July-August, 2022 Vol, 28 No. 4

www.dosonline.org/dos-times DOS Times - Volume 28, Number 4, July-August 2022 51 patients were again shown the circle in different directions more than two consecutive times. If the patients obtained a correct result, they were administered next tests. However, in case of an incorrect result, patients were considered to have high stereopsis. If stereopsis was undetermined, previous steps were repeated again. When correct results were obtained for more than two consecutive times, we used the obtained result as the final finding. If 240 s were not perceived, patients were not included in statistical analysis. Moreover, we performed intraocular pressure and slit lamp, alternate prism cover, and fundus and refraction examinations. All OCT measurements (Cirrus Spectral Domain OCT 4000; Carl Zeiss Meditec, Dublin, CA) were performed after dilating patients’ pupils to at least 5-mm diameter. A single skilled ophthalmologist conducted all measurements. SD-OCT was employed to measure ONH parameters, central macular thickness (CMT), and RNFL. CMT is the average macular thickness in the 1-mm diameter in the center. The signal strength for all scans was set to six. Patients were followed on the postoperative third day, first month, second month, and third month and then every 6 months. Patients with strabismus were followed on the third day postoperatively, first month, third month, and then every six months. Patients underwent comprehensive examination during each follow-up. All patients received stereoacuity tests and SD-OCT during all follow-up visits as a standard protocol. Details regarding patient characteristics, strabismus surgery, and HD-OCT were collected from hospital records. During follow-up visits, data were entered online using a pretested format and exported to an Excel spreadsheet (Microsoft Corp.). Data were audited periodically to ensure complete data collection. Statistical analyses were conducted using SPSS (version 22.0; SPSS Inc., Chicago, IL, USA). Cross tabulation and descriptive statistics were employed to compare cause and effect among different variables. Differences in mean MCT values were observed using Student’s t test and one-way ANOVA. The Pearson correlation was used to evaluate agreements between the variables. P < 0.05 indicated statistical significance. Results Our cohort comprised 54 patients (median: 20 years; mean age: 19.74 ± 9.26 years). Of the 54 patients, 25 (46.3%) were women and 29 (53.7%) were men (Table 1) Age Categories Sex Total Female Male 0-10 7 4 11 11-20 7 13 20 21-30 7 10 17 31-40 3 1 4 41-50 1 1 2 Total 25 29 54 Table 1: Age and sex distribution. The mean stereopsis was −700 ± 792.84 (median: 400) preoperatively and −573.15 ± 708.76 (median: 200; Table 2) postoperatively during the last visit. Of the 54 patients, 24 (44.4%) had amblyopia. Category Mean Std deviation Median Pre-operative central macular thickness od 226.49 39.59 226 Preoperative central macular thickness os 236.60 33.24 237.5 Pre-operative retinal nerve fibre thickness od 76.52 22.67 82 Pre-operative retinal nerve fibre thickness os 83.60 11.81 83.5 Final post-operative central macular thickness od 225.50 41.08 223.50 Final post-operative central macular thickness os 234.34 31.74 240 Final post-operative retinal nerve fibre thickness od 76.59 21.87 82 Final post-operative retinal nerve fibre thickness od 83.51 13.60 87 Table 2: Mean values of central macular thickness and retinal nerve fibre thickness pre and post treatment for both eyes. Of the 54 patients, 25 (46.3%) were children. No significant differences were determined between the adult and pediatric populations for both eyes (p = 0.069 and p = 0.303, respectively). Many other variables were comparable with the final postoperative RNFL values. Subspeciality - Pediatric Ophthalmology & Strabismus

DOS Times - Volume 28, Number 4, July-August 2022 www.dosonline.org/dos-times 52 Variable-1 Variable-2 P value Significance Pre-operative central macular thickness od Final post-operative central macular thickness od 0.341 No Pre-operative central macular thickness os Final post-operative central macular thickness os 0.167 No Pre-operative retinal nerve fibre thickness od Final post-operative retinal nerve fibre thickness od 0.006 Yes Pre-operative retinal nerve fibre thickness os Final post-operative retinal nerve fibre thickness os 0.014 Yes Pre-operative stereopsis Final post-operative stereopsis 0.049 Yes Prep bcva od Final post-operative bcva od 0.000 Yes Pre op bcva os Final post-operative bcva os 0.000 Yes Variable-1 Variable-2 P value Hirschberg test RNFL OD,OS 0.363,0.313 Worth for dot test RNFL OD,OS 0.472,0.108 Amblyopia RNFL OD,OS 0.202,0.647 Nystagmus RNFL OD,OS 0.153,0.151 Alternate deviation RNFL OD,OS 0.000,0.003 Near point of Accommodation RNFL OD,OS 0.000,0.000 Near point of Convergence RNFL OD,OS 0.000,0.000 AC/A ratio RNFL OD,OS 0.000,0.000 Presenting Stereopsis RNFL OD,OS 0.927,0.645 Final stereopsis RNFL OD,OS 0.705,0.058 Table 3: Comparative study of central macular thickness and retinal nerve fibre thickness pre and post treatment for both eyes. Table 4: Comparative study of other variables and retinal nerve fibre thickness pre and post treatment for both eyes. Discussion The results revealed improvements in stereopsis and vision following strabismus treatment. Moreover, mean RNFL but not CMT exhibited significant improvement after treatment. Stereopsis indicates the vision quality.[1, 2, 3, 6, 7] Many conditions affect stereopsis in children.[2, 6, 7] Many methods are available to examine stereopsis.[14-17] A study indicated interpersonal differences in stereopsis measurements.[18] Another previous study compared measurements obtained using different methods.[18] Stereopsis affects performance in learning, catching, and literacy.[19-23] A study revealed that stereopsis can affect movements in older patients.[24, 25] Moreover, stereopsis causes a reading deficiency.[26, 27] Improvement in stereoacuity following squint management was reported.[28-31] All strabismus types exhibited improvement including esotropia, accommodative esotropia, and exotropia; this result is similar to ours.[28-31] Here, we observed increases in RNFL following improved stereoacuity and vision. No study has demonstrated this improvement. This finding suggests neuroanabolism, which refers to functional improvements in affected retinal tissue structures. Studies have examined stereoacuity and retinal cellular structures.[38, 39] Many studies examined MCT in amblyopia.[39-43] A study revealed thickness changes in anisometropic amblyopia.[44] Araki et al observed the reversal of macular changes after amblyopia management but could not find any difference.[45] Okamoto et al found improved stereoacuity and retinal microstructure after macular hole surgery.[46] A study limitation is the inclusion of a small sample with a short follow-up. Multicenter studies including individuals of different races and ethnicities should be conducted to establish this finding. Early improvement in strabismus can improve stereoacuity, thus resulting in structural improvement. Subspeciality - Pediatric Ophthalmology & Strabismus

www.dosonline.org/dos-times DOS Times - Volume 28, Number 4, July-August 2022 53 Conclusion Functional improvement may be associated with structural improvement following stereoacuity correction and strabismus surgery. References 1. Crawford, M. L., G. K. von Noorden (1983). “Binocular neurons and binocular function in monkeys and children.” Invest Ophthalmol Vis Sci 24(4): 491-5. 2. Heron, G., S. Dholakia (1985). “Stereoscopic threshold in children and adults.” Am J Optom Physiol Opt 62(8): 505-15. 3. Ciner, E. B., G. S. Ying (2014). “Stereoacuity of preschool children with and without vision disorders.” Optom Vis Sci 91(3): 351-8. 4. Rutstein, R. P., R. J. Fullard,(2015). “ Aniseikonia induced by cataract surgery and its effect on binocular vision.” Optom Vis Sci 92(2): 201- 7. 5. Endo, T., T. Fujikado (2016). “Stereoscopic perception of 3-D images by patients after surgery for esotropia.” Jpn J Ophthalmol 60(1): 7-13. 6. Pan, C. W., X. Chen, (2016) “Prevalence and causes of reduced visual acuity among children aged three to six years in a metropolis in China.” Ophthalmic Physiol Opt 36(2): 152-7. 7. Zhu, H., J. J. Yu(2015) “Association between childhood strabismus and refractive error in Chinese preschool children.” PLoS One 10(3): e0120720. 8. Bodack, M. I., I. Chung (2010). “An analysis of vision screening data from New York City public schools.” Optometry 81(9): 476-84. 9. Wong, B. P., R. L. Woods (2002). “Stereoacuity at distance and near.” Optom Vis Sci 79(12): 771-8. 10. Haegerstrom-Portnoy, G., M. E. Schneck.(1999). “Seeing into old age: vision function beyond acuity.” Optom Vis Sci 76(3): 141-58. 11. Singh, D., R. Saxena. “Stereoacuity changes after laser in situ keratomileusis.” Optom Vis Sci 92(2): 196-200. 12. Kirwan, C. and M. O’Keefe (2006). “Stereopsis in refractive surgery.” Am J Ophthalmol 142(2): 218-22. 13. Shi, M., H. Jiang.(2014) “Hyperopic corneal refractive surgery in patients with accommodative esotropia and amblyopia.” J Aapos 18(4): 316-20. 14. Moganeswari, D., J. Thomas.(2015) “Test Re-Test Reliability and Validity of Different Visual Acuity and Stereoacuiety Charts Used in Preschool Children.” J Clin Diagn Res 9(11): NC01-5. 15. Holmes, J. M., E. E. Birch (2007). “New tests of distance stereoacuiety and their role in evaluating intermittent exotropia.” Ophthalmology 114(6): 1215-20. 16. Han, S. B., H. K. Yang, (2016). “Quantification of Stereopsis in Patients with Impaired Binocularity.” Optom Vis Sci 93(6): 588-93. 17. Fan, W. C., B. Brown (1996). “A new stereo test: the double two rod test.” Ophthalmic Physiol Opt 16(3): 196-202. 18. Antona, B., A. Barrio(2015). “Intraexaminer repeatability and agreement in stereoacuiety measurements made in young adults.” Int J Ophthalmol 8(2): 374-81. 19. Creavin, A. L., S. T. Creavin(2014) “Why can’t my child see 3D television?” Br J Hosp Med (Lond) 75(8): 457-60. 20. Bogdanici, S. T., D. Costin(2015). “Quality of life for amblyopic children and their parents.” Rev Med Chir Soc Med Nat Iasi 119(1): 214- 20. 21. Ponsonby, A. L., K. Smith(2013). “Poor stereoacuiety among children with poor literacy: prevalence and associated factors.” Optom Vis Sci 90(1): 75-83. 22. Livingstone, M. S., R. Lafer-Sousa,(2011) “Stereopsis and artistic talent: poor stereopsis among art students and established artists.” Psychol Sci 22(3): 336-8. 23. Black, A. and J. Wood (2005). “Vision and falls.” Clin Exp Optom 88(4): 212-22. 24. Saladin, J. J. (2005). “Stereopsis from a performance perspective.” Optom Vis Sci 82(3): 186-205. 25. Kiely, P. M., S. G. Crewther, et al. (2001). “Is there an association between functional vision and learning to read?” Clin Exp Optom 84(6): 346-353. 26. Palomo-Alvarez, C. and M. C. Puell (2010)”Binocular function in school children with reading difficulties.” Graefes Arch Clin Exp Ophthalmol 248(6): 885-92. 27. Noguera, H., J. C. Castiella Acha,(2014). “Medical and surgical treatment of primary divergent strabismus.” Arch Soc ESP Oftalmol 89(11): 431-8. 28. Mitchell, D. E., K. MacNeill(2016). “Recovery of visual functions in amblyopic animals following brief exposure to total darkness.” J Physiol 594(1): 149-67. 29. Guclu, H., V. P. Gurlu(2015). “Prognostic factors for stereopsis in refractive accommodative esotropia.” Pak J Med Sci 31(4): 807-11. 30. Endo, T., T. Fujikado (2016) “Stereoscopic perception of 3-D images by patients after surgery for esotropia.” Jpn J Ophthalmol 60(1): 7-13 31. Kim, J., H. J. Shin (2015). “Comparison of conventional versus crossed monovision in pseudophakia.” Br J Ophthalmol 99(3): 391-5. 32. Mansouri, B., R. C. Stacy(2013). “Deprivation amblyopia and congenital hereditary cataract.” Semin Ophthalmol 28(5-6): 321-6. 33. Choi, H. J., J. H. Lee,(2011). “Secondary intraocular lens implantation in longstanding unilateral aphakia.” Optom Vis Sci 88(5): 608- 12. 34. Kim, D. H., J. H. Kim,(2012) “Long-term results of bilateral congenital cataract treated with early cataract surgery, aphakic glasses and secondary IOL implantation.” Acta Ophthalmol 90(3): 231-6. 35. Hwang, J. M., E. R. Matsumoto, et al. (1999). “The relationship between stereopsis and monocular optokinetic optokinetic nystagmus after infantile cataracts.” J Aapos 3(4): 221-6. 36. Wright, K. W. (1997). “Pediatric cataracts.” Curr Opin Ophthalmol 8(1): 50-5. 37. Ohzawa, I., G. C. DeAngelis, et al. (1996). “Encoding of binocular disparity by simple cells in the cat’s visual cortex.” J Neurophysiol 75(5): 1779-805.Johnston, A. (1986). “A spatial property of the retino-cortical mapping.” Spat Vis 1(4): 319-31. 38. Shen Y, Zhao J, Sun L, et al. The long-term observation in Chinese children with monocular myelinated retinal nerve fibers, myopia and amblyopia. Transl Pediatr. 2021;10(4):860-869. doi:10.21037/tp-20- 452. 39. Repka MX, Kraker RT, Tamkins SM, et al. Retinal nerve fiber layer thickness in amblyopic eyes. Am J Ophthalmol. 2009;148(1):143-147. doi:10.1016/j.ajo.2009.01.015. 40. Jun JH, Lee SY. The effects of optic disc factors on retinal nerve fiber layer thickness measurement in children. Korean J Ophthalmol. 2008;22(2):115-122. doi:10.3341/kjo.2008.22.2.115. Subspeciality - Pediatric Ophthalmology & Strabismus

DOS Times - Volume 28, Number 4, July-August 2022 www.dosonline.org/dos-times 54 41. Szigeti A, Tátrai E, Szamosi A, et al. A morphological study of retinal changes in unilateral amblyopia using optical coherence tomography image segmentation. PLoS One. 2014;9(2):e88363. Published 2014 Feb 6. doi:10.1371/journal.pone.0088363. 42. Masri OS, Abiad B, Darwich MJ, et al. Morphological changes in amblyopic eyes in choriocapillaris and Sattler’s layer in comparison to healthy eyes, and in retinal nerve fiber layer in comparison to fellow eyes through quantification of mean reflectivity: A pilot study. PLoS One. 2021;16(8):e0255735. Published 2021 Aug 6. doi:10.1371/journal.pone.0255735. 43. Miki A, Shirakashi M, Yaoeda K, et al. Retinal nerve fiber layer thickness in recovered and persistent amblyopia. Clin Ophthalmol. 2010;4:1061-1064. Published 2010 Sep 20. doi:10.2147/opth.s13145. 44. Chen W, Xu J, Zhou J, et al. Thickness of retinal layers in the foveas of children with anisometropic amblyopia. PLoS One. 2017;12(3):e0174537. Published 2017 Mar 22. doi:10.1371/journal. pone.017453. 45. Araki S, Miki A, Goto K, et al. Macular retinal and choroidal thickness in unilateral amblyopia using swept-source optical coherence tomography. BMC Ophthalmol. 2017;17(1):167. Published 2017 Sep 15. doi:10.1186/s12886-017-0559-3 . Dr. Mehul Shah, MS Vitreo REtinal Fellow Sankara Nethralaya Corresponding Author: 46. Okamoto F, Moriya Y, Sugiura Y, et al. Stereopsis and retinal microstructures following macular hole surgery. Sci Rep. 2020;10(1):19534. Published 2020 Nov 11. doi:10.1038/s41598-020-76648-4. Subspeciality - Pediatric Ophthalmology & Strabismus

www.dosonline.org/dos-times DOS Times - Volume 28, Number 4, July-August 2022 55 Visual Outcomes of Secondary Lens Implants in Children With Different Etiologies Shreya Shah[1], DOMS, ORBIS fellow, Mehul Shah[2], MD, Apeksha Kataria[2], MBBS, Ashvini Korane[2], MBBS 1. Drashti Netralaya, Dahod, Gujarat, India. 2. Vitreo REtinal Fellow Sankara Nethralaya. Abstract: Aim: This study investigated visual outcomes and factors that impact vision in children receiving secondary intraocular lens (IOL) implants. Methods: Children who had traumatic or congenital cataracts and underwent secondary lens implantation for aphakia at Drashti Netralaya between 2000 and 2019 were retrospectively examined. We included all the eyes with secondary implants for aphakia correction with placement either in the bag or sulcus or through scleral fixation. We obtained data from electronic medical records and analyzed using SPSS 22 through descriptive analysis, cross tabulation, and t test. We evaluated visual outcomes among different patients. Results: Our cohort consisted of 84 eyes (mean age: 7.88 ± 6.07 years). Of the 84 eyes, 24 (28.6%) and 60 (71.4%) were female and male patients, respectively, and 32 (38.1%) had traumatic cataract. We observed significant improvements in vision following lens implantation (p=0.000). Those with nontraumatic cataracts exhibited better outcomes that did the traumatic cataract group (p=0.004). Corneal opacity caused comorbidities in the traumatic group (14/52,14.29%). Visual outcomes significantly improved in young patients and were not affected by other variables. Conclusion: Secondary lens implantation significantly improved vision in aphakic children. Young patients and those with nontraumatic cataracts demonstrated more favorable visual outcomes. Introduction The estimated prevalence of congenital cataract (CC) ranges from 2.2 to 13.6 per 10,000 individuals globally.[1] Variations in prevalence among populations are likely attributable to the difference in factors among countries including screening programs, immunization rates, nutritional status, and population genetics.[1,2] Moreover, the necessity for treatment varies according to density of opacities at birth, partial cataracts at birth, and cataract progression during childhood. Optimal outcomes can be obtained through early identification and diagnosis and appropriate clinical care. Typically, a team of health-care professionals should manage children with cataracts. Moreover, well-established referral pipelines and clinical networks are crucial to achieve favorable outcomes. Although patient management, ranging from diagnosis to surgery, has substantially altered recently, variations are still noted among different countries. Acquired monocular blindness is mainly caused by ocular trauma. Open-globe injury caused by intraocular foreign bodies, posttraumatic endophthalmitis, penetrating injuries, or ocular rupture results in poor vision outcomes.[2-8] Posttraumatic endophthalmitis is a rare and severe complication of open-globe injury with a poor prognosis. In infants, intraocular lens (IOL) implantation can be beneficial in terms of visual rehabilitation and reduce postoperative complications. However, the timing of implanting lens in children with congenital cataract must be carefully decided by considering age during surgery, postoperative complication risks, and treatment affordability of patients’ families along with the selection of suitable IOL power and type. IOL can be safely and effectively implanted in infants aged ≥6 who have well-developed eyeballs and satisfactory systemic conditions. Otherwise, surgeons can opt for secondary lens implants. Congenital cataract, which is characterized by vision loss and amblyopia formation, is a treatable cause of loss of vision in childhood.[1] Visual rehabilitation can be successful when performed when children are aged <3 months, which is considered the amblyogenic window.[2] The axial length rapidly increases until 2 to 3 years of age in healthy children.[2] Moreover, lens implantation after cataract removal can cause myopic shift in patients aged <2 years. Furthermore, these children can develop cosniderable uveal inflammation[9,10] and intensive posterior capsule opacification. Because the safety and efficacy of IOL implantation remain controversial, primary cataract removal is preferred in cases detected early. Subsequently, contact lenses or spectacles can be employed for aphakia correction combined with amblyopia management.[11,12] In the Infant Aphakia Subspeciality - Pediatric Ophthalmology & Strabismus

DOS Times - Volume 28, Number 4, July-August 2022 www.dosonline.org/dos-times 56 Treatment Study, no differences in visual acuities were noted between children who had unilateral cataract and received primary lens implants and those using contact lenses for surgical aphakia correction.[10] Secondary lens implantation is opted when aphakic children aged >2 years cannot tolerate wearing contact lenses or spectacles.[13] Limited studies have examined secondary IOL implantation’s long-term vision outcomes. This study investigated secondary IOL implantation’s long-term vision-related outcomes in children with aphakia aged >2 years and potential factors impacting visual acuity postoperatively. Secondary lens implantation result in satisfactory outcomes in vitrectomized eyes. After vitrectomy, spectacles can be employed for correcting vision. However, the technique and timing of secondary lens implantation to correct vitrectomized aphakia remain unclear, particularly for the loss of capsule integrity and zonular dialysis. Primary lens implantation performed during initial reconstruction resulted in satisfactory outcomes in injured eyes.[8-11] However, primary lens implantation can lead to complications including synechiae, fibrinous uveitis, retinal detachment, pupillary capture, and those related to the posterior segment.[14-17] Material and Methods We retrospectively evaluated the medical details of children receiving secondary lens implants between 2000 and 2019. The ethical committee approved this study. To ensure the identification of eligible children, a chronological surgery list was cross-referenced by performing a database search of children receiving treatment for traumatic or nontraumatic cataract. Children who were aged between 0 and 18 years during their secondary lens implantation, which was performed by a single surgeon, were examined. Children with congenital glaucoma or retinopathy of prematurity were excluded. In addition, those with incomplete data regarding cataract removal or postimplantation follow-up were excluded. Intra- and postoperative complications and visual outcomes at the final visit were evaluated. Information regarding sex, age during surgery, ethnicity, cataract type, laterality, corneal diameter, keratometry, axial length determined through immersion A-scanning, age during IOL implantation, IOL power and type implanted, reason for IOL implantation, and site of IOL fixation was collected. All data were exported in the online pretest format and added in an Excel sheet; all data were examined using SPSS 22. Descriptive analysis, cross tabulation, and t test were performed for statistical analyses. A P value of <0.05 was considered to be statistically significant. Discussion Aphakia is caused due to many factors in children. This study examined factors such as congenital cataract, open-globe ocular trauma, and congenital anomalies such as ectopia lentis unlike other studies that focused on congenital cataracts, traumatic cataracts, or ectopia lentis.[3-8] Here, we compared visual outcomes for all categories. The nontraumatic category exhibited more favorable outcomes possibly due to comorbidities in traumatic cases (p=0.004; Table). Vision Categories Aetiology Total Nontraumatic Traumatic <1/60 4 8 12 1/60-3/60 11 11 22 6/60-6/36 3 5 8 6/24-6/18 26 3 29 6/12-6/9 7 4 11 6/6-6/5 1 1 2 Total 52 32 84 P=0.004 Vision Categories IOL Placement Total ACIOL BAG IN SULCUS SFIOL <1/60 0 0 8 4 12 1/60-3/60 1 1 11 9 22 6/60-6/36 0 1 4 3 8 6/24-6/18 0 11 14 4 29 6/12-6/9 0 0 7 4 11 6/6-6/5 0 0 1 1 2 Total 1 13 45 25 84 P=0.09 Table 1: Comparative study of visual out come amongst traumatic and non traumatic aetiology. Table 2: Comparative study of visual outcome according to Lens location. Secondary lens were implanted in different locations, namely the bag and sulcus; scleral-fixated and posterior chamber iris claw lens were implanted. No significant differences were observed (p=0.09). According to Wood et al., secondary lens implanted in the capsular bag resulted in fewer complications than did those in the ciliary sulcus. Many patients recruited to this study received implants in the capsular bag (69.4%). This finding may be responsible for low complication rates and indicates that capsular bag preservation is crucial for secondary lens implantation. However, this finding limits the generalizability of study results to other centers where a higher proportion received implants in the bag and sulcus.[18] The major complication or cause of nonimprovement of vision in this study was corneal opacity (12/84 patients, 14.29%, Table). A study reported VAO, secondary glaucoma, and refractive problem as causes in 5.4%, 16.4%, and 8.1% of Subspeciality - Pediatric Ophthalmology & Strabismus

www.dosonline.org/dos-times DOS Times - Volume 28, Number 4, July-August 2022 57 Table 4: Comparative study of visual outcome according to Lens material. Table 3: Comparative study of reasons for no improvement of vision amongst traumatic and non traumatic aetiology. patients, respectively. The current study included many (32/84) Cause Non Traumatic Traumatic Total No % No % No % Corneal opacity 4 7.69 10 31.25 14 14.29 Lens malposition 1 1.92 2 6.25 3 3.57 Inflammation 1 1.92 3 9.37 4 4.76 Ps problems 1 1.92 6 18.75 7 8.33 Secondary glaucoma 1 1.92 3 9.37 4 4.76 Amblyopia 4 7.69 0 0 4 4.76 Pseudophakic bullous keratopathy 1 1.92 2 6.25 3 3.57 Normal 36 69.23 9 28.12 45 53.57 Lost follow up 1 1.92 1 3.12 2 2.38 84 100 The mean ages during secondary lens implantation were 94.56 ± 72.84, 55.2 ± 21.6, and 46.64 ± 29.37 months in our study, Wood et al.’s study, and Rong et al.’s study, respectively.[18,19] This might be attributed to the lack of awareness in rural areas and ignorant parents. Owing to the low socioeconomic status, compliance of aphakic spectacles and contact lenses is poor, thus affecting the outcome because of amblyopia. The mean followup period was 3.53 ± 5.6 years in this study, 57.6 ± 33.6 months in Woods et al.’s study, and 109.09 ± 18.89 months in Rong et al.’s study, respectively. This difference can be due to variations in sociodemographic factors. Furthermore, 42 (50%) and 12 (14.3%) of 84 (50%) patients achieved visual acuities of >6/24 and <1/60, respectively. The median visual acuities reported by Woods et al. and Rong et al. at the final visit were 20/40 and 6/18, respectively. These results are similar to those reported by previous studies[16,17] including that conducted by Nihalani and Vanderveen[14] who demonstrated that 50% eyes had a BCVA of ≥20/40 and Shenoy et al. who found that 35% eyes had a BCVA of ≥20/40.[20] Hu et al. demonstrated that secondary iris claw lens implantation resulted in satisfactory vision.[21] Forlini indicated that retro pupillary iris claw lens is a suitable option for scleral-fixated or angle-supported lens.[22] Retropupillary iris claw lens implantation can safely and effectively correct aphakia without capsule support.[23,24] He et al indicated that secondary lens implants can safely correct aphakia in for open-globe injury patients undergoing vitrectomy. This finding is in agreement with that of this study; we noted no differences in outcomes among various lens positions.[25] Secondary sulcus IOL could be implanted after preserving the anterior lens capsule during primary implantation in children with anterior PFV; this procedure resulted in favorable vision outcomes after operation and a compatible proportion of complications.[26-28] Yu and Maxwell observed favorable longer-term findings and few complications after sutured scleral-fixated foldable lens implantation. Their procedure is safe, does not need complex equipment, and can correct aphakia in the absence of adequate capsule support.[29,30] Edelstein S reported successful outcomes of scleral-fixated lens implants in congenital ectopia lentis, which is similar to this study.[31] This study compared the outcomes of various lens positions in different etiologies and exhibited no significant differences. A strength of the present study is that the same surgeon operated all eyes. The study is limited by its retrospective nature; however, incomplete records were excluded. Future studies should include more patients and examine different postoperative complications. In addition, because young patients were enrolled, we could not perform BCVA Snellen measurements. Vision Categories IOLMATERIAL Total Acrylic PMMA <1/60 0 12 12 1/60-3/60 3 19 22 6/60-6/36 0 8 8 6/24-6/18 11 18 29 6/12-6/9 0 11 11 6/6-6/5 0 2 2 Total 14 70 84 posttrauma cases causing corneal opacities (Table).[18] Subspeciality - Pediatric Ophthalmology & Strabismus

DOS Times - Volume 28, Number 4, July-August 2022 www.dosonline.org/dos-times 58 A more standardized method for measuring visual acuity can be beneficial. Conclusion Secondary lens implantation significantly improved children’s vision. Outcomes were favorable for congenital than traumatic cataracts. Lens placement in the bag, sulcus, or through scleral fixation significantly affects the visual outcome. References 1. Infant Aphakia Treatment Study Group, Lambert SR, Lynn MJ, Hartmann EE, DuBois L, Drews-Botsch C et al. Comparison of contact lens and intraocular lens correction of monocular aphakia during infancy: a randomized clinical trial of HOTV optotype acuity at age 4.5 years and clinical findings at ae 5 years. JAMA Ophthalmol 2014; 132: 676–682. 2. Infant Aphakia Treatment Study Group, Lambert SR, Buckley EG, Drews-Botsch C, DuBois L, Hartmann E et al. The infant aphakia treatment study: design and clinical measures at enrollment. Arch Ophthalmol 2010; 128: 21–27. 3. Chiquet C, Zech JC, Gain P, Adeleine P, Trepsat C. Visual outcome and prognostic factors after magnetic extraction of posterior segment foreign bodies in 40 cases. Br J Ophthalmol. 1998;82(7):801-806. 4. Doskova H, Vlkova E. Surgical treatment of combined injuries of the anterior and posterior segment of the eye with intraocular metallic foreign body. Ceska a slovenska oftalmologie: casopis Ceske oftalmologicke spolecnosti a Slovenske oftalmologicke spolecnosti. 2006;62(1):42-47. 5. Riazi M, Moghimi S, Najmi Z, Ghaffari R. Secondary Artisan- Verysise intraocular lens implantation for aphakic correction in post-traumatic vitrectomized eye. Eye (Lond). 2008;22(11): 1419-1424. 6. Chorągiewicz T, Nowomiejska K, Wertejuk K, et al. Surgical treatment of open globe trauma complicated with the presence of an intraocular foreign body. Klin Oczna. 2015;117(1):5-8. 7. Besek NK, Nacaroglu SA, Er MO, et al. The Effect of Secondary Intraocular Lens Implantation Time on Visual Prognosis in Aphakia Cases after Open Globe Injury. Korean J Ophthalmol. 2021;35(5):368-375. doi:10.3341/kjo.2020.0004. 8. Chuang LH, Lai CC. Secondary intraocular lens implantation of traumatic cataract in open-globe injury. Can J Ophthalmol. 2005;40(4): 454-459. 9. Vaegan, Taylor D. Critical period for deprivation amblyopia in children. Trans. Ophthalmol. Soc. U. K. 1979; 99(3):432–9 PMID: 298827. 10. Elston J, Timms C. Clinical evidence for the onset of the sensitive period in infancy. Brit J Ophthalmol 1992; 76(6):327–28. 11. Wilson ME. Intraocular lens implantation: has it become the standard of care for children? Ophthalmology 1996; 103(11):1719–20 PMID: 8942861. 12. Lambert SR, Drack AV. Infantile cataracts. Surv Ophthalmol 1996; 40(6):427–58 PMID: 8724637. 13. Lorenz B, Wörle J. Visual results in congenital cataract with the use of contact lenses. Graefes Arch. Clin. Exp. Ophthalmol. 1991; 229(2):123–32 PMID: 2044971. 14. Nihalani BR, Vanderveen DK. Secondary intraocular lens implantation after pediatric aphakia. J AAPOS 2011; 15(5):435–40 doi: 10.1016/j.jaapos.2011.05.019 PMID: 22108355. 15. Basti S, Ravishankar U, Gupta S. Results of a prospective evaluation of three methods of managementof pediatric cataracts. Ophthalmology 1996; 103(5):713–20 PMID: 8637679. 16. Magli A, Forte R, Rombetto L. Long-term outcome of primary versus secondary intraocular lens implantationafter simultaneous removal of bilateral congenital cataract. Graefes Arch. Clin. Exp. Ophthalmol.2013; 251(1):309–14 doi: 10.1007/s00417-012-1979-7 PMID: 22411128 . 17. Kim DH, Kim JH, Kim SJ, Yu YS. Long-term results of bilateral congenital cataract treated with earlycataract surgery, aphakic glasses and secondary IOL implantation. Acta Ophthalmol 2012; 90(3):231– 36 doi: 10.1111/j.1755-3768.2010.01872.x PMID: 20819081. 18. Wood KS, Tadros D, Trivedi RH, Wilson ME. Secondary intraocular lens implantation following infantile cataract surgery: intraoperative indications, postoperative outcomes. Eye (Lond). 2016;30(9):1182- 1186. doi:10.1038/eye.2016.131. 19. Rong X, Ji Y, Fang Y, Jiang Y, Lu Y. Long-Term Visual Outcomes of Secondary Intraocular Lens Implantation in Children with Congenital Cataracts. PLoS One. 2015;10(7):e0134864. Published 2015 Jul 31. doi:10.1371/journal.pone.0134864. 20. Shenoy BH, Mittal V, Gupta A, Sachdeva V, Kekunnaya R. Complications and visual outcomes after secondary intraocular lens implantation in children. Am J Ophthalmol 2015; 159: 720–726. 21. Hu S, Wang M, Xiao T, Zhao Z. Iris reconstruction combined with iris-claw intraocular lens implantation for the management of irislens injured patients. Indian J Ophthalmol 2016;64:216-21. 22. Forlini M, Soliman W, Bratu A, Rossini P, Cavallini GM, Forlini C. Long-term follow-up of retropupillary iris-claw intraocular lens implantation: a retrospective analysis. BMC Ophthalmol. 2015;15:143. Published 2015 Oct 27. doi:10.1186/s12886-015-0146-4. 23. Toro MD, Longo A, Avitabile T, et al. Five-year follow-up of secondary iris-claw intraocular lens implantation for the treatment of aphakia: Anterior chamber versus retropupillary implantation. PLoS One. 2019;14(4):e0214140. Published 2019 Apr 10. doi:10.1371/journal. pone.0214140. 24. Thulasidas M. Retropupillary Iris-Claw Intraocular Lenses: A Literature Review. Clin Ophthalmol. 2021;15:2727-2739. Published 2021 Jun 25. doi:10.2147/OPTH.S321344. 25. He T, You C, Chen S, Meng X, Liu Y, Yan H. Secondary Sulcus-Fixed Foldable IOL Implantation with 25-G Infusion in Patients with Previous PPV after Open-Globe Injury. Eur J Ophthalmol. 2017;27(6):786- 790. doi:10.5301/ejo.5000963. 26. Liu JH, Li SF, Deng GD, Jiao YH, Lu H. Outcomes of secondary sulcus intraocular lens implantation in unilateral anterior persistent fetal vasculature. Int J Ophthalmol. 2019;12(4):592-596. Published 2019 Apr 18. doi:10.18240/ijo.2019.04.11. 27. Prakhunhungsit S, Berrocal AM. Diagnostic and Management Strategies in Patients with Persistent Fetal Vasculature: Current Insights. Clin Ophthalmol. 2020;14:4325-4335. Published 2020 Dec 10. doi:10.2147/OPTH.S236117. 28. Vasavada AR, Vasavada SA, Bobrova N, Praveen MR, Shah SK, Vasavada VA, Pardo A JV, Raj SM, Trivedi RH. Outcomes of pediatric cataract surgery in anterior persistent fetal vasculature. J Cataract Refract Surg 2012;38(5):849-857. 29. Yu T, Yu M, Wu W, et al. Outcomes and Complications of Sutured Scleral-Fixated Foldable Intraocular Lens Implantation: A Retrospective Study of 5-Year Follow-Up. J Ophthalmol. 2021;2021:5525064. Subspeciality - Pediatric Ophthalmology & Strabismus

www.dosonline.org/dos-times DOS Times - Volume 28, Number 4, July-August 2022 59 Published 2021 Jul 16. doi:10.1155/2021/5525064. 30. Stem MS, Todorich B, Woodward MA, Hsu J, Wolfe JD. Scleral-Fixated Intraocular Lenses: Past and Present. J Vitreoretin Dis. 2017;1(2):144-152. doi:10.1177/2474126417690650. 31. Hsu HY, Edelstein SL, Lind JT. Surgical management of non-traumatic pediatric ectopia lentis: A case series and review of the literature. Saudi J Ophthalmol. 2012;26(3):315-321. doi:10.1016/j. sjopt.2012.05.001. Dr. Shreya Shah, DOMS, ORBIS fellow Drashti Netralaya, Nr. GIDC, Chakalia Road. Dahod, Gujarat. Corresponding Author: Subspeciality - Pediatric Ophthalmology & Strabismus

DOS Times - Volume 28, Number 4, July-August 2022 www.dosonline.org/dos-times 60 Kayser Fleischer Ring and Sunflower Cataract in Wilsons Disease Divya Ramraika, DOMS, DNB, Shivcharan Lal Chandravanshi, MS, FMRF Atal Bihari Vajpayee Government Medical College, Vidisha, MP. A 19 year old male patient was referred to department of Ophthalmology from the department of pediatrics with the diagnosis of Wilson disease, haemochromatosis with hepatic features of chronic liver disease, portal hypertension and neuropsychiatric manifestations like deafness, unable to speak, lower limb weakness. Patient was referred to Ophthalmology department for the evaluation of Kayser Fleischer ring. We found the Kayser Fleischer ring along with sunflower cataract on slit lamp examination as shown in figure 1. Wilson disease is defined as an autosomal recessive disease with inborn error of copper metabolism and it is also known as hepatolenticular degeneration. It commonly affects the brain (putamen), cornea, liver and kidney. The disease process starts as a result of copper accumulation in tissues. Patients are treated by keeping them on low copper diet, use of chelating agent i.e. D penicillamine. Hepatic transplantation is done for fulminant hepatic failure. Figure 1: Diffuse slit lamp examination showing kayser Fleischer ring with black arrow and sunflower cataract with white arrow. Dr. Divya Ramraika, DOMS, DNB Senior Resident, Department of Ophthalmology, Atal Bihari Vajpayee Government Medical College, Vidisha, MP. Corresponding Author: Subspeciality - Systemic Diseases and Eye

www.dosonline.org/dos-times DOS Times - Volume 28, Number 4, July-August 2022 61 Surgical Technique of Tenon Patch Graft in Corneal Fistula and Corneal Perforations Deepali Singhal, MD Centre For Sight, Bhubaneswar, India. Introduction Corneal fistula is a rare complication of healed keratitis that can be missed if not examined carefully using fluorescein staining. It is an open track or communication between anterior chamber and corneal surface lined with epithelium. It is most described in cases of healed keratitis or failed graft or opaque cornea.[1,2] Corneal perforation is a more common condition which occurs due to trauma, infective keratitis, or inflammatory causes. Both these conditions should be managed to close the aqueous leakage immediately to avoid complications like endophthalmitis, panophthalmitis or phthisis bulbi. The goal of treatment is to restore the globe integrity, allow healing of the defect to make the cornea amenable for future corneal transplantation. Depending upon the size these conditions can be managed with tissue adhesives, bandage contact lenses (BCL), multilayered amniotic membrane graft (AMG) and corneal patch graft.[3] However, these techniques have their own limitations. Tissue adhesives like cyanoacrylate glue cause surface irregularity, postoperative inflammation leading to ocular discomfort, induce severe stromal vascularization affecting the outcome of future keratoplasty. In developing countries its use is limited by the availability as well as cost. Though, Amniotic membrane reduces inflammation, vascularization, and scarring, it does not provide any tectonic support. Immediate availability of donor corneas, which is needed for large perforations, may not be possible in all emergency settings. The technique of tenon patch graft was described first in cases of perforated corneal ulcers in a video presentation by Rasik B. Vajpayee in American Academy of Ophthalmology meeting on December 11, 2012.[4] Thereafter, several authors have described this technique with some modifications.[2,4–7] Tenon capsule, being a fibrous and tough structure provides better tectonic support and being autologous will be free of any rejection as well as is cost effective. Herein we describe the surgical technique of TPG in cases of corneal perforations and corneal fistula. Preop Evaluation Pre-op evaluation includes noting the demographic data, diagnosis, best-corrected visual acuity (BCVA), and intraocular pressure. Slit lamp examination including the condition of lids and adnexa, ocular surface, conjunctiva. Corneal examination includes measuring the size of the perforation or fistula, noting any area of surrounding stromal thinning or melting, area of epithelial defect and infiltrates, anterior chamber details, status of iris and lens and posterior segment evaluation. Ultrasonography B scan should be done if posterior segment is not visible. Surgical Technique The surgery is performed under peribulbar block or general anesthesia in children or patients with large perforation. At the beginning of the procedure, the size of the corneal perforation is measured using calipers and confirmed using fluorescein staining. A 26-G needle or a 15-degree blade (Beaver-Visitec International, Massachusetts, MA 02451, United States) is then used to freshen the edges of the fistula and debride the surrounding epithelium. Following this, a stromal pocket is created 360 degrees around the perforation using a crescent blade (Alcon Surgical, Fort Worth, Texas, USA). The conjunctiva, supero-temporal or supero-nasal quadrant is marked 1 mm more than the size of fistula and a linear peritomy is done. Conjunctiva is separated from the underlying tenons tissue using blunt dissection with the help of a conjunctival scissors. The tenon tissue is separated from the underlying episcleral tissue using blunt dissection with the help of a blunt scissors. The tenon tissue corresponding to the size of conjunctival marking is excised with the help of Vanna’s scissors (Appasamy Associates; Chennai, Tamil Nadu) and the graft is then transferred to the site of perforation. The cut edges of conjunctiva are approximated, by applying firm pressure with the help of serrated forceps, for a few seconds to achieve firm adhesion. The procured graft is then placed over the defect and the edges are trimmed to match the size and shape of the defect. Further, these edges are tucked into the stromal pocket created previously. The graft is then sutured with the help of multiple (4-5) interrupted 10-0 monofilament nylon sutures oriented radially. Anterior chamber is formed with air. A watertight compartment is ensured at the end of the procedure. A bandaged contact lens is then placed over the ocular surface. Eye is patched after putting antibiotic eye drops (moxifloxacin hydrochloride 0.5%). It is important to note that suturing of the graft and formation of a watertight compartment is essential at the end of surgery to avoid any incarceration of iris tissue into the perforation or fistula. Since, formation of adherent leucoma might lead to a high-risk keratoplasty later as compared to a lecomatous scar without any iris incarceration. In addition, the surrounding Surgical Technique

DOS Times - Volume 28, Number 4, July-August 2022 www.dosonline.org/dos-times 62 stroma should be intact in order to create 360 degree stromal pocket and tuck-in the graft. Post-op Evaluation and Follow-Up Postoperatively patient was started on medical management including antibiotic eye drops (moxifloxacin hydrochloride 0.5% four times a day), topical homoatropine hydrobromide 2% four times a day, topical prednisolone phosphate 1 % four times a day. Follow-up was done on day 1, day 7, 2 weeks, 1 month, 3 months and 6 months. BCL was removed at 4 weeks. Sutures were removed when they became loose or exposed. Advantages of tenon patch graft • An autologous tissue • Easily available • No additional cost • No risk of rejection • Promotes healing by producing autologous fibroblast and connective tissue • Gets incorporated into the corneal stroma • Can be used in emergency when donor cornea is not available • Minimal surface irregularity and post-op inflammation and vascularization as compared to cyanoacrylate glue • Helps to obviate the need of establishment and maintenance of an eye bank and various laboratories required for preservation of donor corneas and AMG Limitations of tenon patch graft • An opaque tissue • Does not improve visual acuity if used for central perforations • Lower tensile strength than donor corneal tissue Complication of Tenon patch graft technique can be graft displacement and retraction due to loose or broken sutures, need for repeat suturing. To conclude, Tenon patch graft is a simple, effective, and inexpensive method of managing corneal perforations and fistulas. Figure 1: 1a, 2a, 3a: Pre-op clinical picture of three patients with healed keratitis and corneal fistula showing a leucomatous scar with stromal vascularisation with a central translucent cystic area measuring 1x 2 mm in size with underlying uveal tissue adherent to the fistula margin. 1b, 2b, 3b: Post-op clinical picture showing a well attached and tucked-in tenon patch graft. Surgical Technique

www.dosonline.org/dos-times DOS Times - Volume 28, Number 4, July-August 2022 63 References 1. Singhal D, Sahay P, Maharana PK, Amar SP, Titiyal JS, Sharma N. Clinical presentation and management of corneal fistula. Br J Ophthalmol 2019;103(4):530–3. 2. Maharana PK, Singhal D, Sahay P, Titiyal JS. Tenon patch graft for corneal fistula: a rare entity treated by a simple technique. Case Rep 2017;2017:bcr-2017. 3. Singhal D, Nagpal R, Maharana PK, Sinha R, Agarwal T, Sharma N, et al. Surgical alternatives to keratoplasty in microbial keratitis. Surv Ophthalmol 2020; 4. Sharma N, Singhal D, Maharana PK, Vajpayee RB. Tuck-in tenon patch graft in corneal perforation. Cornea 2019;38(8):951–4. 5. Kate A, Vyas S, Bafna RK, Sharma N, Basu S. Tenon’s Patch Graft: A Review of Indications, Surgical Technique, Outcomes and Complications. Semin Ophthalmol 2021;1–9. 6. Shekhawat NS, Kaur B, Edalati A, Abousy M, Eghrari AO. Tenon Patch Graft With Vascularized Conjunctival Flap for Management of Corneal Perforation. Cornea 2022;41(11):1465–70. 7. Bafna RK, Kalra N, Rathod A, Asif MI, Lata S, Parmanand K, et al. Hitch suture assisted tuck in Tenon’s Patch Graft for management of Corneal Perforations. Eur J Ophthalmol 2022;32(6):3372–82. Dr. Deepali Singhal, MD Associate Consultant Ophthalmology (Cornea, Cataract and Refractive surgery Department) Centre For Sight Eye Hospital, Bhubaneswar, India. Corresponding Author: Figure 2: Technique of tenon patch graft. (a) Corneal fistula seen with Siedle’s positive test, (b) Size of the corneal perforation and the area of thinning is measured using calipers, (c & d) conjunctiva in supero-temporal quadrant is marked 1 mm more than the measured size of the thinning, (e) a linear peritomy is done over the marked area, (f) conjunctiva dissected from tenon tissue, (g) separated tenon tissue is pulled and corresponding to the size of conjunctival marking is excised with the help of Vanna’s scissors, (h) the cut edges of conjunctiva are approximated, by applying firm pressure with the help of serrated forceps, for a few seconds to achieve firm adhesion, (I) the edges of the fistula are freshened, (j) a 360 degree intrastromal tunnel created, (k) the procured graft is trimmed to match the size and shape of the defect, (l,m) the graft is then tucked inside the stromal pocket carefully, (n) the graft is then sutured with the help of multiple interrupted 10-0 monofilament nylon sutures, (o) the suture is first passed through the edge of the graft then through the stromal pocket and then taken out from the host cornea, (p) at the end of the procedure, anterior chamber is formed with air. Surgical Technique

DOS Times - Volume 28, Number 4, July-August 2022 www.dosonline.org/dos-times 64 Peripheral Corneal Ectatic Disorders Sohini Mandal, MD, FAICO, Vaibhav Namdev, MBBS, Prafulla K Maharana, MD Dr Rajendra Prasad Centre for Ophthalmic Science, AIIMS New Delhi. Pellucid Marginal Degeneration Introduction Pellucid marginal degeneration (PMD) is a non-inflammatory, non-hereditary disorder, bilateral, often asymmetrical, characterized by peripheral thinning and ectasia separated from limbus by an area of 1–2 mm in width.[1] Predominantly this condition involves the inferior cornea, with peripheral thinning of 4 clock hours ranging from 4-o´clock to 8- o´clock position.[2] However, this disorder might also involve superior[3,4], temporal[5,6] and nasal[6] areas of cornea thus making itself a close differential of other conditions. This is considered as the second most common corneal ectatic disorder after keratoconus. Etiology The etiology of PMCD is mostly unknown. One school of thought believes PMD, keratoconus and keratoglobus to belong to the same disease spectrum and represent different clinical presentations. Obesity, obstructive sleep apnoea and floppy eyelid syndrome have been reported to be accompanied with PMD in literature. Epidemiology The most common affected age group is second to fifth decade. In 10% of patients with corneal ectasia, PMD and keratoconus seems to be co-existing. Clinical Presentation The patients usually present with gradual, progressive painless decline in vision or poor vision due to high astigmatism. Corrected distance visual acuity often declines in advanced stages of the disease and corneal topography reveals high irregular, against-the-rule astigmatism. The vertical meridian is relatively flatter due to tissue loss and a thin stroma inferiorly. The steepening and ectasia occur at the intersection of the involved and uninvolved tissue, thereafter giving a typical high cylindrical loop and high against-the-rule astigmatism. Rarely, they can present with an acute painful red eye with decline in vision with or without a history of minor trauma suggestive of acute hydrops and/or spontaneous corneal perforation. Slit lamp evaluation reveals crescent shaped band of stromal thinning of the peripheral cornea, extending from 4 o’clock to 8 o’clock (Figure 1). When visualised sideways, advanced stages of PMD cornea gives an appearance of a beer belly as the zone of maximal ectasia lies above the thinnest location. Figure 1A: Slit lamp photograph in diffuse illumination examination reveals a crescentic band of corneal thinning that extends from 4-8 o’ clock hours parted from limbus by a healthy cornea of 1–2 mm in width with protuberance/ectasia. Figure 1B and 1C: Slit lamp photograph reveals localised inferior corneal thinning with ectasia just above it (“beer belly appearance”). Although PMD is a bilateral condition, unilateral cases have also been stated. PG Corner

www.dosonline.org/dos-times DOS Times - Volume 28, Number 4, July-August 2022 65 Evaluation Corneal tomography has been the gold standard investigation for diagnosing and prognostication of PMD and other corneal ectasias. The topographical pattern is often confused with keratoconus due to the presence of inferior corneal steepening. However, the major difference is the presence of an island of flattening just below the midline within the steep area, which is pathognomonic for PMD. This gives rise to a characteristic “crab-claw,” “butterfly,” or “kissing doves” appearance on the curvature/keratometric map on topography. (Figure 2) Figure 2A and 2B: Demonstrates the axial curvature and Belin Ambrosio enhanced ectasia display of Pentacam topography maps that reveal the characteristic high against-the-rule astigmatism pattern seen in patients with pellucid marginal degeneration. Inferior steepening is also present, with the presence of the classic “crab claw” topographic appearance. There is presence of an island of flattening just below the midline within the steep area, which is pathognomonic for PMD. PG Corner

DOS Times - Volume 28, Number 4, July-August 2022 www.dosonline.org/dos-times 66 A typical hot spot area or an area of elevation in the inferior periphery is pathognomonic on elevation maps. Greater emphasis must be given on the clinical and topographic relationship for a definitive diagnosis as sometimes, the elevation map change can also be observed in advanced keratoconus. The percentage thickness increase (PTI) on the Belin Ambrosio enhanced ectasia display (BAD) map of PMD patients shows the red curve moving upwards i.e., thinner pachymetry in the inferior periphery and thicker at the centre. Figure 3: Anterior segment optical coherence tomography (ASOCT) image of a patient with pellucid marginal degeneration that reveals the exact location and extent of corneal thinning and the corresponding pachymetry and epithelial thickness map showing thinnest area of 48 microns in the inferonasal part of cornea. The far peripheral changes cannot be picked up on topography as it is beyond the range of the corneal area sampled by the topography machine. To counteract this shortcoming, highresolution anterior segment optical coherence tomography (ASOCT) and Scheimpflug imaging devices might guide in locating the thinnest corneal point. (Figure 3) Differential Diagnosis As each ectatic disorder has its specific management, it becomes clinically very relevant to have a clear distinction between all the ectatic disorders. The main differentiating points to differentiate PMD from rest of the ectatic disorders are elaborated in details. 1. Keratoconus 2. Keratoglobus 3. Terrien marginal degeneration 4. Mooren’s ulcer Management Patients with PMD can be managed either conservatively or surgically for optimal visual rehabilitation. 1. Spectacles 2. Contact lens- RGP-CL, hybrid CL, semi scleral, mini scleral and scleral CL [prosthetic replacement of ocular surface ecosystem (PROSE)] lenses are beneficial in such cases. Surgical treatment comprises: 1. Cross-linking (CXL) 2. Intracorneal ring segments (ICRS) 3. Partial and total corneal replacement procedures- The various surgical options for visual rehabilitation in cases with PMD include lamellar or penetrating keratoplasty with a large diameter eccentric graft. “Tuck in” lamellar keratoplasty (TILK) is an exclusive category of lamellar keratoplasty, performed for advanced peripheral ectatic disorders such as PMD, keratoglobus, PMD combined with keratoconus and post PKP ectasia. It is comprised of a central donor corneal button obtained by lamellar dissection with an extra intrastromal tuck of the peripheral flange of the graft into the peripheral intrastromal pocket of the host. (Figure 4 and 5) PG Corner

www.dosonline.org/dos-times DOS Times - Volume 28, Number 4, July-August 2022 67 Figure 4: Slit lamp photograph reveals clear graft with minimal peripheral opacification at 6 months postoperative following tuck in lamellar keratoplasty. The graft host junction also shows the intrastromal tuck with well-integrated donor lamellar graft into the host corneal tissue. Figure 5: Diagrammatic representation depicting central lamellar keratoplasty with peripheral tuck of the large graft into the intrastromal pocket of host corneal tissue. Other surgical procedures such as crescentic lamellar keratoplasty, combined central penetrating keratoplasty, intrastromal lamellar keratoplasty, lamellar or full-thickness crescentic wedge resection and epikeratoplasty have been tried successfully by various surgeons. Terrien ‘s Marginal Degeneration Introduction Terrien marginal degeneration (TMD) is a rare, asymmetrically bilateral slowly progressive disease characterized by the following pathognomonic features: a) a peripheral crescentic area thin cornea with furrow formation, b) superficial, radial and tortuous or circumferential appearing blood vessels in the peripheral thinned area, c) lipid deposition at the leading edge, and d) undamaged corneal epithelium without apparent inflammatory signs or symptoms (Figure 6). Etiology While the exact etiology is unknown, various authors have come up with different hypotheses behind the etiology of TMD. a) Degenerative origin: This is characterized by relatively slow progression with a long course, asymptomatic nature, and lipid deposition at the leading edge. b) Inflammatory origin: This is characterized by repeated episodes of pain, photophobia, watering, conjunctival injection, and/or epithelial defect. c) Phagocytosis of collagen by histiocytes: Süveges proposed that stromal collagen lamellae are phagocytosed by histiocyte-like cells.[7] Most common systemic and ocular association reported with TMD are arthritis and meibomian gland dysfunction respectively. However, these associations may only be a contributing factor as systemic disease might be absent in many TMD patients. Epidemiology There is no exact data on incidence and prevalence of TMD in literature, because of its rare occurrence. A recent case series has stated that the disease can occur at any age, with a mean manifestation at 44 years and a slight male preponderance (54%).[8] Clinical Manifestations Although, the disease is detected incidentally, TMD patients usually present with decline in visual acuity or mild foreign body sensation. TMD is characteristically associated with high against the rule astigmatism as the degenerative process typically originates from the superior or superonasal area of the cornea. The peripheral corneal thinning leads to flattening in the vertical meridian, leading to relative steepening in the opposite meridian. PG Corner

DOS Times - Volume 28, Number 4, July-August 2022 www.dosonline.org/dos-times 68 Figure 6A and 6B: Slit lamp examination, diffuse and slit illumination shows the presence of a fine, white-yellow peripheral opaque band with lipid deposition at the leading edge in the superior half of the cornea, as well as superficial vascularization in the transparent area between the limbus and the opaque band. The trajectory of the blood vessels is often radial with some tortuosity and circumferential extension. Descemet membrane detachments and corneal hydrops have been described to occur very rarely. Hydrops in TMD appears as a focal corneal edema with large intrastromal fluid clefts that can rarely spread underneath the conjunctiva, thus giving an appearance of a filtering bleb. The classical form of TMD encompasses to have intact epithelium in absence of any inflammatory signs or symptoms, however in the past decade, the debate about the latent existence of an inflammatory type of TMD has continued. Iwamoto et al have classified the disease into two types: inflammatory and quiescent.[9] TMD is also reported to be associated with puberty and menstrual cycle. TMD can be associated with various corneal and systemic diseases such as lattice stromal dystrophy, posterior polymorphous corneal dystrophy, vernal keratoconjunctivitis, and rheumatoid arthritis. Differential Diagnosis The close differentials of TMD include: • Peripheral ulcerative keratitis • Mooren ulcer • Peripheral infectious keratitis • Fuchs superficial marginal keratitis • Pellucid marginal degeneration • Dellen • Arcus senilis • Senile marginal furrow degeneration Use of Recent Investigative Modalities in TMD The conventional topography map of TMD displays flattening over the areas of peripheral thinning, and a consecutive steepening 90 degrees away. a) Scheimpflug imaging- provides more detailed information about the cornea periphery compared to other diagnostic techniques. Therefore, Scheimpflug imaging holds a significant place diagnosis and staging of TMD. (Figure 7-10) Figure 7: Pentacam quad map of a patient of terrien’s marginal degeneration (TMD) in right eye showing high against the rule astigmatism with flattening of the peripheral thinned cornea in the vertical meridian and relative steepening of the corneal 90° away on the axial sagittal curvature map. The thinnest point is located in the superotemporal quadrant. PG Corner

www.dosonline.org/dos-times DOS Times - Volume 28, Number 4, July-August 2022 69 Figure 8: The Pentacam Belin Ambrosio enhanced ectasia display (BAD) of the same patient as shown in Figure 3, showing corneal graph lying outside 2 standard deviation (SD) with abnormal D value, pachymetry progression index and Ambrosio relational thickness. Figure 9: Pentacam quad map of another patient of terrien’s marginal degeneration (TMD) in right eye showing against the rule astigmatism with flattening of the peripheral thinned cornea in the vertical meridian and relative steepening in the opposite meridian on the anterior sagittal curvature map. There is also loss of the symmetric bowtie pattern with inferior steepening. PG Corner

DOS Times - Volume 28, Number 4, July-August 2022 www.dosonline.org/dos-times 70 Figure 10: Pentacam quad map of the same patient of Terrien’s marginal degeneration (TMD) in left eye showing high oblique astigmatism with marked flattening in the inferotemporal quadrant on the anterior sagittal curvature map. b) Anterior segment optical coherence tomography (ASOCT)- It is a non-invasive imaging modality that provides a high-definition in vivo cross-sectional image of the cornea. It very well depicts the morphologic changes and can help in surgical management by providing information about the thinnest corneal location, that may prevent intraoperative inadvertent perforation. c) High resolution ultrasound biomicroscopy (UBM)- This modality very nicely demonstrates the morphological changes of the cornea in TMD. Treatment Non-surgical treatment The progression of the disease cannot be halted with medical management. 1. Symptomatic treatment for mild irritation experienced by a few patients can benefit with artificial tears and bandage contact lenses. 2. In early stage of the disease, spectacles alone can be used to visually rehabilitate the patient. 3. As the disease advances, high degree of against the rule and irregular astigmatism comes into play, rigid gas permeable (RGP) or scleral contact lenses may be instituted in such cases. The Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE), is a customized scleral contact lens that vaults over the cornea and limbus. An oxygenated tear pool rests between the contact lens and cornea, with presence of radial venting conduits to prevent suction. Surgical treatment Advanced cases of TMD often require surgical intervention which can be categorized into two groups: tectonic and vision enhancement surgeries. a) Tectonic surgeries are primarily indicated for restoration of the globe integrity which include conjunctival flaps and scleral autotransplantation in cases of donor cornea paucity. (Figure 11) b) Vision enhancement surgery intends to improve the visual acuity and restore globe integrity as well. These surgeries include ectatic tissue removal with suture apposition of the adjacent healthy cornea, epikeratophakia, partial or total full thickness keratoplasty or lamellar keratoplasty. PG Corner

www.dosonline.org/dos-times DOS Times - Volume 28, Number 4, July-August 2022 71 Figure 11: Schematic representation of crescentic lamellar or full thickness corneal patch graft anchored to the recipient bed using interrupted 10-0 monofilament nylon sutures. Conclusion Although TMD has been familiar since the last century, the exact etiology remains a blur. Despite its ambiguous etiology, the management of TMD has evolved drastically with the target of enhancing the visual outcomes and corneal integrity. Preoperative assessment using ASOCT enables corneal surgeons to integrate manual or femtosecond-assisted LK in the treatment of the disease. References 1. M.W. Belin, I.M. Asota, R. Ambrosio et al. What’s in a name: keratoconus, pellucid marginal degeneration, and related thinning disorders, Am J Ophthalmol 152 (2) (2011) 157–162. 2. M.S. Sridhar, S. Mahesh, A.K. Bansal et al. Pellucid marginal corneal degeneration, Ophthalmology 111 (6) (2004) 1102–1107. 3. M.S. Sridhar, S. Mahesh, A.K. Bansal et al. Superior pellucid marginal corneal degeneration, Eye (Lond) 18 (4) (2004) 393–399. 4. H. Dundar, N. Kara, V. Kaya et al. Unilateral superior pellucid marginal degeneration in a case with ichthyosis, Cont Lens Anterior Eye 34 (1) (2011) 45–48. 5. P. Puy, B.T. Stoica, N. Alejandre et al. Temporal pellucid marginal degeneration displaying high “with-the-rule” astigmatism, Can J Ophthalmol 48 (6) (2013) 142–144. 6. S.K. Rao, R. Fogla, P. Padmanabhan et al. Corneal topography in atypical pellucid marginal degeneration, Cornea 18 (3) (1999) 265– 272. 7. Su¨veges I, Le´vai G, Alberth B. Pathology of Terrien’s Disease: Histochemical and Electron Microscopic Study. Am J Ophthalmol. 1972;74(6):1191-200. 8. Chan AT, Ulate R, Goldich Y, et al. Terrien Marginal Degeneration: Clinical Characteristics and Outcomes. Am J Ophthalmol. 2015;160(5):867-72. 9. Ashenhurst M, Slomovic A. Corneal hydrops in Terrien’s marginal degeneration: an unusual complication. Can J Ophthalmol. 1987;22(6):328-30. Dr. Sohini Mandal, MD, FAICO Senior Resident in Cornea, Cataract and Refractive Services, Dr Rajendra Prasad Centre for Ophthalmic Science, AIIMS New Delhi. Corresponding Author: PG Corner

DOS Times - Volume 28, Number 4, July-August 2022 www.dosonline.org/dos-times 72 Newer Technology for Myopia Control Preeti Sharma, M.Opt, Prem Kumar Singh, M.Opt Dr. Shroff’s Charity Eye Hospital, Daryaganj, New Delhi . Abstract: Slowing the progression of myopia has become a substantial concern for parents of myopic children and the prevalence of myopia is higher in individuals whose both parents are myopic. Studies suggest that the progression of myopia is linked with education and the amount of time spent near work; hence, activities increase the exposure to optical blur. Recently, there has been an increase in efforts to slow the progression of myopia because of its relationship to the development of severe pathological conditions such as macular degeneration, retinal detachments, glaucoma, and cataracts. This article reviews the literature regarding recent treatment modes to slow down myopia progression. Several strategies are ineffective for myopia control, including under correction of myopic refractive error, Atropine, alignment fit gas-permeable contact lenses, outdoor time, and bifocal or multifocal spectacles. However, a recent clinical trial with DIMS (Defocus Incorporated Multiple Segments) glasses showed a significantly retarded myopia progression and axial elongation in myopic children. Key Words: Myopia, Myopia control, DIMS (Defocus Incorporated Multiple Segments), axial elongation. Myopia and its progression is one of the most common eye disorders and an important public health concern and has affected the population worldwide.[1–3] The prevalence of high myopia reaches high in Asian regions.[4-6] This myopia epidemic is most challenging in the developed regions of East and Southeast Asia, where high myopia is estimated to affect up to 21% of urban university-aged students in China,[7] Taiwan,[4] Korea,[8] and Singapore.[9] The prevalence of myopia found in a population of Australian children at 1.43% is among the lowest reported, slightly higher than the rate in Nepal.[10] However, 13.1 % of the Delhi population is myopic reported by Rohit Saxena et al.[11] The high amount of myopia is associated with an increased risk of sight-threatening problems, such as retinal detachment, choroidal degeneration, cataract, and glaucoma. The World Health Organization estimates that half of the population of the world may be myopic by 2050.[12,13] In recent years, insufficient time spent in outdoor activities has been recognized as a major risk factor for myopia development and its progression.[14,15] The duration and intensity of near-work activities are also associated with myopia.[16] Myopia progression and the associated axial elongation leading to visually debilitating pathologic retinal conditions is a growing concern. With the rise of the pandemic in the year 2019 (COVID-19), higher myopia progression rates have been noted than what was noted in the pre-COVID era, possibly due to a combination of a more indoor-centric lifestyle (digital ecosystem, involvement in intensive near work activities) and limited outdoor time[17] (Dandan Ma et.al). The current rapid rate of myopia progression in children emphasizes the need for a more aggressive approach to controlling axial elongation. The various treatment modalities available for halting the progression of myopia are low dose atropine (LDA, 0.01%), high dose atropine (0.05%, 0.1%, 1%), orthokeratology, multifocal contact lenses, defocus incorporated multiple segments and highly aspheric lens lets[18] (James R Landreneau et.al). Apart from atropine, all the other strategies aim to reduce peripheral hyperopic blur in myopic patients. This peripheral hyperopic blur has been shown to cause axial length elongation in various animal studies[19] (Earl Lal Smith et.al). Recently, DIMS (Defocus incorporated Multiple segments) glasses have been introduced in India. These glasses consist of a dual-focus spectacle lens consisting of a central optical zone for correcting distance refractive error, and a batch of tiny circular segments with a relative positive power of 3.50D equally distributed throughout the mid-peripheral area in a honeycomb pattern. This design simultaneously introduces myopic defocus and provides a clear vision for the wearer at all viewing distances. There are multiple foci from myopic defocus at a plane in front of the retina. Thus these glasses impose a peripheral myopic defocus yet provide a clear central vision. A two-year randomized clinical trial conducted in Hong Kong Chinese children aged 8-13 years with myopia -1.00 to -5.00D and no more than 1.50D astigmatism wore either single vision distance (SV) or the DIMS spectacle lens. After two years (n=160), average myopia progression was -0.41D vs -0.85D and 0.21mm vs 0.55mm in DIMS and SV respectively, representing a 50-60% control effect. Studies showed that the DIMS spectacles were effective in slowing the progression of myopic refractive error by 52% and axial length by 62% as compared to single vision glasses[20] (Carly Sin yin Lam et.al). The paper reported that 21.5% of children who wore DIMS had no myopia progression over two years, compared to only 7% of those who wore SV lenses. Basic Ophthalmology

www.dosonline.org/dos-times DOS Times - Volume 28, Number 4, July-August 2022 73 Distance and near acuity in DIMS was similar to SV at around 6/6 or 20/20. While children with strabismus or binocular vision (BV) anomalies were excluded from the study, DIMS showed no influence on near euphoria or lag of accommodation compared to SV. The same group has published their 3 years of follow-up data stating the sustained effect of these glasses in those who continue to use them and also slowing of progression of myopia in those who switched from single vision glasses to DIMS[20] (Carly Sin yin Lam et.al). Conclusions DIMS lens significantly slowed myopia progression and axial elongation in myopic school children as compared with wearing SV spectacle lenses reported in studies. They provided good vision while presenting simultaneous intervention that is simple to use and is the least invasive method compared with pharmacological or contact lens treatments. The DIMS spectacle lens offers an alternative treatment modality for myopia control. Conflicts of Interest There was no conflict of interest. References 1. French AN, Morgan IG, Burlutsky G, et al. Prevalence and 5- to 6-year incidence and progression of myopia and hyperopia in Australian schoolchildren. Ophthalmology. 2013;120:1482–1491. 2. Morgan IG, French AN, Ashby RS, et al. The epidemics of myopia: etiology and prevention. Prog Retinal Eye Res. 2018;62:134–149. 3. Vitale S, Sperduto RD, Ferris FL, III. Increased prevalence of myopia in the United States between 1971–1972 and 1999– 2004. Arch Ophthalmol. 2009;127:1632–1639. 4. Lin LL, Shih YF, Hsiao CK, et al. Prevalence of myopia in Taiwanese schoolchildren: 1983 to 2000. Ann Acad Med Singapore. 2004;33:27– 33. 5. Morgan I, He M, Rose K. Epidemic of pathologic myopia. Retina. 2017;37:989–997. 6. Wong YL, Saw SM. Epidemiology of pathologic myopia in Asia and worldwide. Asia Pac J Ophthalmol (Phila). 2016;5:394–402. 7. Sun J, Zhou J, Zhao P, et al. High prevalence of myopia and high myopia in 5060 Chinese university students in Shanghai. Invest Ophthalmol Vis Sci. 2012;53:7504–7509. 8. Jung SK, Lee JH, Kakizaki H, et al. Prevalence of myopia and its association with body stature and educational level in 19-year-old male conscripts in Seoul, South Korea. Invest Ophthalmol Vis Sci. 2012;53:5579–5583. 9. Koh V, Yang A, Saw SM, et al. Differences in prevalence of refractive errors in young Asian males in Singapore between 1996–1997 and 2009–2010. Ophthalmic Epidemiol. 2014;21:247–255. 10. Pokharel GP, Negrel AD, Munoz SR, Ellwein LB. Refractive error study in children: results from Mechi Zone, Nepal. Am J Ophthalmol. 2000;129:436–444. 11. Rohit Saxena 1, Praveen Vashist 2, Radhika Tandon 1, R M Pandey 3, Amit Bhardwaj 2, Vimala Menon 1, Kalaivani Mani 3PMID:25719391 PMCID: PMC4342249:DOI: 10.1371/journal. pone.0117349. 12. Morgan IG, Ohno-Matsui K, Saw SM. Myopia. Lancet. 2012;379(9827):1739-1748. doi:10.1016/S0140-6736(12)60272- 4PubMedGoogle ScholarCrossref. 13. Holden B, Mariotti S, Kocur I, et al The impact of myopia and high myopia: report of the Joint WHO–Brien Holden Vision Institute, Global Scientific Meeting on Myopia. 2015. 14. He M, Xiang F, Zeng Y, et al. Effect of time spent outdoors at school on the development of myopia among children in China: a randomized clinical trial. JAMA. 2015;314(11):1142-1148. doi:10.1001/ jama.2015.10803. Article PubMed Google Scholar Crossref. 15. Lingham G, Mackey DA, Lucas R, Yazar S. How does spending time outdoors protect against myopia? a review. Br J Ophthalmol. 2020;104(5):593-599. doi:10.1136/bjophthalmol-2019-314675PubMedGoogle ScholarCrossref. 16. Wen L, Cao Y, Cheng Q, et al. Objectively measured near work, outdoor exposure and myopia in children. Br J Ophthalmol. 2020;104(11):1542-1547. doi:10.1136/bjophthalmol-2019-315258. 17. Ma D, Wei S, Li SM, Yang X, Cao K, Hu J, Peng X, Yan R, Fu J, Grzybowski A, Jin ZB. The Impact of Study-at-Home during the COVID-19 Pandemic on Myopia Progression in Chinese Children. Front Public Health. 2022; 9: 720514. Published 2022 Jan 6. doi:10.3389/push.2021.720514. 18. Landreneau JR, Hesemann NP, Cardonell MA. Review on the Myopia Pandemic: Epidemiology, Risk Factors, and Prevention. Mo Med. 2021 Mar-Apr; 118(2):156-163. PMID: 33840860; PMCID: PMC8029638.. 19. Smith EL 3rd, Hung LF, Huang J, Blasdel TL, Humbird TL, Bockhorst KH. Effects of optical defocus on refractive development in monkeys: evidence for local, regionally selective mechanisms. Invest Ophthalmol Vis Sci. 2010 Aug; 51(8):3864-73. doi: 10.1167/iovs.09-4969. Epub 2010 Mar 10. PMID: 20220051; PMCID: PMC2910632. 20. Lam CS, Tang WC, Tse DY, Lee RP, Chun RK, Hasegawa K, Qi H, Hatanaka T, To CH. Defocus incorporated multiple segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomized clinical trial. Br J Ophthalmol 2020; 104:363–8.doi:10.1136/bjophthalmol-2018-313739. Dr. Preeti Sharma, M.Opt Dr. Shroff’s Charity Eye Hospital, Daryaganj, New Delhi. Corresponding Author: Basic Ophthalmology

DOS Times - Volume 28, Number 4, July-August 2022 www.dosonline.org/dos-times 74 Setting up Ocular Microbiology Laboratory for an Secondary Center Hospital/Smaller Set ups: Ten Step Guide for Comprehensive Ophthalmologists and Stand Alone Ophthalmic Centers Arpan Gandhi[1], MBBS, MD, Javed Hussain Farooqui[2], MBBS, DNB 1. Director Laboratory Services, Dr. Shroffs Charity Eye Hospital and Secondary Centers. 2. Senior Registrar, Cornea and Anterior Segment, Royal Adelaide Hopsital, Adelaide, Australia. According to 2010 World Health Organization (WHO) data, 4.9 million people suffer from bilateral corneal blindness globally, and these numbers are as high as 23 million if we consider unilateral corneal blindness. By some estimates, 98% of corneal blindness exists outside the developed world. In India, corneal blindness has been projected to grow from 0.66% (2001) to 0.84% (2020), largely unilateral cases. These are expected to reach 10 million by the year 2020. A recent national survey has attributed 7.4% of total blindness in Indians above 50 years, second only to cataracts. One of the most important causes of corneal blindness in our country is infective keratitis (IK). IK blinds at least 1.5 million eyes every year in the world; and it’s projected that India alone will have 0.6 million people blind due to IK by 2020. From studies describing it as a ‘silent epidemic’, to others referring to it as an ‘ophthalmic emergency’, IK is a problem which cannot be ignored in a world of growing antibiotic resistance. The core requirement in combating IK is to have targeted treatment specific to the causative microorganisms. This is possible when corneal scraping and microbiology work up is done for all patients presenting with IK. All eye hospitals and ophthalmologists should set up protocols for integrating microbiology services in their practice. We describe 10 simple steps to take into consideration for ophthalmologists to set up a basic laboratory, which would aid in diagnosis and help manage patients better. 1. Identifying a room with a sink: The room should be well light, running tap water and should have a sink dedicated to staining. A tabletop with washable surfaces and enough space to both stain the slides and later do bench work should be there. The room must follow all waste disposal guidelines and safety protocols. 2. (A) Microscope: A basic one but with good lenses is mandatory. It should be from a standard company with provision for an AMC for 3 years atleast, Presently these are available with atelast 4-5 manufactures. (B) Consumables: Slide boxes, Cover Slips, Grams, Giemsa Stains, Zeil Nelson Stain Chemicals Grams Crystal Violet, Grams Iodine, Grams Decolourizer and Safranin, 0.5% ZN STAIN (AFB STAIN) Carbol Fuchsin, Acid Fast Decolorizer and Methylene Blue Potassium Hydroxide preparation or KOH prep, is a quick, inexpensive fungal test Culture media-Blood Agar, Chocolate Agar, SDA Sabouraud Dextrose Agar Media these are a must. Additional Media like LJ media – Must be used might get expired otherwise. Culture Swabs, Culture Sterile bottles, Distilled Water. 3. Resident/Fellow training: It is important to impart microbiology training to post graduate residents and fellows during their training period. Small, structured courses of 2-4 week duration should be incorporated in the training curriculums. Such courses make the ophthalmologist independent in performing basic laboratory work and enhance their skill. Laboratory rotations are mandatory for postgraduates and fellows under training at our institute, and we encourage other training centers to also incorporate similar courses. 4. Allied Ophthalmic Personnel (AOP) training: A lot of hospital work and responsibility is shared by AOPs, where they contribute to the daily working of the hospital and patient management. Many hospitals, especially in south India, train young girls to become AOPs. Our institute runs one of the biggest AOP programs in north India. We have imparted 1 month training to some of our AOPs stationed at secondary centers in basic laboratory work up to help the cornea fellows in clinics. This has gone a long way in increasing the number of patients coming to the clinics and decrease in the number of patients being referred to the tertiary center (unpublished data; under review). We recommend other hospitals to consider training their paramedical staff in the same way to help their doctors. 5. Cold storage: A fridge with proper temperature control is important. Basic Ophthalmology

www.dosonline.org/dos-times DOS Times - Volume 28, Number 4, July-August 2022 75 6. Maintaining a record: Detailed registers with all details must be maintained. A good idea to back it up on an Electronic Medical Record. 7. Budgeting: Microscope – 30-40000 rs Stains – Cost per slide would be 5-10 rs Cost of Grams Stain complete kit Media- Per Media 40-80 rs if procured and if made inhouse 30-50 rs per media which is not needed in the initial stages. Would need three media for one full scrapping diagnosis atleast Fridge, Incubator – Total about 50000 rs Incase u need details CULTURE MEDIA - Consumable Cost in Rs. Approximated BLOOD AGAR Rs.35/Test CHOCOLATE AGAR Rs.35/Test SDA Rs.20/Test BHI Rs.15/Test Thio Rs.15/Test NUTRIENT AGAR Rs.20/Test STAINING - Consumable Cost in Rs. Approximated GRAM STAIN Rs.20/Test AFB STAIN Rs.15/Test GIEMSA Rs.10/Test KOH Rs.10/Test Additional Requirements PLATINUM LOOP, SPRIT LAMP, Normal saline, SLIDES, Cover Slip and Marking Pencil. 8. Navigating Challenges: There were different ones. The need to have this set up was first discussed with the Ophthalmologist. There was a challenge to convince the person. Training videos were shared which helped in getting things started. In house training was organized for 3 weeks, Challenges of each person picking up staining modules and identification was there but overcome with the help of the digital sharing and the fact that there was reference slides and images to compare as well as teaching videos too. Once the challenges were overcome it worked out very well. 9. Building collaborations: With time, once the ophthalmologist is comfortable in laboratory diagnosis and treatment, he can collaborate with other eye hospitals, which could send their samples for review. Also, for diagnostic dilemmas, arrangement to send the sample to other national laboratories (like we get from all over to our hospital) should be made. Lastly, data collection and sharing could be used for any future research projects that may be worth sharing with the ophthalmic fraternity. Even though numbers of existing corneal blindness is daunting, we must not forget that 80% of corneal blindness is preventable. A lot of work is being done in medical care and infrastructure, including successful eye bank development efforts and evolving techniques in corneal transplantation. However, more emphasis needs to be given to preventative care to address corneal blindness, which can be done through proper management of cases in the clinics. We hope that this paper will not only help general ophthalmologists, but also institutes to set up laboratory services in their secondary centers for better uptake of services. This, when combined with teleophthalmology, could improve eye care services in areas of need, where a trained AOP could help the resident ophthalmologist with scraping andimages could be relayed to the main center. Such simple steps and innovations could help us tackle corneal blindness in years to come in more systematic fashion. Dr. Arpan Gandhi, MBBS, MD Director Laboratory Services, Dr. Shroffs Charity Eye Hospital and Secondary Centers. Corresponding Author: Basic Ophthalmology

DOS Times - Volume 28, Number 4, July-August 2022 www.dosonline.org/dos-times 76 Beyond Ophthalmology Humour in Ophthalmology 1. “An eye doctor who is obsessed with Apple products is called an iDoctor.” 2. “Do you know why programmers have perfect vision? – Because they can C++.” 3. “What would make our eyes feel lonely? – Eye-solation.” 4. My nephew told me that he’s never had vision insurance. I told him he really should look into it.” 5. The kid says to his mother: ‘Mom, I lost my contact lens!’ The mother replies: ‘I already told you to keep your eye on them!’” 6. What do you call a fish with no eyes? – Fishually impaired.” 7. During the exam period, some Ophthalmology students drink a lot because they believe that alcoholic beverages could double their vision. 8. Do you know what is used to provide vision at night on school playgrounds? – Recessed lighting 9. A great Pick up Line for far-sighted people: ‘Hey beautiful girl, eye can see you in my future!’” 10. Guess who I bumped into on the way to the eye doctor? Everyone 11. What does the eye say once it finally has a new pair of glasses? – ‘Eye am back!’” 12. The teacher wore her sunglasses to work because she had such bright students in her class 13. An Ophthalmologist’s child is without a doubt the apple of their eyes. 14. Iris my case,’ said the eye medic to the judge when he was asked to testify in court 15. The Ophthalmologist was brought to court since he was the only eye-witness 16. A man goes to the Ophthalmologist for his eye test and is asked what he can see. ‘I see empty airports, empty football fields, closed theaters, and closed pubs,’ he says. To which the r Ophthalmologist replies, ‘Perfect — you’ve got 2020 vision! 17. The man bought four new pairs of glasses for the cost of two. He thought the purchase was eye-deal. 18. What did the blonde say to the contact lenses? – ‘I cannot take my eyes off you! 19. Who has two asses and one eye? – An assassin 20. Your eyelashes are supposed to keep things out of your eye, yet most of the time, they’re the only things getting stuck in there. How eyeronic ! 21. The eye doctor always takes the elevator. He hates the stares 22. My cousin quietly retired from his job as an eye glass manufacturer yesterday. He didn’t want to make a spectacle. 23. A man goes to the eye doctor, sits down, and the receptionist asks why he’s there. The man complains, ‘I keep seeing spots in front of my eyes.’ The receptionist asks, ‘Have you ever seen a doctor?’ To which the man replies, ‘No, just spots. 24. Eye doctors are the best because they used to be good pupils at school and university 25. The eyebrows and eyelids are always in a fight. They never see eye to eye. 26. The man vowed to find the thief who stole his glasses. He had contacts. 27. I love wearing glasses. They make spectacular accessories. Jatinder Singh Bhalla, MBBS, MS, DNB, MNAMS Senior Consultant & Academic Incharge, Department of Ophthalmology, DDU Hospital, New Delhi. Dr. Jatinder Singh Bhalla, MBBS, MS, DNB, MNAMS Senior Consultant & Academic Incharge, Department of Ophthalmology, DDU Hospital, New Delhi. Corresponding Author:

www.dosonline.org/dos-times DOS Times - Volume 28, Number 4, July-August 2022 77 COVID-19 Vaccine Associated Ocular Adverse Effects Parul Ichhpujani, MS Professor, Deptt. of Ophthalmology, Govt. Medical College and Hopsital, Chandigarh. S. No. Vaccine Adverse Event RNA Vaccines 1. BNT162b2 mRNA SARS-CoV-2 (BioNTech/Pfizer) 1. Acute unilateral and bilateral endothelial graft rejections 2. Panuveitis with significant choroidal thickening 3. Submacular hemorrhage 4. Retinal vein occlusions 5. Acute macular neuroretinopathy (AMN) 6. Intermediate uveitis with cystoid macular edema 7. Herpes zoster ophthalmicus (HZO) with conjunctivitis 8. Multiple evanescent white dot syndrome (MEWDS) 9. Bilateral sequential Bell’s palsy 10. Abducens nerve palsy 11. Eyelid edema and erythema 12. Ecchymotic lesions 13. Purpuric lesions 14. Central serous retinopathy 15. Foveolitis 16. Neuroretinitis 17. Arteritic anterior ischemic optic neuropathy (AAION) 18. Multiple cranial neuropathies, namely incomplete oculomotor, abducens, and facial nerve palsy. 19. Ptosis 20. Dry eye 2. mRNA-1273 Moderna COVID-19 Vaccine (ModernaTX, Inc.) 1. Acute Zonal Occult Outer Retinopathy (AZOOR) 2. HZO 3. Conjunctivitis 4. Bell’s palsy 5. ION 6. Uveitis 7. Unilateral Graft Rejection 8. Oculomotor nerve palsy 9. Ptosis 10. Dry eye Tearsheet

DOS Times - Volume 28, Number 4, July-August 2022 www.dosonline.org/dos-times 78 S. No. Vaccine Adverse Event Viral Vector Based Vaccines 1. AZD1222 ChAdO × 1 nCoV-19 (AstraZeneca) 1. Acute unilateral or bilateral endothelial graft rejection 2. AMN 3. Multifocal choroiditis 4. Submacular hemorrhage 5. Retinal vein occlusions 6. Central serous retinopathy 7. Reactivation of Vogt–Koyanagi– Harada disease 8. BRAO 9. Angle Closure Glaucoma attack 10. Lens displacement 11. Multifocal choroiditis 12. Recurrence of herpes simplex stromal keratitis 13. Seronegative Neuromyelitis Optica Spectrum disorder with bilateral optic neuritis 14. Superior ophthalmic vein thrombosis 15. Bilateral optic disc edema 16. Conjunctivitis 17. 4th cranial nerve palsy 18. Abducens nerve palsy 19. Reactivation of Acute Retinal Necrosis ChAdOx1 nCoV-19 SARS-CoV-2 vaccine (Covishield). 1. Paracentral acute middle maculopathy (PAMM) 2. AMN 3. Choroiditis 4. Superior Ophthalmic Vein (SOV) Thrombosis 5. Serous RD and Optic disc hyperemia 2. Sputnik V (Gamalaya) CME 3. Ad26.COV2.S Johnson and Johnson (Janssen): 1. Episcleritis 2. HZO 3. Scleritis 4. Uvietis 5. Macular edema 6. Macular degeneration 7. ION 8. Glaucoma 9. Iritis 10. Dry Eye Inactivated Virus Vaccines 1. BBIBP-CorV Sinopharm COVID-19, 1. Acute Anterior Uveitis 2. Episcleritis 3. Anterior Scleritis 4. AMN Tearsheet

www.dosonline.org/dos-times DOS Times - Volume 28, Number 4, July-August 2022 79 S. No. Vaccine Adverse Event 5. Optic neuritis 3. BBV152 Covaxin Anterior uveitis 4. Unspecified inactivated Vero cell-based vaccine Choroiditis Protein Based 1. Novavax - Dr. Parul Ichhpujani, MS Professor, Deptt. of Ophthalmology, Govt. Medical College and Hopsital, Sector-32, Chandigarh. Corresponding Author: Tearsheet

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