as hyphema, intraocular pressure (IOP) spikes, and inflammation. Notably, the I-stent procedure stands out as the safest in terms of complications. Rare complications include Descemet’s membrane detachment, lens contact, cataract formation, and iridodialysis. Despite these considerations, MIGS procedures, as a rule, demonstrate a high level of safety, characterized by minimal complications that pose a threat to vision. Major challenge in MIGS is about safeguarding your ethics and professional integrity versus jumping in to do costly stents for the sake of making money and peer pressure. With pressure from Pharma and control over conferences, speakers and even publications to some extent, the truth about safety and efficacy of device MIGS is often not spoken in public or reported due to risk of financial loss.2 MIGS are relatively new procedures, and optimal visualisation of the angle requires microscope tilt, patient head positioning – both these combined results in the extension of the arm and increased distance from the surgical field. Also operations are performed at a high magnification. As this requires precision, it is possible to overcome these challenges by practice of intra-operative gonioscopy at the end of routine cataract surgery with either a Sinsky or an iris repositor introduced in the AC, to ‘reach’ out for the trabecular meshwork. Once intra-operative gonioscopy is mastered, any and every angle surgery is possible. Regurgitation of blood from the Schlemm’s canal (SC) is a desirable feature, but if excessive, then it can compromise operative field view, posing great challenge for completion of the procedure. Visco can be used to clear the blood from the operative field, however, from the patient point of view, this is usually transient and disappears in 1-2 days. If using iStent Inject, then an over or under implantation is a likelihood; this is said to be reduced with the use of the next gen model, iStent Inject W. If BANG or KDB is done, then formation of gonio-synaechiae (GS)/ PAS is a distinct possibility. One must keep monitoring the surgically unroofed SC with periodic gonioscopy in the OPD. Pilocarpine may be used if there is a likelihood of formation of adhesions. Steroid response is encountered much more in MIGS – as the rest of the trabecular meshwork (TM) is very much in ‘play’ – unlike Trab where a 100-200 micron ostium acts like a bypass to the TM, or in a tube which is a large conduit for aqueous. But by-far the greatest challenge for MIGS is its acceptance, understanding its indications and using it in appropriate conditions. When this is not done, outcomes are likely to be poor and thus there is a danger of the procedure/s being inaccurately labelled as ineffective. However, cost is cited as one of the biggest insurmountable barrier. Operative challenges include learning intraoperative gonioscopy and operating under high magnification with a tilted microscope on the TM and improper implantation of expensive iStents with no back up for replacements on table. Very severe hyphema can occur with 360 degree surgery (GATT), reflux bleed can occur in late post-operative period and there is no merit in operating more than 3-4 clock hours of the TM for any patient.3 TD: VPR:

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 73 SURGEON’S VIEW POINT | JAN-APR 2024 SURGEON’S VIEW POINT: MIGS – ‘WHERE WE STAND TODAY’ I routinely do GATT in CHRONIC SYNECHIAL ANGLE CLOSURE GLAUCOMA (with cataract in phakic eyes and as standalone in pseudophakic eyes). You just need to do a localised synechiolysis to expose say 2 mm of trabecular meshwork and the rest of the case is same as in an open angle glaucoma. I do not do combined surgery in angle closure disease where angle opens up on indentation gonioscopy. These cases should first be offered cataract surgery only. In phakics not requiring cataract surgery and angle opening up with indentation gonioscopy – better do a NON MIGS PROCEDURE. MIGS procedures, particularly those involving goniectomy, may be considered subsequent to iridectomy in cases of angle closure glaucoma. It is imperative, however, to assess the status of the angle meticulously. Syneciolysis is a feasible intervention in patients exhibiting intermittent peripheral anterior synechiae (PAS), particularly when partial visualization of the angles is feasible. Conversely, caution is advised in contemplating such procedures for patients with angles that are entirely closed. Additionally, the use of I-Stent is discouraged in individuals with narrow or closed angles. Yes in PAC and early/moderate PACG, MIGS can be done after lens extraction and goniosynechiolysis. We only do BANG so there is no additional cost to patient. If the angle opens up post laser peripheral iridotomy (LPI), then MIGS can be done in such eyes just as one would do in open angles.The menace lies in synaechial angle closure; in such cases goniosynaechiolysis may be attempted with an iris repositor in the infero-nasal quadrant, followed by angle surgery. I have done a tube shunt in a failed GATT in a NVG case. Also have done deep sclerectomy in a few failed MIGS cases but as such no specific challenges or technique modification is needed. Indeed, empirical investigations have demonstrated that MIGS can effectively reduce Intraocular Pressure in individuals experiencing unsuccessful trabeculectomy with Mitomycin C (MMC) and Glaucoma Drainage Device (GDD) surgery, owing to the fact that the collector channels do not undergo complete atrophy. Furthermore, substantiating this, there exists supporting evidence suggesting that MIGS can contribute to IOP reduction even when trabeculectomy with mitomycin C fails to achieve the designated target IOP, even with the adjunctive use of Anti-Glaucoma Medications. Drawing from personal experience, Goniectomy procedures performed subsequent to Trabeculectomy and tube implantation have consistently demonstrated a notable decrease in the necessity for anti-glaucoma medications. Nevertheless, in such scenarios, it is imperative to engage in thorough patient counseling regarding the ongoing requirement for AGMs and potential future interventions. Yes, I have done Trabeculectomy after failed BANG. No major challenges as it is a pseudophakic eye but better to delay surgery to after 6 months - 1 year so that there is no inflammation (blood aqueous barrier). Failures in MIGS have been few – and have been mostly on IOP criterion (>5 and ≦18). Therefore, I do not have much experience yet with Trab or tube post MIGS. If iris is floppy in the region, then a sectoral iridectomy may be done. However, in such situations, inflammation may be excessive and result in GS or PAS – frequent post-operative gonioscopy, potent topical steroids +/- Pilocarpine may provide a satisfactory solution. On the other hand, in my experience, ECP has been the most effective MIGS in angle closure disease as it is an angle independent procedure. AM: SD: TD: VPR: AM: SD: TD: VPR: MB. Have you done conventional glaucoma surgery (trabeculectomy) or tube shunt surgery in any patient post MIGS? Any specific challenges inherent to the situation?

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 74 SURGEON’S VIEW POINT | JAN-APR 2024 SURGEON’S VIEW POINT: MIGS – ‘WHERE WE STAND TODAY’ MB. Where do you see MIGS in our practice 5 years from hence? Is it here to co-exist or overshadow the conventional glaucoma surgeries or may become less relevant with passing time? I have been doing MIGS, deep sclerectomy and canaloplasty since 2013. I see MIGS as something that can be offered to all mild to moderate glaucoma cases undergoing cataract surgery since anyways till now most cataracts with mild glaucoma would receive only cataract surgery only leaving the disease to progress. So I see MIGS leading to some decrease incidence of conventional trab and tube surgeries but a huge increase in MIGS surgery leading hopefully to much slower progression of the disease, and maybe decreasing the number of end stage glaucoma patients walking around. The landscape of glaucoma management is evolving, and MIGS, characterized by its less invasive nature and favourable safety profile, has gained considerable traction. It is foreseeable that MIGS will likely maintain a prominent position in our practice, coexisting with conventional glaucoma surgeries. Its appeal lies in reduced postoperative complications, faster recovery times, and potentially enhanced patient satisfaction. However, the future role of MIGS may be influenced by ongoing advancements in both MIGS technologies and traditional glaucoma surgeries. If MIGS continues to demonstrate efficacy in a broader spectrum of glaucoma cases and addresses limitations that currently exist, it could potentially overshadow some conventional procedures. Ultimately, the interplay between MIGS and conventional glaucoma surgeries in our practice will likely be dynamic and contingent on the evolution of both approaches. Regular reassessment of the evidence base, technological developments, and clinical outcomes will guide our decision-making processes as we navigate the landscape of glaucoma management in the years to come. MIGS is here to stay and all training programmes should incorporate this surgery. New techniques are evolving to make MIGS better and safer. In India we should work on devising low cost MIGS. For advanced glaucoma - Trabeculectomy is still the Gold standard and no MIGS has been able to outperform it. MIGS has changed the paradigm in the management of mild-to-moderate glaucoma and in my opinion is not competing with trabeculectomy, which is still the preferred option in advanced glaucoma. Having said that, for the past year I have been combining two MIGS procedures in advanced glaucoma – reducing inflow and enhancing outflow - with good effect (Table 2). ECP is the only procedure that reduces inflow; however, all the other procedures (BANG, KDB, iStent/inject and MIT) enhance outflow. It helps to avoid creating a bleb with all its incumbent risks, yet it does not jeopardise a future Trab, if it is required. Some of the eyes in this cohort are post failed filtration; almost all underwent simultaneous phaco surgery. Stabilisation of IOP and reduction in AGM is remarkable in combined MIGS – it has made a very significant impact in my practice. I am now doing trabs mainly in phakic eyes (clear lens) with advanced glaucoma. MIGS, as we know it today, may yet undergo a change, but it is here to stay per se. It provides options in early glaucoma, AM: SD: TD: VPR:

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 75 SURGEON’S VIEW POINT | JAN-APR 2024 SURGEON’S VIEW POINT: MIGS – ‘WHERE WE STAND TODAY’ In my opinion, both will co-exist, but need for trab will decline over a period of time, but not necessarily in 5 years. This is likely to happen once the potential for early detection of glaucoma is realised and increasingly such patients with cataract choosing to have their AGM clocks reset with simultaneous MIGS surgery. MB. What advice would you give to surgeons planning to start using these devices in their practice? which was hitherto not available and understandably surgeons were reluctant to perform trabs with all its incumbent risks, in this stage of the disease FIRST of all MIGS is not DEVICES alone. There are MIGS options where devices are not required. But device or no device u need to master one thing – INDENTATION GONIOSCOPY and make this your deciding factor along with perimetry as to whether to do MIGS or not . SECOND – obviously intraoperative gonioscopy but I feel that’s the easy part so, for me most important skill to learn is INDENTATION GONIOSCOPY. The successful implantation of a MIGS device or the execution of a MIGS procedure necessitates the acquisition of a completely new skill set. In the pursuit of integrating MIGS into their practice, surgeons must prioritize intraoperative gonioscopy and hands-on training. It is imperative to commence this transformative journey with a deliberate focus on proper patient selection. The foundational step involves a gradual initiation, emphasizing the importance of staying wellinformed through continuous learning. This, coupled with effective patient communication and diligent outcome monitoring, forms the bedrock of a successful MIGS integration strategy. Embracing this thoughtful and informed approach not only enhances surgical skills but also elevates the standard of patient care. In essence, the integration of MIGS demands a conscientious dedication to professional growth, ensuring a positive impact on both surgeon proficiency and the broader landscape of glaucoma treatment. Do wet labs on MIGS, buy an intraoperative gonioscope and start focusing and touching the TM in your routine cataract surgeries - then start with a BANG Practice intra-operative gonioscopy! Practice intra-operative gonioscopy!!Practice intra-operative gonioscopy!!! Choose the patient correctly and wisely Counsel appropriately, laying down clear and concise aims Manage patient expectations Learn to counsel patients honestly as MIGS surgery may not work at all or fail early and you will have to do a second surgery. Glaucoma surgery success is more about healing response of the human body than your surgical expertise. This is the main reason for an unpredictable/ variable response. A prayer to Mother Nature to lend a helping hand before starting surgery may prove useful AM: SD: TD: VPR:

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 76 SURGEON’S VIEW POINT | JAN-APR 2024 SURGEON’S VIEW POINT: MIGS – ‘WHERE WE STAND TODAY’ REFERENCES Dubey S, Bansal T, Garg P, Hegde A, Das R, Rekha PD. Outcomes of ab-interno irrigating goniectomy with trabectome in primary and secondary glaucoma from a single center in India. Indian J Ophthalmol. 2022;70 (10):3569-74. Dada T, Mahalingam K, Bhartiya S. Minimally Invasive Glaucoma Surgery-to Remove or Preserve the Trabecular Meshwork: That is the Question? J Curr Glaucoma Pract. 2021; 15(2):47-51 Dada T, Ramesh P, Sethi A, Bhartiya S. Ethics of Glaucoma Widgets. J Curr Glaucoma Pract. 2020;14(3):77-80. 1. 2. 3. Financial disclosure Conflict of Interest Acknowledgements Copyright Transfer None None Nil Copyright transfer form signed by corresponding author on behalf of all co-authors FOOTNOTES AND DISCLOSURES

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 77 Oxygen cylinder related ocular emergencies during second wave of Covid-19 pandemic in India Mainak Bhattacharyya MS, DNB, FICO (Glaucoma)1 , Gunjan Budhiraja DO, DNB, FICO, Fellow (Cornea, SCEH)2 , Awaneesh Upadhyay DNB, Fellow (Retina)1 , Shreyans Jain MD1 ARTICLE INFORMATION AFFILIATION OF ALL AUTHORS: ABSTRACT 1. EyeQ Super speciality eye hospital, Gurugram, India 122001 2. Dr Shroff’s Charity Eye Hospital, Ansari road, Daryaganj, New Delhi- 110019 Corresponding author Dr. Mainak Bhattacharyya Consultant – EyeQ Super speciality eye hospital, Gurugram, India 122001 Email - drmainakb@gmail.com We describe here three unfortunate cases of ocular trauma while handling oxygen cylinders at home for Covid positive patients during the second wave of the pandemic in India. All three patients described here had significant ocular injuries causing long term impact on their ocular health. Public health awareness should be taken into consideration while handling oxygen cylinders at home by novice users, ignored due to general panic and haste in managing the covid-19 patients at homes. Article received Article accepted Article on line Keywords Presented at January 2024 January 2024 February 2024 Coronavirus disease- 19 (COVID 19), oxygen cylinder, ocular trauma, ocular emergencies, home quarantine Not Presented INTRODUCTION: Coronavirus disease- 19 (Covid-19) pandemic had hit the world in an unprecedented manner over the initial years of this decade. There had been rising cases of Covid-19 in bout of waves in different parts of the world at different timelines. In India, a second wave had hit with exponentially high number of cases in second quarter of 2021, leading to overwhelming of the healthcare system and shortage of intensive care units /ventilators and hospital beds in the country. This shortage of the intensive care unit beds and hospital beds led to triaging of mild to moderate Covid-19 positive patients at home under the supervision of the tele-consultations by the medical practitioners [1]. Patients who needed additional oxygen support to counter the unpredictable hypoxia were being managed with either the oxygen concentrators or the oxygen cylinders at their homes [2,3]. The acute shortage of oxygen availability in hospital settings meant an even greater struggle to acquire these cylinders/ concentrators by the families of those under home quarantine. Even though the right method of application was emphasized on the cylinders itself as well as on many platforms over the country, sometimes these cylinders posed a challenge in installations and adjustments of optimum oxygen levels by novice user [4]. Improper handling by the users in panic and haste had invited lot of accidents related to either the bursting of cylinders or expelling out of the valves leading to serious trauma. (Figure 1) CASE REPORT -1 | JAN-APR 2024 Figure 1a: Oxygen cylinder with the flow regulator knob

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 78 CASE REPORT -1 | JAN-APR 2024 OXYGEN CYLINDER RELATED OCULAR EMERGENCIES DURING SECOND WAVE OF COVID-19 PANDEMIC IN INDIA Case 3: Figure 1e: Corneal epithelial defect with DM folds Figure 1f: Slit lamp photo showing residual corneal scar and early rosette cataract Case 2: Figure 1b: Showing lacerations over bridge of nose and upper lid Figure 1c: Sclerolimbal perforation with uveal and vitreous prolapse through the wound Figure 1d: USG B-scan showing vitreous hemorrhage CASE REPORT We are describing experiences from eye care centers of Northern India in the form of a case series of three patients with facial injuries and ocular trauma while handling these oxygen cylinders at home. The mode of injury in all our patients was with the flow regulator knob while adjusting the oxygen flow (case 1) and while installation of cylinder (case 2 and case 3). (Figure 1) Further ocular findings and OTS score are described in Table 1. Table 1: Demographic and clinical details of the patients

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 79 CASE REPORT -1 | JAN-APR 2024 OXYGEN CYLINDER RELATED OCULAR EMERGENCIES DURING SECOND WAVE OF COVID-19 PANDEMIC IN INDIA DECLARATION OF PATIENT CONSENT The authors also certify that they have obtained all appropriate patient consent forms, wherein the patient has given his consent for his images and other clinical information to be reported in the journal. The patient was assured that his name and initials will not be published and due efforts would be made to conceal his identity, though anonymity cannot be guaranteed. DISCUSSION Oxygen cylinders and concentrators had played an indispensable role in home management of mild cases of Covid-19 and helped in alleviating undue burden on the healthcare system. It is recommended to follow enough precautionary measures while handling, storage or transport of oxygen cylinders, in order to avoid significant accidental injuries. Management of these affected individuals poses an additional challenge for the family amidst the crisis of managing the covid-19 positive patients, and to the treating ophthalmologists as well, posing a risk of exposure, as these patients might be carriers themselves. In our case series the injuries were significant closed globe injury associated with other facial injuries. Visual acuity at initial presentation was poor in all the patients. All the patients would require multiple interventions, investigations and subsequent longer follow ups with relatively guarded visual prognosis. All the injuries were related to flow regulator knob/valve mishap, so training with safety guidelines should be followed [5]. The following measures can be taken to prevent unintentional injuries in caretakers [4,5] 1. Cylinder related: Purpose-built trolleys should be used for mobilizing oxygen cylinders Lubricants like oil or grease should not be used as they react with oxygen and burn at low temperature. Valve should be opened slowly and only with the proper regulator in place. Stand with the cylinder between yourself and the regulator (valve outlet facing away) when opening the cylinder valve. Soapy water should be used to check for gas leak. 2. Ocular protective measures: Wear protective plastic goggles to avoid surface injuries while handling the cylinders. Immediate consultation from an ophthalmologist and necessary early interventions. Although, oxygen cylinder related injuries have been reported from industries in the past, with the advent of oxygen cylinder use at homes in these unprecedented times, the risks of such injuries have increased many folds in the domestic set-up. Thereby, we strongly advocate following these safety guidelines to reduce potential risks to the care givers of the Covid patients. Financial disclosure Conflict of Interest Acknowledgements Copyright Transfer None None Nil Copyright transfer form signed by corresponding author on behalf of all co-authors FOOTNOTES AND DISCLOSURES

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 80 CASE REPORT -1 | JAN-APR 2024 OXYGEN CYLINDER RELATED OCULAR EMERGENCIES DURING SECOND WAVE OF COVID-19 PANDEMIC IN INDIA REFERENCES https://www.mohfw.gov.in/pdf/RevisedguidelinesforHomeIsolationofmildasymptomatiCOVID19cases. Accessed on May13, 2021. Sardesai I, Grover J, Garg M, et al. Short Term Home Oxygen Therapy for COVID-19 patients: The COVID-HOT algorithm. J Family Med Prim Care. 2020;9(7):3209-3219. O'Driscoll BR, Howard LS, Earis J, Mak V. British Thoracic Society Emergency Oxygen Guideline Group; BTS Emergency Oxygen Guideline Development Group. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017;72:ii1-ii90. Gupta S, Jani CB. Oxygen cylinders: "life" or "death"? Afr Health Sci. 2009;9(1):57-60. https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=521117400. Accessed on May 13, 2021. 1. 2. 3. 4. 5.

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 81 Combined Retinal Vascular Occlusion as the Presenting Clinical Sign of SLE Zakia Anwer MD1 , Deependra V Singh FASRS2 , Sandhya Gaur MD3 ARTICLE INFORMATION AFFILIATION OF ALL AUTHORS: ABSTRACT 1. Fellow- Vitreoretinal Surgery EyeQ Super speciality eye hospital, Gurugram, India 122001 2. Department of Retina and Uvea, Eye-Q Super Speciality Eye hospital, Gurgaon, India 3. Department of Retina and Uvea, Sadguru Netra Chikitsalaya, Chitrakoot, India Corresponding author Dr. Zakia Anwer Fellow- Vitreo-Retina Surgery Eye-Q Superspecialty Eye Hospitals Email - zakia.anwer@gmail.com An apparently healthy 35 year old female patient presented with a history of diminution of vision in the left eye since the previous evening. Her BCVA recorded as 6/60 in the left eye, and 6/6 in the right eye. Fundus evaluation revealed a combined CRVO (central retinal vein occlusion) + CLRAO (cilioretinal artery occlusion). She was promptly started on oral steroids and was later tested positive for serum ANA antibodies with a raised ESR. Our patient recovered her vision within 10 days of therapy, needing no further treatment on follow up. This is one of the very few cases of combined CRVO+ CLRAO manifesting as the first clinical sign of SLE, managed promptly with systemic steroids, obtaining a good visual gain. Article received Article accepted Article on line Keywords Presented at January 2024 January 2024 February 2024 Combined retina artery and vein occlusion, SLE, Retinal Vein occlusion, Vasculitis. Not Presented INTRODUCTION: Combined retinal vascular occlusion can present from within a wide spectrum of clinical entities comprising either CRVO + BRAO (branch retinal artery occlusion) or CRVO + CLRAO, CRVO + CRAO (central retinal artery occlusion), less commonly as BRVO (branch retinal vein occlusion) + BRAO. Although, aetiology wise, risk factors for both retinal artery and vein occlusion occurring as an exclusive event overlap, comprising systemic hypertension, diabetes mellitus, cardiovascular disease, coagulopathies and blood dyscrasias[1-3], the cause for combined simultaneous occlusion is still under speculation. Patients present with sudden onset painless diminution of vision with the characteristic findings of venous occlusion (multiple superficial haemorrhages with dilated engorged veins) along with intense whitening and odema of the retinal area supplied by the blocked artery. In case of an associated CRAO, a characteristic cherry red spot is also evident. Fluorescein angiography reveals a delayed arterial phase along with multiple areas of blocked fluorescence. Case report: A 35 year old female patient came to our OPD with the complaints of diminution of vision in the LE since 6 hrs. On evaluation, her visual acuity was found to be 6/60 in the affected eye, and 6/6 in the RE. She had a normal intraocular pressure in both the eyes, and no RAPD was noted in the left eye. Anterior segment evaluation was unremarkable for both the eyes. Fundus evaluation of the LE revealed disc odema along with multiple superficial and dot blot haemorrhages in all 4 quadrants with increased tortuosity of the retinal veins, associated with segmental whitening of the retina corresponding to the cilio-retinal artery drainage (Figure-1-a). Fluorescein angiography was done the same day, CASE REPORT -2 | JAN-APR 2024 which demonstrated multiple areas of blocked fluorescence, corresponding to the areas of superficial haemorrhages, along with a delayed cilio-retinal artery fill in the left eye (22 sec, compared to 12 seconds in the right eye), with a non-ischemic CRVO, confirming our diagnosis of a combined CRVO with CLRAO (figure 2). As the patient was not a known case of any systemic ailment, she was advised for blood investigations, and was started on oral prednisolone (1mg/kg), on grounds of a high clinical suspicion, for an inflammatory cause of the occlusion. On follow up, 2 days later, she was found to have raised titres of ANA (anti-nuclear antibody) along with an elevated ESR (erythrocyte sedimentation rate). A rheumatology opinion was sought for, and she was diagnosed with SLE. She was further followed up a week later, with a functional improvement in vision to 6/6P, fundus revealed mild improvement in the retinal odema and superficial hemorrhages (figure 1-b). Her oral steroids were then tapered weekly by 10 mg/ kg, and finally stopped after 6 weeks. By 3rd week of presentation, the hemorrhages and odema had significantly reduced. (figure 1-c), and almost cleared 2 months later (figure 1-d). Two months after therapy, our patient’s vision maintained at 6/6P, with no macular odema or neovascularisation detected in the retinal periphery.

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 82 Fig 1: Fundus image of the LE. a- day of presentation, b- one week later. c- 3 weeks later. d- 2 months later. Fig 2: a-FFA of the RE showing arterial phase at 12 second; b-FFA of the left eye, at 22 second, showing blood in the retinal arteries, with delayed perfusion of the cilioretinal artery; c-blood column in the cilioretinal artery, at 24 second; d-retraction of the blood column at 26 second; e-laminar flow of blood in the retinal veins at 34 second, indication delayed perfusion. DISCUSSION: Combined vascular occlusions are a rare entity, reported by Raval et al to be around 0.02% of all the vascular occlusions (seen in a tertiary care hospital over a 3 year period)[4]. Combined occlusions are ususally found in the young, with mean age of 48 years[5,6]. The risk factors in young patients are majorly inflammatory autoimmune conditions like Bechets disease, SLE[7-10], leukaemia[11,12], hyperhomocystenemia[13], coagulation disorders[14], interferon therapy[15]. And hence it becomes imperative to conduct CASE REPORT -2 | JAN-APR 2024 Combined Retinal Vascular Occlusion as the Presenting Clinical Sign of SLE a battery of investigations including a complete hemogram with ESR, a peripheral blood smear, ANA profile, serum HLA-B51, serum homocysteine levels and serum ACE levels to rule out these conditions, as it may their first clinical presentation at times. The exact mechanism behind the pathogenesis of such combined occlusions is not clear yet, but theories propose a venous thrombosis to begin with, followed by an increase in the intraluminal pressure of the capillary bed, leading to a hemodynamic block in the retinal artery (and not a frank thrombosis)[3,4]. In a study conducted by Munroe at al, the hemodynamic block of the cilio retinal artery in combined CRVO +CLRAO was elucidated as blood column propagation during systole, and retraction during diastole[17] (also seen in figure 2-c,d). SLE is an autoimmune disorder which can affect multiple organs. SLE retinopathy is postulated to occur due to auto-immune endarteritis or either due to circulating immune complex deposition, causing thrombosis[18]. The most common retinopathy changes in SLE are superficial hemorrhages and cotton wool spots, whereas the most visually disabling complication is vasoocclusive crisis[23]. In a study conducted by Bashiri et al, prevalence of retinopathy was found to be 15.8% for newly diagnosed SLE cases, amongst which 78% had cotton wool spots[19]. Over all, incidence of retinopathy in active SLE is found to be up to 29%, with a strong correlation to the disease severity[18]. Very few cases of simultaneous combined retinal vascular occlusions have been reported in SLE patients, wherein, almost all were tested positive for ANA antibodies, but few also tested positive for APLA (anti phospholipid antibody), with an extremely poor prognosis[8-10,20-22]. Treatment wise, systemic immune-suppressives are the mainstay, however visual prognosis depends upon the severity of involvement, and also in the delay in initiating therapy. Other treatment modalities include the use of anticoagulants as well as anti VEGF injections, retinal photocoagulation, and also vitrectomy in few cases for the management of retinal ischemia[18]. CONCLUSION: Combined retinal venous and arterial occlusion is a rare and devastating entity, which carries a very guarded visual prognosis. Timely diagnosis of the condition by a thorough fundus evaluation and early initiation of therapy can significantly improve visual prognosis, preventing severe blinding complications.

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 83 CASE REPORT -2 | JAN-APR 2024 Combined Retinal Vascular Occlusion as the Presenting Clinical Sign of SLE REFERENCES Kolar P. Risk factors for central and branch retinal vein occlusion: a meta-analysis of published clinical data. J Ophthalmol. 2014;2014:724780. doi:10.1155/2014/724780 Zhang XT, Zhong YF, Xue YQ, et al. Clinical Features of Central Retinal Vein Occlusion in Young Patients. Ophthalmol Ther. 2022;11(4):1409-1422. doi:10.1007/s40123-022-00534-7 Hayreh SS. Central retinal artery occlusion. Indian J Ophthalmol. 2018;66(12):1684-1694. doi:10.4103/ijo.IJO_1446_18 Raval V, Nayak S, Saldanha M, et al. Combined retinal vascular occlusion: Demography, clinical features, visual outcome, systemic co-morbidities, and literature review. Indian J Ophthalmol. 2020;68(10):2136-2142. doi:10.4103/ijo.IJO_2116_19 Hayreh SS, Fraterrigo L, Jonas J. Central retinal vein occlusion associated with cilioretinal artery occlusion. Retina. 2008;28(4):581-594. doi:10.1097/IAE.0b013e31815ec29b Wang H, Chang Y, Zhang F, et al. Clinical Features of Combined Central Retinal Artery and Vein Occlusion. J Ophthalmol. 2019;2019:7202731. Published 2019 Oct 9. doi:10.1155/2019/7202731 Kahloun R, Jelliti B, Abroug N, et al. Occlusion combinée de l’artère centrale de la rétine et de la veine centrale de la rétine révélant une maladie de Behçet [Combined central retinal artery occlusion and central retinal vein occlusion secondary to Behçet’s disease]. J Fr Ophtalmol. 2016;39(7):e191-e192. doi:10.1016/j.jfo.2015.03.033 Moreno Páramo D, Rayón Rodríguez MA, García Leonardo JI. Combined central retinal artery and vein occlusion; first manifestation of lupus in a pediatric patient. Oclusión mixta de arteria y vena central de la retina; primera manifestación de lupus en paciente pediátrico. Arch Soc Esp Oftalmol (Engl Ed). 2019;94(3):141-144. doi:10.1016/j.oftal.2018.10.009 Kumar K, Dan S, Sinha TK, Bhattacharya D. Severe Vaso-Occlusive Retinopathy in Systemic Lupus Erythematosus: A Case Series. Cureus. 2021;13(1):e13019. Published 2021 Jan 30. doi:10.7759/cureus.13019 Bawankar P, Samant P, Lahane S, Jain A, Pathak P. Combined central retinal artery and vein occlusion as the presenting manifestation of systemic lupus erythematosus. Indian J Ophthalmol. 2018;66(12):1864. doi:10.4103/ijo.IJO_996_18 Salman AR, Olsen TW. Combined Ophthalmic Artery and Central Retinal Vein Occlusion Secondary to Advanced Mantle Cell Lymphoma. JAMA Ophthalmol. 2022;140(10):e223230. doi:10.1001/jamaophthalmol.2022.3230 Panigrahi PK, Navyasree C, Srija YN. Combined central retinal vein occlusion with branch retinal artery occlusion in a leukaemic patient with COVID-19. Clin Exp Optom. 2023;106(8):933-934. doi:10.1080/08164622.2022.2116270 Parchand SM. Combined central retinal vein and branch retinal artery occlusion in hyperhomocysteinaemia. BMJ Case Rep. 2016;2016:bcr2016218379. Published 2016 Dec 14. doi:10.1136/bcr-2016-218379 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Financial disclosure Conflict of Interest Acknowledgements Copyright Transfer None None Nil Copyright transfer form signed by corresponding author on behalf of all co-authors FOOTNOTES AND DISCLOSURES

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 84 CASE REPORT -2 | JAN-APR 2024 Combined Retinal Vascular Occlusion as the Presenting Clinical Sign of SLE Desai S, Rai N, Kulkarni P, Natarajan S. Combined CRVO with CRAO in a patient with protein C deficiency. Retin Cases Brief Rep. 2014;8(2):145-149. doi:10.1097/ICB.0000000000000027 Rubio JE Jr, Charles S. Interferon-associated combined branch retinal artery and central retinal vein obstruction. Retina. 2003;23(4):546-548. doi:10.1097/00006982-200308000-00019 Pinna A, Zinellu A, Serra R, Boscia G, Ronchi L, Dore S. Combined Branch Retinal Artery and Central Retinal Vein Occlusion: A Systematic Review. Vision (Basel). 2023;7(3):51. Published 2023 Jul 28. doi:10.3390/vision7030051 Munro M, Andrews R, Hamilton RD, Palakkamanil M, Adatia FA. Unravelling the mechanism of combined cilioretinal artery and retinal vein occlusion: documentation of the oscillating blood flow column and a review of the literature. Can J Ophthalmol. 2019;54(5):e251-e254. doi:10.1016/j.jcjo.2018.11.011 Palejwala NV, Walia HS, Yeh S. Ocular manifestations of systemic lupus erythematosus: a review of the literature. Autoimmune Dis. 2012;2012:290898. doi:10.1155/2012/290898 Bashiri H, Karimi N, Mostafaei S, Baghdadi A, Nejadhosseinian M, Faezi ST. Retinopathy in newly-diagnosed systemic lupus erythematosus: should we screen for ocular involvement?. BMC Rheumatol. 2021;5(1):34. Published 2021 Oct 1. doi:10.1186/ s41927-021-00203-5 Akhlaghi M, Abtahi-Naeini B, Pourazizi M. Acute vision loss in systemic lupus erythematosus: bilateral combined retinal artery and vein occlusion as a catastrophic form of clinical flare. Lupus. 2018;27(6):1023-1026. doi:10.1177/0961203317727602 Prakash, S., Gunderia, A. M., & Khadar, S. M. A. (2023). A rare simultaneous presentation of combined occlusion and optic neuritis in a lupus erythematosus patient with anti-phospholipid antibody syndrome. Lupus, 32(6), 804–809. https://doi. org/10.1177/09612033231171342 Nishiguchi KM, Ito Y, Terasaki H. Bilateral central retinal artery occlusion and vein occlusion complicated by severe choroidopathy in systemic lupus erythematosus. Lupus. 2013;22(7):733-735. doi:10.1177/0961203313490435 Shoughy SS, Tabbara KF. Ocular findings in systemic lupus erythematosus. Saudi J Ophthalmol. 2016;30(2):117-121. doi:10.1016/j. sjopt.2016.02.001 14. 15. 16. 17. 18. 19. 20. 21. 22. 23.

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 85 Topiramate induced angle closure in a oneeyed patient Foram Desai MS FMRF FAICO FICO1 , Kruti Shah DOMS, MS2 ARTICLE INFORMATION AFFILIATION OF ALL AUTHORS: ABSTRACT 1. EyeQ Super speciality eye hospital, Surat, India 2. EyeQ Super speciality eye hospital, Surat, India Corresponding author Dr. Foram Desai Consultant – EyeQ Super speciality eye hospital, Surat, India Email - d.foram.236@gmail.com We report a case of patient with phthisis bulbi in right eye and sudden painful dimness of vision in left eye. He had shallow anterior chamber, high intraocular pressure, myopic shift and ciliochoroidal effusion which was confirmed on ultrasound biomicroscopy (UBM). He was on tablet topiramate for chronic headache. He was diagnosed with drug induced secondary angle closure. He was asked to stop topiramate and started on cycloplegic eyedrops, topical steroids and antiglaucoma medications. His condition resolved completely in 5 days. Article received Article accepted Article on line Keywords Presented at January 2024 January 2024 February 2024 angle, closure, topiramate Ophthaquest 2024 INTRODUCTION: Topiramate is a sulfamate substituted monosaccharide. Its commonly used for epilepsy, neuropathic pain and migraine. It acts by blocking sodium and L-type calcium channels, enhancing gamma-aminobutyric acid (GABA) receptors, a-amino-3- hydroxy-5-methylisoxazole- 4-propionic acid (AMPA) and kainite current suppression, and carbonic anhydrase inhibition [1]. Its systemic adverse effects include weight loss [2], dizziness, kidney stone [3], cognitive dysfunction [4] etc. It can also lead to ophthalmic side effects like acute angle closure, induced myopia, uveal effusion, uveitis, visual field defects [5]. If left untreated these can potentially lead to blindness. CASE DESCRIPTION A 50year old male patient presented with complaint of headache, dimness of vision and pain in left eye for 1 day. His right eye had undergone phthisis following a penetrating injury in childhood. He could not perceive light in right eye. His uncorrected visual acuity was 3/60 and it improved to 6/12 with pinhole. His best corrected visual acuity was 6/9 with – 6.75 D spherical correction in left eye. On Slit lamp examination his left eye had conjunctival congestion, mild corneal oedema and markedly shallow anterior chamber (Figure 1a). Pupillary reaction was sluggish. His left eye intraocular pressure was 52mmHg by Goldmann applanation tonometry and 360° appositional angle closure (Figure 1b) was noted on gonioscopy. His disc and central fundus were normal. On detailed questioning , patient admitted that he was being treated for chronic headache and tablet topiramate 50mg/day was added 7 days back. Ciliochoroidal effusion was noted on ultrasound biomicroscopy (UBM) (Figure 2) . Anterior segment optical coherence tomography (ASOCT) showed swallowing of anterior chamber and peripheral iridocorneal touch(Figure 3a). CASE REPORT -3 | JAN-APR 2024 Shallow choroidal effusion was noted on B scan ultrasonography (Bscan) (Figure3b). Topiramate induced angle closure was considered to be the primary diagnosis. Patient was given timolol and brimonidine combination eyedrops, cycloplegic eyedrops and topical steroids. He was advised to discontinue topiramate and notify his neuro physician. By the 5th day IOP was 10 mmHg, anterior chamber was deep and angles were open on gonioscopy. Best corrected visual acuity was 6/6 with -2.25D Spherical correction (using glasses). Anti glaucoma medications were tapered sequentially. Fig 1a: Slit lamp examination depicting shallow anterior chamber Fig 1b: Angle closure on gonioscopy 1a 1b

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 86 Fig 2: UBM showing ciliochoroidal effusion Fig 3a: Peripheral Iridocorneal touch on ASOCT Fig 3b: Shallow Choroidal effusion on DISCUSSION: Topiramate was implicated as a cause of bilateral secondary angle closure for the first time in a case reported by Banta et al [6]. Uveal effusion following consumption of sulphonamide drugs has been commonly documented since then [7]. A theory suggests that pharmacological stimulation of prostaglandins leads to vasodilation and increases permeability in the ciliary body, CASE REPORT -3 | JAN-APR 2024 Topiramate induced angle closure in a oneeyed patient. however the exact mechanism of effusion with sulpha drugs is still not clear. Its incidence in few patients only is suggestive of possible idiosyncratic reaction[7]. Ciliochoroidal effusion causes forward shift of lens iris diaphragm which in turn causes ‘bilateral´ acute angle closure and induced myopia[8]. Sudden bilateral myopic shift arouses suspicion of sulphonamide induced angle closure even before examining the patient. In our case the patient was one eyed. In such cases lenticular myopia with primary angle closure can be a differential and can mislead the further management. Patients of sulpha drugs induced angle closure usually present with sudden onset diminution of vision, shallow anterior chamber with angle closure and raised intraocular pressure. Since this presentation mimics primary acute angle closure glaucoma, these patients are often misdiagnosed. It is important to note that inspite of overlapping symptoms, the treatment of both the conditions is markedly different. In primary acute angle closure glaucoma, patient is pilocarpinised and laser peripheral iridotomy is done. Whereas cycloplegics are given in lens induced secondary angle closure as they push the lens iris diaphragm backwards and deepen the anterior chamber. Topical anti glaucoma medications and topical steroids are given as per requirement. The causative sulpha drug is stopped. The episode usually resolves in few days without any major sequelae. Although predicting idiosyncratic reactions with sulphonamides is not possible, preparedness, early diagnosis and treatment can preserve patient´s vision. CONCLUSION: Primary and secondary glaucoma as well as open angle and angle closure glaucoma are different entities. But their presentation can often be similar causing a major diagnostic dilemma. What adds to the dilemma is the fact that the treatment of these glaucomas can be markedly contrasting. So, thorough knowledge of various types of glaucoma is necessary. For definite treatment of glaucoma, addressing the etiology is equally or more important than just controlling the intraocular pressure. Also, it is mandatory for ophthalmologists as well as physicians to be aware of systemic side effects of topical medications and ocular side effects of systemic drugs for holistic treatment of patients. 3a 3b Financial disclosure Conflict of Interest Acknowledgements Copyright Transfer None None Nil Copyright transfer form signed by corresponding author on behalf of all co-authors FOOTNOTES AND DISCLOSURES

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 87 CASE REPORT -3 | JAN-APR 2024 Topiramate induced angle closure in a oneeyed patient. REFERENCES Minton GC, Miller AD, Bookstaver PB, Love BL. Topiramate: safety and efficacy of its use in the prevention and treatment of migraine. J Cent Nerv Syst Dis. 2011;3:155-168. Published 2011 Jun 23. doi:10.4137/JCNSD.S4365 Verrotti A, Scaparrotta A, Agostinelli S, Di Pillo S, Chiarelli F, Grosso S. Topiramate-induced weight loss: a review. Epilepsy Res. 2011;95(3):189-199. doi:10.1016/j.eplepsyres.2011.05.014 Mahmoud AA, Rizk T, El-Bakri NK, Riaz M, Dannawi S, Al Tannir M. Incidence of kidney stones with topiramate treatment in pediatric patients. Epilepsia. 2011;52(10):1890-1893. doi:10.1111/j.1528-1167.2011.03245.x Fritz N, Glogau S, Hoffmann J, Rademacher M, Elger CE, Helmstaedter C. Efficacy and cognitive side effects of tiagabine and topiramate in patients with epilepsy. Epilepsy Behav. 2005;6(3):373-381. doi:10.1016/j.yebeh.2005.01.002 Abtahi MA, Abtahi SH, Fazel F, et al. Topiramate and the vision: a systematic review. Clin Ophthalmol. 2012;6:117-131. doi:10.2147/ OPTH.S27695 Banta JT, Hoffman K, Budenz DL, Ceballos E, Greenfield DS. Presumed topiramate-induced bilateral acute angle-closure glaucoma. Am J Ophthalmol. 2001;132(1):112-114. doi:10.1016/s0002-9394(01)01013-3 Lee GC, Tam CP, Danesh-Meyer HV, Myers JS, Katz LJ. Bilateral angle closure glaucoma induced by sulphonamide-derived medications. Clin Exp Ophthalmol. 2007;35(1):55-58. doi:10.1111/j.1442-9071.2006.01365.x Tripathi RC, Tripathi BJ, Haggerty C. Drug-induced glaucomas: mechanism and management. Drug Saf. 2003;26(11):749-767. doi:10.2165/00002018-200326110-00002 1. 2. 3. 4. 5. 6. 7. 8.

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 88 A hidden hemangioma Shipra Sharda1 , Smriti Dabas2 , Deependra V Singh3 ARTICLE INFORMATION AFFILIATION OF ALL AUTHORS: ABSTRACT 1. Eye-Q Super speciality eye hospital, Gurugram, India 2. Eye-Q Super speciality eye hospital, Gurugram, India 3. Eye-Q Super speciality eye hospital, Gurugram, India Corresponding author Dr. Smriti Dabas MS Fellow(Glaucoma) – Eye-Q Super SpecialityEye Hospital, Gurugram,India Email-smriti4@hotmail.com Not Presented Article received Article accepted Article on line Keywords Presented at January 2024 January 2024 February 2024 Haemangioma, Vascular malformations Not Presented A 26 year old, 1 month post-partum, female presented with a history of bloody discharge from the left eye since 2 days. Visual acuity was 20/20 both eyes. On examination, her lids, ocular motility, bulbar conjunctiva, cornea and sclera were normal. On eversion of the left upper lid, a pedunculated, aneurysmal lesion was seen(Figure 1). She had no prior history of any ocular trauma or surgery. A clinical diagnosis of haemangioma was made, and as she was symptomatic, the lesion was excised and sent for biopsy. Haemangiomas are developmental malformations of blood Figure 1: Slit lamp image showing a pedunculated, aneurysmal lesion on eversion. IMAGE UNDER LENS | JAN-APR 2024 vessels, they can either be sessile or pedunculated1 . Changes in hormones during pregnancy can cause the development of vascular malformations2 . Management depends on the presentation and extent. This case highlights the importance of everting the eyelids during examination.

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 89 CASE REPORT -1 | JAN-APR 2024 A HIDDEN HAEMANGIOMA REFERENCES Drolet BA, Esterly NB, Frieden IJ. Hemangiomas in children. N Engl J Med. 1999 Jul 15;341(3):173-81. doi: 10.1056/NEJM199907153410307. PMID: 10403856. Pushker N, Bajaj MS, Kashyap S, Balasubramanya R. Acquired capillary haemangioma of the eyelid during pregnancy. Clin Exp Ophthalmol. 2003;31(4):368-369. doi:10.1046/j.1442-9071.2003.00676.x 1. 2. Financial disclosure Conflict of Interest Acknowledgements Copyright Transfer None None Nil Copyright transfer form signed by corresponding author on behalf of all co-authors FOOTNOTES AND DISCLOSURES

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 90 “It takes two to Tango and three for remarkable creations!” Behind our SRK FORMULA Dr. Tarun Gupta1 ARTICLE INFORMATION AFFILIATION OF ALL AUTHORS: ABSTRACT 1. Eye-Q Superspecialty Eye Hospitals at Sheetla Hospital, Gurugram Corresponding author Dr. Tarun Gupta Consultant – Senior Consultant and Clinical Incharge, Eye-Q Superspecialty Eye Hospitals at Sheetla Hospital, Gurugram Email - drtarungupta@eyeqindia.com NA Article received Article accepted Article on line Keywords Presented at January 2024 January 2024 February 2024 NA NA In 1949, Harold Ridley implanted the first IOL but his patient had a refractive surprise of nearly 20 diopters. Prior to development of A scan machine, IOL power was calculated based on clinical historypreoperative refractive error prior to cataract development in eye. Adherent to Empirical method would implant a 19.0 D lens thinking that this would behave like natural lens. Fyodorov and coworkers first estimated the optical power of an IOL using vergence formulas in 1967. In the 1970s, after availability of accurate “A” scans, several studies were conducted to establish and publish various theoretical vergence formulas like Binkhorst (1972), Colenbander (1973). The concept of A constant was not there, all lenses were assumed to have predetermined fixed position in the eye. In the early 1980s, several IDEM (ideal emmetropia) lenses were also attempted, so named as the pre- and post – refraction from them were similar. On similar lines, Standard lenses were also attempted, after Gernet and Zorkendorfer in 1982 showed that the average refractive power of natural lens is +23.70D. In mid 1980s after the introduction of phacoemulsification, the concept of in the bag implantation of IOLs started getting widely recognised this set the stage for second generation IOL formulas and the concept of A constant. In 1988 DONALD SANDERS, DR JOHN RETZLAFF and DR MANUS KRAFF came up with the SRK FORMULA (SANDER RETZLAFF KRAFF FORMULA) P=A-2.5L-0.9K Dr John Retzlaff was born in Harlingen, Texas in 1932. He completed his residency in ophthalmology from Mayoclinic in 1968. He began working on IOL power calculation after his 1st lens implantation in 1976. Dr Manus Kraff was born in Chicago and brought up in a small town in Washington. He did his residency from Cook County Health PEEK INTO HISTORY | JAN-APR 2024 and Hospital, Chicago from 1951-1961. Donald Sanders was a researcher at University of Illinois. Dr Manus Kraff and Donald Sanders were working on regression formula at University of Illinois and they met Dr John Retzlaff at Hoffer IOL power course. After their presentation at American Intraocular Implant Society meeting at Los Angeles in 1981, the 3 of them decided to collaborate. They studied a series of more than 2500 patients and found that doptric power of the IOL for assuring emmetropia fundamentally depends on the axial length and corneal dioptric power. In this way they developed and perfected a simplified regression formula termed as “SRK REGRESSION FORMULA”

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 91 *1980 LEFT TO RIGHT Donald Sander, Dr John Retzlaff, Dr Manus Kraff *2015 LEFT TO RIGHT Donald Sander, Dr John Retzlaff, Dr Manus Kraff *Photo courtesy: Facebook account of DR Manus Kraff PEEK INTO HISTORY | JAN-APR 2024 Conjunctivitis-23, Is it a COVID-19 type epidemic of the Eye? BIBLIOGRAPHY: Pubmed IOL Power club Youtube REFERENCES https://eyewiki.org/Biometry_for_Intra-Ocular_Lens_(IOL)_Power_Calculation Fedorov SN, Kolinko AI, Kolinko AI. Estimation of optical power of the intraocular lens. Vestn Oftalmol 1967;80:27–31 1. 2. Financial disclosure Conflict of Interest Acknowledgements Copyright Transfer None None Nil Copyright transfer form signed by corresponding author on behalf of all co-authors FOOTNOTES AND DISCLOSURES

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 92 INFORMATION FOR AUTHORS SCOPE OF JOURNAL AND OBJECTIVES Haryana Journal of Ophthalmology is the official journal of Haryana Ophthalmological Society (HOS). It was initiated in 1997 and bears the ISSN No. 2223-0309. It has been printed for private circulation among members of HOS till 2022. Editorial team intends to make it on line and now invites articles from authors and researchers from all over the world. All submissions would be subjected to a peer-review by team of experts who are on our editorial board. The publications are published quarterly and receives submissions on different categories as listed below. To support postgraduates and fellows there is no article processing or publication fees. HJO prefers for good articles that are tailored to post graduates and practicing ophthalmologists. All submissions should be submitted electronically and have to be mailed at editor.hjo@haryanaophthalmologicalsociety.com MANUSCRIPT CATEGORIES • Guest Editorials • Review articles • Original Article • Surgeon’s View point • Innovation and Surgical Techniques • Case Series • Commentaries • Image under Lens • Research Methodology • Peek into Histtory • My most epiphanic Case • My Nightmarish case GUEST EDITORIALS This submission is following invitation only. Topics chosen would be of wider interest of ophthalmologists and will address a subject on current interest. The experts and stalwarts would share the overview and there take on these topics and help readers develop an opinion about any new development, technique or concept in ophthalmology. REVIEW ARTICLES A review of the literature is published on a particular subject matter and according to a rigorous pre-defined methodology. A review of the literature and data sources pertaining to clinical topics, emphasizing factors such as cause, diagnosis, prognosis, therapy, or prevention. We invite review articles on clinical subjects only. ORIGINAL ARTICLE This can include Research studies, eg, randomized controlled study, case-control study, cohort study, intervention study, observational study, survey. This is also a platform for ophthalmology residents to publish their thesis work. The studies need to be completed and complete results with analysis and final outcome should be available at the time of submission. SURGEON’S VIEWPOINT This section would be following invitation and will involve a panel discussion in Q&A format on subjects and topics on which surgeons have different approaches or viewpoints. This would involve discussions on adopting a new device or technique. INNOVATION AND SURGICAL TECHNIQUES This would invite submissions on any innovation or modification in existing surgical technique or new device or bringing a costeffective alternative to any equipment or technology related to ophthalmology or eyecare delivery. Surgeons and clinicians can also submit less frequently practiced approaches here. CASE SERIES This invites a collection 2 or more similar cases. New, interesting and rare cases or unforeseen complications or exceptionally good outcomes can be reported. They should be unique, describing a great diagnostic or therapeutic challenge and should provide a learning point or take-home message for the readers. Cases with clinical significance or implications will be given priority. COMMENTARIES This section is for brief extension of the published article, where authors can further discuss any recent updates in this research or analyze the issues addressed in the focal article. One can restate the issues discussed but should not summarize the focal article exactly in the same way/Title of the commentary should not be the same as the focal article. Here we also invite concise summary of published articles in a format that is useful for residents pursuing ophthalmology. We will also accept Letter to Editor in this category. Letter to the editor are short letters either responding to a specific article published in HJO or raising new issues. If the former, only letters relating to articles published within the last 6 months will be considered. Letters in response are invited responses to submitted letters. HARYANA JOURNAL OF OPHTHALMOLOGY | JAN-APR 2024

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 93 HARYANA JOURNAL OF OPHTHALMOLOGY | JAN-APR 2024 RESEARCH METHODOLOGY This will be section that invites one page submissions from successful authors who can write upon topics like How to initiate scientific writing, Statistics – basics and advanced, Planning trials, Publishing your original work, working upon patent etc… PEEK INTO HISTORY Rich history of ophthalmology globally and in the state of Haryana can excite and help us advocate ophthalmology. This section would share some of the most exciting progresses and developments that has happened in last 200 years in the field of ophthalmology internationally and at the state of Haryana.. MY MOST EPIPHANIC CASE All of us have encountered clinical situations where eyes have done surprising well despite all odds. Idea is to share a well-documented case where prognosis was expected to be unfavorable but conventional or unconventional approach brought surprising good outcome. It would be great to share these cases with our readers who might get inspired to take up more challenging cases and get going even when situation is demanding. MY NIGHTMARISH CASE Clinicians and Surgeons do encounter unexpected clinical results even after following standard and conventional treatment approaches for ophthalmic diseases. We invite such cases that are well documented and demonstrate these unforeseen complications or turn of events. Sharing these with our colleagues adds valuable information and also documents such mishaps in literature. MANUSCRIPT CATEGORIES AND FORMATTING GUIDELINES Article Type Abstract Word Limit Type of study Maximum figures/ tables Maximum References Review Article Unstructured Abstract Maximum 300 words Maximum 6000 words (Excluding figures/ tables/ References/Abstract/Legends) Review of descriptive studies Systematic Review or Meta-analysis 10 figures/10 Tables Maximum 100 Original Article Neural crest cells Maximum 3500 words (Excluding figures/tables/ References/Abstract/ Legends) 1.Randomised Controlled Trial 2.Case Control Study 3.Cohort Study 4.Interventional Study 5.Survey Studies 6 Tables/6 Figures Maximum 100 Case Series Unstructured Abstract Maximum 150 words Maximum 1000 words (Excluding figures/tables/ References/Abstract/ Legends) ) Case series of 2 or more similar cases with clinical interest 5 Tables/Figures Maximum 10 Guest Editorials Not Required Maximum 1000 words excluding references and title Editorial 5 Tables/Figures Maximum 20

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 94 HARYANA JOURNAL OF OPHTHALMOLOGY | JAN-APR 2024 Surgeon’s Viewpoint Unstructured Abstract maximum 200 words Maximum 3000 words Different perspectives in Q and A format 5 Tables/Figures Maximum 30 Commentaries Not Required Maximum 400 words (Excluding figures/tables/ References/Legends) Letter To the editor/ Single Case Report 2 Tables/Figures Maximum 5 Innovation and Surgical Techniques Unstructured Abstract maximum 150 words Maximum 1000 words Surgical Techniques/ Innovations 4 Tables/Figures Maximum 5 Image Under Lens Not Required Maximum 100 words Clinically relevant Images Maximum 5 images/one formatted composite image with no more than 5 parts Maximum 5 Research Methodology Unstructured Abstract maximum 200 words Maximum 3000 words (Excluding figures/tables/ References/Legends) Research Methodology 5 Tables/Figures Maximum 20 Peek Into History Not Required Maximum 600 words Historical milestone/ Method/Technique/ Person 2 Tables/Figures Maximum 5 My most epiphanic Case Unstructured Abstract Maximum 150 words Maximum 1000 words A Single case or Case series of 2 or more similar cases with clinical interest 3 Tables/Figures Unstructured Abstract Maximum 150 words My Nightmarish case Unstructured Abstract Maximu 150 words Maximum 1000 words A Single case or Case series of 2 or more similar cases with clinical interest 3 Tables/Figures Unstructured Abstract Maximum 150 words

Vol. XVI (No. 1) | ISSN NO. 2322-0309 Page no. 95 HARYANA JOURNAL OF OPHTHALMOLOGY | JAN-APR 2024 PREPARING YOUR MANUSCRIPT Structured Abstract will include following headings in similar order: a. Introduction (Clearly describing the objective) b. Methods (Study design, place of study, methods applied, no of patients, exclusion and inclusion criteria, data sources) c. Results (Results of study in context with the available literature, limitations of study) d. Conclusion (Concise summary of study along with take home points) Formatting: The format for manuscript should be in Word format. Tables should be self-explanatory and submitted in the sequence as they appear in main text. Explanatory matter should be placed in foot notes not in heading. Reference Styles References should be numbered in order in which they are mentioned in the text not in alphabetical order. References should be cited in the format of “American Medical Association” (AMA) style. The titles of journals should be abbreviated according to the style used in Index Medicus. Avoid using abstract as references. Figures/Images/Tables Images should be of good quality with high resolution, preferably in colour and should not be included in main manuscript. Each image should be less than 2 MB in size. Images can be in JPEG or TIFF file format. Resolution of images should be minimum of 350 dpi. Do not zip the files. Images should be named in sequence as 1a,1b,c or so on and should be mentioned in manuscript as required. Legends of the images should be included at the end of the main manuscript. Tables can be submitted separately as images and should not be included in main manuscript. Tables should directly be made in word file and should not be pasted from other application. Presentation Double spacing in main text. Margins 2.5 cm from all four sides. TIMES NEW ROMAN font styling in word. Page numbering should be done in bottom. Title page should contain; Running Title, Authors names, Affiliations, Corresponding Author name, email address, corresponding address and phone number, Number of words in main text, Number of images/tables, Key Words related to manuscript. Cover letter should consist of; Statement stating source of funding if any, Conflict of interest if any, Patient consent if required, Ethics committee approval if taken, Previous publication if any. Heading should be in title case NOT ALL CAPITALS. Abstract should be provided with full title of the manuscript. American English in full text Authorship Papers should only be submitted to the journal once all contributing authors have given consent. There should be statement in the cover letter stating no conflict of interests among authors. Ethics and Patient Consent Submitted manuscripts should conform to the ICMJE Recommendations for the conduct, reporting, editing and publication of scientific work in medical journals. Studies involving animal/ human and/ or interventional studies should include approval from the institute/hospital Ethics Committee or Review Board whichever deems fit. Manuscripts involving personal details or pictures revealing the identity of the patients through any means should include a statement stating written or verbal consent taken from the involved patient/guardian. Funding There should be a statement in cover letter about source of any funding or research grant if present. Acknowledgment Individuals who have substantially contributed to the manuscript but do not meet the criteria for authorship should be listed in the Acknowledgment section with their contribution described. This includes, but not limited to, technical, writing, material, financial and general support. Written permission must be obtained from each individual before inclusion in the manuscript.