DJO July- Sep Volume 32 issue (1)

DJO Vol. 32, No. 1, July-September 2021

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DJO Vol. 32, No. 1, July-September 2021

Delhi Journal of Ophthalmology DJO

Official Journal of Delhi Ophthalmological Society Editorial Board Volume 32   Number 1   July-September, 2021

Editor-in-Chief
Vinod Kumar

R.P. Centre, AIIMS, New Delhi

Associate Editor

Devesh Kumawat

Assistant Editors

Pranita Sahay      Sonali Gupta      Pallavi Singh

Abhidnya Surve Abhishek Dagar Section Editors Amit Mehtani Annu Joon
Arvind Kumar Morya Ashwini Behera Bhuvan Chanana Chirakshi Dhull
Daraius Shroff Hanspal Binder Amit Khosla Jitender Bhalla Mainak Bhattacharyya
Manpreet Kaur M.D. Singh Bhupesh Singh N. Lomi Neha Goel
Noopur Gupta Pallavi Sugandhi Ikeda Lal Prafulla Maharana Priyanka Ramesh
Puneet Jain Rachna Meel Monika Kapoor Rajat Jain Ritesh Narula
Ritika Mukhija Ritika Sachdev Pradeep Kumar Rushad Shroff Saumya Yadav
Saurabh Kamal Seema Das Rahul Mayor Shorya Azad Smriti Nagpal
Sumit Monga Suneeta Dubey Rohan Chawla Swati Phuljhele Taru Dewan
V Krishna Vikas Menon Shikha Gupta
Suraj Senjam
Vivek Gupta

International Editors

Antonio Carlos Centelhas Arun Nrayanswami Haroon Tayyab Hidetaka Matsumoto
Jai Shankar Luke Nicholson
Jay Chabblani Kamal Sahni

Ajay Aurora Arun Sangal Emeritus Editors Dinesh Talwar Kamlesh
M. Vanathi Mahipal S. Sachdev Rajpal Rohit Saxena
Ruchi Goel V. P. Gupta Bhavna Chawla
Rajesh Sinha

A.K. Grover Anju Rastogi Advisory Board B. Ghosh Cyrus Shroff
G.K. Das Hemant Trehan J.L. Goyal Jolly Rohatgi
J.S. Tityal J.S. Tityal Atul kumar Lalit Verma Mahipal S. Sachdev
M.S. Bajaj Namrata Sharma J.C. Das Noshir Shroff Om prakash
Parijat Chandra P.K. Pandey Kirti Singh Pradeep Sharma Pradeep Venkatesh
Praveen Vashisht Ramanjeet Sihota Neelam Pushkar Ritu Arora Sarita Beri
S.K. Khokhar Subhash Dadeya P.K. Sahu Tanuj Dada Tushar Agarwal
Umang Mathur Upreet Dhaliwal Radhika Tandon
Sushil Kumar
Virender Sangwan

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DJO Vol. 32, No. 1, July-September 2021

Contents

Editorial
Love Your Eyes, Everyone Counts: Underscored ���������������������������������������������������������������������������������������� 6
Kirti Singh
COVID- Residency, and Life ��������������������������������������������������������������������������������������������������������������������������� 7
Mohmmad Sabir, Vinod Kumar
Review Article
Atropine in Myopia..........................................................................................................................................9
Priyanka Mishra, Rebika Dhiman, Bhavika Bansal, Rohit Saxena
Amblyopia Revisited: Putting The Theoretical Knowledge To Practical Use ............................................18
Sahil Panjwani, Amritjeet Kaur
A to Z of ReLEx SMILE: All you need to know ...............................................................................................25
Sanjana Vatsa, Pallavi Dhawan, Shana Sood
Ophthalmic manifestations of psoriasis.......................................................................................................32
Kritika Katoch, Ratan Kumar Sharma, Vikram mahajan, Rajeev Tuli

Original Article
Practice Of Ophthalmic Self-Medication Among Patients In Central India:
Questionnaire Based Study ..........................................................................................................................34
Lipi Chakrabarty

A causal assessment of blindness in schools for blind in southern Rajasthan..........................................40
Hardik Kiri, Lipa Mohanty, Seemal Goyal

Presence of SARS-Cov-2 in Nasopharyngeal and Conjunctival Swab
of Residents of Hotspot Areas of Jaipur .....................................................................................................46
Rekha Singh, Madhu Gupta, Mohammad Abbas Ali, Narottam Sharma,
Avinsha Mathur, Vijay Arora, Vikas Krishnia

Change in Perimetric Global Indices Following Cataract Surgery in Patients with
Glaucoma .....................................................................................................................................................49
Sandeep Arora, Sumita Karandikar

Case Report
A Case Report of Unilateral Peripheral Necrotizing Keratitis Following LASIK ......................................55
Sudhakar Potti, Prasad Patil

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DJO Vol. 32, No. 1, July-September 2021

Case Report: Accidental Ocular Blast Injury To A Farmer’s Eye by Gandhak Potash ...............................58
Nimisha Nagpal, Pawan Prasher, Inderjit Kaur
Adult Onset Orbital Lymphangioma Presenting with Globe Luxation:
A Rare Presentation of A Rare Disease .......................................................................................................62
Deepsekhar Das, Swechya Neupane, Sahil Agrawal, Mousumi Banerjee
Mandeep Singh Bajaj, Seema Kashyap
Diplopia Following External Dacryocystorhinostomy with Intracystic Pawar Implant Implantation:
The Tale of an Unheard Complication ........................................................................................................65
Deepsekhar Das, Mandeep Singh Bajaj, Swechya Neupane, Sahil Agrawal, Saloni Gupta
A Rare Case of Upper Eyelid Cutaneous Horn ............................................................................................68
Neeraj Sharma, Rupali Kashyap, Priyanka Kumar, Sonakshi Sehrawat, Soumya Sharma
Bilateral Non Arteritic Anterior Ischemic Optic Neuropathy Associated With Optic Nerve Head Drusen
And Vascular Risk Factors ............................................................................................................................ 71
Eathi Tuli, Aakanksha Sharma, Gaurav Sharma, Shalu Gupta
Resolution of Combined Hamartoma of Retina And Retinal Pigment Epithelium (CHRRPE) Following
Pars Plana Vitrectomy ................................................................................................................................. 74
Monika Kapoor, Siddharth Madan, Priyanka Sankaran, Preeti Singh, Sarita Beri
Penetrating Injury Into The Orbit By A Needle Fish: An Unusual Case of Ocular Trauma .......................76
Rajender Singh Chauhan, Apoorva Goel, Chetan Chhikara, Ashok Rathi
An Unusual Case of Surma (Eye Cosmetic) Induced Conjunctival and Scleral Ulceration .......................79
Chandana Chakraborti, Nabanita Barua, Ajoy Kr Saha, Rupanjili Lakra
Chronic Anterior Uveitis: Diagnosing Primary Sjogren’s .......................................................................... 82
Srijita Mitra, Sahil Sarpal, Abhijit Chattopadhyay, Subhankarsri Paul, Jonaki Ghosh Roy
Choroidal Detachment in Idiopathic CD4 Lymphocytopenia ....................................................................84
Avadhesh Oli, Raja Narayanan, INHS Asvini, Navy Nagar, Colaba, Smt Kanuri Santhamma
Bilateral Buried Optic Nerve Head Drusen Mimicking Idiopathic Intracranial Hypertension ...............88
Juhi Sahu, Muthukrishnan Vallinayagam, C Alekhya
PG Snippet
Ocular Manifestations Of Goldenhar Syndrome; At A Glance .................................................................. 91
Isha Acharya, Jolly Rohatgi, Ashit Handa, Anchal Arora, Saini Aarushi, Tadu Nampi

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DJO Vol. 32, No. 1, July-September 2021

Ophthalmic Manifestations of Immunoglobulin G4-Related Disease (IgG4-RD) ............................................93
Ayushi Agarwal, Samreen Khanam, Akash Raut, Ruchi Goel
Coats’ White Ring: The Embellished and Spruced up Iron Remnant in the Cornea ...............................95
Vishnu Teja Gonugunta
Pictorial CME
Anomaly In Development and Regression of Hyaloid Artery
- The Bergmeister's Papillae ....................................................................................................................... 97
Prajnya Ray, Shruthy Vaishali Ramesh, Prasanna Venkatesh Ramesh
Spontaneously Reattached Retinal Detachment (SRRD) .........................................................................99
Priya Rasipuram Chandrasekaran
Letter to Editor
Comment on Re: Smartphone Fundus Videography for
Documentation of Retinal and Optic Nerve Head Diseases ..................................................................... 101
Joseph W. Fong, Sami H. Uwaydat, Jeffrey L. Yee
Cover Image
Electric Burn Resulting in Bilateral Cataract (RE Operated)
Kirti Singh

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DJO Vol. 32, No. 1, July-September 2021

DOS Executive Members 2019-2021

DOS Office Bearers

Dr. Subhash Dadeya Dr. Pawan Goyal Dr. Namrata Sharma Dr. Hardeep Singh
President Vice President Secretary Joint Secretary

Dr. Jatinder S. Bhalla Dr. Vinod Kumar Dr. Manav Deep Singh
Treasurer Editor Library Officer

Executive Members

Dr. Dewang Angmo Dr. Jatinder Bali Dr. Shantanu Gupta Dr. C. P. Khandelwal

Dr. Rahul Mayor Dr. Vipul Nayar Dr. Rajendra Prasad Dr. Kirti Singh

DOS Representative to AIOS Ex-Officio Members

Dr. J.S. Titiyal Dr. M. Vanathi Dr. S.K. Khokhar Dr. Subhash C. Dadeya Dr. Arun Baweja

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DJO Vol. 32, No. 1, July-September 2021

Editorial

From the Incoming Editor’s Desk

Love Your Eyes, Everyone Counts: Underscored

In this transition issue I take the opportunity to thank all DOS Members (my mentors, colleagues and friends) for entrusting
the charge of editorship of this prestigious journal. We are the inheritors of a legacy of our predecessors, who have worked
hard to raise DJO to the current status.

This editorial team’s vision for DJO would be Symbiosis of academic excellence with rational practice. The focus would be
on theme issues of “I series.” In addition, we would be ushering in sections on standard operating protocol and narratives
of the legends in the field of ophthalmology.

This editorial reiterates World Sight Day 2021 theme of “Love your eyes, everyone counts”. This theme draws attention to
awareness of one’s own ocular health and address the bigger picture through national and global interventions. The onus is
on everyone to take cognizance and responsibility for their eye health by prioritizing vision, protecting and preserving sight
and taking steps to prevent its loss. Through ‘Everyone Counts: Global challenge’, the International Agency for Prevention
of Blindness aims to get one million people to pledge to have their eyesight tested.

The past turbulent period of the COVID has exposed the deficiencies in scientific, technical, and infrastructural aspects of
health care delivery. The devastating effect of injudicious drugs, irrational treatment regimens with no clear guidelines on
dosage and duration of drug therapy was witnessed by ophthalmologists in horrifying scenario of orbital and sinus related
mucormycosis. Overuse, misuse, shortages, patient agony, physicians despair, overwhelmed administration; this year was
a horrifying narrative of how disease management can spill out of control. Indian ophthalmologist’s decades old fight to
rationalize steroid use was again tested.

WHO estimates that more than half of all medicines are prescribed, dispensed or sold inappropriately. Fifty percent of all
patients fail to take the prescribed medicines correctly. Interventions to promote more rational use, multidisciplinary national
body to coordinate policies on medicine use, clear cut clinical guidelines, inclusion of problem-based pharmacotherapy
training in undergraduate curricula, continual in-service medical education as a licensure requirement, public education,
avoidance of perverse financial incentives are a few of WHO key interventions to promote rational use of drugs.

The need of the hour is to promote rational drug use based on scientific management protocols for eye care. There should
be no need for heroic salvage measures and costly interventions for control of spin-offs and over-the cliff events. If Gotham
city had an efficient and effective police force, there would have been no need for Batman! DOS and DJO would attempt to
work on this by elaborating on our focus of Symbiosis of academic excellence with rational practice.

This DJO team thanks my predecessor Dr Vinod and his team for compiling this current issue in the transition phase.
Looking forward to a more fruitful association with the DOS family.

Dr. Kirti Singh DOI : http://dx.doi.org/10.7869/djo.679
MD, DNB, FRCS, FAIMER, DHA
Incoming Editor, Delhi Journal of Ophthalmology
Dir Prof & Director GNEC, MAMC Mamc and associated hospital’s’
New Delhi State Progr. Officer, NPCB

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DJO Vol. 32, No. 1, July-September 2021

Editorial

From the Editor’s Desk

COVID- Residency, and Life

‘And the more I think of it, the more I realize when this battle finally ends, there will be no

great warriors but only scarred survivors’ – Chauhan, Divya

Covid has had the entire medical resident community in a fix- physically, emotionally, and academically. Because being
at the forefront of the healthcare team, COVID has had us working in PPE’s where every breath was a constant reminder
to our living selves; the frail, fragile beings we are, and tend to be. We worked in shifts- morning, afternoon, evening, and
night. Further, despite the allotted breaks after every shift, we spent entire days tired and physically drained. It has had us
away from our homes for the longest of times, from the beings quintessential to our existence, family, because of the constant
worry for their safety. Further, we have digressed, a lot, from our choices of residency specialties to the practical workforce
at the frontline.

As an ophthalmology trainee, we have a come a long semester away from ophthalmology in being called onto our skill sets
of the yester years as a medical student. It was all in its existence, a tiresome process. For all of us, as a resident community,
had at that particular point in time moved on from that space of putting in a central line during our intern year through the
years to intravitreal antibiotics as a resident. Our academic sessions came to halt while the cast was still setting over the
advent of covid, and gradually over time moved onto online platforms. As comfortable as they were, the lack of one-to-one
interactions with the professors were new and made us realize how much more effective and personal the offline classes
were.

As trainee surgeons, months went by, and we now had entire semesters when we didn’t operate, an unprecedented hiatus
from the paths we had originally embarked upon. Looking back, we have now passed two waves of covid, with the stringed
emotional, physical, personal and academic toll with the after effects still lurking around. We look around and see our
juniors have had an even worse predicament. The surgical skill sets have moved down two or three semesters in comparison
to how it was pre-covid. They tell us they haven’t done much through the years in their residency. But then when we look
back into our own shoes, back when we were juniors, to see our seniors, extremely skilled at what they did, I realize we
aint that far ahead of our juniors but are miles behind our seniors. The residents trained in the pre-covid times; residents
of exceptional skill sets. Further, now being the senior lot of the trainee residents, I see a lot of us at a halt in the process
of our doctoral dissertations. A lot of patients lost to follow up. The worst part? We still are not through the woods with the
constant threat of the impending next wave.

We have now come to terms with the fact that the time and space we now get to ourselves can only be used to strengthen
our theoretical foundations of the subject, as limited as they can be. For medicine as a field, requires that we learn from our
patients. And one without the other is, for all practical purposes, a futile attempt. With our dissertations, most of us have
now shifted to lower sample sizes for the well-being of everyone involved. Something that we realize affects the quality of
research that we do as clinician-cum-scientist. And for surgeries? we tell our juniors, and ourselves to practice as much
we can on the goat’s eye. Because as senior trainees assisting ourselves and our juniors through surgery in this phase of
uncertainty, it helps for them, and us to be practiced in ways of surgery, the required chirurgical skills of suturing.

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DJO Vol. 32, No. 1, July-September 2021

It, therefore, becomes imperative that all of us abide to the highest standards of COVID appropriate behavior. For us, for
our loved ones with us, and for our existential beings back home- family. Because as doctors, ‘being trained in the covid era’
won’t fend for us when we move on life; when we move on in life to cater to the suffering and the ailing. When we move on
in life to progress knowledge as researchers. I guess, in the end, when all this ends, there really won’t be any great warriors,
but only scarred survivors.

Dr. Mohammad Sabir
Junior Resident, Dr. Rajendra Prasad Centre
for Ophthalmic Sciences, All India Institute
of Medical Sciences (AIIMS), New Delhi

Dr. Vinod Kumar
MS, DNB, MNAMS, FRCS
Editor, Delhi Journal of Ophthalmology
Associate Professor, Vitreo-retina Services
Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences (AIIMS), New Delhi

DOI : http://dx.doi.org/10.7869/djo.680

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DJO Vol. 32, No. 1, July-September 2021

Review Article

Atropine in Myopia

Priyanka Mishra, Rebika Dhiman, Bhavika Bansal, Rohit Saxena

Department Of Ophthalmology, Dr R P Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Myopia is emerging as a global public health problem with nearly half of the world’s population predicted to become
myopic by 2050. Genetic factors along with evolving lifestyle modifications like reduced outdoor activity, increased
screen time and near work have contributed to this surge. Of several therapies described for anti-myopia therapy, topical
atropine is emerging as the most popular management option owing to the ease of administration and minimal side
Abstract effects. Based on the effect versus side effect profile, 0.01% atropine appears to be the optimal concentration for reducing
myopia progression. In this review, we discuss the effectiveness of atropine therapy, its side effects and indications of
use in the light of the best available literature. Some questions like duration of therapy, role of higher dose of atropine in
non-responders and role of combination therapy with other interventions like orthokeratology still needs to be explored.

Delhi J Ophthalmol 2021; 32; 9-17; Doi http://dx.doi.org/10.7869/djo.681

Keywords: Myopia, Atropine, Myopia Progression

Introduction the society19,20 It has negative bearing on self-esteem, career
choice, peer acceptance and relationships.21
With the rising incidence of myopia worldwide, the disease is
becoming a major public health issue. According to the Global Genetic background
Burden of Disease estimates, uncorrected distance refractive
error is the second most common cause of blindness and the Ip et al, reported that the prevalence of myopia was 7.6%
leading cause of moderate to severe vision impairment.1 In in children with no myopic parents, 14.9% with one
2010, approximately 1950 million people (28.3% of the global myopic parent, and 43.6% with both parents myopic.22
population) were myopic. The prevalence is expected to rise The environmental drivers become important especially
to a staggering figure of 4758 million that accounts for nearly in individuals already prone via genetic constitution.23 The
half of the global population by 2050 2,3 with 10% of them genome wide association studies(GWAS) have identified
being high myopes. around 39 loci that are associated with refractive error and
myopia in adults.24 Although the genetic risk variants explain
The problem is most overwhelming in the East Asian approximately 12% of refractive error variation, they explain
countries like Singapore, Taiwan and Hong Kong, where around 22% of the high myopia cases.25
the condition affects around 80-90% of young adults.4–7The
disease has come to spotlight with a rising prevalence being Environmental Factors
reported even from countries like United States,8 Europe9
and Australia10 initially thought have a lower prevalence. Lifestyle and environmental factors are important
In United States the prevalence has reportedly increased predisposing factors in myopia. The North India Myopia
from 25% in 1971 to 42% in 1999. In Indian scenario, the study found that increased near work like reading-writing,
population‐based estimates of prevalence of myopia in use of computers/ video games and watching television were
children and adults(>30 years) were 5.3%11 and 27.7%12 significant risk factors for progression of myopia in the urban
percent respectively. The North India Myopia Study (NIM schools of Delhi, while the duration of outdoor activities
Study)13 in 2015 reported the incidence to be as high as 13.1% (>2 hours/day) were protective. The explanation for this
in the school going children in Delhi.14 Considering the protective effect might be that the radiant intensity of sunlight
enormous population of the country, this would amount to peaks at a wavelength of about 550 nm, corresponding
a humongous number making myopia an important public to the peak sensitivity of human retina, while indoor
health concern. illumination peaks at longer wavelengths.26 This means that
the indoor light will be preferentially focused behind the
The World Health Organization (WHO)15 proposed the retina creating a hyperopic defocus, thus stimulating eye
following definitions, especially in context of Rapid growth.27 Another possible mechanism is high illuminance
Assessment of Avoidable Blindness (RAAB) surveys. (around 10,000 to 20,000 lux) outdoors which has been found
Myopia is “a condition in which the spherical equivalent to be protective in myopia compared to <500 lux typical
objective refractive error is ≤ −0.50 D in either eye”. High of indoors.28,29 However, according to a meta - analysis,
Myopia is “a condition in which the spherical equivalent although the outdoor time is protective for the development
objective refractive error is ≤ −5.00 D in either eye”. The of myopia, it is not effective in slowing the progression in
ocular morbidity caused by myopia is known to increase already myopic eyes.30 Accommodation associated with near
with every millimeter of axial length elongation. It includes work, especially in down gaze adversely affects the axial
primary open angle glaucoma, cataract, MMD(myopic length, choroidal thickness, and anterior eye biometrics as
macular degeneration), retinal detachment, retinoschisis and a function of time.31,32 Also, lens in accommodation state
macular hole.16–18 The visual impairment due to uncorrected causes more hyperopic defocus and reduced light intensity
myopia not only affects the patient’s quality of life19 due in the periphery. All these factors predispose to myopia and
to psychological, cosmetic, practical, and financial factors therefore the risk of myopia increases by as high as 80% in
but also, amounts to huge economic and social burden to patients with prolonged near work.

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DJO Vol. 32, No. 1, July-September 2021

Mechanism of action of atropine group.56 Although, the treatment was most effective with
0.5% atropine, but considering the high dropout rates due
Atropine is an alkaloid extracted from the plant Atropa to side effects of photophobia and near vision impairment,
belladonna, Datura innoxia, D. metel, D. stramonium and they suggested the use of 0.25% or 0.1% atropine to control
members of the genera Brugmansia and Hyoscyamus. It is a myopia progression. They further confirmed the efficacy of
non-selective muscarinic antagonist that acts on receptors 0.5% atropine in a clinical trial (2002) comparing atropine
M1 to M5. Earlier it was thought that atropine exerts its with multifocal lenses versus regular lenses and multifocal
effect through the blocking of accommodation. However, lenses alone where the myopia progression/axial elongation
even after abolishing the accommodation reflex by optic noted was -0.42±0.07 D/0.22±0.03mm in 0.5% atropine with
nerve sectioning, or bilateral Edinger Westphal nuclei multi‐focal lenses group versus -1.19±0.07 D/0.49±0.03mm
destruction, the experimental myopia induction could not in the multifocal lens group and -1.40±0.09 D/0.59±0.04mm
be inhibited.33,34,35 Stone et al. showed that experimentally in the regular lens group (p<0.0001).The multifocal lenses
induced myopia in chicks can be controlled with atropine. were given in the atropine group to allow clear vision at
This also points to a non-accommodative mechanism, since in all working distances. Almost half of the children in the
chicks the intraocular muscles are striated, and have nicotinic combined atropine and multifocal lens group did not
receptors.36,37 Lastly, the fact that selective M1 antagonist like progress. Multi-focal lenses alone had no advantage over
pirenzepine is effective against myopia, and not the M2 and single vision lenses.57
M3 selective antagonists, further supports the neural locus of
action. In humans, M3 is found in ciliary muscles and M1 in Atropine for the treatment of childhood myopia (ATOM1)
neural tissues.38 was a randomized trial to compare the effectiveness of
atropine 1% versus placebo administered once nightly
Now, it is thought that retinal pigment epithelium (RPE) for 2 years in one eye followed by 1 year wash-out period
serves as a relay for growth-modulating signals that are in Singaporean population.58 All children were given
generated in the retina and acts on the choroid and sclera.39–43 photochromic progressive glasses. Mean myopia progression
Some of the chemical mediators that have been described for paralleled with axial length elongation and was significantly
these signaling pathways are dopamine44,45 Tumor necrosis less in the atropine group (-0.28±0.92 D/0.02±0.35mm) as
factor beta (TGFβ)46 FGF-2 or basal fibroblast growth factor47,48 compared to placebo group (-1.2±0.69 D/0.38±0.38mm) at 2
nitric oxide(NO)49 melatonin50 and inflammatory cytokines.51 years. Overall, there was 77% reduction in the mean myopic
Cristaldi et al52 has shown that atropine and 7-methylxanthine progression in the atropine treated eye at the end of 2 years.
modulates the extracellular matrix production (collagen I and But a rebound effect was noted after stopping the drug for
fibronectin) differently in scleral and choroidal fibroblasts a year during which the myopia progression in atropine
cell culture. The drugs stimulate the former and inhibit the treated eyes (-1.14 D) was far greater than the placebo (-0.38
latter in vitro. This might apply that it leads to reinforcement D). But the mean progression overall at the end of three
of sclera and increased choroidal perfusion at the same time. years (2 years of therapy and 1 year washout) was still less
Choroid is also thought to play an active role in signaling in the atropine treated eyes(-0.46 D) compared to placebo
from retina to sclera.53 (-0.52 D). The therapy did not seem to have any effect on
the astigmatism component of the refractive error and the
Clinical Trials Of Atropine astigmatism increased equally in both the groups.59 Based on
the three years data, Kumaran et al reported that the effect
Various interventions have been described for the prevention of atropine was mainly on the posterior part of the eyeball
and control of school myopia that includes optical therapies that is, vitreous chamber depth. Blurring of vision, glare and
like orthokeratology, bifocal soft contact lenses, bifocal allergy to atropine were main side effects noted with the
and progressive or multifocal spectacle glasses, and drug that led to the dropout rate of 17%.60
pharmacological therapy with atropine. Of these, atropine is
the most commonly used intervention owing to the ease of The same group from Singapore then designed ATOM2
administration and minimal side effects. With the growing to compare the safety and efficacy of lower concentrations
popularity of this drug in myopia, it has also become of atropine (0.5%, 0.1%, 0.01%) to offset the problems of
commercially available in many countries including India. mydriasis and reduced accommodation noted with higher
concentrations.61 It was a five year study with 2 years of
The use of atropine for myopia was first proposed by treatment (Phase 1) followed by washout for 1 year (Phase
Donders31 in 1864 and later encouraged by Pollock54 in 1916. 2). And those who continued to progress were decided to
The first randomized placebo controlled trial to report the get retreatment with one of the three concentrations, based
efficacy of atropine 1% in controlling childhood myopia was on study results over the past 3 years (Phase 3). A dose-
conducted in 1989 by Yen et al in Taiwanese children.55 But dependent response was noted at 2 years of treatment with
drug related photophobia was a major drawback that was higher concentrations achieving better myopia control. The
seen in almost all cases. A decade later in 1999, Shih et al. mean myopic progression and axial length elongation in the
in another randomized placebo controlled trial in Taiwanese 0.5%, 0.1% and 0.01% groups were -0.30±0.60 D/0.27±0.25mm,
population evaluated the efficacy of lower concentrations -0.38±0.06/0.28±0.28mm and -0.49 D±0.63/0.41±0.32mm
of atropine for 2 years, and found that 61%, 49% and 42% respectively. Myopia had progressed <0.5D in 63%, 58%
children, in atropine 0.5%, 0.25% and 0.1% groups respectively and 50% in the 0.5%, 0.1% and 0.01% groups respectively.
had not progressed (defined as progression of <-0.25 D/
year in the spherical equivalent) as against 8% in control

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DJO Vol. 32, No. 1, July-September 2021

Interestingly, after the washout maximum progression was -0.81±0.53D/ 0.41±0.22mm in the 0.05%, 0.025%, and 0.01%
seen with higher concentrations, i.e. -0.87D in 0.5% -0.68D atropine groups, and placebo groups, respectively (P<0.001
in 0.1% group when compared to -0.28D progression noted for both). All concentrations were well tolerated. There was
in 0.01% group and the change in axial length was not a reduction of 67%, 43%, and 27% in myopia progression
significantly different in the three groups (P=0.787). The effect and51%, 29%, and 12% in axial length elongation in the
of rebound phenomena totally reversed the overall results 0.05%, 0.025%, and 0.01% atropine groups, respectively,
such that the total increase in spherical equivalent noted at when compared with the placebo group. Importantly, there
the end of Phase 1 and 2 of the study was -1.15 D, -1.04 D and was no significant difference in axial length change between
-0.72 D in the 0.5%, 0.1% and 0.01% groups respectively.62 the 0.01% and placebo group implying that 0.01% does not
Higher concentrations of atropine were associated with have appreciable effect on the axial length elongation. Similar
greater rebound effect, therefore making 0.01% as the optimal trend was seen in ATOM 2 with no significant change in the
concentration for anti-myopia therapy with more modulated axial length at 2 years in 0.01% group (0.41±0.32mm) versus
and sustained effect. Also atropine 0.01% had minimal effect the control group of ATOM 1 (0.38±0.38mm). Based on the
on pupil dilatation and accommodation amplitude. The above findings, 0.05% was found to be most effective in
lower myopia progression in the 0.01% group continued myopia therapy that was also corroborated by the results
during phase 3 with a progression of ≥-0.50 D in at least 1 of Phase 2. But it is too soon to comment on the optimal
eye to be noted in only 24% in 0.01% group versus 59% and concentration of atropine as LAMP is an ongoing study with
68% in 0.1% and 0.5% respectively. Also, the axial length results of phase 3 and 4 awaited. It would be interesting to
increase was minimum in 0.01% group (0.19±0.18mm) than observe the rebound effect and what impact it will have on
the 0.5% (0.26±0.23mm; P=0.013) and 0.1% (0.24±0.21mm; the myopia progression eventually after the cessation of
P=0.042) groups at the end of Phase 3.63 Thus, 0.01% atropine treatment.
was recommended over the higher doses to control myopic
progression. But an important limitation was a lack of control The effectiveness of atropine for myopia control has been
group. Anticipating minimal or no effect with the super proven beyond doubt by such well powered randomized
diluted concentration of 0.01% atropine, this group was clinical trials and meta analyses.68,69 But the study populations
supposed to serve as control which instead showed favorable in these trials are predominantly of Asian ethnicity, thus there
results. So, they had to use the historical control from ATOM is need to evaluate the efficacy of atropine in different ethnic
1 that had different baseline characteristics. Furthermore, groups. Atropine 0.01% was found to reduce progression
despite the decrease in myopia progression significant axial from -1.05 D/Y to -0.04 D/Y at 1 year in 56 German
length elongation continued in 0.01% group. schoolchildren.70 Diaz-Llopis et al studied 0.01% atropine in
100 Spanish children. Myopia progression was reduced by
Following this landmark trial, a lot of interest has revived 25% (-0.14 versus -0.65 D in the no treatment group).71 Clark et
in the use of low concentration atropine in myopia. A meta- al showed in a multiethnic cohort in California that atropine
analysis by Li et al., suggested that the atropine therapy 0.01% was effective in low initial myopia, while it might fail
achieved better results in Asians than in non-Asians by in cases with rapid progression.72 A substantial number of
slowing the myopia progression by 0.54D/year and 0.35D/ children may be resistant, irrespective of ethnicity. Low dose
year respectively and the concentration does not seem to atropine has proved to be effective in different ethnic cohorts
affect the outcomes. But these results could be confounded from Germany, Italy,73 Korea.74 Netherlands,75 and Spain. In
by the absence of RCTs in non-Asian population.64 Another a study by Fang et al, atropine 0.025% has been found to be
meta-analysis by Pineles et al. concluded that atropine effective in the prevention of onset of myopia in pre-myopes
therapy is effective in reducing the myopia progression in (defined as spherical equivalent ≤1D).76,77 But, it needs further
children by as much as 1D/year and recommended the use elucidation.
of 0.01% atropine.65 Cooper et al. proposed that the highest
tolerable dose of atropine with minimal side effects in white There are many other ongoing registered RCTs especially
population was 0.02%.66 in non-Asian population like the CHAMP-UK(Childhood
Atropine for Myopia Progression-United Kingdom)78 in
Low-Concentration Atropine for Myopia Progression British, MOSAIC(Myopia Outcome Study of Atropine in
(LAMP) Study was a Hong Kong based randomized masked Children) study79 in European and WA-ATOM(Western
study started in January 2016 to compare the efficacy of Australia Atropine for the Treatment of Myopia) study in
low dose atropine (0.05%, 0.025%, and 0.01%) in myopic Australian population.80
children.67 The study has been divided into four phases:
Phase 1(1-year) comparing treatment versus placebo, phase There are no published well-designed RCTs in Indian
2(1-year) switching over of placebo to the best determined population. A cohort study from India reported the
concentration, phase 3 (1-year) washout period to look effectiveness of 1% atropine that reduced the rate of
for rebound effect and phase 4 (2-years) when atropine progression from a mean of -0.6D/year to -0.2D/year at 23
will be resumed in children showing progression > 0.5D months follow-up.81 The authors concluded that 1% atropine
at concentration to be decided. In phase 1, a concentration maybe considered for myopes with rapid progression, higher
dependent response was noted with mean change in spherical myopia at baseline, during the years of active growth, and
equivalent/axial elongation to be -0.27±0.61D/ 0.20±0.25mm, among the “poor” responders to the lower concentrations
-0.46±0.45D/ 0.29±0.20mm, -0.59±0.61D/ 0.36±0.29mm, and of atropine. They emphasized the possible preference of

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DJO Vol. 32, No. 1, July-September 2021

Table 1: Summary of various studies elucidating the role of atropine in myopia

Author Design Country F/U Sample Age Treatment Parameters Baseline Baseline Change in Change
Taiwan size (yrs) assessed SE AL SE (D/ in AL
Taiwan 12 year) (mm/ Comment
Yen et RCT Taiwan months 96 6-14 AL,Km, -0.5 to -4 Not year)
al(55) Singapore 32 10.5 Atropine 1% CR,IOP -1.52(0.96) reported -0.22(0.54) Both atropine
Upto 24 32 10 Cyclopentolate 1% -1.45(0.85) -0.58(0.49) Not and
China months 32 CR, IOP reported
Taiwan 186 10.4 Placebo cyclopentolate
Taiwan 18 41 6-13 -1.59(0.92) -0.91(0.58) effective, but
Singapore months 47 atropine was the
49 most potent
24 49
Shih et RCT months 227 -0.5 to-6.75 NA NA
al(56) 76
8-12 75 9.8 Atropine 0.5% -4.89(2.06) 0.04(0.63) Atropine 0.5%
months 76 9.7 Atropine 0.25% -4.24(1.74) 0.04(0.63) most effective,
400 8.9 Atropine 0.1% -4.41(1.47) 0.04(0.63) but drop out
12-36 200 8.3 Tropicamide -4.5(1.86) 0.04(0.63)
months due to side
200 0.5%(control) effect more
3-8 years
Shih et RCT (mean 22 6-13 CR,IOP,
al(57) 4.5y) 23 Atropine corneal
26 0.5%+mfpl radius, -3.28(0.13) 24.62(0.10) -0.42(0.07) 0.22(0.03) No difference
24 KM,AL, in progression
months 50 Placebo+mfpl LT,ACD -3.34(0.14) 24.80(0.09) -1.19(0.07) 0.49(0.03) between mfpl
24 Placebo+svl -3.20(0.14) 24.75(0.10) -1.40(0.09) 0.59(0.04) and svlgroups
26
Chuaet RCT 6-12 CR, ACD, At 2 years At 2 years
al(ATOM 117 LT,AL, mfERG
97
1) 20 9.2 Atropine1% treated 3.36(1.38) 24.80(0.83) -0.28(0.92) 0.02(0.35) Essentially no
(58) eye 3.40(1.35) 24.81(0.84) change in axial
400
Atropine 1% 3.58(1.17) 24.80(0.84) -1.20(0.69) 0.38(0.38) length of the
161 untreated fellow atropine treated
155 eyes, at the end
84 eye
of two years
9.2 Placebo treated eye

Placebo untreated 3.55(1.21) 24.76(0.86)
fellow eye

Liang RCT CR, IOP, AL Combined
2008(87)
9.9 Atropine0.25% -2.09(1.68) 24.11(0.89) 0.38(0.32) 0.16(0.09) therapy
10.9 Atropine 0.5% -2.17(1.48) 24.24(0.53) 0.15(0.15) 0.12(0.12) with acupressur

e was

10.2 Atropine -1.19(1.20) 24.95(0.77) 0.21(0.23) 0.14(0.11) comparable

0.25%+acupressure to 0.5% atropine

results

Fang et Retrospective, 6-12 CR Not Not In premyopes
al(76) cohort Atropine 0.025%
No treatment -0.31(0.45) assessed -0.14(0.24) assessed (SE<1 D)atropine

-0.17(0.5) -0.58(0.34) 0.025% can
prevent

myopic shift

Wu et Retrospective 6-12 Atropine CR -2.45 Not -0.31(0.26) Not 45% children
al(91) case control years, 0.05%or 0.1% (1.63) D assessed assessed on atropine
mean CR, AL, 0.05% were
8.4y No treatment AA, PD -1.87 shifted onto
(0.94) D 0.1% due to
-0.90(0.30) progression
-4.5(1.5) of >0.5 D in 6
Chia et al RCT 6-12, -4.8(1.5) At 2 years, At 2 years,
(ATOM2, mean -4.7(1.8) months.
phase1)
9.7 All the
(58) years concentrations
are effective.
Atropine 0.01% 25.1(1.0) -0.49(0.63) 0.41(0.32)
Clinical
Atropine 0.1% 25.2(0.8) -0.38(0.60) 0.28(0.27) difference in
Atropine0.01% 25.2(0.9) -0.30(0.60) 0.27(0.25) progression

among
the three
groups

small.

Lin et Retrospective, Taiwan 3 years 210 7-17 Atropine CR,AL, The superiority
al(86) cohort years 0.125% corneal of one modality
OK lenses endothelium
over another
105 Mean -4.0(1.75) 24.23(1.35) -0.28(0.18) 0.37(0.09) could not be
11.1 -4.25(1.5) 24.12(1.25) -0.34(0.21) 0.28(0.08)
established
105 Mean definitely
11.8 Combination of
atropine and or
thokeratology
may be
potentially
effective.

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DJO Vol. 32, No. 1, July-September 2021

Kumaran RCT Singapore 3 years 313 6-12 CR,ACD, At 3 years, At 3years, Rebound
et al(97) (2 years) years LT, AL, changes in changes progression
of ATOM KM,VCD in median
1+1 yr off 147 9.2 y Atropine 3.36(1.38) 24.80 median values after
treatment 166 9.2 y 1% CR,AL, 3.58(1.17) (0.83) values stopping
IOP, 0.26 mm treatment
Placebo 24.80 -1.35 D was seen. But
treated fundus (0.84) still the overall
OCT -1.55 D 0.53 mm progression
over 3 years was
Yi et RCT China 12 132 7-12 -0.5 to- less with
al(98) months 2.0 D atropine.

68 9.91 Atropine -1.23(0.32) 23.75(0.10) 0.32(0.22) -0.03(0.07) Atropine is
1% effective
64 9.72
60 6-15 Placebo for low myopia
30 10.2
Atropine -1.15(0.30) 23.72(0.12) -0.85(0.31) 0.32(0.15)
28 10.2 0.01% NA
Clark et Retrospective, US Mean Manifest 1.1 D NA The strongest
al(72) case control 1.1 years Placebo SE -0.11 clinical
-2(1.6) -0.1(0.6) (0.20)
CR, AL D/Y -0.12 improvement
PD (0.14) was
-2(1.5) -0.6(0.4) [P=0.73]
CR D/Y Not seen in the low
assessed myopia group
Polling Prospective, Netherlands 12 77 10.3 CR, AL, AA,
et al(75) interventional months (3.2) PD (≤ 1 D)

60 Atropin -6.7(3.6) 25.19 -1.0(0.7 The effect of
e 0.5% -6.5(2.8) (0.97) D/Y therapy was the
17 Ceased lowest and the
drug 25.46 -0.5(0.6 highest in less
200 9-12 (1.21) D/Y
years Atropine than
Diaz- RCT Spain 60 0.01% -0.5 D to Not 9 and more than
Llopis months 100 10.4 No -2.0 D assessed
et al(71) 12 years,
100 10.1 treatment -1.1(0.5) -0.14(0.35) respectively.

-1.2(0.4) -0.65(0.54) Therapy was
abandoned in
2% of children

due to
side-effect
(photophobia,
reading difficulty,
headaches,
mydriasis;
another
5% had similar
complaints.

Yam et RCT Hong Kong 12+12 383 4-12
al(LAMP months years
Atropine
phase 97 8.23 Atropine 0.01% -3.77(1.85) 24.70(0.99) -1.12(0.85) 0.59(0.38) 0.05%
1+2) -3.71(1.85) 24.86(0.95) -0.85(0.73) 0.50(0.33)
(67,92) 91 8.54 Atropine was the best
0.025% -3.98(1.69) 24.85(0.90) -0.55(0.86) 0.39(0.35) concentration,
and its effect
102 8.45 Atropine -3.85(1.95) 24.82(0.97) -1.00(0.77) 0.58(0.33)
0.05% was twice
that of 0.01%.
93 8.42 Placebo for 1
year→0.05%

Moon Retrospective South Korea 12 285 7.0(2.1) Control: before CR, AL, -2.76(2.38) 24.39(1.36) -1.61(1.92) 0.55(0.24) All three
et al(74) months of atropine NPA, PD -3.84(2.47) 20.86(1.22) -0.84(0.86) 0.44(0.32) concentrations
treatment -3.97(1.65) 24.66(0.93) -0.56(0.86) 0.30(0.24) were effective.
89 8.0(2.2) Atropine 0.01% -3.94(2.76) 24.91(1.43) -0.23(0.67) 0.23(0.25)
Korean
63 8.4(2.1) Atropine children
133 8.1(2.1) 0.025% might require
higher
Atropine concentration.
0.05%

ACD Anterior chamber depth mfERG Multifocal electroretinogram RCT Randomized control trial
CR cycloplegics refraction mfpl Multifocal progressive lenses
D/Y Diopter per year IOP svl Single vision lenses
AA accommodation amplitude LT intraocular pressure
AL axial length NPA Lens thickness VCD Vitreous chamber depth
KM keratometry OCT
near point of accommodation
optical coherence tomography

atropine 1% over the lower concentrations in dark irides Combination Therapy With Atropine
population such as in India. Moreover, they also advocated
the morning administration of drops, as was done by Combination therapy for myopia progression using optical,
Brodstein et al.82 A multicentric randomized blinded trial pharmaceutical and environmental interventions may be
evaluating the efficacy of 0.01% atropine versus placebo useful in individuals poorly responsive to a particular
has been registered in Clinical trial registry of India and its modality. Moreover, drugs with differing mechanisms can
results are expected soon.83 have additive effect, as in cases of various diseases such as
glaucoma, diabetes mellitus etc. In this regard, the effect

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DJO Vol. 32, No. 1, July-September 2021

of atropine with orthokeratology has been studied, with Table 2 : Clinical guidelines for children aged 6-10 years with
promising outcomes.84-86 Some role of acupressure combined myopia >1.0 D and documented progression >0.5 D per year(15)
with atropine therapy has also been seen.87
(Adopted from Myopia Report for Web by the WHO)
Implementation In Clinical Practice
Treat children with atropine 0.01% for 2 years
Following the surge in the use of atropine in myopia control,
0.01% atropine has become commercially available in several Good responder:almost no Moderate Poor response:
countries including India. According to a survey 88 involving myopic progression( <0.5 D response : myopic progression > 1.0
the Mumbai Group of Pediatric Ophthalmologists and over second year) progression of D over second
Strabismologists in India, every clinician had used atropine 0.5 D to 1.0 D year
0.01% for myopic progression and two-thirds prescribe it over second year
routinely. The cut-off for progression used as an indicator
for atropine therapy is 0.5D to 1D per year. A recent global Taper and stop atropine Continue May be a non-
survey including 940 pediatric ophthalmologists worldwide atropine 0.01%for responder.
found that atropine 0.01% is the most popular eye drops for a further 1-2 Consider taper
preventing myopia progression.89 years, then taper and stop atropine
and stop atropine
Age, baseline refractive error, evidence of recent progression, and
presence of myopia in parents are certain factors that predict Follow subject for a year post stopping atropine
the likelihood of myopia progression in a child. Cycloplegic Recommence atropine if significant rebound and continue review
refraction should be done at baseline and again repeated after
2-3 weeks to account for the hyperopic shift due to atropine Side Effects
therapy. The most accepted regimen at present is once nightly
administration of atropine 0.01% eye drops. Subsequent Atropine, especially high doses, should be administered with
follow up can be done at 6 monthly intervals. Parents caution in children with spastic paralysis, Down syndrome,
should be educated about the side effects like photophobia, brain disorders and those taking drugs with CNS effects like
accommodation problems, dry eye and allergic reactions. They barbiturates, phenothiazines and anti-emetics. Fever, altered
should also be explained about the long duration of therapy, mental status, dry mouth, flushing of skin, tachycardia,
and the possible poor response to therapy. Additionally, urinary retention and constipation, are some systemic side
role of environmental modulation and lifestyle change effects that have been reported with higher doses. Parents
should be adequately emphasized upon during counselling. should be advised to present immediately if signs of adverse
reactions are observed.
Though there is no consensus regarding the usage of atropine,
the World Health Organization (WHO)(15) has given the Common ocular side effects include near blur and
guidelines for atropine therapy in myopia. (Table 2) photophobia. In ATOM2, accommodation amplitude was
reduced to 4.0 D, 6.8 D and 11.8 D in the 0.5%, 0.25% and 0.01%
The period of atropine therapy should be at least for 2 groups respectively. This translates functionally to impaired
years as the stabilization effect is usually achieved by then. near visual acuity especially in the former two groups who
Therapy can be discontinued thereafter if the refractive error may need progressive glasses. Pupil size, both mesopic and
remains stable or can be restarted if progression is noted. photopic, was minimally affected (1mm) in the 0.01% group
The age group targeted in most studies related to atropine as compared to higher concentrations (change ≥3 mm). But
was 6-13 years, but in Taiwan therapy is given for myopes these effects are temporary and complete recovery is noted
till 18 years.90 But in case of sub-optimal responders we have after cessation of atropine and is quickest in the 0.01% group.
to consider alternate approaches. Alternatives strategies In LAMP study, near visual acuity was unaffected at 2
include increasing the concentration of atropine; continuing years follow-up in all groups (0.05%, 0.025% or 0.01%) and
the same atropine concentration with environmental none required progressive glasses.92 Accommodation might
modifications like increased outdoors activity, change to be symptomatically reduced even with 0.01% atropine,
different treatment modalities like orthokeratology. The but recovers within 3 months.93 Sun protection should be
role of environmental factors and the benefit of higher advised if prescribing concentrations above 0.02%.94 Allergic
concentration is doubtful at this stage. Changing to higher conjunctivitis, allergy associated dermatitis, dry eye95 and
concentration after 6 months of treatment in case of non- convergence excess esotropia96 have also been described with
responsiveness has been recommended by Wu et al91 But atropine use. But overall, low dose atropine has been found
as reported in ATOM 2 study, the effect of atropine 0.01% is to be very acceptable especially in Asians eyes.
evident only in the second year of therapy, thus, it would be
reasonable to wait for the response into the second year. So Missing Links
we are still in the process of figuring out the best approach
for myopia prevention. Till then one can follow the above Role of atropine therapy for myopia control is an evolving
subject with several missing links. Still algorithms have to
guidelines or treat the patient on a case-to-case basis. be developed to address issues like when to start or stop the
therapy, duration and concentration of the drug, and the
variability in these aspects according to the ethnicity, age of
onset, the level of myopia, or progression. Among the three
concentrations of atropine(0.5%, 0.025% and 0.01%) used in
ATOM2 study,0.01% appears to be the most effective. The
two year result of the LAMP trial (atropine 0.05%, 0.025%
and 0.01%) has shown 0.05% to be the best with comparable

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DJO Vol. 32, No. 1, July-September 2021

side effects, while the rebound effect remains to be studied. 12. Sheeladevi S, Seelam B, Nukella PB, Borah RR, Ali R, Keay L.
However, the highest concentration without significant Prevalence of refractive errors, uncorrected refractive error,
side effects has been shown to be 0.02%. Thus, the best and presbyopia in adults in India: A systematic review. Indian
concentration still needs to be determined. The management J Ophthalmol. 2019 May 1; 67(5):583.
of non-responders or poor responders (to atropine therapy)
is still unknown. Last but not the least, the effectiveness of 13. Saxena R, Vashist P, Tandon R, et al. Prevalence of myopia and
atropine therapy in late onset myopia has not been studied. its risk factors in urban school children in Delhi: the North India
The use of atropine among children 13–18 years of age and in Myopia Study (NIM Study). PLoS One. 2015; 10(2):e0117349.
pre-myopes needs clinical studies. Published 2015 Feb 26. doi:10.1371/journal.pone.0117349

Conclusion 14. Saxena R, Vashist P, Tandon R, et al. Incidence and progression
of myopia and associated factors in urban school children in
To conclude, it can be said that the efficacy of atropine in Delhi: The North India Myopia Study (NIM Study). PLoS One.
2017; 12(12):e0189774. Published 2017 Dec 18. doi:10.1371/
controlling progression in myopia, is established beyond journal.pone.0189774

doubt. Yet, the concentration that is the best compromise 15. World Health Organization - Brien Holden Vision Institute.
The impact of myopia. In: The Impact of Myopia and High
between the effectiveness and side-effects remains to be Myopia. Report of the Joint World Health Organization–Brien
Holden Vision Institute Global Scientific Meeting on Myopia.
determined. Till date, atropine 0.01% remains the optimal Available at: https://www.visionuk.org.uk/download/WHO_
Report_Myopia_2016.pdf.
concentration for antimyopia therapy with best effect versus
16. Verhoeven VJM, Wong KT, Buitendijk GHS, Hofman A,
side effect profile. Better elucidation of the pathway of action Vingerling JR, Klaver CCW. Visual consequences of refractive
errors in the general population. Ophthalmology. 2015 Jan;
of atropine, and eye growth in general may help in developing 122(1):101–9

new strategies and agents for myopia control. There is a need 17. Younan C, Mitchell P, Cumming RG, Rochtchina E, Wang JJ.
Myopia and incident cataract and cataract surgery: the blue
of evidence based general guidelines for easier incorporation mountains eye study. Invest Ophthalmol Vis Sci. 2002 Dec;
43(12):3625–32.
of atropine in clinical practice. Further, the combination
18. Qiu M, Wang SY, Singh K, Lin SC. Association between
therapy with modalities like bifocal or progressive spectacles myopia and glaucoma in the United States population. Invest
Ophthalmol Vis Sci. 2013 Jan 28; 54(1):830–5.
lenses, dual focus contact lenses and orthokeratology needs
19. Rose K, Harper R, Tromans C, Waterman C, Goldberg D,
more elucidation. References Haggerty C, et al. Quality of life in myopia. Br J Ophthalmol.
2000 Sep 1; 84(9):1031–4.

20. Smith TST, Frick KD, Holden BA, Fricke TR, Naidoo KS.
1. Bourne RRA, Stevens GA, White RA, Smith JL, Flaxman SR, Potential lost productivity resulting from the global burden
of uncorrected refractive error. Bull World Health Organ. 2009
Price H, et al. Causes of vision loss worldwide, 1990-2010: a Jun; 87(6):431–7.

systematic analysis. Lancet Glob Health. 2013 Dec;1(6):e339-349. 21. Łazarczyk JB, Urban B, Konarzewska B, et al. The differences in
level of trait anxiety among girls and boys aged 13-17 years with
2. Fricke TR, Jong M, Naidoo KS, Sankaridurg P, Naduvilath TJ, myopia and emmetropia. BMC Ophthalmol. 2016;16(1):201

Ho SM, et al. Global prevalence of visual impairment associated 22. Ip JM, Huynh SC, Robaei D, Rose KA, Morgan IG, Smith W, et
al. Ethnic differences in the impact of parental myopia: findings
with myopic macular degeneration and temporal trends from from a population-based study of 12-year-old Australian
children. Invest Ophthalmol Vis Sci. 2007 Jun; 48(6):2520–8.
2000 through 2050: systematic review, meta-analysis and
23. Polling JR, Verhoeven VJM, Tideman JWL, Klaver CCW. Duke-
modelling. Br J Ophthalmol. 2018 Jul; 102(7):855–62. Elder’s Views on Prognosis, Prophylaxis, and Treatment of
Myopia: Way Ahead of His Time. Strabismus. 2016;24(1):40–3.
3. Holden BA, Fricke TR, Wilson DA, Jong M, Naidoo KS,
24. Fan, Q., Guo, X., Tideman, J. et al. Childhood gene-environment
Sankaridurg P, et al. Global Prevalence of Myopia and High interactions and age-dependent effects of genetic variants
associated with refractive error and myopia: The CREAM
Myopia and Temporal Trends from 2000 through 2050. Consortium. Sci Rep 6, 25853 (2016).

Ophthalmology. 2016 May;123(5):1036–42. 25. Klaver C, Polling JR; Erasmus Myopia Research Group.
Myopia management in the Netherlands. Ophthalmic Physiol
4. Lin LL, Shih YF, Tsai CB, Chen CJ, Lee LA, Hung PT, et al. Opt. 2020;40(2):230-240.

Epidemiologic study of ocular refraction among schoolchildren 26. Cao K, Wan Y, Yusufu M, Wang N. Significance of Outdoor
Time for Myopia Prevention: A Systematic Review and Meta-
in Taiwan in 1995. Optom Vis Sci Off Publ Am AcadOptom. Analysis Based on Randomized Controlled Trials. Ophthalmic
Res. 2020; 63(2):97–105.
1999 May; 76(5):275–81.
27. Schmid KL, Wildsoet CF. Effects on the compensatory
5. Lin LL, Shih YF, Hsiao CK, Chen CJ. Prevalence of myopia responses to positive and negative lenses of intermittent lens
wear and ciliary nerve section in chicks. Vision Res. 1996 Apr;
in Taiwanese schoolchildren: 1983 to 2000. Ann Acad Med 36(7):1023–36.

Singapore. 2004; 33(1):27-33. 28. Norton TT. What Do Animal Studies Tell Us about the
Mechanism of Myopia – Protection by Light? Optom Vis Sci
6. Wu HM, Seet B, Yap EP, Saw SM, Lim TH, Chia KS. Does Off Publ Am AcadOptom. 2016 Sep; 93(9):1049–51.

education explain ethnic differences in myopia prevalence? 29. Cohen Y, Belkin M, Yehezkel O, Solomon AS, Polat
U. Dependency between light intensity and refractive
A population-based study of young adult males in Singapore. development under light-dark cycles. Exp Eye Res. 2011 Jan;
92(1):40–6.
Optom Vis Sci Off Publ Am AcadOptom. 2001 Apr;78(4):234–9.
30. Xiong S, Sankaridurg P, Naduvilath T, Zang J, Zou H, Zhu J,
7. Kim H, Seo JS, Yoo W-S, Kim G-N, Kim RB, Chae JE, et al.

Factors associated with myopia in Korean children: Korea

National Health and nutrition examination survey 2016–2017

(KNHANES VII). BMC Ophthalmol. 2020 Jan 20; 20(1):31.

8. Vitale S, Sperduto RD, Ferris FL. Increased prevalence of

myopia in the United States between 1971-1972 and 1999-2004.

Arch Ophthalmol Chic Ill 1960. 2009 Dec; 127(12):1632–9.

9. Williams KM, Bertelsen G, Cumberland P, Wolfram

C, Verhoeven VJM, Anastasopoulos E, et al. Increasing

Prevalence of Myopia in Europe and the Impact of Education.

Ophthalmology. 2015 Jul; 122(7):1489–97.

10. McCarty CA, Taylor HR. Myopia and vision 2020. Am J

Ophthalmol. 2000 Apr; 129(4):525–7.

11. Sheeladevi S, Seelam B, Nukella PB, Modi A, Ali R, Keay L.

Prevalence of refractive errors in children in India: a systematic

review. ClinExpOptom. 2018; 101(4):495–503.

E-ISSN: 2454-2784  P-ISSN: 0972-0200 15 Delhi Journal of Ophthalmology

DJO Vol. 32, No. 1, July-September 2021

et al. Time spent in outdoor activities in relation to myopia Coll Ophthalmic Opt Optom. 2017;37(5):557–67.
prevention and control: a meta‐analysis and systematic review. 51. Yuan, J., Wu, S., Wang, Y. et al. Inflammatory cytokines in
ActaOphthalmol (Copenh). 2017 Sep; 95(6):551–66.
31. Donders FC, Moore WD. On the Anomalies of Accommodation highly myopic eyes. Sci Rep 9, 3517 (2019).
and Refraction of the Eye, with a Preliminary Essay on 52. Cristaldi M, Olivieri M, Pezzino S, Spampinato G, Lupo G,
Physiological Dioptrics. Br Foreign Med Chir Rev. 1864;
34(68):443-445. Anfuso CD, et al. Atropine Differentially Modulates ECM
32. Huang HM, Chang DS, Wu PC. The Association between Production by Ocular Fibroblasts, and Its Ocular Surface
Near Work Activities and Myopia in Children-A Systematic Toxicity Is Blunted by Colostrum. Biomedicines. 2020 Apr;
Review and Meta-Analysis. PLoS One. 2015; 10(10):e0140419. 8(4):78.
Published 2015 Oct 20. doi:10.1371/journal.pone.0140419 53. He L, Frost MR, Siegwart JT, Norton TT. Gene expression
33. Troilo D, Gottlieb MD, Wallman J. Visual deprivation causes signatures in tree shrew choroid in response to three
myopia in chicks with optic nerve section. Curr Eye Res. 1987 myopiagenic conditions. Vision Res. 2014 Sep 1;102: 52–63.
Aug; 6(8):993–9. 54. Pollock WBI. The Reduction of Myopia in Children of School
34. Schaeffel F, Troilo D, Wallman J, Howland HC. Developing Age.Glasg Med J. 1916 Oct; 86(4):214–9.
eyes that lack accommodation grow to compensate for imposed 55. Yen MY, Liu JH, Kao SC, Shiao CH. Comparison of the effect of
defocus. Vis Neurosci. 1990 Feb; 4(2):177–83. atropine and cyclopentolate on myopia. Ann Ophthalmol. 1989
35. McBrien NA, Moghaddam HO, Reeder AP. Atropine May; 21(5):180–2, 187.
reduces experimental myopia and eye enlargement via a 56. Shih YF, Chen CH, Chou AC, Ho TC, Lin LL, Hung PT.
nonaccommodative mechanism. Invest Ophthalmol Vis Sci. Effects of different concentrations of atropine on controlling
1993 Jan; 34(1):205–15. myopia in myopic children. J OculPharmacolTher Off J
36. Stone RA, Lin T, Laties AM. Muscarinic antagonist effects on AssocOculPharmacolTher. 1999 Feb; 15(1):85–90.
experimental chick myopia.Exp Eye Res. 1991 Jun; 52(6):755–8. 57. Shih YF, Hsiao CK, Chen CJ, Chang CW, Hung PT, Lin LL. An
37. Honkanen RE, Howard EF, Abdel-Latif AA. M3-muscarinic intervention trial on efficacy of atropine and multi-focal glasses
receptor subtype predominates in the bovine iris sphincter in controlling myopic progression. ActaOphthalmol Scand.
smooth muscle and ciliary processes. Invest Ophthalmol Vis 2001 Jun;79(3):233–6.
Sci. 1990 Mar 1; 31(3):590–3. 58. Chua WH, Balakrishnan V, Chan YH, et al. Atropine for
38. Goyal RK. Muscarinic receptor subtypes. Physiology and the treatment of childhood myopia. Ophthalmology.
clinical implications. N Engl J Med. 1989 Oct 12; 321(15):1022–9. 2006;113(12):2285-2291.
39. Fischer AJ, Miethke P, Morgan IG, Stell WK. Cholinergic 59. Chia A, Chua WH, Tan D. Effect of topical atropine on
amacrine cells are not required for the progression and astigmatism. Br J Ophthalmol. 2009 Jun;93(6):799–802.
atropine-mediated suppression of form-deprivation myopia. 60. Kumaran A, Htoon HM, Tan D, Chia A. Analysis of Changes
Brain Res. 1998 May 25; 794(1):48–60. in Refraction and Biometry of Atropine- and Placebo-Treated
40. Norton TT, Essinger JA, McBrien NA. Lid suture myopia in Eyes. Invest Ophthalmol Vis Sci. 2015;56(9):5650-5655.
tree shrews with retinal ganglion cell blockade. Vis Neurosci. 61. Chia A, Chua WH, Cheung YB, Wong WL, Lingham A, Fong
1994 Jan; 11(1):143–53. A, et al. Atropine for the treatment of childhood myopia: safety
41. Tkatchenko TV, Troilo D, Benavente-Perez A, Tkatchenko AV. and efficacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the
Gene expression in response to optical defocus of opposite Treatment of Myopia 2). Ophthalmology. 2012; 119(2):347–54.
signs reveals bidirectional mechanism of visually guided eye 62. Chia A, Chua WH, Wen L, Fong A, Goon YY, Tan D. Atropine
growth. PLOS Biol. 2018 Oct 9; 16(10):e2006021. for the treatment of childhood myopia: changes after stopping
42. Rymer J, Wildsoet CF. The role of the retinal pigment atropine 0.01%, 0.1% and 0.5%. Am J Ophthalmol. 2014;
epithelium in eye growth regulation and myopia: a review. Vis 157(2):451-457.e1.
Neurosci. 2005 Jun; 22(3):251–61. 63. Chia A, Lu QS, Tan D. Five-Year Clinical Trial on Atropine for
43. Zhang Y, Maminishkis A, Zhi C, Li R, Agarwal R, Miller SS, the Treatment of Myopia 2: Myopia Control with Atropine
et al. Apomorphine Regulates TGF-β1 and TGF-β2 Expression 0.01% Eyedrops. Ophthalmology. 2016;123(2):391-399.
in Human Fetal Retinal Pigment Epithelial Cells. Invest 64. Li SM, Wu SS, Kang MT, et al. Atropine slows myopia
Ophthalmol Vis Sci. 2009 Apr 28;50(13):3845–3845. progression more in Asian than white children by meta-
44. Zhou X, Pardue MT, Iuvone PM, Qu J. Dopamine signaling and analysis. Optom Vis Sci. 2014;91(3):342-350.
myopia development: What are the key challenges. ProgRetin 65. Pineles SL, Kraker RT, VanderVeen DK, Hutchinson AK, Galvin
Eye Res. 2017 Nov;61: 60–71. JA, Wilson LB, et al. Atropine for the Prevention of Myopia
45. Schwahn HN, Kaymak H, Schaeffel F. Effects of atropine on Progression in Children: A Report by the American Academy
refractive development, dopamine release, and slow retinal of Ophthalmology. Ophthalmology. 2017; 124(12):1857–66.
potentials in the chick. Vis Neurosci. 2000 Apr; 17(2):165–76. 66 Cooper J, Eisenberg N, Schulman E, Wang FM. Maximum
46. Meng B, Li SM, Yang Y, et al. The association of TGFB1 genetic atropine dose without clinical signs or symptoms. Optom Vis
polymorphisms with high myopia: a systematic review and Sci Off Publ Am AcadOptom. 2013 Dec;90(12):1467–72.
meta-analysis. Int J Clin Exp Med. 2015;8(11):20355-20367. 67. Yam JC, Jiang Y, Tang SM, Law AKP, Chan JJ, Wong E, et al.
47. Barathi VA, Weon SR, Beuerman RW. Expression of muscarinic Low-Concentration Atropine for Myopia Progression (LAMP)
receptors in human and mouse sclera and their role in the Study: A Randomized, Double-Blinded, Placebo-Controlled
regulation of scleral fibroblasts proliferation. Mol Vis. 2009;15: Trial of 0.05%, 0.025%, and 0.01% Atropine Eye Drops in
1277-1293. Published 2009 Jun 30. Myopia Control. Ophthalmology. 2019; 126(1):113–24.
48. Seko Y, Tanaka Y, Tokoro T. Influence of bFGF as a potent 68. Gong Q, Janowski M, Luo M, Wei H, Chen B, Yang G, et al.
growth stimulator and TGF-beta as a growth regulator on Efficacy and Adverse Effects of Atropine in Childhood Myopia:
scleral chondrocytes and scleral fibroblasts in vitro. Ophthalmic A Meta-analysis. JAMA Ophthalmol. 2017 01; 135(6):624–30.
Res. 1995; 27(3):144–52. 69. Huang J, Wen D, Wang Q, McAlinden C, Flitcroft I, Chen H, et
49. Carr BJ, Stell WK. Nitric Oxide (NO) Mediates the Inhibition of al. Efficacy Comparison of 16 Interventions for Myopia Control
Form-Deprivation Myopia by Atropine in Chicks. Sci Rep. 2016 in Children: A Network Meta-analysis. Ophthalmology. 2016
Dec 5;6(1):9. Apr; 123(4):697–708.
50. Kearney S, O’Donoghue L, Pourshahidi LK, Cobice D, Saunders 70. Joachimsen L, Böhringer D, Gross NJ, Reich M, Stifter J,
KJ. Myopes have significantly higher serum melatonin Reinhard T, et al. A Pilot Study on the Efficacy and Safety of
concentrations than non-myopes. Ophthalmic Physiol Opt J Br 0.01% Atropine in German Schoolchildren with Progressive
Myopia.OphthalmolTher. 2019 Sep;8(3):427–33.
71. Diaz-Llopis M, Pinazo-Durán MD. Superdiluted atropine at

E-ISSN: 2454-2784  P-ISSN: 0972-0200 16 www.djo.org.in

DJO Vol. 32, No. 1, July-September 2021

0.01% reduces progression in children and adolescents. A 2017]. Graefes Arch Clin Exp Ophthalmol. 2018;256(12):2457-
5 year study of safety and effectiveness. Arch Soc Espanola 2466.
Oftalmol. 2018 Apr; 93(4):182–5. 90. Fang YT, Chou YJ, Pu C, et al. Prescription of atropine eye
72. Clark TY, Clark RA. Atropine 0.01% Eyedrops Significantly drops among children diagnosed with myopia in Taiwan from
Reduce the Progression of Childhood Myopia. J 2000 to 2007: a nationwide study. Eye (Lond). 2013;27(3):418-
OculPharmacolTher Off J AssocOculPharmacolTher. 2015 424.
Nov; 31(9):541–5. 91. Wu PC, Yang YH, Fang PC. The long-term results of using
73. Sacchi M, Serafino M, Villani E, Tagliabue E, Luccarelli S, low-concentration atropine eye drops for controlling myopia
Bonsignore F, et al. Efficacy of atropine 0.01% for the treatment progression in schoolchildren. J Ocul Pharmacol Ther.
of childhood myopia in European patients. ActaOphthalmol 2011;27(5):461-466
(Copenh). 2019; 97(8):e1136–40. 92. Yam JC, Li FF, Zhang X, et al. Two-Year Clinical Trial of the
74. Moon J-S, Shin SY. The diluted atropine for inhibition of Low-Concentration Atropine for Myopia Progression (LAMP)
myopia progression in Korean children.Int J Ophthalmol. 2018 Study: Phase 2 Report. Ophthalmology. 2020;127(7):910-919
Oct 18; 11(10):1657–62. 93. Wang Y, Yao J, Qu X. Atropine 0.01% for the Control of Myopia
75. Polling JR, Kok RGW, Tideman JWL, Meskat B, Klaver CCW. in Chinese Children: Effect on Accommodation Functions and
Effectiveness study of atropine for progressive myopia in Pupil Size. Zanon-Moreno V, editor. J Ophthalmol. 2020 Feb
Europeans. Eye Lond Engl. 2016 Jul; 30(7):998–1004. 26;2020:7525180.
76. Fang PC, Chung MY, Yu HJ, Wu PC. Prevention of myopia 94. Fricke T, Hurairah H, Huang Y, Ho SM. Pharmacological
onset with 0.025% atropine in premyopic children. J Ocul interventions in myopia management. Community Eye Health.
Pharmacol Ther. 2010;26(4):341-345. 2019;32(105):21–2.
77. Flitcroft DI, He M, Jonas JB, Jong M, Naidoo K, Ohno-Matsui 95. Burgalassi S, Panichi L, Chetoni P, Saettone MF, Boldrini E.
K, et al. IMI – Defining and Classifying Myopia: A Proposed Development of a simple dry eye model in the albino rabbit
Set of Standards for Clinical and Epidemiologic Studies. Invest and evaluation of some tear substitutes. Ophthalmic Res.
Ophthalmol Vis Sci. 2019 Feb 28; 60(3):M20–30. 1999;31(3):229–35.
78. Azuara-Blanco A, Logan N, Strang N, Saunders K, Allen PM, 96. Kothari M, Modak M, Khan H, Jahan S, Solanki M, Rathod
Weir R, et al. Low-dose (0.01%) atropine eye-drops to reduce V. Convergence excess consecutive esotropia associated
progression of myopia in children: a multicentre placebo- with 0.01% atropine eye drops usage in patients operated for
controlled randomised trial in the UK (CHAMP-UK)-study intermittent exotropia. Indian J Ophthalmol. 2020 Apr 1;68(4):
protocol. Br J Ophthalmol. 2019 Oct 25. 653.
79. McCrann S, Flitcroft I, Strang NC, Saunders KJ, Logan NS,
Lee SS, et al. Myopia Outcome Study of Atropine in Children Cite This Article as: Priyanka Mishra, Rebika Dhiman, Bhavika
(MOSAIC): an investigator-led, double-masked, placebo- Bansal, Rohit Saxena.Atropine in Myopia. Delhi J Ophthalmol
controlled, randomised clinical trial protocol. HRB Open Res. 2021; 32 (1) : 9 - 17.
2019;2:15.
80. Lee SSY, Mackey DA, Lingham G, Crewe JM, Richards MD, Acknowledgments: Nil
Chen FK, et al. Western Australia Atropine for the Treatment
of Myopia (WA-ATOM) study: Rationale, methodology Conflict of interest: None declared
and participant baseline characteristics. Clin Experiment
Ophthalmol. 2020 Feb 26; Source of Funding: None
81. Kothari M, Rathod V. Efficacy of 1% atropine eye drops in
retarding progressive axial myopia in Indian eyes. Indian J Date of Submission: 24 Jun 2020
Ophthalmol 2017;65:1178-81 Date of Acceptance: 03 Aug 2020
82. Brodstein RS, Brodstein DE, Olson RJ, Hunt SC, Williams RR. The
treatment of myopia with atropine and bifocals.A long-term Address for correspondence
prospective study. Ophthalmology. 1984 Nov; 91(11):1373–9.
83. Atropine eye drops to decrease myopia progression in Rebika Dhiman Assistant Professor
children;CTRI/2016/11/007450.
84. Wan L, Wei CC, Chen CS, et al. The Synergistic Effects of Department of Ophthalmology
Orthokeratology and Atropine in Slowing the Progression of Dr. R. P. Centre for Ophthalmic Sciences
Myopia. J Clin Med. 2018;7(9):259. Published 2018 Sep 7. All India Institute of Medical Sciences
85. Tan Q, Ng AL, Cheng GP, Woo VC, Cho P. Combined Atropine Ansari Nagar, New Delhi, India.
with Orthokeratology for Myopia Control: Study Design and E-mail: [email protected]
Preliminary Results. Curr Eye Res. 2019;44(6):671–8.
86. Lin HJ, Wan L, Tsai FJ, et al. Overnight orthokeratology Quick Response Code
is comparable with atropine in controlling myopia. BMC
Ophthalmol. 2014;14:40.
87. Liang CK, Ho TY, Li TC, et al. A combined therapy using
stimulating auricular acupoints enhances lower-level atropine
eyedrops when used for myopia control in school-aged
children evaluated by a pilot randomized controlled clinical
trial. Complement Ther Med. 2008;16(6):305-310.
88. Kesarwani SS, Mumbai Group of Paediatric Ophthalmologists
and Strabismologists. Consensus statement and guidelines
for use of dilute atropine sulphate in myopia control. Indian J
Ophthalmol. 2019;67(4):461–3.
89. Zloto O, Wygnanski-Jaffe T, Farzavandi SK, Gomez-de-
Liaño R, Sprunger DT, Mezer E. Current trends among
pediatric ophthalmologists to decrease myopia progression-
an international perspective [published correction appears
in Graefes Arch Clin Exp Ophthalmol. 2018 Oct;256(10):2015-

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Review Article

Amblyopia Revisited: Putting The Theoretical Knowledge
To Practical Use

Sahil Panjwani,1 Amritjeet Kaur,2

1Department Of Ophthalmology, Gandhi Medical College, Hyderabad , India.
2Department Of Ophthalmology, Osmania Medical College, Hyderabad, India.

Abstract Amblyopia is one of the most common causes of vision loss in childhood. Conventionally, amblyopia has been considered as
a unilateral visual diminution and hence, most definitions fail to describe the visual acuity in defining bilateral amblyopia .
The mainstay of treatment consists of occluding the sound eye with patches. Choosing the appropriate duration of patching
remains a source of confusion for many clinicians. There are also greatly varied opinions when it comes to deciding the
upper limit of age for which patching is effective. Many clinical trials have been performed to answer these questions.
This article aims to review the current literature regarding the amblyopia definition and treatment strategies to guide the
clinician in diagnoses and management of amblyopia more confidently.

Delhi J Ophthalmol 2021; 32; 18-24; Doi http://dx.doi.org/10.7869/djo.682
Keywords: Amblyopia, Amblyopia Classification, Amblyopia Treatment, Patching, Perceptual Learning, Dichoptic Training.

Introduction Classification

Amblyopia literally means ‘‘dullness of vision’’ (Greek Amblyopia can be classified based on the cause as follows:
ambly dull, + ops, vision, sight).
Strabismic Amblyopia
It is defined as a decrease of visual acuity in one eye when
caused by abnormal binocular interaction or occurring in Patients with strabismus who strongly favour one eye for
one or both eyes as a result of pattern vision deprivation fixation and who have a unilateral rather than an alternating
during visual immaturity, for which no cause can be detected fixation pattern are most likely to acquire strabismic
during the physical examination of the eye(s) and which in amblyopia.6 It is more common in esotropes than in
appropriate cases is reversible by therapeutic measures.1 exotropes. This could be attributed to the fact that exotropia
is often intermittent at its onset. Secondly, in esotropia the
Albrecht von Graefe is said to have defined amblyopia as the fovea of the deviating eye has to compete with the strong
condition in which the observer sees nothing and the patient temporal hemifield (nasal retina) of the fellow eye while in
very little.2 exotropia the fovea competes with the weaker contralateral
nasal hemifield (temporal retina).7 Strabismic amblyopia is
Epidemiology always unilateral and occurs as a result of active inhibition
within the retinocortical pathways of visual input originating
Amblyopia is a growing social burden. It is difficult in the fovea of the deviating eye to avoid diplopia and visual
to measure the frequency of amblyopia in the general confusion.
population. However, many regional and population
specific studies have attempted to estimate the prevalence. Refractive Amblyopia
In a metanalysis, the global prevalence of amblyopia was
estimated to be 1.44%.3 In another study, the prevalence was Refractive amblyopia results from consistent defocus
1.1% of the school children in Southern India.4 of retinal image in one or both eyes. There are 3 types:
Anisometropic, Isoametropic and Meridional.
Pathophysiology
Anisometropic Amblyopia
Amblyopia is primarily a defect of central vision; the
peripheral visual field is usually normal. Abnormal visual In anisometropic amblyopia, dissimilar refractive errors
experiences due to visual deprivation, strabismus, or in the 2 eyes cause the image on 1 retina to be chronically
significant uncorrected refractive errors during the early defocused. This leads to active inhibition of more
postnatal period of cortical development can result in ametropic eye to eliminate sensory interference caused
profound disturbances of neuron function within the visual by superimposition of a focused and a defocused image
system.5 Cells of the primary visual cortex can lose their originating from the fixation point (abnormal binocular
innate ability to respond to stimulation of 1 or both eyes, and interaction). Anisohyperopia > 1.5 D, Anisomyopia of > 3.0
cells that remain responsive can show significant functional D and, Anisoastigmatism > 2.0 D is amblyopiogenic.
deficiencies without significant changes in the retina. The
receptive fields of neurons in the amblyopic visual system Isoametropic Amblyopia
are abnormally large. Abnormalities are also found in
neurons within the lateral geniculate body, but the retina in Isoametropic amblyopia (bilateral ametropic amblyopia) is
amblyopia is essentially normal. a bilateral decrease in visual acuity that results from large,
approximately equal, uncorrected refractive errors in the 2
eyes. The mechanism of this form of amblyopia involves the

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DJO Vol. 32, No. 1, July-September 2021

deleterious effect of blurred retinal images on the immature Table 1. Classification of Amblyopia based on aetiology.

visual system. Hyperopia exceeding 4.00–5.00 D and myopia 1. Strabismic amblyopia

exceeding 5.00–6.00 D carry a risk of inducing isoametropic 2. Refractive amblyopia
a)Anisometropic amblyopia
amblyopia. Meridional Amblyopia b)Isoametropic amblyopia
c)Meridional amblyopia
Meridional amblyopia results from uncorrected bilateral
3. Visual deprivation amblyopia
astigmatism in early childhood leading to a loss of resolving
4. Organic amblyopia
ability limited to the chronically blurred meridians. The
5. Reverse amblyopia
degree of cylindrical isoametropia that produces meridional
6. Idiopathic amblyopia
amblyopia is not known, but most ophthalmologists
Fixation Preference
recommend correction when there is more than 2.00–3.00 D
In preverbal children, with free alternation one may safely
of cylinder. assume that amblyopia is absent. If a patient habitually
prefers one eye for fixation, for instance, if a child repeatedly
Visual Deprivation Amblyopia and strongly objects to having the fixating eye covered but
does not mind if the cover is placed over the deviated eye,
The least common but most severe and difficult to treat of the it is reasonable to assume that visual acuity in the deviated
forms of amblyopia, visual deprivation amblyopia occurs eye is poor.
because of an eye abnormality that obstructs the visual axis or
otherwise interferes with central vision. The common causes Visual Acuity
of visual deprivation amblyopia (also known as amblyopia
ex anopsia) is congenital or early-acquired cataract From a practical clinical standpoint, a difference of 2 or more
blepharospasm, surgical lid closure, unilateral complete lines on Snellen visual acuity chart in unilateral amblyopia
ptosis, corneal opacities, and vitreous haemorrhage. and a visual acuity of 6/12 or worse in bilateral amblyopia
Unilateral visual deprivation amblyopia tends to be worse is commonly used as a diagnostic criterion for amblyopia.
than amblyopia produced by bilateral deprivation of similar However, Paliaga pointed out that any and every difference in
degree, because interocular competition adds to the direct visual acuity produced by amblyopiogenic factors should be
developmental impact of severe image degradation. classified as an amblyopia. Thus, in unilateral cases, a visual
acuity of 6/9 to 6/12 is often considered as mild amblyopia.
Organic Amblyopia Though different studies use different definitions for the
severity, a common description for amblyopia severity is
The term organic amblyopia is applied to reduced visual presented (Table 2).
acuity in the absence of gross, readily detectable anomalies
in an eye with subtle, sub-ophthalmoscopic morphologic Table 2: Classification of Amblyopia based on severity.
retinal damage. This implies that the retina is essentially
normal on ophthalmoscopic evaluation but retinal or
neurological damage is uncovered on further testing.

Reverse Amblyopia Severity Visual acuity
Mild amblyopia 6/9 to 6/12
Reverse amblyopia is a form of visual deprivation amblyopia Moderate amblyopia 6/12 to 6/24
that develops in the fellow eye as a result of patching Severe amblyopia <6/24
(occlusion amblyopia) or penalization.

Idiopathic Amblyopia Crowding Phenomenon

An infrequently occurring and most intriguing form of The inability to discriminate optotypes that are crowded
unilateral amblyopia has been observed in the absence of the together closely is termed as crowding phenomenon or
usual amblyopiogenic conditions and in apparently normal separation difficulties. Most amblyopic eyes seem to have
patients with a negative history for strabismus, uncorrected better single letter acuity than “Snellen” line acuity. This
refractive errors, or visual deprivation.8 As in other forms can be explained based on counter interaction.9 Crowding
of amblyopia, visual acuity improves after patching of phenomenon is not specific to amblyopia.10
the sound eye, but the amblyopia recurs when treatment
is suspended. Von Noorden postulated that binocularly Neutral Density Filters
provoked inhibition has been conditioned during infancy by
an amblyopiogenic factor, such as transient anisometropia Neutral density filters reduce the amount of light reaching
that persists even though this original obstacle to bifoveal the retina. Ammann observed that neutral density filters
fusion is no longer evident (Table 1). reduce vision in eyes with central retinal lesions and
glaucoma, whereas the vision of eyes with amblyopia was
Evaluation not reduced by such filters and was occasionally even slightly
improved.11 This Ammann phenomenon demonstrates
Amblyopia is diagnosed when a patient has a condition known the relative increase in mesopic visual acuity compared to
to cause amblyopia and has decreased visual acuity that photopic conditions in eyes with strabismic amblyopia.12
cannot be fully explained by physical abnormalities of the eye.

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DJO Vol. 32, No. 1, July-September 2021

Near Visual Acuity in the amblyopic eye visual acuity plateaus, is a practical
schedule for monitoring children for an optical treatment
Visual acuity at near fixation has been found to be better effect.
than at distance fixation in a number of amblyopes.13,14

Fixation Pattern Limiting the Use of Better Eye: When patients do not respond
to refractive correction alone, or VA ceases to improve, the
Many patients with strabismic amblyopia have eccentric amblyopic eye can be forced to fixate by limiting the use of
fixation. Such patients do not assume central fixation when better eye in following ways:
the fellow eye is covered.15,16

Colour Vision 1 Occlusion therapy (patching)
2 Pharmacological penalisation
Colour sense in amblyopic eyes is often abnormal, especially 3 Bangerter filters
when the amblyopia is severe. However, the colour vision
defect resembles one detected in normal eyes when eccentric Patching: Occlusion of the sound eye with adhesive patches,
retinal areas are being tested.17,18
or spectacle mounted occluders to obligate the use of

Contrast Sensitivity amblyopic eye. Duration

Contrast sensitivity measured with an alternating pattern of How long to patch? 2 hours of daily patching is as effective

black and white stripes (gratings) of variable width (spatial as 6 hours of daily patching for moderate amblyopia (VA of

frequency) is decreased in amblyopes, especially at higher 6/12 to 6/24 or 20/40 to 20/80).28

frequency.19,20,21,22,23 Treatment 6 hours of daily patching is as effective as full-time daily

patching in severe amblyopia (VA of 6/30 to 3/60 or 20/100

Treatment of Amblyopia involves following steps: to 20/400).29

1 Treat the cause of visual deprivation In case of residual amblyopia after 12 weeks of 2 hours
2 Correct any significant refractive errors patching, increasing the duration to 6 hours led to further
3 Force the use of amblyopic eye by limiting use of the improvement in 40% of children.30

better eye

Treatment of Cause: Prompt removal of corneal and Patching Age Group:
lenticular opacities is advocated to prevent visual Till what age patching is effective? 76-93% children
deprivation amblyopia. Correction of significant degree of responded to in the age group 3 to <7 years in different
strabismus helps in achieving binocular single vision (BSV) amblyopia types with different patching schedule. [28,29]
and eliminate the cause of strabismic amblyopia. 53% children responded to patching in age group 7 to 12
years.31

Refractive Correction: Guidelines based on the results of 25% children responded overall to patching in age group 13
Amblyopia Treatment Studies (ATS) conducted by Paediatric to 17 years. In the same group, response was seen in 47%
Eye Disease Investigator Group (PEDIG): among patients not previously treated.

Full correction of astigmatism, myopia and anisometropia to Pharmacological Penalisation: Pharmacological
provide equally clear retinal images.24
Hyperopia is either fully corrected (e.g., in cases of esotropia) penalisation is carried out by instilling a long-acting topical
or under corrected (e.g., in cases without esotropia) by
no more than +1.5 D spherical equivalent (SE) with any cycloplegic agent, atropine sulphate (1%), into the sound eye
reduction in plus sphere reduced symmetrically in the two
eyes. of a child with amblyopia.

Two ATS studies in 3 to <7 years children have shown that Conclusions from various studies:
refractive correction alone can lead to mean amblyopic eye In moderate amblyopia, pharmacological penalisation
visual acuity (VA) improvement by approximately 3 lines with daily administration of 1 drop of 1% atropine in the
and resolution of amblyopia (equal visual acuity in both sound eye showed similar improvement to 6 hours of daily
eyes or amblyopic eye visual acuity within 1 line of sound patching in children 3 to < 7 years old.32
eye visual acuity) occurred in 25-33% of cases.25,26
VA improvement was slower with atropine penalisation
compared to patching, but the magnitude of VA improvement
at 6 months was similar.

Another study in 3 to <10 years old children concluded the A slightly higher degree of acceptability was reported with
mean improvement in binocular VA of approximately 4 atropine treatment compared to patching. Less frequent
lines.27 administration of 1% atropine drops (weekly once) led to
essentially identical improvement in VA (2.3 lines).33

A follow-up interval of 6 to 8 weeks, until improvement

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DJO Vol. 32, No. 1, July-September 2021

In case of severe amblyopia of 20/125 to 20/400, weekend Figure 1 : Amblyopia Treatment Algorithm Flowchart for Clinical Practice.
atropine administration led an average VA improvement of
4.5 to 5.1 lines in the age group 3 to <7 years, and 1.5 lines in of these visual tasks improves visual performance.
the age group 7 to 12 years.34 These include the following :-

Systemic side effects of Atropine: Dryness, flushing of skin, Vernier Acuity Tasks : these measures the ability to find a
fever, confusion, unusual behaviour, and irritability rarely misalignment among 2 line segments or gratings. It can be
occurred during ATS. When such side effects occur, daily tested unilocular or binocularly.
instillation of 5% homatropine eye drops can be substituted
for atropine. Gabor Patch Detection : A gabors patch consist of a sine
wave grating seen through a gaussian window. The gaussian
Bangerter Filter Treatment: A Bangerter filter is a translucent window eliminates the “sharp edges”, so the change at the
filter that is applied to the sound eye’s spectacle lens for full edges of the grating is not as abrupt so that the waves are
time wear for amblyopia treatment. Different densities of detected instead of the sharp edges.These gabor patches are
filters produce different degrees of defocus. known to match the receptive field properties of the primary
visual cortex.
Full-time wear of Bangerter filter provided VA improvement
(1.8 lines) similar to 2 hours of daily patching (2.3 lines).35 Contrast Detection Or Discrimination : In this visual task,
Parents reported fewer adverse effects and better compliance the observers report which of the two stimuli appears to
with the Bangerter filters than with patching. have a higher contrast.

Clinical Relevance Letter Identification In Noise : In this does the patient is
asked to find a target letter or an object which is hidden
From the preceding discussion, following points can be among the various distractors or in noise.
concluded for clinical practice:
Perceptual Learning Helps in improvement of the specific
A trial of patching should be provided to all children, visual function which is required in the respective task and
irrespective of the age group. also the improvement in the snellen's visual acuity.It has

A 2-hour patching schedule is recommended for initial
therapy, increasing to 6 hours in case of inadequate response.
Alternatively, weekly once atropine penalisation can be
substituted for inadequate response or as initial therapy in
children with poor compliance to patching.
This has been summarised in an algorithmic flow chart for
clinical use (Figure 1).

Recent Advances In Amblyopia Management

The recent advances in amblyopia therapy can be divided
into binocular therapies and pharmacological therapies.

Binocular Therapies

In amblyopia the stereo equity is reduced and there is
abnormal binocular summation.36 But some amount of
binocular cortical communication still persist in amblyopia.37
The hypothesis for binocular therapies is to stimulate these
persistent binocular neural circuits and thereby "awaken
"the amblyopic eye.38,39 The two types of binocular therapies
are:-

1 Perceptual learning
2 Dichoptic training.

Perceptual Learning

In 1963, Eleanor Gibson introduced the term perceptual
learning which refers to long-lasting changes in perception
that results from practice or experience.40 In simple words,
perceptual learning works on the principle that practice
makes perfect. A number of visual tasks have been developed
as a means to apply perceptual learning. Repeated practice

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DJO Vol. 32, No. 1, July-September 2021

also shown reduction in the crowding phenomena due to results in adult amblyopes and therefore give a potential for
reduction in lateral inhibition within the brain improvement of amblyopia outside the critical period.43,44
The drawback of perceptual learning is that most of the
studies which favoured perceptual learning work done in a Recently, the dichoptic training has shifted from being
very small sample and long-term follow-up for the efficacy clinically based to home-based training. Binocular iPad
of the therapy is lacking. Moreover, the efficacy of this therapy involves using iPad display with lenticular overlay
therapy was established in laboratory settings only and not for the purpose of dichoptic training. It consists of a textured
in real life situations (Figure 2,3, and 4).41 screen overlay of two slightly dissimilar images which when
fused gives a perception of depth (example :holograms). The
Figure 2: Vernier Acutit Testing. only difficulty with the lenticular design is that it needs stable
head positioning and therefore it is difficult to use in young
Figure 3: GABORS PATCH which is seen through a gausian window showing children and unsupervised patients.45 This has resulted in
nonsharp margins. a recent shift from the lenticular design to the anaglyphic
designs. It utilizes anaglyphic images i.e red green dichoptic
Figure 4:- Gabor patches. images with accompanying red green glasses in the form of
various iPad games. The falling block game was developed
Dichoptic Training using the same principle however there was poor compliance
associated as the game was not stimulating enough to allow
Unlike in perceptual learning where a single visual stimulus the effective playing time.There is a need for more engaging
is administered to both eyes simultaneously; in dichoptic games with reward reinforcement in order to develop
training ,independent and visually different stimulus is interest and increase the playing time.46
presented to each eye. Therefore, for the completion of
dichoptic training; integration of the these uniocular stimuls Interactive binocular treatment system (I-BiT) is used for
under binocular viewing system is important.As the patient treatment of amblyopia via virtual reality games and movie
utilizes his binocular apparatus; dichoptic training helps watching. This special software selectively stimulates the
the patient to overcome the suppression of amblyopic eye. amblyopic eye without compromising the fellow eye visual
The stimulus which is shown to amblyopic eye usually has acuity.47
a higher contrast than shown to the non amblyopic fellow
eye.42 As the binocular function improves, the contrast is Pharmacological Therapy
gradually reduced still no difference exist between the two
eyes. Early studies of dichoptic training showed promising The pharmacological therapy /drug therapy was developed
to treat amblyopia in children for whom the conventional
treatment has failed and for those outside the critical period
of amblyopia. The two major drugs which have been
investigated for pharmacological therapy of amblyopia are
levodopa-carbidopa and citicholine.

Levodopa-Carbidopa

It is hypothesized that the retinal levels of dopamine are
decreased in amblyopia.48 Therefore increasing the level of
dopamine can improve vision in the context of amblyopia.
Levodopa is an immediate precursor of Dopamine and is
FDA approved for use in neurology as a neuroprotective
agent. Carbidopa is a peripheral decarboxylase inhibitor
which prevents conversion of levodopa to dopamine,
thereby increasing the availability of levodopa in the central
nervous system.

PEDIG investigators conducted a randomised controlled
trial of levodopa in treatment of residual amblyopia after
patching in children of age group 7 to 12 years.49 They
found daily administration of oral levodopa ( 0.76 mg/kg )
with carbidopa( 0.17mg/kg) three times/ day for 16 weeks
in addition to continued two hours of patching produced
no clinically or statistically significant improvement in
visual acuity compared with placebo and patching. Another
prospective study was conducted on 19 patients in the age
group 7 to 30 years, who were subject to treatment with
Levodopa and Carbidopa on doses of 0.7mg/kg/day, a ratio
of 4:1 divided into three daily doses for 5 weeks, combined

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DJO Vol. 32, No. 1, July-September 2021

with full occlusion (24 hours/day) of the dominant eye.50 patching. Medical management of amblyopia is yet to yield
The study reported a significant improvement on the visual convincing results but the future prospect is exciting.
acuity of the amblyopic eye, which persisted up to 1 year
after the treatment. Levodopa was also found to be effective References
in treatment of amblyopia in adults in a dose of 2 mg/kg/
dose for 6 weeks.51 1. Noorden GK. Mechanisms of amblyopia. Doc Ophthalmol
1977;34:93.
Levodopa is usually given along with carbidopa in a 4:1 dose
ratio either as oral tablet or oral suspension. 0.5 - 2 mg/kg/ 2. Revell MJ: Strabismus. A History of Orthoptic Techniques.
dose thrice a day is considered a safe and effective dose.[51] London, Barrie & Jenkins, 1971 p 164.

Levodopa is available as liquid suspension but has an 3. Fu Z, Hong H, Su Z et al. Global prevalence of amblyopia and
unpleasant taste. Its side effects include mild nausea disease burden projections through 2040: a systematic review
vomiting and headache. The gastrointestinal side effects can and meta-analysis. Br J Ophthalmol. Published Online First: 08
be reduced by adding carbidopa to levodopa. As carbidopa November 2019.
cannot cross the blood brain barrier, it inhibits the peripheral
conversion of levodopa to Dopamine, thereby preventing its 4. Ganekal S, Jhanji V, Liang Y et al. Prevalence and etiology of
side effects. amblyopia in Southern India: results from screening school
children aged 5-15 years. Ophthalmic epidemiol. 2013;20(4):228-
Citicholine 31.

Citicholine (Cytidine-5-diphosphocholine) or CDP- 5. Hered RW, Archer SM, Braverman RS et al. Amblyopia.
choline is a complex bimolecule involved in cellular In: Cantor LB, Rapuano CJ, McCannel CA. Paediatric
metabolism. Citicoline activates the biosynthesis of Ophthalmology and Strabismus. San Francisco: American
structural phospholipids in the neuronal membranes, Academy of Ophthalmology; 2019. P 79-86. (Basic and Clinical
increases brain metabolism, and influences the levels of Science Course; vol 6).
different neurotransmitters. It has been shown to increase
acetylcholine, norepinephrine, and dopamine levels in the 6. Noorden GK, Campos EC. Examination of the patient-IV:
central nervous system.52 It is usually used to prevent nerve Amblyopia. In: Lampert R, editor. Binocular Vision and ocular
damage and allowed recovery from traumatic , ischemic motility: Theory and management of strabismus. 6th ed.
and degenerative insults.53 Intramuscular CDP-choline (1 g/ Missouri: Mosby Inc; 2002. p 246-287.
day) for 15 days has been shown to improve visual acuity,
contrast sensitivity and VEP amplitudes in both normal 7. Fahle M. Naso-temporal asymmetry of binocular inhibition.
and Amblyopic eyes.54 Campos et al. reported a statistically Invest Ophthalmol Vis Sci 1987;28:1016.
significant improvement in VA following treatment with
citicoline (1000 mg intramuscular administration, daily for 8. Noorden GK. Idiopathic amblyopia. Am J Ophthalmol
15 days) in older children, and found that significant visual 1985;100:214.
improvement occurred in both amblyopic and sound eye,
which remained stable for at least 4 months after stopping 9. Flom MC, Weymouth FW, Kahneman D. Visual resolution and
the treatment.55 Pawar et al. used oral citicholine in the dose contour interaction. J Opt Soc Am 1963;53:1026.
of 250 mg OD (age <5 years) and 500 mg OD (age >5 years)
for 6 months. After this period, citicholine was gradually 10. Morad Y, Werker K, Nemet P. Visual acuity tests using chart,
tapered by giving half the dose daily for 2 months, half line, and single optotype in healthy and amblyopic children. J
the dose on alternate days for another 2 months and then AAPOS 1999;3:94.
discontinued. The study concluded that improvement in
visual acuity with citicoline plus patching was significantly 11. Ammann E. Einige Beobachtungen bei den Funktionspru
more than that with patching alone, in one year of treatment. ¨fungen in der Sprechstunde: ‘‘Zentrales’’ Sehen— Sehen
der Glaukomato ¨sen Sehen der Amblyopen. Klin Monatsbl
The research work in citicholine ,however lacks behind Augenheilkd 1921;67:564.
that of levodopa. More long-term follow-up is necessary to
establish long term efficacy in citicholine. 12. Hess RF, Howell ER. The luminance-dependent nature of
the visual abnormality in strabismic amblyopia. Vision Res
Conclusion 1978;18:931.

Amblyopia is a significant cause of diminished vision in 13. Cuppers C. Some reflections on the possibility of influencing the
children. Early diagnosis and treatment are the mainstay of pathological fixation act. Ann R Coll Surg Engl 1966;38:308.
management. Previous experience based empirical practice
of full-time patching has given way to new evidence-based 14. Noorden GK, Frank JW. Relationship between amblyopia and
part-time patching practices. Pharmacological penalisation the angle of strabismus. Am Orthopt J 1976;26:31.
and Bangerter filters provide important alternatives to
15. Bangerter A. Amblyopiebehandlung. 2nd ed. Basel: Karger
publishers;1955.

16. Noorden GK. Pathophysiology of amblyopia. Diagnostic and
therapeutic principles of pleoptics. Am Orthopt J 1960;10:7.

17. Francois J, Verriest G: La discrimination chromatique dans
l’amblyopie strabique. Doc Ophthalmol 1967;23:318.

18. Marre M, Marre E. Colour vision in squint amblyopia. Mod
Probl Ophthalmol 1978;19:308.

19. Mayer L, Fulton A, Rodier D. Grating and recognition acuities of
pediatric patients. Ophthalmology 1984;91:947.

20. Moseley MJ, Fielder AR, Thompson JR. Grating and recognition
acuities of young amblyopes. Br J Ophthalmol 1988;72:50.

21. Bradley A, Freeman RD. Contrast sensitivity in anisometropic
amblyopia. Invest Ophthalmol Vis Sci 1981;21:467.

22. Campbell FW. Why do we measure contrast sensitivity? Behav
Brain Res 1983;10:87.

23. Hess RF, Campbell FW, Creenhalgh T. On the nature of the
neural abnormality in human amblyopia. Neural aberrations
and neural sensitivity loss. Pflugers Arch. 1978;377:201.

24. Chen AM, Cotter SA. The amblyopia treatment studies:
implications for clinical practice. Adv Ophthalmol Optom.
2016;1(1):287–305.

25. Cotter SA. Treatment of anisometropic amblyopia in children
with refractive correction. Ophthalmology. 2006;113:895–903.

E-ISSN: 2454-2784  P-ISSN: 0972-0200 23 Delhi Journal of Ophthalmology

DJO Vol. 32, No. 1, July-September 2021

26. Cotter SA, Foster N. Optical treatment of strabismic and Treatment of refractory amblyopia with levodopa associated
combined strabismic-anisometropic amblyopia. Ophthalmology. with full-time occlusion in the dominant eye. Rev bras oftalmol
2012;119:150–8. [Internet]. 2019 Dec [cited 2021 Jan 03] ; 78( 6 ): 389-393.
51. Bogdanici C, Bogdanici T, Moraru A, Costin D, Feraru C.
27. Wallace DK, Chandler DL, Beck RW et al. Treatment of bilateral Levodopa as Treatment for Adults with Amblyopia. Rev. Chim.
refractive amblyopia in children three to less than 10 years of [internet]. 2017 Jul;68(7):1595-1597. Available from: https://doi.
age. Am J Ophthalmol. 2007; 144:487–96. org/10.37358/RC.17.7.5724
52. Pawar PV, Mumbare SS, Patil MS, Ramakrishnan S.
28. Repka MX, Beck RW, Holmes JM et al. A randomized trial of Effectiveness of the addition of citicoline to patching in the
patching regimens for treatment of moderate amblyopia in treatment of amblyopia around visual maturity: A randomized
children. Arch Ophthalmol. 2003;121:603-11. controlled trial. Indian J Ophthalmol [serial online] 2014 [cited
2021 Jan 4];62:124-9. Available from: https://www.ijo.in/text.
29. Holmes JM, Kraker RT, Beck RW et al. A randomized trial of asp?2014/62/2/124/128586
prescribed patching regimens for treatment of severe amblyopia 53. Pescosolido N , Stefanucci A , Buomprisco G , et al . Amblyopia
in children. Ophthalmology. 2003; 110:2075–87. treatment strategies and new drug therapies. J Pediatr
Ophthalmol Strabismus 2014;51:78–86.
30. Wallace DK, Lazar EL. A randomized trial of increased patching 54. Porciatti V, Schiavi C, Benedetti P, Baldi A, Campos EC.
for amblyopia. Ophthalmology 2013;120:2270S–77S. Cytidine-5’-diphosphocholine improves visual acuity, contrast
sensitivity and visually-evoked potentials of amblyopic subjects.
31. Scheiman MM, Hertle RW, Beck RW et al. Randomized trial Curr Eye Res. 1998;17:141–8.
of treatment of amblyopia in children aged 7 to 17 years. Arch 55. Campos EC, Schiavi C, Benedetti P, Bolzani R, Porciatti V. Effect
Ophthalmol. 2005;123:437–47. of citicoline on visual acuity in amblyopia: Preliminary results.
Graefes Arch Clin Exp Ophthalmol. 1995;233:307–12.
32. Glaser SR, Matazinski AM, Sclar DM et al. A randomized trial
of atropine vs patching for treatment of moderate amblyopia in Cite This Article as: , Sahil Panjwani, Amritjeet Kaur.
children. Arch Ophthalmol. 2002;120:268–78. Amblyopia Revisited: Putting the Theoretical Knowledge to
Practical Use. Delhi J Ophthalmol 2021 ; 32 (1) : 18 -24
33. Repka MX, Cotter SA, Beck RW et al . A randomized trial of
atropine regimens for treatment of moderate amblyopia in Acknowledgments: Nil
children. Ophthalmology. 2004;111:2076–85.
Conflict of interest: None declared
34. Repka MX, Kraker RT, Beck RW. Treatment of severe amblyopia
with weekend atropine: results from 2 randomized clinical trials. Source of Funding: None
J AAPOS. 2009;13:258–63.
Date of Submission 06 Nov 2020
35. Rutstein RP, Quinn GE, Lazar EL et al. Bangerter Filters and Date of Acceptance: 28 Dec 2020
patching for the treatment of moderate amblyopia in children.
Ophthalmology. 2010;117:998–1004. Address for correspondence
Sahil Panjwani, MS
36. Hess RF , Thompson B . Amblyopia and the binocular approach
to its therapy. Vision Res 2015;114:4–16 Department of ophthalmology,
Gandhi medical college,
37. Thompson B , Richard A , Churan J , et al . Impaired spatial and hyderabad , india.
binocular summation for motion direction discrimination in Email: [email protected]
strabismic amblyopia. Vision Res 2011;51:577–84
Quick Response Code
38. Joly O , Frankó E . Neuroimaging of amblyopia and binocular
vision: a review. Front Integr Neurosci 2014;8:62

39. Hess RF , Thompson B , Baker DH . Binocular vision in
amblyopia: structure, suppression and plasticity. Ophthalmic
Physiol Opt 2014;34:146–62.

40. Gibson EJ . Perceptual learning. Annu Rev Psychol 1963;14:29–56
41. Qu Z , Song Y , Ding Y . ERP evidence for distinct mechanisms

of fast and slow visual perceptual learning. Neuropsychologia
2010;48:1869–74
42. Mansouri B , Thompson B , Hess RF . Measurement of
suprathreshold binocular interactions in amblyopia. Vision Res
2008;48:2775–84.
43. Hess RF , Babu RJ , Clavagnier S , et al . The iPod binocular
home-based treatment for amblyopia in adults: efficacy and
compliance. Clin Exp Optom 2014;97:389–98.
44. Li J , Thompson B , Deng D , et al . Dichoptic training enables the
adult amblyopic brain to learn. Curr Biol 2013;23:R308–R309.
45. To L , Thompson B , Blum JR , et al . A game platform for
treatment of amblyopia. IEEE Trans Neural Syst Rehabil Eng
2011;19:280–9.
46. Gao TY , Guo CX , Babu RJ , et al . . Effectiveness of a Binocular
Video Game vs Placebo Video Game for Improving Visual
Functions in Older Children, Teenagers, and Adults With
Amblyopia: A Randomized Clinical Trial. JAMA Ophthalmol
47. Eastgate RM , Griffiths GD , Waddingham PE , et al . Modified
virtual reality technology for treatment of amblyopia. Eye
2006;20:370–4.
48. Iuvone PM , Tigges M , Fernandes A , et al . Dopamine synthesis
and metabolism in rhesus monkey retina: development, aging,
and the effects of monocular visual deprivation. Vis Neurosci
1989;2:465–71.
49. Repka MX , Kraker RT , Dean TW , et al . Pediatric Eye Disease
Investigator Group. A randomized trial of levodopa as treatment
for residual amblyopia in older children. Ophthalmology
2015;122:874–81
50. Ribeiro MZ, Lucena AR, Dutra BA, Crispim J, Travassos SB.

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DJO Vol. 32, No. 1, July-September 2021

Review Article

A to Z of ReLEx SMILE: All you need to know

Sanjana Vatsa, Pallavi Dhawan, Shana Sood

Department of Cornea and Refractive Services, Dr. Agarwal’s Eye Hospital, Bangalore, India.

Abstract ReLEx SMILE (Refractive lenticule exchange - Small incision lenticule extraction) is a new generation of laser vision
correction, performed using the Visumax femtosecond laser system (Carl Zeiss Meditec AG, Jena, Germany) for
the correction of myopia and myopic astigmatism. It ensures greater biomechanical stability, lesser chances of dry
eyes and predictable visual and refractive outcomes, making it the procedure of choice for myopic corrections. This
article explains in detail regarding the pre-operative work up, steps of the surgical procedure, laser parameters,
intra-operative complications such as suction loss, opaque bubble layer, dark spots, cap tear, lenticular adhesion
and post-operative complications such as interface haze, interface debris, diffuse lamellar keratitis etc. and their
management. The learning curve of SMILE being steeper than that of LASIK, well experienced surgeon and a well
co-operative patient would ensure better surgical outcomes, minimising the complications. It also briefly explains
about the options available for enhancement post SMILE.

Delhi J Ophthalmol 2021;32; 25-31; Doi http://dx.doi.org/10.7869/djo.683

Keywords: SMILE, Laser Refractive Procedure, Femtosecond Laser, Visumax, Myopia.

Introduction Pre Operative Counselling

The first report of refractive intrastromal lenticule extraction Patient is adequately counselled about the procedure and
was published in 1996 with the use of picosecond (10-12) an informed consent is taken. Topical anaesthetic drops
lasers.1 Femtosecond laser assisted refractive lenticule (proparacaine 0.5%) are instilled to both the eyes. Excessive
extraction procedure using the Intralase machine (Abott use of topical anaesthetic is avoided as it may loosen the
Medicals Optics, USA) was published years later in 2003.2 epithelium and in-turn affect the femtosecond laser delivery
Femtosecond laser offers a unique edge over other lasers resulting in black spots and thus difficult dissection.
as it has better precision and less collateral damage. This
technique was perfected and the VisuMax femtosecond Surgical Procedure

laser system (Carl Zeiss Meditec AG, Jena, Germany) was It involves 4 important steps - Docking, femtosecond laser
developed, which delivers fixed patterns of femtosecond delivery, lenticule dissection and lenticule extraction.
laser pulses to create an intrastromal refractive lenticule at

a particular depth along with side cuts at desired positions a. Docking
and works by the principle of photo-disruption. The patient is made to lie down supine on the operating

SMILE (Small Incision Lenticule Extraction) is the most table. The docking cone is attached to the femtosecond
advanced refractive surgery for the correction of myopia laser delivery system. Selection of the cone depends on
and myopic astigmatism, with a high level of safety, the corneal white-to-white diameter (Figure 1, 2). The eye

efficacy and precision.Unlike LASIK, SMILE is a bladeless

procedure with a small incision of 2-4mm, with lesser

incidence of symptomatic dry eyes post surgery because

of better preservation of corneal innervation.3,4,5 Due to the

pattern of arrangement of the corneal lamellae, a vertical cut

causes more loss of tensile strength than a parallel cut. The

vertical cut in LASIK is almost 270 degrees, while the side

cut in SMILE is only 40 degrees causing lesser disturbance

of corneal biomechanics and thereby providing better

biomechanical stability.6,7

Pre Operative Evaluation Figure 1: Suction cone

• Uncorrected distance visual acuity (UCVA), corrected

distance visual acuity (CDVA) and vision with pinhole

• Manifest and cycloplegic refraction

• Intraocular pressure measurement by Non contact

tonometry

• Slit lamp biomicroscopy

• Dilated fundus examination

• Dry eye assessment (Schirmer's I and II)

• Topography with Pentacam

• Aberrometry

• Specular microscopy

• Anterior segment OCT (if available) Figure 2: Under surface of the Suction cone

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DJO Vol. 32, No. 1, July-September 2021

to be operated is positioned under the cone and patient is Figure 5: Suction bar indicating the level of suction
asked to fixate on the green blinking light (Figure 3). The
bed is moved up till the curved contact glass interface
applanates the corneal surface (Figure 4). Excess saline in the
conjunctival sac is removed. Once the contact lens touches
the cornea, a meniscus tear film appears and the fixation
light becomes clearly visible to the patient. Care is taken to
make sure that it is purely a corneal suction and that there
is no conjunctival tissue prolapse into the cone. The patient
is asked to focus on the green light and suction is activated

Figure 3: Fixation light

Figure 6: Stage of lenticule creation

Figure 4: Docking Figure 7: Completion of lenticule side cut and beginning of cap formation
Figure 8: Completion of anterior cap formation
(Figure 5). The treatment is centred on the coaxial corneal
light reflex (CCLR) and the centration is confirmed using
the infrared light. The suction achieved is gentle and the
maximum suction pressure generated by the VisuMax laser
system is approximately 30-35 mmHg.8 In cases where there
is significant preoperative astigmatism (>0.75D), manual
compensation for cyclotorsion may be performed by gently
rotating the cone after activation of suction and aligning it to
0°-180° axis.9

b. Femtosecond Laser Delivery
The VisuMax laser system delivers femtosecond laser pulses
at a wavelength of 1,043 nm and frequency of 500 kHz to
create an intrastromal refractive lenticule.8 The posterior
surface of the lenticule is created first in a spiral in fashion
followed by the creation of side-cut and then the anterior cap
creation occurs in a spiral out fashion. Finally a 2 – 4 mm
incision is created superiorly.10 (Figure. 6, 7, 8, 9)

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DJO Vol. 32, No. 1, July-September 2021

Figure 9: Incision creation Figure 10: Delineation of the anterior plane
Figure 11: Delineation of the posterior plane
Conventionally, the treatment parameters are set at an
anterior cap depth of 120 µm (range 100–160 µm) and Figure 12: Gas bubble escape sign
minimum lenticule thickness at edge of 15 µm (ranging from
10– 30µm), optical zone ranging from 6.0 – 7.0 mm with no Figure 13: Before the escape of gas bubbles
transition zone for spherical errors and 0.10 mm transition
zone for astigmatism. The cap diameter is set to 1 mm larger Delhi Journal of Ophthalmology
than the lenticule diameter. The pulse energy is set between
100 and 160 nJ. Total suction time is approximately 25–35
seconds (depending on the mode used). Laser parameters
in various treatment modes are as shown in the table below
(Table 1).11

Table 1: Laser Parameters In Various Treatment Modes

Laser Expert Mode Standard Mode Fast Mode

Parameters

Pulse energy 140–200 nJ 130 nJ 170 nJ

Energy 28–40 26 34
offset(1 offset

= 5 nJ)

Track Lenticule Lenticule and Lenticule and

distance (µm) and cap: 4.50 cap: 3.00 cap: 4.50

Lenticule Lenticule side Lenticule and

side and cap and cap side cut: cap side cuts:

side cut: 2.00 2.00 2.00

Spot distance Lenticule Lenticule and Lenticule and

(µm) and cap: 4.50 cap: 3.00 cap: 4.50

Lenticule Lenticule side Lenticule side

side and cap and cap side cut: and cap side

side cut: 2.00 2.00 cut: 2.00

c. Lenticule Dissection
The incision is opened and the edge of the lenticule is
identified by delineating the anterior and posterior planes
(Figure.10, 11). The anterior lenticular plane is separated from
the overlying cap by blunt lamellar dissection, followed by
the posterior plane dissection. A small peripheral area is left
un-dissected till the end to provide counter-traction during
posterior plane dissection and to prevent the lenticule from
folding on to one side.

Gas Bubble Escape Sign (GBE)

The GBE sign refers to the escape of gas bubbles on
delineation of the lenticular planes, followed by an
immediate improvement in the clarity of the interface
(Figure 12, 13, 14). A study by Ganesh et al. showed that GBE
sign indicates an optimized laser energy pattern, which may

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DJO Vol. 32, No. 1, July-September 2021

Figure 14: Increase in the clarity of the interface after the escape of gas Intraoperative Complications
bubbles
1. Suction Loss
Figure 15: Extraction of separated lenticule using lenticule forceps Risk factors: Deep set eyes, narrow palpebral fissure,
excessive eyelid squeezing, flat keratometric power, loose
ease the lenticular dissection and thus provide better quality corneal epithelium, excessive reflex tearing, patient’s
of vision in the immediate post-operative period.12 inability to maintain fixation or follow instructions.17,18

d. Lenticule Extraction Patient should be well counselled pre-operatively to fixate
After making sure that the lenticule is well separated and is on the green light and avoid any eye movements or head
free from all sides, it is extracted through the small incision movements. A self-retaining speculum should be inserted to
using a microforceps. After extraction, the lenticule is spread ensure adequate exposure. Excess fluid in the conjunctival
out over the surface of the cornea and is examined for its sac should be cleared before docking. The presence of a fluid
completeness (Figure 15) meniscus in the periphery after docking is a sign of imminent
Currently, ReLEx SMILE corrects myopia of up to −10.00 D, suction loss and it is advisable to release the suction and re-
myopic astigmatism up to −5.00 D and a spherical equivalent dock in such cases to prevent intra-operative complications.
(SE) of up to −12.5 D.13,14 The management of suction loss depends on the stage at
which it occurs. If it occurs at the stage where more than
Visual Recovery After Smile 10% of lenticule has been formed, SMILE procedure is
abandoned and is converted to LASIK. However, at all other
Although visual outcomes have been good after SMILE, stages re-docking can be done and can proceed with SMILE
visual recovery is relatively slower compared to LASIK. The by reducing the lenticule diameter and cap diameter by 0.2-
backscattered light intensity is seen to be higher in SMILE 0.4mm.
due to the activated keratocytes, extracellular matrix and
irregularity of the interface which may be attributed to the 2. Vertical Gas Breakthrough
slower visual recovery.15 This may occur if there is a focal break or a scar in the
bowman’s layer and in cases of epithelial basement membrane
Post-Operative Dryness dystrophy.19,20 Gas bubbles created during cap/ lenticule
creation can track through anterior corneal scars onto the
Reinstein et al. found that corneal sensation was reduced in surface of cornea. These bubbles can block the successive
the early postoperative period after SMILE, but recovered to laser pulses leading to incomplete lenticule creation in the
baseline in 89% of the eyes by 6 months.16 area of gas bubble and thus causing difficult dissection
intra-operatively and can also lead to the formation of a
buttonhole which can cause post-operative complications
such as epithelial in-growth and scarring.21 Surface ablative
procedures can be considered for the correction of refractive
error at a later date after ensuring complete healing of the
buttonhole.22

3. Opaque Bubble Layer (OBL)
OBL is formed when excess of gas and water bubbles get
trapped between the stromal lamellae, unable to pass
uniformly through the lamellar interface, which in turn
makes the lenticular dissection difficult (Figure 16). It can

Figure 16: Opaque bubble layers (OBL)

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DJO Vol. 32, No. 1, July-September 2021

Figure 17 : Dark spots Figure 19 : Epithelial defect near the incision site

Figure 18 : Dark spots Figure 20 : Cap tear

be observed in cases with too high or too low laser energy Figure 21: Lenticule tear during extraction
settings. Risk factors include thicker corneas and older
patients with denser peripheral collagen that prevent the 19). This can be prevented by limiting the use of anaesthetic
escape of gas bubbles.23 drops. A bandage contact lens is placed postoperatively till
the epithelium heals.25
4. Dark Spots
Debris/meibomian secretions entrapped between the contact 7. Cap Tear
glass and the cornea causes incomplete laser delivery in that Cap tear can occur in the hands of an in-experienced surgeon,
area resulting in the formation of dark spots and subsequent due to micro-adhesions and/or excessive intra-operative
difficult dissection. (Figure 17, 18) Care should be taken to manipulation (Figure 20). Small tears usually heal well,
dissect the area gently to prevent lenticular tear. whereas larger tears extending upto the visual axis can affect
visual outcomes. It is advisable to place a bandage contact
5. Cap Lenticular Adhesion lens until the tear heals, in addition to frequent lubrication.
It results from an inadvertent dissection of the posterior
lenticular plane before separating the anterior surface
from the overlying cap. Care should be taken to carefully
delineate the anterior plane and dissect it completely to
ensure complete separation of the cap from the underlying
lenticule. Improper management of cap lenticular adhesion
can lead to suboptimal visual outcomes with an increased
incidence of cap tears, side-cut tears, retained lenticular
fragments and iatrogenic damage to the corneal stroma.24

6. Epithelial Defects
Excessive use of topical anaesthetic drops can cause
iatrogenic loosening of the epithelium, which in-turn can
cause epithelial defect during lenticule dissection (Figure

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DJO Vol. 32, No. 1, July-September 2021

8. Lenticule Tear Figure 22: Interface debris
This occurs in an attempt to pull the lenticule without
dissecting it completely from all sides, more so in cases meibomian secretions, surgical debris into the interface
of low myopic correction where the lenticule is very have been attributed to this condition. The incidence of DLK
thin and can inadvertently tear during dissection or following SMILE has been reported as between 0.04 and
removal (Figure 21). Care should be taken to ensure 1.6 percent.28,29 Zhao et al. found that DLK was associated
complete dissection and separation of lenticule from with larger lenticular diameter and thinner lenticules.24 The
all sides before pulling it out through the incision. proximity of the larger diameter lenticules to the limbus and
limbal vasculature may cause more inflammatory reaction.
Post Operative Complications Thinner lenticules may represent a greater technical
challenge increasing the intra‐operative manipulation and
1. Interface Haze thereby possible inflammatory response.30 Mild cases are
It may be observed in the immediate post-operative period treated with intense topical steroids and severe cases with a
due to suboptimal laser energy levels and in cases of combination of topical and oral steroids.
difficult dissection due to OBL / sticky lenticule. It usually
resolves well with topical steroids and cyclosporine eye Post Smile Enhancement
drops without having an impact on the long term visual and
refractive outcomes.26 The simplest way to perform an enhancement after SMILE
is photorefractive keratectomy (PRK). An alternative to this
2. Interface Debris is converting the SMILE cap into a flap and then ablating
Lint fibres / debris on the instrument / meibomian secretions the stromal bed to correct the residual refractive error. A
can be inadvertently introduced into the stromal pocket special software called the “Circle” (Carl Zeiss Meditec AG)
during lenticule dissection. (Figure 22) Interface wash is has been developed to convert the original SMILE cap into a
advisable in cases of excess intra-operative manipulation to complete flap.31
wash out the debris if any. Minimal debris not involving the
pupillary axis remains inert without affecting the visual and Post Operative Treatment
refractive outcomes.27
Antibiotics (preferably Fluoroquinolones), Steroids
3. Diffuse Lamellar Keratitis (DLK) (Prednisolone eye drops) in tapering dose and lubricants are
It represents an acute inflammatory response characterised used commonly. Cyclosporine 0.1% eye drops can also be
by accumulation of white granular cells in the interface. added to prevent and treat interface haze.In patients who are
(Figure 23) Patient may present with discomfort, steroid responders, low potent steroids along with pressure
photophobia and blurring of vision. A definitive cause lowering agents are to be used.
is unknown, although factors such as introduction of

Figure 23: Diffuse lamellar keratitis Post Op Follow Up

Day 1, 1 week, 1 month, 3 months, 6 months and 1 yearly. On
each follow up visits visual acuity (Uniocular and binocular),
Intra ocular pressure and corneal interface clarity are looked

at.

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DJO Vol. 32, No. 1, July-September 2021

References 21. Harissi-Dagher M, Todani A, Melki SA. Laser in situ keratomileusis
buttonhole: classification and management algorithm. J Cataract
1. Blum M, Täubig K, Gruhn C, Sekundo W, Kunert KS. Five-year Refract Surg. 2008 Nov;34(11):1892-9.
results of Small Incision Lenticule Extraction (ReLEx SMILE). Br J
Ophthalmol. 2016Sep;100(9):1192-5. 22. Brenner JE, Mohinani AB, Janbatian HY, Melki S. Early Surface
Ablation on Aborted LASIK Flaps. J Refract Surg. 2019 Feb
2. Chansue E, Tanehsakdi M, Swasdibutra S, McAlinden C. Efficacy, 1;35(2):121-125.
predictability and safety of small incision lenticule extraction
(SMILE). Eye Vis (Lond). 2015Aug 31;2:14. 23. Liu CH, Sun CC, Hui-Kang Ma D, Chien-Chieh Huang J, Liu CF,
Chen HF, Hsiao CH. Opaque bubble layer: incidence, risk factors,
3. Seven I, Vahdati A, Pedersen IB, Vestergaard A, Hjortdal J, Roberts and clinical relevance. J Cataract Refract Surg. 2014 Mar;40(3):435-
CJ, Dupps WJ Jr. Contralateral Eye Comparison of SMILE and 40.
Flap-Based Corneal Refractive Surgery: Computational Analysis of
Biomechanical Impact. J Refract Surg. 2017 Jul1;33(7):444-453. 24. Ramirez-Miranda A, Ramirez-Luquin T, Navas A, Graue-
Hernandez EO. Refractive Lenticule Extraction Complications.
4. Li M, Niu L, Qin B, Zhou Z, Ni K, Le Q, Xiang J, Wei A, Ma W, Cornea. 2015;34(Suppl 10):S65–S67.
Zhou X. Confocal comparison of corneal reinnervation after small
incision lenticule extraction(SMILE) and femtosecond laser in situ 25. Titiyal JS, Kaur M, Rathi A, Falera R, Chaniyara M, Sharma N.
keratomileusis (FS-LASIK). PLoS One. 2013 Dec 9;8(12):e81435. Learning Curve of Small Incision Lenticule Extraction: Challenges
and Complications. Cornea. 2017 Nov;36(11):1377-1382.
5. Soong HK, Malta JB. Femtosecond lasers in ophthalmology. Am J
Ophthalmol. 2009 Feb;147(2):189-197.e2. 26. Ivarsen A, Asp S, Hjortdal J. Safety and complications of more than
1500 small‐incision lenticule extraction procedures. Ophthalmology
6. Wang B, Naidu RK, Chu R, Dai J, Qu X, Zhou H. Dry Eye Disease 2014; 121: 822–828.
following Refractive Surgery: A 12-Month Follow-Up of SMILE
versus FS-LASIK in High Myopia. J Ophthalmol. 2015;2015:132417. 27. Chan C, Lawless M, Sutton G, Versace P, Hodge C. Small incision
lenticule extraction (SMILE) in 2015. Clin Exp Optom. 2016;99:204–
7. Knox Cartwright NE, Tyrer JR, Jaycock PD, Marshall J. Effects of 212. doi:10.1111/cxo.12380
variation in depth and side cut angulations in LASIK and thin-flap
LASIK using a femtosecond laser: a biomechanical study. J Refract 28. Moshirfar M, McCaughey MV, Reinstein DZ, Shah R, Santiago-
Surg. 2012 Jun;28(6):419-25. Caban L, Fenzl CR. Small-incision lenticule extraction. J Cataract
Refract Surg. 2015 Mar;41(3):652-65.
8. Titiyal JS, Kaur M, Shaikh F, Gagrani M, Brar AS, Rathi A. Small
incision lenticule extraction (SMILE) techniques: patient selection 29. Zhao J, He L, Yao P, Shen Y, Zhou Z, Miao H, Wang X, Zhou X.
and perspectives. Clin Ophthalmol. 2018 Sep 5;12:1685-1699. Diffuse lamellar keratitis after small-incision lenticule extraction. J
Cataract Refract Surg. 2015 Feb;41(2):400-7.
9. Ganesh S, Brar S, Pawar A. Results of Intraoperative Manual
Cyclotorsion Compensation for Myopic Astigmatism in Patients 30. Zhao J, He L, Yao P, Shen Y, Zhou Z, Miao H, Wang X, Zhou X.
Undergoing Small Incision Lenticule Extraction (SMILE). J Refract Diffuse lamellar keratitis after small-incision lenticule extraction. J
Surg. 2017 Aug 1;33(8):506-512. Cataract Refract Surg. 2015 Feb;41(2):400-7.

10. Shah R, Shah S, Sengupta S. Results of small incision lenticule 31. Riau AK, Ang HP, Lwin NC, Chaurasia SS, Tan DT, Mehta JS.
extraction: All-in-one femtosecond laser refractive surgery. J Comparison of four different VisuMax circle patterns for flap
Cataract Refract Surg. 2011;37(1):127–137. creation after small incision lenticule extraction. J Refract Surg. 2013
Apr;29(4):236-44.
11. Titiyal JS, Kaur M. Small Incision Lenticule Extraction (SMILE):
Surgical Technique and Challenges (Comprehensive Text and Cite This Article as: Sanjana Vatsa, Pallavi Dhawan, Shana Sood,
Video Guide) 1st ed. New Delhi: Jaypee Brothers; 2018. OA to Z of ReLEx SMILE: All you need to know Delhi Journal of
Ophthalmology.2021; Vol 32, No (1): 25 - 31.
12. Ganesh S, Brar S, Arra RR. Gas Bubble Escape Sign: A New
Intraoperative Sign to Predict Immediate Visual Quality After Small Acknowledgments: Nil
Incision Lenticule Extraction. J Refract Surg. 2019 Jul 1;35(7):467-
472. Conflict of interest: None declared

13. Vestergaard AH. Past and present of corneal refractive surgery: Source of Funding: None
aretrospective study of long-term results after photorefractive
keratectomy and a prospective study of refractive lenticule Date of Submission: 23 Dec 2020
extraction. Acta Ophthalmol. 2014 Mar;92 Thesis 2:1-21. Date of Acceptance: 12 Jan 2021

14. Kamiya K, Shimizu K, Igarashi A, Kobashi H. Visual and Address for correspondence
refractive outcomes of femtosecond lenticule extraction and small-
incision lenticule extraction for myopia. Am J Ophthalmol. 2014 Sanjana Vatsa
Jan;157(1):128-134.e2.
MBBS, MS, FPRS, FCRS
15. Agca A, Ozgurhan EB, Yildirim Y, Cankaya KI, Guleryuz NB,
Alkin Z, Ozkaya A, Demirok A, Yilmaz OF. Corneal backscatter Department of Consultant, Cornea and
analysis by in vivo confocal microscopy: fellow eye comparison of Refractive Services, Dr. Agarwal’s Eye
small incision lenticule extraction and femtosecond laser-assisted Hospital, Bangalore, India.
LASIK. J Ophthalmol. 2014;2014:265012. Email : [email protected]

16. Reinstein DZ, Archer TJ, Gobbe M, Bartoli E. Corneal sensitivity Quick Response Code
after small-incision lenticule extraction and laser in situ
keratomileusis. J Cataract Refract Surg. 2015 Aug;41(8):1580-7.

17. Wong CW, Chan C, Tan D, Mehta JS. Incidence and management
of suction loss in refractive lenticule extraction. J Cataract Refract
Surg. 2014 Dec;40(12):2002-10.

18. Qiu PJ, Yang YB. Analysis and management of intraoperative
complications during small-incision lenticule extraction. Int J
Ophthalmol. 2016 Nov 18;9(11):1697-1700.

19. Shah DN, Melki S. Complications of femtosecond-assisted
laser in-situ keratomileusis flaps. Semin Ophthalmol. 2014 Sep-
Nov;29(5-6):363-75.

20. dos Santos AM, Torricelli AA, Marino GK, Garcia R, Netto MV,
Bechara SJ, Wilson SE. Femtosecond Laser-Assisted LASIK Flap
Complications. J Refract Surg. 2016 Jan;32(1):52-9.

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DJO Vol. 32, No. 1, July-September 2021

Review Article

Ophthalmic manifestations of psoriasis

1Kritika Katoch,2 Ratan Kumar Sharma,2 Vikram mahajan,2 Rajeev Tuli

1Department Of Ophthalmology, Zonal Hospital Dharamshala, Himachal Pradesh, India.
2Dr. Rajendra Prasad Government Medical College Kangra, Tanda, Himachal Pradesh, India.

Abstract Psoriasis is a common chronic inflammatory and proliferative condition of the skin associated with systemic manifestations.
The relationship between the eye and psoriasis has been recognized for decades, but the precise eye manifestations in patients
with psoriasis and psoriatic arthritis are only recently coming to light. Ocular involvement occurs in 10% of patients with
psoriasis. Ophthalmic manifestations include blepharitis, dry eye , meibomian gland dysfunction, nonspecific conjunctivitis,
punctate keratitis, corneal recurrent erosions, vascularisation, ulceration, scarring and even melting . Anterior uveitis is another
psoriasis associated manifestation involving 7% to 25% of patients with psoriatic arthritis. Retinal vasculitis, cystoid macular
edema, and papillitis are other uncommon changes seen. Various topical and systemic therapies used to treat psoriasis too
can affect eyes,which includes conjunctiva hyperaemia, dry eye, blepharitis, blepharoconjunctivitis, keratitis, corneal opacities,
cataract, and deceased night vision.

Delhi J Ophthalmol 2021; 32; 32-33; Doi http://dx.doi.org/10.7869/djo.684
Keywords: Psoriasis, Dry Eye, Blepharitis, Uveitis, Cataract, Psoriatic Arthritis

Introduction the prevalence of inflammatory arthritis among psoriasis
patients varies between 7% and 26% and in about 15% of
Psoriasis is a common chronic inflammatory and proliferative them arthritis remains undiagnosed.5
condition of the skin associated with systemic manifestations
in many organ systems. The reported prevalence of psoriasis Ocular involvement occurs in 10% of patients with psoriasis
in countries ranges between 0.09% and 11.4% among all ages, especially in presence of psoriatic arthritis and may even
both genders and all populations making psoriasis a serious precede articular changes.6,7 Psoriasis can affect eyes directly
global problem.1,2 Approximately 75% patients present or as complication of treatment for psoriasis. Blepharitis and
before the age of 40 years (peak at 20-30 years) and the other dry eye are the commonest ocular finding.8 It is thought to
peak occurs at 57-60 years. The prevalence is between 1.5 be triggered by Meibomian duct occlusion by psoriatic scale,
and 5% in most developed countries.3 In India, the reported as well as an underlying lower tear film break-up time in
prevalence is between 0.44 and 2.8%.4 Clinically, cutaneous patients with psoriasis.9 Erythema, edema, and psoriatic
disease presents in non-pustular or pustular forms with each plaques around the eyes can result in madarosis, cicatricial
having its own variants (Table 1). ectropion, trichiasis, loss of lid tissue and obstructive type of
meibomian gland dysfunction.10 It can be difficult to discern
Well-demarcated erythematous and indurated papulo- from non-specific eyelid dermatitis, which has been reported
plaques with loose silvery scales are hallmark clinical in up to 7% of psoriasis patients. Patients with pustular
features of chronic plaque psoriasis or psoriasis vulgaris, psoriasis may have sterile pustules and lid swelling.11
the commonest variant. Mucosal changes are rare and Psoriatic plaques over lids can extend to involve conjunctiva.
nail involvement occurs in 25%‒50% of all cases while A chronic nonspecific conjunctivitis may occur which
can lead to symblepharon and keratoconjunctivitis sicca.
Table 1: Clinical variants of psoriasis An older study suggests that it may occur in up to 64.5%
patients with skin disease.12 Dry eye has been reported in up
Non pustular Pustular psoriasis to 18.75% of patients with psoriasis 13 and 2.7% of psoriatic
psoriasis Localised pustular psoriasis arthritis patients.14 Demarcated, yellowish-red plaques
on the palpebral conjunctiva, limbal lesions resembling
Psoriasis vulgaris- phlyctenules and episcleritis can occur.15,16 Corneal
early or late involvement may include punctate keratitis, filaments,
epithelial thickening, recurrent erosions, vascularisation,
onset Palmoplanterpustulosis ulceration, scarring and even melting can occur especially
in the periphery. Involvement tends to be bilateral and close
Guttate psoriasis Acrodermatitis continua of to the limbus. Histologic evaluation of the thickened corneal
hallopeau opacities reveals parakeratosis analogous to the findings
noted in skin psoriasis.17
Rupoid psoriasis Generalised pustular Anterior uveitis is another psoriasis associated manifestation
psoriasis involving 7% to 25% of patients with psoriatic arthritis. It
seems that psoriasis without arthropathy is not a risk factor
Elephantine and Acute pustular psoriasis of for the development of uveitis. Uveitis tends to develop
ostraceuous von- more frequently in patients with arthropathy or pustular
psoriasis Zumbusch

Unstable psoriasis Impetigo herpetiformis

Psoriatic Infantile and juvenile forms
erythroderma Circinate form

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DJO Vol. 32, No. 1, July-September 2021

psoriasis than in patients with other forms of psoriasis.18 15. Catsarou-Catsari A, Katsambas A, Theodoropoulos P, Stratigos
Although uveitis has been reported in psoriatic patients J. Ophthalmological manifestations in patients with psoriasis.
without arthritis, it tends to be bilateral, prolonged and more Acta Derm Venereol 1984;64:557-9.
severe in patients with psoriatic arthritis. Retinal vasculitis,
cystoid macular edema, and papillitis are other uncommon 16. Kumar Yadalla HK, Vivekananda, Kumar K, Chandrashekar M.
changes seen. Psoriasis: An eye opener – A cross-sectional study in a tertiary
care hospital of South India. Our Dermatol Online 2015;6:5-11.
Various topical and systemic therapies used to treat psoriasis
17. Rehal B, Modjtahedi B S, Morse L S, Schwab IR, Maibach H I.
too can affect eyes in these patients. While corticosteroids Ocular Psoriasis. J Am Acad Dermatol 2011; 65:1202-12.

and phototherapy, with or without psoralens, the commonly 18. Fraga NA, Oliveira Mde F, Follador I, Rocha Bde O, Rego VR.
Psoriasis and uveitis: a literature review. An Bras Dermatol 2012;
used treatment modalities in psoriasis, can cause conjunctiva 87:877-83.

hyperaemia, dry eye and early cataract, treatment with oral 19. Cox NH, Jones SK, Downey DJ, Tuyp EJ, Jay JL, Moseley H, et
al. Cutaneous and ocular side effects of oral pharmacotherapy:
retinoids may lead to blepharitis, blepharoconjunctivitis, results of an 8 year old follow-up study. Br J Dermatol
1987;116:145-52.
keratitis, corneal opacities, dry eyes, cataract, and decrease
20. Fraunfelder FW. Corneal toxicity from topical ocular and
dnight vision. 19,20,21 Conclusion systemic medications. Cornea 2006;25:1133-8.

Ocular manifestations in psoriasis are often considered 21. McClure SL, Valentine J, Gordon KB. Comparative tolerability
of systemic treatments for plaque-type psoriasis. Drug Saf
less common as they largely remain under reported in the 2002;25:913-27.

literature and surveys for the quality of life implications Cite This Article as: Kritika Katoch, Ratan Kumar Sharma,

of psoriasis generally do not address ocular symptoms. Vikram mahajan, Rajeev Tuli. Ophthalmic manifestations of

Another possible reason could be that ocular manifestations psoriasis. Delhi J Ophthalmol 2021; 32 (1) : 32-33.

of psoriasis are too subtle and missed for want of a dedicated Acknowledgments: Nil

ophthalmic examination. Conflict of interest: None declared

References Source of Funding: None

1. Chestnov O. WHO Global reports on psoriasis 2016. World Date of Submission: 24 Jun 2020
Health Organization. Available at: www.who.int (accessed Date of Acceptance: 03 Aug 2020
on:02/09/2017)
Address for correspondence
2. Danielsen K, Olsen AO, Wilsgaard T, Furberg AS. Is the
prevalence of psoriasis increasing? A 30-year follow-up of a Kritika Katoch
population-based cohort. Br J Dermatol 2013;168:1303-10.
Medical Officer Ophthalmology
3. Parisi R, Symmons DP, Griffiths CE, Ashcroft DM, and the
Identification and Management of Psoriasis and Associated Department of Ophthalmology
ComorbidiTy (IMPACT) project team. Global epidemiology of Zonal Hospital Dharamshala, Dist
psoriasis: a systematic review of incidence and prevalence. J Kangra, Himachal Pradesh, India.
Invest Dermatol 2013;133:377-85. Email: [email protected]

4. Dogra S, Yadav S. Psoriasis in India: Prevalence and pattern. Quick Response Code
Indian J Dermatol Venereol Leprol 2010;76:595-601.

5. Villani AP, Rouzaud M, Sevrain M, Barnetche T, Paul C, Richard
MA, et al. Prevalence of undiagnosed psoriatic arthritis among
psoriasis patients: Systematic review and meta-analysis. J Am
Acad Dermatol 2015;73:242-8.

6. Maitray A, Bhandary AS, Shetty SB, Kundu G. Ocular
manifestations in psoriasis. Int J Ocul Oncol Oculoplasty
2016;2:123-31.

7. Au S-C, Yaniv S, Gottlieb AB. Psoriatic eye manifestations.
Psoriasis Forum 2011; 17:169-79.

8. Cram DL. Corneal melting in psoriasis. J Am Acad Dermatol
1981;5:617.

9. Zengin N, Tol H, Balevi S, Gunduz K, Okudan S, Endogru H.
Tear film and meibomian gland functions in psoriasis. Acta
Ophthalmol Scand 1996; 74: 358-60.

10. Fraunfelder FW, Fraunfelder FT. Dermatologic disorders. In:
Roy FH, Fraunfelder FW, Fraunfelder FT, editors. Roy and
Fraunfelder's Current Ocular Therapy, 6th edn. Elsevier Health
Sciences: China: 2008. p.157-8.

11. Shainhouse T. Ocular manifestations of psoriasis. EC
Ophthalmology 2017;5:172-6.

12. Lambert JR, Wright V. Eye Inflammation in psoriatic arthritis.
Ann Rheum Dis 1976;35:354-6.

13. Bhargava R, Kumar P. Evaluation of dry eye in patients with
psoriasis. J Ocular Biol. 2015;3:7.

14. Bernhard JD. Is eyelid involvement a sign of severe psoriasis?
Dermatologica 1987; 174:151.

E-ISSN: 2454-2784  P-ISSN: 0972-0200 33 Delhi Journal of Ophthalmology

DJO Vol. 32, No. 1, July-September 2021

Original Article

Practice Of Ophthalmic Self-Medication Among Patients In
Central India: Questionnaire Based Study

Lipi Chakrabarty

Department of Ophthalmology, Chandulal Chandrakar Memorial Medical College & Hospital, Durg, Chhattisgarh, India.

Abstract Purpose: To identify and analyze the practice of ocular self-medication in adult patients attending an ophthalmology clinic in
central India.

Methods: A cross sectional, descriptive, questionnaire-based observational study was carried out at Durg, Chhattisgarh, India
over a period of eight months from July 2017 to February 2018. The study included 1490 consecutive and consenting adult
patients reporting for the first time in a private ophthalmology clinic. Self-medication was defined as the use of ophthalmic
medicines used in the past one year without consultation of health care professionals. Responses to a semi-structured
questionnaire covering socio-demographic details and various aspects of eye medication usage like duration, source, reason
etc. were obtained with a face-to-face interview. The relationship between self-medication and demographic factors was
analyzed using chi-square test of association, univariate analysis and multivariable logistic regression.

Results: 432 subjects (29%) reported using ophthalmic medications without consulting an ophthalmologist. Patients used
medications commonly for itching of eyes (41%), burning sensation (39%) and watering (38%). The most common used eye
drops were ayurvedic and herbal (21%), antibiotics (17%) and antibiotic-steroid combination (10%). Of the patients who self-
medicated, majority used medications recommended by pharmacist or relatives and friends. Males (OR: 1.51, p= 0.0007),
married subjects (OR: 2.05, p= 0.0001) and rural patients (OR: 1.29, p= 0.046) were more likely to self-medicate. No significant
difference was found in self-medication practices according to age (p=0.291) and level of education (p=0.983).

Conclusion: Arbitrary practice of ophthalmic self-medication is prevailing. This warrants educational efforts, public awareness
and regulatory legislations to lessen the consequences.

Delhi J Ophthalmol 2021; 32; 34-39 Doi http://dx.doi.org/10.7869/djo.685
Keywords: Self-Medication, Eye Drops, Ophthalmic Medicine, Questionnaire, Central India

Introduction involved, the profile of individuals who self-medicate and
the features of such behavior in patients who were seen in
Self-medication is defined as the use of drugs to treat self- a private ophthalmology centre in Central India. Relying
diagnosed disorders or symptoms, or the intermittent or on self-medication practice not only hinders and delays the
continued use of a prescribed drug for chronic or recurrent management of a serious disease, but also can cause adverse
diseases or symptoms.1 Apart from being a common effects. Correct identification of these practices and the
phenomenon all over the world it has been reported to be population profile can guide a healthcare worker in creating
very common in the developing countries.2 Worldwide from adequate awareness in the intended population.
all drugs purchased without any prescription, 80% was
accounted by the developing countries.3 Self-medication Materials & Methods
behavior includes purchasing drugs without a prescription,
using leftover doses from previous prescriptions, sharing This cross sectional, descriptive, questionnaire-based study
drugs with other family members or social groups, or misusing was done over a period of eight months from 1 July 2017
the medical prescription either by prolonging, interrupting to 28 February 2018. New patients attending ophthalmology
or modifying the dosage and the administration period.4 To clinic were invited to participate in the study, with adequate
quickly relieve their discomfort, or because they lack other time given to the patient and attender(s) to consider whether
options, patients often use medicines without appropriate they wished to participate. Informed consent was obtained
medical supervision. This inappropriate practice may result from willing patients. The study included 1490 consecutive
in irrational medicine use, delayed seeking medical advice, and consenting adult patients (≥ 18years) of either sex
increased side effects and drug interactions.5 Globally, the attending ophthalmology clinic for the first time. Since the
reported prevalence of ophthalmic self-medication ranges questionnaire was in Hindi language; adults able to speak
from 18.2% to 73.6%.6-14 Self-medication is influenced by and comprehend the language were included. Non-willing
many factors such as education, gender, socioeconomic subjects, patients requiring rapid emergency care, patients
status and availability of medicines.6,15 with communication difficulties and patients not living in
the state were excluded. All participants were informed
Regarding self-medication in ophthalmic practice, the about the scope and purpose of the study and told that it
evidence is scarce in Indian population.16 The aim of this was voluntary to participate, without any compensation,
study was to identify the prevalence of ophthalmologic self- and that their medical assistance would not be compromised
medication with commercial topical ophthalmic preparations if they refused or decided to participate in the survey. The
and to analyze the practice including the type of medications study adhered to the tenets of the Declaration of Helsinki.

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DJO Vol. 32, No. 1, July-September 2021

Permission and ethical clearance was obtained from the 1. Illiterate or incomplete primary school.
Institutional Ethical Committee of the medical college with 2. completed primary school (till fifth standard or class of
which the principal investigator is associated and affiliated
to. formal school education).
A pilot study including 20 adults was conducted to identify 3. completed secondary school (till twelfth class).
potential problem areas and deficiencies in the questionnaire 4. completion of University or tertiary studies.
and protocol. The questionnaire used was designed
by the investigator and was in local language (Hindi). For ease of interpretation, age group was divided into: ≤
Previously used questionnaires used for self-medication 60 years and older than 60 years. Similarly education was
were referred while designing.8,17,18 The semi-structured limited to two groups: till primary school (fifth standard)
questionnaire consisted of five questions on demography and more than primary school.
and fifteen questions on self-medication details. The pilot
tested whether the questionnaire was comprehensible and The complaint for which medication was used went in
appropriate, and that the questions were well defined, the semi structured questionnaire as: eye itching or gritty
clearly understood and presented in a consistent manner. sensation, burning sensation, watering of eyes, eye pain
Patient information statements and consent forms were also or strain, redness of eyes, discharge from eyes, defective
tested for comprehension. vision, photophobia or glare, other symptoms (to be filled by
participant) and no symptoms. The types of medication used
This pre-tested questionnaire was used to collect data from were classified into eight groups: ayurveda or herbal, artificial
participants. The questionnaire was self-administered. tears, antibiotics, anti-allergic drugs and vasoconstrictors,
The attender was allowed to assist the patient in difficulty. corticosteroids and steroid combinations, non-steroidal anti-
The patient and attender were instructed to check item inflammatory agents and other substances. Pharmacological
completion at submission which was double checked by the associations were taken into consideration.
investigator. Any unanswered or incomplete response was
requested to be completed. All data was coded, entered and analyzed using Microsoft
excel 2010 and Epi info 7 (7.2.2.6, Center for Disease Control
The questionnaire collected demographic data such as and Prevention). Descriptive data analysis was conducted
patient’s age, sex, residential area, level of education and and reported as mean, standard deviation, frequencies
marital status. The questionnaire related to the topical eye and percentage. The relationship between self-medication
medication(s) used in the past twelve months including the and demographic factors was analyzed using Pearson’s
number, the duration, the frequency, the source, the reason chi-square test of association. Univariate analysis and
and the general concept and opinion on the usage. A few multivariable logistic regression analysis was conducted
examples of the questions include: to find the strength of association. The results for the same
were reported as odds ratio (OR). For 95% confidence level,
1. What is the highest level of education that you have a probability value (p) ≤ 0.05 was considered statistically
completed? significant.

2. Are you currently using or have you used ophthalmic Results
medications not prescribed by a health care specialist in
the past 12 months? Out of 1532 new patients attending the clinic, 1490 consented
for the study giving a response rate of 97.26%. Among these
3. Who encouraged you to use the medication? 1490 subjects, 432 subjects (29%) reported using ophthalmic
4. What eye complaints made you to self-medicate? medications without consulting an ophthalmologist or
5. What were your reasons for not consulting with a licensed medical doctor. On average, the respondents took about
10-15 minutes to complete the questionnaire. Demographic
health care specialist? features of respondents have been tabulated (Table 1). The
6. Are you aware of the details of the used eye drop? Have age of the patients ranged from 18 years to 82 years and
the mean age of patients was 54.4± 8.2 years. Amongst
you read the patient information leaflet? participants, 59% were males.
Males (OR: 1.51, p= 0.0007), married subjects (OR: 2.05, p=
Self-medication was defined as the use of topical ophthalmic 0.0002) and rural patients (OR: 1.29, p= 0.046) were more
medicine(s) used in the past one year without consultation likely to self-medicate (Table 2). No significant difference
of health care professional(s). The urban and rural area was found in self-medication practices according to age
definition of Census of India, 2011 was taken. According to (p=0.291) and level of education (p=0.983).
this; constituents of urban area are statutory towns, census
towns and outgrowths. All other areas other than urban are Itching of eyes and/or gritty sensation was the most common
rural. complaint for which participants self-medicated (Table 3).
Subjects also used eye drops for miscellaneous complaints
Four age groups were arbitrarily assigned: 18- 40 years old, like swelling of eyes, injury, cataract, refractive error,
41 - 60 and > 60 years. Regarding educational level, four glaucoma, strabismus, removal of foreign body from eye etc.
divisions were established: (grouped into the category ‘Others’). About 6% participants

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DJO Vol. 32, No. 1, July-September 2021

Table 1: Demographic variables of respondents and relationship to Table 2: Association of socio-demographic factors with

self-medication self-medication in the study population

Variable Ophthalmic Chi square, Unadjusted Variable Ophthalmic Unadjusted OR Adjusted OR
self- P value OR self- (95% C.I.) (95% C.I.)
P value P value
medication (95% C.I.) medication
P value
Yes No

Yes No Age group
(in years)
Age group
(in years) ≤60 222 555 1 1

18-40 112 258 1 >60 210 503 1.04 (0.83, 1.31), 1.01 (0.78, 1.24), 0.291
0.354
41 -60 110 297 1.13, 0.85 (0.62, 1.17), 0.16

>60 210 503 0.568 0.96 (0.73, 1.27), 0.39 Gender

Gender Male 282 602 1.42 (1.13, 1.80), 1.51 (1.19,1.91),
0.001 0.0007
Male 282 602 8.92, 1.42 (1.13, 1.80), 0.001

Female 150 456 0.003 1 Female 150 456 1 1

Residence Residence

Rural 146 293 5.50, 1.33 (1.05, 1.70), 0.008 Rural 146 293 1.33 (1.05, 1.70), 1.29 (1.00, 1.66), 0.046
0.008

Urban 286 765 0.191 1 Urban 286 765 1 1

Education level Education
level
Illiterate or 84 184 1.18 (0.84, 1.67), 0.166
incomplete
primary school Up to 194 475 1.00 (0.80, 1.25), 0.91(0.81, 1.19), 0.983
primary 0.498
school
Completed 110 291 1.66, 0.98 (0.72, 1.34), 0.451
primary school
Above 238 583 1
primary
Completed 132 308 0.645 1.11 (0.82, 1.51), 0.246
secondary
Marital
school status

Completion of 106 275 1 Currently 387 856 2.03 (1.44, 2.86), 2.05 (1.45, 2.92),
tertiary studies/ Married 0.00003 0.0001

college

Marital status Currently 45 202 1 1
Single
Currently 387 856 16.7, 2.03 (1.44, 2.86),
Married 0.00003 *OR- Odds Ratio,
*C.I.- Confidence Interval

Currently Single 45 202 0.000044 1 Table 4: Pharmacological category of ocular medication

*OR- Odds Ratio, Category of topical medication Frequency Percentage
*C.I.- Confidence Interval (n) (%)

Table 3: Complaint that led to self-medication Ayurvedic or Herbal 89 20.60

Symptoms Frequency (n)* Percentage (%)* Antibiotics 74 17.13

Eye Itching/ Gritty 177 40.97 Antibiotic with steroid 42 9.72
sensation
Antiallergic with or without artificial tears 40 9.26

Burning sensation 167 38.66 Steroid 18 4.17

Watering of eyes 166 38.43 Artificial tears 08 1.85

Eye pain/strain 147 34.02 Nonsteroidal anti inflammatory agents 08 1.85

Redness of eyes 125 28.94 Others 05 1.16

Discharge from eyes 95 21.99 Not remembering the medicine 162 37.50

Defective vision 78 18.06

Photophobia/glare 71 16.43 combination (9.7%). Fourteen patients used more than one
category of medication (Table 4). 38% patients did not carry
Others 34 7.87 or remember the medicine being used. 55% patients did
not know the details of their medication. Only 10% of the
No symptoms 26 6.01 patients had read the patient-information leaflet in the eye
drop package. 260 patients (60.2%) did not check the expiry
* Many subjects had more than one symptom leading to self-medication date of the drug before they used it.
The major reason for ophthalmic self-medication was
used eye drops not directed to any particular complaint, but
for general ocular well-being.
The most common used eye drops were ayurvedic and
herbal (20.6%), antibiotics (17.1%) and antibiotic-steroid

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DJO Vol. 32, No. 1, July-September 2021

the advice from family, friends, pharmacist, optician and and 25.7% for Cordoba and Barranquilla, respectively).6,19-21
compounder (61%), followed by no time to visit at the eye These rates are low when compared to frequencies published
health care center (31%). Many subjects had a combined by Indian studies of Kadri et al (35.47%), Shallam et al
influence of more than one factor leading to self-medication (37.5%) and Gupta R et al (41.2%).7,22,16 This discrepancy may
(Table 5). The major source of medicine was pharmacy be explained on the basis of the study design wherein we
(49%), followed by relatives and friends (20%). 19% patients have limited the participants to adult patients and patients
used eye drops available at home which had been used in who have self-medicated during the past one year. We have
also excluded patients requiring emergency critical care.
Table 5 : Factors influencing self-medication We have not considered the homemade traditional ocular
medications as done in Shallam et al study.22 Including them
Influencing factor Frequency Percentage could have increased the percentage of people who self-
(n)* (%)* medicated in our population.
Advice from family and friends
Advice from pharmacist/optician/ 140 32.40 In the present study, no significant difference was found
in self-medication practices according to age and level of
compounder 123 28.47 education. In the Gupta et al study at Gurgaon, no significant
Being Busy differences were found in self-medication practices according
Long distance from eye care services/ 135 31.25 to age (p= 0.962), gender (p= 0.599), level of education
Non availability of eye care 91 21.06 (p = 0.41) or religion (p = 0.632).6 In Shallam et al study of
Believes that symptoms are not Mangalore, younger age group of 20- 40 years of age self-
significant 86 19.90 medicated more and the educated patients were more likely
Economic reason to self-medicate.22 There was a significant gender difference
Had a medication at home 78 18.05 in self-medication practices, with 33% of males compared to
74 17.13 20% of females admitting to the practice of self-medication
in the study in Argentina (p=0.004).19 Males were 1.84 times
Others/ No reason 48 11.11 more likely to report self-treatment compared to females as
per the research at Malawi in Africa.9 This finding is similar
Considers qualified for self-treatment 42 9.72 to our study, wherein the prevalence of self-medication has
been found more in males (OR: 1.51, p=0.0007).
*Many subjects had a combined influence of more than one factor
As per this study, married patients self-medicated more.
leading to self-medication Unmarried subjects were more likely to self-medicate in
Gupta et al study (p= 0.044), though on multivariate analysis,
Figures : 1 Source of medicine no difference was found.6 In the present study, rural patients
were found to practice ophthalmic self- medication 1.3
past for their ocular problem. 12% patients bought the eye times more than the urban counterpart. Use of traditional
eye medicines and self-medication has been documented in
drop influenced by newspaper or radio or television (Figure people of rural residence.6,23 In general, self-medication in
rural areas is common.24,25 Most published Indian studies on
1). Most patients using ayurvedic eye drops belonged to this ophthalmic self-medication have not taken the variables of
marital status and residence of patient in their analysis.
category. Discussion
In our study, itching and grittiness in eyes was the most
The present study used a questionnaire to examine the extent common complaint for which the patients chose self-
medication (41%). In the study conducted in South India
of ocular self-medication, with commercial eye medications by Kadri et al,7 33% had similar complaints. In a study
performed by Tayanithi et al26 the factor which influenced
in patients seen in a private Ophthalmology practice in the use of eye drops most was 'dust in the eye' (55%). Ocular
allergic symptoms such as itching, irritation, tearing were the
Central India. Self-medication was reported in 28.99% of the second most common cause. In our study too, burning and
watering constituted the second most common symptoms.
survey sample, showing that about one in four patients self- Over the counter (OTC) products are often the first line of
self-therapy for ocular allergy and dry eye.
medicates before seeking medical advice. Comparable rates
In the present study, ayurvedic and herbal eye drops
were found in a community based Indian study by Gupta N constituted majority of the OTC medications used
(20.6%). Herbal and indigenous eye drops belonging to
et al (18.3% and 26.4%), in Gabriel et al study (25.6%), study the alternative medicines were found to be used in 13.2%
participants in Gupta et al study of 2017.6 This indicates
by Adimassu et al (28.6%) and in Marquez et al study (25.6%

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DJO Vol. 32, No. 1, July-September 2021

the growing interest in using ayurvedic eye drops and also controls over medical advertising, low medical literacy
hints on their wider availability with easy accessibility. In
past studies, the category of ayurvedic-herbal drops has not among the population and also the compulsion to reduce
been found, though use of traditional eye medicines have
been assessed.6,22 Antibiotics (17%), antibiotic-steroid (10%) health-care costs seem to be the motivating factors for self-
and anti-allergic vasoconstrictive agents (9%) were the other
major drugs used in our study. Antibiotics have constituted medication. Conclusions
to be the highest number of medications used in Indian
studies. About 38% of the respondents were not aware of the Self-medication in ophthalmology has been found to be a
names of the medicines used. Not knowing the names of the
medicines used by the patients who practice self-medication common phenomenon among people of all ages, diverse
was reported to be 40.2% in the Indian study by Gupta R et
al.16 35.3%of the patients were not aware of the names of the levels of education and different genders. The use of random
eye drops in Kadri et al study.7
eye drops could delay professional medical attention,
Of the patients who self-medicated, majority used
medications recommended by pharmacist or relatives and resulting in serious ophthalmologic complications. This
friends. Most did not seek specialist care because of advice
from family-friends or due to busy schedule. Similar to our warrants educational efforts, public awareness and
findings, in another Indian study, common reasons given
by the patients for self-medicating was easy availability regulatory legislations to lessen the consequences.
of drugs from pharmacist, advise from relatives who had
similar complaints and not having time to visit a doctor.22 References
In the Argentinean residents, the pharmacist, the patient’s
personal decision and counseling from friends or family 1. Organisation WHO. Guidelines for the Regulatory Assessment
were the main reasons for drug misuse.19 of Medicinal Products for Use in Self-Medication., Geneva,
Switzerland, 2000. (WHO/EDM/QSM/00.1).
In present study, 49% of patients got the drug from pharmacy.
The most common source from where the patients obtained 2. Shankar PR, Partha P, Shenoy N. Self-medication and non-
the drug was chemist shops in 56.5% of the patients in doctor prescription practices in Pokhara valley, Western Nepal:
Gupta et al study of North India.16 In Adimassu et al20 study a questionnaire-based study. BMC Fam Pract. 2002;3:17.
in Ethiopia, the major sources of ophthalmic medicine for
self-medication were pharmacy house (72.2%), followed by 3. Gore PR, Madhavan S. Consumers' preference and willingness to
leftover medication. There is a need to address these issues pay for pharmacist counselling for non-prescription medicines. J
by generating awareness through educational campaigns. Clin Pharm Ther. 1994;19:17-25.
Better control in drug selling may rationalize the utilization
of ophthalmic medicines. 4. Loyola Filho AI, Lima-Costa MF, Uchôa E. Bambuí Project: a
qualitative approach to self-medication. Cad Saude Publica.
Being a private clinic-based and questionnaire-based 2004;20:1661-9.
study, the study has associated limitations. The study
cohort may not be representative of general community. 5. Asam F. Sawalha. Assessment of Self-Medication Practice among
Participants may have been aware that self-medication University Students in Palestine: Therapeutic and Toxicity
practice is not encouraged, hence might have withheld Implications. The Islamic University Journal (Series of Natural
some information while they may be practicing it. Adequate Studies and Engineering).2007;15(2):67-82.
response rate and no missing data in the questionnaire
have limited the questionnaire bias. A strong sample size 6. Gupta N, Vashist P, Tandon R, Gupta SK, Kalaivani M, Dwivedi
of diverse demography contributes to the study. There SN. Use of traditional eye medicine and self-medication in rural
are few publications on self-medication in ophthalmology India: A population-based study. PLOS ONE.2017;12:e0183461.
worldwide and to date, no published data on this specific
issue in central India, as per author’s knowledge. 7. Kadri R, Hegde S, Kudva A, Achar A, Shenoy S. Self-medication
with over-the- counter ophthalmic preparations: is it safe? Int J
Ophthalmic self-medication is a common phenomenon Biol Med Res. 2011;2:528-30.
all over the world, especially in developing countries
where easy accessibility to a large range of drugs without 8. Ajayi, I., Omotoye, O., Ajite, K., Fadamiro, C., & Ajayi, E. Self
prescription, the growing number of over-the-counter Medication Practices among Patients seen in A Suburban
medicines, irresponsible publicity, and difficult access to Tertiary Eye Care Centre in Nigeria. Asian Journal of Medical
health care services, contribute to its practice.19,26-30 In India, Sciences.2013;5:85-90.
easy availability of a wide range of prescription drugs across
the counter without a valid prescription, lack of stringent 9. Bisika T, Courtright P, Geneau R, Kasote A, Chimombo L,
Chirambo M. Self treatment of eye diseases in Malawi. Afr J
Tradit Complement Altern Med. 2008;6:23-9.

10. Kagashe GAB, Msela BB. Self-medication among patients seen
at four hospitals in dar es salaam Tanzania IOSR J. Pharm.
2012;2:21-5.

11. Kumari R, Chitra DK, Bandyopadhyay A. Knowledge, Attitude,
and Practice of Ocular Topical Steroid Self-use in and Around
Kishanganj, Bihar. Int J Sci Stud 2017;5:280-83.

12. Carvalho RS, Kara-Jose N, Temporin ER, Kara-Junior Noma-
Campos R. Self medication initial treatments used by patients
seen in an ophthalmology emergency room. Clinics 68(8), 2009,
735-41.

13. Onwubiko SN, Eze BI, Udeh NN, Arinze OC, Okoloagu MN,
Chuka-Okosa CM. Mapping the pathways to eye care in a rural
south-east Nigerian population: any implications for practice,
eye care programs and policy? Rural Remote Health. 2014;14:27-
29.

14. Kara-Jose N, Saba HC, Cartocci AA, et al. Knowledge and
practice in ocular health of 1,000 people in the city of Campinas
(Sao Paulo).Arq Bras Oftalmol 1985;48:160-5.

15. Selvaraj K, Kumar SG, Ramalingam A. Prevalence of self-
medication practices and its associated factors in Urban
Puducherry, India. Perspect Clin Res. 2014;5:32-6.

16. Gupta R, Malhotra P. Self-medication in ophthalmology - a
northern Indian tertiary hospital experience Int J Basic Clin
Pharmacol. 2016;5:2556-60.

E-ISSN: 2454-2784  P-ISSN: 0972-0200 38 www.djo.org.in

DJO Vol. 32, No. 1, July-September 2021

17. Limaye, D., Limaye, V., Krause, G., & Fortwengel, G. A Cite This Article as: Lipi Chakrabarty Practice of ophthalmic
systematic review of the literature on survey questionnaires to self-medication among patients in Central India: Questionnaire
assess self-medication practices. Int J Community Med Public based study, Delhi J Ophthalmol 2020 ; 32 (1) 34 -39.
Health 2017;4:2620-31. Acknowledgments: Nil
Conflict of interest: Nil
18. Roulet L, Asseray N, Foucher N, Potel G, Lapeyre-Mestre M, Source of Funding: None
Ballereau F. A questionnaire to document self-medication Date of Submission: 14 Sep 2020
history in adult patients visiting emergency departments. Date of Acceptance: 14 Oct 2020
Pharmacoepidemiol Drug Saf. 2013;22:151-9.
Address for correspondence
19. Marquez GE, Torres VE, Sanchez VM, et al. Self-medication in Lipi Chakrabarty MBBS, DNB, MNAMS
ophthalmology: a questionnaire-based study in an Argentinean
population. Ophthalmic Epidemiol. 2012;19:236-41. (Ophthalmology), FAEH (Glaucoma)

20. Adimassu NF, Woldetsadik ZG, Alemu HW. Proportion of Chandulal Chandrakar Memorial
Ophthalmic Self-Medication and Associated Factors among Medical College & Hospital, Durg,
Adult Ophthalmic Patients Attending Borumeda Hospital, Chhattisgarh, India
Dessie, Northeast Ethiopia. J Ophthalmol. 2020;2020:6932686. Email: [email protected]
doi: 10.1155/2020/6932686.
Quick Response Code
21. Marquez GE, Pineros-Heilbron H, Sanchez VM, Torres
VE, Gramajo AL. Eye Drop Self-medication: Comparative
Questionnaire-based Study of Two Latin American Cities. J Clin
Exp Ophthalmol. 2014;5:330.

22. Shallam A., Mendonca N. Self Medication Practices Among
Patients Attending Ophthalmology Opd in A Tertiary Hospital
in Mangalore. IOSR Journal of Dental and Medical Sciences.
2017;16:11-13.

23. Courtright P, Lewallen S, Kanjaloti S, Divala DJ. Traditional
eye medicine use among patients with corneal disease in rural
Malawi. Br J Ophthalmol 1994;78: 810–12.

24. Keche Y, Yegnanarayan R, Bhoyar S, Agrawal R, Chavan R,
Mahendrakar P. Self medication pattern in rural areas in Pune,
India. International Journal of Medicine and Public Health.
2012;2(4):7-11.

25. Ahmad A, Patel I, Mohanta G, Balkrishnan R. Evaluation of self
medication practices in rural area of town sahaswan at northern
India. Ann Med Health Sci Res. 2014;4:S73-8.

26. Tayanithi P, Aramwit P. Self-medicated over the counter
ophthalmic solutions in central Bangkok. J Med Assoc Thai.
2005;88:S330-4.

27. Gupta S, Singh M. Self-medication among North Indian first-
year undergraduate healthcare students: A questionnaire-based
study. Trop J Med Res 2016;19:162-7.

28. Bennadi D. Self-medication: A current challenge. J Basic Clin
Pharm. 2013;5:19-23.

29. Marathe P A, Kamat S K, Tripathi R K, Raut S B, Khatri N P.
Over-the-counter medicines: Global perspective and Indian
scenario. J Postgrad Med 2020;66:28-34.

30. Gillian Porter, Nathan Grills, Medication misuse in India: a
major public health issue in India. J. Public Health 2016;38,e150-
57.

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DJO Vol. 32, No. 1, July-September 2021

Original Article

A causal assessment of blindness in schools for blind in
southern Rajasthan

Hardik Kiri, Lipa Mohanty, Seemal Goyal

Department of Ophthalmology, Geetanjali Medical College, Udaipur, Rajasthan India.

Abstract Aims: To determine the causes of blindness and major anatomical site of lesion leading to blindness in schools for blind
in Southern Rajasthan.

Study Design: Survey based observational study.

Methods: All the students (114) of blind schools were included in study. All data were recorded using a modified World
Heath Organization Prevention of Blindness (WHO/PBL) eye examination record for children, including the anatomical
and aetiogical classification. This was used to categorize the causes of blindness and to record the findings using the
definitions in the coding instructions.

Statistical analysis used: The data were entered into a database and analyzed using SPSS version 21 for Windows.

Results: Whole globe was affected in majority of the students (36.9%) which led to blindness, followed by uvea (15.8%),
lens (14.9%), cornea (14%), optic nerve (9.6%), and retina (8.8%). In majority of students exact aetiology which led to
blindness could not be determined (62.3%). 14% students had hereditary factors, 2.6% had neonatal factors and 21.1%
had childhood factors which led to vision loss.

Conclusions: 52.7% students had avoidable cause of blindness. 33.4% students had preventable causes and 19.3%
students had treatable causes. Childhood factors have become increasingly significant as causes of visual loss in children
who became blind after the year 2000.

Delhi J Ophthalmol 2021; 31; 40-45; Doi http://dx.doi.org/10.7869/djo.686
Keywords: Schools For Blind, Childhood Blindness, Hereditary Diseases, Avoidable Blindness

Introduction The prevalence of childhood blindness ranges from
approximately 0.3/1000 children in wealthy regions to
The number of blind children in the world was 1.5 million 1.5/1000 in the poorest communities.6
in 1990, which reduced to 1.14 million in 2015.1 Childhood
blindness is the second largest cause of blind-person years, India has an estimated 320,000 blind children, highest in the
followed by cataract. Globally, approximately 70 million world.7 Even though this represents a small portion of the
blind person years are caused by childhood blindness. total blindness, the control of blindness in children is one
Approximately 500 000 children become blind every year of the priority areas of the World Health Organization’s
and about half of them die within one or two years of (WHO) “vision 2020: The right to sight” program. This
becoming blind.2 global initiative was launched by WHO in 1999 to eliminate
In developing countries range of 31% - 70% childhood avoidable blindness worldwide by the year 2020.8
blindness is avoidable; range of 10% - 58% treatable; and
range of 3% - 28%, preventable blindness.3 The global financial cost of blindness with an onset in
childhood, in terms of loss of earning capacity (per capita
Despite considerable efforts in many developing countries, GNP), is greater than the cost of adult blindness and has
through national blindness prevention programmes, the recently been estimated to be between US$6000 million and
number of blind and visually disabled seems to be growing $27 000 million.9 Most of this is accounted for by children
globally, mainly as an effect of population increase.4 living in high income countries, where the prevalence is less,
Blindness in childhood has far reaching implications for the but life expectancy and earning capacity greater, than in
affected child and family and throughout life profoundly low income countries. However, these financial costs alone,
influences educational, employment, personal and social provide only one perspective of the public health burden of
prospects. blindness.

It is estimated that in every minute a child goes blind Reliable population based data on the causes of blindness
somewhere in the world . This is indeed troubling in view in children are difficult to obtain in developing countries as
of the attendant problems and hopelessness associated registers of blind do not exist, and very large sample sizes
with blindness especially in children. Childhood blindness would be required for formal cross sectional surveys. The
describes a number of disorders and conditions that occur in advantages of blind school studies are that many children
childhood. Most of them can be prevented or avoided. When can be examined in a standard manner by a limited number
they do occur and even after treatment or if left untreated of observers.
they can result in lifetime blindness.5

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DJO Vol. 32, No. 1, July-September 2021

Examination of children in institutions has increasingly been was not contraindicated). Additional disabilities like hearing
used to provide data on the causes of blindness in children, loss, physical handicap, epilepsy and others were recorded
but possible sources of bias need to be borne in mind. The according to child’s medical records.
standard reporting form for recording the causes of visual
loss in children, developed by the international center for Visual acuity was assessed in each eye using a Snellen
eye health, London for WHO/PBL program10 has been used tumbling ‘E’ visual acuity test chart. Students who were not
in various states of India.11,12 able to read with the ‘E’ chart, were assessed for the ability to
fix and follow light. Near vision was assessed using figures
Aims & Objectives equivalent to N18. Working distance was not specified in the
near vision measurement, encouraging children to adopt
To determine the causes of blindness and major anatomical their usual posture when attempting to read.
site of lesion leading to blindness in schools for blind in
Southern Rajasthan. And to identify the changing pattern of The student’s functional vision was assessed by - the ability to
causes of blindness in Southern Rajasthan. walk unaided around chairs set 2 meters apart, to recognize
faces at a distance of 3 meters, and to recognize the shape of
Methods three 2 cm symbols at any near distance. If child was able
to perform any two or more functional vision tests then his
Study Design functional vision was recorded as good otherwise as poor.
Survey based observational study. The anatomical classification of causes of visual loss defined
that part of the eye which had been damaged leading to
Study Setting visual loss (such as cornea, lens, retina, optic nerve, whole
After getting the clearance from Human Research Ethics globe). Where two or more anatomical sites were involved
Committee (HREC), the study was conducted at three the major site was selected, or where two sites contributed
schools for blind in Udaipur, Mount Abu and Dungarpur. equally, the most treatable condition was selected.

Study period Examination of the children was done in the presence of
March 2017 to September 2018 teachers because all the parents were not present. Further,
previous medical records were not available, hence diagnosis
Sample size was made based on history and as per coding instructions
given in WHO/PBL eye examination record and suspected
Students (114) of 3 schools for the blind were included in causes of blindness were identified.

study. Inclusion criteria To identify changing pattern of blindness in southern
Rajasthan students were divided in two groups.
• All students aged 16 years or less in the schools were Group A – Students who became blind in/before year 2000.
Group B - Students who became blind after year 2000.
included in study. These groups are compared by major anatomical sites
which led to blindness, aetiology of diseases and avoidable
• Students older than 16 years but who become blind at/ blindness. Hence the causes of childhood blindness before
and after the year 2000 can be identified.
before the age of 16 were also included in study.
The data were entered into a database and analyzed using
Exclusion criteria SPSS version 21 for Windows.

Best corrected visual acuity in better eye >3/60. Results
All data were recorded using a modified World Health
Organization Prevention of Blindness (WHO/PBL) eye A total 127 students were examined in 3 schools for blind in
examination record for children , including the anatomical southern Rajasthan during March 2017 to September 2018.
and aetiogical classification. This was used to categorize After initial vision assessment, out of which 13 students
the causes of blindness and to record the findings using the were excluded from the study because their best corrected
definitions in the coding instructions. visual acuity in better eye was >3/60. So the total number
of students(n) included in study was 114. List of schools for
The required consent for screening of the children was blind with number students is as follows:
obtained from the principal of each school. The concerned
authorities of each school were briefed about the aims and 1. Pragya Chaksu Sikshan Shansthan Andh Vidyalaya,
objectives of the study. Relevant information regarding Udaipur.(77)
history of blindness and systemic illness was collected
from the class teachers, parents (whenever possible) and by 2. Nab-Phiroze & Noshir Merwanji Rehabilitation Centre
reviewing school medical records. In case of unavailability for the Blind, Mount Abu.(11)
of parents, telephonic conversation was made if needed and
possible. 3. Swami Vivekanand Netrahin Vidyalaya, Faloj, Dist –
Dungarpur.(26)
A brief history of onset of visual loss, family history and
history of eye surgery was taken. There were 85 students (74.56%) in the age group of 10 to
Anterior segment examination was done using flashlight and
magnifying loupe. Posterior segment examination was done
using a direct and/or indirect ophthalmoscope (if mydriasis

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DJO Vol. 32, No. 1, July-September 2021

19 years. Only 6 students (5.26%) were less than 10 years of 21.9% students followed by cataract (15%) and coloboma
age and 23 students (20.18%) were above the age of 20 years. (14%) (Table 1). In majority of students exact aetiology
The students above 16 years were included in study because which led to the blindness could not be determined (62.3%).
they became blind before the age of 16. Out of 114 students 14% students had hereditary factors, 2.6% had Neonatal
101(88.6%) were male and only 13 (11.4%) were female. factors and 21.1% had childhood factors which led to vision
loss(Table 2). Out of 114 students 8 had improvement for
Among 114 students 20 students had history of blindness near vision with low vision aids (LVA) magnifiers. With use
in family members and 94 students did not have history of of LVA working distance for near was reduced and they were
blindness in family members. Since birth 85 students were prescribed for the same. 4 students had severe conjunctival
blind, while 2 students became blind during 1st month of and corneal xerosis for which they were prescribed vitamin
life and 27 students became blind after 1st month of life but A supplementation. 60 students (52.7%) had avoidable cause
before the age of 16 years. Out of 114 students 34 students of blindness. In which 38 students (33.4%) had preventable
had no perception of light and 80 students had visual acuity causes and 22 students (19.3%) had treatable causes. Most
of less than 3/60 to light perception. In all 114 students who common preventable cause was hereditary diseases and
participated in study, 30 students had good functional treatable cause was cataract (Table 3).
vision and 84 had poor functional vision. Out of 114 students
3 students had history of epilepsy, 1 student was physically Table 2: Aetiological classification of visual loss
handicapped and 1 student had hearing loss. 109 students
had no additional disability. Aetiology Frequency Percentage

Hereditary Disease – 16(14%)

Autosomal dominant 14 12.3

19 students had history of previous eye surgery. Among Autosomal Recessive 2 1.8
which 11 students had history of eye surgeries in both eyes
and 8 had unilateral eye surgeries. 17 eyes were operated Perinatal / Neonatal Factor – 3(2.6%)
for cataract, 4 eyes were removed (enucleation/evisceration),
2 had keratoplasty and in 7 eyes type of surgery could not Cerebral hypoxia/injury 2 1.8
be identified. Whole globe was affected in majority of the
students 42(36.9%) which led to blindness, followed by uvea Other 1 0.9
(15.8%), lens (14.9%), cornea (14%), optic nerve (9.6%), and
retina (8.8%). Microphthalmos was the commonest cause in Postnatal / Infancy / Childhood Factor – 24(21.1%)

Vitamin A deficiency 7 6.1

Measles 2 1.8

Trauma 3 2.6

Table 1: Anatomical site of lesion leading to Blindness Other (Meningitis, etc) 12 10.5

Anatomical site Frequency Percentage Cannot determine (unknown aetiology) – 71(62.3%)

Whole Globe – 42(36.9%) Cataract 13 11.4

Phthisis 6 5.3 Glaucoma / Buphthalmos 7 6.1

Anophthalmos 4 3.5 Retinoblastoma 1 0.9

Microphthalmos 25 21.9 Abnormality since birth 49 43.0

Buphthalmos 5 4.4 Other 1 0.9

Disorganised 1 0.9 Total 114 100.0

Cryptophthalmos 1 0.9 Table 3: Avoidable (Preventable + Treatable) causes of blindness

Cornea – 16(14%) Frequency Percentage

Staphyloma 5 4.4 Preventable causes – 38(33.4%)

Scar 3 2.6 Autosomal dominant 14 12.3

Other Opacity 8 7.0 Cerebral hypoxia/ 2 1.8
Injury
Lens – 17(14.9%)

Cataract 17 15.0 Vitamin A deficiency 7 6.1

Uvea – 18(15.8%) Measles 2 1.8

Coloboma 16 14.0 Trauma 3 2.6

Uveitis 2 1.8 Meningitis 6 5.3

Retina – 10(8.8%) TORCH 4 3.5

Dystrophy 9 7.9 Treatable causes – 22(19.3%)

Retinoblastoma 1 0.9 Cataract 13 11.4

Optic Nerve – 11(9.6%) Uveitis 2 1.8

Atrophy 11 9.6 Glaucoma 7 6.1

Total 114 100.0 Avoidable causes 60 52.7

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DJO Vol. 32, No. 1, July-September 2021

Table 4: Comparison of Anatomical lesion which led to blindness Changing pattern of blindness
between Group A and B
Students were divided in two groups.
Group A Group B Group A – Students who became blind in/before 2000.
Group B - Students who became blind after 2000.
Whole Globe This will enable us to study the changing pattern of
blindness in Southern Rajasthan. In group A Anophthalmos
Phthisis Count 15 (5.9%), Microphthalmos (35.3%) and Coloboma (20.6%)
had higher incidence than compared with group B where
Percentage 2.9% 6.3% Anopthalmos was seen in 2.4% students, Microphthalmos in
16.3% students and Coloboma in 11.3% students. In group
Anophthalmos Count 22 A Optic Atrophy was not seen in any case where in group B
13.8% students had Optic Atrophy(Table 4).
Percentage 5.9% 2.4%

Microphthalmos Count 12 13

Percentage 35.3% 16.3%

Bupthalmos Count 14

Percentage 2.9% 5%

Disorganised Count 0 1 Abnormality since birth was seen in 55.9% students in
Cryptophthalmos Percentage 0 1.2% group A and 37.5% students in group B. Childhood factors
have significance in the study as their Chi-Square (P value)
Staphyloma Count 2 1 is 8.33(0.04). P value less than 0.05 is significant. Group A
Percentage 5.9% 1.2% had 26.5% of preventable causes and group B had 36.9% of
preventable causes. Group A and B had 44.1% and 56.3%
Cornea 3 avoidable causes respectively. Total avoidable causes among
Count 3.8%
Percentage

Scar Count 03 114 students was 52.7%.

Percentage 3.8% Discussion

Other Opacity Count 1 7 This is a survey based observational study of 114 students in
Cataract Percentage 2.9% 8.8% 3 blind schools of Southern Rajasthan. Those students who
Coloboma had BCVA of <3/60 in better eye were included in study.
Lens 6 11 Blind school studies have the advantage that a large number
Count 17.7% 13.8% of children can be examined in a short time, are relatively
Percentage inexpensive, can be done by a single observer, and provide
7 9 an indication of relative importance of the different causes
Uvea 20.6% 11.3% of blindness.
Count
Percentage

Uveitis Count 0 2 Our study revealed that girls constituted only 11.4% of the
Percentage 2.4% total number of blind students. Hence encouragement of
Dystrophy 2 girls should be enhanced for admission in blind schools so
Retinoblastoma Retina 5.9% 7 that their quality of life can improve. 17.5% students had
Count 8.8% positive family history. 73.7% students had poor functional
Atrophy Percentage 0 vision. In our study major anatomical site for vision loss was
Total Count 1 whole globe (36.9%), similar to the result of the study done
Percentage 0 1.2% by Titiyal et al (2001) which showed that 32.3% of students
Optic Nerve 34 had whole globe as major site of abnormality. The result of
Count 100% 11 our study differs from that school based study of Javed et
Percentage 13.8% al (2004)13 in which the whole globe was the major site of
Count abnormality in only 20.1% of the total number of students
Percentage 80 (Table 5).
100%

Table 5: Comparison of major anatomical site leading to vision loss in different studies

Whole globe Southern North India Uttar Pradesh Gujarat Myanmar Karachi
Cornea Rajasthan
Lens Present study Titiyal et al[6] Agarwal et Danayak et Meucke et Javed et al13
Uvea 2001 al[14] 2015 al[12] 2011 al[15] 2007 2004
Retina 42(36.9%) 29(40.3%) 76(42.4%) 54(26.6%)
16(14%) 210(32.3%) 19(26.4%) 88(43.6%) 29(20.1%)
Optic Nerve 17(14.9%) 141(21.7%) 43(24%) 29(14.4%) 9(6.3%)
Other 18(15.8%) 71(10.9%) 5(6.9%) 13(7.3%) 26(18.1%)
Total 10(8.8%) 57(8.8%) 8(11.1%) 7(3.9%) 5(2.5%) 1(0.7%)
11(9.6%) 98(15.1%) 6(8.3%) 21(11.7%) 15(7.4%) 59(41%)
69(10.6%) 3(4.2%) 19(10.6%) 13(9%)
0 2(2.8%) 8(4%) 7(4.9%)
114(100%) 5(0.8%) 72(100%) 0 3(1.5%) 144(100%)
650(100%) 179(100%) 202(100%)

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DJO Vol. 32, No. 1, July-September 2021

In our study majority of the cases of childhood blindness were 2000; in whom the occurrence was 2.4%, 16.3% and 11.3%
of unknown etiology (62.3%). This is similar to the study of
Danayak et al (2011)12 (63.1%). Study of Agarwal et al (2015)14 respectively.
had least number of cases with unknown aetiology (29.1%).
Hereditary diseases were found in 14% of cases in our study, Childhood factors have become increasingly significant as
similar to studies of Titiyal et al (2001) and Meucke et al
(2007)15 i.e. 13.4% and 11.9% respectively. According to the causes of visual loss in children who became blind after the
study of Agarwal et al (2015), 56.9% students had hereditary
diseases(Table 6). year 2000. Conclusion

In our study 52.7% cases had avoidable causes of blindness. In this study, it was found that 52.7% students had avoidable
This is similar to the study done by Javed et al (2004)13 in
which 53.5% students had avoidable causes of blindness. cause of blindness. In which 33.4% students had preventable
Our study shows preventable causes in 33.3% students and
treatable causes in 19.3% students.(Table 7). causes and 19.3% students had treatable causes, indicating

the need of new focused public health strategies. Childhood

factors have become increasingly significant as causes of

visual loss in children who became blind after the year 2000

(P value = 0.04).

Out of 114 students 8 had improvement for near vision with
LVA devices. Hence similar studies should be encouraged to

Table 6: Comparison of aetiology of visual loss in different studies

Southern North India Uttar Pradesh Gujarat Myanmar Karachi
Rajasthan
Hereditary Disease Present study Titiyal et al[6] Agarwal et al[14] Danayak et al[12] Meucke et al[15] Javed et al[13]
2001 2015 2011 2007 2004
Intrauterine factor 16(14%)
0 87(13.4%) 41(56.9%) 18(10.1%) 24(11.9%) 47(32.6%)
Perinatal/ Neonatal
factor 3(2.6%) 6(0.9%) 0 0 9(4.5%) 6(4.2%)

Postnatal/ Infancy/ 8(1.2%) 0 3(1.7%) 14(6.9%) 6(4.2%)
Childhood factor
24(21.1%) 182(28%) 10(13.8%) 45(25.1%) 67(33.2%) 14(9.7%)
Cannot determine
(unknown aetiology) 71(62.3%) 367(56.5%) 21(29.1%) 113(63.1%) 88(43.6%) 71(49.2%)

Total 114(100%) 650(100%) 72(100%) 179(100%) 202(100%) 144(100%)

Table 7: Comparison of avoidable blindness in different studies

Southern Rajasthan North India Gujarat Myanmar Karachi Nine states of
India
Preventable Present study Titiyal Danayak Meucke Javed
Treatable et al[6] 2001 et al[12] 2011 et al[15] 2007 et al[13]2004 Rahi
38(33.3%) et al[16] 1993
Total Avoidable 22(19.3%) 182(28%) 53(29.6%) 55(27.3%) 58(40.3%)
60(52.7%) 408(31%)
101(15.5%) 30(16.8%) 33(16.3%) 19(13.2%)
214(16.3%)
283(43.5%) 83(46.4%) 88(43.6%) 77(53.5%)
622(47.3%)

In our study 8 students had visual improvement with LVA improve the quality of vision, thereby improving the quality
devices. 4 students had xerophthalmia which was treated of life of such visually impaired students all over the country.
with Vitamin A supplementation and artificial tears. This
study suggests there is still a scope of visual improvement by References
optical devices even in students of schools of blind. Further
preventable causes of blindness like Vitamin A deficiency 1. Gilbert C, Bowman R, Malik AN. The epidemiology of blindness
and measles can be treated if diagnosed early. Hence similar in children: changing priorities. Community eye health.
studies should be encouraged to improve the quality of 2017;30(100):74.
vision, thereby improving the quality of life of such visually
impaired students all over the world. 2. World Health Organization. Report of WHO/IAPB scientific
meeting, Hyderabad, India 13-17th April. Childhood Blindness
In our study, Anophthalmos (5.9%), Mircrophthalmos Prevention. WHO/PBL/87. 1999.
(35.3%) and Coloboma (20.6%) were observed to be more
common in students who became blind in/before year 2000, 3. Kong L, Fry M, Al-Samarraie M, Gilbert C, Steinkuller PG. An
as compared with the students who became blind after year update on progress and the changing epidemiology of causes
of childhood blindness worldwide. Journal of American
Association for Pediatric Ophthalmology and Strabismus. 2012
Dec 1;16(6):501-7.

4. Thylefors B. A global initiative for the elimination of avoidable

E-ISSN: 2454-2784  P-ISSN: 0972-0200 44 www.djo.org.in

DJO Vol. 32, No. 1, July-September 2021

blindness. Community Eye Health. 1998;11(25):1. Cite This Article as: Hardik Kiri, Lipa Mohanty, Seemal
5. Omolas CO, Aina AS, Omolase BO, Omolade EO. Causes of Goyal, A causal assessment of blindness in schools for
blind in southern Rajasthan, Delhi J Ophthalmol 2021;32; (1)
blindness and visual impairment at the school for the blind Owo, 40 - 45.
Nigeria. Annals of Ibadan postgraduate medicine. 2008;6(1):49- Acknowledgments: Nil
52. Conflict of interest: None declared
6. Titiyal JS, Pal N, Murthy GV, Gupta SK, Tandon R, Vajpayee RB, Source of Funding: None
Gilbert CE. Causes and temporal trends of blindness and severe Date of Submission: 29 Aug 2019
visual impairment in children in schools for the blind in North Date of Acceptance: 11 Sep 2019
India. British journal of ophthalmology. 2003 Aug 1;87(8):941-5.
7. Gilbert C, Rahi J, Quinn G. Visual impairment and blindness in Address for correspondence
children. In: Johnson G, Minassian D, Weale W, West S, editors. Lipa Mohanty Professor and Head,
Epidemiology of Eye Disease. 2nd ed. UK: Arnold Publishers;
2003. Department of Ophthalmology,
8. World Health Organization. Global Initiative for the Elimination Geetanjali Medical College,
of Avoidable Blindness. WHO/PBL/97.61. Geneva: WHO; 1997. Udaipur,Rajasthan, India.
9. Smith AF, Smith JG. The economic burden of global blindness: a Email: [email protected]
price too high! Br J Ophthalmol 1996;80:276–7.
10. Gilbert C, Foster A, Negrel AD, Thylefors B. Childhood blindness: Quick Response Code
a new form for recording causes of visual loss in children.
Bulletin of the World Health Organization. 1993;71(5):485.
11. Bhalerao SA, Tandon M, Singh S, Dwivedi S, Kumar S, Rana J.
Visual impairment and blindness among the students of blind
schools in Allahabad and its vicinity: a causal assessment. Indian
Journal of Ophthalmology. 2015 Mar;63(3):254.
12. Danayak PM, Patel RB. Avoidable blindness and its correction
in schools for the blind in Gujarat, India. International Journal of
Advances in Medicine. 2017 Jan 22;2(4):370-4.
13. Khan SJ, Hassan A, Khalid L, Karim U, Hashmi E, Gul F, Jehan
I. Blindness in children at the Ida Rieu school for the blind and
deaf. JPMA. 2007 Jul;57(7):334-7.
14. Agarwal P, Maan V, Omaer M, Gupta K, Chauhan L, Khurana
A. Clinical profile of childhood blindness and inappropriate
enrolment of children in schools for visually impaired in
Uttar Pradesh, India. Indian journal of ophthalmology. 2018
Oct;66(10):1456.
15. Muecke J, Hammerton M, Aung YY, Warrier S, Kong A, Morse
A, Holmes M, Yapp M, Hamilton C, Selva D. A survey of visual
impairment and blindness in children attending seven schools
for the blind in Myanmar. Ophthalmic epidemiology. 2009 Dec
1;16(6):370-7.
16. Rahi JS, Sripathi S, Gilbert CE, Foster A. Childhood blindness
due to vitamin A deficiency in India: regional variations.
Archives of disease in childhood. 1995 Apr 1;72(4):330-3.

E-ISSN: 2454-2784  P-ISSN: 0972-0200 45 Delhi Journal of Ophthalmology

DJO Vol. 32, No. 1, July-September 2021

Original Article

Presence of SARS-Cov-2 in Nasopharyngeal and Conjunctival
Swab of Residents of Hotspot Areas of Jaipur

Rekha Singh, Madhu Gupta, Mohammad Abbas Ali, Narottam Sharma, Avinsha Mathur, Vijay Arora, Vikas Krishnia

Department of ophthalmology, Rukmani Devi Beni Prasad Jaipuria Hospital (RDBP) Jaipuria hospital, Jaipur, Rajasthan, India.

Introduction: The COVID-19 pandemic, is an ongoing pandemic of coronavirus disease 2019 (COVID19), caused by

severe acute respiratory syndrome coronavirus 2 (SARSCoV2). This is still a big question, whether the corona virus is present

inconjunctival secretion or not? The relationship between COVID-19 and the ocular surface (conjunctiva, corneal epithelium

and tear film) as a potential portal of entry and as a transmission mechanism is currently under discussion due to the high

transmission rate of the disease. We did this study to identify presence of the virus at the conjunctiva and prevention of spread

in the ophthalmology context.

Methods: This Community based descriptive observational study was done in different hot spot areas by department of

ophthalmology of government RDBP Jaipuria hospital (attached RUHS-CMS) Jaipur, Rajasthan in collaboration with CMHO

Abstract Jaipur team. Total 158 subjects from the 4 hotspot areas of 18 years to 60 years age group (those who had history of contact
with COVID positive patient) were included in our study and ophthalmological evaluation is done by torch light and tested for

presence of SARS-Cov-2 by RT-PCR method in nasopharyngeal and conjunctival swab samples.

Results: Out of total 158 subjects, in all 4 hotspot areas (A+B+C+D), 37 (23%) were symptomatic, rest 121 were asymptomatic.
In hotspot area C (closed campus), out of total 37 subjects, 20 were symptomatic. At all the 4 hotspots (A+B+C+D) out of
total 158 screened subjects 29 (18.35%) were positive for nasopharyngeal swab for COVID-19 but none of them had positive
conjunctivalswab. At hotspot C (closed campus) out of total 37 screened subjects 16 (43.24%) were positive for nasopharyngeal
swab for COVID-19 but none of them had positive conjunctival swab.

Conclusions:On the basis of our study, we can conclude that risk of transmission of SARS-CoV-2 is unlikely through conjunctical
secretions if patient is asymptomatic.

Delhi J Ophthalmol 2020;32; 46-48; Doi http://dx.doi.org/10.7869/djo.687

Keywords: Conjunctival Swab, Covid-19, Nasopharyngeal Swab, Sars Cov 2

Introduction Although tears have been reported by the World Health

The COVID-19 pandemic, is an ongoing pandemic of Organization in 2003 to be one of the body fluids that might

coronavirus disease 2019 (COVID19), caused by severe acute contain SARS-CoV, the infectivity and clinical importance is

respiratory syndrome coronavirus 2 (SARS-CoV-2).The not yet understood.4 Recent investigations have revealed that

outbreak was first identified in Wuhan, China, in December highly infectious human CoVs (mainly SARS-CoV and 2019-

2019.The World Health Organization declared the outbreak nCoV) are rarely detected by RT-PCR and never isolated

a public health emergency of international concern on 30 by virus culture in tears and conjunctival secretions from

January, and a pandemic on 11 March.1 SARS and COVID-19 patients.5 Hence, it is hard to assess the

infectivity of tears and conjunctival secretions and their roles

Human CoVs mostly spread through respiratory droplets in virus transmission.

expelled by infected individuals and direct contact with

virus contaminated fomites.2 We did this study to identify presence of the virus on the

conjunctiva and prevention of spread in the ophthalmology

Symptoms of COVID-19 can be relatively non-specific; the context.
Methods
two most common symptoms are fever and dry cough. Less
common symptoms include fatigue, sputum production This Community based descriptive observational study
(phlegm), loss of the sense of smell, loss of taste, shortness of was done by Department of Ophthalmology of government
breath, muscle and joint pain, sore throat, headache, chills, RDBP Jaipuria hospital (attached RUHS-CMS) Jaipur,
vomiting, coughing out blood, diarrhea, and rash.3 Rajasthan in collaboration with CMHO Jaipur after getting

approval from institutional ethical committee.
The respiratory problems caused by this pathogen is well

known, but the ophthalmological implications of the Among the 10 hotspot areas (1km radius area from the
syndrome have not yet been well described. Currently, epicenter) from containment area (3km radius area from
more detailed information about the transmission of 2019- the epicenter), we randomly selected 4 hotspots and named
nCoV is urgently needed to prevent its pandemic spread. them – A,B,C,D and performed random sampling.We
Anatomically, the conjunctiva of the eye is easily exposed randomly selected 35-43 subjects of age 18 years to 60 years
to infectious droplets and fomites during close contact with age group (those who had history of contact (9) with COVID
infected individuals and contaminated hands. positive patient) from each hotspot for our study. Pregnant

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DJO Vol. 32, No. 1, July-September 2021

females, critically ill patients and patients who refused for Hotspot C
consent were excluded from the study.
Age Male Female Total Positive Positive
in Subjects Subjects Subjects Nasopharyngeal Conjunctival
Years
Our Ophthalmologist examined eyes with torch light and Swab swab
took conjunctival secretion swab from the lower conjunctival
fornix of right eye with sterile nylon flocked swabs without 18 -30 9 0 9 4 (44.44%) 0
topical anesthesia. At the same time nasopharyngeal swab 31-40 10 0 10 4 (40.00%) 0
was taken by CMHO team. The tips of the swab sticks were 41-50 11 0 11 6 (54.54%) 0
broken off and placed into a viral transport medium. Viral 51-60 7 0 7 2 (28.57%) 0
transport media is specific for COVID 19. Total 37 0 37 16 (43.24%) 0

Conjunctival secretion sample was collected in aseptic Hotspot D
conditions in labeled Viral Transfer Media (V.T.M). VTM
sealed and kept in plastic zipper bag and sealed samples Age Male Female Total Positive Positive
were sent for RT- PCR in sample carrier box at 2 to 6 degree in Subjects Subjects Subjects Nasopharyngeal Conjunctival
centigrade temperature. Cold chain maintained during the Years
sample transportation to laboratory. Swab swab
Data collection is done and analyzed by using appropriate
statistical methods. 18 -30 6 8 14 1 (07.14%) 0
0
Observations & Results 31-40 8 2 10 0 (00.00%) 0
0
In hotspot area A, out of total 35 subjects, only 3 were 41-50 4 6 10 2 (20.00%) 0
symptomatic.
In hotspot area B, out of total 43 subjects, only 8 were 51-60 6 3 9 0 (00.00%)
symptomatic.
In hotspot area C (closed campus), out of total 37 subjects, 20 Total 24 19 43 3 (06.98%)
were symptomatic.
In hotspot area D, out of total 43 subjects, only 6 were Table 2 :Hotspot (A+B+C+D) Tested Positive for Nasopharyngeal &
symptomatic. Conjunctival Swab
Out of total 158 subjects, in all 4 hotspot areas (A+B+C+D), no
patient is having conjunctivitis. 37 (23%) were symptomatic, Age Male Female Total Positive Positive
rest 121 were asymptomatic. in Subjects Subjects Subjects Nasopharyngeal Conjunctival
Years
Swab swab

18 -30 6 8 14 1 (07.14%) 0
0
31-40 8 2 10 0 (00.00%) 0
0
At hotspot A out of total 35 screened subjects 4 (11.43%) were 41-50 4 6 10 2 (20.00%) 0
positive for nasopharyngeal swab for COVID-19 but none of
them had positive conjunctival swab. 51-60 6 3 9 0 (00.00%)

Table 1: (Hotspot A )Asymptomatic Subjects Vs Symptomatic Total 24 19 43 3 (06.98%)
Subjects
At hotspot B out of total 43 screened subjects 6 (13.95%) were
Age Male Female Total Positive Positive positive for nasopharyngeal swab for COVID-19 but none of
in Subjects Subjects Subjects Nasopharyngeal Conjunctival them had positive conjunctival swab.
Years
Swab swab At hotspot C (closed campus) out of total 37 screened

18 -30 4 6 10 0 (00.00%) 0 subjects 16 (43.24%) were positive for nasopharyngeal swab

31-40 4 4 08 2 (25.00%) 0 for COVID-19 but none of them had positive conjunctival

swab.

41-50 5 4 09 1 (11.11%) 0 At hotspot D out of total 43 screened subjects 3 (06.98%) were

51-60 4 4 08 1 (12.50%) 0 positive for nasopharyngeal swab for COVID-19 but none of

them had positive conjunctival swab.

Total 17 18 35 4 (11.43%) 0 At all the 4 hotspots (A+B+C+D) out of total 158 screened

Hotspot B subjects 29 (18.35%) were positive for nasopharyngeal swab

for COVID-19 but none of them had positive conjunctival

Age Male Female Total Positive Positive swab. Discussion
in Subjects Subjects Subjects Nasopharyngeal Conjunctival
Years
Swab swab There are raising concerns about possibility of transmission

18 -30 5 3 8 2(25.00%) 0 of SARS-CoV-2 through conjunctival secretions, thereby
31-40 8 5 13 1 (07.69%) 0
posing a risk for transmission of infection in eye healthcare

41-50 5 6 11 3 (27.27%) 0 providers. Recently, human CoV RNA in tears and

conjunctival scraping samples were tested by reverse

51-60 6 5 11 0 (00.00%) 0 transcription-polymerase chain reaction (RT-PCR) assay in

Total 24 19 43 6 (13.95%) 0 patients with SARS and COVID-19, yet the positive rate of

the RT-PCR test was extremely low.6

E-ISSN: 2454-2784  P-ISSN: 0972-0200 47 Delhi Journal of Ophthalmology

DJO Vol. 32, No. 1, July-September 2021

Zhang and colleagues, reported conjunctivitis in two patients 2 Belser JA, Rota PA, Tumpey TM. Ocular tropism of respiratory
out of 72 laboratory-confirmed COVID-19 cases; however, viruses.MicrobiolMolBiol Rev. (2013) 77:144–56. doi: 10.1128/
2019-nCoV was detected in conjunctival swab samples by MMBR.00058-12
RT-PCR in only one patient who was a nurse working in the
Emergency Department.7 3 "WHO COVID-19 situation report 29" (PDF). World Health
Organization (WHO). 19 February 2020.
Xia and colleagues reported unilateral conjunctivitis in one
patient out of 30 confirmed COVID- 19 cases; conjunctival 4 World Health Organization. Update 27 - One Month Into the
swabs sampled from this patient 3 and 5 days after the onset Global SARSOutbreak: Status of the Outbreak and Lessons for the
of COVID-19 were both positive for 2019-nCoV by RT-PCR, Immediate Future. (2003).Available online at: https://www.who.
whereas 58 conjunctival swab samples from the other 29 int/csr/sars/archive/2003_04_11/en/
COVID-19 patients were all negative for 2019-nCoV.
5 Bonn D. SARS virus in tears? Lancet Infect Dis. (2004) 4:480–480.
Our study showed that out of total 158 subjects, in all 4 hotspot doi: 10.1016/S1473-3099(04)01093-X
areas (A+B+C+D), no patient is having conjunctivitis and is
not on any ocular medication. 37 (23%) were symptomatic, 6 Xia J, Tong J, Liu M, Shen Y, Guo D. Evaluation of coronavirus
rest 121 were asymptomatic. In hotspot area C (closed in tears andconjunctival secretions of patients with SARS-CoV-2
campus), out of total 37 subjects, 20 were symptomatic. infection. J Med Virol.(2020). doi: 10.1002/jmv.25725.

Our study showed that from all the 4 hotspots (A+B+C+D), 7 Zhang X, Chen X, Chen L, Deng C, Zou X, Liu W, et al. Theevidence
out of total 158 screened subjects 29 (18.35%) were positive of SARS-CoV-2 infection on ocular surface. Ocular Surf. (2020).
for nasopharyngeal swab for COVID-19 but none of them had doi: 10.1016/j.jtos.2020.03.010. [Epub ahead of print].
positive conjunctival swab for SARS-Cov-2 using RT‑PCR. At
hotspot C which was closed campus, a closed area with less 8 Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, et al.
scope of social distancing, out of total 37 screened subjects, Genomiccharacterisation and epidemiology of 2019 novel
16 (43.24%) were positive for nasopharyngeal swab for coronavirus:implications for virus origins and receptor binding.
COVID-19 but none of them had positive conjunctival swab. Lancet. (2020)395:565–74. doi: 10.1016/S0140-6736(20)30251-8
Low level of viral detection in conjunctival swabs can be due
to various factors like the time for maximum replication of 9 WHOreferencenumber:WHO/2019-nCoV/ContactTracing/2020.1
the virus, the timing of performing of sampling, and possibly
less secretion of the virus through conjunctival secretion, Cite This Article as: Rekha Singh, Madhu Gupta, Mohammad
and also low sensitivity of RT‑PCR.8 Abbas Ali, Narottam Sharma, Avinsha Mathur, Vijay Arora,
Vikas Krishnia Presence of SARS-Cov-2 in Nasopharyngeal and
The contribution of antimicrobial agents, including Conjunctival swab of Residents of Hotspot areas of Jaipur. Delhi J

lactoferrin and secretoryIgA, in tears and constant tear Ophthalmology 2021, 32 (1): 46-48.
Acknowledgments: Nil
rinsing, which continuously eliminates the virus on the Conflict of interest: None declared
Source of Funding: None
ocular surface into the nasal cavity through the nasolacrimal Date of Submission: 12 Jun 2020
Date of Acceptance: 15 Aug 2020
duct may be the reason for low positivity rate in conjunctival
Address for correspondence
swab. Rekha Singh MS Ophthalmology

The limitations of this study is that sampling done only from Department of Ophthalmology
RDBP Jaipuria hospital, Jaipur India
one eye. Conclusion Email id: [email protected]

This study shows that out of total 158 subjects, in all 4 hotspot Quick Response Code

areas (A+B+C+D), 37 (23%) were symptomatic, rest 121 were

asymptomatic. In hotspot area C (closed campus), out of total

37 subjects, 20 were symptomatic. SARS‑CoV‑2 was negative

in conjunctival secretion swabs of all the subjects living in

hotspot areas. Hotspot C (closed campus) which was a closed

area had a very high positivity of nasopharyngeal swab for

COVID-19 disease (43.24%) but none of them had positive

conjunctival swab testing by RT-PCR method. On the basis

of our study, we can conclude that risk of transmission of

SARS-CoV-2 is unlikely through conjunctival secretions.

References

1 Statement on the second meeting of the International Health
Regulations (2005) Emergency Committee regarding the outbreak
of novel coronavirus (2019-nCoV)". World Health Organization
(WHO). 30 January 2020.

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