Background: Measurement of for near point of convergence (NPC), amplitude of accommodation (AA) and phoria are important components of diagnosing nonstrabismic binocular vision anomalies. There is a huge variation in the normative data established for orthoptic parameters because of the variation in measurement technique. There are only limited studies for normative data based on nonclinical population in Indian population. Therefore, we aim estimate the normative values for NPC, AA, and phoria measurement in Indian population using techniques, which has good repeatability and reliability. Materials and Methods: Subjects between the age group 10-35 years participated in this prospective cross-sectional study. A self-administered symptom questionnaire was used to exclude patients with asthenopic symptoms. Clinical techniques which have good repeatability and reliability were used. NPC was measured using pen light red, green glass test. AA was measured using minus lens technique. Horizontal and vertical phoria at distance and near was measured using modified Thorington method. Results: One hundred and fifty subjects participated in the study. We found that NPC receded with age, which could because of the increase in horizontal phoria at near with age. The mean normative value for objective NPC, break and recovery of subjective NPC, monocular and binocular AA, horizontal and vertical phoria at distance and near for the three age groups are reported in the study. Conclusion: The data presented in this study can be used as a cut-off by eye care practitioners while diagnosing convergence, accommodation related anomalies in Indian population.

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Background : Current amblyopia screening methods are not cost effective. Aim : To evaluate the diagnostic capability of a modified Brückner test (MBT) for amblyopiogenic risk factors. Materials and Methods : We applied the MBT using the streak retinoscope to identify anisometropia and strabismus by noting an inter-ocular difference in movement and glow, from children who failed 6/9 Snellen on community vision screening, followed by comprehensive eye examination. Statisitics : Data were analyzed by 2 Χ 2 tables for diagnostic test parameters (95% CI). Results : From 7998 children vision-screened, 392 failed 6/9 VA and were referred. Since 34 failed to reach the centers, and 15 were excluded due to poor/ no glow, data from 343 was analyzed. The prevalence of anisometropia of 0.5D was 17%, of 1D was 11% and of strabismus 5%. For the MBT the accuracy was ≥ 90% (95%CI 89% to 97%) over the three outcomes. The sensitivity, specificity, NPV and +LR for anisometropia of 0.5D were: 0.57 (0.48, 0.64), 0.97 (0.95, 0.98), 0.92 (0.90, 0.93) and 18 (9.7, 35); for 1D: 0.74(0.60, 0.82), 0.95 (0.94, 0.97), 0.97 (0.95, 0.98) and 16 (9.3, 28); and for strabismus: 0.5 (0.32, 0.66), 0.98 (0.97, 0.98), 0.97 (0.96, 0.98) and 20 (9.1, 42). Conclusion : Our data suggests that the MBT is highly accurate and useful for ruling in anisometropia and strabismus in children who fail 6/9 Snellen. The MBT needs further validation, both by different care givers and on differing populations. It offers an affordable, portable, and clinically useful tool to detect anisometropia and strabismus. We suggest that performing an MBT prior to uniocular retinosocpy should be a routine practice.

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Iris tumors are broadly classified into cystic or solid lesions. The cystic lesions arise from iris pigment epithelium (IPE) or iris stroma. IPE cysts classically remain stable without need for intervention. Iris stromal cyst, especially those in newborns, usually requires therapy of aspiration, possibly with alcohol-induced sclerosis, or surgical resection. The solid tumors included melanocytic and nonmelanocytic lesions. The melanocytic iris tumors include freckle, nevus (including melanocytoma), Lisch nodule, and melanoma. Information from a tertiary referral center revealed that transformation of suspicious iris nevus to melanoma occurred in 4% by 10 years and 11% by 20 years. Risk factors for transformation of iris nevus to melanoma can be remembered using the ABCDEF guide as follows: A=age young (<40 years), B=blood (hyphema) in anterior chamber, C=clock hour of mass inferiorly, D=diffuse configuration, E=ectropion, F=feathery margins. The most powerful factors are diffuse growth pattern and hyphema. Tumor seeding into the anterior chamber angle and onto the iris stroma are also important. The nonmelanocytic iris tumors are relatively uncommon and included categories of choristomatous, vascular, fibrous, neural, myogenic, epithelial, xanthomatous, metastatic, lymphoid, leukemic, secondary, and non-neoplastic simulators. Overall, the most common diagnoses in a clinical series include nevus, IPE cyst, and melanoma. In summary, iris tumors comprise a wide spectrum including mostly iris nevus, IPE cyst, and iris melanoma. Risk factors estimating transformation of iris nevus to melanoma can be remembered by the ABCDEF guide.

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Because of their varied spectrum of clinical presentation and difficulty in management, pediatric uveitis remains a challenge to the ophthalmologist. Variations in clinical presentation, difficulties in eye examination, extended burden of the inflammation over quality of life, limited treatment modalities, risk of amblyopia are the main challenges in the management of pediatric uveitis. Pediatric uveitis is a cause of significant ocular morbidity and severe vision loss is found in 25-33% of such cases. This article summarizes the common causes of uveitis in children with special approach to the evaluation and diagnosis of each clinical entity.

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Chemical burns represent potentially blinding ocular injuries and constitute a true ocular emergency requiring immediate assessment and initiation of treatment. The majority of victims are young and exposure occurs at home, work place and in association with criminal assaults. Alkali injuries occur more frequently than acid injuries. Chemical injuries of the eye produce extensive damage to the ocular surface epithelium, cornea, anterior segment and limbal stem cells resulting in permanent unilateral or bilateral visual impairment. Emergency management if appropriate may be single most important factor in determining visual outcome. This article reviews the emergency management and newer techniques to improve the prognosis of patients with chemical injuries.

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Dacryocystorhinostomy or DCR is one of the most common oculoplastics surgery performed. It is a bypass procedure that creates an anastomosis between the lacrimal sac and the nasal mucosa via a bony ostium. It may be performed through an external skin incision or intranasally with or without endoscopic visualization. This article will discuss the indications, goals, and simple techniques for a successful outcome of an external DCR.

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Angle kappa is the difference between the pupillary and visual axis. This measurement is of paramount consideration in refractive surgery, as proper centration is required for optimal results. Angle kappa may contribute to MFIOL decentration and its resultant photic phenomena. Adjusting placement of MFIOLs for angle kappa is not supported by the literature but is likely to help reduce glare and haloes. Centering LASIK in angle kappa patients over the corneal light reflex is safe, efficacious, and recommended. Centering in-between the corneal reflex and the entrance pupil is also safe and efficacious. The literature regarding PRK in patients with an angle kappa is sparse but centering on the corneal reflex is assumed to be similar to centering LASIK on the corneal reflex. Thus, centration of MFIOLs, LASIK, and PRK should be focused on the corneal reflex for patients with a large angle kappa. More research is needed to guide surgeons' approach to angle kappa.

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Keratoconjunctivitis sicca, more commonly known as dry eye, is an extremely common and often unrecognized disease. It is the condition in ophthalmology that in its mild grade of severity will affect most of the population at one time or other. Due to a wide variety of presentations and symptoms, it often frustrates the ophthalmologists as well as patients. Due to multifactorial and elusive etiology, it is often challenging to treat dry eye. Ocular surface disorders are also clinically important to treat especially in terms of visual acuity. Xero-dacryology is therefore becoming a very important branch of ophthalmology. Recent studies have given insight into the inflammatory etiology of dry eye. The conventional and main approach to the treatment of dry eye is providing lubricating eye drops or tear substitutes. However, the newer treatment approach is to target the underlying cause of dry eye instead of conventional symptomatic relief. In light of the above knowledge, the present article focuses on newer theories on pathogenesis of dry eye and their impact on dry eye management. Method of Literature Search: A systematic literature review was performed using PubMed databases in two steps. The first step was oriented to articles published for dry eye. The second step was focused on the role of inflammation and anti-inflammatory therapy for dry eye. The search strategy was not limited by year of publication. A manual literature search was also undertaken from authentic reference books on ocular surface disease.

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Choroidal melanoma is the most common primary intra-ocular malignant tumor and second most common site of ten malignant melanoma sites in the body. Current diagnosis of choroidal melanoma is based on both the clinical experience of the specialist and modern diagnostic techniques such as indirect ophthalmoscopy, A- and B-ultrasonography scans, fundus fluorescein angiography, and transillumination. Invasive studies such as fine needle aspiration cytology can have significant morbidity and should only be considered if therapeutic intervention is indicated and diagnosis cannot be established by any other means. Several modes of treatment are available for choroidal melanoma. Multiple factors are taken into account when deciding one approach over other approaches, such as visual acuity of the affected eye, visual acuity of the contralateral eye, tumor size, location, ocular structures involved and presence of metastases. A comprehensive review of literature available in books and indexed journals was done. This article discusses in detail epidemiology, diagnosis, current available treatment options, and prognosis and survival of choroidal melanoma.

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Third nerve paralysis has been known to be associated with a wide spectrum of presentation and other associated factors such as the presence of ptosis, pupillary involvement, amblyopia, aberrant regeneration, poor bell's phenomenon, superior oblique (SO) overaction, and lateral rectus (LR) contracture. Correction of strabismus due to third nerve palsy can be complex as four out of the six extraocular muscles are involved and therefore should be approached differently. Third nerve palsy can be congenital or acquired. The common causes of isolated third nerve palsy in children are congenital (43%), trauma (20%), inflammation (13%), aneurysm (7%), and ophthalmoplegic migraine. Whereas, in adult population, common etiologies are vasculopathic disorders (diabetes mellitus, hypertension), aneurysm, and trauma. Treatment can be both nonsurgical and surgical. As nonsurgical modalities are not of much help, surgery remains the main-stay of treatment. Surgical strategies are different for complete and partial third nerve palsy. Surgery for complete third nerve palsy may involve supra-maximal recession - resection of the recti. This may be combined with SO transposition and augmented by surgery on the other eye. For partial third nerve, palsy surgery is determined according to nature and extent of involvement of extraocular muscles.

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Optic nerve hypoplasia (ONH) is a congenital anomaly of the optic disc that might result in moderate to severe vision loss in children. With a vast number of cases now being reported, the rarity of ONH is obviously now refuted. The major aspects of ophthalmic evaluation of an infant with possible ONH are visual assessment, fundus examination, and visual electrophysiology. Characteristically, the disc is small, there is a peripapillary double-ring sign, vascular tortuosity, and thinning of the nerve fiber layer. A patient with ONH should be assessed for presence of neurologic, radiologic, and endocrine associations. There may be maternal associations like premature births, fetal alcohol syndrome, maternal diabetes. Systemic associations in the child include endocrine abnormalities, developmental delay, cerebral palsy, and seizures. Besides the hypoplastic optic nerve and chiasm, neuroimaging shows abnormalities in ventricles or white- or gray-matter development, septo-optic dysplasia, hydrocephalus, and corpus callosum abnormalities. There is a greater incidence of clinical neurologic abnormalities in patients with bilateral ONH (65%) than patients with unilateral ONH. We present a review on the available literature on the same to urge caution in our clinical practice when dealing with patients with ONH. Fundus photography, ocular coherence tomography, visual field testing, color vision evaluation, neuroimaging, endocrinology consultation with or without genetic testing are helpful in the diagnosis and management of ONH. (Method of search: MEDLINE, PUBMED).

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Fraser syndrome (FS) is a rare disorder characterized by a combination of acrofacial and urogenital malformations with or without cryptophthalmos. We report a newborn and its two elder siblings who had multiple congenital anomalies and clinico-radiological features consistent with FS.

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This is an observational case series of five cases of acute acquired comitant esotropia (AACE) with diplopia, aged between 5 and 12 years. The duration of presenting complaints ranged from 4 days to 2 months. A detailed ophthalmic evaluation and neuroimaging were done on all patients. Three patients were found to have intracranial pathology. Two patients had pontine glioma and one patient had benign intracranial hypertension. One patient was diagnosed as accommodative spasm and one patient was diagnosed as having Type 2 AACE. We would like to conclude that AACE can be of a varied aetiology ranging from convergence spasm to those harboring serious intracranial diseases. We reiterate that AACE has a small but significant association with intracranial disorders. Neuroimaging is a definite need in cases which cannot be proved to be either Type 1 or 2.

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Obstructive sleep apnea (OSA) is one of the systemic risk factors for glaucoma which causes irreversible visual field (VF) damage. We reviewed the published data of all types of studies on the association between these two conditions and papers regarding functional and structural changes related to glaucomatous damage using Scopus, web of science, and PubMed databases. There is evidence that the prevalence of glaucoma is higher in OSA patients, which independent of intraocular pressure (IOP). Studies have reported thinning of retinal nerve fiber layer (RNFL), alteration of optic nerve head, choroidal and macular thickness, and reduced VF sensitivity in patients of OSA with no history glaucoma. A negative correlation of apnea-hypopnea index with RNFL and VF indices has been described in some studies. Raised IOP was noted which is possibly related to obesity, supine position during sleep, and raised intracranial pressure. Diurnal fluctuations of IOP show more variations in OSA patients before and after continuous positive airway pressure (CPAP) therapy when compared with the normal cases. The vascular factors behind the pathogenesis include recurrent hypoxia with increased vascular resistance, oxidative stress damage to the optic nerve. In conclusion, comprehensive glaucoma evaluation should be recommended in patients with OSA and should also periodically monitor IOP during CPAP treatment which may trigger the progression of glaucomatous damage.

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Spasm of accommodation is a rare condition characterized by a sudden increase in myopia. It can occur in emmetropes, hypermetropes and myopes. All the physiological changes that occur in normal accommodation are exaggerated. Mostly the cause is functional disorder and the condition gradually improves. We hereby present the changes occurring in spasm of accommodation as seen on Scheimpflug imaging.

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Purpose : To study the accuracy of different recent intraocular lens (IOL) calculation formulas in predicting a target postoperative refraction ± 1.0D (Diopters) in patients with long eyes (axial length ≥ 26.0 mm) undergoing phacoemulsification. Materials and Methods : This study comprised 127 eyes of 87 patients who presented with cataract and axial eye length ≥ 26 mm. Before phacoemulsification and IOL implantation; axial length measurement using immersion ultrasound A-scan technique, and autokeratometry with or without computerized corneal topography for K readings were done. The IOL power was calculated using four formulas, namely the SRK-T, Hoffer-Q, Holladay-2, and Haigis formulas. Four months after surgery, refraction was done. Differences between actual postoperative refraction and assumed target refraction using the different formulas were analyzed. P < 0.05 was considered statistically significant. Results : In all 127 eyes, the mean axial length was 31.71 mm (range, 26.06-37.11 mm) and the mean K was 44.68 D (range, 40.05-55.14D). The mean preoperative spherical equivalent (SE) was -17.52D (range, -12.25 to -30.50D). After surgery, the mean spherical equivalent was -0.8 ± 0.83D (range, +1.25 to -3.75D). The mean postoperative refractive SE when implanting a plus power IOLs was -0.3 ± 0.51D (P < 0.001) while the mean postoperative refractive SE when implanting a minus power IOLs was +1.21 ± 0.11D denoting a highly significant tendency toward hyperopia (P < 0.001). Concerning the minus power group, most postoperative refractive error was within +1.0 to +2.0D in the actual implanted IOL and in all other formula calculated IOL power. However, Haigis formula showed the least deviation while SRK-T and other formulas showed a greater tendency toward hyperopia. Conclusions : In eyes with high axial myopia, the performance of SRK-T, Hoffer-Q, Holladay-2 and Haigis formulas are comparable in low plus-powered IOL implantation. Haigis formula is the best formula when minus power IOL is implanted.

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Purpose : We present the level of Knowledge, Attitude and Practice (KAP) among diabetic patients regarding eye complications and their care. Materials and Methods : A cross sectional study was conducted in 2008 at seven regions of Oman. Arabic speaking nurses interviewed diabetics at clinics. They used a closed ended questionnaire with 15 questions. The responses were analyzed and the KAP were grouped into excellent (>80%), good (60 to 79%), average (40 to 59%), poor (20 to 39%) and very poor (<20%). They were also compared among epidemiologic variants. Result : Of the 750 participants, 'Excellent', grade of knowledge about diagnosis and eye care was present in 547 (72.9%) and 135 (18%) persons respectively. The 'excellent' grade of attitude about eye involvement and eye care was found in 135 (18%) and 224 (29.9%) participants. The practice for undergoing eye check up and accepting treatment was of 'excellent' grade in 390 (52%) and 594 (79.2%) respectively. Age (OR = 0.98), Sharqiya region (OR = 25) and '5 to 9' duration of DM (OR = 2.1) were associated with the knowledge. '<1 year' duration (OR = 0.3) and Dhakhiliya region (OR = 39) were associated with the attitude while '5 to 9 year' duration (OR = 3.4) was associated with better practices. Conclusions : Knowledge about eye complications and care is satisfactory among persons with diabetes. However, levels of attitude and practice were less than desired and should be improved. This could strengthen program approach for early detection and care of eye complications of diabetes in Oman.

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Sebaceous gland carcinoma, commonly arises in the periocular area, is an uncommon condition. It represents 1-5.5% of eyelid malignancies and is considered to be the third most common eyelid malignancy after basal cell and squamous cell carcinomas, although few reports placed this tumor as second most common after basal cell carcinoma. It usually affects elderly women and characterized by high rate of local recurrence, regional, and distant metastases. A delay in diagnosis, which can be attributed primarily to ability of this tumor to masquerade as more benign conditions, often leads to inappropriate management with increased morbidity and mortality rates. In this study, the authors discuss key elements of the primary disease and therapeutic options available to treat such devastating problem.

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Tumors of the conjunctiva and cornea comprise a large and varied spectrum of conditions. These tumors are grouped into two major categories of congenital and acquired lesions. The acquired lesions are further subdivided based on origin of the mass into surface epithelial, mucoepidermoid, melanocytic, vascular, fibrous, neural, histiocytic, myxoid, myogenic, lipomatous, lymphoid, leukemic, metastatic and secondary tumors. Ocular surface tumors include a variety of neoplasms originating from squamous epithelium, melanocytic tumors and lymphocytic resident cells of the conjunctival stroma. In this review, we highlight clinical features of these lesions, important diagnostic and investigative tools and standard care of management.

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Central serous chorioretinopathy (CSC), the fourth most common nonsurgical retinopathy, is characterized by serous retinal detachment most commonly involving the macular region. Although natural history of CSC shows a self-limiting course, patients are known to present with persistent, recurrent, or even bilateral CSC with distressing visual loss. Multimodal imaging techniques for CSC include optical coherence tomography (OCT) with enhanced depth imaging, fundus autofluorescence, fluorescein angiography, indocyanine green angiography, and OCT angiography. Evolution of new imaging techniques in addition to conventional imaging modalities has revolutionized the understanding about the pathophysiology of CSC and hence the diagnosis and management. This review article elaborates on current understanding about pathophysiology and risk factors, as well as multimodal imaging-based features of CSC.

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Background : Corneal diseases are one of the major causes of visual loss and blindness, second only to cataract. Amongst corneal diseases, microbial keratitis is a major blinding disease. In some countries, fungal keratitis accounts for almost 50% of patients with culture-proven microbial keratitis. Aim : This study was conducted to determine the epidemiological characteristics of fungal keratitis in an urban population of West Bengal and identify the specific pathogenic organisms. Methods : The charts of patients with microbial keratitis who attended the Cornea Services of Priyamvada Birla Aravind Eye Hospital from January to December 2008 were retrospectively reviewed. Records of patients with 10% KOH mount and culture positive fungal keratitis were analyzed for epidemiological features, laboratory findings and treatment outcomes. Results : Of the 289 patients of microbial keratitis included in the study, 110 patients (38.06%) were diagnosed with fungal keratitis (10% KOH mount positive). Of the 110 patients, 74 (67.27%) fitted the study inclusion criteria (10% KOH mount and culture positive). Forty five of 74 patients (60.81%) in the study group were in the older age group (>50 years). Ocular trauma in 35 cases (47.29%) was identified as a high risk factor and vegetative injuries in 17 cases (22.97%) were identified as a significant cause for fungal keratitis. Maximum organism source was from corneal scrapings in 41 cases (55%). The predominant fungal species isolated was Aspergillus sp (55.40%) followed by Candida albicans 14 cases (18.91%) and Fusarium sp. in 8 cases (10.81%). Agricultural activity related ocular trauma was the principal cause of mycotic keratitis and males were more commonly affected. Thirty of 74 cases (40.55%) of the culture positive patients healed with corneal scar formation with medical treatment whereas 44 cases (59.45%) required therapeutic keratoplasty. Conclusion : Fungal keratitis is an important cause of microbial keratitis with injury to the cornea being a leading predisposing factor. Although Aspergillus sp. was implicated in most of the patients in our study population, Candida sp. were found in higher numbers than previously reported. Keratitis caused by filamentous fungi responds adequately to medical management. Therapeutic keratoplasty continues to remain an important treatment modality in infections with Candida sp. Early diagnosis with prompt identification of the pathogenic organism is mandatory to initiate appropriate therapy and thereby reduce morbidity.

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