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

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

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

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

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As ophthalmologists, we often come across visually impaired persons (VIPs) whose poor vision we cannot improve. They would benefit with low-vision aids (LVA), but most are reluctant to use them. The visually impaired find it difficult to use advanced technology, as it is often not designed with them in mind. When the world switched from phones with keyboards to full-screen touchscreens, VIPs found it difficult without the tactile feedback of physical keyboard buttons. However, in recent years, there have been numerous innovative apps to assist people with low vision, to not only navigate their smartphone but also their environment and daily life. Programmers have made the use of the high-resolution cameras, gyroscope sensor, vibration feedback, and audio feedback to convert smartphones into LVA, often for free and with no additional hardware. The authors review some of the smartphone apps available for those with low vision. These apps can bring a certain level of independence and self-confidence in these people who are otherwise often dependent on others.

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

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

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Purpose: The aim of this study is to evaluate the reasons for delayed presentation, lens-induced glaucoma (LIG) incidence, intra- and post-operative course and visual outcome among patients with hypermature cataract in Kanchipuram district. Materials and Methods: A prospective interview-based study was undertaken among 304 patients with hypermature over 3 years in the Ophthalmology department of a medical College located in Kanchipuram. Presence of LIG was noted. After small incision cataract surgery, intra- and post-operative complications, final best-corrected visual acuity (BCVA) at 6 weeks were noted and compared with delayed presentation using Chi-square test. Results: Good visual acuity in the other eye was the reason for delayed presentation in 160 (52.6%) patients. Poor post-operative visual acuity was associated with delayed presentation (r = −0.203, n = 304 and P < 0.012). LIG was seen in 30 (10%) patients and 26 (8.5%) of these were pseudophakic in the fellow eye. 8 (2.6%) patients had zonular dehiscence. Difficulty in doing rhexis (156 patients), corneal edema (62 patients), and inferior subluxation of posterior chamber intraocular lens (12 patients) were the most common intraoperative, early and late postoperative complications. Final BCVA of 6/12 or better was seen in 282 patients. Conclusion: Hypermature cataract and LIG are still seen in rural and suburban India and are more likely to develop in patients having good visual acuity in the fellow eye following previous cataract surgery. As delayed presentation is associated with poor postoperative outcome, it is important to educate the community about the need for early surgery.

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Cystoid macular edema is a complication of uveitis which can lead to severe visual impairment if left untreated. Uveitic macular edema occurs when the balance between the water entering the eye and pumped out of the eye is altered thus losing equilibrium in the physiologic function of the retina. Edema has a negative impact on visual recovery in patients with uveitis and may continue to exist despite control of uveitis. This delayed resolution of edema observed clinically and by imaging is most frequent following intermediate uveitis, birdshot retinochoroidopathy, sarcoid uveitis, panuveitis, and iridocyclitis associated with human leukocyte antigen B27. Literature about management of uveitic macular edema is limited, and no consensus has been reached with regard to management protocol. Several treatment options exist including corticosteroids, nonsteroidal anti-inflammatory drugs, immunomodulatory agents, implants, and surgery. These therapies can be administered through various routes such as oral, topical, periocular, or intravitreal injections. A response to treatment is seen as decrease in macular thickness and improvement in visual acuity.

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In this article, we introduce a custom-made smartphone slit-lamp adapter that is designed by one of the authors and made using three-dimensional (3D) printing technology. It is built upon a commercially available part used in selfie sticks and tripods which is used to hold the phone. The rest of the adapter is designed and 3D printed to enable attaching the mobile with that holder to the selected eyepiece. The design depends on each slit-lamp or microscope eyepiece dimensions, and the idea is about making a complementary design that automatically fits the eyepiece which slides in the adapter and then the mobile weight and gravity do the rest to hold the adapter in place. Within few seconds of sliding the phone into the adapter, place the camera against the eyepiece then you are ready to go. It is named blink to allude to its ease of use and quick adjustment like in a blink of an eye.

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Necessity and opportunity in the form of rapidly advancing technology has made affordable innovations possible at a fast pace in ophthalmology. This article tries to cover a few of the recent frugal innovations which have a clinical potential for ophthalmologists.

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Retinal vein occlusion is commonly seen in the elderly.This article aims to comprehensively discuss the etiology,classification,risk factors and latest modalities of management of this condition.

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

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

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Optical coherence tomography (OCT), widely used in the management of macular disorders and glaucoma, has proved its usefulness in many neurophthalmic disorders. OCT can quantify the retinal nerve fiber layer thickness and ganglion cell layer thickness and provides an idea about the neuronal integrity of the anterior visual pathway, which cannot be picked up by routine fundoscopy. Here, we are discussing some neurophthalmic and neurologic diseases where OCT can contribute to the diagnosis, disease monitoring and can provide prognostic information.

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Thyroid-associated ophthalmopathy (thyroid eye disease [TED], thyroid-associated orbitopathy, or Graves' orbitopathy) is the most common, yet a complex and poorly understood autoimmune orbital pathology. It occurs in association with systemic dysthyroid states, most commonly presenting with hyperthyroidism, but also occurs in association with hypothyroidism or euthyroidism. Despite the ongoing research, the pathogenesis and effective treatment strategies remain obscure, hence presenting a challenge for the treating ophthalmologist. The ocular presentation can vary from mild disease to severe irreversible sight-threatening complications. Ocular manifestations can follow the thyroid dysfunction, present parallel to it, or seldom precedes it. The ocular disease has its own natural course divided into an active and inactive phase. Scoring individual patients for the severity of disease has been frequently revised. The clinical examination, activity, and severity aid the ophthalmologist to decide the stage of the disease and come up with the treatment strategy for each patient. Management strategies include a multidisciplinary team effort. Recently, we have witnessed a leap to newer targeted biologic therapy that not only improves the course of the disease but also the quality of life of these patients. In this review, we present an update of the current understanding of etiopathogenesis, clinical features, and management options for this common yet challenging orbital inflammatory disease.

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Purpose: The aim of this study was to assess the final visual outcome and various complications, encountered in the posterior iris-claw intraocular lens (IOL) implantation in aphakic eyes with inadequate capsular support. Methodology: Prospective case series of 30 eyes of 29 patients who underwent posterior iris-claw intraocular lens implantation in a tertiary care center within 1 year (January 2016 to June 2017) with a follow-up period of 6 months. All patients with visually significant posterior segment problems were excluded from the study. Main outcome measures were visual acuity, anterior chamber reaction, corneal edema, the stability of IOL, and cystoid macular edema (CME) at 6 months. Results: Of the 30 eyes enrolled in the study, 24 (86.7%) eyes were taken for elective secondary implantation. Four (13.3%) eyes were for primary iris-claw implantation, where subluxated or dislocated lens was noticed preoperatively. The indications for posterior iris-claw IOL in our study were surgical aphakia (24/30), traumatic subluxation of the cataractous lens (2/30), dislocated lens (2/30), and decentered posterior chamber IOL (2/30). Postoperative mean best-corrected visual acuity (BCVA) was LogMAR 0.3. Analysis of complications showed that the most common postoperative complications were iritis (36%), corneal edema (30%), striate keratitis (26.6%), hyphema (6.66%), iris capture (6.66%), and CME (3.33%). Conclusion: Surgical aphakia is the most common indication for posterior iris-claw IOL implantation. Postoperative mean BCVA is comparable with other methods. Iritis is the most common complication. This technique is a relatively safe and easy procedure learned by postgraduate students.

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Purpose: The purpose of this study is to compare the incidence of retinopathy of prematurity (ROP) in small-for-gestational-age (SGA) infants with appropriate-for-gestational-age (AGA) infants. Materials and Methods: A hospital-based prospective descriptive study was conducted on all cases of preterm babies <34 weeks of gestation and/or <1500 g of birth weight admitted in a tertiary care center, who were sent for ROP screening. Babies were divided into two groups using Lubchenco growth chart. Group 1 consisted of all AGA preterm babies. Group 2 consisted of SGA preterm babies. Screening and staging of ROP were done. Babies were managed appropriately. Data were entered and analyzed. Results: Out of the 300 babies examined, 67 babies were SGA and rest 233 were AGA. The overall incidence of ROP was 29% and it was increased in SGA group to 40% compared to AGA group, which was 25.8%. SGA had a significant association with ROP. Other significant factors were oxygen delivery, mechanical ventilation, sepsis, respiratory distress syndrome, surfactant, apnea, blood transfusions, and acidosis. Maternal factors such as oligohydramnios, premature rupture of membranes, and preeclampsia were also associated with ROP significantly. On multivariate analysis, apnea, blood transfusion, low partial pressure of oxygen, lower gestational age, and maternal gestational diabetes mellitus were independent risk factors. Conclusion: The incidence of ROP is higher in SGA compared to AGA. Being small for gestation is a risk factor for developing ROP.

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Aim: The aim of this study is to evaluate the accuracy of the anterior segment optical coherence tomography (AS-OCT) in measuring the distance from the limbus to the insertion of primary and previously operated horizontal rectus muscles. Materials and Methods: This was prospective observational study; we did AS-OCT preoperatively and measured the distance from angle of anterior chamber to muscle insertion using the caliper tool provided in the software. We calculated limbus-insertion distance by adding 1 mm to the angle-insertion distance. We compared this value with intraoperative measurement obtained with surgical caliper. Results: Totally 35 muscles were evaluated, including 12 previously operated muscles. 88.6% of the measurements were within the 1 mm difference considered clinically acceptable. Bland– Altman plots showed good agreement between the two methods. Conclusions: AS-OCT can image the horizontal rectus muscle insertions well and provide good reliability and accuracy in measurement of the limbus-insertion distance.

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Objective: The objective was to study the incidence and risk factors predisposing to retinopathy of prematurity (ROP) and to assess the outcome after laser photocoagulation. Design: This was a retrospective cohort observational study. Materials and Methods: Infants admitted to a Neonatal Intensive Care Unit of 12 referral hospitals in Kerala between May 2015 and June 2016 were followed up till retinal vascularization completes. Preterm infants with birth weight <1700 g and gestation >34 weeks were screened for ROP at 4 weeks after birth or 31–33 postconceptional age, whichever was later. Infants with birth weight >1700 g and gestation >35 weeks were screened only on neonatologist's discretion. All infants were screened according to the Indian guidelines of type 1 and 2 ROP. We treated both eyes of all infants showing threshold ROP. Statistical analysis was done using SPSS version 16 (SPSS Inc., Chicago, IL, USA). Results: The incidence of ROP in 622 infants screened was 158 (25.4%), of which threshold ROP was seen in 61 (9.80%). No ROP was found in infants weighing >2000 g or with a gestational age >36 weeks. Risk factors predisposing to ROP were hours on ventilator, hemoglobin%, oxygen therapy, and number of blood transfusions, which were more significant in infants with type 1 or threshold ROP than type 2 ROP. Out of 97 infants with type 2 ROP, we saw stage 1 in 31 (30.92%), stage 2 in 59 (60.82%), and stage 3 in 7 (7.21%) infants. 61 (9.80%) infants with threshold ROP were treated with laser photocoagulation. Aggressive posterior ROP or rush disease was seen in 29 (47.54%) of 61 infants with type 1 ROP. Only 2 (3.27%) infants showed falciform fold over macula and 1 (1.63%) infant was blind due to retinal detachment. Conclusion: One-fourth of the infants showed ROP, of which one-tenth needed laser photocoagulation, the outcome of which was good. Risk factors predisposing to ROP were low hemoglobin, high oxygen therapy, increased number of blood transfusions, and hours of ventilator.

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

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Aim: The aim of this study is to compare the outcome of conjunctival autograft (CAG) surgery for pterygium using autologous serum versus fibrin glue. Materials and Methods: A prospective, randomized controlled trial was carried out on 40 patients over a period of 2 years. Group I (20 eyes) underwent CAG with fibrin glue and Group II (20 eyes) underwent CAG with autologous serum. Postoperatively, the parameters noted in both the groups were the time taken for surgery in both the groups, postoperative outcomes such as redness and discomfort during blinking, outcome of the graft (graft edema, graft retraction, graft rejection, graft displacement, and graft loss), and recurrence of the pterygium. Results: In Group I (autologous serum), the mean surgical time was 34.8 min (standard deviation [SD] = 3.664912), whereas in Group II (fibrin glue), the mean surgical time was 22.95 min (SD = 3.086047). The intensity of postoperative discomfort was greater in Group I (autologous serum) than Group II (fibrin glue) on postoperative visits. However, the difference was not statistically significant. Graft rejection was observed in one patient belonging to the fibrin glue group, after 1 month postoperatively, which eventually by the end of 3 months led to graft loss. We found decreased postoperative inflammation and decreased recurrence rate at both a 3- and 6-month time period with the use of fibrin glue compared with autologous serum. Conclusion: Fibrin glue is generally considered safe; however, since it is made from human plasma, it carries the risk of transmitting infections. There was marked reduction in the operating time in fibrin glue group as compared with the autologous blood group. Cost of the surgery was more with fibrin glue. The graft edema, graft loss, graft retraction, and displacement of the graft were more with the use of fibrin glue. However, the difference was not statistically significant.

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