The sclera is a dense poorly vascularized connective tissue structure composed of Types I, III, IV, V, VI, and VIII collagen. The characteristic blue sclera is caused by thinness and transparency of the collagen fibers of the sclera that allow visualization of the underlying uvea. The sclera may be thinned in congenital diseases such as osteogenesis imperfecta or in acquired diseases such as iron deficiency anemia.

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Fortification means to intensify or strengthen the medication, to achieve adequate drug concentration. Fortified antimicrobials are not commercially available, thus should be, prepared of optimal constitution in a sterile pharmaceutical dispensary. This article provides guidelines on topical fortified therapy dosage concentration and methodology of preparation of drugs for patients with infectious keratitis. Acquaintance on fortified antimicrobial medication, its appropriate usage and timely intervention will help us to treat most of the resistant microbial keratitis and prevent the need for surgical intervention.

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Prisms are used in diagnosis and Therapy of Ophthalmic disorders. Prismotherapy provides symptomatic relief not only in many kinds of squints, but also in non strabismic conditions like convergence insufficiency, nystagmus, heminopia etc. One of the most important therapeutic skill we have acquire in this direction, is the localisation of such clinical needs and the timely use of the wonderful therapeutic functions of prisms for the relief of such conditions. Thin Fresnel prisms are now more used in clinical practice.

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Blepharoptosis, or ptosis of the eyelid, refers to drooping of the upper eyelid that usually results from a congenital or acquired abnormality of the muscles that elevate the eyelid. Ptosis may be the presenting sign or symptom of a serious neurologic disease. Regardless of the etiology, when ptosis obstructs vision, it is disabling. The appropriate management requires recognition of the underlying cause. This review article highlights the various aspects of ptosis evaluation and management.

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Shield ulcer is a severe form of vernal keratoconjunctivitis (VKC). Shield ulcer is an uncommon, incapacitating corneal manifestation that occurs in 3%–11% of patients suffering from VKC. Patients might present with intense itching, sensitivity to light, and “ropy” discharge from the eyes. Shield ulcer, as a rare complication of VKC, should always be kept in mind for patients suffering from vernal conjunctivitis.

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Aim: The aim of this study was to evaluate the safety and efficacy of biosimilar intravitreal ranibizumab (Razumab) for the treatment of chorioretinal vascular diseases such as diabetic macular edema (DME), neovascular age-related macular degeneration (nAMD), and macular edema secondary to retinal vein occlusions (RVOs). Methods: A prospective analysis was performed on consented patients with DME (Group 1), nAMD (Group 2), and macular edema secondary to RVO (Group 3). All patients received Razumab at baseline. Snellen visual acuity assessment, anterior segment and fundus evaluation, fundus photo, and optical coherence tomography imaging were done at days 0, 1, 7, and 30, respectively. The International Society for Clinical Electrophysiology of Vision standard electroretinography (ERG) was performed at baseline and day 30 (23 eyes who could afford the investigation). Primary and secondary outcome measures were safety parameters that included signs of clinical and ERG toxicity and changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT), respectively. Results: One hundred and twenty-three eyes of 95 patients received biosimilar intravitreal ranibizumab injection between November 2015 and April 2016. No serious drug-related ocular or systemic adverse events were identified. Mean pretreatment BCVA was 0.67 ± 0.41 logMAR with CMT 345.90 ± 128.84 μm and postinjection BCVA at day 30 was 0.57 ± 0.37 logMAR with CMT reducing to 287.66 ± 90.28 μm, indicating statistical significance (P = 0.001 and P< 0.0001, respectively) for all groups. Conclusion: The biosimilar intravitreal ranibizumab for DME, nAMD, and macular edema secondary to RVO was tolerated over a month with improvements in BCVA and CMT without detectable ocular and systemic toxicity. While the long-term safety and efficacy remain unknown, these short-term results suggest that biosimilar ranibizumab could become a safe, low-cost therapy for macular diseases.

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Hydroxychloroquine (HCQ) in recent times has been used in treatment for a variety of autoimmune diseases and dermatological and rheumatological conditions. Retinal toxicity from HCQ and its analog chloroquine has been recognized for many years. Retinal toxicity secondary to HCQ is irreversible and can continue to progress even after cessation of therapy. Prompt screening and serial monitoring, with the utilization of imaging modalities, is of paramount importance to early detection.

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The technology of three-dimensional (3D) printing has evolved over the past few years with cumulative improvements in the resolution, accuracy, cost-effectiveness, and speed of this highly customizable manufacturing process. Ophthalmologists have designed multiple 3D printed smartphone based fundus cameras with some of the designs available as open-source for all to download and 3D-print. Now, the technology has been used for anything from eyewear and medical devices to printing of live cells and tissues like an artificial cornea. It also has uses in education and surgical planning. The author had the opportunity to work with a 3D printer and make some of these models. The future is bright for innovations in this field as we are only beginning to understand the capabilities of this technology.

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Artificial intelligence (AI) and machine learning (ML) have entered several avenues of modern life, and health care is just one of them. Ophthalmology is a field with a lot of imaging and measurable data, thus ideal for application of AI and ML. Many of these are still in research stage, but show promising results. The ophthalmic diseases where AI is being used are diabetic retinopathy, glaucoma, age-related macular degeneration, retinopathy of prematurity, retinal vascular occlusions, keratoconus, cataract, refractive errors, retinal detachment, squint, and ocular cancers. It is also useful for intraocular lens power calculation, planning squint surgeries, and planning intravitreal antivascular endothelial growth factor injections. In addition, AI can detect cognitive impairment, dementia, Alzheimer's disease, stroke risk, and so on from fundus photographs and optical coherence tomography. We will surely see many more innovations in this rapidly growing field.

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The first iPhone was released in 2007 and the first Android phone in 2008. Ten years later, smartphones are becoming ubiquitous. They now have more advanced sensors, cameras and more processing power, which have allowed several innovative apps to be made, which were not possible a few years ago. These apps will change the way we interact with patients and with clinical data, provide affordable and advanced testing, enhance the way we learn, and hopefully improve doctor–patient interactions. However, most of these apps are made without professional input and needvalidation before use. We try to review the current landscape of Smartphone Apps in Ophthalmology.

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Eyelid malpositions are the result of forces acting upon the eyelid margin. A normal eyelid should have a quick return snap to the eyeball. Frequently, tendon laxity at the medial and lateral canthi will render the eyelid margin unstable making it susceptible to contractile forces. Based on the contractile forces either entropion, ectropion, retraction or lagophthalmos can occur. The goal in treating a given eyelid malposition is to reposition the eyelid so that the new healing forces will overcome the pathologic forces. The common approaches include eyelid and canthal tendon tightening, eyelid retractor advancement or recession and skin grafting or transposition flaps. This review article briefly describes the various aspects of lid malpositions in detail.

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Pupil examinations are quick, noninvasive tests that give a clue to the health of our eyes and nervous system. Pupillary assessment is an important part of neurological assessment because changes in the size, equality, and reactivity of the pupils can provide vital diagnostic information. This article intends to throw light into the basic techniques of pupillary assessment and common conditions that should not be missed in your clinical evaluation.

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Aim: The aim is to study the change in Newcastle Control Score (NCS) and angle of deviation after a trial of overminus therapy in intermittent exotropia (IXT). Context: Overminus therapy in IXT. Settings and Designs: This prospective observational study was conducted at Comtrust Eye Hospital, Calicut, Kerala, which is a tertiary eye care center from July 2015 to May 2017. Materials and Methods: Fifty-three children with IXT, aged 1–5 years, were recruited. NCS scores and angle of deviation were recorded. Treatment was instigated with the minimum minus lens required to achieve control of the manifest deviation. NCS and angle of deviation were recorded with the overminus glasses at 6 weeks, 6 months, and 1 year. Statistical Analysis: Data were tabulated and analyzed using the SPSS software (SPSS statistics for Windows 17.0 Chicago, SPSS Inc). Paired t-test was used to compare change in NCS and angle of deviation before and after treatment. P < 0.05 was taken as statistically significant. Results: Fifty-three children were recruited, 31 females and 22 males with a mean age of 3.6 ± 1.633 years. Majority were of the basic type of IXT. The NCS at 1 year showed significant reduction from baseline values. At 1 year, 27% patients had the same NCS as baseline, 32% showed a reduction by 1, 21% reduced by 2, and 5% showed a reduction by 3 in the total score. The angle of deviation with the overminus for both distance and near also showed significant reduction. Conclusion: This study showed definite improvement in control of IXT with overminus, and hence, a trial of overminus therapy is recommended for IXT in children below 5 years, as surgery has its own side effects like overcorrection, leading to consecutive esotropia with loss of stereopsis and high amount of recurrence.

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The pediatric population with refractive error needs regular assessment and prescription adjustment. Detection of refractive error and accurate prescription of glasses to prevent amblyopia in children is possible only if the general ophthalmologist is aware of the basic steps of assessment and prescription. This paper discusses the considerations for prescribing a refractive correction in infants and children, with reference to the current literature.

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Convergence insufficiency is a common disorder of binocular vision in children and young adults. Common symptoms include eyestrain, headache, blurred vision, double vision, etc., Diagnosis of the condition involves a battery of tests for assessment of refraction, convergence, and accommodative functions. Management involves proper refractive correction, prism, and vision therapy. This review stresses on the systematic evaluation of this condition and the common treatment strategies employed.

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Eyelid lacerations form a major bulk of the ocular trauma that we see in our casualty. These are managed differently depending on the depth, width, and location of the injury. Repairing of eyelid injuries requires good anatomic knowledge and meticulous approach. This article gives a brief overview of the practical aspects in managing an eyelid laceration.

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Neovascular glaucoma (NVG) is an intractable secondary glaucoma characterized by the growth of new vessels accompanied by a fibrovascular membrane over the iris and iridocorneal angle. Majority of the cases of NVG are associated with ischemia and hypoxia of retina. The three most common predisposing conditions are ischemic central retinal vein occlusion, proliferative diabetic retinopathy, and ocular ischemic syndrome. Early identification of anterior segment neovascularization followed by prompt treatment is very important to prevent significant visual impairment. A high index of suspicion, with careful anterior segment evaluation and gonioscopy in an undilated pupil, is the key for early detection of neovascularization of iris and angle. Early stages of the disease can be managed with panretinal photocoagulation along with adjunctive use of vascular endothelial growth factor inhibitors with or without intraocular pressure lowering agents. Medical management may not be sufficient in advanced disease and may require surgical intervention.

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Inflammatory macular diseases, a group of disorders, are a major cause of severe visual impairment. They may be caused by primary ocular disease or secondary to systemic or infectious disease. All of them present with almost similar symptoms. The key to successful management is early detection and aggressive treatment with steroids, antimicrobials, and if needed, immunosuppressives. Risk of recurrences and complications, such as choroidal neovascularization, are taken in to account in the management.

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Context: Central corneal thickness (CCT) was assumed to be a constant when Goldmann designed his applanation tonometer. Knowledge of the CCT is of importance in the assessment of intraocular pressures (IOPs). Aim: The aim of the study was to examine the association of CCT with ocular, demographic, and metabolic factors such as age, race, gender, smoking, alcoholism, diabetes mellitus, hypertension, obesity, metabolic syndrome, corneal curvature, and axial length. Settings and Design: A cross-sectional study was conducted in 166 patients aged between 30 and 70 years who had presented for routine eye checkup from January 1, 2014, to July 1, 2015, in our Ophthalmology Department. Subjects and Methods: Patient parameters were recorded using an interview schedule, and complete ocular examination, including visual acuity and IOPs, were recorded. CCT was measured using PacScan Plus A-Scan/Pachymeter. Statistical Analysis Used: Mean CCT across different variables were compared using ANOVA and t-test. Further analysis was done using univariate and multivariate analysis. Results: On univariate analysis, it was found that age, presence, and duration of diabetes, elevated fasting blood sugar levels, alcohol consumption, corneal curvature (in diopters), and IOP were associated with CCT. Multivariate analysis showed significant association of CCT with age, duration of diabetes, corneal curvature, and IOP (P < 0.05). Conclusions: From our study, we concluded that CCT was significantly associated with age, duration of diabetes, corneal curvature, and IOP. Duration of diabetes and IOP showed a positive correlation with CCT whereas age and corneal curvature showed a negative correlation.

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This clinical query section discusses the use of topical atropine in childhood myopia among Indian children. Experts from across the country share their viewpoints, clinical experience, and concerns on the subject.

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Retinopathy of prematurity (ROP) is a vasoproliferative disease that affects premature infants. ROP is on a rise in India as a result of the improved neonatal care and better neonatal survival rate. Identifying and screening of at-risk premature infants performed by an experienced ophthalmologist remains the most important strategy in the management of ROP. In developing countries, the introduction of Retcam-assisted screening enables screening and follow-up of the rural population where an experienced ophthalmologist may not be available. Currently, laser photocoagulation of avascular retina has replaced cryotherapy as the gold standard treatment for ROP depending on the severity of disease. Among the various ongoing treatment approaches currently under trial to suppress the neovascularization, anti-vascular endothelial growth factor drugs provide valuable and encouraging information, especially in Zone 1 disease. Although many ongoing animal trials aimed at finding an ideal treatment have come out with newer treatment options, their safety and efficacy in humans are yet to be established.

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Pediatric cataract remains a very important and difficult problem to manage, in spite of dramatic advances that have occurred in the field over the past 10 years. Since early treatment is the most important factor in determining the visual outcome in congenital cataract, prompt detection and treatment in the neonatal period are the aims. This review is to update the reader on advances and present concepts on the topic.

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Ophthalmology is a very visual science; therefore, visualizing the eye and its pathology in good clarity is essential for a diagnosis. Over the past several years, smartphones have evolved to replace several gadgets in our daily life, including cameras. In ophthalmology, they have been very useful to take good quality photographs through slit lamp, gross photographs and also fundus photos using low-cost smartphone fundus cameras. In this article, we elaborate on the techniques, tips, and tricks to obtain excellent smartphone ophthalmic photographs and videos with a mid-level smartphone camera. We teach how to take diffuse and slit photographs, with and without an adapter, in addition, how to take Gonioscopy, specular microscopy, and fundus via 90D. These photos and videos can also be edited on the smartphone itself and used for case discussion, second opinion, teaching, presentations, and publications.

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