Publications by authors named "Ramesh Kekunnaya"

128 Publications

Tribal Odisha Eye Disease Study (TOES). Report # 8. Childhood cataract surgery and determinants of visual outcome in tribal districts.

Indian J Ophthalmol 2021 Aug;69(8):2072-2077

Department of Statistic and Ethical Committee Member of Holy Family Hospital, New Delhi, India.

Purpose: The purpose of this study is to describe the demographic profile, clinical features, visual outcomes, and follow-up patterns after successful cataract surgery in children from the tribal community in Odisha, India.

Methods: We retrospectively reviewed records of tribal children aged 4 months-16 years, who underwent public health financed cataract surgery at our institute from January 1, 2015, to December 31, 2019. Collected data included demographic profile, clinical features, outcomes, and follow-up. Univariate and multivariate linear regression identified factors affecting the visual outcome at a 6-week follow-up.

Results: During this period, a total of 352 children [536 eyes; mean age: 9.11 ± 4.4 years, 219 boys (62%)] underwent cataract surgery. The most common etiology and presenting complaints were idiopathic congenital cataract and decreased vision, respectively. In 304 children (86%), presenting best-corrected visual acuity (BCVA) was <20/200 (1.0 LogMAR), 113 (32%) had associated strabismus, and 57 (16%) had associated nystagmus. The public health agency did not sponsor postoperative follow-up, and only 195 (56%) and 61 (17.3%) children completed a 6-week and a 3-month follow-up, respectively. Median BCVA at 6-week and 3-month review was 20/125 (0.8, interquartile range [IQR], 0.2-2 LogMAR) and 20/60 (0.5, IQR, 0.25-1.35 LogMAR), respectively.

Conclusion: This study showed that children from the tribal community presented late with poor presenting VA and had suboptimal visual outcomes with inconsistent follow-ups. Greater advocacy, delivery of care closer to the place of residence, and financial support for follow-up care could improve early detection, regular evaluation, and outcomes.
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http://dx.doi.org/10.4103/ijo.IJO_3332_20DOI Listing
August 2021

The effect of congenital blindness on resting-state functional connectivity revisited.

Sci Rep 2021 Jun 14;11(1):12433. Epub 2021 Jun 14.

Biological Psychology and Neuropsychology, Institute for Psychology, University of Hamburg, Von-Melle-Park 11, 20146, Hamburg, Germany.

Lower resting-state functional connectivity (RSFC) between 'visual' and non-'visual' neural circuits has been reported as a hallmark of congenital blindness. In sighted individuals, RSFC between visual and non-visual brain regions has been shown to increase during rest with eyes closed relative to rest with eyes open. To determine the role of visual experience on the modulation of RSFC by resting state condition-as well as to evaluate the effect of resting state condition on group differences in RSFC-, we compared RSFC between visual and somatosensory/auditory regions in congenitally blind individuals (n = 9) and sighted participants (n = 9) during eyes open and eyes closed conditions. In the sighted group, we replicated the increase of RSFC between visual and non-visual areas during rest with eyes closed relative to rest with eyes open. This was not the case in the congenitally blind group, resulting in a lower RSFC between 'visual' and non-'visual' circuits relative to sighted controls only in the eyes closed condition. These results indicate that visual experience is necessary for the modulation of RSFC by resting state condition and highlight the importance of considering whether sighted controls should be tested with eyes open or closed in studies of functional brain reorganization as a consequence of blindness.
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http://dx.doi.org/10.1038/s41598-021-91976-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8203782PMC
June 2021

Oculomotor synkinesis: an uncommon sequela of paediatric cavernous sinus thrombosis.

BMJ Case Rep 2021 May 13;14(5). Epub 2021 May 13.

Paediatric Ophthalmology, Strabismus and Neuro-ophthalmology, Jasti V Ramanamma Children's Eye care Center, Child Sight Institute, LV Prasad Eye Institute, Hyderabad, Telangana, India.

We report an unusual case of acquired oculomotor synkinesis as a sequela of cavernous sinus thrombosis in a child. A 4-year-old male child presented to our emergency services with sudden onset periorbital swelling with complete ptosis of the left upper eyelid. This was preceded by a febrile episode and a furuncle at the tip of the nose. Computerised axial tomography of the orbit revealed orbital cellulitis in the left eye. The child was started on systemic antibiotics followed by a short course of systemic steroids. MRI of the brain with contrast revealed left cavernous sinus and superior ophthalmic vein thrombosis. Following administration of systemic anticoagulants and antibiotics, the ocular motility and ptosis improved remarkably. However, 6 months post-treatment, the child developed signs of aberrant regeneration of the third cranial nerve (oculomotor synkinesis).
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http://dx.doi.org/10.1136/bcr-2020-239819DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8126313PMC
May 2021

Newer insights into the clinical profile of posterior lenticonus in children and its surgical, visual, refractive outcomes.

Eye (Lond) 2021 May 6. Epub 2021 May 6.

Child Sight Institute, Jasti V Ramanamma Children's Eye Care Centre, L V Prasad Eye Institute, Hyderabad, India.

Purpose: To analyze the clinical profile of patients with posterior lenticonus and their surgical, visual, and refractive outcomes.

Results: Retrospective interventional case series of 84 eyes of 63 patients with posterior lenticonus. The incidence of posterior lenticonus was 3.98% during a study period of 5 years. One-third of cases had bilateral posterior lenticonus. The mean age was 4.78 ± 4.28 years (unilateral cases were significantly older than bilateral, P = 0.0001). Males were 54%. Mean axial length and keratometry were 21.49 mm and 44.88 D, respectively. Eyes with the bilateral disease were significantly shorter (axial length, P = 0.0012) and smaller (horizontal corneal diameter, P < 0.0001) compared to those with unilateral disease. While 88% were pseudophakic; 12% were aphakic. The posterior capsular defect was noted intraoperatively in 44%. Sixty-eight percent of eyes had a pre-operative diagnosis of posterior lenticonus, 32% were diagnosed intraoperatively. The mean follow-up period was 1.3 years. Best-corrected visual acuity (BCVA) at 6 months was fair to poor in two-third of patients (median 20/100). The mean ± SD visual acuity (LogMAR) and spherical equivalence for unilateral and bilateral cases were 0.70 ± 0.27, 0.67 ± 0.26D (p = 0.57) and 2.04 ± 2.74, 5.15 ± 3.73D (p = 0.0001), respectively. Visual outcomes were better in children who are aged 2 years or more (P = 0.0056). Eight percent needed a second surgery.

Conclusion: We report a higher prevalence of bilateral posterior lenticonus in this cohort. The clinical profile of bilateral disease differs from unilateral disease. The diagnosis is not always clinical. In the bag, intra-ocular lens (IOL) implantation is possible in the majority. The visual outcomes remain fair to poor, possibly due to late presentation and the presence of dense refractory amblyopia.

Synopsis: The manuscript consists of the largest series of posterior lenticonus to date. It provides the prevalence of posterior lenticonus along with characteristics difference between unilateral and bilateral cases of posterior lenticonus. Newer insights in terms of diagnostics, pre-operative pick-up rate, how to improve, visual and refractive outcomes of unilateral and bilateral cases are described.
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http://dx.doi.org/10.1038/s41433-021-01564-4DOI Listing
May 2021

ICO-OSCAR scoring for pediatric cataract surgeries performed by pediatric ophthalmology fellows in training-stage of fellowship and quality of surgery.

J AAPOS 2021 Apr 22;25(2):99.e1-99.e4. Epub 2021 Apr 22.

Child Sight Institute, Jasti V Ramanamma Children's Eye Care Centre, LV Prasad Eye Institute, KAR Campus, Hyderabad, Telangana.

Purpose: To compare quality of surgical steps in pediatric cataract surgery performed by pediatric ophthalmology fellows in various stages of training by applying the International Council of Ophthalmology-Ophthalmology Surgical Competency Assessment Rubric (ICO-OSCAR).

Methods: Two experienced pediatric ophthalmologists analyzed video recordings of fellows performing pediatric cataract surgery at our institution between August 2019 and March 2020; fellows were scored according to the ICO-OSCAR with respect to the six key surgical step, namely, (1) wound construction, (2) anterior capsulorrhexis, (3) irrigation and aspiration, (4) intraocular lens implantation, (5) primary posterior capsulotomy (PPC)/anterior vitrectomy (AV), and (6) wound suturing. Cohen's kappa was used for inter-rater agreement. Fellows were categorized by months of training as stage 1 (first 6 months), stage 2 (7-18 months), and stage 3 (19-24 months).

Results: We analyzed 79 procedures performed by 11 pediatric ophthalmology fellows. The inter-rater agreement ranged from 85% to 96%; κ ranged from 0.64 to 0.91. Fellows in stages 2 and 3 of their training required less time and demonstrated superior technical proficiency in PPC and AV compared with fellows in stage 1 (median score, 4 vs 3).

Conclusions: Objective scoring of cataract surgeries performed by fellows at various stages of training highlighted the steep learning curve for PPC and AV and confirmed that execution improves with experience.
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http://dx.doi.org/10.1016/j.jaapos.2020.11.019DOI Listing
April 2021

An interplay of microglia and matrix metalloproteinase MMP9 under hypoxic stress regulates the opticin expression in retina.

Sci Rep 2021 Apr 2;11(1):7444. Epub 2021 Apr 2.

Prof. Brien Holden Eye Research Centre, LV Prasad Eye Institute, Hyderabad, India.

Inflammation plays a key role in the pathogenesis of retinal vascular diseases. We have shown earlier an increase in the activity of matrix metalloproteinases in the vitreous and tears of preterm born babies with retinopathy of prematurity (ROP) compared to those with no-ROP leading to a shift in the balance of angiogenic (vascular endothelial growth factor [VEGF], matrix metalloproteinase [MMPs], complement component [C3]) and anti-angiogenic (opticin, thrombospondin) in ROP eyes. We now confirmed that tear MMP levels in premature infants perfectly correlates with disease severity. Next, we demonstrated that a reduced opticin levels in ROP vitreous are regulated by MMPs secreted by activated microglia. Upon exposing the human microglia cell line (CHME3) to hypoxia, an increased expression of inflammatory proteins (MMP9, VEGF) was noticed while opticin reduced significantly (p = 0.005). Further, the reduced opticin's expression by microglial cells under hypoxia could be rescued by inhibiting the MMP activity using doxycycline and EDTA. The inhibition of MMP activity altered the expression of other key signaling molecules under hypoxia. Our study clearly explains that increased activity of MMPs under hypoxia regulates the expression of opticin as seen in the vitreous humor of ROP and could serve as a potential target for ROP management.
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http://dx.doi.org/10.1038/s41598-021-86302-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8018966PMC
April 2021

Consecutive Esotropia with and without Abduction Limitation - Risk Factors and Surgical Outcomes of Lateral Rectus Advancement.

J Binocul Vis Ocul Motil 2021 Apr-Jun;71(2):62-70. Epub 2021 Mar 30.

Jasti V Ramanamma Children's Eye Care Centre, Child Sight Institute, L V Prasad Eye Institute, Hyderabad, India.

: To identify risk factors for abduction limitation in consecutive esotropia following surgical correction of exotropia. To study outcomes of lateral rectus advancement for consecutive esotropia correction.: Patients with consecutive esotropia (>10PD) operated between 2007 and 2019 with a minimum follow-up of 2 months were reviewed retrospectively. Preoperative and postoperative alignment and ocular motility were recorded. Patients were classified into those with full abduction (group-A) and with abduction limitation (group-B). Success was defined as deviation ≤10 PD of esotropia or exotropia in the primary position.: Forty-cases fulfilled the inclusion criteria (group-A = 28 and group-B = 12). Median age at surgery was five years, median consecutive esotropia was 20PD and follow-up was 29.18 months. Abduction limitation (group-B) was associated with constant exotropia ( = .01) and larger bilateral lateral rectus recession (group-A = 13 mm, group-B = 15 mm; = .04). Nineteen patients underwent lateral rectus advancement (group-A = 12, group-B = 7), one underwent medial-rectus recession and two were excluded due to lack of postoperative follow-up. Five patients had spontaneous resolution with good alignment (group-A = 3, group-B = 2), two refused surgery, three were observed and eight were lost to follow-up. Success following second surgery was similar in both groups (group-A = 86%, group-B = 77%)(p = 1).: Constant exotropia and larger lateral rectus recession were associated with abduction limitation in consecutive esotropia. Lateral rectus advancement produced good outcomes irrespective of abduction limitation.
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http://dx.doi.org/10.1080/2576117X.2021.1880311DOI Listing
March 2021

The size-weight illusion is unimpaired in individuals with a history of congenital visual deprivation.

Sci Rep 2021 Mar 23;11(1):6693. Epub 2021 Mar 23.

Biological Psychology and Neuropsychology, University of Hamburg, 20146, Hamburg, Germany.

Visual deprivation in childhood can lead to lifelong impairments in multisensory processing. Here, the Size-Weight Illusion (SWI) was used to test whether visuo-haptic integration recovers after early visual deprivation. Normally sighted individuals perceive larger objects to be lighter than smaller objects of the same weight. In Experiment 1, individuals treated for dense bilateral congenital cataracts (who had no patterned visual experience at birth), individuals treated for developmental cataracts (who had patterned visual experience at birth, but were visually impaired), congenitally blind individuals and normally sighted individuals had to rate the weight of manually explored cubes that differed in size (Small, Medium, Large) across two possible weights (350 g, 700 g). In Experiment 2, individuals treated for dense bilateral congenital cataracts were compared to sighted individuals in a similar task using a string set-up, which removed haptic size cues. In both experiments, indistinguishable SWI effects were observed across all groups. These results provide evidence that early aberrant vision does not interfere with the development of the SWI, and suggest a recovery of the integration of size and weight cues provided by the visual and haptic modality.
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http://dx.doi.org/10.1038/s41598-021-86227-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7988063PMC
March 2021

Commentary: Posterior optic buttonholing of intraocular lens implantation through posterior capsulorrhexis margin: A technique of intraocular lens implantation in cases of anterior capsulorrhexis extension in pediatric cataract surgery.

Indian J Ophthalmol 2021 04;69(4):977-978

Child Sight Institute, Department of Pediatric Ophthalmology, Strabismus and Neuro-Ophthalmology, Child Sight Institute and Jasti V Ramanamma Children's Eye Care Centre, L V Prasad Eye Institute, Hyderabad, Telangana, India.

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http://dx.doi.org/10.4103/ijo.IJO_3342_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8012932PMC
April 2021

Profile of congenital cataract in the first year of life from a tertiary care center in South India - A modern series.

Indian J Ophthalmol 2021 04;69(4):932-936

Pediatric Ophthalmology and Strabismus Services, LVPEI, Hyderabad, India.

Purpose: To report the etiology, clinical presentation, and morphology of congenital cataract in a tertiary care center.

Methods: It is a prospective cohort study conducted at L V Prasad Eye Institute, Hyderabad. All children with congenital cataract ≤ 12 months of age that required surgical intervention between August 2015 and July 2016 were included in the study. 109 such patients were subjected to meticulous history taking, pedigree charting, ocular, and systemic examination, B-scan, TORCH testing, clinical photographs, pediatrician consult and blood tests, which included serum calcium, serum phosphorous and urine for reducing sugars.

Results: The mean age of presentation was 4.1 months (±2.6 months) and both the genders were equally affected (P = 0.49). Eighty-five patients (77.9%) presented with bilateral cataracts while 24 patients had a unilateral presentation (22.1%). The common morphological presentation was either a total or a nuclear cataract, both variants noticed in 47 patients (43.1%). TORCH infections were responsible for a maximum (37 patients, 33.4%) number of cases followed by familial (20 patients, 18%) and developmental anomalies (11 patients, 10.1%) while the total number of idiopathic cases were 24% (27 patients). Eighteen patients (16.5%) had congenital heart defects and the majority (16 patients, 88.9%) of these had positive TORCH titres.

Conclusion: Familial cataract and those possibly due to TORCH are still the predominant cause of congenital cataract in this series-highlighting the role of vaccination and preventive measures.
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http://dx.doi.org/10.4103/ijo.IJO_1558_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8012959PMC
April 2021

One-year Profile of Eye Diseases in Infants (PEDI) in secondary (rural) eye care centers in South India.

Indian J Ophthalmol 2021 04;69(4):906-909

L V Prasad Eye Institute, KAR Campus, Banjara Hills, Hyderabad, Telangana, India.

Purpose: The aim of this study was to report the proportion and patterns of eye diseases observed among infants seen at two rural eye care centers in South India.

Methods: A retrospective review of case records of infants seen between January 1, 2017 and December 31, 2017 at two rural secondary eye care centers attached to L V Prasad Eye Institute, Hyderabad. Data were collected regarding their demographic profile, the pattern of eye problems observed, management at the facility itself, and need for referrals.

Results: During this period, a total of 3092 children were seen. Among them, 141 were infants (4.56%, 71 boys: 70 girls, median age: 8 months). Twenty-five percent of infants were less than 6 months of age. The most common eye problem was congenital nasolacrimal duct obstruction (n = 76, 53.90%), followed by conjunctivitis (n = 33, 23.40%), retinopathy of prematurity (n = 4, 2.84%) and strabismus (n = 3, 2.13%). One case each of congenital cataract and suspected retinoblastoma were identified. Majority of the cases (58.8%) belonged to the oculoplastic and orbital surgery sub-specialty. Sixteen percent of the infants (n = 23) had sight-threatening eye problems. Twenty percent (n = 28) were referred to tertiary care hospital for further management.

Conclusion: Profile of eye disease in infants in secondary or rural eye care centers ranged from simple to complex, including sight-threatening diseases. While our study concluded that nearly 4/5 of these eye problems were simple and could be managed by a well-trained comprehensive ophthalmologist, 20% of these cases required a referral to a tertiary care center.
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http://dx.doi.org/10.4103/ijo.IJO_1084_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8012936PMC
April 2021

Bilateral myopic strabismus fixus with fat prolapse treated by silicone band loop myopexy and excision of fat.

BMJ Case Rep 2021 Feb 26;14(2). Epub 2021 Feb 26.

Paediatric Ophthalmology, Strabismus and Neuro-ophthalmology, Child Sight Institute, Jasti V Raamanamma Children's Eye Care Center,LV Prasad Eye Institute, Hyderabad, Telangana, India

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http://dx.doi.org/10.1136/bcr-2020-238364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7919575PMC
February 2021

Definition of successful outcomes after surgery for each type of strabismus: a Delphi study.

J AAPOS 2021 02 16;25(1):3.e1-3.e5. Epub 2021 Feb 16.

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Background: The Delphi process has been widely used to delineate guidelines for the treatment of disorders for which there is little or no evidence in the published literature. The purpose of this study was to use the Delphi process to identify areas of consensus and disagreement on the definition of success after surgery for each type of strabismus.

Methods: Two rounds of electronic questionnaires were sent to 28 members of the Strabismus Success Definition Delphi Study Group. For the first round, responses to 70 questions were captured as agree (= 1) and disagree (= 2). For round 2, a total of 89 questions were captured on a Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Consensus was determined a priori at 85%.

Results: In both the first and second rounds, inter-rater agreement of 85% consensus was reached for only 20% of questions. Intra-rater agreement per question was low, with κ values ranging from -0.11 to 0.62. Intra-rater agreement was also low among themes, ranging from poor to fair agreement: κ = 0.25 for motor, κ = 0.28 for sensory, and κ = 0.35 for follow-up.

Conclusions: This study highlights consensus areas that could be considered by researchers in designing studies and identifies areas where lack of consensus indicates that further research is needed.
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http://dx.doi.org/10.1016/j.jaapos.2020.08.014DOI Listing
February 2021

Bilateral augmented superior rectus transposition with medial rectus recession for bilateral esotropic Duane retraction syndrome.

J AAPOS 2021 Apr 16;25(2):116-119. Epub 2021 Feb 16.

Academy of Eye Care Education, Department of Pediatric Ophthalmology, Strabismus, and Neuro-ophthalmology, Child Sight Institute and Jasti V. Ramanamma Children's Eye Care Centre, L V Prasad Eye Institute, KAR Campus, Hyderabad, Telangana, India. Electronic address:

Superior rectus transposition with medial rectus recession is commonly performed for unilateral esotropic Duane syndrome. For bilateral esotropic Duane syndrome, bilateral medial rectus recession is the most frequently performed surgery and usually provides satisfactory alignment in primary position; however, there is limited improvement in abduction. We report the outcomes of bilateral augmented superior rectus transposition and medial rectus recession in 4 patients with bilateral esotropic Duane syndrome. Postoperatively, abduction was improved in all patients; 3 were orthotropic in the primary position, and 1 had residual esotropia.
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http://dx.doi.org/10.1016/j.jaapos.2020.11.006DOI Listing
April 2021

Surgical Outcomes of Exotropic Duane Retraction Syndrome From a Tertiary Eye Care Center.

J Pediatr Ophthalmol Strabismus 2021 Jan;58(1):9-16

Purpose: To report surgical outcomes of patients with exotropic Duane retraction syndrome.

Methods: A retrospective review of the medical records from patients with exotropic Duane retraction syndrome who underwent strabismus surgery and had at least 2 months of postoperative follow-up was conducted. Surgical success was defined as a postoperative horizontal deviation within 8 prism diopters (PD), abnormal head posture (AHP) less than 5 degrees, and a two-step decrease in overshoots.

Results: Seventy-three patients with exotropic Duane retraction syndrome (38, 52% male, mean age 14 ± 7.9 years) met the study criteria. Unilateral type 3 Duane retraction syndrome was seen in 56 (77%) patients and type 1 in 14 (19%) patients. The mean follow-up period was 22 weeks (range: 8 to 209 weeks). Unilateral and bilateral lateral rectus recession were performed in 48 (65%) and 25 (34%) patients, respectively. In addition to recession, a lateral rectus Y-splitting was performed in 42 (56%) patients. Five patients underwent differential medial rectus and (larger) lateral rectus recession to alleviate severe globe retraction. The mean primary position reduced from 23 PD (CI: 19.6 to 26 PD) preoperatively to 9 PD (CI: 7.02 to 11.02 PD) postoperatively (P < .0001). Postoperatively 50% of patients were orthotropic in the primary position. Surgical success for primary position deviation, AHP, and overshoots were achieved in 74%, 81%, and 71% of patients, respectively.

Conclusions: In the current study, type 3 Duane retraction syndrome was the most common subtype necessitating surgery for exotropic Duane retraction syndrome. Good surgical outcomes were obtained for various indications. Unilateral or bilateral lateral rectus recession was successful in improving motor alignment and AHP. The addition of lateral rectus Y-splitting corrected overshoots greater than grade 2 in most patients with exotropic Duane retraction syndrome. [J Pediatr Ophthalmol Strabismus. 2021;58(1):9-16.].
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http://dx.doi.org/10.3928/01913913-20200910-02DOI Listing
January 2021

Horizontal rectus muscle transplantation for recurrent and residual strabismus.

Strabismus 2021 Mar 20;29(1):42-50. Epub 2021 Jan 20.

Consultant, Child Sight Institute, Nimmagadda Prasad Childrens Eye Care Centre, L V Prasad Eye Institute, GMR Varalakshmi Campus, Visakhapatnam, Andhra Pradesh, India.

: To report outcomes of muscle transplantation for recurrent/residual strabismus. Retrospective, multicentric, observational study.  : We retrospectively reviewed records of all patients operated at three institutes who underwent transplantation of the resected muscle for re-operations for residual/recurrent strabismus from January 1, 2018, to December 31, 2019. Data were collected regarding age, gender, visual acuity, type of strabismus, fixation preference, associated amblyopia, the surgical procedure performed, preoperative and postoperative primary position deviation, limitation of ductions, associated intra-operative and post-operative complications. Surgical success was defined as heterotropia less than or equal to 8 PD, and cosmetic success was defined as manifest deviation ≤12 PD (at 6 weeks follow up). : During this period, we identified records of seven patients (5 men: 2 women, median age: 24 years) who underwent muscle transplantation for residual/recurrent strabismus. Six patients underwent extraocular muscle surgery for residual/recurrent exotropia (XT) and one for residual esotropia (ET). In all the patients, median pre-operative primary position deviation reduced from 40 prism diopters (PD) (range: 30 to 55 PD) to 8 PD (range: 6 PD ET to 10 PD XT) at six-weeks follow-up. Four patients had residual exotropia (10-16PD), two had orthotropia and one patient had small-angle esotropia (6PD) at the last follow-up. Excluding two patients who underwent supramaximal re-recession of lateral rectus (≥11 mm from insertion) and re-resection of medial rectus, 3/5 (60%) patients achieved surgical success, and all (100%) achieved cosmetic success at six-weeks-follow-up. There was mild (up to -1) limitation of duction in all patients except one patient (-2 limitation of abduction) who underwent re-recession of lateral rectus to 11 mm from insertion along with medial rectus re-resection and muscle transplant procedure. No intra-operative or post-operative complications were encountered. No patient reported postoperative diplopia. : This study describes the feasibility and successful use of muscle transplantation procedure to correct residual/recurrent strabismus, with or without re-recession, especially in patients planned for surgery in one eye. However, larger prospective studies with longer follow-ups will be needed to establish long-term outcomes and correction achieved from this procedure, and comparison with other approaches for reoperations.
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http://dx.doi.org/10.1080/09273972.2020.1871378DOI Listing
March 2021

Identification of amblyogenic risk factors with the Brückner reflex test using the low-cost Arclight direct ophthalmoscope.

Eye (Lond) 2021 Jan 7. Epub 2021 Jan 7.

Head, Child Sight Institute & Jasti V Ramanamma Children's Eye Care Center, LV Prasad Eye Institute (LVPEI), Hyderabad, India.

Background/objectives: The Arclight is a novel, low-cost, solar-powered direct ophthalmoscope developed for low resource settings as an alternative to more expensive, conventional devices. The Brückner reflex test (BRT) is a quick and effective means to screen for eye disease and amblyogenic risk factors. This test is however rarely performed in low resource settings due to the lack of access to ophthalmoscopes and trained health care workers. Our aim was to establish the sensitivity and specificity of the BRT when performed by a non-expert using an Arclight and compare to an expert as well as the results of a full clinic workup.

Subjects/methods: In this prospective, blinded study, 64 patients referred to a paediatric ophthalmology clinic had the BRT performed by a 'non-expert' observer (medical student) then an 'expert' observer (consultant ophthalmologist). These results were then compared against the 'gold standard' outcomes of a full clinical workup.

Results: BRT screening by the expert observer led to a sensitivity of 75.0% [95% CI: 57.9-86.8%] and a specificity of 90.6% [95% CI: 75.8-96.8%] in picking up media opacity, strabismus, refractive error or a combination of the above. For the non-expert, the sensitivity and specificity were 71.9% [95% CI: 54.6-84.4%] and 84.4% [95% CI: 68.3-93.1%], respectively.

Conclusions: The Arclight can be effectively used to perform the BRT and identify eye disease and common amblyogenic risk factors. Even when performed by a non-expert the results are highly specific and moderately sensitive. This study consequently offers support for the use of this low-cost ophthalmoscope in the expansion of eye screening by health care workers in low resource settings.
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http://dx.doi.org/10.1038/s41433-020-01341-9DOI Listing
January 2021

Visual experience dependent plasticity in humans.

Curr Opin Neurobiol 2021 04 16;67:155-162. Epub 2020 Dec 16.

Jasti V Ramanamma Children's Eye Care Center, Child Sight Institute, L V Prasad Eye Institute, Banjara Hills, Hyderabad 500034, India.

While sensitive periods in brain development have often been studied by investigating the recovery of visual functions after a congenital phase of visual deprivation in non-human animals, research in humans who had recovered sight after a transient phase of congenital blindness is still scarce. Here, we discuss the hypothesis put forward based on non-human primate work which states that the effects of experience increase downstream the visual processing hierarchy. Recent results from behavioral and neuroscience studies in sight recovery individuals are discussed in the context of research findings from permanently congenitally blind humans as well as from prospective studies in infants and children.
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http://dx.doi.org/10.1016/j.conb.2020.11.011DOI Listing
April 2021

Management of esotropia: hypotropia in neurofibromatosis type 1 - simulating myopic strabismus fixus.

BMJ Case Rep 2020 Dec 17;13(12). Epub 2020 Dec 17.

Jasti V Ramanamma Children's Eye Care Center, Child Sight Institute, LV Prasad Eye Institute, Hyderabad, Telangana, India

A 28-year-old man presented with a progressive inward deviation of the left eye in the last 4 years. Examination revealed -3 abduction and elevation deficit in the left eye with 50 prism diopters (PD) esotropia and 12 PD of hypotropia. The patient had multiple fibromas on the forearms with pulsatile globe and was diagnosed as neurofibromatosis type 1. Myopic strabismus fixus was suspected. MRI revealed left temporal lobe herniation through a dysplastic sphenoid wing, compressing the posterior half of the superior rectus and lateral rectus muscles, resulting in an esotropia-hypotropia complex. Surgical treatment involved suture myopexy (Yokoyama's technique) of the left superior rectus and lateral rectus muscles with a 6.5 mm left medial rectus recession. Two months postoperatively, the patient had minimal residual esotropia and hypotropia. MRI orbits should always be performed in high myopes with strabismus to assess extraocular muscle pathways.
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http://dx.doi.org/10.1136/bcr-2020-236648DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7747570PMC
December 2020

The "Namaste" sign for superior oblique muscle tuck surgery.

J AAPOS 2021 02 9;25(1):34-34.e1. Epub 2020 Dec 9.

Department of Pediatric Ophthalmology, Strabismus, and Neuro-ophthalmology, Child Sight Institute, Jasti V Ramanamma Children's Eye Care Centre, L V Prasad Eye Institute, KAR Campus, Hyderabad, Telangana, India. Electronic address:

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http://dx.doi.org/10.1016/j.jaapos.2020.05.020DOI Listing
February 2021

Neural mechanisms of visual sensitive periods in humans.

Neurosci Biobehav Rev 2021 01 23;120:86-99. Epub 2020 Nov 23.

Biological Psychology and Neuropsychology, University of Hamburg, Germany.

Sensitive periods in brain development are phases of enhanced susceptibility to experience. Here we discuss research from human and non-human neuroscience studies which have demonstrated a) differences in the way infants vs. adults learn; b) how the brain adapts to atypical conditions, in particular a congenital vs. a late onset blindness (sensitive periods for atypical brain development); and c) the extent to which neural systems are capable of acquiring a typical brain organization after sight restoration following a congenital vs. late phase of pattern vision deprivation (sensitive periods for typical brain development). By integrating these three lines of research, we propose neural mechanisms characteristic of sensitive periods vs. adult neuroplasticity and learning.
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http://dx.doi.org/10.1016/j.neubiorev.2020.10.030DOI Listing
January 2021

An electrophysiological biomarker for the classification of cataract-reversal patients: A case-control study.

EClinicalMedicine 2020 Oct 6;27:100559. Epub 2020 Oct 6.

Biological Psychology and Neuropsychology, University of Hamburg, Hamburg, Germany.

Background: Untreated congenital blindness through cataracts leads to lasting visual brain system changes, including substantial alterations of extrastriate visual areas. Consequently, late-treated individuals (> 5 months of age) with dense congenital bilateral cataracts (CC) exhibit poorer visual function recovery compared to individuals with bilateral developmental cataracts (DC). Reliable methods to differentiate between patients with congenital and developmental cataracts are often lacking, impeding efficient rehabilitation management and introducing confounds in clinical and basic research on recovery prognosis and optimal timing of surgery. A persistent reduction of the P1 wave of visual event-related potentials (VERPs), associated with extrastriate visual cortical activity, has been reported in CC but not in DC individuals. Using two experiments, this study developed and validated P1-based biomarkers for diagnosing a history of congenital blindness in cataract-reversal individuals.

Methods: Congenital and developmental cataract-reversal individuals as well as typically sighted matched controls took part in a first experiment used for exploring an electrophysiological biomarker (  = 13,  = 13,  = 26). Circular stimuli containing gratings were presented in one of the visual field quadrants while visual event-related potentials (VERPs) were recorded. Two biomarkers were derived from the P1 wave of the VERP: (1) The mean of the normalized P1 amplitude at posterior electrodes, and (2) a classifier obtained from a linear support vector machine (SVM). A second experiment with partially new CC/DC individuals and their matched controls (  = 14,  = 15,  = 29) was consecutively used to validate the classification based on both biomarkers. Performance of the classifiers were evaluated using receiver operating characteristic (ROC) curve analyses. All cataract-reversal individuals were tested after at least one year of vision recovery.

Findings: The normalized P1 amplitude over posterior electrodes allowed a successful classification of the CC from the DC individuals and typically sighted controls (area under ROC curve, AUC = 0.803 and 0.929 for the normalized P1 amplitude and the SVM-based biomarker, respectively). The validation for both biomarkers in experiment 2 again resulted in a high classification success (AUC = 0.800 and 0.883, respectively for the normalized P1 amplitude and the SVM-based biomarker). In the most conservative scenario involving classification of CC from DC individuals in a group of only cataract-reversal individuals, excluding typically sighted controls, the SVM-based biomarker was found to be superior to the mean P1 amplitude based biomarker (AUC = 0.852 compared to 0.757 for the mean P1 based biomarker in validation). Minimum specificity obtained was 80% across all biomarkers.

Interpretation: A persistent reduction of the P1 wave provides a highly specific method for classifying cataract patients post-surgically as having suffered from bilateral congenital vs. bilateral developmental cataracts. We suggest that using the P1 based non-invasive electrophysiological biomarker will augment existing clinical classification criteria for individuals with a history of bilateral congenital cataracts, aiding clinical and basic research, recovery prognosis, and rehabilitation efforts.

Funding: German Research Foundation (DFG) and the European Research Council (ERC).
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http://dx.doi.org/10.1016/j.eclinm.2020.100559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7548424PMC
October 2020

Biological Action Identification Does Not Require Early Visual Input for Development.

eNeuro 2020 Sep/Oct;7(5). Epub 2020 Oct 28.

Biological Psychology and Neuropsychology, University of Hamburg, Hamburg, Germany.

Visual input during the first years of life is vital for the development of numerous visual functions. While normal development of global motion perception seems to require visual input during an early sensitive period, the detection of biological motion (BM) does not seem to do so. A more complex form of BM processing is the identification of human actions. Here, we tested whether identification rather than detection of BM is experience dependent. A group of human participants who had been treated for congenital cataracts (CC; of up to 18 years in duration, CC group) had to identify ten actions performed by human line figures. In addition, they performed a coherent motion (CM) detection task, which required identifying the direction of CM amid the movement of random dots. As controls, developmental cataract (DC) reversal individuals (DC group) who had undergone the same surgical treatment as CC group were included. Moreover, normally sighted controls were tested both with vision blurred to match the visual acuity (VA) of CC individuals [vision matched (VM) group] and with full sight [sighted control (SC) group]. The CC group identified biological actions with an extraordinary high accuracy (on average ∼85% correct) and was indistinguishable from the VM control group. By contrast, CM processing impairments of the CC group persisted even after controlling for VA. These results in the same individuals demonstrate an impressive resilience of BM processing to aberrant early visual experience and at the same time a sensitive period for the development of CM processing.
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http://dx.doi.org/10.1523/ENEURO.0534-19.2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7598910PMC
June 2021

Ocular structural changes in patients with Duane retraction syndrome: Does a correlation exist?

Indian J Ophthalmol 2020 Oct;68(10):2196-2198

Child Sight Institute, Nimmagada Prasad Children's Eye Care Centre, L V Prasad Eye Institute, GMRV Campus, Visakhapatnam, Andhra Pradesh, India.

Purpose: The purpose of this study was to investigate the structural changes (axial length, central macular thickness (CMT), subfoveal choroidal thickness, and keratometry) in subjects with unilateral Duane retraction syndrome (DRS) as compared with the normal fellow eye.

Methods: In this prospective study, we included 34 subjects with unilateral DRS from January 2016 to December 2016 seen at our institute. Data was collected for axial length, keratometry using partial coherence interferometry, CMT, subfoveal choroidal thickness using the enhanced depth imaging-optical coherence tomography (EDI-OCT). All these measurements were compared between the affected and fellow eye.

Results: During this period, we included 34 subjects with unilateral DRS (22 Type I, 1 Type II, and 11 Type III). The mean age (±SD) of subjects was 14 ± 8 years (range: 5-28 years). There were 15 males and 19 females. Eyes with DRS were significantly shorter (median axial length 22.4 mm, interquartile range (IQR): 21.56 - 23.17) as compared to fellow eye (median axial length 22.7 mm, IQR: 22.35-23.55), P = 0.04. Choroidal thickness, CMT, and average keratometry were similar in DRS and fellow eyes (P = 0.39, 0.06, and 0.11, respectively). A significant difference in axial length was found only between Type I and Type III DRS (P = 0.03).

Conclusion: This study suggests that in subjects with DRS, the affected eye has shorter median axial length when compared with the fellow eye. Prevalence of refractive error in eye with DRS was higher compared to fellow eye. But, there was no difference in magnitude of refractive error found between eye with DRS and normal fellow eye.
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http://dx.doi.org/10.4103/ijo.IJO_123_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7727943PMC
October 2020

Interobserver Variability for Measurement of Grating Acuity in Preverbal and Nonverbal Children Using Lea Grating Paddles.

J Pediatr Ophthalmol Strabismus 2020 Sep;57(5):305-308

Purpose: To study interobserver variability for measurement of grating acuity in preverbal and nonverbal children with developmental delay using Lea Grating Paddles (Lea Hyvärinen).

Methods: In this prospective study, preverbal patients younger than 3 years and older nonverbal patients (with developmental delay) were included. Those with poor neck holding were excluded. Binocular and monocular visual acuity assessment was done simultaneously using Lea Grating Paddles by two examiners who were blinded from each other's results.

Results: Thirty-one children were tested (19 [61.29%] males and 12 [38.71%] females). The mean age was 28.5 months (range: 4 to 44 months). A total of 92% of the observations showed interobserver agreement of 0.5 octave or better in binocular testing. Results for monocular testing showed interobserver agreement (0.5 octaves or better) in 95.65% and 95.23% of right and left eyes, respectively. Combined results showed agreement better than 0.5 octaves in 94.20%. The mean binocular visual acuity was 2.07 and 2.14 cycles per degree (cpd) for the first and second observer, respectively (P = .59). Similarly, the mean monocular visual acuity for the right and left eyes was 0.98 and 0.97 cpd for observer 1 and 0.89 and 0.79 cpd for observer 2, respectively (P = .91 and .14, for the right and left eyes, respectively).

Conclusions: Interobserver variability for grating acuity measurement using Lea Grating Paddles is minimal, signifying it to be a reliable and reproducible alternative to conventional preferential looking testing procedures. [J Pediatr Ophthalmol Strabismus. 2020;57(5):305-308.].
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http://dx.doi.org/10.3928/01913913-20200701-02DOI Listing
September 2020

Sensory experience during early sensitive periods shapes cross-modal temporal biases.

Elife 2020 08 25;9. Epub 2020 Aug 25.

Biological Psychology and Neuropsychology, University of Hamburg, Hamburg, Germany.

Typical human perception features stable biases such as perceiving visual events as later than synchronous auditory events. The origin of such perceptual biases is unknown. To investigate the role of early sensory experience, we tested whether a congenital, transient loss of pattern vision, caused by bilateral dense cataracts, has sustained effects on audio-visual and tactile-visual temporal biases and resolution. Participants judged the temporal order of successively presented, spatially separated events within and across modalities. Individuals with reversed congenital cataracts showed a bias towards perceiving visual stimuli as occurring earlier than auditory (Expt. 1) and tactile (Expt. 2) stimuli. This finding stood in stark contrast to normally sighted controls and sight-recovery individuals who had developed cataracts later in childhood: both groups exhibited the typical bias of perceiving vision as delayed compared to audition. These findings provide strong evidence that cross-modal temporal biases depend on sensory experience during an early sensitive period.
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http://dx.doi.org/10.7554/eLife.61238DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7476755PMC
August 2020

Duane-minus (Duane sine retraction and Duane sine limitation): possible incomplete forms of Duane retraction syndrome.

Eye (Lond) 2021 Jun 24;35(6):1673-1679. Epub 2020 Aug 24.

Child Sight Institute, Jasti V Ramanamma Children's Eye Care Center, LV Prasad Eye Institute, Hyderabad, Telangana, India.

Purpose: To report ocular motility patterns that mimic, but do not fulfil the full clinical picture of Duane retraction syndrome (DRS) and to describe their clinical features and surgical management.

Methods: This is a retrospective case series study conducted on patients with DRS, mimicking non-comitant exotropia or esotropia and a face turn. Patients were included only if they lacked either globe retraction on adduction (sine retraction) or limitation of adduction or abduction on ductions (sine limitation not >0.5). Any overshoots or pattern strabismus was recorded. The ocular motility and alignment, details of surgery and their surgical outcomes were analysed.

Results: Twenty-one patients were identified; 13 in the sine retraction and 8 in the sine limitation group. All patients presented with a compensatory face turn. Overshoots were present in 10 (77%) and 7 patients (88%) in the sine retraction and sine limitation groups, respectively. Forced duction test showed tightness of the ipsilateral medial and the ipsilateral lateral rectus muscle in esotropic (n = 3) and exotropic patients (n = 18), respectively. Orthotropia was achieved in 82% of patients following ipsilateral medial or lateral rectus muscle recession.

Conclusions: There is a subset of patients who present with motility pattern similar to DRS but lack its complete diagnostic criteria. The presence of a face turn, overshoots on adduction or an ipsilateral tightness of the affected muscle should make one consider DRS sine retraction/sine limitation. The patients in our study responded well to lines of management similar to those of DRS.
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http://dx.doi.org/10.1038/s41433-020-1118-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8169851PMC
June 2021

Pivoting to teleconsultation for paediatric ophthalmology and strabismus: Our experience during COVID-19 times.

Indian J Ophthalmol 2020 Jul;68(7):1387-1391

Child Sight Institute, Jasti V Ramanamma's Children's Eye Care Center, L V Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana, India.

Purpose: The objective is to analyse and report the data of teleconsultations provided to paediatric ophthalmology and strabismus patients during COVID-19 times and to elaborate our experience for guiding future teleconsultation practices to General, paediatric Ophthalmologists and Strabismologists.

Methods: Retrospective analysis of electronic medical record data of teleconsultations provided in the department of Strabismus, Paediatric and Neuro-ophthalmology was done. Patients with optic nerve related disorders were excluded. Study period was one month. Statistical analysis of collected data was done using Microsoft excel.

Results: A total of 198 patients were provided teleconsultations (an average of seven teleconsultations/day). The final analysis included 161 patients after excluding optic nerve related disorders. The median age was seven years. We had a near equal gender distribution (53% males and 47% females) of whom a third were new cases. Video calling was used in 14%, review of clinical photos shared was used in 53%. Rest of the 33% were given telephonic advice. Allergic conjunctivitis (14%), pseudophakia (9%), strabismus (12%), status post strabismus surgery (8%), cranial nerve palsies (11%) were common diagnoses. 19% (n = 30) were advised/needed visit in emergency services on same or next day.

Conclusion: Our experience of teleconsultation during COVID-19 times for paediatric ophthalmology and strabismus patients was very encouraging. Pivoting teleconsultation platform can provide primary eye care to most of the patients and work as essential forward triage for rest. As we continue to further explore the currently available avenues in multimedia such as video conferencing and web/mobile based applications, we believe that tele-ophthalmology platform can provide a reliable service in patient care.
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http://dx.doi.org/10.4103/ijo.IJO_1675_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7574089PMC
July 2020

Cataract surgery in treated retinoblastoma eyes: A study of 29 eyes.

Eur J Ophthalmol 2020 Jun 25:1120672120938575. Epub 2020 Jun 25.

Child Sight Institute, LV Prasad Eye Institute, Hyderabad, India.

Purpose: To study the outcomes of cataract surgery in treated retinoblastoma (RB) eyes.

Methods: Retrospective study of 29 eyes of 27 patients.

Results: Based on International Classification of Intraocular Retinoblastoma, tumors belonged to group B ( = 3, 10%), C ( = 1, 4%), D ( = 10, 34%), and E ( = 3, 10%). The remaining 12 eyes (41%) had regressed tumors on presentation due to prior treatment. The RB treatment details included intravenous chemotherapy ( = 24, 83%), external beam radiotherapy ( = 14, 48%), and others. The mean time interval between tumor regression and cataract surgery was 51 months (median, 26 months; range, 6-245 months). The post-operative visual acuity was 20/200 or better in 12 (41%) eyes. Overall, 16 (55%) eyes displayed improvement of vision post-cataract surgery, while 13 (45%) eyes had no improvement in vision. The complications of cataract surgery included visual axis opacification ( = 15, 52%), pupillary membrane ( = 4, 14%), hyphema ( = 1, 3%), and extraocular tumor extension ( = 1, 3%). Clearer fundus view post-surgery revealed underlying tumor edge recurrence in 1 (3%) eye, and two (7%) patients had tumor recurrence at a mean interval of 8 months (median, 8 months; range, 7-8 months) following cataract extraction. Globe salvage was achieved in 26 (90%) eyes over a mean follow-up period of 103 months (median, 91 months; range, 19-267 months).

Conclusion: Cataract surgery in treated RB is safe with vision salvage in 55% eyes and globe salvage in 90% eyes. Though there is a risk of extraocular tumor extension, its occurrence is rare (3%).
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http://dx.doi.org/10.1177/1120672120938575DOI Listing
June 2020

Commentary: To capture or not in pediatric cataract surgery?

Authors:
Ramesh Kekunnaya

Indian J Ophthalmol 2020 01;68(1):89

LV Prasad Eye Institute, Hyderabad, Telangana, India.

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http://dx.doi.org/10.4103/ijo.IJO_1561_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6951165PMC
January 2020
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