“Eye surgery is an art. You work in such a tiny space, and if you create a beautiful job, the painting is worth so much money. You put pictures in people’s eyes. You paint them stunning flowers, their children’s faces, or lines that are clear and sharp. You paint a perfect vision”, defines Dr. G. Natchiar. An arty ophthalmologist, a vivacious personality, inimitable vision with immaculate standards of professionalism and values, Dr. G Natchiar is an epitome of simplicity and positivity and her life story is truly inspiring. In a career spanning decades, Dr. G. Natchiar assumed a myriad of demanding roles and in each, she pioneered innovative concepts towards ensuring comprehensive and efficient delivery of eye care with no compromise on quality. Currently the Director Emeritus of Aravind Eye Care System, she was born on September 15, 1940, at Vadamalapuram village in Tirunelveli District, Tamil Nadu, as the youngest of the five children [Fig. 1] to Mr. Govindappa Naicker with Gandhian traits and Mrs. Lakshmiamma with admirable leadership skills. After the early demise of her father, her brother Dr. Govindappa Venkataswamy (Dr. V) being 23 years older than her, played multiple roles - as a parent, brother, mentor and confidant in her life. Dr. V’s vision and foresight which was remarkable and not easily comprehensible was spun into reality by Dr. G. Natchiar. She didn’t flinch away from devoting her entire life to ophthalmology.Figure 1: Miss. Govindappa Natchiar during her school days in 1953After school, Natchiar joined the Madurai Medical College in 1958 where she started her journey by becoming Dr. G. Natchiar in 1963. There she also found her match – Dr. P. Namperumalsamy [Fig. 2] and the duo served a decade in the Government Rajaji Hospital at Madurai.[1] Dr. G. Natchiar pursued a fellowship in ocular pathology under the guidance of Dr. David Apple at the University of Illinois; and a fellowship in Ophthalmic Pathology and Neuro-ophthalmology, at Harvard University, Boston. She then joined Dr. V to start the Aravind Eye Hospital (AEH) in 1976 in Madurai with the legendary union of a group of like-minded people [Fig. 3]. In the past four decades, this institute has run on the purest of principles and evolved from an eleven bedded hospital to the highly affordable and equitable group of institutions, providing eye care services to all as the AECS. Due to her interest in Neuro-ophthalmology, she founded the neuro-ophthalmology department at the hospital along with Dr. M. Natarajan (neuro-surgeon) and Dr. K. Srinivasan (neurologist). She is also the first neuro-ophthalmologist in India who revolutionized the patient approach.Figure 2: The dynamic couple Dr. P. Namperumalsamy and Dr. Govindappa Natchiar: (a) 1966 and (b) 2010Figure 3: Founding members of the Aravind Eye Care System in 1976“Mother of the growth and evolution of the Aravind Eye Care System.” – Dr. William Stewart Dr. G. Natchiar has played an indispensable role in shaping AECS by contributing as a clinician, surgeon, teacher and administrator. She designed and started the Micro Surgery Training Programme in 1993 at AECS, with support from Sightsavers International to address the challenges of developing the skills required for microsurgery with intra-ocular lens (IOL) implants, thus improving the quality of cataract surgery worldwide. This training programme has helped train about 4,000 senior ophthalmologists in developing countries such as India, Bangladesh, Pakistan, Sri Lanka, Indonesia and Africa. A skilled surgeon herself, quality of care was always the top-most priority for Dr. G. Natchiar. She drilled down into the details of various clinical aspects and implemented systems to ensure supreme quality at all stages of eye care delivery. Dr. G. Natchiar headed the out-reach eye camps, conducted by the AECS team, to provide doorstep care to the rural communities. What started as one camp a week, resulted in a strong network with over 3,000 camps in a year, across Tamil Nadu and Pondicherry.[2] At the same time, the rate of surgical complications was reduced (with software-based monitoring), IOLs were made affordable, cataract surgeons were trained extensively, innovative operating practices were developed and specialty-based diversification of camps was done. She played an instrumental role in initiating and scaling an innovative service delivery model for rural populations through Aravind’s vision centers and outreach activities. At the peak of her cataract career, Dr. G. Natchiar shifted gears to utilize her soft skills to develop the Human Resource Department at AECS. As the Director of Human Resources Department, she developed a new cadre of allied ophthalmic professionals, termed as “Mid-level Ophthalmic Personnel (MLOP)”. Though sheer need for manpower necessitated the training and recruitment of young rural girls as allied ophthalmic personnel, very soon, she realised the immense potential that it held in improving the lives of several poor rural families. Over many years, this programme has stood tall as an example of women empowerment and is being widely replicated [Fig. 4]. Her sharp acumen and analytical skills have resulted in her being exceptionally good in manpower planning and in improving the productivity or efficiency of her staff. She introduced the novel idea of calendar-based assessment, at the Medical Records Department of the expected new and review patients which led to optimized manpower and resource allocation. She has a flair for identifying people’s talents and getting the best out of them.Figure 4: Dr. G. Natchiar with a group of empowered women at Aravind“An enabling influence on Woman-power in Eye-care who owned responsibility and earned respect.” – Dr. R Krishnadas One of her greatest contributions towards ensuring quality is the introduction of a periodic and stringent appraisal system across all the departments holistically, which gives a platform to monitor and analyze the performance and bring in the necessary changes in the system. Dr. G. Natchiar always believes that the success of an organization is hinged on empowerment of people and not mere dependence on them. She always prioritizes people’s development as the key to organizational growth and as a means to achieving the organization’s goals and mission. “I opted to resign from clinical services in 2010, having realized that we need not cling on to ophthalmology forever and that one should find time to pursue other passions. Now, I dedicate my time to something that has been always close to my heart – farming and I enjoy a special satisfaction each passing day.” – Dr. G Natchiar Dr. G. Natchiar is a woman with phenomenal organizational consciousness and a vivid personal style. She is equal parts tyrannical, generous and concerned. She has always been, and continues to be, the unofficial keeper of the Aravind culture.[3] There are no airs or graces about her; she always remained grounded despite the marvelous feats that she as an individual and AECS as an organization has achieved. Having played a pivotal role in shaping up AECS and dedicating over four decades in eye care, Dr. Natchiar now pursues her passion, something that was always close to her heart – farming. She single-handedly maintains a huge farm of about 70 acres which is noted for its biodiversity and is certified as completely organic by the Government of Tamil Nadu. “I had no scientific training but followed my instincts and interest and started planting a variety of trees,” she says. Today, her family, staff, friends and visitors to Aurofarm marvel at the “blossoming property” buzzing with butterflies and birds.[4] Dr. G Natchiar with a tough persona is practical, modest, confident, graceful and in every role she has ever taken up, her focus has always remained the same – “Do good for the community and ensure the welfare of your fellow-beings.” “Even at 83, I am fairly active. My mind is occupied. I have a purpose to live and I constantly feel that there is a lot more that I can do. My life is a great example for the fact that an ordinary human being if empowered with the right guidance is capable of achieving a lot.” – Dr. G. Natchiar

Purpose: To analyze the ocular biometric parameters of eyes with acute primary angle closure (APAC) as compared to fellow eyes. Methods: A cross-sectional study was conducted on 27 patients presenting with recent onset APAC to a tertiary eye institute in India. Anterior and posterior ocular biometric parameters were measured simultaneously by anterior segment optical coherence tomography (AS-OCT), A-scan, ultrasound biomicroscopy (UBM), and B-mode ultrasonogram (USG). The parameters measured were anterior chamber depth (ACD), anterior chamber angle (ACA), angle opening distance (AOD500, AOD750), lens vault (LV), axial length (AL), ciliary body thickness maximum (CBTmax) and at the point of scleral spur (CBT0), anterior placement of the ciliary body (APCB), and retinochoroidal thickness (RCS). Results: Mean age ± SD of patients with APAC was 55.66 ± 7.2 years with female preponderance (21:6 patients). Mean presenting IOP ± SD of the affected eye and fellow eye were 54.74 ± 11.67 mm Hg and 18.7 ± 11.67 mm Hg, respectively. Eyes with APAC had statistically significant narrower anterior ocular biometric parameters, higher LV, decreased ciliary body thickness, more APCB, and longer AL than the fellow eyes. CBTmax is the only variable that had significance (β = −0.421,95% CI: −0.806 to − 0.035, P = 0.034) in the univariate analysis with RCS thickness in APAC eyes. Further, there was a correlation between CBT0 and APCB with CBTmax both in univariate (β = 0.894, P < 0.0001 and β = −0.351, P = 0.039) and multivariable analysis (β = 0.911, P < 0.0001 and β = −0.416, P = 0.016). Conclusion: Compared to the fellow eyes, APAC eyes had different ocular biometric parameters. In addition to known biometric parameters associated with pupillary block (narrower anterior biometric parameters-ACA, ACD, and AOD), our study found multiple nonpupillary block factors such as higher lens vault and thinner and more anteriorly placed ciliary body to be associated with APAC.

Aniridia is an uncommon hereditary bilateral panocular disorder affecting not only the iris but also the cornea, anterior chamber angle, lens, retina, and optic nerve with associated life-threatening conditions. Glaucoma is associated with aniridia in around 50% of the cases and usually develops in the first two decades of life. The treatment of glaucoma is challenging and often needs surgical intervention to achieve adequate intraocular pressure (IOP) control in cases refractory to medical treatment. Here, we report the familial nature of aniridia with secondary glaucoma and discuss the challenges in the management with a comprehensive review of the literature. The elder one, a 16-year-old girl presented with absolute glaucoma in the right eye and high IOP with advanced disk damage in the left eye for which she underwent a non-valved glaucoma drainage implantation. The younger one, a 12-year-old boy presented with a high IOP of more than 40 mmHg in both eyes (OU) for which he underwent sequential glaucoma drainage devices (GDD) implantation in OU. The intermediate-term outcomes in both of them showed a well-placed Aurolab aqueous drainage implant (AADI) tube with adequately controlled IOP.

Dr Govindappa Venkataswamy, affectionately referred to as Dr V by his admirers, has transformed Aravind eye care system into a replicable model for providing affordable eye care to all in need. His visionary leadership enabled Aravind to provide affordable eye care services by diligently pruning the costs of operations, with no compromise of quality of outcomes or patient experience. Dr V kept cost of providing eye care low by building an efficient, high‐volume assembly line process to examine patients or perform surgeries by minimizing waste. Every step ranging from patient registration, examination, to surgery was standardized and optimized, which helped to improve efficiency while achieving optimal clinical outcomes. This remains key to Aravind’s operating model of sustainable eye care delivery.

Purpose:To correlate and analyze the pattern of the visual field (VF) defects by perimetry and anterior chamber angle parameters by AS-OCT in primary angle-closure glaucoma (PACG) across varied severity levels on presentation to a tertiary eye care center. Methods:This was a cross-sectional study, which included 323 eyes of clinically diagnosed cases of PACG. Glaucoma severity was categorized according to mean deviation (MD) as mild (-6.00 dB or more), moderate (-6.01 to -12.00 dB), and severe (-12.01 to -30.00 dB). AS-OCT measured the nasal (N) and temporal (T) angle opening distance at 500 μm (AOD 500) and 750 μm (AOD 750), anterior chamber angle (ACA), lens vault (LV), and anterior chamber width (ACW). The VF severity was then correlated with the AS-OCT parameters using statistical analysis. Results:The mean age ± standard deviation (SD) of the patients included in the study was 56.03 ± 8.6 years, with a 1:1.2 gender ratio. The number of eyes with mild, moderate, and severe VFs were 140 (43.3%), 88 (27.24%), and 95 (29.41%), respectively. There was no statistically significant correlation in the mean anterior chamber angle parameters (AOD 500, AOD 750, ACA 500, ACA 750, LV, ACW, and axial length (AL)) among the groups. However, the correlation between AOD 500 and LV thickness was found to be significant (P = 0.0000) with a negative Spearman's rank correlation coefficient (r = -0.3329). Conclusion:The ACA parameters obtained by AS-OCT along the horizontal axis after elimination of pupillary block by laser peripheral iridotomy do not correlate and cannot be used to assess the disease severity of PACG.

Notwithstanding the many advances in glaucoma filtering surgery, including minimally invasive glaucoma surgery and nonpenetrating deep sclerectomy, trabeculectomy continues to be the gold standard surgical procedure in containing progressive visual loss in glaucoma.[1] The success of this filtering procedure depends on constant shunting of aqueous humor from the anterior chamber to the subconjunctival space through the creation of a surgical fistula, and excessive subconjunctival scarring is the predominant cause of failure of trabeculectomy to consistently achieve low eye pressures. Intraoperative use of antimetabolites like Mitomycin[2] have largely addressed the issue of excessive subconjunctival scarring, significantly increasing the likelihood of long-term success of filtering surgery. The widespread use of antimetabolites in glaucoma filtering surgery has nevertheless resulted in sight-threatening complications,[3] including prolonged wound leaks, hypotony, and maculopathy, bleb-related complications including bleb leaks, blebitis, and endophthalmitis. Considering that trabeculectomy is a filtering surgery that can address the varied mechanisms contributing to elevated IOP and progressive visual field loss across the spectrum of different types of glaucoma, it is crucial to optimize its outcomes. A continued area of focus in glaucoma filtering surgery is the evolution of newer modalities and devices to improve long-term success and lower the rate of serious complications. In concomitant glaucoma surgery with cataract surgery and intraocular lens implantation, the likelihood of long-term surgical success is further diminished owing to increased intraoperative manipulation and inflammation. In a study comparing the bleb morphology by anterior segment optical coherence tomography and clinical outcomes after phacotrabeculectomy with mitomycin C or Ologen implant, Chelerkar et al.[4] have studied the evolution of the morphology of the filtering bleb by ASOCT and compared the clinical outcomes in eyes undergoing phacotrabeculectomy with either MMC or collagen matrix implant and followed up for 1 year. They need to be commended for the useful and additional information they have been able to collate on the role of adjunctive Mitomycin and implantable collagen in combined cataract and glaucoma filtering surgery. The authors observed that bleb morphology, mean IOP, and medications at 1 year were comparable in the two groups. This is largely in agreement with the earlier studies[5678] comparing collagen matrix and Mitomycin in phacotrabeculectomy published in other populations. In a prospective randomized control trial of phacotrabeculectomy using Collagen matrix or Mitomycin, Wlaz et al.[7] had observed that the former provides similar surgical outcomes compared with Mitomycin and concluded it to be safe and effective alternative to Mitomycin for combined phacotrabeculectomy surgery. These results were in predominantly Caucasian eyes and may not necessarily be applicable across all ethnic groups. In a study by Narayanaswamy et al.,[6] the overall performance of Collagen matrix in combined phacotrabeculectomy was suboptimal compared with combined surgery with mitomycin C. Eyes in the Ologen group required more frequent bleb needling procedures. There was similar frequency (<10%) of adverse events in both groups, and there were no complications directly related to the collagen implant. Although in the study by Chelerkar et al.[4] the mean postoperative IOP and medications at end point were comparable between the two groups, the proportion with surgical failure was significantly higher in the Collagen matrix group. Surgical failure in the Collagen matrix group (10%) was more than 5 times as in the Mitomycin group (1.8%). It is possible that ethnic differences between the populations studied could contribute to the differences in surgical outcomes following Collagen matrix and Mitomycin as adjunctive to glaucoma filtering surgery. Major concerns with Mitomycin-augmented trabeculectomies have been ocular hypotony, hypotony-related maculopathy, thin cystic blebs, bleb leaks, and bleb-related endophthalmitis, in particular, in eyes with high myopia, low scleral rigidity, connective tissue disorders and in young individuals with Juvenile open-angle glaucoma. Much of the search for alternative modalities of wound modulation and innovations in glaucoma surgery in the past 2–3 decades have been to optimize IOP control while eliminating complications due to overfiltration arising out of excessive inhibition of fibroblastic response to wound healing following glaucoma surgery. Whereas Collagen matrix has been observed to cause comparable IOP control with reduction in hypotony-related adverse effects in a Caucasian population, similar efficacy has not been seen in Asian and Indian eyes, although long-term hypotony in general has been significantly lesser in eyes which have had adjunctive collagen implants as opposed to those treated with Mitomycin.[4678] In lesser developed economies such as India and elsewhere, it is crucial to balance cost effectiveness with benefits from interventions to lower IOP and prevent progressive glaucoma. Collagen implants used in glaucoma filtering surgery are expensive and may not be as effective as Mitomycin[5] in preventing subconjunctival bleb fibrosis and prolong bleb function to achieve lower-target pressures. Histopathology of Collagen implants studied in human eyes with failed trabeculectomies reveal presence of fibroblasts, myofibroblasts, and fibronectin within the implant and enclosure of the implants by collagenous pseudocapsule,[9] contributing to increased resistance to aqueous flow. Currently available evidence do not support routine use of collagen matrix implants to improve outcomes of phacotrabeculectomy. Data available from Asian and Indian eyes undergoing phacotrabeculectomy seem to suggest the current standard of care of using intraoperative Mitomycin to improve long-term surgical outcomes. Collagen matrix implants may, however, be preferred in eyes at risk of hypotony or maculopathy and thin avascular blebs at risk of sight-threatening complications like endophthalmitis, as in young myopic eyes with Juvenile glaucoma, where potent antimetabolites like Mitomycin are contraindicated.

Innovative technology is making it easier to assess visual function from home/community settings without need for huge infrastructural requirements of hospitals using portable or virtual methods. Such out-of-the clinic methods are likely to facilitate monitoring of patients with glaucoma or suspects and possibly screen for glaucoma detection particularly in low-resource communities. Portable visual field technologies have several advantages over conventional perimetric techniques. Though automated perimetry continues to be the gold standard in diagnosis and monitoring of persons with glaucoma, they are large and require stringent maintenance as to calibration and administered by trained perimetrist to ensure the subjects maintain focus and guided throughout the test. Perimetry test is highly subjective, prone for short- and long-term fluctuations in patient responses and needs to be repeated often to assess progression in those with established glaucoma. Added to these are problems with subject's focus, patient fatigue factors, and loss of attention resulting in inaccurate responses and interpretation. Typically, patients perform one to two tests in ophthalmology clinics per year, and fewer when lost to follow-up, even in developed health economies. Even in centers of excellence in glaucoma and tertiary eye care centers in India where recent generation of perimeters is widely available, it is impractical to perform perimetry on a routine basis to assess progression or periodically screen suspects given the logistics of cost of testing, crowded clinics, and increased wait times deterring periodical visual field testing. Portable or virtual perimetry, which enables patients to test their visual function in home settings, avoiding travel and waiting time in the clinics, also decongests already resource-strained ophthalmology clinics, apart from being a major cost-saving measure. Home-based virtual perimetry is useful in reassuring that suspects have still not progressed from baseline requiring further observation and in assessing whether those with established glaucoma are progressing. Full-threshold visual field evaluation will still be required for confirmatory testing and any change in treatment recommendations. An easier, quicker, self-administered virtual testing could be used as an initial screening method to determine when patients need to visit an ophthalmologist for more definitive diagnostic evaluation. Most patients with glaucoma need to routinely visit an ophthalmologist every 3–6 months, depending on one's risk categorization and severity of disease. Virtual evaluation of visual function hence offers the possibility of remote monitoring and enabling tele-glaucoma care. In one of the first reported home-based visual field test for glaucoma screening, Tsapaki et al.[1] used a software implementing a suprathreshold algorithm that allows self-testing using a computer monitor or virtual reality glasses on an Android smartphone with a 6-inch display. The software included an expert system to analyze the visual field images and validate the reliability of results. This home-based visual field test had exhibited a reasonable agreement with Humphrey visual field results without the need of specialized equipment, rendering the test useful for glaucoma screening. A recent study by Nakanishi et al.[2] describes validation of a portable brain–computer interface (nGoggle, NGoggle, Inc., San Diego, CA, USA) for objective assessment of visual function. The device integrates a wearable, wireless EEG system and a head-mounted display (HMD) to allow acquisition of multifocal steady-state visual-evoked potential signals (mfSSVEP) in response to visual stimulation. In a pilot study where nGoggle was compared with standard perimetry, assessment of diagnostic accuracy was superior for the nGoggle parameters when compared with those of threshold perimetry. As a portable, objective method of assessing visual function, nGoggle appears to be a promising method in diagnosing or detecting progressive visual dysfunction in glaucoma, particularly when applied for home-based screening in underserved areas. In a yet another study validating a head-mounted virtual reality visual field screening device from India, Lukas and Swathi et al.[3] investigated the C3 field analyzer (CFA) as a possible subjective field test for glaucoma screening and monitoring. The CFA presented stimuli in the same positions as the Humphrey SITA 24-2 program using a suprathreshold algorithm. While the CFA could not reliably identify defects that matched standard threshold perimetry, it was moderately effective in identifying glaucoma subjects. Johnson et al.[4] evaluated the performance of the Visual Field Easy (VFE) screening procedure in an iPad for clinic-based visual field testing and compared the results with conventional visual field evaluation by standard autoperimetry on Humphrey field analyzer. VFE is an application available for iPad that can be downloaded for free and evaluates 96 test locations (24 per visual field quadrant) throughout the central 30° of the visual field at a testing distance or 33 cm. A majority of patients were also subject to standard 24-2 SITA threshold perimetry. From their observations, the authors suggest that it is possible to perform visual function screening in remote communities using a tablet-based application. The sensitivity, specificity, and positive predictive value of such a screening procedure can be significantly enhanced when combined with other risk factors such as optic nerve appearance using portable non-mydriatic fundus photography, as well as clinical and demographic risk factors such as age, IOP, and family history of glaucoma when available. The investigators of the study found high correlation between conventional threshold automated perimetry and the table-based suprathreshold visual field test and this approach represents a paradigm shift for detecting potentially blinding conditions such as glaucoma in remote communities in a cost-effective manner. In a similar study in an Indian cohort,[5] comparing VFE with that of Humphrey SITA Fast strategy, investigators had comparable observations although it was not clear whether subjects had prior perimetric experience before being enrolled in the study. VFE, however, demonstrated the ability to accurately predict visual field dysfunction in patients with advanced glaucoma, though similar correlation could not be observed in persons with early to moderate glaucomatous visual field defects. Although the authors of the current study do not recommend VFE for screening populations in communities owing to its poor accuracy in eyes with early glaucomatous visual loss, it can be expected that such inexpensive, suprathreshold testing strategies can be widely used by ophthalmologists to detect those with advanced glaucomatous disc damage in low-resource communities where screening populations is impractical. Incidentally, persons with such advanced disease are those at the highest risk of blindness in their lifetime and their detection and appropriate therapeutic intervention need to be prioritized. Needless to say, research needs to be focused on evolving more sensitive tools to screen for and identify individuals at risk of glaucoma blindness early in the course of the disease. Though further refinement is required, these portable visual testing applications hold promise for simplifying screening and will enable remote testing of populations with poor access to eye care or in their home settings to monitor glaucoma. It can thus be concluded that tablet-based visual field applications are a viable alternative for performing visual field screening for disease detection or monitoring in a variety of settings. In the not too remote future, such an approach is likely to provide visual function testing for not only glaucoma but also diabetic retinopathy and other ocular or neurologic diseases. Future research into refinement and validation of these approaches is likely to provide a means of screening large populations at risk, facilitating patients to perform not only home testing but also in vision centers and can be of immense value in tele-ophthalmology services, apart from waiting areas in busy ophthalmology clinics prior to consulting an ophthalmologist.

Thyroid eye disease (TED) is the most common and disfiguring orbital disease in adults. This complex condition is characterized by autoimmune-mediated inflammation of the orbital soft tissues, extraocular muscles, and eyelids. Majority of those with TED have autoimmune hyperthyroidism (Graves disease), but rarely patients can have hypothyroidism or normal thyroid function. Association of TED with open-angle glaucoma has been reported widely, whereas its association with angle-closure glaucoma has been sparsely reported as case reports. We report two instances of secondary angle-closure glaucoma (SACG) in patients with active TED, with focus on clinical presentation, diagnostic challenges, and presumed mechanisms of angle closure.

Glaucoma is a leading cause of irreversible blindness. Though early diagnosis and therapeutic intervention are key to prevent glaucoma blindness, detection is challenging in early stages due to its asymptomatic nature. In most developing nations, including India, less than 10% of those with glaucoma are detected. Population-based screening for glaucoma is impractical owing to its low prevalence in the communities, lack of cost effectiveness, and other logistic barriers. Automated glaucoma detection, especially when combined with teleglaucoma approach, may enable large-scale glaucoma screening in high-risk, targeted populations.[1] Clinical optic nerve head evaluation and optic disc photography remain the cornerstone in glaucoma screening. Disc photography read by experienced observers achieve similar diagnostic performance as that of advanced imaging methodology, such as optical coherence tomography. A major concern with this approach, however, is its subjective nature and interobserver disagreements even among experienced glaucoma specialists. Fundus photography-based qualitative glaucoma screening may be feasible through automated detection utilizing artificial intelligence and deep learning algorithms (DLA). Earlier machine learning algorithms were primarily based on cup to disc ratio estimation, evaluation of retinal nerve fiber layer, and peri papillary atrophy without adjustment for disc size or other physiological variations in disc appearance.[2] A major advance in this area in recent times has been the development of DLA, in particular, the use of convolutional neural network (CNN), which facilitates improved image analysis with an enhanced capability to extract low-level coarse features or high-level fine features to diagnose glaucoma from fundus images. CNN-based algorithm achieved a high diagnostic accuracy in differentiating the glaucomatous discs from the healthy fundus.[3,4] DLA that interpret the fundus-based biomarkers characterizing glaucomatous optic nerve damage similar to or more reliably than humans can facilitate early diagnosis of glaucoma by quickly screening several individuals at any given time.

Childhood glaucoma is a potentially blinding disease and poses crucial challenges in both diagnosis and management. We report a rare case of secondary glaucoma associated with nonacquired ocular anomalies in a 3-month infant with a family history of pigmentary glaucoma (PG) in two generations presenting as bilateral buphthalmos associated with ectropion uveae, microspherophakia, and high myopia. The child was successfully managed by combined trabeculotomy and MMC-augmented trabeculectomy with stabilized IOP at 12 months follow-up.

A 42-year-old female patient has been referred for high intraocular pressure (IOP) in both eyes (BE). Examination revealed dilated, tortuous conjunctival, and episcleral vessels in BE with no apparent cause, also the patient had advanced glaucomatous damage in the left eye (LE). A diagnosis of bilateral idiopathic elevated episcleral venous pressure with secondary open-angle glaucoma (Radius Maumenee syndrome) was made. She was treated with aqueous suppressants in BE and underwent Partial diode cyclophotocoagulation in LE for control of high IOP. Nearly 50–55 cases have been reported till now. We publish here as this is a rare entity; also we discuss certain management controversies and provide literature review about this entity.

A 23-yr-old female presented with sudden diminution of vision in the left eye (LE) for 4 days associated with headache and vomiting. No history of ocular trauma or previous surgery or similar complaints in the family. Her best-corrected visual acuity (BCVA) was 20/50 with + 8.00 Dsph in RE, HM in LE. Intraocular pressures (IOP) were 14 mm Hg in RE and 54 mm Hg in LE. Anterior segment evaluation revealed a quiet eye with a deep anterior chamber (AC), iridodonesis, aphakia in RE, and focal corneal edema with a microspherophakic cataractous lens in the AC touching the corneal endothelium in LE [Fig. 1a and b]. Fundus evaluation of the RE showed an inferiorly dislocated cataractous lens in the vitreous cavity [Fig. 2a and b]. Ultrasound biomicroscopy (UBM) of the LE showed a small spherical lens in the AC touching the corneal endothelium with an increased anterioposterior diameter (3.72 mm) and decreased equatorial diameter (4.65 mm) [Fig. 3a and b]. B scan revealed dislocated microspherophakic lens into the vitreous cavity in RE and anteriorly dislocated lens in LE [Fig. 4a and b]. IOP in LE was controlled with oral carbonic anhydrase inhibitors and topical IOP-lowering agents.Figure 1: (a) Slit-lamp photograph of the left eye (LE) showing dislocated microspherophakic cataractous lens in the anterior chamber, (b) magnified view of microspherophakic cataractous lensFigure 2: (a) Optos image of the right eye (RE) showing inferiorly dislocated microspherophakic cataractous lens in vitreous, (b) magnified view of microspherophakia lens in vitreousFigure 3: (a) Ultrasound biomicroscopy (UBM) image of the LE showing small spherical lens in the anterior chamber touching corneal endothelium with completely wide open angles (b) white arrows showing small spherical lensFigure 4: (a) B scan RE showing dislocated lens (white arrows) in vitreous (b) B scan of the LE showing anteriorly dislocated lens (white arrows)Microspherophakia is a rare developmental condition characterized by increased anteroposterior diameter and decreased the equatorial diameter of the lens due to the simple arrest of lens development between the 5th and 6th months of intrauterine life. It can occur as an isolated entity or familial entity or associated with systemic disorders such as Weill Marchesani syndrome, Homocystinuria, Marfan syndrome, Alport syndrome, Klinefelter syndrome, Lowe syndrome, Peter's anomaly, Cri-du-chat syndrome. Glaucoma in isolated microspherophakia can occur from spherical lenses causing a pupillary block, irritation of ciliary body by the dislocated lens or complete dislocation of the lens into AC.[1234] Our patient had no clinical features characteristic of any syndrome. She had corneolenticular touch in LE due to anteriorly dislocated lens with very high IOP which may lead to corneal decompensation if not treated appropriately. Microspherophakic lens usually causes secondary angle-closure glaucoma but our patient had open angles that can be clearly visualized with UBM. Elevated IOP probably due to the inflammation caused by the dislocated lens in AC as well as inverse pupillary block impairing the aqueous outflow. Our patient underwent Pars plana lensectomy and scleral fixated IOL in LE. Two partial-thickness scleral pockets were made, 180 degrees apart, at a distance of 1.5 mm from limbus with a 23G microvitreoretinal (MVR) blade for containing the IOL haptics. Three standard 23G pars plana vitrectomy ports and two ciliary sulcus-based sclerotomies were created close to the scleral pockets using a 24G needle, through which IOL haptics would be externalized. After performing lensectomy and core vitrectomy with 23G vitrectomy cutter, a three-piece non-foldable IOL (Aurolab, Madurai, India) was placed into AC through the tunnel and the haptics was externalized with a 25G end-gripping forceps (Alcon Laboratories, Fort Worth, Texas, USA) and tucked into the scleral pockets. Finally, the vitrectomy ports, the scleral tunnel, and conjunctiva were sutured, leaving the globe saline-filled. The postoperative period was eventful. Best-corrected visual acuity (BCVA) and IOP during the last follow-up were 20/70 and 20 mm Hg in the LE. She was advised to continue antiglaucoma eye drops in the LE. We report this case because of an unusual presentation of isolated microspherophakia with bilateral simultaneous lens dislocation posteriorly into the vitreous cavity in RE and anteriorly into the AC in LE with secondary glaucoma. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgement Dr. Karthikeyan K, Retina Fellow, Department of Vitreoretinal Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai.

Primary open angle glaucoma (POAG) is a multifactorial disease characterized by chronic optic neuropathy involving several risk factors. Intraocular pressure (IOP)[1] and alterations in ocular blood flow[2] contribute significantly to the onset and progression of glaucomatous optic nerve damage. Peak IOP and fluctuation[3] are also potential risk factors for glaucoma progression. Association between IOP peaks[4] and visual field deterioration in POAG has been documented in several studies, though role of IOP fluctuation continues to be debated. IOP measurements during routine office hours failed to detect peaks in a significant proportion of patients and detection of both IOP peak values as well as fluctuations was more accurate when 24 h IOP measurements[5] were made. More than 70% of IOP peaks are observed during the night and early morning hours. Repeated tonometry at regular time interval remains the clinically most practiced procedure to measure IOP fluctuation during day and night. However, such repeated IOP measurements to estimate 24 h diurnal variations is both impractical and an insufficient tool in clinical practice. Continued IOP monitoring, though critical in monitoring progression of disease, remains an unfulfilled need in glaucoma practices. Several approaches are currently explored to study the circadian variation in IOP in normal and glaucomatous eyes. An interesting concept has been the use of a contact lens sensor (CLS) to measure corneal curvature variations linked to variations in IOP. An IOP variation of 1 mm Hg alters the radius of corneal curvature by 3 μm. Leonardi et al.[6] developed a soft contact lens embedded microstrain gauge that measures changes in corneal curvature and a good correlation between IOP variations and changes in corneal curvature was reported. Mansouri and Shaaraway[7] used these sensors to report 24 h variations in IOP and a nocturnal acrophase in two thirds of patients with POAG. Continuous 24-h IOP monitoring with the CLS revealed a nocturnal acrophase in healthy subjects and, more markedly, in glaucoma.[8] The diurnal IOP profile does not seem to predict the nocturnal rhythm, and hence the circadian IOP pattern should be evaluated in clinical practice and may be of significant import in management of glaucoma. Rather than being a static variable, IOP fluctuates following a circadian rhythm. While healthy subjects reveal a 3–6 mm physiological increase in IOP at night, persons with glaucoma often have a more pronounced fluctuation exceeding 10 mmHg, which is considered an independent risk factor for disease progression. New devices to monitor IOP over 24 h, rather than snap-shot, single, day time office measurements in sitting posture are essential to assess and eliminate risk of progression. The SENSIMED triggerfish contact lens sensor (Sensimed AG, Lausanne, Switzerland) is a silicone contact lens with an embedded sensor that allows outpatient IOP monitoring as patients continue their routine activities. The CLS contains 2 titanium–platinum strain gauge or wire loops that detect fluctuations in the diameter of corneo scleral junction establishing a correlation between volumetric changes and IOP.[9] Measurements are taken for 30 s every 5 min for the entire 24 h period, generating a total of 288 responses. The lens transmits information through a battery powered antennae and data can be transferred through a bluetooth adapter for analysis. Measurements from CLS are in electrical units (milliVolts) and is represented graphically as IOP curves using an arbitrary unit of measure (millivolt equivalents, mV eq). CLS-mediated diurnal IOP studies have made it possible to study the efficacy of treatments on the amplitude of IOP related fluctuation. Muniesa et al.,[10] for instance, observed that IOP fluctuation was greater in patients treated medically as compared to those who have had surgery, providing evidence to the effect that surgery could more efficaciously flatten the diurnal IOP curve as compared to medications. Not only did the patients in the medical arm have a more pronounced nocturnal acrophase compared to the surgical group, but a higher proportion of individuals on medical treatment had significantly elevated nocturnal IOP. Although medications effectively reduce mean IOP, they may not be as effective as surgical treatment in blunting IOP fluctuations. Surgeries probably preserve visual fields better by flattening the circadian rhythm of IOP. In a prospective, cross sectional study,[11] IOP related parameters obtained with 24 h recording with a CLS were correlated with the rate of visual field progression in treated glaucomatous eyes. Investigators of this study suggested CLS measured parameters may be useful in detecting eyes at higher risk of glaucoma progression while receiving treatment. IOP-related patterns throughout 24 h cycle can be used to evaluate the effect of topical ocular hypotensive medications in blunting IOP fluctuations. Prostaglandin analogue,[12] but not other classes of medications, reduced the nocturnal IOP rise that accompanies the change in body position. In the current issue, Dubey et al. have studied the relationship between nocturnal[13] intraocular pressure peak measured by CLS and glaucoma progression in treated eyes and have observed that thosewho progressed despite apparently normal day time IOP, were significantly more likely to experience nocturnal IOPspikes as compared to those who had not progressed onvisual field criteria. This study, however is limited by its small sample size and attempts to correlate a single parameter, the nocturnal peak IOP indicated by CLS as associated with visual field progression. De Moraes et al.,[14] in a similar, but a multi-centered study with a much larger sample size, have observed that 24 h CLS recordings may be associated with prior rates of visual field progression of glaucoma. Rather than merely nocturnal peak IOP, the investigators had observed several CLS variables that were associated with visual field progression that included mean peak ratio, night bursts ocular pulse frequency, and night bursts ocular pulse amplitudes. CLS variables had better association with glaucoma progression than Goldman applanation IOPs in a regression model. The use of CLS to obtain patterns of electrical signals owing to volumetric changes in the eye, though does not measure the IOP, are correlated with fluctuations in IOP. In addition, the fact that CLS estimates how the ocular structures respond to pressure rather than IOP directly, provides far greater information than IOP alone in clinical management and understanding of structural alternations in glaucoma. From many of these studies of volumetric fluctuations of the eye obtained from CLS, it may be understood that in addition to the mechanical damage to retinal ganglion cell axons directly from elevated IOP, glaucomatous disc damage may also be a function of the response or resilience of ocular tissues to mechanical stress induced by IOP based on their biomechanical properties[14] as well. In summary, based on the current knowledge of CLS obtained parameters, it is possible to risk stratify treated patients with glaucoma, and be able to predict possible future visual field progression to make meaningful clinical decisions in glaucoma management. Future studies are essential to address practical barriers to routine use of contact lens sensor to identify individuals with diurnal peak pressures and appropriately treat them to achieve flattening of circadian fluctuations in IOP and prevent progressive visual loss from glaucoma.

A 78-year-old male, farmer by occupation, presented with defective vision in both eyes (OU) with best-corrected visual acuity of 20/120 and 20/200 in the right eye (OD) and Left eye (OS), respectively. He had no history of trauma or infrared radiation exposure. Intraocular pressure were elevated in OU. Slit-lamp examination revealed bilateral nuclear cataracts OS > OD and double delamination of anterior lens capsule (ALC) in OU [Fig. 1a and b]. Fundus examination revealed CDR-0.7 in OD and CDR-0.8 in OS. ASOCT confirmed the presence of split in the ALC. The patient started on antiglaucoma medications followed by uneventful cataract extraction in OS. Adequate cohesive viscoelastics and capsular staining with tryphan blue dye were used during continuous curvilinear capsulorrhexis, as double-ring sign of the ALC was noted. True exfoliation, a rare disorder where anterior layer of lens capsule delaminates and appears as thin fluttering membrane in anterior chamber, was first reported by Elschnig in 1922 in glassblowers.[1] Double delamination, a rare clinical finding, occurs due to different stages in detachment of outer and inner anterior lens flaps and there exists a narrow space between the detached flaps.[2] Predisposing factors for true exfoliation are infrared-radiation, inflammation, trauma, idiopathic, senility, radiotherapy, and laser iridotomy.[345] Association between true exfoliation and glaucoma has been sparsely reported in ethnic Indian eyes.Figure 1: (a and b) 1a-Slitlamp examination OD showing scrolled flap of anterior lens capsule from 10-7 o' clock and 1b-Slitlamp examination OS showing floating rolled edge of delaminated flap of anterior lens capsule from 9-2 o' clockDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Corticosteroids, recommended for the therapy of a variety of ocular or systemic diseases can increase intraocular pressure (IOP), even when administered by non-ocular route, and pose significant risk to visual function[1] due to glaucomatous disc damage and visual field loss. Corticosteroid-induced ocular hypertensive response and consequent glaucoma have been widely studied and reported in the adults, though little has been known about steroid responsiveness in the pediatric population. Initial reports had indicated IOP response to steroids in children may not be as substantial as is seen in adults, but later studies[2] have confirmed that children are even more likely to be susceptible to steroid-induced glaucoma than are adults. More than a fifth[34] of the children treated with steroids for various indications have been demonstrated to develop steroid-induced glaucoma. Although the incidence of glaucoma is comparable across the various age groups, glaucoma has been found to be more severe, of earlier onset and more rapid in progression[56] in children, as compared to adults. Although prolonged and sometimes indiscriminate use of steroids causes IOP rise and glaucomatous visual field loss, it is not unknown to encounter significant IOP elevation within hours[7] of use. This adverse effect of steroid use may not be reversible[8] in certain susceptible individuals. Topical steroids[3] usually to manage uveitis or vernal conjunctivitis in children is the most common form of administration of steroids resulting in steroid response or steroid-induced glaucoma. In a large series of children with glaucoma in a tertiary hospital in India, steroid-induced glaucoma accounted for 4.7%, and two-thirds of these children had significant visual impairment owing to glaucomatous optic neuropathy in either or both eyes.[9] Some of the children in the study had been indiscriminately using steroids for close to 8 years, in spite being followed up by ophthalmologists before being diagnosed with advanced glaucoma. Inexpensive drugs such as dexamethasone or betamethasone, dispensed in pharmacies without valid physician prescriptions were found to be the most common drug used by children that had resulted in advanced glaucomatous visual field loss in this series of children. The cost of many drugs in the topical corticosteroid group has been capped by government regulations in India, which had further facilitated its unregulated use by children for symptomatic relief of ocular allergies without appropriate physician supervision. The sale of topical steroids in India has been estimated to be 20 times that in the United States. Filtering surgery was also indicated in 45% of children with steroid-induced glaucoma, reflecting the advanced and refractory nature of this iatrogenic glaucoma to treatment. Studies[39] in the recent past have highlighted the significant role played by injudicious use of corticosteroids in children, especially vernal keratoconjunctivitis, with a considerable proportion of those with acquired childhood glaucoma to be because of steroid induced. Sen et al.[10] have studied the prevalence of steroid-induced glaucoma in a large cohort of children with vernal keratoconjuctivitis. In total, 15% of the children in their study have been using topical steroids for therapy without physician prescriptions and a little more than 3% of the children had steroid-induced glaucoma. The study not only highlights the visual disability caused by the inadvertent use of steroids in children but also observes that the children and parents were not adequately counseled about the adverse effects of prolonged use of steroids for a seemingly innocuous ocular condition such as allergic conjunctivitis. They were also not adequately educated about periodical monitoring of eye pressures to detect ocular hypertension early for the cessation of therapy with steroids, so that needless vision impairment could be prevented. Most studies have observed a reversal of ocular hypertensive response in children who had minimal or no optic nerve damage, testifying to the fact that there is no permanent alteration of outflow pathways when the condition is detected early and therapy discontinued. Most children on continued therapy with topical steroids for close to two or more years had presented with significant resistance to aqueous outflow and visual impairment from glaucomatous disc damage, necessitating surgical intervention. It is also appalling that a significant proportion of children in most of the studies in India were blind in one or both eyes at the time of presentation, truly calling for introspection by the ophthalmic fraternity, who have to be accountable and take proactive measures to reverse this disturbing trend. The worldwide prevalence of childhood blindness ranges from 0.03% in the developed world to as high as 0.12% in developing nations. Glaucoma accounts for 4–5% of childhood blindness. It is probable that steroid-induced glaucoma accounts for a very small proportion of children with significant vision impairment, while the prevalence of glaucoma attributable to use of steroids in children in the general population has not been reported. Low prevalence of steroid-induced glaucoma in the population would imply that it may not qualify to be a crucial public health issue to attract allocation of resources to plan preventive measures. However, a high incidence of glaucoma with insidious blindness and late presentation as in the study reported by Sen et al.[10] in children using steroids would result in a significant proportion of blind years in those affected and care provider burden. There is no information of the direct economic impact of steroid-induced glaucoma and blindness in children, while childhood blindness accounted for close to USD 22.2 billion[11] cumulative loss over a lifetime in India in 1997. Judicious use of steroids and close monitoring of children on therapeutic steroids is hence, highly imperative. Considering the potential harm of prolonged steroid therapy in children, primary eye care providers need to consider non-steroidal modalities to address the management of vernal keratoconjunctivitis. Tacrolimus and cyclosporine considered as effective steroid sparing therapy need to be considered in the management of allergic disorders of the eye. Although no published literature currently exists on the changing pattern of steroid-induced glaucoma in children with allergic conjunctivitis and uveitis, it is possible that ophthalmologists are increasingly resorting to non-steroid therapy in the management of trivial conditions such as ocular allergies. Ophthalmologists in clinical practice could possibly attest to the fact that steroid-induced glaucoma is probably declining owing to alternative therapies available for allergic keratoconjunctivitis. Nevertheless, new forms of administration of steroids, such as intravitreal steroids for chronic uveitis, inhalational steroids for allergic bronchitis, and topical steroids for dermatological disorders continue to be used in children. Hence, not only ophthalmologists but specialists of related disciplines also need to be sensitized about the possible ocular adverse effects of steroids, which could easily be overlooked by them. There is an urgent need for educating the public on potential adverse effects of steroids used in any form on the eye. Regulations need to be in place to prevent dispensing of steroids by pharmacists without a valid and approved prescription from the treating physician. Recent, updated prescriptions from physicians need to be made mandatory for dispensing steroids to prevent the practice of over-the-counter sale of these potentially harmful drugs. Physicians of all disciplines need to sensitized about the ocular adverse effects of steroids and those on chronic therapy require to be monitored for serious complications suchas glaucoma by referral to ophthalmologists. All ophthalmologists are also to be educated about frequent IOP monitoring and careful evaluation of the optic nerve head and retinal nerve fiber layer under mydriasis of all children at risk of steroid-induced glaucoma. Steroid-induced glaucoma in children is a complication that is better avoided altogether.

Primary angle closure glaucoma (PACG) is a leading cause of blindness[1] worldwide, especially in Asia. An estimated 5.3 million persons will be blind globally from the disease by 2020,[2] a majority of whom are women and inhabit the densely populated Asian nations. Although primary open‐angle glaucoma (POAG) is the most common form of glaucoma, PACG is more likely to result in blindness if inappropriately treated. Half of those blind from glaucoma are due to angle‐closure disease,[3] although it accounts for only 25% of persons detected with any glaucoma. Risk of blindness is at least three times higher than in open‐angle glaucoma (OAG). Early detection of PACG and its appropriate management presents a challenging task, especially in the developing world.

As pathological confirmation of lung cancer influences treatment selection for suspected early stage lung cancer, high pre-treatment tissue confirmation rates (90%) have been recommended by the National Lung Cancer Audit 2018. However, this practice prior to radical management of patients with early stage lung cancer has never been studied. Using prospective collection of pre-defined biopsy data within multi-disciplinary teams in UK centres, we sought to define the management and outcomes of incomplete pre-treatment tissue confirmation of primary lung cancer in patients undergoing surgery in a multi-centre clinical trial. Methods VIOLET is an UK National Institute of Healthcare Research (NIHR) Health Technology Assessment (HTA) funded clinical trial (Ref: 13/04/03) comparing video-assisted thoracic surgery (VATS) versus open surgery for known or suspected lung cancer. Diagnostic patient pathways were identified and documented for participants with and without pre-surgical tissue confirmation of primary lung cancer. Methods of tissue confirmation (where undertaken) were documented, with resected pathology report as reference compared against the outcome of inappropriate lobectomy (benign disease or secondary lung cancer). Results From July 2015 to February 2019 a total of 2,109 patients were screened, of whom 503 patients were eligible and consented to participate in VIOLET. In total 263 (52%) of patients had a pre-operative pathologic confirmed diagnosis of primary lung cancer. Of the remaining 240 (48%) patients, the majority 205 (85%) did not have a pre-operative biopsy attempted and 35 patients (15%) received a pre-operative non-diagnostic biopsy. Of the 240 patients who entered the operating theatre without pathological confirmation of primary lung cancer, biopsy and frozen section analysis was undertaken in 144 (60%) patients. In the remaining 96 (40%) a lobectomy was undertaken without tissue confirmation (19% of the cohort of 503 trial participants). The overall lobectomy rate for benign disease was 6/503 (1.2%). Conclusions Our results suggest low levels of inappropriate resection can be achieved with a pre-surgical tissue confirmation rates of approximately 50% through a combination of intra-operative confirmatory biopsy and correct risk estimation of lung cancer. The practice would need to be monitored to ensure acceptable levels are consistently achieved across multi-disciplinary teams caring for patients with suspected primary lung cancer.Abstract S23 Figure 1