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

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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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Diplopia or double vision is a frequent reason for ophthalmology consultation. Monocular diplopia is usually ocular or retinal in origin, whereas binocular diplopia is often due to neurological causes. Detailed history beginning with any childhood visual disorders or head tilt and covering comorbid conditions and drug intake is essential. The alignment of images and direction of maximum separation point to the muscle(s) are involved. Temporal profile including onset, progression, and fluctuations along with comorbid conditions helps to narrow down the etiology. Refraction, ocular examination, and fundoscopy can identify ocular and retinal conditions; meticulous examination of ocular ductions and versions is mandatory to localize the cause of diplopia and to initiate investigations for the underlying disease process. Isolated ocular motor palsies are mostly due to microvascular ischemia; in the absence of red flags, investigation may be deferred for 6–8 weeks. Large vertical fusional amplitudes may be a clue to a decompensated congenital trochlear palsy. A partial third nerve palsy with early pupillary involvement, progressive signs, involvement of multiple cranial nerves, and elderly patients with rapid Erythrocyte Sedimentation Rate (ESR) are some situations warranting early imaging and other investigation. Myasthenia gravis and thyroid disease may present with diplopia and ophthalmic manifestations alone without systemic symptomatology. Immunoglobulin G4-related orbital myositis and anti-GQ1b antibody-mediated ocular neuropathies are relatively recently recognized immune-mediated conditions that may present with diplopia to an ophthalmologist. Ophthalmoplegic migraine has been renamed recurrent ophthalmoplegic neuropathy and is a diagnosis of exclusion at initial presentation.

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This clinical query section discusses the current trends in the practice of advanced-technology intraocular lenses. Experts from across the country share their viewpoints and practice patterns on the subject.

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Management of posterior segment ocular trauma is a challenge. A proper knowledge of the imaging in this condition is greatly helpful in charting out a strategy in planning the treatment. Ultrasound B scan is very useful in the event of obscured posterior segment. Optical coherence tomography and fundus autofluorescence are helpful in macular problems after trauma. Computed tomography and Magnetic resonance imaging are useful to detect problems in the retroocular space and in orbit. These will help in proper documentation of the posterior segment and has a medicolegal value. This review article will deal with the different practical uses of imaging technique in posterior segment ocular trauma.

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Arteriovenous malformations (AVMs) are developmental anomalies that occur when the embryonic vascular network fails to differentiate. Proptosis can be caused by both intraorbital and extraorbital AVMs. Digital subtraction angiography (DSA) is essential for the diagnosis and for planning the management of orbital AVMs. In this article, we are discussing two cases of proptosis with AVM as the underlying pathology, but managed by different modes of treatment. Decision on the mode of treatment of AVMs should be taken carefully after weighing the pros and cons.

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Background: Diabetic macular edema (DME) is an important cause of visual impairment in type 2 diabetes. Central macular thickness (CMT) measured using optical coherence tomography (OCT) is a noninvasive method for diagnosis and quantification of DME. OCT not only helps in follow-up and prognosis of macular edema but also aids in early detection of DME, which might not be clinically evident. The study suggests that inflammatory process plays a critical role in retinopathy. C-reactive protein (CRP), an inflammatory marker, is expected to be elevated in patients with poor glycemic control. Furthermore, data on possible association of CRP with diabetic retinopathy are sparse and a limited number of studies reported inconsistent results. The present study is to find the correlation of CRP and glycosylated hemoglobin (HbA1c) on severity of DME. Materials and Methods: This was a case–control study done in a tertiary hospital including 75 cases (type 2 diabetes patients with DME) and 75 controls (diabetics without DME) of diabetic age >5 years. Cases subdivided based on CMT into mild (201–300 μ), moderate (301–400 μ), and severe macular edema (>400 μ). Results: CRP was positive (>0.6 mg/dl) in 32 cases (42.7%) and five controls (6.7%), and positive correlation was obtained between CRP and DME severity. Elevated HbA1c level was associated with increased severity of DME. Conclusion: As inflammation plays a significant role in the pathogenesis of DME, CRP level can be considered as a biomarker to determine the severity of DME along with HbA1c levels.

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Purpose: The purpose of this study is to analyze the effect of integration of the existing noncommunicable disease clinics (NCDC) in government hospitals for early detection and treatment of diabetic retinopathy (DR) using teleophthalmology. Methods: Population-based screening was done in selected clusters of Thrissur district of Kerala, covering the population attending the NCDCs. Trained optometrists screened all the patients with diabetes mellitus (DM), using handheld nonmydriatic fundus camera (Bosch Eye Care Solutions, Finland). Those who required treatment were referred to higher centers. The data were statistically analyzed. Results: Out of the 11,298 patients screened, DR was present among 914 (8.09%) patients. Nonproliferative DR was detected in 727 (80%) and proliferative DR (PDR) in 187 (20%). There was significant association between >10-year duration of DM and occurrence of PDR (P < 0.00001, Chi-square test, odds ratio = 2.76) and between >5-year duration of DM and the occurrence of PDR (P < 0.001, Chi-square test, odds ratio = 2.56). There was significant association between irregular follow-up status for DM at the NCDCs and the occurrence of PDR (P < 0.0001, Chi-square test, odds ratio = 3.4). There was no significant association between age (P = 0.57) and gender (P = 0.08) with follow-up status at NCDCs. Conclusion: Prevalence of DR among DM patients attending NCD clinics of Kerala is 8.09%. There is a significant association between duration of DM, irregular follow-up at NCDCs for DM with the occurrence of PDR. Although DM is routinely treated at the NCDCs of Kerala, DR detection has not received the needed attention. This missing link has to be strengthened.

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Background: Optical coherence tomography (OCT) is a noninvasive method of analyzing in vivo retinal architecture. It also measures retinal nerve fiber layer (RNFL) thickness, which is useful in managing diseases of the retina. Age-related thinning of the retinal ganglion cell complex has been measured using OCT. The present study is to evaluate the RNFL and ganglion cell layer (GCL) thickness using spectral domain OCT in patients with cognitive impairment (CI) and to study the correlation between RNFL and mini–mental state examination (MMSE) scores. Materials and Methods: A case–control study was done on 88 eyes of 44 patients, of which 27 belong to mild CI (MCI) and 17 were controls. They were assessed using MMSE/MINICOG/Montreal Cognitive Assessment tests and retinal OCT for RNFL, GCL, and inner plexiform layer (GCL + IPL) analysis. Results: RNFL thickness was reduced in all quadrants, more in superior and inferior quadrants in patients with MCI. GCL + IPL layer showed overall thinning in all quadrants, of which inferonasal and inferior quadrants were thinnest. Conclusion: MCI patients were prone to develop neurodegeneration even in the absence of microvascular changes in the retina. Hence, it is suggested to carry out routine evaluation of retina with OCT in all patients above the age of 60 to detect early neurodegenerative changes for early management. It is also noted that the sensitivity of GC + IPL was higher than that of RNFL to discriminate MCI from controls.

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A case report of a 66-year-old male who presented with bilateral simultaneous full-thickness macular hole (MH) developed persistent MH after the first uncomplicated MH surgery. In persistent MH, early intervention within a month after the first surgery resulted in excellent anatomical MH closure along with significant improvement in final visual acuity.

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A 43-year-old male underwent laser-assisted in situ keratomileusis and maintained good vision for 9 years. Later, he developed interface fluid syndrome secondary to steroid-induced glaucoma as a consequence of the use of steroids postoperatively for vitrectomy with silicone oil infusion for retinal detachment and cataract surgery.

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