Purpose: To study the endoscopic ostium characteristics and outcome of 8 × 8 mm osteotomy in external dacryocystorhinostomy (DCR) using the microdrill system. Methods: This prospective interventional pilot study was performed on 40 eyes of 40 patients with primary acquired nasolacrimal duct obstruction (NLDO) from June 2021 to September 2021 in patients undergoing external DCR. An 8 × 8 mm osteotomy was performed using round, cutting burr attached to a microdrill system. Success was defined as patent ostium on lacrimal syringing (anatomical) and a Munk score <3 (functional) at 12 months. Postoperative endoscopic ostium evaluation was done using a modified DCR ostium (DOS) scoring system at 12 months. Results: The mean age of the study participants was 42.41 ± 11.77 years and the male-to-female ratio was 1:4. The mean duration of surgery was 34.15 ± 1.66 minutes and that for osteotomy creation was 2.5 ± 0.69 minutes. The mean intraoperative blood loss was 83.37 ± 11.89 ml. Anatomical and functional success rates were 95% and 85%, respectively. The mean modified DOS score was “excellent” in 34 patients (85%), “good” in 1 patient (2.5%), “fair” in 4 patients (10%), and “poor” in 1 patient (2.5%). Complications included nasal mucosal injury in 10% (4/40) of patients, complete cicatricial closure of ostium in 2.5% (1/40), incomplete cicatricial closure in 10% (4/40), nasal synechiae in 5% (2/40), and canalicular stenosis in 2.5% (1/40). Conclusion: An 8 × 8 mm–sized osteotomy created by powered drill and covered by lacrimal sac–nasal mucosal flap anastomosis in external DCR is an effective technique that has minimal complications and shorter surgical time.

To study the orbital perfusion parameters of ophthalmic artery (OA) and central retinal artery (CRA) in inactive TED and the changes following surgical decompression. Non-randomised clinical trial. 24 inactive moderate-to-severe TED orbits of 24 euthyroid cases underwent surgical decompression and examined again at 3 months. The peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistivity index (RI) of OA and CRA were evaluated using colour doppler imaging and normative database was established using 18 healthy controls. The mean age was 39.38 ± 12.56 years and male: female ratio was 1: 1.18. Intraocular pressure was higher, and CRA-PSV, CRA-RI, OA-PSV, and OA-EDV were lower in TED in comparison to heathy orbits. The CRA-PSV, CRA-EDV, OA-PSV, and OA-EDV negatively correlated with proptosis and duration of thyroid disease. The area under curve of OA-PSV (95% CI:0.964–1.000, p < 0.001) and OA-EDV (95% CI:0.699–0.905, p < 0.001) helped in differentiating TED orbits from HC, and in predicting the severity of disease. Post decompression, CRA-PSV, CRA-EDV, OA-PSV, and OA-EDV improved, with decrease in CRA-RI and OA-RI in both lipogenic and MO. The orbital perfusion is reduced in inactive TED. The changes in OA flow velocities can help in differentiating inactive TED from healthy orbits and progression of TED. Sequential orbital CDI of OA and CRA can serve as an objective tool for case selection and monitoring response to surgical decompression.

Arora, Ritu MD; Goel, Ruchi MS; Loomba, Poonam MD; Khanam, Samreen MS Author Information

Purpose: To correlate the clinical, radiological, and histopathological features in Covid-associated Rhino-orbito-cerebral mucormycosis cases presenting with acute visual loss. Design: Cross-sectional study. Methods: Covid-associated Rhino-orbito-cerebral mucormycosis cases with unilateral visual loss, planned for exenteration, underwent orbital and ophthalmological ocular examination. The available radiological sequences, doppler ultrasonography and histopathology findings were correlated with clinical manifestations. Results: The median age was 51 years and the male: female ratio was 3:1. All except one presented with unilateral ophthalmoplegia. The ocular media were hazy in 2 eyes. In 8 eyes, retinal changes were suggestive of occlusion of CRA (6), combined occlusion of CRA and central retinal vein (1), and myopic degeneration with hypertensive retinopathy (1). The contralateral eye showed retinal ischemic changes in one patient. Radiological imaging showed orbital apex involvement in the 10 affected eyes and one contralateral eye. Ipsilateral cavernous sinus thrombosis, diffusion restriction on MRI of optic nerve, internal carotid artery narrowing/thrombosis, and cortical watershed infarcts were seen in 8, 4, 4, and 2 cases, respectively. The blood flow in CRA and ophthalmic artery was absent or reduced in all the 10 affected eyes and in 1 contralateral eye. On histopathology, orbital fat necrosis, fungal hyphae, acute inflammation, granuloma formation, ischemic thrombosis of ophthalmic artery was observed in 10 specimens. CRA was patent in 9 and thrombosed in 1 eye. Optic nerve was ischemic in 8 and viable in 2 eyes. Conclusion: Acute visual loss in ROCM cases is associated with orbital apex involvement and thrombotic ischemia of ophthalmic artery. Cessation of flow in CRA possibly occurs secondary to ophthalmic artery thrombosis.

A middle-aged lady presented with a firm, nontender mass on the left upper lid and area behind the left ear following lid reconstruction with postauricular graft for cicatricial ectropion 11 months prior. She had a similar mass on the right shin. She was diagnosed as a case of multiple keloids. Intralesional injection of triamcinolone acetonide suspension and 5-Fluorouracil (5-FU) in the upper lid keloid resulted in ulceration of its surface. Surgical excision, injection of 5-FU in the keloid bed with temporal forehead flap reconstruction, was performed. Occurrence of inadvertent postoperative wound infection with Acinetobacter baumannii was treated with local dressing with colistimethate sodium. Adjuvant therapy with topical imiquimod cream 5% was given subsequently for 24 weeks with no recurrence of the lid keloid after 16 months. The patient was managed using a combination of conservative and surgical therapy and multidisciplinary team work and kept on a long term follow-up.

Dear Editor, We commend the sincere efforts of Muralidhar A, Das S, and Tiple S[1] in unearthing new information regarding the clinicodemographic profile of thyroid eye disease (TED) in Indian cohort. The authors wish to put forth their own observations regarding the presentation and epidemiology of TED in the Indian subcontinent. Despite the fact that the natural course of the disease is not fully understood, most of the current literature derives its understanding of the disease from Rundle’s biphasic curve, which describes an initial steep phase of activity followed by a static period of inactive, quiescent disease.[2] Striking differences in disease presentation and demography can be seen between patients from the Indian subcontinent (including our observations and those by Muralidhar et al.[1]) and those documented in western literature [Table 1].Table 1: Comparison of demographic profile and incidence of noninflammatory diseaseNoninflammatory TED, a sparingly reported entity in the west,[3] is a frequent presentation in our clinic and has also been reported as “silent presenter” by Naik and Vasanthapuram.[4] A recent study from the west by Íñiguez-Ariza NM et al.[5] also acknowledges the existence of “Quiet” TED, a subgroup which presents atypically and departs from the Rundle’s curve. These patients do not require corticosteroids during the course of their disease and are more likely to benefit from supportive therapy and surgery, if indicated. Inactive disease, unilateral presentation of TED, proptosis as the initial presenting sign, and orbitopathy with euthyroid status have more commonly been seen by us as well as other investigators from India. Also, delayed onset of disease activity, in patients initially presenting with inactive disease, is a deviation from the biphasic course and mandates identification as a distinct subgroup. The above findings may suggest strong ethnic and genetic influences on the clinical course of the disease and enable us to acknowledge cases that deviate significantly from the clinical picture classically described through the Rundle’s curve. Studies focusing on the population prevalence and clinical course of noninflammatory TED in different ethnic groups of the world are needed. It would also be interesting to re-explore the pathophysiology of TED in this subtype of patients. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Side port infection and corneal abscess after cataract surgery can produce devastating outcomes. Topical antibacterial drugs are the mainstay in management of these cases. Although intrastromal antifungal agents are an established modality for fungal keratitis, such use of antibacterial agents is rarely reported due to better pharmacokinetic profile of antibacterial agents.We report a case of methicillin-resistant Staphylococcus aureus corneal abscess following phacoemulsification that responded to intrastromal vancomycin injection in addition to conventional therapy.This case of postphacoemulsification corneal abscess highlights the importance of postoperative hygiene practices, use of anterior segment optical coherence tomography for monitoring these patients and use of intrastromal vancomycin as an adjunct to topical and systemic therapy.

Anterior segment optical coherence tomography (AS-OCT) is a non-invasive method, employed for structural assessment of lacrimal punctum.[1] Being considered as in vivo clinical biopsy, its use has been explored for diagnosis and post intervention monitoring of punctal procedures.[2] DCR with retrograde intubation and pseudopunctum creation is used for the management of proximal canalicular blocks.[3] We describe the characteristics of pseudopunctum in 10 eyes with bicanalicular blocks, <6 mm from the true punctum that were managed with DCR with bicanalicular silicone intubation tube with pseudopunctum creation. The tubes were removed after 6 weeks and at 6th month, after confirming anatomical patency on syringing, AS-OCT was done. The pseudopunctum was studied in terms of external lacrimal punctum diameter (ELP), internal lacrimal punctum diameter (ILP) and vertical canalicular height (VCH) and compared with those reported in literature.[4] The pseudopunctum was 'funnel-shaped' [Figures 123] with sloping walls as compared to 'cylindrical' shape and nearly vertical walls of true punctum [Figure 4]. Distinct layers of canalicular wall were discernible and tear film was visualized as a meniscus at the mouth of pseudopunctum as in true punctum.Figure 1: (a) Clinical photograph of right lower pseudopunctum (white arrow) and true punctum (yellow arrow) (b) AS-OCT of pseudopunctum showing funnel-shaped opening with a steep medial wall and a gradually curved lateral wall with long vertical canaliculus; distinct tissue layers seen as varying degrees of hyperreflectivity (red lines i, ii, iii) (c) infrared image indicating axis of scanFigure 2: (a) Clinical photograph of left lower pseudopunctum (white arrow) and true punctum (yellow arrow) (b) AS-OCT of pseudopunctum showing wide outer diameter with gradual curving of lateral wall compared to the taller medial wall; tear meniscus visible as a hyperreflective line at the mouth (c) infrared image of pseudopunctum showing axis of scanFigure 3: (a) Clinical photograph of left lower pseudopunctum (white arrow) and true punctum (yellow arrow) (b) AS-OCT shows wide-mouthed pseudopunctum with gradual sloping of both the walls; ILP can be seen opening in medial wall, tear meniscus is visible as a hyperreflective line with underlying hyperreflective mottled areas (c) infrared image indicating axis of scanFigure 4: (a) Clinical photograph of the true right lower punctum (white arrow) (b) AS-OCT showing a gradual symmetrical sloping of both medial and lateral walls with distinct layers of tissue histologically identified as (i) epithelium (ii) dense fibrous tissue (iii) muscle of Riolan; tear meniscus is seen as a hyperreflective area in the lumen (c) infrared image indicating axis of scanThe mean ELP of pseudopunctum was 809.7 ± 166.217 μ that was significantly wider than that reported for the true punctum, 424.65 ± 170.546 μ (independent t test P value = 0.0001). The mean ILP of pseudopunctum was found to be 197.6 ± 36.676 μ, which was comparable to that of true punctum, 234.34 ± 144.375 μ (independent t test P value = 0.4456). The mean VCH of pseudopunctum 550 ± 153.815 μ was found to be significantly greater than that of true punctum 250.44 ± 109.880 μ (independent t test P value = 0.0001). Discussion The overall size of pseudopunctum was observed to be significantly larger, providing a roomy entry for tears into the lacrimal drainage system. AS-OCT hence offers a no-touch objective technique for postoperative assessment of pseudopunctum. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Purpose: To list the clinico-epidemiological profile and possible risk factors of COVID-19 associated rhino-orbital-cerebral mucormycosis (CA-ROCM) patients presenting to a COVID dedicated hospital during the second wave of COVID-19 in India. Patients and Methods: A cross-sectional, single-center study was done on 60 cases of probable CA-ROCM based on clinical features and supportive diagnostic nasal endoscopic findings and/or radiologic findings. Patients with recent or active COVID-19 were included. The demographic profile, clinical features, possible risk factors and diagnostic workup (microbiological, pathological and radiological) were analysed to identify the triggering factors for CA-ROCM. Results: The age of patients ranged from 29 to 75 years and male-female ratio was 3:1. The duration between the first positive COVID report and onset of CA-ROCM was 0 to 47 days. Forty-nine (81.66%) patients had a recent COVID infection and 11 (18.33%) had active COVID infection at presentation. Thirty-five patients (58%) had ocular/orbital involvement at presentation. In the affected eye, 10 had no perception of light and in the rest visual acuity ranged from log MAR 0 to +1.5. Ocular manifestations were ptosis (29), ophthalmoplegia (23), periocular tenderness and edema (33), proptosis (14), black discoloration of eyelids (3), facial palsy (3), endophthalmitis (4), retinal artery occlusion (8), disc edema (4) and disc pallor (5). Twenty-two (25%) patients had neither received steroids nor oxygen. Thirty patients (50%) were managed with oxygen while 38 patients (63.3%) with systemic steroids. The most common risk factor was diabetes in 59 patients. The average glycosylated hemoglobin (HbA1c) was 10.31 +/- 2.59%. Systemic Amphotericin B was started in all the patients. Radical surgical debridement was performed in 12 patients and the remaining were planned. Conclusion: SARS-CoV-2 variant with accompanying glycaemic dysregulation was found to be the triggering factor for the epidemic of CA-ROCM.

The authors present a retrospective, observational case study of seven patients, who presented with retained Intra-Orbital Foreign Bodies (IOrbFBs) following penetrating orbital injury at a tertiary eye hospital over a period of one year. Cases were reviewed for epidemiological features, mechanism of injury, nature of foreign body, clinical features, imaging modality, associated complications, management outcomes, and the final prognosis. The mean age of presentation was 27.43 years. Amongst the seven patients, two were children (aged <10 years). The male : female ratio was 4 : 3. Of the seven retained IOrbFBs, two were plastic, two wooden, and three metallic in nature (one gunshot injury, one ball projectile (commonly referred to as BB) injury, and one with knife). Two out of seven had no light perception at presentation. The periocular location of the foreign bodies was inferior in 4 cases and medial in 3 cases. Computed Tomography scan confirmed the diagnosis in five cases and Magnetic Resonance Imaging (MRI) was diagnostic in one. Surgical intervention was done in five cases, and two cases were managed conservatively. The authors conclude that favourable outcome can be achieved even without surgical removal in cases of inert metallic/inorganic IOrbFBs. The properties of plastic FBs can frequently render them invisible on imaging, or they may mimic chronic inflammatory conditions like tuberculosis. Long-standing wooden IOrbFBs evade identification radiologically due to prolonged hydration. The ultimate choice of intervention must be individualised, weighing the risks of retention against the risk of iatrogenic damage.

Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibro-inflammatory condition known to have a diverse range of clinical presentation, involving single or multiple organs. The lesion, in all such cases, shows characteristic lymphoplasmacytic infiltration with fibrosis on

Color Doppler imaging (CDI) is a non-invasive technique for two-dimensional visualization of normal and pathological vasculature. CDI for the orbital vessels has been used for diagnosis, prognostication, and serial follow-up of ocular pathologies. It is an effective tool in research and understanding the pathogenesis of a variety of ophthalmic diseases.

Objective: To compare the surgical outcomes of dacryocystorhinostomy with retrograde intubation and conjunctivo-dacryocystorhinos-tomy for the management of proximal mid-bicanalicular lacrimal obstruction. Design: Randomized, controlled trial. Methods: The study was conducted in 50 eyes of 50 adult patients with bicanalicular obstruction < 6 mm from the punctum. The etiology, duration of symptoms, and Munk scores were recorded. Group A underwent dacryocystorhinostomy with retrograde intubation, and in group B, conjunctivo-dacryocystorhinostomy was performed. Success was defined as anatomic patency on syringing, a negative fluorescein dye disappearance test, and a Munk score < 2 twelve months postoperatively. Results: There were 23 males and 27 females, 18-66 years of age, with a 6-month to 20-year duration of epiphora. The etiologies were idiopathic, trauma, and allergic conjunctivitis and ocular surface inflammation. In group A, the pseudopunctum was located medial to the diag-nosed level of canalicular block by 1.28 +/- 0.54 mm and 1.04 +/- 0.88 mm in upper and lower canaliculi, respectively. Four post-traumatic cases required intervention following closure of the pseudopunctum, all being located > 7 mm from the true punctum (p = 0.001). The complication rate was higher in group B than in group A (p = 0.001). At 12 months, the success rate was 100% in group A and 88% in group B (22 of 25; p = 0.74), with reduction in Munk scores from preoperative levels in both groups (p = 0.001). Conclusion: Dacryocystorhinostomy with retrograde intubation and conjunctivo-dacryocystorhinostomy have comparable success rates in the management of proximal mid-bicanalicular obstructions. Dacryocystorhinostomy with retrograde intubation has lower complication rates and does not require long-term maintenance of the bypass tube, unlike conjunctivo-dacryocystorhinostomy.

Dysthyroid optic neuropathy (DON) represents the most dreaded manifestation of Thyroid Eye Disease (TED), one of the most common autoimmune diseases of the orbit. DON, previously termed as the crowded orbital apex syndrome, is characterized by thyroid-related impairment of optic nerve function that may lead to a profound loss of vision. The European Group on Grave’s Orbitopathy (EUGOGO) classifies the severity of TED as mild, moderate-severe, or sight-threatening. Sight threatening TED, characterized by DON and/or keratopathy, warrants the need for urgent intervention. DON is a multifactorial entity, the diagnosis of which is extremely challenging, owing to its early subclinical stage, presence of confounding factors, and alternative causes of sight loss in TED. A thorough evaluation of DON and subsequent timely management is crucial to avoid permanent blindness in TED.

Multiple studies have documented lower serum zinc levels in patients with febrile seizures in comparison to febrile patients without seizure. However, there is limited evidence comparing the effects of zinc supplementation with placebo on recurrence of febrile seizures in children. To study the effects of zinc supplementation on recurrence rate of febrile seizures in children less than 60 months of age. Systematic review and meta-analysis of randomized and quasi-randomized controlled trials. We searched PubMed, EMBASE and CENTRAL databases for articles reporting randomized or quasi-randomized controlled trials comparing the effects of zinc supplementation with placebo on recurrence of febrile seizures in children aged less than 60 months. We performed a fixed effect meta-analysis to provide pooled odds ratio of febrile seizure recurrence. Quality of evidence was assessed using GRADE approach. Children aged less than 60 months. Zinc supplementation Odds of febrile seizure recurrence. Four clinical trials with a total of 350 children were included in the review. There was no statistically significant difference between odds of febrile seizure recurrence during one year follow up, in children on zinc supplementation compared to those on placebo (OR 0.70; 95% CI 0.41 `- 1.18, I2 = 0%). Available evidence is very low quality and thus inadequate to make practice recommendations.

The preoccupation of the medical community in the management of the COVID-19 crisis has resulted in the neglect of non-COVID-19 medical conditions. The limitation in the number of surgical cases to maintain the social distancing guidelines and deferred operations have added to the surgical backlog considerably.[1] To reverse this downturn the world is struggling to bounce back by adopting the "new normal." Resumption of health care services poses a challenge due to the safety concerns for the medical and paramedical personnel. More importantly, in presymptomatic cases, the signs and symptoms of COVID-19 may manifest in the postoperative period, culminating in adverse patient outcomes.[2] The patients undergoing surgery may be presymptomatic or asymptomatic COVID-19 cases. The reported transmission efficiency of an asymptomatic carrier is one-third of that of symptomatic cases.[3] Real-time reverse transcriptase–polymerase chain reaction (RT-PCR) of the nasopharyngeal swab is thus recommended prior to intervention, especially in procedures involving aerosol generation.[45] However, the probability of detection of SARS-CoV-2 nucleotide by RT-PCR peaks on day 3 of symptoms, and the sensitivity in asymptomatic cases is not known.[67] To evaluate the rationale for preoperative COVID testing, we performed a retrospective analysis of RT-PCR of nasopharyngeal samples of patients posted for elective ophthalmic surgery from July 26, 2020, to August 25, 2020, at Guru Nanak Eye Center, New Delhi. Institutional ethics committee clearance was obtained for data analysis. Due to the diversion of anesthetists and reservation of hospital beds for management of critically ill COVID-19 patients, all ophthalmic surgeries were performed under local anesthesia on a daycare basis. The patients with signs or symptoms/positive lab-confirmed COVID-19 cases in the prior 2 weeks, uncontrolled diabetes, hypertension, heart disease, pregnancy, chronic lung/liver disease, or immunocompromised status were not included. All patients planned for elective ophthalmic surgery underwent RT-PCR for SARS COV-2 from the nasopharyngeal swab a day prior to the procedure. The RT-PCR testing was performed at the advanced virology laboratory, Maulana Azad Medical College, New Delhi, using an Indian Council of Medical Research approved kit.[8910] In the patients with a positive nasopharyngeal swab, cycle threshold (Ct) values of E gene, ORF1b/N gene, and RdRp gene were determined from the amplification curves. [Fig. 1a-c] Ct value of the E gene was used to study the viral load. These patients were also contacted telephonically to ascertain the development of signs and symptoms related to COVID-19 until 3 weeks after the test.Figure 1: Real-time reverse transcriptase–polymerase chain reaction amplification curves of case number 12 (a) E gene (b) ORF1b gene (c) RdRp geneIn the 1-month period, 355 asymptomatic patients planned for cataract, squint, lid, lacrimal, and retinal surgery underwent RT-PCR testing. Thirty cases, with ages ranging from 18 years to 64 years and male:female ratio 8:7 tested positive [Table 1]. None of these patients developed COVID-19 symptoms in the 21 days after the test. The average Ct value of the E gene of the positive cases was 27.63 and in nine cases being <24 (15-22).Table 1: Demographic profile and cycle threshold values of E gene, ORF1b/N gene, and RdRp gene in patients with positive reverse transcriptase-polymerase chain reaction of nasopharyngeal swabAsymptomatic COVID-19 cases are common in young and middle-aged population, the median age being 32.5 years and 49 years, respectively.[1112] The median age in our study also was 36.5 years. The reported population prevalence of active COVID-19 cases in Delhi in the study period was 10.47%.[13] This included both symptomatic as well as asymptomatic laboratory-confirmed cases. The incidence of asymptomatic COVID-19 infections has been reported to vary from 1.6% to 56.5%.[1113141516] We observed RT-PCR positivity of 8.4% in the nasopharyngeal samples of preoperative ophthalmic surgery cases. The absence of systemic symptoms in these patients could be attributed to the innate immune response.[17] The median period reported for an asymptomatic patient to become negative for viral nucleic acid is 9.5 days and the longest is up to 21 days.[18] All the positive patients were informed, quarantined for 14 days and the surgeries were deferred. The major drawback of RT-PCR is its inability to demonstrate infectivity. The viral nucleic acid positivity, merely indicates that the viral load in a sample reaches a certain limit.[19] Definitive proof of the potential for viral transmission can be obtained by in-vitro infectiousness on cell lines, but is labor-intensive and requires containment level three facilities. Bullard et al. demonstrated that infectivity as evidenced by the growth in cell culture was significantly reduced when RT-PCR values were >24 and the odds ratio for infectivity decreased by 32% for every 1 unit increase in Ct value.[20] In our study, nine cases (30% of the positive samples; 2.53% of total tested samples) had Ct values <24, which could have been infective. Their age groups varied from 18 to 51 years. The remaining 19 cases though positive, had Ct value more than 24, chances of infectivity being less. The infectivity has been observed to decrease when the duration of symptoms is more than 8 days. In asymptomatic cases, it is not possible to predict the infectivity in terms of duration of illness as the time of exposure is not known. Though RT-PCR is a qualitative test, the Ct value can thus serve as a guide to determine the infectiousness of the patient. An asymptomatic apparently healthy patient undergoing elective ophthalmic surgery could be a source of COVID-19 transmission to the health care workers. With the ease of availability and emphasis on more testing, RT-PCR for COVID should form a part of the standard operating protocol, prior to all ophthalmic procedures. We hope that our experience in this evolving public health challenge would help in strategic planning to enable the provision of safe surgical care. 1.1 About the authors Ruchi Goel Prof. Ruchi Goel is serving at the Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi since 2006. She is a volunteer faculty at ORBIS International. She has authored the book "Manual of Oculoplasty" in 2019 and has co-authored "Manual of SICS" with focus on difficult situations and complications in 2011. She has contributed over 100 articles in journals, book chapters and three CME series by AIOS. She is the recipient of Dr. V.P. Chadha Memorial University Gold Medal (Delhi University), Smt. Rukmani Gopala Krishnan Memorial Gold Medal (Delhi University), AIOS-APAO-Honavar Award for the Best Paper in the lacrimal session, AIOS-IJO Silver Award and the Outstanding Paper by the International College of Surgeons. Ritu Arora Prof. Ritu Arora, Director, Guru Nanak Eye Center, New Delhi is a graduate and post-graduate from AIIMS, New Delhi. She did her WHO fellowship at Wills Eye Hospital, and Toronto Western Hospital in 1996 and endothelial keratoplasty training at Oregon under Dr Mark Terry. Her areas of interest are cornea, refractive surgery, ocular surface and eye banking. She has 95 publications in national and international peer reviewed journals and has contributed 12 book chapters. She has over 300 presentations in national and international forums. She has conducted 8 clinical trials as the principal investigator. She is the recipient of the AAO Achievement Award 2010, Noel Moniz Oration 2016 and ISCKRS Appreciation Award 2017.

The fourth cranial nerve, also known as the trochlear nerve, arises from the midbrain at the level of the inferior colliculus (ventral to the Sylvian aqueduct). This nerve supplies only a single muscle - the superior oblique (SO) muscle. It is the only cranial nerve that emerges from the dorsal aspect of the brainstem and decussates to supply the muscle of the contralateral side.The nerve has a very long course, making it more vulnerable to injury. Palsy of the trochlear nerve is a common presentation in ophthalmology clinics.

Purpose: To evaluate the rotational stability of toric intraocular lens (IOL) when co-implanted with a capsular tension ring (CTR) as compared to that of a toric IOL without a CTR. Methods: This was a prospective randomized clinical trial performed in a tertiary care centre in India. Fifty adult human eyes with visually significant cataract and regular corneal astigmatism ≥1.5D divided into two groups of 25 eyes each, A and B by simple randomization. Eyes with corneal pathology, lens subluxation, and a specular endothelial cell count <2000/mm2 were excluded from the study. The eyes in both the groups underwent standard phacoemulsification and were implanted with a toric IOL. In Group A, a CTR was put in the bag before IOL implantation. The groups were called for follow-up on day 1, 1 week, 1 month, and 3 months, postoperatively. The axis of the toric IOL on each visit was measured by slit lamp imaging in retroillumination and analyzed digitally. Results: Mean rotation of toric IOL at 3 months postoperatively was 1.85 ± 1.72° in Group A and 4.02 ± 2.04° in Group B. The difference was statistically significant (P = 0.003). Conclusion: Coimplantation of a CTR is a safe and effective technique for ensuring better rotational stability of toric IOLs.