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  1. Video glass based vision testing for Home / School vision testing may make testing complete

    Vision testing is a very tedious process. If a complete testing including contrast testing,colour testing,amsler test,glare test,speed of reading and other tests are undertaken it may take a lot of time.It is a reality that even today visual acuity testing alone is the deciding factor for undertaking cataract surgery. It has been noted by some authors that lack of government-funded routine eye examinations is associated with a reduced incidence of self-reported glaucoma and cataracts, probably due to reduced detection rates (1) this only means that some method of home testing may be essential.It is also possible that many kids would not go blind due to amblyopia if vision was to be tested .So it may be useful to test vision at home or school, which can be reported to the eye surgeon. Some authors have envisaged a lay person administered vision test which may be valid for identifying amblyopia in a controlled environment thus making a cost-effective and easily accessible vision screening performed by lay people a reality (2). A school vision screening program involving only school teachers was found to have resulted in more efficient screening than a program including professionals with the costs being a third of what would have been spend and it was found to also improve compliance with regards to hospital referral (3). Many authors have tried mobile app based methods for vision and concluded that while the results are not interchangeable with paper-based charts, mobile app tablet-based tests of reading speed are reliable and rapid to perform, with the potential to capture functional visual ability in research studies and clinical practice(4). Such apps can be easily incorporated into video glasses routinely used by children in video games.

    We used a video glass available for playing video games and projected vision charts at an appropriate distance into the glass and tested vision at home. The fact that the glass had covers on the side, nullified the effect of ambient light. Also some homes in India may be actually cubicles and so may not have the requisite distance for testing and so in such cases a mobile app based visual testing with charts projected into the video glass helps in such situations. Following the ease of testing and the improved ability of patients or care takers who are now being able to test vision at home; different aspects of vision are now being tested by patients or care takers. When this becomes more common even eye surgeons will begin to do more tests.

    References:-

    1) Chan CH, Trope GE, Badley EM, Buys YM, Jin YP. The impact of lack of government-insured routine eye examinations on the incidence of self- reported glaucoma, cataracts, and vision loss. Invest Ophthalmol Vis Sci. 2014 Dec 9;55(12):8544-9. doi: 10.1167/iovs.14-15361. 2) Longmuir SQ, Pfeifer W, Shah SS, Olson R. Validity of a layperson- administered Web-based vision screening test. J AAPOS. 2015 Feb;19(1):29- 32. doi:10.1016/j.jaapos.2014.10.021 3) Priya A, Veena K, Thulasiraj R, Fredrick M, Venkatesh R, Sengupta S, BassettK. Vision screening by teachers in southern Indian schools: testing a new "all class teacher" model. Ophthalmic Epidemiol. 2015 Feb;22(1):60- 5. doi:10.3109/09286586.2014.988877. 4) Kingsnorth A, Wolffsohn JS. Mobile app reading speed test. Br J Ophthalmol.2014 Oct 29. pii: bjophthalmol-2014-305818. doi:10.1136/bjophthalmol-2014-305818.

    Conflict of Interest:

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  2. Indirect ophthalmoscope , will it get replaced by smart phones in some settings?- Serial video recording of retinal conditions in ICCU setting with indirect ophthalmoscopy with inexpensive smart phones

    Indirect ophthalmoscopy has advanced since its inception. We now recognize the importance of video imaging of the retina. Authors deviced various slit lamp adaptors to capture retinal image(1) Many authors have used smartphones coupled with indirect ophthalmoscopy and some even identified an iPhone application that can control the flash and reduce the intensity to levels that do not damage the retina.(2,3,4,5)

    Some authors described a lightweight, compact, user-friendly, 3D printed attachment which enabled high quality fundus photos achieved by coupling smartphones to indirect ophthalmoscopy lens. (6)

    In January 2013, the FDA approved the iExaminer (Welch Allyn), the first smartphone-based imaging adaptor system that attaches an iPhone 4 (Apple Inc, Cupertino, CA) to Welch Allyn's Panoptic Ophthalmoscope to capture images of the retina in combination with the iExaminer App.(7)

    But all of the methods with adapters and iPhones are expensive or bulky and impossible to use in ICCU setting.

    We used a blackberry Z 3 mobile phone to capture serial video recordings of cases in ICCU setting in patients on ventilator support and recorded various cases like Terson's syndrome and papillodema and other retinal conditions that need serial follow up. The smartphone allowed us to use 1080 p HD recording and the autofocus and ambient light sensors in recent cameras as well as the other features allow better evaluation of the retina.

    The audio video combine recording allows for simultaneous commentary too which is important for Medical records and to save time in ICCU setting. The audio and video format supported are 3GP, 3GP2, M4A, M4V, MOV, MP4, MKV, MPEG-4, AVI, ASF, WMV, WMA, MP3, MKA, AAC, AMR, F4V, WAV, AWB, OGG, FLAC and these allow viewing in any setting,transfer over any media and storage and editing with ease so as to create a time compressed view of the condition for patient education and counselling.

    The blackberry at a cost of Indian currency of 13,000 rupees is a very cheap piton for such video recording of the retina. It was very easy to train ICU residents and the ability to transfer data through encrypted messengers like Telegram allows for excellent management of such patients in the follow up period especially in ICCU setting in rural areas where Superspeciality may not be available round the clock in a country like India. The ease with which even residents and non ophthalmologists can acquire images and transfer the images ,makes smart phones replace indirect ophthalmoscopes in these settings. Besides the use of these methods by those screening for diabetic retinopathy in rural outreach settings makes it all the more exciting.The ability to see the video in slow motion allows for better screening as well as in better assessment in telepath alkaloid from rural areas as has been our experience.

    Considering all these developments the traditional indirect ophthalmoscope may need to be modified and made less expensive and less bulkier and easier to use and learn even in emergency rooms and ICCU settings to withstand the competition from smart phones.

    References:- 1) Chakrabarti D. Application of mobile technology in ophthalmology to meet the demands of low-resource settings. Journal of Mobile Technology in Medicine 2012;1(4S):1-3. 2) Lord RK, Shah VA, San Filippo AN, Krishna R. Novel uses of smartphones in ophthalmology. Ophthalmology 2010;117(6):1274. e3 3) Chakrabarti D. Application of mobile technology in ophthalmology to meet the demands of low-resource settings. Journal of Mobile Technology in Medicine 2012;1(4S):1-3. 4) Haddock LJ, Kim DY, Mukai S. Simple, Inexpensive Technique for High- Quality Smartphone Fundus Photography in Human and Animal Eyes. Journal of Ophthalmology 2013;2013. http://dx.doi.org/10.1155/2013/518479 5) Chhablani J, Kaja S, Shah VA. Smartphones in ophthalmology. Indian J Ophthalmol 2012;60(2):127 6) David Myung, Alexandre Jais, Lingmin He.Mark S. Blumenkranz, Robert T. Chang, 3D Printed Smartphone Indirect Lens Adapter for Rapid, High Quality Retinal Imaging. Journal MTM 3:1:9-15, 2014 7) Teichman JC, Sher JH, Ahmed IIK. From iPhone to eyePhone: A technique for photodocumentation. Canadian Journal of Ophthalmology/Journal Canadien d'Ophtalmologie 2011;46(3):284-6.

    Conflict of Interest:

    None declared

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  3. Endoscopic suturing of flaps in endonasal DCR with stenting further improves results

    Endoscopic suturing of lacrimal sac flap to the nasal mucosa flap in Dacryocystorhinostomy ( DCR) was described by us as early as 2004 and a video of the procedure was published in textbook of oculoplasty (1) The audits done showed that the short term results were excellent and the only concern was the time taken to do the surgery. Three years later another paper described excellent results with suturing of the flaps and it was reported to have a primary success rate of 96 percent and ultimate success rate of 100 percent and the authors contemplated replacement of external DCR with endonasal DCR (2) Traumatic Dacryocystitis has been treated often by external DCR and some authors have suggested external DCR with stenting in such cases (3) We have noted in our audits that doing an endonasal DCR with suturing of the flaps and stenting both leads to 100 percent results even in cases with trauma where in there is Dacryocystitis with coexisting orbital fracture too. The endoscopy procedure does not disturb the lacrimal pump and the suturing of the flap causes healing by primary intention and makes the procedure 100 percent successful especially when combined with stents.

    Reference

    1) Sunil Moreker, Sneha K, Kirtane MV, Mankekar G. Endoscopic Dacrocystorhinostomy :Recent advances. Oculoplasty and reconstructive surgery , Jaypee publications 2010, page 286 2) Kirtane MV, Lall A, Chavan K, Satwalekar D. Endoscopic dacryocystorhinostomy with flap suturing. Indian J Otolaryngol Head Neck Surg. 2013 Aug;65(Suppl):236-41. doi: 10.1007/s12070-011-0354-z. 3) Rizvi SA, Sharma SC, Tripathy S, Sharma S. Management of traumatic Dacryocystitis and failed dacryocystorhinostomy using silicone lacrimal intubation set. Indian J Otolaryngol Head Neck Surg. 2011 Jul;63(3):264-8. doi:10.1007/s12070-011-0230-x.

    Conflict of Interest:

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  4. Re: Intrastromal voriconazole for deep recalcitrant fungal keratitis: a case series

    Dear Editor; I have read the article entitled "Intrastromal voriconazole for deep recalcitrant fungal keratitis: a case series" by Kalaiselvi et al. with interest.1 The authors investigated the efficacy of intrastromal voriconazole injection in the management of deep recalcitrant fungal keratitis and found it safe and effective. I would like to contribute to the article in terms of clinical practice.

    The authors' choice was voriconazole as an antifungal agent, and it seems reasonable because of its' safety and potency on various fungal species especially aspergillus spp. On the other hand, itraconazole could also be studied due to a distinct characteristic of it. Goktas et al. revealed that itraconazole can reduce corneal neovascularization.2 Recalcitrant corneal infections usually result in corneal scars and sometimes corneal neovascularizations. Therefore; intrastromal administration of itraconazole would be more beneficial in which cases the infectious agents are found sensitive to itraconazole.

    Zeng et al. have recently reported that amniotic membrane covering (AMC) may enhance cornea epithelial regeneration after debridement of fungal keratitis.3 I suppose that AMC could be helpful alone or in combination with intrastromal administration of antifungal agents. It will promote wound healing, support corneal integrity and decrease the risk of perforation due to such persistent fungal infections.

    Conflict of Interest:

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  5. Ranibizumab for neovascular AMD in eyes with good baseline visual acuity.

    We read with interest and congratulate Lee et al1 on publishing the largest study to date on visual outcomes reported upto 36 months, with intravitreal ranibizumab treatment for neovascular age related macular degeneration (AMD). However we do not agree with their conclusion that this is the first publication to focus on the visual outcomes on this subgroup of patients, excluded from treatment by the NICE UK criteria. Our group2 was the first to publish, in this journal, the 12-month treatment outcomes in a retrospective small case series of fourteen patients. Subsequently, Williams and Blyth3 reported the outcomes from Wales, UK. Other investigators have published good treatment outcomes with earlier treatments at good baseline visual acuity 4,5. Surprisingly, none of these investigators seem to have been acknowledged or referenced in the discussion section by Lee et al1. We agree with the authors that earlier treatment in neovascular age related macular degeneration has the potential to maintain good visual function for longer duration and await the cost effectiveness analysis the authors wish to publish in future. Clinical experience and logic does dictate that once there is clinical and/or OCT based imaging evidence of disease activity in neovascular age related macular degeneration, commencing treatment earlier rather than waiting for visual acuity to deteriorate to 6/12 and below, is the best course of action. REFERENCES

    1. Lee AY, Lee CS, Butt T , et al. UK AMD EMR USERS GROUP REPORT V : benefits of initiating therapy for neovascular AMD in eyes with vision better than 6/12. Br J Ophthalmol. 2015 Feb 13. Pii:bjophthalmol-2014- 306229. Doi: 10.1136/bjophthalmol-2014-306229. Epub ahead of print.

    2. Raja MS, Saldana M, Goldsmith C, Burton BJ: Ranibizumab treatment for neovascular age- related macular degeneration in patients with good baseline visual acuity (better than 6/12): 12-month outcomes. Br J Ophthalmol 2010; 94:1543-1545.

    3. Williams TA, Blyth CP: Outcome of ranibizumab treatment in neovascular age related macular degeneration in eyes with baseline visual acuity better than 6/12. Eye (Lond) 2011;25:1617-1621.

    4. Saito M, Iida T, Kano M: Intravitreal ranibizumab for exudative age-related macular de- generation with good baseline visual acuity. Retina 2012;32:1250-1259.

    5. Kato A, Yasukawa T, Suga K, et al. Intravitreal ranibizumab for patients with neovascular age related macular degeneration with good baseline visual acuity. Ophthalmologica . 2015;233(1):27-34.

    Conflict of Interest:

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  6. Prevalence of canaliculitis after smartplug insertion during long-term follow-up

    In the recently published study by Klein-Theyer and colleagues, the authors conducted a retrospective case series study to evaluate the number of eyes (and patients) that develop canaliculitis over time after having SmartPlugs inserted into the eye for underlying dry eye syndrome. The authors described the measure of disease occurrence as prevalence; however, this is incorrect. Prevalence is the proportion of the population that has the disease at a particular time. In this study, disease-free eyes were followed over time to determine the occurrence of new cases of canaliculitus during the observation period. This describes a measure of incidence, not prevalence. This error has implications for the appropriate interpretation of the observed results. The authors reported a cumulative probability of the event during the observation period; however, this assumes none of the patients had been lost to follow -up. Patients were followed for a median of 7.9 years, which means some of the patients were censored and their limited participation must be accounted for in the denominator. Therefore, an incidence rate based on person-time should have been calculated. Authors are strongly encouraged to conduct a reanalysis of their study data and provide readers with the appropriate measure of incidence, amending their interpretation as warranted.

    Conflict of Interest:

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  7. SLET allograft in bilateral Limbal stem cell deficiency

    In routine keratoplasties, HLA matching and systemic immunosuppressive drugs are not employed, yet 90% of the uncomplicated transplants survive. (1) But allografts of stem cells may need to be taken from live HLA matched donors as cadaver stem cells have been reported to fail in the long term inspite of continued immunosuppressive treatment with cyclosporine A,steroids, FK 506 and mycophenolate mofetil.Also the success of the said procedure as described by Sangwan et al (2) needs to be tested as an allograft in cases of immune damage to stem cells too. We did an allograft SLET on a 29 year old patient's eye with vision of hand movements upto one feet ; by taking the stem cell from the patient's sister in the same manner as described by Sangwan et al but modified it and did a sandwich technique placing the stem cell on tissue glue between two layers of amniotic membrane and covered it with a bandage contact lens. The patient had bilateral Limbal stem cell deficiency due to a host graft rejection phenomena after a bone marrow transplant at the age of six with poor vision in both eyes. Post operatively he was maintained on immunosupression with steroids systemically and locally. The final visual acuity at two months post operatively was 6/36. There have been cases reports (3) of success with stem cell allografts but this probably needs to be further evaluated especially in cases which are bilateral like our case. Allograft stem cell has been used successfully in Limbal stem cell deficiency due to chemical burns (4). It has also been described for Steven Johnson syndrome (5) and authors have described that HLA nonmatched live relative donor's stem cell fail to reconstitute the corneal surface. But the efficacy of such a procedure when done as an allograft in Limbal stem cell deficiency after host graft rejection process due to bone marrow transplant in childhood needs to be further evaluated. We attempted to do the same and achieved reasonable success in the short term. Long term follow up should provide us with more information. In the meantime any advice would be welcome.

    References 1. Niederkorn JY, Kaplan HJ (eds): Immune Response and the Eye. Chem Immunol Allergy. Basel, Karger, 2007, vol 92, pp 290-299 . 2. Sangwan et al. Simple limbal epithelial transplantation (SLET): a novel surgical technique for the treatment of unilateral limbal stem cell deficiency. Br J Ophthalmol 2012 96:931-934; doi:10.1136/bjophthalmol- 2011-301164 3. Gardu?o -Vieyra L. * Gonzalez C.R. * Hernandez-Da Mota S.E. Limbal Stem Cell Allografts and Corneal Transplant in a Patient with Severe Corneal Perforation due to Thermokeratoplasty andCross-Linking Treatment Burn Case Rep Ophthalmol 2012;3:364-369 4. Huang T, Wang Y, Zhang H, Gao N, Hu A. Limbal allografting from living- related donors to treat partial limbal deficiency secondary to ocular chemical burns.Arch Ophthalmol. 2011 Oct;129(10):1267-73. doi: 10.1001/archophthalmol.2011.251. 5. Rao SK, Rajagopal R, Sitalakshmi G, Padmanabhan P. Limbal allografting fromrelated live donors for corneal surface reconstruction. Ophthalmology. 1999 Apr;106(4):822-

    Conflict of Interest:

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  8. Outcomes of posterior-approach 'levatorpexy' in congenital ptosis repair

    Dear Editor We read with great interest the article entitled "Outcomes of posterior- approach 'levatorpexy' in congenital ptosis repair" by Al-Abbadi Z et al.(1) In their article, the authors described posterior-approach levatorpexy surgical technique for management of congenital ptosis. In this technique, the first suture was passed through the levator aponeurosis- levator muscle junction or above according to levator function. The second suture was passed 2 mm medial to first suture. (1) However, in their previous article the authors used the second suture 2 mm lateral to first suture for management of involutional aponeurotic ptosis. (2) The authors did not discuss the reason why they moved the second suture from lateral to medial.

    REFERENCES 1. Al-Abbadi Z, Sagili S, Malhotra R. Outcomes of posterior-approach 'levatorpexy' in congenital ptosis repair. Br J Ophthalmol. 2014 Dec;98(12):1686-90. 2. Patel V, Salam A, Malhotra R. Posterior approach white line advancement ptosis repair: the evolving posterior approach to ptosis surgery. Br J Ophthalmol. 2010 Nov;94(11):1513-8.

    Conflict of Interest:

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  9. RE: Alberti M, la Cour M. Face-down positioning versus non-supine positioning in macular hole surgery. Br J Ophthalmol 2015;99:2 236-239

    We read the paper by Alberti and la Cour [1] with great interest as we are shortly to commence a randomised controlled clinical trial to determine the value of face-down positioning following surgery for large (> 400 micrometres) macular holes [2]. We would urge readers to be mindful of the message recently emphasised by the Ophthalmic Statistics Group that absence of evidence is not evidence of absence, and that confidence intervals can be informative in such situations [3]. The data provided by Alberti and la Cour give an odds ratio of surgical success following face-down versus non supine positioning of 0.77 (0.06, 7.06). Whilst the data are entirely consistent with there being no difference, it is clear that there is much uncertainty. We have ignored unit of analysis issues [4] in computing this effect estimate. When developing our research proposal we discussed the issue of positioning with people who had recently undergone surgery for macular hole. Whilst they very much agreed that positioning could be arduous they also expressed the view that they would do whatever necessary to minimise any need for further surgery.

    1.Alberti M, la Cour M. Face-down positioning versus non-supine positioning in macular hole surgery. Br J Ophthalmol 2015;99:2 236-239 2.http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=17966 3.Bunce C, Patel KV, Xing W. Ophthalmic statistics note 2: absence of evidence is not evidence of absence. Br J Ophthalmol 2014;98:703-705 4.Bunce C, Patel KV, Xing W. Ophthalmic statistics note 1: unit of analysis. Br J Ophthalmol 2014;98:3 408-412

    Conflict of Interest:

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  10. Inconclusive treatment recommendations with ranibizumab in retinal vein occlusion by an expert panel

    Title page:

    Inconclusive treatment recommendations with ranibizumab in retinal vein occlusion by an expert panel

    Dan Calugaru, PhD 1 and Mihai Calugaru, PhD 2

    1Department of Ophthalmology, University of Medicine Cluj- Napoca/Romania

    Phone number: 0745 827 552

    Fax number: 0040 264 591468

    E-mail: dan.calugaru@ymail.com

    2Department of Ophthalmology, University of Medicine Cluj- Napoca/Romania

    Phone number: 0741 165 094

    Fax number: 00 40 264 591468

    E-mail: mihai.calugaru@mail.dntcj.ro Address of the Corresponding Author:

    Mihai Calugaru

    Strada Br??ncoveanu 11

    3400 Cluj-Napoca/Romania

    E-mail: mihai.calugaru@mail.dntcj.ro The manuscript has been seen and approved by all authors; None of the authors has conflict of interest with the submission; The authors have never received financial support for this article;

    Inconclusive treatment recommendations with ranibizumab in retinal vein occlusion by an expert panel Re: Ranibizumab in retinal vein occlusion: treatment recommendations by an expert panel. Gerding et al. Br J Ophthalmol 2015;99 (3): 298-304 doi:10.1136/bjophthalmol-2014-305041

    In their article, Gerding et al.1, developed treatment recommendations with ranibizumab (Lucentis, Genentech, Inc., South San Francisco, CA) in patients with macular edema secondary to retinal vein occlusions. For central retinal vein occlusion (CRVO), the authors' recommendations were based on evidence delivered mainly from the Cruise study.2 Of note, the conclusions described by Gerding et al. related only to nonischemic occlusions because 98.5% of the treated patients had had a perfused retinal status. Moreover, the authors' recommendations were not updated with the available long-term results 3,4 of the Cruise study, 2 which revealed a worsening of the initial remarkable outcomes achieved after aggressive treatment was applied for 12 months. Thus, the 12-month extension 3 of the Cruise study 2 showed a deterioration in the outcomes measures in all three groups of patients, i.e., sham/0.5 mg, 0.3 mg, and 0.5 mg of ranibizumab (decrease in the best corrected visual acuity [BCVA] with -4.2, -5.5, and -4.1 letters, respectively, and an increase in the foveal thickness with 63, 88.6, and 72.4 ?m, respectively). Furthermore, a study with an extension of the follow-up to 51.4 months 4 after the Cruise study baseline reported that 56% of patients still required frequent injections; 6 patients experienced a reduction in the BCVA of -33, -18, - 11, -4, -3, and -3 letters, having serious ischemic macular damages. Delayed deterioration of visual functions could be explained by the lower frequency of injections as well as the long period of time before the initiation of therapy, during which patients went without treatment (the CRVO diagnosis was made within 12 months before initiation of screening). These facts favored the delayed occurrence of irreversible and ischemic lesions of the macular retinal ganglion cells, close to the foveola. In conclusion, CRVO (both ischemic and nonischemic forms) should be considered an ophthalmic emergency, which has to be promptly treated with anti-angiogenic agents. Every delay of treatment adversely influences the delayed deterioration of visual functions, which are difficult to correct even with subsequent treatment.5

    References

    1. Gerding H, Mones J, Tadayoni R, et al. Ranibizumab in retinal vein occlusion: treatment

    reccomendations by an expert panel. Br J Ophthalmol 2015;99:297-304.

    2. Campochiaro PA, Brown DM, Awh CC, et al. Sustained benefits from ranibizumab for macular

    edema following central retinal vein occlusion: twelve-month outcomes in a phase III study.

    Ophthalmology 2011;118:2041-49.

    3. Heier JS, Campochiaro PA, Yau L, et al. Ranibizumab for macular edema due to retinal vein

    occlusion: long-term follow-up in the Horizon trial. Ophthalmology 2012;119:802-9.

    4. Campochiaro PA, Sophie R, Pearlman J, et al. Long-term outcomes in patients with retinal vein

    occlusion treated with ranibizumab. The Retain study. Ophthalmology 2014;121:209-19.

    5. Calugaru D, Calugaru M. Intravitreal bevacizumab in acute central/hemicentral retinal vein

    occlusions: three-year results of a prospective clinical study. J Ocul Pharmacol Ther. doi: 10.1089.

    /jop.2014.0037.

    Conflict of Interest:

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