Glaucoma in its early stages is left undiagnosed as it starts affecting the vision from the perip... more Glaucoma in its early stages is left undiagnosed as it starts affecting the vision from the periphery and gradually move towards the centre. In general, 24‐2 and 30‐2 threshold VF testing strategies, are done routinely to pick up early glaucomatous changes. 10-2 VF testing is reserved for advanced glaucoma and those who have tunnel vision in 24-2 or 30-2 VF testing. Recently 10 -2 VF testing is helpful in the detection of progressive visual field loss in glaucoma suspects which is often missed with routine 24-2 or 30-2 testing strategies. It helps reclassify “glaucoma suspects” or “pre‐perimetric glaucoma as “severe glaucoma” at the much earlier stage. 10‐2 VF functional defects are correlating with GCL structural defects. Hence, clinicians should be encouraged in performing 10‐2 tests in patients with early glaucoma, suggesting a structure‐function correlation.
A 75-year-old male patient came for a regular ophthalmic examination with a best corrected visual... more A 75-year-old male patient came for a regular ophthalmic examination with a best corrected visual acuity of 20/20 in both eyes. Examination revealed involuntary closure of his right eyelid on opening his mouth [Figure 1]. On questioning, the patient revealed that he had developed facial paralysis 40 years ago, after which he had involuntary right eyelid movements. The presence of nasolabial fold and the absence of lower lid retraction indicate a near complete recovery of the palsy with minimal residual facial weakness, which is denoted by the absence of forehead creases and reduced prominence of the nasolabial fold on the right side compared to the left side of the face [Figure 1]. This finding is consistent with Marin-Amat syndrome, an aberrant regeneration of the facial nerve. Marin-Amat syndrome is a rare acquired form of facial synkinesis seen after facial nerve paralysis. There is involuntary closure of the eye on the opening of the jaw and is associated with the orbicularis oculi muscle (OOM). This syndrome may be confused with inverse Marcus Gunn syndrome, a congenital condition involving levator palpebrae superioris, requiring a different management approach. Some treatment options are botulinum toxin injections and preseptal OOM resection. We report one such rare case of Marin-Amat syndrome. Careful examination is paramount in providing appropriate treatment to patients.
Original Article introduction Artificial intelligence (AI) is getting more and more popular in di... more Original Article introduction Artificial intelligence (AI) is getting more and more popular in diagnosing fundus images using the basic convolutional neural network (CNN). More than 1,00,000 fundus images are open source for research purposes by the medical research community and available on various platforms such as Kaggle. [1] A well-trained CNN using the open public dataset was able to identify the scale of diabetic retinopathy (DR) (ranging from 0 to 4) with above 84% accuracy. However, the models were not widely accepted as it was criticised as a black box by the ophthalmological community. [2] In the black box dilemma, the CNN-based systems analyse the data based on their own self-generated rules where predictions are made; however, the real rationale behind the predictions in the first place was not clearly understood. In general terms, this refers to a machine learning model that provides a result or reaches a decision without explaining or showing how it did so. There is still a lack of transparency regarding the various weighted factors and internal processes. The eye care professionals Purpose: A novel convolutional neural network approach in detecting diabetic retinopathy (DR) was employed to overcome the black box dilemma in artificial intelligence (AI). In addition to identification and classification, this tool is intended to identify signs such as microaneurysms, hard exudates, dot-blot haemorrhages and flame-shaped haemorrhages, and neovascularisation with the help of customised human annotations. Design: This is a prospective cross-sectional study. Subjects: Eight thousand confocal high-resolution fundus images of 5,174 patients were included in this study. Methods: Dataset involved 8,000 fundus images of DR with 5,200 images for training, 1,400 images for validation and 1,400 images for the held-out test. The 1,400 images used for the held-out test were non-annotated fundus images. You Only Look Once (YOLO) 5 algorithms were used for detection. Main Outcome Measures: The AI tool was evaluated with mean average precision, objectness loss, classification loss, precision and recall. The number of images in which all the clinical signs of DR were correctly predicted, wrongly predicted and missed were also calculated. Results: Tests showed consistent increments from 79.5% to 91% accuracy in predicting the diagnosis, severity, and clinical fundus signs pertaining to DR. The overall sensitivity was 81.6% and the specificity was 100%. Conclusion: To our knowledge, this is the first paper to train fundus images with high-resolution confocal images and annotate every clinical sign of the DR fundus along with diagnosis and severity for accurate predictions with their various fundus signs, thus overcoming the black box dilemma. With constant training via a feedback mechanism, there was a continuous upsurge in prediction accuracy.
Review Article introduction Cerebrovascular disease comprises conditions that affect the blood fl... more Review Article introduction Cerebrovascular disease comprises conditions that affect the blood flow and the blood vessels of the brain. Pathologies that affect blood flow include narrowing of the blood vessels (stenosis), clot formation (thrombosis), blockage (embolism), ballooning and weakening of the arterial wall (aneurysms), cerebral arteriovenous fistula (AVF), transient ischemic attack (TIA), and arteriovenous malformations (AVM). In this review, various ophthalmology-related cerebral arterial circulation diseases are explained in detail, along with detailed 3D images. Anatomy The circle of Willis [Figure 1] is a ring of vessels that provides important colligative communications between the anterior and posterior circulations of the midbrain and hindbrain. It is named after Thomas Willis (1621-1675), an English physician. [1] The circle of Willis plays an important role in defending against ischemia, by providing collateral arterial flow to the affected brain regions. [2-4] Cerebral arterial circulation comprising the circle of Willis includes the following: Anterior circulation Anterior circulation is comprised of bilateral anterior cerebral artery (ACA), which is linked by the anterior communicating artery (AComA).
In this manuscript, we have reported an augmented reality (AR) application named, 'Eye MG AR' inn... more In this manuscript, we have reported an augmented reality (AR) application named, 'Eye MG AR' innovated by us, to show different anatomical/pathological parts of the eyeball pertaining to glaucoma, from multiple customized angles of the user's choice to simplify glaucoma learning and clinical counseling. It is available free of cost from the Google Play Store for Android users. Procedures ranging from a simple outpatient department procedure (yttrium aluminium garnet peripheral iridotomy) to a complex surgical technique (trabeculectomy/tube surgery) can be explained and counseled with this Android application. Also, complex structures such as the angle of the anterior chamber and optic nerve head, are constructed in advanced real-time three-dimensional (3D) high-resolution confocal images. These 3D models are useful for glaucoma neophytes' immersive learning and 3D patient counseling experiences. This AR tool aims to reinvent the approach to glaucoma counseling with 'Unreal Engine' software and is created in a patient-friendly approach. Incepting 3D pedagogy and counseling with AR in glaucoma with real-time and high-resolution TrueColor confocal images has never been reported in the literature according to our knowledge.
This is an open access journal, and articles are distributed under the terms of the Creative Comm... more This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Commentary: The never-ending story of COVID-19: Accustoming to the new abnormal in glaucoma practice, Mar 3, 2023
Rethinking 10-2 visual fields in early diagnosis of glaucoma for a glided glaucoma practice: The ... more Rethinking 10-2 visual fields in early diagnosis of glaucoma for a glided glaucoma practice: The right choice to pick up a feeble noise? Indian
Microspherophakia usually presents with various systemic and ocular features, and is rarely as an... more Microspherophakia usually presents with various systemic and ocular features, and is rarely as an isolated incident. In this manuscript, we have reported a rare occurrence of bilateral isolated microspherophakia with unilateral total anterior luxation of the phakic crystalline lens into the anterior chamber, in a child with no systemic and other ocular involvement. The crystalline lens was seen touching the corneal endothelium. Anterior segment imaging modalities, timely intervention, genetic studies and glaucoma evaluation have been emphasized in such scenarios.
Perimetry is an elaborate test that largely depends on the subjective component of the patient. D... more Perimetry is an elaborate test that largely depends on the subjective component of the patient. Due to the subjective nature of this functional test, untrustworthy results are not uncommon. The extent of untrustworthy results has been reported to range from 3% to 29%, among all visual field tests performed. [1-5] A poorly executed perimetry test hardly has any diagnostic value and fails to achieve its purpose. [6] So, it is crucial to make sure that the time invested in communicating to the patient regarding what is expected of them during the test is as important as the time invested in doing the perimetry test itself. However, unfortunately, this is not the case because this practice more often than not falls into our blind spot.
The authors of the accompanying article investigated, in great detail, the extent to which glauco... more The authors of the accompanying article investigated, in great detail, the extent to which glaucoma disease process can challenge patients economically. [1] Various factors associated with financial dependence on medical expenditure and total expenditure were explored, and the study concluded that the economic burden of glaucoma was high and burnt a hole in the patient's pocket. The study also focused on the economic burden of various glaucoma procedures, such as peripheral iridotomy and trabeculectomy, with limited or no information on minimally invasive glaucoma surgeries (MIGSs). [1] Also, as there is minimal literature currently available on the economic burden of MIGS, we have shed light on this grey area with respect to developing countries like India. [2,3] The current MIGS Indian journey-Where we stand MIGS has made slow and steady definitive inroads in the last few years in India. The number of MIGS procedures and devices that are currently available and accessible in India are limited in their type and number [Tables 1 and 2]. However, cost-effective alternatives to their expensive western counterparts are readily available. Prolene suture gonioscopy-assisted transluminal trabeculotomy (GATT) is the cost-effective alternative to the OMNI Surgical System (Sight Sciences Inc., CA, USA). Bent ab-interno needle goniectomy (BANG) is the cost-effective alternative to the Kahook Dual Blade (New World Medical, CA, USA) that was recently granted regulatory approval in India.
This is an open access journal, and articles are distributed under the terms of the Creative Comm... more This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Aims: This study aims to evaluate the non-mydriatic fundus image quality obtained with a confocal... more Aims: This study aims to evaluate the non-mydriatic fundus image quality obtained with a confocal fundus device. Also, to evaluate the influence of non-mydriatic pupil size on image quality. Settings and Design: A cross-sectional study was conducted in the outpatient department of a high-volume tertiary eye care centre in South India during the third phase of the COVID-19 lockdown. Subjects and Methods: 831 consenting, consecutive patients (1539 eyes) were photographed from May 5 to May 17, 2020, and were graded excellent, fair, adequate, or inadequate; based on white noise, black noise, and image acquisition signals. Pupil diameters were obtained with light-emitting diode flash technology. Statistical Analysis: The collected data were analyzed using SPSS software. Descriptive statistics in the form of frequencies and percentages were calculated. Simple (univariate) linear regression analysis and adjusted regression analysis were used to establish the relationship between pupil size and fundus photo quality. Results: The quality of the fundus photo was excellent in 70.12% (n = 1079), fair in 15.72% (n = 242), adequate in 5.78% (n = 89), and inadequate in 8.38% (n = 129). Of the 1410 obtained images (subtracting the inadequate quality images), 87.66% (n = 1236) were normal and 12.34% (n = 174) were pathological. There was a positive linear relationship between pupil size and quality of retinal photograph; OS (R 2 = 0.935) had a slightly better association than OD (R 2 = 0.901). Conclusions: The majority of the confocal images were excellent in quality. Our four-point grading system serves as a reliable measure of non-mydriatic photograph quality. Pupil size is a significant predictor of image quality for non-mydriatic photographs in surveillance programs.
A 35-year-old female patient came to the outpatient department with a sudden loss of vision in he... more A 35-year-old female patient came to the outpatient department with a sudden loss of vision in her left eye (OS). On evaluation, the right eye (OD) was within normal limits [Figure 1a] with best corrected visual acuity (BCVA) of 20/20, and OS revealed a normal anterior segment with multiple pockets of subretinal fluids (SRF) all over the posterior pole [Figure 1b], with BCVA of 20/60. Optical coherence tomography (OCT) revealed multiple SRF pockets, increased choroidal thickness and retinal pigment epithelial (RPE) undulations [Figure 1c and d] with all classical features of Vogt-Koyanagi-Harada (VKH) syndrome. A set of tailored blood investigations were done to rule out other systemic causes and was found to be within normal limits. The patient was a known diabetic on treatment, with no other systemic illness or history of trauma. As the VKH syndrome was in its acute phase, intravenous (IV) methylprednisolone 1 gram over 1 hour was administered under a physician's supervision for 3 days, after contraindications to it were ruled out, followed by high-dose systemic oral prednisolone 60 mg/day. Following therapy, there was a resolution of VKH features [Figure 2a] but subtle RPE undulations [Figure 2b] and disc oedema [Figure 2c] developed in OS, which were not present on the previous visit. Fundus fluorescein angiography (FFA) with indocyanine green angiography (ICGA) was performed [Figures 3 and 4] during the next visit. The patient also started developing bilateral anterior uveitis with cells 2+ and flare 1+, for which she was started on topical steroids along with systemic oral prednisolone 60 mg/day (i.e., 1 mg/kg body weight as the weight of the patient was 60 kg). The BCVA improved to 20/20 in OS with a resolution of signs at 2-month follow-ups. However, the patient had poor medication adherence and she subsequently developed Vogt-Koyanagi-Harada (VKH) syndrome is a rare bilateral granulomatous panuveitis typically affecting the more pigmented races, and women more than men. VKH syndrome is theorized due to a T-cell-mediated autoimmune reaction against antigens related to melanin and melanocytes, that may happen due to cutaneous or viral triggers. Along with the clinical evaluation, it is mandatory to utilise additional investigative modalities such as fundus fluorescein angiography (FFA), indocyanine green angiography (ICGA), optical coherence tomography (OCT) and ultrasonography, which will help pick up pathognomonic signs, that can be missed on clinical evaluation. In this manuscript, we have reported striking multimodal images of a VKH patient with poor adherence; and have emphasized early detection, initiation of therapy without delay, aggressive therapy, good compliance, very slow tapering of oral steroids and use of immunosuppressants for a good visual prognosis.
Glaucoma in its early stages is left undiagnosed as it starts affecting the vision from the perip... more Glaucoma in its early stages is left undiagnosed as it starts affecting the vision from the periphery and gradually move towards the centre. In general, 24‐2 and 30‐2 threshold VF testing strategies, are done routinely to pick up early glaucomatous changes. 10-2 VF testing is reserved for advanced glaucoma and those who have tunnel vision in 24-2 or 30-2 VF testing. Recently 10 -2 VF testing is helpful in the detection of progressive visual field loss in glaucoma suspects which is often missed with routine 24-2 or 30-2 testing strategies. It helps reclassify “glaucoma suspects” or “pre‐perimetric glaucoma as “severe glaucoma” at the much earlier stage. 10‐2 VF functional defects are correlating with GCL structural defects. Hence, clinicians should be encouraged in performing 10‐2 tests in patients with early glaucoma, suggesting a structure‐function correlation.
A 75-year-old male patient came for a regular ophthalmic examination with a best corrected visual... more A 75-year-old male patient came for a regular ophthalmic examination with a best corrected visual acuity of 20/20 in both eyes. Examination revealed involuntary closure of his right eyelid on opening his mouth [Figure 1]. On questioning, the patient revealed that he had developed facial paralysis 40 years ago, after which he had involuntary right eyelid movements. The presence of nasolabial fold and the absence of lower lid retraction indicate a near complete recovery of the palsy with minimal residual facial weakness, which is denoted by the absence of forehead creases and reduced prominence of the nasolabial fold on the right side compared to the left side of the face [Figure 1]. This finding is consistent with Marin-Amat syndrome, an aberrant regeneration of the facial nerve. Marin-Amat syndrome is a rare acquired form of facial synkinesis seen after facial nerve paralysis. There is involuntary closure of the eye on the opening of the jaw and is associated with the orbicularis oculi muscle (OOM). This syndrome may be confused with inverse Marcus Gunn syndrome, a congenital condition involving levator palpebrae superioris, requiring a different management approach. Some treatment options are botulinum toxin injections and preseptal OOM resection. We report one such rare case of Marin-Amat syndrome. Careful examination is paramount in providing appropriate treatment to patients.
Original Article introduction Artificial intelligence (AI) is getting more and more popular in di... more Original Article introduction Artificial intelligence (AI) is getting more and more popular in diagnosing fundus images using the basic convolutional neural network (CNN). More than 1,00,000 fundus images are open source for research purposes by the medical research community and available on various platforms such as Kaggle. [1] A well-trained CNN using the open public dataset was able to identify the scale of diabetic retinopathy (DR) (ranging from 0 to 4) with above 84% accuracy. However, the models were not widely accepted as it was criticised as a black box by the ophthalmological community. [2] In the black box dilemma, the CNN-based systems analyse the data based on their own self-generated rules where predictions are made; however, the real rationale behind the predictions in the first place was not clearly understood. In general terms, this refers to a machine learning model that provides a result or reaches a decision without explaining or showing how it did so. There is still a lack of transparency regarding the various weighted factors and internal processes. The eye care professionals Purpose: A novel convolutional neural network approach in detecting diabetic retinopathy (DR) was employed to overcome the black box dilemma in artificial intelligence (AI). In addition to identification and classification, this tool is intended to identify signs such as microaneurysms, hard exudates, dot-blot haemorrhages and flame-shaped haemorrhages, and neovascularisation with the help of customised human annotations. Design: This is a prospective cross-sectional study. Subjects: Eight thousand confocal high-resolution fundus images of 5,174 patients were included in this study. Methods: Dataset involved 8,000 fundus images of DR with 5,200 images for training, 1,400 images for validation and 1,400 images for the held-out test. The 1,400 images used for the held-out test were non-annotated fundus images. You Only Look Once (YOLO) 5 algorithms were used for detection. Main Outcome Measures: The AI tool was evaluated with mean average precision, objectness loss, classification loss, precision and recall. The number of images in which all the clinical signs of DR were correctly predicted, wrongly predicted and missed were also calculated. Results: Tests showed consistent increments from 79.5% to 91% accuracy in predicting the diagnosis, severity, and clinical fundus signs pertaining to DR. The overall sensitivity was 81.6% and the specificity was 100%. Conclusion: To our knowledge, this is the first paper to train fundus images with high-resolution confocal images and annotate every clinical sign of the DR fundus along with diagnosis and severity for accurate predictions with their various fundus signs, thus overcoming the black box dilemma. With constant training via a feedback mechanism, there was a continuous upsurge in prediction accuracy.
Review Article introduction Cerebrovascular disease comprises conditions that affect the blood fl... more Review Article introduction Cerebrovascular disease comprises conditions that affect the blood flow and the blood vessels of the brain. Pathologies that affect blood flow include narrowing of the blood vessels (stenosis), clot formation (thrombosis), blockage (embolism), ballooning and weakening of the arterial wall (aneurysms), cerebral arteriovenous fistula (AVF), transient ischemic attack (TIA), and arteriovenous malformations (AVM). In this review, various ophthalmology-related cerebral arterial circulation diseases are explained in detail, along with detailed 3D images. Anatomy The circle of Willis [Figure 1] is a ring of vessels that provides important colligative communications between the anterior and posterior circulations of the midbrain and hindbrain. It is named after Thomas Willis (1621-1675), an English physician. [1] The circle of Willis plays an important role in defending against ischemia, by providing collateral arterial flow to the affected brain regions. [2-4] Cerebral arterial circulation comprising the circle of Willis includes the following: Anterior circulation Anterior circulation is comprised of bilateral anterior cerebral artery (ACA), which is linked by the anterior communicating artery (AComA).
In this manuscript, we have reported an augmented reality (AR) application named, 'Eye MG AR' inn... more In this manuscript, we have reported an augmented reality (AR) application named, 'Eye MG AR' innovated by us, to show different anatomical/pathological parts of the eyeball pertaining to glaucoma, from multiple customized angles of the user's choice to simplify glaucoma learning and clinical counseling. It is available free of cost from the Google Play Store for Android users. Procedures ranging from a simple outpatient department procedure (yttrium aluminium garnet peripheral iridotomy) to a complex surgical technique (trabeculectomy/tube surgery) can be explained and counseled with this Android application. Also, complex structures such as the angle of the anterior chamber and optic nerve head, are constructed in advanced real-time three-dimensional (3D) high-resolution confocal images. These 3D models are useful for glaucoma neophytes' immersive learning and 3D patient counseling experiences. This AR tool aims to reinvent the approach to glaucoma counseling with 'Unreal Engine' software and is created in a patient-friendly approach. Incepting 3D pedagogy and counseling with AR in glaucoma with real-time and high-resolution TrueColor confocal images has never been reported in the literature according to our knowledge.
This is an open access journal, and articles are distributed under the terms of the Creative Comm... more This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Commentary: The never-ending story of COVID-19: Accustoming to the new abnormal in glaucoma practice, Mar 3, 2023
Rethinking 10-2 visual fields in early diagnosis of glaucoma for a glided glaucoma practice: The ... more Rethinking 10-2 visual fields in early diagnosis of glaucoma for a glided glaucoma practice: The right choice to pick up a feeble noise? Indian
Microspherophakia usually presents with various systemic and ocular features, and is rarely as an... more Microspherophakia usually presents with various systemic and ocular features, and is rarely as an isolated incident. In this manuscript, we have reported a rare occurrence of bilateral isolated microspherophakia with unilateral total anterior luxation of the phakic crystalline lens into the anterior chamber, in a child with no systemic and other ocular involvement. The crystalline lens was seen touching the corneal endothelium. Anterior segment imaging modalities, timely intervention, genetic studies and glaucoma evaluation have been emphasized in such scenarios.
Perimetry is an elaborate test that largely depends on the subjective component of the patient. D... more Perimetry is an elaborate test that largely depends on the subjective component of the patient. Due to the subjective nature of this functional test, untrustworthy results are not uncommon. The extent of untrustworthy results has been reported to range from 3% to 29%, among all visual field tests performed. [1-5] A poorly executed perimetry test hardly has any diagnostic value and fails to achieve its purpose. [6] So, it is crucial to make sure that the time invested in communicating to the patient regarding what is expected of them during the test is as important as the time invested in doing the perimetry test itself. However, unfortunately, this is not the case because this practice more often than not falls into our blind spot.
The authors of the accompanying article investigated, in great detail, the extent to which glauco... more The authors of the accompanying article investigated, in great detail, the extent to which glaucoma disease process can challenge patients economically. [1] Various factors associated with financial dependence on medical expenditure and total expenditure were explored, and the study concluded that the economic burden of glaucoma was high and burnt a hole in the patient's pocket. The study also focused on the economic burden of various glaucoma procedures, such as peripheral iridotomy and trabeculectomy, with limited or no information on minimally invasive glaucoma surgeries (MIGSs). [1] Also, as there is minimal literature currently available on the economic burden of MIGS, we have shed light on this grey area with respect to developing countries like India. [2,3] The current MIGS Indian journey-Where we stand MIGS has made slow and steady definitive inroads in the last few years in India. The number of MIGS procedures and devices that are currently available and accessible in India are limited in their type and number [Tables 1 and 2]. However, cost-effective alternatives to their expensive western counterparts are readily available. Prolene suture gonioscopy-assisted transluminal trabeculotomy (GATT) is the cost-effective alternative to the OMNI Surgical System (Sight Sciences Inc., CA, USA). Bent ab-interno needle goniectomy (BANG) is the cost-effective alternative to the Kahook Dual Blade (New World Medical, CA, USA) that was recently granted regulatory approval in India.
This is an open access journal, and articles are distributed under the terms of the Creative Comm... more This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Aims: This study aims to evaluate the non-mydriatic fundus image quality obtained with a confocal... more Aims: This study aims to evaluate the non-mydriatic fundus image quality obtained with a confocal fundus device. Also, to evaluate the influence of non-mydriatic pupil size on image quality. Settings and Design: A cross-sectional study was conducted in the outpatient department of a high-volume tertiary eye care centre in South India during the third phase of the COVID-19 lockdown. Subjects and Methods: 831 consenting, consecutive patients (1539 eyes) were photographed from May 5 to May 17, 2020, and were graded excellent, fair, adequate, or inadequate; based on white noise, black noise, and image acquisition signals. Pupil diameters were obtained with light-emitting diode flash technology. Statistical Analysis: The collected data were analyzed using SPSS software. Descriptive statistics in the form of frequencies and percentages were calculated. Simple (univariate) linear regression analysis and adjusted regression analysis were used to establish the relationship between pupil size and fundus photo quality. Results: The quality of the fundus photo was excellent in 70.12% (n = 1079), fair in 15.72% (n = 242), adequate in 5.78% (n = 89), and inadequate in 8.38% (n = 129). Of the 1410 obtained images (subtracting the inadequate quality images), 87.66% (n = 1236) were normal and 12.34% (n = 174) were pathological. There was a positive linear relationship between pupil size and quality of retinal photograph; OS (R 2 = 0.935) had a slightly better association than OD (R 2 = 0.901). Conclusions: The majority of the confocal images were excellent in quality. Our four-point grading system serves as a reliable measure of non-mydriatic photograph quality. Pupil size is a significant predictor of image quality for non-mydriatic photographs in surveillance programs.
A 35-year-old female patient came to the outpatient department with a sudden loss of vision in he... more A 35-year-old female patient came to the outpatient department with a sudden loss of vision in her left eye (OS). On evaluation, the right eye (OD) was within normal limits [Figure 1a] with best corrected visual acuity (BCVA) of 20/20, and OS revealed a normal anterior segment with multiple pockets of subretinal fluids (SRF) all over the posterior pole [Figure 1b], with BCVA of 20/60. Optical coherence tomography (OCT) revealed multiple SRF pockets, increased choroidal thickness and retinal pigment epithelial (RPE) undulations [Figure 1c and d] with all classical features of Vogt-Koyanagi-Harada (VKH) syndrome. A set of tailored blood investigations were done to rule out other systemic causes and was found to be within normal limits. The patient was a known diabetic on treatment, with no other systemic illness or history of trauma. As the VKH syndrome was in its acute phase, intravenous (IV) methylprednisolone 1 gram over 1 hour was administered under a physician's supervision for 3 days, after contraindications to it were ruled out, followed by high-dose systemic oral prednisolone 60 mg/day. Following therapy, there was a resolution of VKH features [Figure 2a] but subtle RPE undulations [Figure 2b] and disc oedema [Figure 2c] developed in OS, which were not present on the previous visit. Fundus fluorescein angiography (FFA) with indocyanine green angiography (ICGA) was performed [Figures 3 and 4] during the next visit. The patient also started developing bilateral anterior uveitis with cells 2+ and flare 1+, for which she was started on topical steroids along with systemic oral prednisolone 60 mg/day (i.e., 1 mg/kg body weight as the weight of the patient was 60 kg). The BCVA improved to 20/20 in OS with a resolution of signs at 2-month follow-ups. However, the patient had poor medication adherence and she subsequently developed Vogt-Koyanagi-Harada (VKH) syndrome is a rare bilateral granulomatous panuveitis typically affecting the more pigmented races, and women more than men. VKH syndrome is theorized due to a T-cell-mediated autoimmune reaction against antigens related to melanin and melanocytes, that may happen due to cutaneous or viral triggers. Along with the clinical evaluation, it is mandatory to utilise additional investigative modalities such as fundus fluorescein angiography (FFA), indocyanine green angiography (ICGA), optical coherence tomography (OCT) and ultrasonography, which will help pick up pathognomonic signs, that can be missed on clinical evaluation. In this manuscript, we have reported striking multimodal images of a VKH patient with poor adherence; and have emphasized early detection, initiation of therapy without delay, aggressive therapy, good compliance, very slow tapering of oral steroids and use of immunosuppressants for a good visual prognosis.
The healthcare sector has had a relatively late implementation of environmental thinking in its s... more The healthcare sector has had a relatively late implementation of environmental thinking in its setup. “Green electronic technologies and go green healthcare system” has recently evolved to address the biodegradability and biocompatibility issues faced by inorganic electronics and non-biodegradable materials. Green healthcare has the capability to promote global health both directly and indirectly. With the rise in environmental degradation, utilizing innovative ‘Go Green’ strategies in ophthalmology is of utmost importance. It has been structured to imbibe environmentalism into healthcare. In this chapter, we have emphasized a few simple patient point of care (POC) innovations in the field of ophthalmology that could transform the future of disease management toward a much more sustainable model by reducing resource and energy consumption. We have discussed how we innovated the novel coronicle (corona + cubicle) during the COVID-19 era, which housed all the essential ophthalmic gadgets and was interconnected using the local area network (LAN) for data access in patient care. Turning to patient counseling, we have highlighted how our innovative and cost-effective 3D augmented reality, and 4D holographic diagnostics and counseling platforms are effective in replacing the conventional paper-based system.
Thromboembolic manifestations of the eye can vary from a trivial tributary retinal vein occlusion... more Thromboembolic manifestations of the eye can vary from a trivial tributary retinal vein occlusion to a catastrophic cerebral venous sinus thrombosis. These conditions can be classified as pathologies directly affecting the eye or those causing secondary lesions due to systemic issues and can be managed accordingly. Also, recently the incidence of thrombotic phenomenon affecting multiple organs (with the eye being no exception) is estimated to be around 25% among patients hospitalized in the intensive care unit for COVID-19, even though anticoagulant treatment was administered prophylactically. In this chapter, the various pathophysiologies of the ocular thrombotic events are highlighted with a special focus on the COVID-19 induced thrombotic ocular complications. Ophthalmologists, sometimes being the first responder, have a vigilant role to play with a heightened awareness of these atypical extrapulmonary thrombotic ocular manifestations, which are not only vision-threatening; in certain instances, lifethreatening too. This chapter summarizes the recent advances in ocular thrombotic diseases with focal points on the current recommendations in COVID-19 induced ocular thrombotic complications. The potential diagnostic and preventive actions such as the prophylactic role of anti-thrombotic therapy, baseline non-contrast chest computed tomography, as well as recommendations for patients with COVID-19 infection are discussed in detail.
Cerebral circulation is the flow of blood through a group of arteries and veins which supply the ... more Cerebral circulation is the flow of blood through a group of arteries and veins which supply the brain. There are various diseases related to ophthalmology, due to pathologies in the cerebral arterial system. Arteries inside the skull can be blocked by plaque or disease, which in turn triggers a series of events leading to various cranial nerve palsies, visual fields defects, retinal diseases, etc. The highlights of this chapter are the novel three-dimensional (3D) animative videos created by us, to simplify various cerebral arterial circulation diseases and their diagnostic concepts for neophytes. 3D animative videos can aid learning and help in the cognitive concept building of these complex pathologies.
The field of augmented reality (AR) and three-dimensional (3D) printing are rapidly growing with ... more The field of augmented reality (AR) and three-dimensional (3D) printing are rapidly growing with many new potential applications in medical education and pedagogy. In this chapter, we have used 3D AR and 3D printed models of the cerebral arterial circulatory system, created by us to simplify concept learning. Various cerebral circulation diseases pertaining to ophthalmology can be explained in detail for immersive learning, with the help of various 3D models, for structures such as the circle of Willis, cavernous sinus, various cranial nerves, cerebrum, cerebellum and the eye. These models not only help in cognitive understanding of cerebral circulation diseases but also aid in diagnosing them with better conviction. Ophthalmologists, sometimes being the first responder, have a vigilant role to play with a heightened awareness of these cerebral arterial circulation diseases, which are not only vision-threatening but life-threatening too. This chapter summarizes the construction and holistic application of these 3D ophthalmology-related arterial cerebral circulation models in AR and 3D printing.
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Papers by Aji K Devadas
the capability to promote global health both directly and indirectly. With the rise in environmental degradation, utilizing innovative ‘Go Green’ strategies in ophthalmology is of utmost importance. It has been structured to imbibe environmentalism into healthcare. In this chapter, we have emphasized a few simple patient point of care (POC) innovations in the field of ophthalmology that could transform the future of disease management toward a much more sustainable model by reducing resource and energy consumption. We have discussed how we innovated the novel coronicle (corona + cubicle) during the COVID-19 era, which housed all the essential ophthalmic gadgets and was interconnected using the local area network (LAN) for data access in patient care. Turning to patient counseling, we have highlighted how our innovative and cost-effective 3D augmented reality, and 4D holographic diagnostics and counseling platforms are effective in replacing the conventional paper-based system.