Young Ophthalmologists Times : Paediatric Ophthalmology Training Special by divakant

ISSUE, AUGUST 2020

Dr. DAMARIS MAGDALENE

Dr. JON PEITER SAUNTE

Dr. ROHIT SAXENA

Dr. JAN TJEERD DE FABER

Dr. R. KRISHNAPRASAD

Dr. SOWMYA R

Dr. RAMESH KEKUNNAYA

Dr. SUMITA AGARKAR

Dr. KALPANA NARENDRAN

PEDIATRIC OPHTHALMOLOGY TRAINING SPECIAL

On the cover: Pediatric cataract represents an important cause of visual impairment in childhood with a huge emotional, social and economic impact. Managing cataracts in children remains a challenge and requires a dedicated team effort by the parents, surgeon, pediatrician, anesthesiologist and orthoptist. Etiology of pediatric cataract is varied and diagnosis of specific etiology helps in prognostication and effective management. Pediatric cataract surgery has evolved dramatically over the years with more predictable and favourable outcomes.

Cover photograph: A child with pediatric cataract getting ready for surgery.

Photo Credit: Mr. Sunil Kumar Mishra, Deputy Director Projects and Hospitals, Admin Kalinga Eye Hospital, Dhenkanal, Odisha.

Format Credits: Ms. Uma Ch. Momin Mr. Joney Rabha Sri Sankaradeva Nethralaya, Guwahati, Assam.

Kindly help us in improving this issue by sending us your valuable feedback. Please click here http://bit.ly/YOTfeedback or type it in your address bar to submit your feedback. You can mail your feedback to secretariat@yosi.in as well

C H I E F

E DI TOR ’ S

DE SK

Dear Friends, We bring to you the “Paediatric Ophthalmology” issue of Young Ophthalmologists Times which is the hard work of our excellent editorial team lead by Dr Nilutparna Deori. Dr Deori has successfully put together an excellent issue and I congratulate the team for such a wonderful job. I am sure this issue will inspire ophthalmologists to take up Paediatric Ophthalmology and help Young Paediatric ophthalmologists to excel in the speciality. YOSI has recently started various new activities which our reader should be aware about : YOSI Job Portal : A job portal which focusses on jobs for young ophthalmologists Late Night Retina by YOSI : Live posterior segment case discussions Surging the anterior segment by YOSI : Live anterior segment case discussions YOSI Resident’s Network : An initiative that focuses on educating and connecting ophthalmology residents YOSI Exam Simulator (YES) Series : A recorded session where a resident gets the opportunity to present exam cases in front of experienced faculty. YOSI Newsletter : A monthly update from the world of ophthalmology and of YOSI activities. YO Slides : Peer reviewed power point presentations.

YO TiMES I AUG 2020

Like previous year its the time for the following Annual YOSI Awards : YOSI YO Award YOSI YO Tube Best Video Award YOSI Flash Notes Award YO Slides Awards The submission process and others details will be shared in due course. I would like to encourage all our members and readers to get involved with these YOSI activities. Stay Healthy and Stay Safe!.

Dr. DIVA KANT MISRA DO, DNB, MNAMS, FVRS

CHIEF EDITOR Young Ophthalmologists Times GENERAL SECRETARY Young Ophthalmologists Society of India CONSULTANT VITREORETINA EyeQ Super-speciality Eye Hospital, Lucknow Ph No: +91 9670964875 / +91 7002180323 Email: divakant@gmail.com / secretariat@yosi.in Website: www.yosi.in

YO TiMES I AUG 2020

EDITORIAL Dear Friends, Greetings from YOSI!! At the very outset, I wish you all good health and happiness. Pediatric Ophthalmology & Strabismus has always been a dreaded subject for the young residents. As they try to understand the tropias & phorias and binocularity of vision, they stumble upon neuro-ophthalmology and the genetics of various diseases/disorders. To add to their woes, the crying child tests their patience and questions their ability to examine the child. A sincere effort has been made by the editors of this issue to create an environment that makes it possible for the young ophthalmologists to explore and enjoy the different aspects of Pediatric Ophthalmology rather than fear it. This issue of YOT continues the Times tradition of guiding the YOs who wishes to take up Pediatric Ophthalmology & Strabismus and reinforce their concept. In the segment, Mentor s Perspective , the doyens in the field of Pediatric Ophthalmology, Neuro-ophthalmology, Genetics and Strabismus speak about the historical and factual aspects of their respective field. In addition to their words of wisdom, this segment focuses on life skills and values aimed at developing good character in residents and equipping them with skills needed to cope with different challenges in life. Mentor s Panel on Pediatric Ophthalmology and Strabismus Training takes up the residency/ fellowship program not only as a mere calculation of the number of surgeries performed by the resident but also gives them ample opportunities to explore the various aspects of Pediatric Ophthalmology. The segment on New Frontiers is specially designed to cover the inter-related topics like Oculoplastics and Community ophthalmology, by the legends in their respective field. It also includes challenges interwoven in stories from different walks of life- from motherhood to investing in private practice to handling the new normal in Covid times. Fellowship pearls showcases the various national and international observership/ fellowship/ residency programs. The YOs share their experiences and provide information

about these programs. They share their tips to study the subject, offer clues to differential

dilemmas and references for online resources. We have provided relevant information to the aspiring Pediatric Ophthalmologists about the institutes that offer Pediatric Ophthalmology training in India in the segment Institute Watch. We hope to continuously update this segment in the YOSI Help Desk for the benefit of the young residents. This issue is dedicated to the Mentors and Teachers who not only sharpened our skills but also invested in our capability for a significant contribution to the society. We owe a great debt to the Mentors and Seniors who gave their time in writing the articles and contributed wholeheartedly towards this issue. It would not have been possible without their constant encouragement. We also thank the contributors for their excellent articles and timely submission. YOT, Pediatric Issue has been a team effort. It was a pleasure and gratitude that I acknowledge the entire editorial team for making this issue possible. We hope you find this issue helpful and interesting. Please feel free to send us your feedback.

Dr. Nilutparna Deori DO, DNB, Fellow Orbit &Oculoplasty, Senior Residency Pediatric Ophthalmology & Strabismus Issue Editor, Pediatric Ophthalmology Young Ophthalmologists Times Executive Committee Member Young Ophthalmologist Society of India President, State chapter (Assam) Consultant, Pediatric Ophthalmology & Strabismus Sri Sankaradeva Nethralaya, Guwahati, Assam Ph no. +917577073750 Email: nilutparnadeori@gmail.com/secretariat@yosi.com Website: www.yosi.in

I S

Y O S I J O B P O R TA L I S YOSI announces a JOB portal which will specially focus on Jobs for Young Ophthalmologists It will be a free service available to all YOSI Members. 1

Please fill Form 1 (hospital form) if you are an employer/hospital in search of an ophthalmologist.

Please fill Form 2 (doctor's form) if you are an ophthalmologist looking for a job.

secretariat@yosi.in

https://yosi.in/yosi-job-portal/

Consultant, Vitreoretina Eye Q Hospital, Lucknow

Dr. Anisha Rathod

Dr. Annu Joon

Dr. Biswajeet Dey

Assistant editor (Pediatric issue)

Dr. Chandrasekhar Sahoo

Dr. Diva Kant Mishra

Dr. Deepika Dhingra

Dr. Jenil Sheth

Dr. Digvijay Singh

Dr. Nilutparna Deori Editor (Pediatric issue)

Dr. Santha Sathyan

Dr. Sumit Grover

Dr Singh Dr.Simar SimarRajan Ranjan Singh

Dr. Sonal Kalia

i executive members

YOSI AT A GLANCE

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1 . G u e s t E d it o r ia l : Ma xi m i zi n g t h e e xp e r i e n ce o f a P e d i a t ri c O p h t h a lm o lo g y a n d S t r a b i sm u s F e l lo ws h i p

2 . A n in t e r vi e w wi t h D r . M a r i a P a p a d o p o u l o s D r . M a r ia P a p a d o u p o ul o s

3 . W h y sh o u l d I b e a n O cu la r G e n e t i c i st ? D r . Al e x Le v i n

4 . N e u r o - O p h t h a l m o l o g y: T h e 3 r d E ye o f P e d i a t r i c O p h t h a lm o lo g y D r . C e l i a C he n

D r . P r a d e e p S ha r m a 6 . A n I n t e r vi e w wi t h D r . C l a i r e G i l b e r t D r. C l a i r e G il b e r t

7 . L e s so n s f ro m a Me n t o r Dr. Jagat Ram

P e r sp e ct i ve D r . P V ij a y a L ak s h m i 9 . 5 Q u e s t i o n s wi t h D r . H a r sh a D r . H a r s h a B ha t t a c h a r j e e

1 0 . R e n d e zvo u s o n m y j o u r n e y wi t h R O P D r . K a r ob i R a n i L a h i r i

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On Fellowship Dr. Damaris Magdalene

D r . J a n - T j e e rd d e F a b e r

D r . K a l p an a Na r e n d r a n

D r . J o n P e i t e r S a u n te

D r R . K r i sh n a pr a s a d

D r . R a me s h K e k u n n ay a

D r . Ro h i t S a xe n a

Dr. Sowmya R

D r . S u m i t a A ga r k a r

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1 1 . S t r a b i sm o lo g y: A F r i g h t o r D e l i g h t D r . C h a n d in i C h a k r a b o r ty

1 2 . C h i ld a t C l in i c V s C h i ld a t H o m e - A (n o t so ) Y o u n g

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P e d i a t r i c O p h t h a lm o lo g i s t P e r sp e c t ive D r . D e e p t i J os hi

1 3 . H o w t o se t u p a S u c ce s sf u l P e d ia t r i c O p h t h a lm o l o g y P r a c t ic e

107

D r . J i te n d r a Je t h a n i

F u t u re P i l l a r s

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1 5 . T h e Ch a rm a n d C h a l l e n g e o f O cu l o p l a st i c s in Ch i ld r e n

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Dr. Kavitha V

D r . U sh a S i n g h

1 6 . P e d ia t r i c E ye C a r e in I n d i a D r . R i s h i R a j Bo r a h

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FELLOWS SPEAK 17. Soar to New Heights! My Experience at International Observership in Pediatric Ophthalmology

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Dr. Anisha Rathod 18. A Day in the Life of a Resident Dr. Bhawnna P Khurana

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19. Pediatric Glaucoma Residency Program in PGI Chandigarh Dr. Deepika Dhingra

129

20. Fellowship: To do or not to do? Dr. Fatema Bin Rajab

131

Dr. Lana Datuashvili

134

22. Sharing My Experience at LVPEI Dr. Willard B. Mumbi

136

23. Examining a Child- The Art of Subtle Skills Dr. Simar Rajan Singh

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OP India ~Implementation of Control Strategies! Dr. Sumit Grover

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DIFFERENTIAL WARS

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2 5 . D r . A n n u J oo n

HOW TO STUDY

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2 6 . T i p t o De a l wi t h S t r a b i sm o lo g y f o r t h e Y o u n g P e d i a t r i c O p h t h a lm o lo g y S t u d e n t Dr. Smita Ghosh

ONLINE RESOURCE 2 7 . P e d ia t r i c O p h t h a lm o lo g y R e s o u rc e s f o r Re s id e n t s a n d F e l l o ws D r . An k i t A h i r D r . K un a l S h i n d e D r . R i d dh i R a ic h u r a

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175 2 9 . A ra vi n d E ye Ho s p it a l , M a d u ra i

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3 0 . B B E ye F o u n d a t i o n , K o l k a t a

182 185

3 2 . H V D e sa i E ye H o s p it a l , P u n e

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3 3 . J yo t i rm a y E ye C l i n i c , T h a n e

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3 4 . L V P r a sa d E ye I n st i t u t e ( L V P E I ) , H yd e r a b a d

199

3 5 . M M Jo s h i E ye H o s p it a l , H u b b a l i

201

3 6 . S it a p u r E ye Ho s p it a l , U t t r a kh a n d

204

3 7 . S a d g u ru Ne t ra C h i k i t sa la ya , C h it r a k o o t

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3 8 . S a n k a ra E ye Fo u n d a t io n

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4 9 . S a n k a r a N e t h ra l a ya , C h e n n a i

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4 0 . S r i S a n ka r a d e va N e t h r a l a ya , G u wa h a t i

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4 1 . S u s r u t E ye F o u n d a t i o n & R e se a r c h Ce n t r e

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MAXIMIZING THE EXPERIENCE OF A PEDIATRIC OPHTHALMOLOGY AND STRABISMUS FELLOWSHIP

My fellowship year was a turning point in my career. I arrived a very confident young ophthalmologist, a Senior Registrar from Oxford Eye Hospital, trained by Jack Kanski, knew everything. I soon learnt I knew very little in the subspecialty I had chosen. I have learned silence from the talkative, toleration from the intolerant, and kindness from the unkind; yet, strange, I am ungrateful to those teachers

-Khalil Gibran

10 Pieces of Advice

Be humble and be willing to deconstruct what you have learnt, so that you can reconstruct a better, stronger self. I felt very uncomfortable the first 2 months because I was being asked things that no-one had ever asked me before and I was being held at a higher standard than I

had been held to before. For example, I was being asked about the molecular basis of disease, about the genes causing conditions I thought I knew about. I felt completely out of my comfort zone.

You cannot grow and learn if you are always within your comfort zone; so don t stress just work hard, read, listen and that uncomfortable feeling will dissipate as you develop your expertise. As someone once said Life is not about avoiding the thunderstorms, it s about learning to dance in the rain! Some of my co-fellows were very anxious to get number of surgeries under their belt but I was just as interested in watching and observing what the mentors were doing. After every surgery I either assisted or did, I would go home and draw the steps of the surgery in a book. After one year I had a complete atlas of surgery and procedures which I still have until today

As Marilyn vos Savant said, To acquire knowledge, one must study; but to acquire wisdom, one must observe . Learn to observe during your fellowship. I was very eager to learn everything I could but I realized quickly that the best way of getting the most out of my clinical experience was to be kind and helpful to ALL the clinic staff from the secretaries, administrators, nurses, janitors and of course all my colleagues. By being helpful to the clinic staff, they were in turn helpful to me and ensured that any interesting cases were flagged up to me. Of course, they also became great friends.

Respect is how to treat everyone not just those you want to impress Theodore Roosevelt. I also found that the more I taught the residents the more I understood myself. I would do imaging rounds where I would show the residents slide after slide and ask them what the diagnosis was. I built a camaraderie with them; we were all learning together. I would share ideas and discuss cases with my co-fellows and with my mentors. I would teach nurses and operating room staff.

Interaction with colleagues, medical or nursing, hones your teaching skills and forces you to ensure that you understand what you are teaching. There is no better way to learn. I would work very hard every day. I felt that the fellowship year was the last year I could see patients, operate, and interact with patients with the ultimate responsibility lying with my bosses. This meant I could ask questions, discuss ideas and not be afraid of harming the patient because my bosses would guide me to make the right diagnosis and deliver the correct therapy. Remember that your bosses do take stress to train you; if you make their daily routine easier, by working hard in clinic, organizing the operating list well and know all your patients well, you will decrease stress on your bosses. This means that they are more likely to take stress and let you operate on their cases in the operating room.

Work hard and honestly during your fellowship- it is a golden opportunity. Remember what Thomas A. Edison said, We often miss opportunity because it's dressed in overalls and looks like work. I would read textbooks and then journal articles. Every time I saw something in the clinic that I didn t know about I would go home and read about it and make notes on a small piece of card. Over 12 months I wrote 365 such cards, all with information about rare conditions that I had seen. I took time to research things

on PubMed as well as traditional libraries. In many ways, I was preparing for cases I might see again and especially preparing for surgical cases that were going to be on the operating list.

Always prepare for your patients. Remember, if you fail to prepare, then be prepared to fail. I learnt the art of honest disagreement. I learnt that two good and sincere physicians could disagree about a diagnosis, or a therapy and discuss the merits of each other s opinions without being bitter or resentful. In fact some of the most important things I had to re-learn were from such debates. I always defined my opinion robustly but more importantly always kept an open mind, in case I had made an error in my understanding of the case.

Honest disagreement is often a good sign of progress - Mahatma Gandhi. Argue, Discuss and Debate but do it with the utmost of respect for your colleagues. I remember a couple of moments during my fellowship that had a profound effect on me. Both were to do with patients in whom I had a made an incorrect clinical diagnosis. The first was an eight (8) month old baby who I thought had a Retinoblastoma. Despite doing an ultrasound I could not see a mass on the scan but because I had seen this flash of white lesion in the fundus, it was set in my mind that this was a Retinoblastoma. The mistake I made was that although I was seeing the scan, I was not observing what I was seeing. Because I had decided that the white lesion was a retinoblastoma, I ignored the scan findings and stuck to my diagnosis of Retinoblastoma. When the child was taken to the operating room for an exam under anesthesia, it turned out to be a round chorioretinal coloboma but one that was very white indeed!

Do not lose the Art of Observation and much more importantly do not make what you see, fit with a diagnosis you have already made in your mind. In other words, make the signs of what you observe guide you to make the diagnosis, do not make the signs you see fit the diagnosis you have made. At the end of my fellowship year, I was extremely sad to leave. I had learnt so much, I had grown tremendously as a clinician, I had made such great friends and I had developed a sense of self identity. I was blessed to have become a Pediatric Ophthalmologist. I planned my life and career in 5 year blocks, mapping out what I wanted to achieve personally and professionally.

It s your road, and yours alone. Others may walk it with you, but no one can walk it for you

Rumi

Dr. Kanwal Ken Nischal

Dr. Ken Nischal (MD, FRCOphth) is the Chief, Division of Pediatric Ophthalmology, Strabismus and Adult Motility, UPMC Children's Hospital of Pittsburgh. Medical Director, UPMC Children's Telemedicine Program. Director, Pediatric Program Development, UPMC Eye Center.Professor of Ophthalmology, University of Pittsburgh School of Medicine. After graduating from King's College Hospital Medical School, University of London, in 1988, Dr. Nischal trained in Ophthalmology in Oxford and Birmingham in the United Kingdom and completed a fellowship in Pediatric Ophthalmology at the Hospital for Sick Children in Toronto, Canada. In 1999, he accepted a position at Great Ormond Street Hospital in d. There he honed his expertise in developmental disorders of the eye and began the first program in the United Kingdom to treat children with rare conditions that cause opaque corneas. His program soon became a referral center for children not only from across the United Kingdom but also from Europe, Africa and the Middle East. In 2011, Dr. Nischal joined UPMC Children's Hospital of Pittsburgh as Chief of the Division of Pediatric Ophthalmology, Strabismus and Adult Motility. He also directs Pediatric Program Development at the UPMC Eye Center and is a Professor of t Pediatric Eye Specialists and an author of more than 100 published research articles.

Dr. Nischal has pioneered the use of new surgical techniques, previously used only in adults, in children with corneal disorders. One of these techniques, Deep Anterior Lamellar Keratoplasty (DALK), involves removing the top of the membrane. This technique may be more resistant to eye trauma than a conventional corneal transplant, he says. For this reason, DALK may provide better results in children whose corneas are damaged by progressive neurometabolic diseases and who may also have an elevated risk for eye trauma. 6

An Interview with Dr. Maria Papadopoulos

What are things that you wish you knew as a young ophthalmologist (in

your training years)?

In fact you never stop

training , in that you have to constantly be

willing and have the passion to learn and improve your skills. Having said that,

being a doctor can be all-consuming if you allow it to be, and so I wish I knew the importance of your wellbeing and of striking a good work / life balance. Finally, the importance of saying yes

to any professional opportunities that arise no

matter how inconvenient or challenging they may initially seem, as one never knows where these opportunities will lead you.

What will be your advice to young ophthalmologists thinking of

specialising one glaucoma & pediatric glaucoma especially?

When sub-specialising one must be passionate about the field you

choose, especially if it is a challenging condition which is chronic and potentially blinding such as glaucoma. As you never discharge patients with glaucoma, you develop a long-term professional relationship, which is very different from that of patients, for example, with cataracts who you will eventually discharge after surgery. A trusting relationship is even more important between pediatric patients and glaucoma specialists, as they remain under your care for your whole professional life. Glaucoma patients will often at various times need to be managed with a lot of compassion, especially those patients who continue to lose their vision despite your best efforts. But one must never lose hope, as this is sometimes all your patients have.

What are some pitfalls you faced in the landmark pediatric glaucoma trials

(BIG Eye, UKPaed.Glaucoma study) you performed ?

The BIG Eye study was a national study looking at newly diagnosed children

with glaucoma in the UK, so the number of patients was small, around 100 children. But more challenging as a study was the International Study of Childhood Glaucoma (ISOCG) recently published in Ophthalmology Glaucoma, as this was a large collaborative, international study of 17 centres in 8 countries with

over 400 patients and data from almost 700 eyes to analyse. Challenging aspects were developing the dataset in a way that was comprehensive but user friendly for the investigators and not too onerous to complete. Also it was challenging to sift out the important messages to report on, given the volume of the data generated.

UK has a racially diverse population. How do you tailor your approach to

pediatric glaucoma patients of varying severity due to ethnicity?

I think identifying in advance who the potentially challenging cases will

be is the key, for example a baby of Pakistani descent whose parents are related and presents with neonatal-onset PCG. You know that these children have a worst prognosis and that their glaucoma must be promptly controlled surgically to improve their visual outcome. In other words, if your first operation has failed, the next operation must be definitive in controlling the IOP. Also of significance in these cases is not to miss the potential diagnosis of glaucoma in their siblings (current and future), who must also be examined.

Despite being a speaker of repute, one learns subtle points from medical

practices elsewhere. What have you, if at all, learnt from your travels to various international conferences recently?

You highlight a very important point, in that one must always be open to

changing and improving one s practice by seeing what your international colleagues are doing and how they are managing cases, especially the more challenging ones. If you are vexed by a case, they are sure to have seen, managed and have been similarly challenged by it too. Furthermore, it is very easy to continue practicing in the same way. However, when you read and hear colleagues discussing new approaches you should critically consider them also. A

good example is microcatheter-assisted circumferential trabeculotomy, which is safe, associated with superior results following a single operation compared to probe trabeculotomy, and has a low complication rate. I personally moved from goniotomy to circumferential trabeculotomy, which I taught myself despite the steep learning curve involved. The transition became necessary, as I learnt that microcatheter-assisted circumferential trabeculotomy was a better operation than goniotomy for my PCG patients.

How was ophthalmological teaching and work different in Australia from

UK?

The main difference when I qualified in Australia was that ophthalmology

training was very intensive, so only 4 years inclusive of your fellowship. And all surgical training was consultant-supervised, so of a very high level. However, when I arrived in the UK over 20 years ago, the training in the UK was much longer and surgery was not always supervised so surgical training was more variable. However, both training programmes have since been modified. When I started working in the UK, I noticed a much greater emphasis on public NHS patients due to its history, and that the standard of care for these patients was, and remains, very high at Moorfields Eye Hospital.

Q What is your approach to secondary glaucomas arising in ROP cases? A ROP management is evolving but these cases remain quite challenging. The glaucoma is secondary angle closure in nature, which is multifactorial and likely to complicate the more advance stages of the disease. These babies must be watched closely for the development of glaucoma and often require glaucoma drainage devices when all other approaches have failed. Furthermore, it is

important to remember that these patients may develop glaucoma decades later

and require long-term surveillance.

Dear ma am, please share some of your pearls for Trabeculectomy in

pediatric eyes?

The first thing to say is that trabeculectomies in phakic children can be

successful and that it must remain part of our limited surgical repertoire. The contemporary pediatric trabeculectomy technique based on Prof Khaw s Safer Surgery System, has resulted in favourable bleb morphology i.e. diffuse, elevated blebs with high success rates off medication, even in infants. The main pearls I would suggest are to fashion the scleral flap with short radial cuts to encourage posterior aqueous flow without creating a valve. Always do the surgery with an AC maintainer to prevent intraoperative hypotony and associated complications. And you must see the children regularly in the early postop period, just as we do adults, to assess bleb inflammation and ensure bleb filtration, even if it requires examination under anaesthesia.

Q What is your message to Young Ophthalmologists? A You have chosen a fantastic specialty and I would encourage you to advance it to the best of your abilities. Always keep learning and improving your clinical and surgical skills. Do the best you can for your patients. Be kind and compassionate.

In your expert opinion, Is genetic study going to be the missing part for

solving the complex pediatric glaucoma puzzles?

I hope so! Due to the multifactorial nature of pediatric glaucoma, I think it

will be a key part of the jigsaw puzzle as we seek better outcomes for these children who need them most.

YO Special Correspondent

Dr. Sonal Kalia(MS-Gold Medallist) Assistant Professor, Upgraded

Department of Ophthalmology, S.M.S Medical College, Jaipur

Vice president, YOSI Executive member, Jaipur Ophthalmological Society

Email-dr_sonal21@yahoo.co.in

Dr. Maria Papadopoulos had worked as a Consultant Ophthalmic surgeon in the Glaucoma Service at Moorfields Eye Hospital with a subspecialist interest in Pediatric Glaucoma. She completed her Ophthalmology training at the Royal Victorian Eye and Ear Hospital in Melbourne, Australia then joined the Glaucoma Service at Moorfields as a Glaucoma fellow followed by a specific fellowship in Pediatric Glaucoma before being appointed as a Consultant, and is now the Director of the Pediatric Glaucoma Service. She was the Chief Investigator of the British Infantile/Childhood Glaucoma (BIG) Eye study (2007), the first prospective, national population based study of pediatric glaucoma in the United Kingdom. She was an editor of the World Glaucoma Childhood Glaucoma published in 2013. She is a member of the executive committee of UK Pediatric Glaucoma Society and Childhood Glaucoma Research Network, which sponsored the International Study of Childhood Glaucoma (ISOCG) for which she was the Chief Investigator and developed the OpenEyes database. The ISOCG is the first international web based study to ascertain existing worldwide clinical practice of childhood glaucoma. Dr. Maria also has an interest in developing world glaucoma and is a visiting consultant with ORBIS in Pediatric Glaucoma.

Why should I be an Ocular Geneticist? Modern genetics is completely revolutionizing ophthalmology and ophthalmology is leading the field of modern genetics.

The eye is unique is the only organ in which we can see live nerves and blood vessels with the barely aided human eye. This gives us access to changes, due to genetic aberrations, that cannot be so easily obtained that with other organs such as the brain, heart, or kidneys. This feature has drawn many of us into ophthalmology itself. The accessibility of the eye also allows us the unique ability to recognize, characterize, and perhaps even treat genetic disorders. The ocular geneticist treats children and adults with both primary ocular genetic disease, such as retinitis pigmentosa, or the ocular manifestations of systemic diseases, such as neurofibromatosis, trisomy 21 (Down syndrome), and Marfan syndrome. Most ocular genetic disorders are rare. By concentrating s disorders in the care of a single individual, that person becomes adept at recognizing unusual disease. The ocular geneticist also has a special ability to apply modern genetic knowledge to allow for appropriate counseling, genetic test selection, test interpretation, and the development of novel treatments. The field of ophthalmic genetics has led to an explosion of new diagnostic paradigms and most recently, the real prospect of gene therapy, with the 2017 approval of subretinal gene injection for patients with by allelic RPE65 mutations causing Leber congenital amaurosis and later onset retinal dystrophies. There are now over 20 clinical trials underway for other genetic retinal dystrophies. To access this promise of restored site or the prevention of blindness, patients must have accurate diagnosis: thus the ocular geneticist. Imagine coming to work every day enjoying the challenge of finding the diagnosis which many other physicians were unable to do, making new discoveries, giving

patients the time and expertise they rarely can get from the general practitioner, and potentially changing their lives in terms of offering them understanding of the eye condition which previously was a complete mystery. This is the field of ocular genetics. Yet, despite the explosion of genetic information related to the eye, there are only approximately 70-80 ocular geneticists in the world. What an opportunity for a young ophthalmologist! There is a worldwide need for this resource (albeit a paucity of fellowship training programs) and a great appreciation from patients and families who benefit from the specialty. There are many pathways to becoming an ocular geneticist. Some go into the field directly from an ophthalmology residency whereas others first do fellowships in pediatrics ophthalmology or medical retina most commonly. There have also been ocular geneticists who had previously trained in cornea or surgical retina, and even more rarely, done a medical genetics residency. Either way, the ideal path is to ultimately obtain an ocular genetics fellowship that is usually one year with or without an additional research year. Most fellowships require some form of clinical or laboratory research. Training is devoted to the development of pattern recognition, understanding of the wide variety of diagnostic testing required for these disorders (e.g. electrophysiology, optical coherence tomography, fundus autofluorescence, etc.), acquiring knowledge of strategies for genetic testing, updating understanding of basic genetics, interpretation of genetic test results, and genetic counseling. Many fellowships will allow the fellows to be involved with clinical trials either underway or in development. Some fellowships are more confined to specific aspects of ocular genetics such as retinal dystrophies, retinoblastoma, or anterior segment malformations. Other fellowships will combine various sub disciplines into the clinical year(s). Although it is true that some people come to ocular genetics as a hobby and simply find an increasing amount of time in which they are concentrating on these disorders, formal training is clearly the most structured and optimal way to proceed. I love my job. Patients come to me from all over the world desperately seeking a diagnosis. Finding a diagnosis leads to understanding, counseling, access to support networks, relieving of guilt, blame and shame, family understanding, reproductive choices, and in many cases, the possibility of definitive treatment, if

not simply improving supportive interventions and appropriate screening, which may even be live saving. Many patients have searched for their diagnosis for decades. Even finding a physician who is simply familiar with their known rare diagnosis is a relief. Too often they have gone from doctor to doctor hearing only, I don t know , or having the physician have to look it up to assist them. The expertise of the ocular geneticist is so very welcome by families and the applications of the knowledge gained are many fold. There is also the challenge for ocular geneticist themselves; always the sleuth trying to unravel a complex clinical scenario or even discover a new disease. Ocular genetics also offers great opportunities for research, publication, and education, the latter being the teaching of families, our colleagues, and trainees at all levels. Ocular genetics is the wave of the future. It affects every subspecialty of ophthalmology. Ocular genetics has been leading the world in the development of gene therapy and stem cell treatment as well as diagnostics.

Want to have fun, intellectual stimulation, and enormous satisfaction? Become an ocular geneticist! There is enormous opportunity, fantastic need, and a career that awaits you with open arms.

-Dr. Alex Levin

Dr. Alex V. Levin (M.D, MHSc, FAAP, FAAO, FRCSC) is the Chief, Pediatric Ophthalmology and Ocular Genetics, Adeline Lutz Steven S.T. Ching, M.D. Distinguished Professorship in Ophthalmology, Flaum Eye Institute. Chief, Pediatric Genetics Golisano almology and Pediatrics, University of Rochester. Following completion of a Pediatric residency at the Children's Hospital of Philadelphia, Dr. Levin was a child abuse pediatrician. He then completed an Ophthalmology residency at Wills Eye Hospital in Philadelphia, followed by a Pediatric Ophthalmology fellowship at The Hospital for Sick Children in Toronto where he returned to become Professor in the Departments of Pediatrics, Genetics and Ophthalmology and Vision Sciences at the University of Toronto while working as a staff ophthalmologist at The Hospital for Sick Children for over 16 years. There he started the Ocular Genetics Program in 1995 with Dr. Brenda Gallie. In 2008 he returned to Wills as the Chief of Pediatric Ophthalmology and Ocular Genetics and Professor at the Sidney Kimmel Medical College of Thomas Jefferson University. There he established a new Ocular Genetics program. He serves on the Executive Committee of the International Society of Genetic Eye Disease and Retinoblastoma (ISGEDR) and is a frequent lecturer and contributor to the medical literature on topics related to ocular genetics. He had held or holds leadership positions for many family groups devoted to rare genetic disorders including the Pediatric Glaucoma and Cataract Family Association, Alstrom International, Sturge-Weber Foundation, the Cornelia de Lange Foundation. He is a member of the AAPOS Genetics Task Force. He has been working as an ocular geneticist for over 25 years. 17

Neuro-Ophthalmology: The 3rd Eye of Pediatric Ophthalmology

Many ophthalmologists often have an unhealthy fear of Neuro-Ophthalmology and a degree of trepidation in dealing with Pediatrics. You can imagine the level of anxiety that the combination of the words, Neuro-ophthalmology in Pediatrics will cause.

Believe me!! Pediatric Neuro-Ophthalmology is not hard and there is no need to fear.

The Principle of Pediatric Neuro-Ophthalmology is to understand that children are not miniature adults and that you must look at the whole context. You are not just the child s Ophthalmologist, you are, by default, the whole family s Ophthalmologist now. I always try to explain things to my patient in a lay person s term to help them understand. That is instrumental in patients undergoing investigations and treatment that sometimes can be invasive. I came to learn that all patients have a degree of anxiety when they see a doctor. This degree of anxiety is amplified exponentially when the subject is one s child.

There are many exciting advances in Pedatric Neuro-Ophthalmology. This gives rise to many research opportunities for Young Ophthalmologists. For instance, there are many groups looking at changes in OCT to help distinguish between Pediatric Optic Disc Drusen and a True Optic Nerve Swelling. For example, some

authors have demonstrated that the horizontal diameter of the Bruch membrane opening is enlarged in patients with true Papilledema compared to Pseudopapilledema. Future studies may evaluate neuroprotective agents for use in ODD patients who appear at risk for visual field loss.

Pediatric Neuro-Ophthalmology is a great sub-speciality where work-life balance can be achieved. All of us need to create and maintain a healthy balance between career success, personal health and relationships with family and friends outside of work. For Pediatric Ophthalmologists, the work satisfaction is immense and that forms the foundation for a happy work-life balance. In summary, Pediatric Neuro-Ophthalmology is not scary!

It helps you to be a holistic Ophthalmologist and provides exciting research opportunities.

-Dr. Celia Chen

Dr. Celia Chen is currently an Associate Professor and consultant neuro-ophthalmologist/ clinicianscientist at Flinders University. She is also the Director, Vision SA. Dr. Chen completed a prestigious NeuroOphthalmology fellowship at the Wilmer Eye Institute, Johns Hopkins Hospital Dr.

include: -

Over 90 peer reviewed papers in leading journals. Raised more than $800,000 in funding, including prestigious Australia National Health and Medical Research Council grants and fellowships Contributions to the field include committee roles at national (President elect, Neuro-Ophthalmology Society of Australia) and international conferences (including recent [2019] achievement award from the Asia Pacific Academy of Ophthalmology)

She has an excellent research record and is the recipient of both national and international scholarships and awards including the American Australian Education Fellowship, South Australian Science Excellence award, Asia Pacific Academy of Ophthalmology Achievement awards.

Strabismologically YO urs Hello young friends, YO! Strabismus and Pediatric ophthalmology is an interesting specialty to develop interest in and practice. This is especially so if you love children to be your patients. Strabismus has been changing exponentially recently, it is no more straightening the eyes to make the individual ready to be packaged for marriage! Now it is the specialty that protects and restores stereopsis, by ensuring the normal development of binocular vision. It is truly the Pursuit of Stereopsis, that is so stimulating.

We are not born with 6/6 vision nor with full stereopsis to enjoy the 3D world in its full glory and all dimensions, but we acquire this in the initial formative years, maximally in infancy and the rest in the next five years of life. Any disruption to the visual pathways and any misalignment of the eyes can prevent this and render one or both eyes amblyopic and rob the stereopsis, forever, if not treated in time. But if restored, it is really gratifying to have regained nature's best gift to humankind.

The fellowship of Strabismus and Pediatric Ophthalmology, SPO, is therefore challenging and rewarding like none other. The added advantage is that it requires much fewer infrastructural inputs, unlike the other specialties which are cost-intensive. An SPO fellow, if he has a good understanding of the subject, loves to work with children, can easily start his practice. He just needs a child-friendly environment, multiple toys and above all a playful attitude with children. Apart from accommodation-controlling toys, a set of prism bars, retinoscope, a few tests like Bagolini glasses, Red-green glasses, test for stereopsis for near and good vision charts for kids for distance and near is all one may require. One has to be sharp and observant, because the recipe of success in SPO is OCIPE:

Observe, Confirm, Infer, Plan and Execute . Proper prescription of glasses and perseverance and motivation to treat amblyopia, followed by surgery, which too requires just a simple surgical microscope (preferred over loupes, as it provides good illumination and magnification) and some simple specialized instruments. And YO! You are ready to go! Our moolmantra is stereopsis and we need to prevent its loss and restore it, when lost. It will also be applicable for adults with strabismus or refractive problems who may need your expertise. The good news is that with the newer technology, people are getting aware of the importance of binocular vision, 3D vision and true stereopsis and not just sharp sight! This is because of the 3D TVs, 3D movies and VR games on mobile smart-phones. Also exciting is the development of newer devices to stimulate and promote binocular vision and stereopsis with the 3D virtual reality, VR, devices. Most of the orthoptic exercises are now possible to be delivered on these VR devices or maybe just on patient's smartphone in his own home and monitored by you from your office. The times are promising and exciting for all those interested in Strabismus and Pediatric Ophthalmology. I close with this song of stereopsis: Spreading Sight and happiness For kids the world across! By maintaining the stereopsis And restoring the loss! So that everyone can see And see the world : 3D With full Bi-no-cular-ity Not just with clarity! We ai'nt born with 6-by-6, The vision comes gradually, Just like we learn our mother-tongue That comes so naturally! And anything in the visual path Affects its development,

So should be treated well in time With two eyes in alignment. Later, restoring is DIFFICULT In childhood the effort is mild, So restoring the stereopsis We owe it to every child! This specialty earlier was very much feared and avoided because few teachers understood it and passed on this scare, as of mathematics. In reality it is much simpler and if one understands the fundamentals, it is fun to practice. I can say this from my own personal experience as I have enjoyed every moment of my work. It is a pleasure when it is with children and challenging when it is with adults, but really gratifying in both to restore the binocular vision and stereopsis.

The idea of stimulating the interest in this field was the underlying motto of writing "Strabismus Simplified", the title initially considered as an oxymoron! Strabismus and Simplified!!! But its acceptance by the students and fellows, as also ophthalmic practitioners, has testified it to be true to its name. I thank each one of you for that. So love the field of Strabismus and Pediatric Ophthalmology and enjoy the Pursuit of Stereopsis! Strabismologically Yours

-Dr. Pradeep Sharma

Dr. Pradeep Sharma (MD, FAMS) is the Professor and Head of Section of Pediatric Ophthalmology, Strabismus and Neuro- Ophthalmology at Dr RP Centre, AIIMS, New Delhi. He completed his MBBS (1979) and MD (1982) both from All India Institute of Medical Sciences, New Delhi. Fellow of National Academy of Medical Sciences, 2003.Fellowship for Advanced training in Strabismus in USA at Jules Stein Eye Institute UCLA, Wills Eye Hospital Philadelphia and Richmond awarded by International Strabismological Association, 2001. Visiting faculty in ORBIS, the Flying Eye Hospital. 2002. First Asian invited to deliver Knapp Lecture by American Association for Pediatric Ophthalmology and Strabismus, AAPOS Vancouver 2016, titled Pursuit of Stereopsis. Achievement Award by American Academy of Ophthalmology, 2017.Col Rangachari Gold Medal for the Best Scientific Paper 1984, and Dr Athavle Award, 2002 of All-India Ophthalmological Society, Awarded Orations of State Ophthalmological Societies of 24 Gujarat, Andhra Pradesh, West Bengal, Vidarbha, Delhi, Punjab, Bihar, Kerala, Poona-Maharashtra, Tamil Nadu. Prof IS Roy Oration of KAO 2019, Prof HK Tewari Golden Apple 2019, Prof P Siva Reddy Oration of APOS, Kakinada AP. Dr Lall oration of HOS Sirsa, Haryana. International Membership of American Association for Pediatric Ophthalmology and Strabismus, since 2004 and International Strabismological Association 2000, Member Communications Committee International Pediatric Ophthalmology and Strabismus Council, IPOSC. Chairman, Pediatric Ophthalmology & Strabismus, AIOS Collegium for FAICO. Vice President, Ophthalmic Research Association, RPC, AIIMS. President, SPOSI, Strabismus and Pediatric Ophthalmological Society of India Over 200 scientific articles in National and International journals or chapters in books and Books authored: Strabismus Simplified, and Essentials of Ophthalmology.

An Interview with Dr. Claire Gilbert

What prompted you to choose the area of

childhood blindness as your core area of research?

A This area of research was suggested by Allen Foster. This was because the first WHO meeting on blindness in children had recently been held, which he attended, at which it became clear that there was very little information on the frequency and causes of blindness in children in different parts of the world. In fact, the first recommendation from the WHO meeting was to obtain more data, and I was delighted to be asked to do this.

Q As the Professor of International Eye Health in the International Centre for Eye Health, can you share your perspective about bridging the gap between affordability and access to quality eye care in low income countries?

A These are both enormous topics! The way I think about these kind of topics is from a public health perspective, with equity in access being a very important factor. In all countries the wealthy can afford good quality care in the private sector, but poorer people, including those who live in rural areas, women and

children often cannot afford these services. Eye care services also need to have high coverage i.e., they are well spread throughout the population, and a way to achieve this is by integrating (including) eye care into government services and systems at all levels. For example, every country has a primary health care system, but in most low income countries eye care is either not included at all, or only a few conditions such as eye infections are included. This must change. Every district (for a population of 1-2 million people) needs to have services for cataract and refractive errors, again ideally as part of the government health system. Tertiary level eye care is also needed. However, having said that including eye care in government health systems should be the priority, some hospitals charge quite high fees which means that the poor still cannot afford the services. There are ways round this, such as starting a revolving fund within the eye department, but this needs a lot of advocacy with hospital management.

Q What are the essential qualities that you look forward to in aspirants for Research programmes at London School of Hygiene and Tropical Medicine?

Public health research is not glamorous and working in an academic

institution will never make you rich. So what I look for is the underlying motivation and commitment to a vision which is aligned with that of the School i.e., wanting to bring about positive change for the most disadvantaged. Previous research experience and an ability to think and communicate clearly and precisely verbally and in writing are also important. Being a good research planner also requires imagination - you have to be able to imagine what it must be like working in a primary health care facility in a rural area, or how it feels to be a young, poor mother of children with bilateral cataract, for example.

Having associated with a number of projects on childhood eye health in

India, what are your comments/ suggestions regarding the training of eye health professionals from India?

A Doing good research requires an understanding of the underlying theory and principles of research as it relates to public health, epidemiology and statistics and clinical problems. For those starting out it is important to have a mentor, as research is always better when undertaken as a team activity. In my view a good way to get started is to take time out and study research methods, possibly in a Master s degree or by registering with online courses. This requires commitment of time and other resources some people manage to gain these skills through reading on their own, but this can be more difficult and disheartening.

Q What are the core principles that have guided your journey in the field of elimination of childhood blindness?

A Unlike clinical care where the results can be almost immediate, certainly in eye care, in public health you need to have a long term vision of the positive change you would like to see, and then address the research questions which need to be answered. I have tried to do this for blinding eye diseases in children, particularly for retinopathy of prematurity. However, doing research alone is not enough, as the findings need to be disseminated to the right audiences, and advocacy is a key element. Planning programmes is another aspect of public health for eye care, and I have spent a considerable period of time helping to run workshops to help people plan services at national level. Guidelines which summarise the evidence of interventions are also important, and I have also spent time working with groups to write technical guidelines (the what to do ) and operational guidelines (the how to do it ). I am very fortunate in having had such a varied and fascinating career, and I have met and worked with some wonderful people in a large number of countries over

the years. I have also been working long enough to have seen some very positive change, which is extremely rewarding.

YO Special Correspondent Dr. Sanitha Sathyan Consultant, Pediatric Ophthalmology and Strabismology, Chaithanya Eye Institute, Kochi, Kerala Email : dr.sanitha@gmail.com

Dr. Clare Gilbert worked as a Clinical Ophthalmologist for 10 years, and has an MD in Surgical Retina. She completed the MSc in Epidemiology at LSHTM 1995, and worked in the Department of Preventive Ophthalmology, Institute of Ophthalmology, London from 1990 before joining the London School in 2002. Dr. Gilbert is Professor of International Eye Health in the Disability and Eye Health Group. She is a technical advisor to several organizations including the Vision Impact Institute and USAID's Child Blindness Program, and between 2013 and 2019 was a Scientific Program Advisor to The Queen Elizabeth Diamond Jubilee Trust's avoidable blindness programme. She also co-directed the eye group between 2006 and 2019. Dr. Gilbert's research focus is the epidemiology of blinding eye diseases in children in low and middle income countries. One of her contributions was to develop a system for classifying the causes of blindness in children in collaboration with the World Health Organization (WHO). Data collected by Dr. Gilbert and others raised awareness of the regional variation in the causes and magnitude of blindness in children, and control became one of the priorities of the global strategy of WHO and International Agency for the Prevention of Blindness to eliminate avoidable blindness, VISION 2020 the Right to Sight. Other areas of Dr. Gilbert's research include population-based surveys of blindness and visual impairment, glaucoma and school eye health. Her research findings have been crucial for the development and planning of eye care programs for children in Africa, Asia and Latin America. Dr. Gilbert is a technical advisor to a number of organisations including the Queen Elizabeth Diamond Jubilee Trust, USAID's Child Blindness Program and the Vision Impact Institute.

Lessons from a Mentor At the outset, it is a privilege and honor for me to contribute to the special issue of the YO Times on Pediatric Ophthalmology and Strabismus. I must congratulate the hard working YOs led by Dr. Digvijay Singh (President of YOSI), Dr. Divakant Mishra (Chief Editor YO Times and General Secretary YOSI), Dr. Nilutparna Deori (Issue Editor), and all the bright, young and dynamic YOs of our country. YOSI has formed the perfect platform for the next generation YOs who are promising to provide an excellent all-round academic leadership in our country. Just as the leaders of YOSI need to build this organization with utmost care, passion and enthusiasm, it is relevant for an Ophthalmologist dedicated to the field of Pediatric Ophthalmology to nurture each child who presents to him with unsurpassable compassion, hard work and empathy.

I began my journey in the field of Pediatric Ophthalmology many decades ago, when we did not have significant technological advances and Indian healthcare was under tremendous pressure to tackle the growing population demands and high birth rates, and most of these babies were then able to survive and make it to adulthood. I hailed from a small village in Himachal Pradesh, which was cut off from urban life by several hundreds of kilometers. Facing numerous personal and professional challenges, I decided to take up the task of alleviating preventable blindness in children. In my journey of nearly 38 years as a faculty member in PGIMER, one of the Premier institutes in the country and internationally, I have focused on Pediatric Cataract surgeries which often presents as a unique surgical challenge. From operating children who are as young as 28 days old, to children with complex diseases such as PHPV, we believe that we have made a mark despite the resource-limited setting that we practice in. Today, we are catering to

children visiting from all over India as well as internationally. I pursued my passion throughout my career even though my administrative responsibilities grew, from being a Unit Chief to Head of the Department, and now Director a mega institute, PGIMER, along with upcoming tertiary centers of excellence, AIIMS Bathinda and AIIMS Rae Bareilly.

The highlight of my career has been recognition by ASCRS in 2013, when I was awarded the Most Prestigious International Award, the Best of the Best Award for New Surgical Technique: Management of Double Crystalline Lens . ESCRS also recognized our efforts in 2012, and we received the Oscar of Pediatric Ophthalmology subsequently in 2015 by ASRCS. It has been my honor and privilege to receive the prestigious Prof. P. Siva Reddy Award by AIOS in 2012, and distinguished service award by Asia Pacific Academy of Ophthalmology in 2013. Again Best of the Best ASCRS Award in 2016 for our work on Cataract surgery in children with PHPV. Padma Shri awarded by Honorable President of India Sh Ram Nath Kovind ji for the year 2019.

While these recognitions bring laurels to our institute, for me, I have always dedicated these to my patients, my faculty colleagues, my students (residents and senior residents) and to PGIMER. It is important that we make a global impact and place India on the map showcasing our excellence. With over 250 publications, 400 lectures, and several book chapters and editor of special issues including Ophthalmology Journal, I believe that my journey has been truly eventful. However, we have much more to achieve and our country needs YOs with a missionary zeal to control and reduce the childhood blindness in our country. The field of Pediatric Cataract surgery is challenging because managing these children is a long-term mission. Once a child is operated by the surgeon, it is his/her lifelong responsibility. As a surgeon, it is important for us to play a central role in

the postoperative care and management of these children, which includes rehabilitation (both medical and vocational) in collaboration with our colleagues from Glaucoma, ROP (retina), Pediatricians, Social workers, Anaesthesiologists, School teachers, and Anganwadi workers. It is only then we can truly make a social impact and change the lives of millions of our fellow Indians.

In our country, Pediatric Ophthalmology is still an area that requires many more hands and I am sure that many YOs who are reading this issue of YO Times are aregearing up for the challenges that lay ahead.

Jai Hind!

-Dr. Jagat Ram

Dr. Jagat Ram is Director and Professor of Ophthalmology at Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh. He is in the Board of Governors of Medical Council of India since 2018, Director, AIIMS, Rae-Bareilly, Bathinda, Bilaspur. He is recognized internationally for his outstanding contributions in the field of Cataract and Refractive surgery. He has conducted over 9500 surgical procedures in children since last 40 years. He is recipient of Most

and Refractive Society (2013) San Francisco, USA; Best of the Best Award (2016) New Orleans, USA at the ASCRS and Oscar of Pediatric Ophthalmology at World Congress of Pediatric Ophthalmology in Barcelona in 2015. Prof. Jagat Ram has regularly offered his services to the poorest of poor patients. He has excelled as a teacher in training hundreds of postgraduate students and from all over the country. He has contributed over 300 research publications in the reputed indexed National and International Medical Journals including New England Journal of Medicine and Lancet. He contributed Survey of Ophthalmology, 1999. Prof. Ram is truly an inspiration and best known for his untiring devotion to both, patient care and teaching. As a recognition of his exceptional surgical skill and compassion he was awarded the Padma Shree by Hon. President of India in year 2019 33

Growth of Pediatric Ophthalmology in India A Mentor s Perspective Strabismus and orthoptics was elevated to the status of a subspecialty since the 1960s when expert strabismologists eventually started promoting the specialty. However, when I was a resident in 1975, me and my colleagues looked at the department of strabismus and orthoptics as something alien, not related to our careers, knowing only the bare minimum to pass exams as it was part of the curriculum. There were various factors for this attitude. The foremost is that this area deals with normal and abnormal neurophysiology of visual sciences including binocular functions, many of which were being extensively researched and it was not easy to understand the intricacies of the visual processing.

Second, because of the prevailing myths and beliefs in the community, patients with strabismus hardly came forward for ophthalmic consultation. These major reasons made ophthalmologists to presume that this area is unlikely to be a high yielding specialty. The scenario has changed to good now. In 1983, when I started practising strabismus along with general ophthalmology, I understood the significance of detecting strabismus and amblyopia either as a lone entity or in association with other eye diseases in all age groups, to get optimal visual outcomes post treatment. Also we realized that amblyopia was being missed or was not dealt with, by retinal surgeons treating cataracts with lensectomies at that time and corneal surgeons dealing with corneal lesions and injuries. Hence, a separate facility was started in the year 1984, first of its kind in the country, catering services to all children aged 15 years and below who came with any eye disease, and all adults with strabismus, attending the hospital. As the demand for training in the field increased, we started providing a structured long term fellowship (18 months, first in 1990) in Pediatric Ophthalmology and Strabismus, with the focus of grooming the fellows as comprehensive pediatric

ophthalmologists with the ability to handle all eye diseases including congenital vision impairment in children 15 years and below apart from handling strabismus in adults. Though the training is being offered in various other institutes, still there are underserved regions in the country. This needs to be identified and we should work towards achieving the standard of 1 (0.61 at present) Pediatric ophthalmologist available for each 10 million population as recommended by the WHO. Having dealt with more than 200 fellows in these 3 decades, I feel happy to share my thoughts regarding the fellowship in Pediatric ophthalmology.

Basic knowledge- As a preparation to the course, one needs to have a background knowledge to the related speciality, such as the anatomy of Extraocular muscles (EOM), visual pathway including the cortical streams, physiology of vision, pathophysiology of binocular anomalies and EOM. This will definitely make the fellowship more productive as the candidate is better oriented to the subject before pursuing the course.

o Innate love and affection towards children- It is important to understand that, by expressing empathy, children will co-operate well. The usual teaching is that no child should be branded as unco-operative but should be viewed as our inability to assess or gain their co-operation. Respect the senior orthoptists and try to utilize their experience. Take an ownership of all your patients even when they need other expert s opinion. o Communication skills- Communication skills should be focused on convincing about your management including the spectacles wear. Most importantly one should know that we are not dealing the child alone but the whole family. Hence, it is essential to show the same empathy to parents and take time to discuss with them regarding their ward s condition and the proposed management in detail. When in need of surgery the discussion should be towards alleviating their fear about general anesthesia, the surgical procedure and the post-operative recovery period. Develop empathetic

communication skills when dealing parents of children with retinoblastoma and congenital vision impairment. o Learning surgeries- Knowledge of preoperative evaluation, intraoperative and post-operative findings thereby acquiring decision making skills. Do not concentrate on the number of surgeries. It is wise to learn the techniques precisely, initially in adults when it comes to cataract and strabismus. One has to utilize the wet labs to shorten his/her learning curve in surgeries on pediatric patients. We should always remember that not even a single child should become visually impaired in our hands. o Respect the time- 18 or 24 months is not enough to learn all about strabismus. Hence, try to spend every minute productively in the library, group discussions with the peers, journal clubs etc. Use your special postings more productively. Actively get yourself involved in the community outreach camps especially when it comes to school eye screening, screening for ROP etc. o Active participation - Don t hesitate to take the advice from seniors

when it comes to either the examination, diagnosis or investigations. Show enthusiasm in learning by actively participating in all the department activities including research. Try to take classes for residents and other trainees in the department which will lead onto better understanding of the subject. Do not ignore the log books. Understand that learning is facilitated with a good team involvement. o Think beyond treating the diseases-Don t forget that in your

practice you will definitely come across a set of patients with untreatable visual loss. In view of high demand of the professionals dealing with rehabilitation, it may be beneficial to identify an individual nearby and try to develop a network with them for referral collaboration. In relation to school going children, identify nearby schools which provide inclusion education to guide them in a right direction. o Utilize

the

opportunity

learn

some

organizational

techniques- learning to set up your own facility, developing a link with neonatologists in NICUS in your region towards screening the children with

risks for developing ROP, working with pediatricians, pediatric neurologists on developing a system of follow up of children who were discharged from NICUs for assessing the development of visual and general milestones, developing a systematic screening of school going children for ocular morbidity both in normal and special schools, finding a local philanthropist or a government agency to provide spectacles to the needy. For a successful practice, one should get associated with different societies, constantly keep in touch with the recent developments in the field.

o In the OPD- In their initial period consider them like residents. Try to

follow the curriculum in place. Try to understand their shortcomings and act accordingly. Adequate exposure in orthoptics and strabismus evaluation is mandatory in the initial phase. The element of Amblyopia detection in all age groups and in all diseases should be made a priority. Expose them adequately to the special cases like, lid anomalies, injuries, ROP detection, congenital vision impairment, Retinoblastoma management etc. Make them understand your expectations. o Surgical performance- After teaching the basic principles, allow them to assist few cases, make them perform the steps under your supervision before letting them independently. o Communication skills - Throughout their fellowship period keep a constant watch on their communication skills, which should get refined in stages. This will make them a good and confident surgeon. o Research- Designate a research topic and follow on its status regularly with constant encouragement. o

Periodic evaluation- Make sure to evaluate them periodically (refer their Log book), assess their strengths and weaknesses before giving inputs.

Finally, expose them in activities like Screening for ocular morbidity in school going children, Screening for ROP and in other community outreach programs including schools for the Blind and special schools.

One more point to stress here is that when we have constraints on a number of Ophthalmologists available, an orthoptist can play a major role in assessing the difficult children with strabismus, evaluating the paretic squints, playing a role of counselor especially for parents of children with Amblyopia. They can help the residents and fellows giving hands on training in evaluation of a motility disorder. From the days when a separate certified course was available region wise, this is becoming almost non-existent now. We should together strive to revive the training, if not should take steps to inculcate a 6 months curriculum into the course of optometry who can be useful to all the Pediatric ophthalmologists. At the completion of training, a fellow should be skillful, confident enough to give services to all children in safe mode and constantly strive to enhance his/her capacity in future. He/she should also be community oriented in providing services. Most importantly, the word rehabilitation should come to his/her mind when the recovery of vision is beyond the current treatment options. He /she should concentrate on how to make the quality of life better for each and every child attending the clinic.

-Dr. P. Vijaya Lakshmi

Dr.Vijayalakshmi joined Aravind Eye hospital as

underwent her fellowship training in Pediatric Ophthalmology and Strabismus in the year 1982 at University of Illinois in Chicago. She established the first Pediatric Ophthalmology and adult Strabismus Clinic, in India in 1983. Her services extended to both school going children and children enrolled in Anganwadis. Since 1990, 130 fellows including 18 international candidates were trained and in 2002, the centre was recognised as one of the best learning and training centre by ORBIS International. Dr. surveillance for congenital Rubella Syndrome in collaboration with ICMR and WHO culminated in a landmark finding of isolating the circulating virus in the region. She has facilitated various Molecular Genetics studies through AMRF on Congenital cataract, Globe anomalies, Aniridia, LCA, RP and Oculocutaneous albinism. Currently, she has been focussing on early intervention programmes for visually impaired infants and toddlers especially with CVI and Autism as one of the core group under Pediatric Low Vision rehabilitation committee of AAPOS. In the book: Ophthalmology and Strabismus 5th edition, by Scott R Lambert and Christopher J Lyons : In the first chapter History of Pediatric Ophthalmology and Strabismus, Dr.Davind S Taylor quotes

Worldwide teaching and training and research 39

5 Questions with Dr. Harsha Bhattacharjee Q

Why should an Ophthalmology trainee consider a career in Pediatric

Ophthalmology and Strabismus?

Decision for career selection is a systematic approach and based on fundamental facts. Any decision is a logical conclusion of rationale thinking on an issue. The ophthalmology residency training programme in our country baring a few mostly whirl around cataract surgery only. As a result, residents lack the specific soft skill and technical dexterity for treating the delicate eyes of the children.

Apprehension of poor surgical outcome and a mammoth responsibility for offering lifelong compassionate care serves as a negative point on decision making. That Pediatric ophthalmology as a career is less rewarding in terms of money further dissuades a trainee to take up this sub-speciality. However, considering the multidimensional scope of Pediatric ophthalmology (which ranges from Refraction, Amblyopia management, Cataract, Glaucoma, ROP to Oncology, Genetic services and Research) and the tremendous impact it has on a child s life, a Young Ophthalmologist can give a wise thought to select Pediatric Ophthalmology as a career and not go for any hybrid specialty. If the decision satisfies the feeling of purpose, it is highly rewarding.

Q Tell us a little about your Pediatric Ophthalmology experience.

A Pediatric Ophthalmology and Strabismus fellowship programme should be ideally-structured,

objective-oriented and comprehensive that will provide an in-depth experience of child care and be inclusive of all aspects of pediatric ophthalmology like strabismus, anterior segment diseases, retinopathy of prematurity, neuroophthalmology, oculoplasty and ocular oncology etc. It will be difficult to master all the subjects but collaborative effort is the key to treat childhood ocular diseases.

What are the most important qualities you look for the prospective Pediatric Ophthalmology fellow?

The most important quality of pediatric ophthalmology fellow is to have a

proper attitude, eagerness to learn and do the job correctly. As the subject is highly mentor dependent so the support of the mentor is also important. Attitude starts with understanding a child and the child psychology. Clinical examination, keen observation of each step of surgery are to be carefully learned and mastered. Post-operative follow-up, meticulous examination and documentation are important as the child cannot communicate and every action depends on clinical findings. It is for sure that a child might need a follow-up for prolonged period of time for many years and pediatric ophthalmologists should address it gracefully.

Q Common mistakes the fellow makes early in fellowship? A Rather, I would like to say How to avoid mistake because a fellow can make any possible mistake. Surgery and its outcome depends how meticulously a case has been prepared during preoperative period, surgery performed and post surgical follow up done. If any mistake happens, failure to recognize it and personal denial are the biggest mistakes and proves to be a hindrance to perfection. Step by step approach is appropriate. Recognition and acceptance of one s mistake never bruises pride or questions an individual s competency.

Q Surgically what are the most important principles to understand? A Detailed understanding of the child s ocular anatomy and physiology as well as the technical aspects of instrumentation helps in the surgical management of pediatric cataract surgery. Maintaining intra-operative globe integrity, IOL power calculation, securing wound closure and minimising postoperative ocular inflammation are a few of the fundamentals of pediatric cataract surgery. Similarly, in case of strabismus surgery a meticulous preoperative evaluation and decision on the surgical approach determines the outcome of the surgery. Understanding the basics of binocular vision and ocular motility is of utmost importance. Therefore, the skill lies not on the surgery but on the expertise in pre-operative planning and decision-making!!

YO Special Correspondent -Dr. Nilutparna Deori Consultant, Pediatric Ophthalmology and Strabismus Sri Sankaradeva Nethralaya, Guwahati, Assam Email : nilutparnadeori@gmail.com

DR HARSHA BHATTACHARJEE , MS, FRCP, FRCS is the Founder, Medical Director and Trustee of Sri Sankaradeva Nethralaya (SSN). An MS in Ophthalmology, Dr Bhattacharjee is also a Fellow of the Royal Colleges of Surgeons (FRCS). After a stint in the government where he grew to the post of Associate Professor at the Regional Institute of Ophthalmology in Assam, Dr Bhattacharjee went on to found SSN in 1994. In addition to offering comprehensive eye health care for all key blinding conditions, SSN trains local eye health teams and engages in research. Community eye health for vulnerable groups is a core element of their ethos, with over 60% of patients being treated free of cost. In 2004, SSN was declared a Centre of Excellence by Dr Manmohan Singh, former Prime Minister of India. Over the years, SSN has impacted on over 25, 24,952 persons in the base hospital excepting outreach patients. Dr Bhattacharjee has pioneered services such as intra-ocular lens implantation, vitreoretinal care, pediatric eye care, occuloplasty and laser surgery in the region. He has performed over 200,000 cataract and anterior segment eye surgeries and over 200,000 other surgeries and ocular cancer treatment interventions till date. He has authored over 250 scientific papers and has co-authored several text books on ophthalmology. His work has been presented in numerous scientific forums and he has chaired several prestigious scientific sessions, both nationally and internationally. Some of the awards and honours that he has received include: Achievement Award by South Asian Academy of Ophthalmology; Achievement Award by Asia Pacific Academy of Ophthalmology; Excellence in Medicine Award conferred by Down Town Hospital, Guwahati and felicitations by Rotary International, among others. Dr Bhattacharjee assists several universities and is a lifetime member of prestigious bodies like American Academy of Ophthalmology, American Society for Cataract & Refractive Surgery and ICEH among others. His pioneering efforts have helped significantly strengthen eye health care in Northeast India. 43

Rendezvous on my journey with ROP Choose a job you love, and you will never have to work a day in your life - Confucius

And I have lived my life each day to this. In the last 30years of my practice, there has never been a day where I have not expressed gratitude for being one of the crusaders in preventing blindness for the premature babies and seeing them share that beautiful smile when they are old enough to make an eye contact with me.

As a resident doctor the ROP chapter was an enigmatic one wondering how such tiny babies with tiny eyes get screened little realizing that, that aspect of Pediatric Ophthalmology would be the first one I would embrace and persevere amongst the several other subheads of the same speciality that I imbibed later.

These tiny soldiers fight hard against the cruel odds of an alien environment. In a struggle for existence and with a little timely help from both the Neonatologist/ Pediatrician and the Ophthalmologist in referral, screening, detection treatment and follow-up the child can sail through unscathed and unscarred through the most difficult and vision threatening period of its life. What does it accomplish? Freedom from blindness and medico-legal hassles

Retina and Pediatric Ophthalmologists have been tirelessly sounding warnings regarding the higher incidence of ROP due to better survival of neonates from improved technology, instrumentation. The preterm birth phenomenon with the ongoing third epidemic for ROP, has resulted in higher rates of childhood blindness due to lack of early detection which stems from lack of awareness of general public.

While recent advances have enhanced premature infant survival rates, but it has not lowered the frequency of complications and we have seen have seen an increase in number of severe ROP cases.

The main challenge of ROP is identification and early treatment. A delay of even1week may be devastating. However, keeping track of preterm infants presents a challenge.

These infants are transferred from one neonatal intensive care unit (NICU) to another without prior notification. An infant's last name typically represents the mother's maiden name, while at discharge, the name usually reverts to the father's last name, making tracking a patient difficult.

Finally parents, burdened as they are with frequent doctor appointments, it may allow a routine eye exam to take a backseat.

My children (patients) and their parents taught me many things and the most important lesson was about raising awareness on this problem at a National level for the general public which covers a broader spectrum.

And as destiny would have it, Dr. R Azad and Dr. Vinekar conferred me the responsibility of ROP National coordinator of the Ambassador programme to start a National campaign towards this noble cause.

With the help and support of the IROP society, doctors and good Samaritans of society we aim to create awareness for general public to stop blindness due to ROP.

In the words of Robert Frost The woods are lovely, dark and deep but I have promises to

And I am positive, this article will encourage Young Ophthalmologists to pursue ROP in their career and be a part of the campaign and join this crusade towards eradicating ROP blindness.

-Dr. Karobi Rani Lahiri

Dr. Karobi Rani Lahiri (M.B.B.S., MS, DOMS, DNB, FCPS, FMRF) is the Associate Professor of Ophthalmology-ConsultantVR Surgeon and Pediatric Ophthalmologist at the Bombay Hospital Institute of Medical Sciences. She is the National Ambassador, ROP (Retinopathy of Prematurity), India. In her 28 years of experience, Dr. Lahiri has presented several lectures, talks, guest lectures, orations and conducted instruction courses at both National and International meetings. She has written 5 book chapters and has 3 publications in peer reviewed journals. She has received the BEST FELLOW Award at Sankara Nethralaya, Chennai (1998-99) in the presence of Hon. President of India, IIRSI Award (2017), SANTINIKETAN Award by VC (2018), Best Teacher Award, WOS 2018; ROLE MODEL Award, BOA FOCUS (2019),RECOGNITION Award WOS (2019), WOS LEADERSHIP Award (2019), SPECIAL RECOGNITION Award for Outstanding Work in Retinopathy of Prematurity by BOA (2019). She has also received APPRECIATION for COMMUNITY PROSPECT ON DIABETIC RETINOPATHY at MOSCON (2019) Dr. Lahiri has the 1st Aditya Jyot Foundation for Twinkling Little Eyes ORATION in collaboration with BOA (2019). A SPECIAL RECOGNITION Award was conferred to Dr. Karobi Lahiri. Apart from academic and community services she enjoys gardening and dancing. 47

MENTORS PERSPECTIVE

Dr. Damaris Magdalene HOD and Senior Consultant Department of Pediatric Ophthalmology & Strabismus Sri Sankaradeva Nethralaya, Guwahati

Dr. Jan Tjeerd de Faber Pediatric Ophthalmologist Rotterdam Eye Hospital

Dr. Jon Pieter Saunte Chief Strabismus Surgeon Department of Ophthalmology University of Copehagen Rigshospitalet Glostrup Copenhagen, Denmark

Dr. Kalpana Narendran Chief, Intraocular Lens & Cataract Services Chief, Pediatric Ophthalmology & Adult Strabismus Services Aravind Eye Hospital, Coimbatore

Dr. Ramesh Kekunnaya Director, Child Sight Institute Eye Care Center LV Prasad Eye Institute Hyderabad

Dr. Rohit Saxena Professor, Department of Ophthalmology, Dr. Rajendra Prasad Center for Ophthalmic Sciences All India Institute of Medical Sciences, New Delhi

Dr. Sowmya R Senior Consultant,Department of Pediatric Ophthalmology and Strabismus Sankara Eye Hospital Bangalore

Dr. Sumita Agarkar Deputy Director, Department of Pediatric Ophthalmology & Strabismus Sankara Nethralaya, Chennai

Dr. R. Krishnaprasad Head of Pediatric Ophthalmology and Glaucoma services M.M Joshi Eye Institute, Hubbali 48

Dr. Damaris Magdalene Pediatric ophthalmology in our country is still in its infancy. Lack of infrastructure and lack of pediatric units makes it difficult for a resident after his/her residency to dive into full-fledged Pediatric Ophthalmology fellowship. Again there is the crunch of finance standing as a barrier. Pediatric Ophthalmology and Strabismus is definitely different from other subspecialties and the resident must bear that in mind because handling children and examining them might turn out to be a nightmare if one does not have a passion for children. Moreover, there is always the parents whom they have to deal with, break their mental block with relation to glasses, surgery and other treatment.

Dr. Jan-Tjeerd de Faber I think most of them are especially when they have true interest in Pediatric Ophthalmology and Strabismus. I think the prerequisites which they must have, which they must bear in mind is that they need knowledge of Pediatric Ophthalmology and Strabismus so dive into textbooks and course books, read as much as you can. Try during your residency to recognize these typical pediatric problems. I also feel Pediatric Ophthalmology is different from other subspecialities because you have to work with children and more important sometimes you have to work with patients. I think Pediatric Ophthalmology is 50% parentology. 49

Dr. Kalpana Narendran The Paediatric Ophthalmology & Strabismus fellowship is very different from other sub specialties because we are dealing with children who have longer living years. Most of the residents are now not fully equipped in handling children, they should have a sound basic surgical exposure and confidence in doing adult surgery before they can treat children. A resident who is interested in Paediatric Ophthalmology must be comfortable in handling children. A friendly, communicative, responsible and conservative in taking decisions while treating children.

Dr. Jon Peiter Saunte Practical skills are they comfortable with different surgical tasks they have been exposed to during training? In Pedstrab daily practice life may be very tough if surgical tasks are difficult and stressful for the doctor. I always invite a resident to join and assist in surgery before considering if their hands work well enough for them to plan for a surgical career. If the young doctors hands are not suited for surgery I am very honest in telling that a job without surgical tasks would make life much easier for them. Intellectual skills are they enthusiastic about difficult challenges in strabismus in trying to understand the complexity of this field? Pedstrab consists of many complex patterns which may be difficult to understand at first glimpse. The crossroads between neuro-ophthalmology and

Do you think most of your residents are equipped to dive into fullfledged Pediatric Ophthalmology and Strabismus fellowship right after residency? What are the pre-requisites a resident must bear in mind before embarking on the journey? Do you feel Pediatric Ophthalmology and Strabismus fellowship is different from other subspecialties? strabismus may present difficult cases where a solution may be difficult to find and may need further studying in textbooks and papers. Communication skills in meeting with the patient child or adult the key to find the correct diagnosis is dependant on appropriate communication with the patient. When examining children the window of opportunity to find the clue and diagnosis may be very short and in examining strabismus patients with complex deviations the information of what surgery can gain and almost more importantly may not solve is important for the patient before accepting the surgery plan. Pedstrab fellowship is different from other specialities in different ways. The theoretical basis is very extensive almost all ophthalmological diseases can be found in the pediatric patient just more difficult to examine. Strabismus is by many regarded as the most complex part of ophthalmology both theoretically and in surgical treatment. In planning a long career in ophthalmology, residents are often aware of where the money in private practice may be hidden in oculoplastics, cataract or refractive surgery and probably not in Pedstrab. But remember: in Pedstrab the patients, diagnosis and treatment differ. The Pedstrab doctor meets both children and adult patients throughout the whole career this will keep their minds challenged and provide the Pedstrab doctor a life with very varying and challenging days even as a consultant you often meet cases you have not seen before- this will keep the Pedstrab doctor stimulated and keep the mind young throughout a long career!

Dr. R. Krishnaprasad Unfortunately Barring few exceptions, most Residency programs in our country do not equip our young ophthalmologist for a full-fledged Pediatric Ophthalmology and strabismus fellowship in particular. Refraction and strabismus are not taught vigorously making it taboo subjects. A robust execution of competency based training of our post graduates is the need of the hour which can bridge these gaps. Good understanding of comprehensive ophthalmology, adequate microsurgical expertise, decent communication skills and a mindset of commitment are the pre requisites before embarking on the journey of pediatric ophthalmology and strabismus training.

Dr. Ramesh Kekunnaya Most of the residents are not ready to take up fellowships immediately after residency. 1) They lack adequate comprehensive ophthalmology skills many do not even know to perform basic cataract surgeries2) They have no knowledge of Strabismus, General Pediatrics and associated systemic diseases and genetics 4) They have no soft and/or communicative skills5) They have no knowledge about writing and have very limited to no publication skills In addition to the above, one MUST like children in general and SHOULD have a lot of patience, if one

wants to pursue a Pediatric &Strabismus fellowship.

Ophthalmology

Pediatric Ophthalmology and Strabismus (POS) is Ophthalmology - plus and is very comprehensive. Hence, one must be comfortable with comprehensive management of any eye issue, be a good communicator/counsellor in addition to possessing an ample knowledge of systemic diseases. Therefore the Fellowship duration must be a minimum of two years.

Dr. Rohit Saxena Yes, I think our residents are well equipped to start the fellowship as they have rotations in the Pediatric cataract as well the Strabismus units twice in the residency and they would have worked up and assisted a fair number of cases. Residents must realize that the visual outcomes in pediatric ophthalmology are not as straight forward as in adults and the follow- up is much more prolonged. The examination itself is a challenge and results are not instantaneous. The Key prerequisites would be motivation, empathy and interest in the specialty and they must develop soft skills of listening and a strong observation. Definitely, the fellowship is different from other subspecialties, the examination, decision making and surgical techniques are quite different from

adult cases. You have to remain a comprehensive ophthalmologist while getting specialisation as you need to diagnose and identify all types of disorders early; children can have multiple issues both in the eye and systemically and so needs to be alert for other issues not evident at presentation.

Dr Sowmya R Yes, to a certain extent. The residents are capable and equipped to deal with most of the common conditions in pediatric ophthalmology and strabismus soon after residency. But dealing with difficult cases, diagnosing squints in infants and toddlers and the surgical skills will require a period of working with seniors to improve further The pre-requisites that must be borne in mind are: Firstly, the place of work may or may not be akin to their place of residency and may be working on different protocols so adaptability is the key. The adherence to necessary and mandatory tests to be done during evaluation of the child and not to adapt to forget the basics of evaluation. Further, patience is necessary both in examining children and to wait for the practice to grow. It is equally important to have effective referral base of pediatricians to handle and treat kids in a complete way. Answering the last part of the question; Pediatric ophthalmology and strabismus is definitely different and special from other sub-specialities in many ways. Dealing with kids demands a lot of patience and at the same time being creative and highly observant to

pick up signs and to examine the child especially in strabismus, even before child actually realizes it is being examined is definitely a task. Making the examination a play time for kids is the biggest challenge, at the same time fun too. Further the fact that children (younger ones) don t tell their problems and it solely relies on the capability and skills of the doctor examining to diagnose properly The sub-speciality is not financially rewarding but the satisfaction seeing the smile on face of children after the treatment is worth all the effort and more.

Dr. Sumita Agarkar I wouldn t say that all are prepared to take a plunge in pediatric ophthalmology. In fact several of my residents report feeling daunted by the prospect of examining children. So the first prerequisite is a genuine interest in this admittedly challenging subspecialty. They should be reasonably skilled ophthalmologists before joining training with skills in refraction and fundus evaluation. I also feel personality traits like patience and ability to communicate goes a long way to be good in this subspecialty more than any other branch of ophthalmology.

How have you designed the fellowship teaching program in your institute? What are the different protocols and disciplines you follow in OPD, OR & bedside clinics in grooming the fellows?

Dr. Damaris Magdalene We have designed a one and half year training program. There is a six month research work followed by routine consultant postings with the pediatric consultants by turns for OPD and surgical exposure.

Dr. Jan-Tjeerd de Faber I started the fellowship programme about 15 years ago and it was actually learning by doing. I would ask my fellows during fellowship, what have you learnt? and I also make clear to me what you would do different if you were mine? So in other words you learn from me but I also learn from the fellows because in several countries protocols can be different and also clinical problem can be different. I ve had about 30 fellows now from about 5 continents and I am still learning from my fellows.

Dr. Kalpana Narendran Yes, we have a teaching curriculum in our institute and they have different modules of learning. We also have a Log Book which they have to fill in on a day to day basis- the types of patients they are seeing and also the surgeries they are performing. Each of the fellow will have a mentor who will guide them in following different protocols in the OPD and they are also exposed to General Anaesthesia rounds, Pre and Post OP and they get to spend at least two days in a week in the Operating Room with a surgeon where

How have you designed the fellowship teaching program in your institute? What are the different protocols and disciplines you follow in OPD, OR & bedside clinics in grooming the fellows?

they are taught about Pre-OP evaluation to intra-OP management and Post-operative follow up.

Dr. Jon Peiter Saunte In our clinic the Fellow in Strabismus and Pediatric Ophthalmogy are separate. In strabismus surgery, we provide surgery training 2-3 days a week with a very controlled timeline. The fellow will practice surgical suturing on artificial eyes and pigs eyes before they can join surgery in the Operation Room (OR). In the OR the Pedstrab fellow will perform surgical tasks first as an assistant, later as a surgeon in simple cases. Our aim is to educate the fellow to be able to perform all different surgeries in strabismus also the complicated ones on their own, but supervised the first 30-50 cases. In the outpatient department (OPD), the fellows follow both the orthoptists to learn the different measurement techniques to be able to understand and to perform these tests also. Then the Pedstrab fellow follows the consultant and later may examine patients which are presented to the consultant before scheduled for surgery.

Dr. R. Krishnaprasad Our institution, M. M. Joshi Eye Institute offers an unique blend of flair of private practice with an

How have you designed the fellowship teaching program in your institute? What are the different protocols and disciplines you follow in OPD, OR & bedside clinics in grooming the fellows?

Institutional Academic frame work, making our fellows Industry Ready and Employable , right from day one. The clinical Teachings involve the triad of Didactic / Interactive sessions in everyday morning classes, case discussions on one to one basis with most of the OPD cases which are interesting and a post OPD informal discussion sessions which give ample opportunity for reflecting on the cases seen that day. We do not have any bed side teaching as such. Teaching in operating rooms form the integral part of grooming one future pediatric ophthalmologists.

Dr. Ramesh Kekunnaya We have divided the fellowship into 4 stages of 6 months each. The main goals of the fellowships are imparting (a) clinical care (b) surgical care (c) community eye care & (d)research and education. In the first stage, fellows sharpen comprehensive and basic skills in POS.

their

In the second stage, they enhance their POS skills and develop some research skills. In the third stage, they enter complex POS and community eye care. In the last stage, they run independent OPDs / ORs and participate in teaching residents/paramedics/co fellows in addition to completing their research.

How have you designed the fellowship teaching program in your institute? What are the different protocols and disciplines you follow in OPD, OR & bedside clinics in grooming the fellows?

We have protocols for almost 20 common clinical scenarios in our POS fellowship, which are followed uniformly by everyone in our clinics. Even in the ORs, there is a protocol for preoperative assessment, time out, intraoperative assessment, operation and post-operative instructions. Our modular theatre has excellent facilities for recording both intraocular and extraocular surgeries with a good projection system. Fellows are initially trained on model eyes, followed by supervised assistance and are then are allowed to perform surgeries independently under supervision, before graduation to performing surgeries independently without supervision. Dedicated daily teaching programs include journal clubs, case presentations, interactive sessions with Neurologists&/or Radiologists and discussions with Pediatricians. We also have bed side clinics & discussions on management practices twice a month. Research is an integral part of the fellowship program & fellows are encouraged to publish and present their findings at various national and international platforms. During the fellowship all fellows are made to have a rotation in all sub-specialties of POS, namely Pediatric Retina, Cornea, Glaucoma, Oculoplasty, Neuro-ophthalmology and Child Rehabilitation and Low Vision Services.

How have you designed the fellowship teaching program in your institute? What are the different protocols and disciplines you follow in OPD, OR & bedside clinics in grooming the fellows?

Prof. Rohit Saxena The senior residency programme in RPCentre is broadly similar to any fellowship programme. The Senior resident works up in-patients as well as attends the specialty clinics. They also observe the surgeries in the OT and large number of the surgeries of the speciality. They are also involved in the teaching of post-graduates, have to regularly participate in CMEs, symposiums and case presentations and also in research and publications. The key aspect is practical training, discussion on every case however brief, asking questions and group discussions among the residents. Case based teaching is the most important way to teach this field as each case can be unique. They are encouraged to read about each case they see and come back to pick thing missed. In the speciality clinics, the new cases are seen and discussed with the consultants, the old follow-ups are seen by the fellows and doubtful cases are then discussed. The resident is in-charge of a fixed number of beds in the ward which they workup thoroughly and participate in the planning the next day with the consultants. In the OR, the fellows observe and assist the surgeries of the consultants and also independently operate cases.

How have you designed the fellowship teaching program in your institute? What are the different protocols and disciplines you follow in OPD, OR & bedside clinics in grooming the fellows?

Dr. Sowmya R The overall design of fellowship in out institute consists of general ophthalmogy training for 6 months followed by sub-speciality training for next 18 months. The latter period is further divided in 3 intervals of 6 months each, first being in refraction, orthoptics, low vision clinic with observation in OPD and OR followed by 6 months of working up cases in OPD, attending pediatric screening camps, teachers /volunteer training sessions , evaluating cases posted for surgery, assisting and doing steps in surgery in OR and last 6 months of independently evaluating cases in OPD and doing surgeries albeit under supervision. The residents are also expected to finish a project (study) during their tenure and publish the same. The residents posted in OPD are required to work-up the cases, put up their differential diagnosis, photograph the cases if needed. At the end of the day 2-3 cases are discussed and residents are asked to state points to substantiate or negate the various diagnosis and suggest further line of treatment. In OR, the nuances of surgical steps discussed and taught. Various approaches to same strabismus case discussed and why one particular procedure chosen over the other arrived at. Regular weekly seminars, journal discussions conducted which help in grooming them better.

How have you designed the fellowship teaching program in your institute? What are the different protocols and disciplines you follow in OPD, OR & bedside clinics in grooming the fellows?

Dr. Sumita Agarkar In Sankara Nethralaya, duration of pediatric ophthalmology fellowship is 18 months. Fellows rotate with consultants and see patients independently in last 6 months of fellowship. Surgery is always supervised though attending surgeon may or may not scrub in every case. Apart from pediatric ophthalmology, fellows also have postings in neuroophthalmology as well as oculoplasty departments . They are encouraged to be a part of ROP team and exposed to ROP screening programme. There are research projects that they are expected to work on as a fellowship requirement. They are allowed to attend 2 sponsored meetings during fellowship. They are encouraged to take active part in teaching programme. They have to maintain a log book which is periodically reviewed by the director of the department as well as academic director. We do periodic formal assessment of the fellows in form of viva / tests.

What is the best way to grasp the nuances of Pediatric Ophthalmology & Strabismus and do you recommend any mandatory reading sources for Pediatric Ophthalmology & Strabismus ?

Dr. Damaris Magdalene Reading is mandatory but the best way to grasp the nuances of pediatric ophthalmology is observation. Observing how the mentor deals with the cases because each child is different. One learns more through observation and discussion.

Dr. Jan-Tjeerd de Faber Yes, I think the best way to grasp the nuances in our field is first to Read! Read! Read! Take a look at all the nice photographs and pictured which are mostly online, PDF files and textbooks, for instance for textbooks of Von Noorden and of course the basic sciences of AAO, that s also top notch learning material. Otherwise look in your language if there are good textbooks which you read up to explain and also see what you can see during practice when you re in the clinics.

Dr. Jon Peiter Saunte The Pedstrab fellow needs to prepare by reading textbooks before entering the field we recommend reading the AAO books or other textbooks in the field of pediatric ophthalmology and strabismus. It is

What is the best way to grasp the nuances of Pediatric Ophthalmology & Strabismus and do you recommend any mandatory reading sources for Pediatric Ophthalmology & Strabismus ?

mandatory to understand the basics of theory of strabismus if to work in this field. Both von Noordens Ocular Motility and Strabismus and Plagers book on strabismus are useful, and the Strabismus a case based approach by Hunter et al are recommended. We have a strabismus meeting every week and the orthoptists and doctors in the strabismus team alternate in presenting a new paper or book chapter for the group to create consensus and keep updated on new topics. The Fellows are encouraged to perform scientific projects and the department will normally sponsor travel to a scientific meeting to present the results.

Dr. Kalpana Narendran The best way to Paediatric Ophthalmology & Strabismus is to choose the right institute for doing the fellowship. Yes, there are books on Paediatric Ophthalmology & Strabismus by authors like David Taylor, Kenneth Wright, Arthur Rosenbaum and our own Indian books by Dr Pradeep Sharma.

Dr. R. Krishnaprasad Personally the information explosion with countless resources is more of a problem than a blessing. 64

What is the best way to grasp the nuances of Pediatric Ophthalmology & Strabismus and do you recommend any mandatory reading sources for Pediatric Ophthalmology & Strabismus ?

Digital information available as e Book & online sources can distract a student and the onus is on the Mentor to guide the student to the right source of information. We do recommend the following reference books as a minimum requirementBinocular vision and ocular motility by Von Noorden , Pediatric Ophthalmology and Strabismus & Atlas of strabismus surgery by Kenneth Wright , Clinical strabismsus management by Arthur L Rosenbaum , Pediatric cataract surgery by Edward Wilson and Rupal Trivedi. Additional book include Strabismus by Burton J Kushner and online articles at Cybersight.

Dr. Ramesh Kekunnaya The best to way to learn, is by seeing, hearing and doing, all the while, bearing in mind 3 important things : WHAT,HOW AND WHY? . We also recommend CONCEPTUAL READING for better application of knowledge on patient care. At LVPEI, we conduct two exit competency tests for overall assessment. This helps us gauge the progress of fellows. Additionally, fellows are expected to create clinical pearls, surgical videos and document their surgical outcomes. These become invaluable sources of learning and teaching. They are also expected to read & understand land mark articles in POS & need to

What is the best way to grasp the nuances of Pediatric Ophthalmology & Strabismus and do you recommend any mandatory reading sources for Pediatric Ophthalmology & Strabismus ?

have read a few additional text books that are mandatory for POS by the time they complete their fellowship.

Dr. Rohit Saxena The best way to grasp nuances is by observation and discussion with the seniors. Good knowledge of the basics is a must, but certain decision-making points do come from experience alone. The mandatory books are Binocular Vision and Ocular Motility- Theory and Management of Strabismus by Gunter K. von Noorden and Clinical Strabismus Management: Principles and Surgical Techniques by Arthur Rosenbaum.

Dr. Sowmya R Best way to learn the subject is by reading, observing and applying what has been learnt on day to day basis. When things are repeatedly done, it becomes a habit; that is what is used in evaluation of every case where the resident notes down all the examination findings in order and eventually learns not to forget any tests to be done for cases

What is the best way to grasp the nuances of Pediatric Ophthalmology & Strabismus and do you recommend any mandatory reading sources for Pediatric Ophthalmology & Strabismus ?

Some of the must reads include Strabismus books by Rosenbaum, Kushner, Von Noorden, Kenneth Wright and so on. Pediatric Ophthalmology by Taylor and Hoyt, Kenneth Wright, Pediatric neuroophthalmology by Brodsky are important. Reading articles of relevant topics is very important for better understanding.

Dr. Sumita Agarkar There is a recommended reading list which is provided at the beginning of fellowship. All reputed journals are available to the fellows. They are expected to present one article during weekly journal club. Still the best way to learn the nuances is to examine the patients and to have the curiosity to get the bottom of a problem .

Apart from theoretical knowledge, fellow's ability to think and adapt during surgery case, decision making and technical dexterity play an important role. How do you go about teaching these?

Dr. Damaris Magdalene Hands on training equally plays an important role in acquiring the skills apart from observation. More the hands on experience more will be the fellow s ability to judge the situation and take desired decision for the same.

Dr. Jan-Tjeerd de Faber As a fellow in my fellowship programme, you are able to scrub in and do muscle surgery yourself under direct supervision of me or Martha Jone, my partner. Depending on how much surgical experience you have we take you by the hand and teach you strabismus surgery step by step and since surgery is first of its kind of surgery, our residents do, we are very well aware that sometimes fellows have little experience in surgery and you have simply learnt the basic steps and after a couple of surgeries I have quite a good impression on how the surgical skills are and discuss in all honesty with the fellows to increase the quality of surgical skills.

Apart from theoretical knowledge, fellow's ability to think and adapt during surgery case, decision making and technical dexterity play an important role. How do you go about teaching these?

Dr. Jon Peiter Saunte In teaching the deep understanding of strabismus the fellows role in the OR is to make a summary of the full patient history, symptoms, findings and surgical plan on a whiteboard on the wall in the OR. Before the surgery begins, the fellow and consultant discusses the case and after the mandatory forced duction test performed under general anesthesia, a final plan is written on the whiteboard. Here the fellow is encouraged to propose surgical plans and discuss different surgical options with pros and cons, thus presenting demonstrate theoretical skills allowing for a discussion of deviation, torsion, choice of muscle and dosage etc. The fellow will see the surgical patient next morning together with the consultant to see if the chosen plan worked properly.

Dr. Kalpana Narendran This is mostly done one - on - one with their mentors and also we have lectures and case discussions. It is a learning process every day. Whenever there is a rare/interesting case, the fellows get to see them and we have discussions. In the OR, when they spend time with the consultant, they learn about decision making, managing complications, communicating and dealing with the parents.

Apart from theoretical knowledge, fellow's ability to think and adapt during surgery case, decision making and technical dexterity play an important role. How do you go about teaching these?

Dr. R. Krishnaprasad Operating room skills involve pre-operative decision making, making changes in the operating technique on the table as per the situation, adapting to the challenges which are thrown in during surgery and immediate post-surgical amendments in each case. These are best taught when they are involved actively in each step which allows than to reflect on such or scenarios and prepare them for practice.

Dr. Ramesh Kekunnaya Each case is analysed and discussed in detail in the OR. Fellows are made to note down their surgical plan prior to the surgery. All of their surgeries are recorded & discussed post-operatively & positive criticism is offered (should the need arise). Initially a few surgeries are supervised by faculty, after which fellows are allowed to operate independently when consultants feel they are capable enough. Even in the clinic, fellows are encouraged to decide a treatment plan post a thorough patient work-up. Consultants then modify the same wherever required. These case interactions are a source of continuous training for them. Some consultants even give fellows instant feedback on their plan and let them know how &where they went wrong, etc. Fellows are also expected to maintain a log book where they note down 2-3 important cases or surgeries on that particular

Apart from theoretical knowledge, fellow's ability to think and adapt during surgery case, decision making and technical dexterity play an important role. How do you go about teaching these?

day. They do that day s reading based on the cases they have seen in the OR / OPD.

Dr. Rohit Saxena The ability to think, adapt and nuances in decision making can be developed only by working up a large number of cases and actively discussing with the senior faculty about the decisions taken by them and the rationality behind it. Technical dexterity and surgical techniques can be mastered by assisting the senior faculty and also practicing in the skills lab with goat s eye. Fellows are encouraged to assess each case operated by them and also record surgical videos and critique them. Their surgical videos are discussed in a group so that all fellows can be involved in the discussion.

Dr. Sowmya R Observation with a keen mind is the key to learning. I stress that on my residents everyday. Asking them to substantiate the diagnosis they have arrived at by ruling out other possibilities improves clinical acumen significantly and get a wider perspective. Ask them to be likes Sherlock Holmes, where each symptom/sign acts as a clue and should fit towards diagnosing the culprit (diagnosis) differential diagnosis always. In OR, discuss the various surgical plans for the particular case, and during surgery tell them why you did it differently. Finally, dissect entire surgery /steps to improve their

Apart from theoretical knowledge, fellow's ability to think and adapt during surgery case, decision making and technical dexterity play an important role. How do you go about teaching these?

understanding. Record surgery and analyse the surgical steps in difficult cases.

Dr. Sumita Agarkar Eyes can t see what mind does not know - so theoretical knowledge is essential but it must be complemented with clinical work. There is no substitute to the daily grind of examining and advising patients. I believe learning happens when you have to examine and advise a patient. Surgery requires practice, you do get better as you do more. Independent surgery is good but it is better if there is a mentor to refine your steps to give helpful hints which are not in books. As fellows we tend to ignore importance of doing steps but that gives an opportunity to perfect your steps. It is not enough to do rhexis, it should be round and adequately sized that comes with practice and observing. So I think fellows shouldn t feel disheartened if they don t get opportunity to do full case independently. Same goes for strabismus where skill and expertise lies in decision making more than surgery. Can you teach innovation, adaptability, quick thinking? - it is something innate and some are obviously better than others . Innovative and ambitious fellows who think outside the box need lot more patience and nurturing as they challenge authority but it is totally worth it.

Is there a magic number for surgeries and procedures to declare that a fellow is competent to deal in pediatric cataract or strabismus? Are there any other yardsticks you use to assess surgical competence of your fellows?

Dr. Damaris Magdalene No, as it varies between residents. One may master fast while another can be a slow learner, so setting a magic number is not always wise. Learning surgery in a step wise manner helps.

Dr. Jan-Tjeerd de Faber In our residency programme, we say that the residents need to do between 20-30 procedures in order to become general ophthalmologists in our country and of my fellows I ask a little bit more than those numbers. But it s like a driver s license, in our country you take lessons, you pass the examination you get your driver s license, as is in ophthalmology you become a general ophthalmologist. In order to become a Pediatric Ophthalmologist you will need more time and cases to get good surgical skills, especially in strabismus and the surgery is not that complicated, but it s the indication. So which muscle and how many millimeters should you do in a certain patient? Pediatric cataract takes a long time to get skilled. I myself learnt this in about 2 years. I was already a skilled cataract surgeon before I started to do pediatric cases. In these difficult congenital cataract cases, you need a good mentor and you cannot learn that in 3 months, you need more time.

Dr. Jon Peiter Saunte In strabismus surgery the first 50 surgeries may seem difficult, and after 500 surgeries the fellow rarely needs more assistance. But during the training and also later if needed the surgeon performing strabismus surgery will always have a backup, and then a consultant will join the OR within minutes.

Dr. Kalpana Narendran There is no magic number but they would definitely need a number of cases to become competent. Unlike in adult surgeries, the learning curve will have to be short as we do not have a big number as in adult cases. The surgical training is done one on one with a senior fellow/ consultant standing next to them, guiding and if needed, to take over. The surgical competence is assessed based on their decision making, the number of complications, outcomes, and the way they are handling the situation. The Log Book will help to monitor the surgical competence.

Dr. R. Krishnaprasad There are No magic numbers ! Though the confidence of the Fellow and the surgical safety needs a certain minimum surgical exposure and hands on training,

each student has a different need to achieve this goal. If the fellow who gets into the fellowship already has adequate surgical skills and tissue handling, then it is easy to scale them up to a better position, giving surgical steps early in the training itself. OSCAR is a good objective assessment however the overall impression the mentors is more important.

Dr. Ramesh Kekunnaya Generally, after 6 months of basic training, most fellows are comfortable & have operated on at least 10-15 cases each of strabismus and pediatric cataract. This number however varies with individual fellows. Feedback at each step from various faculty, tissue handling, pre-operative assessment, post or even intra- op complications, analysis of surgical video recordings and even their post-operative outcomes are used as yardstick to assess the surgical competence of each fellow.

Dr. Rohit Saxena There is no magic number for the number of surgeries or procedures. It depends on each fellow individually. More than the number of surgeries the key focus should be the surgical outcome of a case operated by the fellow. Also we evaluate their surgical technique either while they are performing the surgery or review the live recorded videos. This not only helps to assess surgical competence but also gives a feedback for improvement.

Dr. Sowmya R There is no magical number for competency to be reached. Infact, I strongly believe that understanding concepts and doing it rightly under supervision in few cases does wonders than mechanically doing many cases. Keen observation of mentors furthers understanding and improving skills. Encourage the residents to record and critically analyse their own cases to learn further. Recently implemented OSCAR grading system by ICO for assessing surgical skills in both pediatric cataract and strabismus.

Dr. Sumita Agarkar At the end of day ophthalmology is a surgical branch and like all surgery, the more you do the better you are. So while numbers don t tell everything, they are important! More than the numbers, at the end of the training, mentor should feel confident that the fellow will be able to tackle everything routine, and most of the rare, out of the ordinary situations.

What qualities do you value most in your fellows? What sets an extraordinary fellow apart from the rest?

Dr. Damaris Magdalene A good doctor should be honest, humble, reliable, punctual, knowledgeable and teachable. These qualities set a student apart from the rest.

Dr. Jan-Tjeerd de Faber I think what I value in my fellows is that they have real interest in Pediatric Ophthalmology and Strabismus, which is quite rare because normally <5% of our residents are interested in pursuing a career in that subspeciality. If you leave your country and family in order to do fellowship abroad, that s a sacrifice but that will certainly pay off in your future career specially pediatric ophthalmology can be very rewarding. The emotional side of our sub-speciality, happy patients and very grateful parents is a reward you will get. This is one of the best feelings you can get in your career. An extraordinary fellow, I think it s the combination of good brains and good dexterity in your hands and your heart at the right place. You are emotionally prepared to give 400% of dedication and devotion to make your patients see as best as they can, as straight as they can.

What qualities do you value most in your fellows? What sets an extraordinary fellow apart from the rest?

Dr. Jon Peiter Saunte A fellow must be humble and willing to study and practice to achieve the needed skills. Accuracy in measurements are important if to be able to make clever conclusions. And the young surgeons are warned that all surgery harbors a risk of complications it is better to prepare for the first complication to occur instead of worrying if complications occur because they do! The extraordinary fellow is prepared ahead of time and has studied the cases the day before surgery and has excellent surgical skills. The fellow should also be a team player to be able to work well with nurses, orthoptists and other doctors.

Dr. Kalpana Narendran A fellow who takes responsibility and who is committed, hardworking and empathetic is the most valued fellow

Dr. R. Krishnaprasad Clinical acumen, good procedural skills, safe surgical hands and an excellent communication skills are the most valued qualities in a student. If these qualities are available with empathy, enthusiasm to learn and

What qualities do you value most in your fellows? What sets an extraordinary fellow apart from the rest?

commitment to achieve more, then that is an extraordinary student, and every teacher s dream!

Dr. Ramesh Kekunnaya A fellow with good attitude, honesty and discipline in his /her role, irrespective of the kind of exposure / experiences during residency / post-graduation, helps a person climb higher personally and professionally. With the above qualities, an ordinary fellow becomes extraordinary in all aspects of fellowship. Just intelligence is not good enough. The fellows behavior should remain unchanged whether or not he / she is being observed by his/her faculty. This sets a fellow apart and he/ she who has these qualities will invariably do well in life.

Dr. Rohit Saxena In pediatric ophthalmology, interest, patience and willingness to learn are most important values. A fellow willing to learn, question, analyse and constantly seek answers will always stand apart from the rest.

What qualities do you value most in your fellows? What sets an extraordinary fellow apart from the rest?

Dr. Sowmya R Qualities most valuable in any residents are sincerity, dedication and eagerness to learn and consider their mentors as co travellers with experience in the journey towards higher knowledge and better understanding of the subject. Extraordinary people are ones who do ordinary things with passion. Residents who don t lose the enthusiasm and become casual and retain the eagerness to learn till the end are extraordinary in my view.

Dr. Sumita Agarkar The quality that I trust most in fellows is empathy towards children in terms of long term care, reliability in terms of clinical skills and dogged determination to explain the clinical findings. Fellows who question and challenge you as a mentor are the best kinds because they force you to think and in turn make you better.

You must be faced with situations where fellows do not follow instructions or fail to keep up with deadlines for projects that a mentor has assigned. How do you deal with such a fellow?

Dr. Damaris Magdalene Repeated failing to follow instructions needs admonition. But before that a fellow needs to be counselled.

Dr. Jan-Tjeerd de Faber I am a father and a parent and it s like your children you have to raise and this can be successful sometimes, also this can be disappointing because a fellow and the mentor are in a professional situation and one can be honest to each other. If a fellow is not performing like he should do, I will correct him immediately especially during surgery or in order to keep them with deadlines that s the same thing I would do to a resident or a colleague. You have to deliver what is promised and that s the way for a fellow but also for me as a mentor.

Dr. Jon Peiter Saunte If the fellow fails to perform as expected, a serious talk may be needed and when focusing on how to reach a goal or specific result it is often possible to help the fellow to be able to succeed. If a fellow fails to complete assignments and tasks, it may not be possible to sign the approval document after training.

You must be faced with situations where fellows do not follow instructions or fail to keep up with deadlines for projects that a mentor has assigned. How do you deal with such a fellow?

Dr. Kalpana Narendran We rarely get into such situations because we make sure we select the right person. If one deviates, we can call them and counsel them and try to address their problems. Most of the time, when we get to sit with them and talk to them, they fall in line.

Dr. R. Krishnaprasad Our institution is less strung-out compared many other Institutes of repute, in dealing with problem students. The Fellows are responsible adults in whom self-discipline is more important than Institutional discipline. The training opportunities cannot be curtailed in view of their short comings. It is easy to be good, but difficult to be fair!

Dr. Ramesh Kekunnaya We assess their overall performance regularly & also take into account their attitude while scoring them. We undertake a staged approach for this. If someone is not doing well, we have personal discussions and suggest time driven rectification actions. Should they still underperform, we have another discussion, post

You must be faced with situations where fellows do not follow instructions or fail to keep up with deadlines for projects that a mentor has assigned. How do you deal with such a fellow?

which serious action is taken if required. Feedback taken from all faculty, their co-fellows / residents, OPD and OR staff, etc. is regularly compiled & analysed. If projects are not completed on time, the project is handed over to the next fellow and the underperforming fellow loses first authorship or even co-authorship on the project if he / she fails to make a significant / has no contribution towards the same.

Dr. Rohit Saxena Most fellows tend to follow instructions and usually one is faced with only minor mistakes. However rarely one is faced with a difficult situation. To prevent such an occurrence, a carrot and stick policy from the start is must. You must reward the hardworking and enthusiastic fellow and penalize the negligent. However an attempt must always be made to engage and try to understand the mentality and reasons for the behavior. Despite this, repeated and intentional mistakes must be reprimanded.

You must be faced with situations where fellows do not follow instructions or fail to keep up with deadlines for projects that a mentor has assigned. How do you deal with such a fellow?

Dr. Sowmya R Difficult one to answer. Dealing with residents who fail in one or more ways according to their personality and ability to understand. Some residents respond to positive reinforcements and appreciation and some need negative reinforcements to make them achieve. I try to keep up the deadlines myself for them to see and emulate. Finally, as they grow to be better residents, I believe, in the process, I also become a better teacher/ mentor with every mentee/ resident.

Dr. Sumita Agarkar This is a difficult question to answer as most of the fellows are adults but counseling works most of the time. Sometimes disciplinary action is required. It is unenviable but necessary task which must be undertaken.

At the end of the tenure, on what benchmarks do you define a successful Pediatric Ophthalmology & Strabismus fellowship?

Dr. Damaris Magdalene Completion of Pediatric Ophthalmology and Strabismus fellowship is just the beginning and as the proverb goes well begun is half done and definition of successful has a long journey ahead in one s career.

Dr. Jan-Tjeerd de Faber I think when a fellow really enjoys what he/she has learnt during the fellowship, that defines success. Especially if you see that the learning curve is steep, that always gives me rewarding feeling that the fellowship has been successful. Although 3 months is a short time but you can learn a lot in 3 months especially when you have a hands on surgery which is quite rare in the world, I have realized a couple years ago.

At the end of the tenure, on what benchmarks do you define a successful Pediatric Ophthalmology & Strabismus fellowship?

Dr. Jon Peiter Saunte At the end of the tenure, the Pedstrab fellow will have a sufficient theoretical overview of the possible patients they meet, and will have surgical skills where they can work independently in other departments. The skilled Pedstrab fellow will also be able to see red flags in this field and also reject surgery where not applicable.

Dr. Kalpana Narendran The benchmarks to consider would be: 1. Knowledge & Clinical Acumen 2. Surgical Skills 3. Team Player 4. Pleasant 5. Communicative (As a paediatric ophthalmologist, it is the parents who need to be convinced) 6. Decision Making 7. Conservative (Deviating from procedures which are time-tested)

Dr. R. Krishnaprasad Confidence in examination, diagnosis, planning, and surgery of the usual cases. Also the ability to recognize ones limitations and shortcomings and when to seek help.

At the end of the tenure, on what benchmarks do you define a successful Pediatric Ophthalmology & Strabismus fellowship?

Dr. Ramesh Kekunnaya We do score them on the following aspects: -

Attitude Clinical care Communication with the patients Surgical care Academics: Publications and quality of presentation Teaching ability Caring for the underprivileged

Dr. Rohit Saxena Confidence in examination, diagnosis, planning and surgery of the usual cases. Also the ability to recognize ones limitations and shortcomings and when to seek help.

Dr. Sowmya R Defining successful fellowship is complex. But residents having sound knowledge of subject, been exposed to the wide array of cases simple to complex, performed independent surgeries and learnt to make right decisions as to what and when to do; most importantly what not to do and incorporated ethics into the learning sums it up .

At the end of the tenure, on what benchmarks do you define a successful Pediatric Ophthalmology & Strabismus fellowship?

We do a formal assessment at the end of tenure, both theory and practical exams to evaluate them.

Dr. Sumita Agarkar Clinical skills to examine any child, Analytical thinking, Adequate theoretical knowledge, Mental make up to take up this rewarding but exhausting branch.

If you were to do a fellowship in today's era, how differently would you approach it?

Dr. Damaris Magdalene In today s scenario as the technology is advancing, one needs to keep up with its pace along with making sure that one s basic core knowledge is strong. A very honest and sincere effort towards learning would be my approach as Pediatric ophthalmology has a very strong impact on a child s development.

Dr. Jan-Tjeerd de Faber I did my fellowship with Norton in the years 19901991. I would do the fellowship immediately over again. So I was very happy that I was able to do a fellowship with him, it opened many doors which I never knew existed. But because he was the writer of the Bible of Strabismus and Binocular vision. So he was a very renowned teacher, scholar and publisher of many many articles and also a very skilled clinician. So I would do it again. But what I also would add is that I would certainly visit some other clinics and the only clinic in which I was trained outside of the Netherlands, in Houston, Texas. I would have liked to spend several months in different continents with crĂ¨me de la crĂ¨me Strabismus surgeons at that time.

At the end of the tenure, on what benchmarks do you define a successful Pediatric Ophthalmology & Strabismus fellowship?

Dr. Jon Peiter Saunte If I was to do a fellowship in todays era, I would insist on having a senior surgeon by my side for the first many cases in the OR to ensure the patients receive the best treatment also from young fellows and also to reduce the stress a young surgeon may experience in difficult surgical cases.

Dr. Kalpana Narendran In today s era, the understanding of the subject is a lot better with the different learning media that are available. So, it is easy to understand and learning is faster.

Dr. R. Krishnaprasad If I am a fresh post graduate entering a fellowship, I would do several observer ships in various institutions to set up a benchmark for myself and to determine my training goals. I would do some research on various fellowship options to decide the place of fellowship. I would definitely hone my surgical skills with a short term training, so that I am ready for the big occasion.

At the end of the tenure, on what benchmarks do you define a successful Pediatric Ophthalmology & Strabismus fellowship?

Dr. Ramesh Kekunnaya Today s fellows are much more privileged than us. Availability of technology can be a boon as well as a bane. Unfortunately, electronic gadget scan be a major distraction that fellows in today s day & age have easy access to. Most fellows crave instant gratifications& are rewarded via the numerous social media platforms available today. Current fellows need to curb this desire to be on their mobile phones and social media all the time. I would recommend learning to strike a balance & using the available technology appropriately. This can be done by maximising online education material for better patient care. If an individual is passionate, a lot can be achieved in this time& /era. Compassionate care is the need of the hour.

Dr. Rohit Saxena I have always valued my 3 years of training at R P Centre and I would not exchange those years for anything. However with the increased access to online teaching and research material and the availability of excellent videos, learning would be faster and much more fun.

At the end of the tenure, on what benchmarks do you define a successful Pediatric Ophthalmology & Strabismus fellowship?

Dr. Sowmya R If were to do a fellowship in today s era, I would probably be bold enough to ask more questions to my mentors, use the enormous amount of easily available online resource materials to a greater advantage and document in detail every case I observed on daily basis with my mentor.

Dr. Sumita Agarkar If I were to do fellowship again I would arm myself with more knowledge of biostatistics and basic sciences as cutting edge cures are going to come from those areas. Surgeons will most likely be replaced by robots and AI! Very few residency/ fellowship programs pay attention on publishing and critical analysis of evidence. I think we should learn and teach to document and analyze data more effectively. We have wealth of patients, data and skills unmatched anywhere in the world, but we still don t publish enough. So if I were a fellow again I wouldn t obsess about my surgical numbers as much as I did back in 1997.

Final word or any other comment?

Dr. Damaris Magdalene Childhood blindness is one of the priorities in Vision 2020: the Right to Sight. The problems affecting children are different from those that affect adults, and managing them requires teams with specialized skills serving in well-equipped Pediatric Ophthalmology service centers. As per the World Health Organization, we need one of these centers for every 10 million people, with at least one specialty trained or oriented ophthalmologist available. We need to see budding ophthalmologist going to Pediatric ophthalmology fellowship with passion to reduce the burden of blindness as these young children will be the future of India.

Dr. Jan-Tjeerd de Faber I would like to add that Pediatric Ophthalmology and Strabismus subspeciality, I think, is one of the most rewarding subspecialitis. If I look back to my career. I operated on many babies who became teenagers, and now are adults. Some of them I still see back and see how well they are doing despite the handicap of one amblyopia eye and B/L subnormal vision and they pursue successful career despite their disability. I feel grateful that I could make the difference for these children, specially, the hereditary diseases. If I would have to make the choice again I d go for the same subspeciality. I d do the same thing 100%. Thank You!

Final word or any other comment?

Dr. Jon Peiter Saunte My aim for all my fellows is to try to pass on as much as possible of my own theoretical and practical knowlegde and to share as many surgical cowboy tricks as possible with my fellows. The ultimate goal is that the fellows one day will be even better surgeons and clinicians than myself!

Dr. Kalpana Narendran To conclude, Paediatric Ophthalmology & Strabismus fellowship is definitely a good choice, provided we have a good team (anaesthetist). One happy patient is our patient for a lifetime. It gives a lot of satisfaction, when we make these kids see and they follow up with us for many years. It is very gratifying.

Dr. R. Krishnaprasad I strongly feel that we have to create better pan ophthalmologists today with a speciality training. The sub optional training and the clinical inadequacies of PG training are getting validated by a fellowship training which follows it immediately! Too

Final word or any other comment?

much of super specialization is a bane and can be a disservice to ophthalmic practice.

Dr. Ramesh Kekunnaya There are a lot of responsibilities on an Ophthalmologist to make children s eye care better in our country. I hope many residents take on the opportunities of various POS Fellowship programs available across the country and make a difference in children s lives.

Dr. Rohit Saxena Pediatric Ophthalmology and Strabismus has really evolved in the past decade or so and our understanding in this field is growing exponentially. These are exciting times to be in this specialty and practicing it is extremely enjoyable and satisfying. There are a lot of opportunities for research and at present there are not many experts in the field. This is the right time to pick it up as your USP and if you enjoy what you do, work is always a pleasure.

Final word or any other comment?

Dr. Sowmya R Pediatric Ophthalmology and Strabismus combines two beautiful subjects; dealing with kids needs lot of patience and creativity while strabismus demands logic and analytical skills. The precision it demands, inevitable unpredictability brings in humility and inner urge to get better with every child we treat. Touching lives and eyes of children is worth all the efforts and more.

Dr. Sumita Agarkar I strongly believe the generation of young ophthalmologists who are in training now, are confident, smarter and have a better skill set and knowledge than my generation .

Strabismology: A Fright or Delight Considering the demand for Pediatric Ophthalmology and Strabismus services, there is an immense need of Ophthalmologists skilled in this sub-specialty. But there is a general lack of interest in this sub-specialty and Strabismology in particular. In my more than 12 years of teaching experience, I observed that my residents and juniors appeared to have a histamine surge the moment I wanted to show them a strabismus case and they used to disappear from the clinic. This article is to analyze Why such repulsion for strabismology exists?

Why one should choose a carrier in Strabismology? As Ophthalmologists, we know that straight eyes and binocularity is of immense importance in the visual and overall development of a child. Due to lack of adequate number of skilled Strabismologists, most of the strabismic children are deprived of timely care leading to permanent visual impairments in the form of amblyopia and loss of binocularity. Even in adults, strabismus correction is not merely an aesthetic procedure but a reconstructive one to get rid of professional and psychosocial barriers. In this scenario, the Young Ophthalmologists can play a great role in shaping lives of children with disorders of binocularity as well as changing lives of adult strabismic patients.

Some of the lives that we could change

Social acceptance

Lost Job regained

Instant relief from Diplopia

Stereopsis achieved

N.B. All pictures have been published with written Consent of the Patients or the Parents.

What is the cause of such lack of interest? Our existing postgraduate curriculum is mostly cataract oriented and due emphasis is not given on approach to a patient with strabismus. This in turn causes lack of knowledge among general ophthalmologist about timely intervention in strabismus and consequent failure in referral to Strabismologists. There are only few Institutions in India who offer structured fellowship courses in Pediatric Ophthalmology and Strabismus. There is also lack of such structured fellowshipsacross institutes. Lack of mentor and role models for residents have also been reported as a cause of comparatively less interest in this sub-specialty. There is a myth that cataract services are the sole source of revenue for the hospitals. Therefore, there is a generalized lack of interest among corporate and private hospitals in investing for setting up a specialized Squint clinic. This fact discourages the practicing Pediatric Ophthalmologists and Squint surgeons from continuing with their carrier as Strabismologists and they restrict themselves to Pediatric Cataract only.

What are the possible solutions? There should be an increased importance of Strabismology in the post graduate curriculum. Social awareness about strabismus and its ill effects to improve the care seeking behavior of the patients and their family. Frequent interdisciplinary CMEs may be organized to raise awareness among General Ophthalmologists, Pediatricians, Physicians and Neurologists who may be the first point of contact with a strabismus patient. Adequate social marketing through services and group meetings with Parents, School teachers, Special Educators, Optometrists, Health workers may help significantly in raising social awareness. To advocate about the indispensability of a Strabismus set up in every eye hospital and the potential of revenue earning from the services to the private and corporate hospital may improve the situation of Strabismology practice in India and will inspire more and more Young Ophthalmologists to take up the sub-specialty.

A few lines of encouragement for the Young Ophthalmologists from my side as a practicing Pediatric Ophthalmologist and Strabismus Surgeon

o There are immense developments in the field of Strabismology worldwide. This opens avenues for Research and Innovation. o Strabismology is no more restricted to evaluation and surgical correction of squint, it now encompasses modern sophisticated approaches and changing concept of binocular vision science.

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o The initial investment for setting up a Strabismology department is not too high and is very much doable. Make yourself and your management understand the need and benefits of setting up a strabismus clinic in every eye hospital. o There are State of the Art Institutes (though not in large numbers) like Aravind Eye Hospital, Sankara Nethralaya and LVPEI etc. who have wellstructured Pediatric Ophthalmology and Strabismus fellowships offering Strabismology training from basic to advanced.

So, why to hesitate? Be a leader and choose this challenging career. Because challenges make life interesting !!

-Dr. Chandni Chakraborty

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Dr. Chandni Chakraborty (MBBS, MS) was trained in Pediatric Ophthalmology and Strabismus at Aravind Eye Hospital, Madurai. She is presently working as Director,PanVision Eye Clinic, Kolkata, Director, RSMA Institute of Ophthalmic Education& Research, Haldia and Consultant Pediatric Ophthalmologist at AMRI,HMDEF and Drishti Eye care Centre, Kolkata. She previously worked as a Senior Consultant in Deptt of Pediatric Ophthalmology and Strabismus, VMANNN, Chaitanyapur and InCharge VMA Institute of Ophthalmic Training till 2018. Dr. Chakraborty presented Papers, Posters, Videos and Instruction Courses in several State, National and International conferences and also published in State and International Journals. She is a member of OSWB, EIZOC, SPOSI, AIOS, ISA(International Strabismological Association),WSPOS. Fighting against Childhood Blindness and Ophthalmic Teaching are her two passions. e-mail: chandnimimi73@gmail.com

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CHILD AT CLINIC VS CHILD AT HOMEA (NOT SO) YOUNG PEDIATRIC OPHTHALMOLOGIST S PERSPECTIVE

In the current era, the number of women in Ophthalmology has gone from one to some to many. In the past 10 years, more than half of our postgraduates have been women and many more have pursued fellowship in various departments. In WIO news, Dr. Linda reflects a higher global percentage of women in certain specialties, Pediatric Ophthalmology being one amongst them. It can be explained by a simple explanation that many female ophthalmologists are unafraid of showing emotions and if a child s parents needs to communicate on emotional level, it seems more likely to occur with female doctors.

As a pediatric ophthalmologist, our set of patients are more after 3 PM (children are off school then), on Saturdays, Sundays and on holidays, the same time of year when our children need us too! So the natural question which follows is As a Pediatric Ophthalmologist and a mother of two daughters, have I ever felt I cater needs of other children more than my own?

At some point in the last three decades, the clock has become the measure for judging parental performance. How much time do you spend with your kids? The more you spend, the better the mother you are. BUT M

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In that context, the truth I uncovered is even more astonishing. Rather than spending less time with my kids, the guilt which this question gave me 3-4 years back actually made me spend more TOTAL QUALITY TIME with my children than ever before. By total quality time , I mean it includes moments like when I am doing laundry or cooking, I prefer my kids around interacting with me continuously throughout my chores. When you look at time spent interacting with them in any form having a chat with kids, reading them to bed, stories at dinner time we find that we working mothers spend as much time as stay-at-home mothers do.

Living with a toddler is like living with an irrational angry drunk person. The patience and the tricks of managing cranky and irritable children that I had picked up during my fellowship and my practice made me develop a better temperament than mothers around me. I rarely remember losing my frame of mind even when my children threw their worst fit of rage.

Pediatric Ophthalmology is not just eye and kids ; we are exposed to a spectrum of pediatric conditions such as cerebral palsy, cardiac anomalies, muscular dystrophy and the list goes on and on. We get a holistic experience about a child s health. This definitely made me better informed about my children s health. I have never missed her immunization, dentist appointment or for that matter her regular vision evaluation.

Flips always do exist. There are days when I have tearfully left my kids with fever of 102 degrees and vomiting at home to attend a child with emergency at workplace. That is the time when my better half chips in to compensate for my deficiency. I do agree that I have never spent whole vacation with my children, but I make sure that they have their share of vacations with me once the season is off at clinic.

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It is all about priorities which is unique to each person. We must always remember that the loyalty displayed by our patients towards us will never be eternally stable and consistent. We definitely owe more to our children. But it wouldn t be complete if I don t add thatBeing a mother has made me a better Pediatric Ophthalmologist and being a Pediatric Ophthalmologist has made me a better Mother.

To sum it up, it s quality of time that matters, not quantity. When we are burning out, but still force ourselves to spend time with our kids, that is actually bad for our kids. Let s give ourselves a break from all the worry. After all, we are spending more quality time with our kids than ever.

Maybe once in a while less is more !!!

-Dr. Deepti Joshi

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Dr. Deepti Joshi (MBBS, MS) is currently working as a Consultant in Department of Pediatric Ophthalmology and Strabismus in M M Joshi Eye Institute, Hubli. She completed her double fellowship in Pediatric Ophthalmology and Strabismus from Sick Kids Hospital, Toronto and M M Joshi Eye Institute, Hubli. Dr. Joshi is a Member of the Strabismus and pediatric Ophthalmology society of India (SPOSI), All India Ophthalmological society (AIOS), Karnataka Ophthalmological Society (KOS) and Hubli Dharwad Ophthalmological Association (HDOA). She has presented numerous papers/posters at national and international conferences, delivered invited talks and instruction courses. Dr. Joshi has 5 in international peer reviewed journals. Dr. Joshi holds a Gold Medal for being university topper in MS Ophthalmology at Rajiv Gandhi university Of Health Sciences. She also received Best PostGraduate Award for the PG forum presentation in KOS conference 2010 and Best squint paper s got talent award at Karnataka Ophthalmic Conference 2018, Mangalore for best scientific paper. Apart from being a great Pediatric ophthalmologists, Dr. Joshi is a trained Classical dancer. She is invoved groupactively involved in educating school teachers and students against child sexual abuse. She was also a part of training 2000 school teachers for educating students against child sexual abuse, the activity being enrolled in Limca book of World Records.

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How to set up a successful Pediatric Ophthalmology Practice Success is never final and failure is never fatal, it is the courage that counts

as quoted byJohn Wooden is an apt quote to

think of pediatric eye care practice. It is very important to have self-belief and the understanding that success comes to those who start and sustain. Medicine in India fortunately is now turning towards specialization and into niche practice. For Pediatric Ophthalmologist, at this point of time there are two distinct advantages: First, it is still a kind of monopoly practice or niche practice with very few people practicing the subject. Second, the number of young children in India is high in contrast to the western countries. Setting up a pediatric practice is a life long journey because Believe it or not Pediatric Ophthalmology is actually Comprehensive Ophthalmology inclusive of children of all ages as well as adults with strabismus.

Children are not small adults!! We often tend to miss out on the various aspects of Pediatrics like the growth, psychology, co-operation, compliance and most importantly the dependency of these children. They do not complain directly but have indirect signs very much unlike the adults. Setting up the whole practice requires: a. b. c. d.

Promotion: Marketing and advertising Placement: Setting up the clinic proper Price model: Increasing the practice/ Increasing the revenue Propogate: Updating and helping others

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It is very encouraging to see that the younger generation actually takes marketing very seriously. Marketing is any activity that moves your practice in a desired direction. Various purposes for marketing would include increasing income, deterring new competitors, retaining market share, shifting payer patterns, introducing new services, recruiting new providers, entering new marketplaces or combating negative publicity.

Make Your Own Marketing Plan The first and most important part of a marketing plan is the goal, as it is a foundation for all the other decisions. First, develop your five-year goals, since your one-year goals should fit within the context of your five-year plan. Different practices have different business plans and as such should have different marketing goals. Make a goal for a. b. c. d. e. f.

Number of patients for first month, first year and coming years Number of surgeries for first month and likewise Find out your target people like from where you can get patients Who would refer you the patients Why should they sent you the patients How would you handle these patients and the load

Demonstrate Availability, Affability and Ability. That old clichĂŠ what makes a successful practice still holds true. Scheduling should be the most important aspect of your practice as your patients are busy and require convenience. Make sure your staff interacts with your patients in a friendly and pleasant way. Address the patient by name. Make an effort to engage the patient in light conversation. Ask patients about their kids, work/school or the weather.

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Meet people from allied branches like Pediatrics and Visual Rehabilitation centres, who can refer you patients. But remember, compensating for referrals is illegal, so avoid it early in practice. Online platform is a great forum to share educative materials and it is one of the best ways to reach the public directly. The strategy is to build a Web site that reflects the office brochure and patient-education materials, so that it serves as a destination-point for local patients in the process of making a choice among physicians. Make sure that your Web address appears on print, ad and media materials to increase your visibility among ophthalmologists and potential patients. Minimal listing information of your practice should appear in all the appropriate categories of various publications, including the local phone book, ophthalmic directories, physician-listing services and perhaps the local paper. Consider using name-stickers with black ink on a clear background, rather than ink-stamps that may smear. Free-standing office sign is also one of the most effective marketing investments, if the location allows it. Changing the size, shape and/or color will attract more attention. You may get new walk-in patient asking, "I just saw your sign, how long have you been here?" In case external signage is prohibited, you might consider a huge clock with the words around the edge, "Time to have your eyes checked?" that would become a local landmark people glance at regularly as they pass.

Setting up the practice The first thing that comes to your mind is whether you should buy into an established practice, start your own from scratch or go in with a partner? Buying into a business gives you an established base of patients who regularly get their eyes checked or are already coming to the office for other eye-related problems. This means you can rely on these patients to generate income immediately. However, if you start a practice of your own or with a partner, you need to heavily market to find patients who have eye problems or need to find an eye doctor, an endeavor that takes lots of time, marketing and money.

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Choose a location near a busy mall or other high traffic area to help your office get noticed. You need enough space for a waiting room, office administration, an exam room, room for equipment and a place for your technicians to work. Waiting area should be bigger with comfortable seatings to accomodate children and their wards/guardians. It should be Child friendly to impress upon the parents that your clinic solely caters to children and that they have done a right thing by choosing you. Choose pertinent Equipments to start your practice. Vision charts preferably should be computerized so that the various charts like single optotypes, Lea symbols and others are incorporated in single chart. Orthoptics and active vision therapy are integral parts of pediatric ophthalmology practice and also a great source of revenue. Spectacle frames for children are not available at all the optical shops because they cater mainly to adults, so a pediatric ophthalmology clinic can benefit from a large inventory of pediatric frames. One should also keep eye patches in the clinic apart from arm restrainers, cheiroscopes etc. as none of the counterparts would be keeping them. Hire Staff: As a start-up, you can have a front office staff member to take appointments, greet patients and handle insurance claims. Apart from this you need two OT technicians and an optometrist. It would appear as a luxury in the initial practice but as the practice soars, an optometrist would be needed.

Increasing the practice/ Increasing the revenue Grow with colleagues: If you are in a city which already has few pediatric ophthalmologists, join the group. Never try to reduce the cost of the service by thinking that if you sell yourselves cheap it would help you. We should be grateful to previous pediatric ophthalmologist as we don t have to do the ground work of establishing or changing the mindset. We can start from the word go as most of

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the people would know who a pediatric ophthalmologist is. As a pediatric ophthalmologist you never compete with each other but you compete with people who do not refer the patients, who operate at lower cost etc. Joining a trust initially may be a good opportunity for work. You must set a goal and leave the job once you feel that you are confident about your work. This is usually around 100 strabismus surgeries. The trust hospitals may give you work but your practice would start the day you start on your own. Commitment to Quality: Focus on providing extraordinary service to patients to increase patient retention and patient referrals. By doing so, you should reduce the need for further marketing cash-expenditures. Think about examples of extraordinary service you have experienced at other businesses and how those behaviors might be applied to your office. Particularly pay attention to how problems and disputes were resolved to your satisfaction. Examples might include resolving billing disputes or handling appointment tardiness that was not the patient's fault.

Updating yourself It is always a good idea to update oneself with the new surgeries and procedures. Try to attend the conferences and take active part in them. One should conduct CMEs around the city and practice area. We need to collaborate with all the medical professionals and let them know about our specialty. Read journals and periodicals and post them in the social media groups about your specialty to make sure eye surgeons, pediatricians are made aware of various new treatment options available. Be comprehensive. A pediatric ophthalmologist must master the ROP screening and should also learn laser for ROP. As these children have life long ocular morbidity, it is fitting that they should be under the care of a Pediatric

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Ophthalmologists right from the beginning. Create a rapport with the pediatricians and neonatologist for better care of these babies. There are no straight forward rules to a successful practice as the parameters of success are variable and different for different people. You can take one step at a time and may gradually build up the practice but most important is to have empathy and care for the patients. Once you start keeping patients as the center point of your practice it automatically takes shape and grows vertically. Be innovative!! Think out of box for a better practice and never settle for being ordinary. Life is not measured by the number of breaths you take but by the number of moments that take your breath away. Pediatric ophthalmology is a branch which gives you ample opportunities to see, observe and grow with children who are under your care.

- Dr. Jitendra Jethani

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Dr. Jitendra Jethani is a leading practitioner at Vadodara. He is the Director of Baroda Children Eye Care and Squint Clinic. He is the Section Editor, Pediatric Ophthalmology, Indian Journal of Ophthalmology. Dr. Jethani was the President of Baroda Ophthalmic Society and Chairman, Scientific Committee of All Gujarat Ophthalmological Society.

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COVID 19: It s Impact on Students: The Future Pillars! The onset of COVID in December 2019 has brought in lot of mixed feelings amongst all of us. Needless to say our students who are the future pillars of our society as well as our profession, have also been deeply affected. If one has to give a deep thought about their situation, then a few thoughts run in my mind that needs consideration and definitely a deeper thought. With the onset of lockdown in the month of March, students suddenly experienced a sudden relief from a hustle life of having to submit thesis, prepare for exams, running behind schedules and targets and balance between personal and professional life. This relief admixed with a sense of joy was of great magnitude to most of the students. The initial transient POSITIVE effects of lockdown that was experienced were: One got lot of free time for eating good food and sleeping well (the best part and stress free activity for most of us), exercising and physical fitness, got to realize that health is important, relish time with family and friends, to relax and replenish, for cultivating or continuing of hobbies, no stress; no targets to be reached; no peer pressure at workplace, feeling of being important by virtue of being a doctor so be of help to family and friends, got time to introspect and, got opportunity to attend online classes and webinars, there was no feeling of detachment from academics because of continuous online classes. Like the other side of a coin, there were some NEGATIVE thoughts experienced during the latter part of COVID lockdown. At professional front: life suddenly became uncertain regarding completion of degree, pursuing future studies (fellowship), inability to learn surgeries, future seemed dark without aim

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and hope, fear of getting infected and infecting others, too many online classes not able to digest all the overwhelming information surge causing anxiety. As regards personal life :unemployment, unable to travel back home especially for students who are staying far from their respective homes and family (home sickness), postponement of marriage, loss of confidence ,insecure feeling, stress, anxiety, helplessness, fear of family members getting affected especially elderly persons, increasing cases of COVID despite taking precautions has made some feel helpless about the current situation, fear to meet friends and relatives, anger towards people not following safety measures, despite the positive inputs from doctors in some places they are treated badly. These mixed feelings are continuing amongst the students and others too. The first thing that COVID taught all of us as a whole is the phrase Lockdown . It also taught us that all targets that we ran behind so far declined to zero all of a sudden; the only target that was always there in front of each one of us but got highlighted during this critical period isto achieve and maintain good health, good nutrition of oneself and our near and dear ones and to love endlessly and selflessly no matter what. This situation also made us realize that life can go on without extravagant shopping, fancy and elaborate outside dinners ,thus making us think about the less privileged people in the society, thereby teaching us the value of money and food. As goes the good old adage: Old is Gold so did COVID teach us that our old, day to day practices like leaving our footwear outside the house, washing our feet and hands before entering the house, practice of Madi in southern India (Madi: pristine state of mind and body; this is a practice of wearing clean clothes, not being touched by anything or anyone, more so while performing an important deed; this ensures calm, peaceful state of mind to perform a deed with complete devotion and concentration. However, unfortunately with passage of time this concept has been diluted and has been misinterpreted in a negative way. Madi has been compared to exactly the way we surgeons wash and wear sterilized gowns in operation theatre before performing a surgery. Social distancing which is being

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emphasized now can be referred to this) etc., are still the gold standard practices to be adopted, if given a detailed thought with due respects. These need to be followed despite the advancement of technology, rather than perceiving it as old fashioned life style. COVID also taught us to look into overhauling of our lives to some extent if not completely, as regards our body, mind and lifestyle despite the fact that we had to lose on time, money and energy. As is the fact There is always light at the end of the dark, long tunnel , we shall hope that all of us will fare well and tide over this dark phase, especially our students the future pillars.

I acknowledge my students, my colleagues and family.

We are miniatures in front of Nature and there is nothing like living healthily, lovingly and peacefully.

-Dr. Kavitha V

Dr. Kavitha V (MBBS; DO; DNB) is a Senior Consultant and Head of the Department, Pediatric Ophthalmology and Strabismus at Sankara Eye Hospital, Shivamogga, Karnataka. She is the Project Director School Screening Programme (Rainbow) and Mentor for the Pediatric Ophthalmology fellowship and cataract and phaco training at Sankara Eye Hospital, Shivamogga. She is also the DNB co-ordinator . Dr. Kavitha has completed her Pediatric Ophthalmology fellowship(2003) from Sankara Eye Hospital, Coimbatore; Strabismus Fellowship (2005) from All India Institute of Medical Sciences, New Delhi, International Council of Ophthalmology (UK)2004 05 and Mch Ophthalmology (2013) from Boolean University (USAIM), Seychelles. Apart from Paper Presentations and invited talks in different State, National and International Conferences, Dr. Kavitha has received the Best Video Award (2008, 2018), Best Paper Award (2011, 2019) at Karnataka State Ophthalmic Conference. 116

The Charm and Challenge of Oculoplastics in Children Oculoplastic surgery is the corrective, reconstructive and cosmetic surgery around the eye. It is with great excitement and pride that I write this edit onPediatric Oculoplastics which has evolved in its own right. It is an exciting and challenging surgical epithet of oculoplastics and in times with the increasing trend towards specialization. Though it has a strong interdisciplinary association but still remains focussed to ophthalmic practice. Career in this branch requires passion and long-term commitment towards interaction with children and treating diseases affecting them. Children have special needs which can`t be communicated. It is demanding because in-depth study and knowledge is required into the differences in anatomical structure, biochemical, physiological and immunological function in children versus the adults. Modern Pediatric Oculoplastics surgery indulges in newer techniques that reduce scarring, improvements in imaging guidance systems for greater safety, newer and safer drugs for conservative treatment and minimally invasive orbital decompressions. It may require inputs and collaborations with Pediatricians, Dermatologists, Plastic surgeons, and Otolaryngologists. All the above and collaborative research which is trend and desirable in modern times, are changing the way this specialty is perceived today. Oculoplastics specific diseases range from simple dermoids to orbital tumors to complex craniofacial disorders to vascular malformations. Oculoplastics in children is the one branch of ophthalmology that gives one the true feel of surgery. The vast variety of surgeries, the feeling of blood on our gloves , and the impact it has on people`s lives is beyond explanation. Pediatric Oculoplastics gives one the ample opportunity of contributing to lives of people at a stage when life just begins. The ordeal a child goes through in school, when his friends feel he is perpetually crying and he is bullied around, when actually the

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poor child has an untreated nasolacrimal duct obstruction, is just an example of how important oculoplastics is to children. Lacrimal apparatus is just one example of the scope of oculoplastics. Imagine a child with congenital ptosis, who is not only being bullied but also has the risk of losing sight permanently due to stimulus deprivation amblyopia. The impact a routine surgery for us makes to the life of such a child, is boosting not only his childhood but his overall self-esteem. Let`s not forget Oncology. Retinoblastoma, the commonest ocular malignancy in childhood, is so often missed and presents at a late stage where often the only therapy one can offer is enucleation to save the child`s life. A child, barely of 5 to 10 years of age, having an ocular malignancy so devastating that it can cause him to lose his life just as it has begun. The follow up of such children is equally challenging, yet exciting. Routine evaluations under anaesthesia, various modalities of treatment, dealing with anophthalmic sockets and post radiation contracted sockets are just to name a few challenges amongst those seen by an Ophthalmic Plastic Surgeon. The impact we have on the lives of children, not only in terms of quantity (years of life) but also quality (self-esteem) makes Pediatric Oculoplastics a challenging yet exciting and gratifying career option for those who are up for the task. If we are working on something we really care about, then we don`t have to be pushed because our vision pulls us. This spirit has seen our students climb heights of their careers, giving us teachers reason to be proudly satisfied. I would like to conclude with my experience of treating retinoblastoma and oculoplastics in children which has been expressed appropriately in a quote. dren have the ability to ignore all odds and percentages, then maybe we can all learn from them. When you think about it what other choice is there but to hope? We have two options, medically and

- Dr. Usha Singh 118

Dr Usha Singh is currently working as Professor at Advanced Eye Centre in Post Graduate Institute of Medical Education and Research(PGIMER), Chandigarh. She completed her graduation from Jawaharlal Institute of Medical Education and Research[JIPMER], Pondicherry and post-graduation as well as senior residency from PGIMER and later joined as faculty in the department of Ophthalmology in PGI in1995.She is involved with research, teaching and administrative work in the department. Dr. Singh is credited with starting the formal Oculoplastics and Retinoblastoma services in PGI in 1996. She has won . numerous Best Papers Awards at National and International conferences and has publications in cancer of the eye and orbit. She has also written book section on eyelidtumors. Broadly her work experience in Oculoplastics include vascular lesions, orbital tumors, Ptosis surgeries, congenital lesions and thyroid Ophthalmopathy. The Retinoblastoma clinic is the only clinic of its kind in North India, registering more than 1000 cases. She has has won two International Best Scientific Poster Awards at the International Society of Ocular Oncology in 2004 and at the European Congress of Ophthalmologists site as principal investigator. Currently the department gives state of art treatment for retinoblastoma including Intra-arterial chemotherapy, administering it in more than 28 cases. Current research has now expanded into basic research. Dr. Singh is a life member of various national and international societies and was President of Chandigarh Ophthalmological Society. She is also a member of the International Society of Ocular Oncology (ISOO). In September 2019, Dr. Singh was awarded the prestigious Best Women Doctor of the Society by the Bhartiya Vikas Parishad Society of Chandigarh. 119

Pediatric Eye Care in India One of the most critical deficits in Global Eye Health is the lack of an adequately trained workforce. This is the very reason Orbis was founded - to provide ongoing training and support to eye care teams around the world. In 2000, India had only four comprehensive tertiary pediatric eye care centers. At that time, with a population of 1 billion, India needed 100 Children s Eye Centers (CEC) as per the WHO guidelines of one centre per 10 million population. Therefore, building India s capacity for Pediatric Eye Care presented itself as a mammoth challenge when we started our work on Childhood Blindness at that time in India. Examining children needs, special skills and treatment requires specific training, knowledge and equipment. This meant we had to build the infrastructure for service delivery including equipping the facilities and supporting community work, along with development of all cadres of human resources required; having the right people in the right place is the cornerstone of any successful public health program. Keeping all of this in mind, in 2002, the India Childhood Blindness Initiative (ICBI) was launched by Orbis to help ensure that India s children have access to quality eye care for generations to come. The India Childhood Blindness Initiative began by identifying tertiary level eye hospitals where CECs could be established. Further, a country-wide survey was undertaken to generate evidence for human resource and infrastructure requirements for elimination of avoidable childhood blindness. This was the first time that such an extensive survey was undertaken in India. The easier part was the development of infrastructure and systems. The challenging aspect was identifying staff and creating the Pediatric Ophthalmology teams at a time when Pediatric Ophthalmology was not recognized as a distinct

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subspecialty in India. This resulted in limited career options and therefore initially not many individuals were willing to undergo training. But, today, after nearly two decades, we can proudly say that we have played an important role in establishing Pediatric Ophthalmology as a distinct subspecialty in the Indian Ophthalmology landscape thereby making sure that children across India have access to quality care for generations to come. Today there are 33 CECs that have been developed with Orbis support across 17 states in India, and the good work is continuing at these child-friendly facilities. This is the largest network of CECs in the world. Besides, some of these centers continue to provide training and support to the eye care system in India and many neighbouring countries. Further, this model has been successfully replicated in Nepal and Bangladesh. Besides, three of the tertiary level pediatric facilities in the country that existed in 2000 were developed as Pediatric Ophthalmology Learning and Training Centers (POLTCs) by Orbis, providing infrastructure as well as technical support. This included standardisation of the curricula for different cadres of eye health professionals for the CECs and community work. These POLTCs continue to offer fellowships in Pediatric Ophthalmology, short/long-term training programmes and periodically conducted workshops/refresher training as well as continuing medical education (CME) producing more and more able young child eye care professionals who are making sure that children across the length and breadth of India have access to quality pediatric care.

-Dr. Rishi Raj Borah Country Director, India

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Dr. Rishi Raj Borah is an integral part of the Orbis journey in India and has committed an enormous part of his life to help ensure that children across the country have a better life. Although Rishi is a qualified veterinarian, he has always had an inclination towards working for and with people. It was during his college days that his penchant for community work led him to volunteer with a charity that worked for street children. He began his career working with a grassroots organization, Assam Moina Parijat, following which he worked on different community programmes with UNICEF, CORDAID, and Don Bosco Institute all involving children. In 2004, Dr. Rishi channelized his expertise of working with communities seamlessly into the fight against avoidable blindness. He started work at an Orbis partner hospital as Project Manager in northeast India. Rishi played a laudable role in reaching half a million children during his time at Sri SankaradevaNethralaya. His commitment to working on the ground tirelessly continued as he joined Orbis in 2007. Over the years, as Program Manager, Senior Program Manager, Assistant Director, Program and currently as Director, Program, Rishi has worked hard to develop innovative, impactful and sustainable home-grown eye care initiatives for communities across India and Nepal, impacting the lives of millions of children.

the largest network of its type in the world. Through this journey, Rishi has been an able guide to partners developing comprehensive child eye care services with a particular flair for charming people with his affable personality. His resourcefulness and ability to find creative solutions has helped partners surmount challenges and at times exceed their own expectations. His nocturnal lifestyle has endeared him to colleagues in the western hemisphere, and he is well known globally within Orbis for his dietary preference of chicken alone! 122

Soar to new heights! My Experience at International Observership in Pediatric Ophthalmology Hello everyone ! After spending 3 months in Pediatric Ophthalmology Observership at UPMC Children's Hospital Pittsburgh, I thought I should share my experiences. International Observership is a way to gain clinical experience without hands on experience. It essentially allowed me to shadow a world renowned Pediatric Ophthalmologist Dr. Ken Nischal and his esteemed team at UPMC to learn valuable Pearls specially in importance of early visual rehabilitation in Pediatric corneal diseases along with ocular genetics and how it changed the management for the children. Apart from the office and the operating room, I was fortunate to attend grand rounds with the residents and fellows and be a part of the academic discussions. I learned a very important lesson from him "DO NO HARM" which meant to proceed for benefit of the patient according to the best of our ability and judgement. Dr. Nischal was extremely kind, empathetic, soft spoken towards each and every child and parent addressing their concern. Every child who was examined by him always left the hospital with a beautiful smile and happy face

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which is something we do not see routinely in our field. He made sure that each and every parent is counseled properly and meticulously without rushing with time to finish his work. Alongwith that, Dr. Nischal made sure that the research and academics were challenging and enriching and he pushed everyone for thinking out of the box. I was fortunate to have a strong financial back up to cover for my expenses of stay, food and travel as it was a self-funded observership programme. Besides the academics and observership, I learned to live on my own and discover the beautiful city of Pittsburgh alongwith making so many international friends in the hospital. I would definitely suggested that if you have an opportunity to learn and observe with Dr. Nischal and his team and you have a financial backup, then it is totally worth it! "Better than a thousand days of diligent study is one day with a great teacher." PS: Dr. Ken Nischal is that teacher.

Dr. Anisha Rathod (MS, FPOS)completed her Ophthalmology residency from MGM Hospital Aurangabad, Fellowship in Pediatric Ophthalmology and Strabismus from Khan Bahadur Haji Bachoo Ali Eye Hospital, Mumbai and Fellowship in ROP from H.V Desai Eye Hospital, Pune. In this article she shares her experiences during her Clinical Observership in Pediatric Ophthalmology at the Children s Hospital of Pittsburgh, USA. Apart from being a speaker at regional, state, national and international conferences she is an active participant of the National ROP Awareness campaign for general public under the leadership of Dr. Karobi Lahiri (National Ambassador of ROP). She can be reached at rathod_anisha@yahoo.com

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A DAY IN THE LIFE OF A RESIDENT Where is the Interstitial nucleus of Cajal located? What is WEBINO ? What is skewed in a skew deviation?

and I could feel beads of

sweat run down my forehead, while standing at the bedside of a patient with a complex motility disorder. TTrrriiinngggggg

and I was jolted out of my bed, with the realization

that I was dreaming about a scene that would mark the start of my day, a usual day in my life as a Resident. Morning chores and breakfast happened in a jiffy, and off I drove to my alma mater, armed with new knowledge on motility disorders and neuroophthalmology, to combat the questions that we were expected to be bombarded with on that day! So, standing boldly next to a child with Monocular Elevation Deficit, the first question of the day shot on us by our mentorWhat is Reconnaisance ? My mind went numb

???

!!!...... Puzzled faces and even more puzzled minds glanced at each other. This question came as a hard blow as we were already trying to grapple and grasp the neuronal connections and misconnections of upgaze and downgaze.

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Finally mustered courage and asked in innocence,

Sir, I have read

about Monocular Elevation Deficit, but did not come across this term. Is it mentioned in a new article?.... Can I get the reference please?

Our mentor let out a smile famous one liner came out

once again! and the

You people are lagging behind, not just in your understanding of strabismus and motility disorders, but also in general knowledge and vocabulary .... Oh my , once again, our mentor had laid bare our obtuseness right in front of us! Sir please enlighten us with the meaning of this word, we mumbled and

Reconnaisance, Thats what we are going to do with you today

announced our mentor, and we were all ears and attention, in

Reconnaisance is a term that implies strategical bombing.

came up during the world wars, where after one bombing, the bombers would go and inspect the areas that were still left, to map out a plan for their next bombing

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Today we are going to do reconnaiance of your knowledge of Monocular Elevation Deficit and bring out those areas to your attention that still need your bombing to grasp them!!

outlandish answers to others, some made up answers and some outrightly rib tickling funny ones that had all of us in splits. Amidst all of this we learnt to diagnose the patient correctly, also got to know about lacunae in our knowledge and went on to learn the appropriate surgical planning.

answered, many unanswered, kept the hunger and thirst of knowledge alive! At the end of the session all of us felt victorious as we had our fill of new learning for the day. Another day of feeling happy and grateful on assimilating such pearls of knowledge came to fruition and we looked forward to the OR on the following day for our surgical training and culmination of all that we had learnt about the cases. Amidst the hectic long OR lists, and ward full of wailing children and deviating eyes, there was immense satisfaction of having learnt and applied our knowledge under an umbrella of guidance nudging us to become better versions of ourselves each day.

I m forever grateful to the spark initiated during residency, which burns bright each time on seeing a deviating eye and ignites the mind and soul of the clinician and surgeon established in those early years !!

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Dr. Bhawna P Khurana is currently a practising Pediatric Ophthalmologist and Oculoplastics surgeon at Khurana Eye Centre, Rohtak, Haryana, India. She has done her M. S (Ophthalmology) from Guru Nanak Eye Centre, Maulana Azad Medical College, followed by Senior Residency also from GNEC, MAMC itself in the Squint & Pediatric Ophthalmology unit She has undergone fellowship in Orbit, Oculoplasty and Ocular Oncology from Narayana Nethralaya, Bengaluru. Dr. Bhawna has also attained her DNB Ophthalmology degree in 2013, Fellowship of International Council of Ophthalmology, UK in 2014 and FRCS (Glas) in 2019. You can reach her at drbhawnakhurana@gmail.com

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PEDIATRIC GLAUCOMA RESIDENCY PROGRAM IN PGI CHANDIGARH There are very few centres in India with dedicated Pediatric Glaucoma services and PGI Chandigarh is one such Centre of Excellence. I remain indebted to the extremely dedicated faculty at PGI Chandigarh, Pediatric Glaucoma services Professor

Surinder

Singh

Pandav,

Professor

Sushmita

Kaushik and Dr Srishti Raj for teaching me and guiding me during my Residency. All the children attending the centre given dedicated care in the clinic and also special attention is given for the child s age appropriate visual acuity assessment. In the OR, one gets to learn a detailed examination under anaesthesia including detailed eye examination, gonioscopy, axial length, pachymetry measurements and ultrasound bio-microscopy in selected cases. Examination under sedation is also done using pedicloryl and more recently using intranasal dexmedetomidine. In terms of surgery, a good training is given for all types of surgeries including goniotomy, trabeculotomy, trabeculectomy, combined trabeculotomy with trabeculectomy, glaucoma drainage devices, cyclophotocoagulation including micropulse laser, optical iridectomy etc. Under the abled guidance of Professor Sushmita Kaushik, a Senior Resident or Glaucoma Fellow can perform each and every type of Pediatric glaucoma surgeries independently in a fair number with very good surgical exposure. One can get glaucoma training from PGI Chandigarh either by joining as a Senior Resident after obtaining postgraduation degree or can appear for 1-year Glaucoma Fellowship exam which requires 2 years of senior residency as eligibility criteria.

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Dr. Deepika Dhingra (MBBS, MS, FAICO) completed her Ophthalmology residency (Bronze medal) and 3 years of Senior Residency plus 1 year Glaucoma Fellowship from PGIMER, Chandigarh. She has won the First prize in Delhi Ophthalmological Society Quiz, 2016 and bagged the Best Paper and Best Poster Awards in Chandigarh Ophthalmological Society Conference, 2019. She can be reached at dhingradeepika19@gmail.com.

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Fellowship: To do or Not to do? Fellowship is a final step in post graduation clinical training in a subspecialty of a medical or surgical division. It can give a more concentrated clinical and surgical training in a specific subspecialty in which the exposure was not enough during residency program to give an experience for a career set up. However, some fellowships do not provide a stipend for the trainee exhibiting a financial burden on the fellow. So, before committing to a fellowship one needs to answer a few questions: Will this fellowship give the trainee the right skills to assess in fulfilling the needs of the market where he or she comes from? Will it fulfil the trainee passion? Does it give an experience that can be implicated in another country if done overseas? When we treat a child s vision, we treat his future! A residency program should therefore enable the trainee to become a safe and good general practitioner in its own specialty. This sets the right assets for a better sub-specialty training. The program should train the fellow to reach a competent level in concepts and practices of the sub-specialty that entitles the fellow to practice independently in a safe and efficient manner. It should enable the fellow to keep up to date with the on-going practices. The steep and infinitely long learning curve as well as the financial burden of pursuing a Pediatric Ophthalmology fellowship is justified by passion and bigger

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impact of treatment on a child s life as a whole. Pediatric cataract and Strabismus almost form the bulk of our patients and in a well-populated country like India I think it can suffice but in other places where number of subspecialists and number of patients are less as well, it will not. Therefore, a Clinical fellowship of 18 months encompassing Pediatric cataract / Congenital glaucoma/ Neuroophthalmology and Strabismus is good. Strabismus is a great mind game as well and it's a good idea to merge Neuro-ophthalmology with Strabismus. An exposure to other aspects of surgical Cornea/ Retina also aids in dealing with your own complications. A good genetic expertise helps in handling various syndromic patients too. As a Young student, clinic case-based readings are the best to stay in the mind. See a case and try to read about it sooner. I feel it is the best way to learn. I had attended last WSPOS meeting in 2017, and I was not yet into a fellowship program. It gave me so many new prospective on the subspecialty by that time. I just can say, I cannot wait for the next! I believe my training in Pediatric Ophthalmology, Strabismus and Neuroophthalmolgy helped me learn PPC: No, not a primary posterior capsulotomy but Passion, Patience and Caution !!! Passion of mentors to teach and of fellows to learn Patience of mentors to guide and of fellows to learn how to tackle pediatric patients Caution of teaching surgery as it has the longest implications on life and caution of the fellow to learn the best and harm the less. Fellowship: To Do Or Not to do? Definitely YES !!!!

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Pic : At the Clinic with my Mentors and collegues

Dr. Fatema Bin Rajab (MD, CABS) hails from Bahrain and has completed her Fellowship in Pediatric ophthalmology, Strabismus and Neuroophthalmology from L V Prasad Eye Institute, India.

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Young Pediatric Ophthalmologists Experience To be a young ophthalmologist is a real challenge in its own rights but one of the great challenges in this occupation is the lack of practice; to overcome the inexperience we need good supervisors, the top notch professionals who would give advice and show the directions in the career; the supervisor who is vigilant to check how we should hold the instrument at our first performance of operation and trace each and every step in the process. Nevertheless, if we are not lucky enough in the professor-student relationships,the life itself shows the directions and provides chances, which we should not miss. It is essential that we take delight in what we do. As for me, I come from Georgia. (This is the country in the Caucasus, not in USA). The population is about three million and there are 300 ophthalmologists. In order to become an ophthalmologist I studied six years at the University and in Georgia and two more years in the Ukraine. Then I came back to Georgia, passed the certification exams and started to work that was followed by the interesting period of my observer-ship, and fellowships. The critical in my career was the fellowship in Holland in 2018, at Rotterdam Eye Hospital where I was supervised by Dr. Tjeer de Faber, who taught me the surgery of various cases of strabismus. If not Dr. Tjeer de Faber I would not become an independent surgeon so soon. He taught me how to start, proceed and finish the operation, how to rectify flaws and yield the best of the best results through surgery. I met Dr. Tjeer de Faberquite by chance at one of the SOE congresses and he simply offered me to arrive at his clinics.

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I was in India, at SRI SANKARADEVA NETHRALAYA eye hospital, for my phaco training, after 17 hour journey. I met my New Year (2020) here, enjoyed my stay, got good medical experience and made new friends. My idea is, dear young ophthalmologists, be alert to visit fellowship, observerships, conferences and congresses. Meet colleagues from various countries. Networking has great importance. In any chance encounter there might be lurking your great luck to meet your supervisor or a teacher who will map out your route to a great career of an ophthalmologist.

Dr. Lana Datuashvili (MD) Pediatric Ophthalmologist, SOE (European Society of Ophthalmology), YO Committee member, SOE YO Newsletter Editor. Georgia, Europe.

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Sharing my experience at LVPEI My experience as a fellow in the department of Pediatric Ophthalmology, Strabismus and Neuro-ophthalmology at L V Prasad Eye Institute has been a very rewarding one. It not only increased my confidence, efficiency and overall quality of patient care but also narrowed down the knowledge gap and helped me pursue my dream in research and innovation. Fellowship for me is a form of apprenticeship to sharpen my skills in the particular field. So before embarking on my journey, I looked out for the track records of various institutions, the calibre of the faculty and the duration of the fellowship program. LVPEI stood out with a perfect score!! L V Prasad Eye Institute (LVPEI) is a comprehensive eye health facility with its main campus located in Hyderabad, India. A World Health Organization Collaborating Centre for Prevention of Blindness, the Institute offers comprehensive patient care, sight enhancement and rehabilitation services and high-impact rural eye health programs. It was an 18 months long training program where I was exposed to a wide spectrum of intense academic and clinical curriculum. Pediatric ophthalmology and strabismus is usually a grey area and is not adequately covered during postgraduate residency. This sub-specialty is like no other as it is very comprehensive except in children. It is an exciting specialty with many unanswered questions that unfold as you probe. Neuro-ophthalmology became so much easier for me with a strabismus background. I strongly feel Pediatric neurology should be a necessary part of short clinical rotations. Having spent some time in pediatric oculoplastics, cornea, retina, glaucoma and oncology gave me confidence to deal with

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complicated cases as well. The steep and infinitely long learning curve as well as the financial burden of pursuing this fellowship was justified by the dedicated guidance of the well trained faculty of the institute. The benefits of giving sight to a child with long life far outweighed the burden. The journey was very fulfilling and I find joy seeing kids happy. I thank my mentor Dr. Ramesh Kekunnaya for his guidance and overwhelming belief in me.

Dr. Willard B. Mumbi, Pediatric Ophthalmologist. Lusaka Eye Hospital, 59 Chipwenupwenu Road. Makeni, Lusaka, Zambia.

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Examining a Child

The Art of Subtle Skills - Dr. Simar Rajan Singh, Dr. Aditi Mehta

Pediatric ophthalmology is an upcoming sub-specialty which specifically addresses eye diseases affecting infants and young children like congenital cataract, retinal diseases including retinopathy of prematurity and inherited retinal disorders, congenital glaucoma, congenital nasolacrimal duct obstruction, ptosis and strabismus. We, as ophthalmologistsare many times the first point of contact for children with developmental delay and poor eye contact. A proper detailed ophthalmic evaluation can often lead to diagnosis of more sinister systemic conditions like leukemias, metabolic storage disorders and inherited syndromes. The skill set required for examining a childis two-fold. The first involves technical expertise. This include having specialized equipment for vision testing (Tellers and Cardiff cards), occluders and portable imaging systems for anterior segment and fundus photographs. It also involves incorporating into the clinic design a designated play area in the waiting hall and keeping a jar of candy handy. It helps to have bright wallpapers and some interesting looking toys. Some inquisitive children may even be interested in looking at 3D models of the eye. The second skill set is actually an art. It requires one to have a special interest in order to develop a rapport with the young child so that he lets you examine without getting intimidated by the white coats and the ophthalmoscopes. Some basic points to keep in mind are outlined. We should remember that the evaluation begins from the minute the child walks in the clinic or the way the child is looking laying in the mothers lap. While greeting the parents and the child, one is usually able to gauge the level of apprehension. This is important as sometimes when the diagnosis is sinister, anxious parents may get hysterical. Calm dialogue is not possible with a bawling child and a sobbing mother. The degree of irritability of the child may indicate the level of discomfort. In such situations, a simple torch light examination can scare the child. You should first attempt to put the child at ease, make him sit in the mother s lap and give a toy

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to engage his attention. Subjective evaluation of fixation and fixation preference, resistance to occlusion can then be checked while the child is comfortable, and the initial introductions are being made. Don t let the child figure out that you are testing him, it gives him the cue to start testing your patience!

Our mentor, Prof. Amod Gupta examining the fundus of a small child on slit lamp.

From screening newborns with ROP to counselling for enucleation for retinoblastoma, the challenges are immense. Winning over a child s confidence is a true test of your empathy. Children are perceptive. They are intelligent even though they may not understand the actual meaning of your words, they will pick up subtle emotions and changes in tones. They may

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be shy at first but that s because they aren t used to you. They will open up eventually.

The Pediatric Retina and ROP Services under the leadership of Prof. Mangat Dogra at Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh celebrating Children s Day with the tiny babies at our clinic.

It is always a good idea to involve the parents in the examination and investigations of the child. It can sometimes be a double-edged sword as some anxious mothers may get more scared, but more often than not, it instills confidence in them in the process being followed. In case of premature infants, showing them the demarcation between the vascular and avascular retina on Retcam images helps them understand the disease and improves adherence to follow-ups. The older, school going age group children have as much right to make an informed decision about their eye health and treatment. Not only does

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this improve their compliance, but also helps us in providing the most suitable therapy. We are in the age where comprehensive and universal eye care for children is not only our duty, but our biggest responsibility. The impact of saving useful vision in a premature child versus an adult is almost exponential. Incorporating a few of these subtle skills in our practice can go a long way in achieving this goal. The best feedback in this field is when a child tells his / her parents, I want to meet my eye doctor, he / she is my best friend.

A happy child after getting his ultrasonography for retinoblastoma screening done with Dr. Aditi Mehta and Dr. Aman Kumar

Dr. Simar Rajan Singh completed his MS, Ophthalmology with a silver medal (1st in order of merit) from the prestigious Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh. He did his fellowship in the field of Vitreo-retinal surgery and Uveitis from the same institute. His area of interest is pediatric retinal disorders and their management. He was awarded the BestPost Graduate Thesis Award and also received the coveted Prof. I. S. Jain Memorial Silver medal for the Best Post Graduate from PGIMER. Dr.

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Simar received the Carl P Herbort Travel award by the Uveitis Society of India and the coveted Best of the Best award at the Film Festival Awards of the American Society of Cataract and Refractive Surgery. He represented India at the 61st meeting of Nobel Laureates and Scientists at Lindau, Germany dedicated to Physiology / Medicine in the 2011. He serves as areviewer to various national and international journals including the American Journal of Ophthalmology and the European Journal of Ophthalmology. You can reach him at simarrajansingh@gmail.com.

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Vision 20/20 ROP India ~ Implementation of control strategies ! Background Retinopathy of prematurity (ROP) is a proliferative retinal vascular disease affecting the retina of preterm infants. The clinical spectrum of ROP varies from spontaneous regression to bilateral retinal detachment and total blindness. Between these two extremes lies the form of ROP, which is amenable to effective prevention control strategies and treatment. High prevalence of ROP is not limited to developed nations, studies1,2 suggest that ROP is becoming a major cause of potentially avoidable blindness in low- and middle-income countries including India due to Increasing rates of preterm births coupled with better survival rates but lack of uniform quality of neonatal care and absence of effective screening.

Prevalence and Magnitude India is home to largest number of preterm births and neonates at risk of developing ROP, studies suggest that of all the 14.8 million preterm births globally, approximately 23.4% babies are born annually, in India3.It is estimated that 490,000 preterm infants are born with a gestational age of <32 weeks, and at least 5,000 preterm infants require treatment for ROP every year in India4. Recent data from a study shows a 20-fold increase in outpatient attendance of children with ROP while numbers of cataract and glaucoma in pediatric units have remained stable 5. As a part of fulfilling the WHO millennium development goals to reduce neonatal mortality rate in India, over eight hundred specials new- born care units (SNCUs) were established since 2008. This led to improvement in the survival of more pre-term babies consequently increasing the risk of ROP blindness6,7. The main causes for increased ROP burden are high rate of prematurity with improved survival and lack of uniform ROP screening protocols8.

Risk factors for developing ROP In addition to Preterm birth many studies reported APGAR score in first minute, intra ventricular hemorrhage, duration of oxygen therapy, dependence on mechanical ventilation for more than seven days, sepsis, blood transfusion and failure to gain weight as the risk factors for

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ROP9-11. One study shows periventricular leukomalacia and respiratory distress as additional risk factors for ROP in children12.WHO guidelines for facility-based care of neonates advise breast feeding and kangaroo mother care as preventing measures for development of sight threatening (ST-ROP)13.

Strategies for prevention ROP management stands as a good example of all the strategies for prevention for example it includes- a smaller number of preterm births by good obstetric care- Primary prevention, lesser number of ROP by excellent neonatal care Primary Prevention. Screening and prompt referral for treatment- secondary prevention and vitreo-retinal surgery and rehabilitation- constitutes tertiary prevention.

Primary Prevention- refers to measures that prevent occurrence of the disease: Prevention of Pre-term birthHealth education- for prevention of teenage pregnancies. Health promotion- obstetrics care including bed rest for high risk pregnancy. Health policy- for avoiding needless caesarian sections. -Prevention of multiple pre-term birth from unneeded IVF. Good obstetrics practicesAntenatal steroids to mother in case of pre-term labor. Excellent Neonatal care to pre-term babiesHealth promotion- encourage breast milk and kangaroo mother care. Avoiding oxygen resuscitation in first golden-hour Good management of oxygen using oximeters or monitors. Prevention from infections by using aseptic precautions, hand hygiene practices.

Secondary Prevention- refers to early diagnosis and treatment. Screening for ROP for all eligible pre-term babies admitted in neonatal care units to diagnose Type-I ROP. Prompt referral for laser treatment within 48-72 hours.

Tertiary Prevention-refers to management of complications and sequel Vitreo-retinal surgery for stage 4 and 5 ROP

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Low Vision services for rehabilitation Provision of special education

Challenges Although ROP stands out to be a good example for prevention strategies at all levels of service delivery and all the strategies of prevention mentioned above appears to be feasible but there are many challenges for the effective implementation of the same in India due to various factors14,15. Non availability of trained human resources like ophthalmologist trained in laser treatment with huge urban rural disparity. Varying levels of neonatal care in the country. Lack of standard operating protocols and operational guidelines for ROP management. Lack of country specific classification and referral protocols, it has been concluded by various studies in India that screening criteria should be kept broad 16,17. Lack of awareness among parents and apathy of health care providers towards ROP care. Lack of accessibility to point of care and treatment. Lack of maternal education, poverty and negative attitude towards disease in the society. Lack of access to special education and rehabilitation services. Gender bias with less medical care provided to girl child specially in rural areas.

Integration of ROP services within existing Health System The key stake holder in health system for strengthening the eye care services in India is NPCB & VI (National Program for control of blindness & visual impairment) 18 which comes under ministry of health and family welfare (MOHFW), Government of India (GOI). The MOHFW, under the national health mission launched the rashtriyabalswasthyakaryakram (RBSK)19(national integrated child health program), an innovative and ambitious initiative, which envisages child health screening and early intervention services, a systemic approach of early identification and link to care, support and treatment. RBSK covers early detection and management of 4 D s defects at birth, diseases of childhood, deficiencies and developmental delays covering 29 conditions including ROP. Under RBSK it is obliged to follow up the registered child up to the age of seven years to ensure healthy childhood development.

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The department of child health which also comes under MOHFW developed SNCUs as an effort to reduce neonatal mortality rate6,7. These three major programs are mainly accountable for planning and execution of service delivery for prevention of childhood blindness including ROP in India. The management of ROP is a multidisciplinary task involving the healthcare providers from all the cadres at all levels of service delivery. This needs integration of services provided by the stake holders among these three key programs of our health system. MOHFW -----------> Primary/communitylevel

Secondary /District/SNCU level

NPCB

RBSK Raising awareness providing materials.

by IEC

Promote screening of ROP by recruitment of staff through district blindness control societies. Infrastructure developmentensuring

Training and involvement of Accredited social health assistants (ASHA) workers for creating awareness in the community. ASHA workers can educate females in the community regarding good antenatal practices. ASHA and Auxiliary Nurse midwife (ANM) can act as key informant for preterm babies in the community. Encourage mothers for breast feeding and kangaroo mother care in the community. Strengthening of SNCU s Neonatologist and ROP nurse can identify the babies to be screened and timely referred. Maintaining of diary and follow

CHILD HEALTH DEPTT. Training of ASHA and ANM s for encouraging facility-based deliveries in the community. Promotion of good hygiene practices. Health education for safe antenatal practices in case of high-risk pregnancies.

Scaling up of SNCU s Promotion of screening protocols in SNCU s. Regular monitoring and follow up.

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availability equipment diagnosis lasers.

Tertiary/ medical college/RIO slevel

of for and

up schedule of babies at SNCU s. Training and provision of IEC materials to ASHA and ANMs. Record keeping of statistics. Audits of the activities. Follow up of all the children requiring refraction and other healthcare needs up to the age of seven years.

Formation of National task force to tackle ROP Capacity building of Regional institutes of ophthalmology under NPCB. Setup of telemedicine services between RIO s and district hospitals. Strengthening ofRehabilitation units in RIO s and medical colleges under NPCB

Availability of skilled neonatologist, pediatrician and ophthalmologist at this level to cater the complex cases referred from district level. Training of trainers at medical college.

Coordination among District hospitals and medical colleges for referral of complex cases. Provide human resource to support for transportation, screening and laser treatment of babies. Ensure follow up of all preterm babies up to the age of two years.

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Newer Horizons and Role of Public Private Partnership & international NGO s In the last couple of years many innovative projects to tackle the third epidemic of ROP were initiated across India and were proved to be successful. A novel initiative called the KIDROP (Karnataka Internet Assisted Diagnosis of ROP) model is atele-ROP service providing screening and treatment for ROP through telemedicine in Karnataka since 2008. A study20 to explore the cost-effectiveness of KIDROP model concluded that this model could provide ROP screening in low-resource settings, remote centers, and regions with few ROP specialists. Expanding the model to other states with similar demographics can prevent over USD 100 million of blindness burden annually. In 2017 a study21 of mobile van screening for ROP was done in which a trained ophthalmologist performed bedside ROP screening using indirect ophthalmoscope. ROP was graded and managed as per the International Classification of Retinopathy of Prematurity treatment guidelines. Incidence and determinants of ROP were also estimated. The study concluded that the mobile screening method for ROP screening is feasible and cost-effective method to detect ROP and offer timely intervention in areas with limited resources. In 2014 a pilot project was introduced in India to integrate the screening and management of diabetic retinopathy and ROP in rural areas22. The hub-spoke model was introduced where three to four SNCU s or district hospitals were catered by a central medical college hospital. Under the project ROP screening was established in 16 SNCU s in four states in four years. Indian institute of public health in association with the queen Elizabeth diamond jubilee trust and London school of hygiene & tropical medicine, United Kingdom started ROP project in India23. The aim of this program was to develop and integrate ROP services into national health system. The program focused on SNCU s in district hospitals and neonatal units in medical colleges. Initially started as a pilot project in four states the project has now been implemented in 30 districts in six states. Recently a national group of experts representing neonatal care, eye care, public health experts and program managers from MOHFW (Child health, RBSK, NPCB and VI), were called by the national ROP task force to develop the ROP operationalguidelines 24to scale up ROP services. The guidelines are based on the consideration that varying level of neonatal care are prevalent in India.The screening criteria has been kept broad to accommodate bigger babies presenting with aggressive posterior ROP in Indian setting25.

Recommendations

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The statistics of increasing burden of ROP suggests that there is an urgent need of scaling up of ROP services in India along with its integration into the national health system. The MOHFW has a crucial role to play in this regard. The MOHFW is accountable for strengthening of SNCUs and medical colleges by provision of equipment and laser machines. The realization of this target needs a high political will and commitments. The biggest challenge is the lack of awareness in the community regarding primary prevention of diseases like ROP, which can be catered by health education and health promotional IEC activities at community level by primary health care providers like ASHA and ANMs. Mass media including social media sites, radio and newspaper adverts can play a vital role in this regard. Secondly, apathy of the eye care practitioners towards ROP management as it is perceived to be less lucrative and more time consuming with poor prognosis. To overcome this problem proper training and incentives like promotion and appraisals can be given to ophthalmologists who provide ROP services specially in far flung rural areas. Although now operational guidelines are available for of ROP services but unfortunately the scope is limited to states where active partnership and networking exists. Majority of the eye health care providers still have no access to these guidelines. Forums like All India ophthalmological society and state societies can play a crucial role in this regard by urging all members to actively spread awareness, refer and comply with the guidelines. Guidelines can be distributed across states along with the monthly publications of state societies. To conclude, ROP management is gigantic but not unsurmountable problem which requires coordination and sincere efforts by each cadre at each level of health system to brighten the lives of future of India.

References 1. Gilbert C, Rahi J, Eckstein M, O'Sullivan J, Foster A. Retinopathy of prematurity in middleincome countries. Lancet LondEngl1997; 350:12-4 2. Dogra MR, Katoch D, Dogra M. An Update on Retinopathy of Prematurity (ROP). Indian J Pediatr. 2017 Dec;84(12):930-936. doi: 10.1007/s12098-017-2404-3. 3. Blencowe H, Moxon C, Gilbert C. Update on blindness due to retinopathy of prematurity globally and in India. Indian Pediatr 4. et al. Global, regional, and national estimates of levels of preterm birth in 2014: A systematic review and modelling analysis. Lancet Glob Health

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5. Agarwal K, Balakrishnan D, Rani PK, Jalali S. Changing patterns of early childhood blinding conditions presenting to a tertiary eye center: The epidemic of retinopathy of prematurity in India. Indian J Ophthalmol. 2019 Jun;67(6):816-818. doi: 10.4103/ijo.IJO_709_18. 6. et al. Inpatient care of 7. 8. 9.

10. 11.

12. 13.

14.

15.

16.

17.

18. 19. 20.

21.

solutions. BMC Pregnancy Childbirth 2015;15: S7. Neogi S, Khanna R, Chauhan M, Sharma J, Gupta G, Srivastava R, et al. Inpatient care of small and sick newborns in healthcare facilities. J Perinatol Dutta S, Raghuveer T, Vinekar A, Dogra MR. Can we stop the current epidemic of blindness from Retinopathy of Prematurity? Indian Pediatr Shah VA, Yeo CL, Ling YL, et al. Incidence, risk factors of retinopathy of prematurity among very low birth weight infants in Singapore. Ann Acad Med Singapore. 2005;3 4(2):16978. Seiberth V,Linderkamp O. Risk factors in retinopathy of prematurity. a multivariate statistical analysis. Ophthalmologica. KarnaP,Muttineni J,Angell L,et al. Retinopathy of prematurity and risk factors: a prospective cohort study. BMC Pediatr. 2005; 5: 18. Yang CS, Chen SJ, Lee FL, Hsu WM, Liu JH. Retinopathy of prematurity: screening, incidence and risk factors analysis. Zhonghua Yi XueZaZhi (Taipei). 2001;64(12):706 712. retinopathy of prematurity by improving https://www.newbornwhocc.org/Facility-Based-Care-of-Preterm-Infant.html Accessed on 26/01/2020 SuchetaKulkarni, Clare Gilbert, Maria Zuurmond, SupriyaAgashe, MadanDeshpande. Retinopathy of Prematurity in Western India: Characteristics of Children, Reasons for Late Presentation and Impact on Families. Indian Pediatr. 2018 Aug 15;55(8):665-670. Padhi TR, Badhani A, Mahajan S, Savla LP, Sutar S, Jalali S, Das T. Barriers to timely presentation for appropriate care of retinopathy of prematurity in Odisha, Eastern India.Indian J Ophthalmol. 2019 Jun;67(6):824-827. doi: 10.4103/ijo.IJO_972_18. Shah PK, Prabhu V, Ranjan R, Narendran V, Kalpana N. Retinopathy of Prematurity: Clinical Features, Classification, Natural History, Management and Outcome. Indian Pediatr. 2016 Nov 7;53Suppl2: S118-S122. Ratra D, Akhundova L, Das MK. Retinopathy of prematurity like retinopathy in full-term infants. Oman J Ophthalmol. 2017 Sep-Dec;10(3):167-172. doi: 10.4103/ojo.OJO_141_2016. NPCB&VI GOI. Available from https://npcbvi.gov.in/Home. Accessed on 12/February/2020 RBSK GOI Available from https://rbsk.gov.in/RBSKLive/Default.aspxAccessed on 09/February/2020 Vinekar A, Mangalesh S, Jayadev C, Gilbert C, Dogra M, Shetty B. Impact of expansion of telemedicine screening for retinopathy of prematurity in India. Indian J Ophthalmol. 2017 May;65(5):390-395. doi: 10.4103/ijo.IJO_211_17. Kelkar J, Kelkar A, Sharma S, Dewani J. A mobile team for screening of retinopathy of prematurity in India: cost -effectiveness, outcomes, and impact assessment. Taiwan J Ophthalmol. 2017 Jul-Sep;7(3):155-159. doi: 10.4103/tjo.tjo_48_17.

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22. Gudlavalleti VS, Shukla R, Batchu T, Malladi BVS, Gilbert C. Public health system integration of avoidable blindness screening and management in India. Bull World Health Organ. 2018 Oct 1;96(10):705-715.doi: 10.2471/BLT.18.212167. 23. DRROP. Available from https://drropindia.org/retinopathy-of-prematurity/ Accessed on 02/02/2020 24. Shukla R, Murthy G V, Gilbert C, Vidyadhar B, Mukpalkar S. Operational guidelines for ROP in India: A summary. Indian J Ophthalmol [serial online] 2020 [cited 2020 Feb 3];68, Suppl S1:108-14. Available from: http://www.ijo.in/text.asp?2020/68/13/108/275720 25. Shah PK, Narendran V, Kalpana N. Aggressive posterior retinopathy of prematurity in large preterm babies in South India. Arch Dis Child Fetal Neonatal.

Dr. Sumit Grover DO, DNB (Ophthal.), FICO (UK), MBA (Hospital Management), MPH, LSHTM (Univ. of London) Associate Professor & Program Director Deptt.of Optometry School of Health Sciences Sushant University (erstwhile Ansal University) Email: dr.sumitgrover@gmail.com

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YOSI DIFFERENTIAL WARS

Various Strabismic entities present with almost similar presentation on cursory examination, however, a detailed evaluation and looking for subtle features helps differentiate

looking for in such cases to narrow it down from the numerous differential diagnosis into one final diagnosis. In this section of differential wars, we discuss two such case scenarios which can create a diagnostic dilemma.

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Case 1: A CASE OF BILATERAL PTOSIS WITH CHIN UP AHP AND GENERALISED RESTRICTION OF EXTRAOCULAR MOTILITY

CFEOM CONGENITAL

CPEO ONSET REVIEW OF CHILDHOOD PHOTOS

ADULTHOOD

AD/AR (DEPENDING ON THE VARIOUS TYPES)

INHERITANCE

MITOCHONDRIAL

RESTRICTIVE

TYPE OF MOTILITY RESTRICTION

PARETIC TO BEGIN WITH, RESTRICTIVE IN LATER STAGES

COMMONLY HYPOTROPIA (CFEOM-1)

PRIMARY VERTICAL POSITION OF EYE

VERTICALLY STRAIGHT (EXOTROPIC) (HYPOTROPIA UNCOMMON)

SYNERGISTIC CONVERGENCE MAY BE SEEN IN CFEOM-1

CONVERGENCE

POOR

OPTIC NERVE HYPOPLASIA, CHORIORETINAL COLOBOMAS, MICROPHTHALMIA

OCULAR ASSOCIATIONS

PIGMENTARY RETINOPATHY, LEBER S HEREDITARY OPTIC NEUROPATHY, CATARACT

INGUINAL HERNIA, CRYPTORCHIDISM

SYSTEMIC ASSOCIATIONS

CARDIAC DISEASES (KEARNS SAYRE SYNDROME), NEUROLOGICAL (PHARYNGEAL WEAKNESS, CEREBELLAR ATAXIA, DEAFNESS, PERIPHERAL NEUROPATHY)

CHILHOOD PHOTOS REFLECT PTOSIS AND OCULAR DEVIATION

NORMAL CHILDHOOD PHOTOS, PROGRESSION WITH AGE

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Case 2: A PATIENT PRESENTING WITH LIMITATION OF ELEVATION IN ADDUCTION

BROWN S SYNDROME LIMITATION IN DUCTIONS= VERSIONS USUALLY ABSENT (WHEN PRESENT RARELYCALLED AS BROWN S PLUS) POSITIVE V PATTERN

INFERIOR OBLIQUE PALSY LIMITATION OF ELEVATION IN ADDUCTION SUPERIOR OBLIQUE OVERACTION

LIMITATION IN DUCTIONS> VERSIONS

FORCED DUCTION TEST PATTERN

NEGATIVE A PATTERN

PRESENT

A thorough knowledge of the anatomy, physiology, development and functioning of extra ocular muscles is a key to be good at motility issues and their diagnosis. Happy Learning !!! Dr. Annu Joon [MS, DNB, FICO (UK)] is currently working as an Assistant Professor in Maulana Azad Medical College (Guru Nanak Eye Center) New Delhi. She is a dynamic young ophthalmologist with 5 years of clinical experience in the fields of cataract, pediatric ophthalmology and strabismus (including ROP screening) and glaucoma. Dr. Annu has a passionate interest in teaching and research and has to her credit 30 presentations (instruction courses/ papers/ posters) and numerous publications at national and international level. She is an executive committee member of YOSI, a reviewer for DJO and has served as an Assistant Editor of DOS Times Glaucoma Issue. You can reach her atannujoon@gmail.com

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TIPS TO DEAL WITH STRABISMOLOGY FOR THE

YOUNG PEDIATRIC OPHTHALMOLOGY STUDENT BASIC ANATOMY AND DEFINITIONS: Anatomy of the extraocular muscles, blood supply, anatomy of the nerves supplying them, relevant neuro-anatomy, pulley concept, actions of the muscles, field of action, spiral of Tillaux, Concept of yoke muscle, Herring s law and Sherrington s law. Definitions - phoria and tropia, orthophoria, primary & secondary visual direction, corresponding retinal points, horopter, Panum s fusional area. Retinal correspondence (normal & anomalous) Binocular single vision and it s grades, Suppression & Amblyopia- types, treatment, Amblyopia Treatment Study. Definitions- Concomitant/ Incomitant / paralytic / restrictive strabismus.

HISTORY TAKING: Age of onset, intermittent or constant, h/o trauma or illness, direction of squinting eyes, any c/o shaking of eye ball/ abnormal head posture (AHP) noted by parents/attendant. Any h/o double vision (common- adults-decompensated congenital/ acquired, rarely in children) Birth history: gestation age, mode of delivery, antenatal maternal infections or diseases, h/o delayed crying, NICU stay, supplemental oxygen, seizures, hypoglycaemia, infection, hyperbilirubinemia. Vaccination details, developmental milestones (any associated occupational therapy in case delayed milestones). Consanguinity of marriage

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Any associated ocular or systemic diseases. Any refractive error h/o glass wear and h/o patching. Family history of squint/ ocular or systemic disease or syndromes. Always check old photos of the patient to note for squinting or AHP.(passport photos or photos in straight gaze)

EXAMINATION: Begins as the patient comes in the examination room- check for child s response to the new environment and toys/ any facial asymmetry & AHP SENSORY EVALUATION:

Done before tests for motor evaluation & vision testing (before breaking of fusion). Tests for Stereopsis: without glasses- Frisby, Langs 1 & 2, synoptophore. With glasses- Titmus fly, Randot & TNO. Tests for retinal correspondence: Worth s 4 dot, Bagolini s glasses, after image test, red filter test, synoptophore s striated glasses, after image test MOTOR EVALUATION: OCULAR ALIGNMENT AND OCULAR MOTILITY Ocular alignment: Qualitative tests- Cover/ Uncover/ Alternate cover test/ Maddox rod test Quantitative tests light reflex based- Hirschberg, modified Krimsky, Bruckner s test. Quantitative tests Prism based (apex towards deviation) Simultaneous prism cover test, Prism under cover test (for DVD)

Prism bar cover test,

Deviations are measured for distance and near, 9 cardinal positions, right and left eye fixating (paralytic pattern Effects on deviation of high power minus and plus lenses.

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Ocular motility: Uniocular- ductions, Binocular Versions and Vergences. Normal limits of AD- & ABductions Underactions (UA) and overactions (OA) of superior oblique (SO) & inferior oblique (IO) Forced duction test (FDT) / Active force generation test/ Force Degeneration test (DRS ) Parks 3 step test Pursuits and saccades.

VISION AND REFRACTION: Vision Assessment as per age and development of child: Indirect assessment- blinking & pupil reaction. Fixation reflex- Fixates and follows, Central Steady Maintained (CSM) Preferential looking tests (infants to preschool)- Lea paddle/ Allens / Teller Acuity cards/ Cardiff Acuity test/ visual evoked reaction Preschool & school going- Lea symbols/ Snellens / HOTV (check if child holds an AHP at the time of reading)

Cycloplegic refraction: the cycloplegics used with their onset and duration of action, adverse effects and contraindications. Age and condition at which each agent is used.

PUPILS, ANTERIOR AND POSTERIOR SEGMENT: Pupils- to rule out any abnormal reactions/ RAPD in sensory causes of strabismus/ in case of a 3rd cranial nerve palsy. Slit lamp in older children and adults, hand held slit lamp in younger children Indirect Ophthalmoscopy- fundus evaluation, in young children atleast posterior pole evaluation is mandatory. To check Fundus torsion in c/o torsional diplopia / SO or IO involvement.

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INVESTIGATIONS: Diplopia charting Hess charting Imaging- MRI brain and orbit in appropriate cases eg nerve palsies. CT scan in some cases. VEP ERG Other lab investigations, electromyography, saccadic velocity testing, etc.

ESOTROPIA Classification of esotropia (ET) Infantile ETAge of onset, angle of deviation (usually large angle). Deviation evaluation- Hirschberg or modified Krimsky test. Presence of -cross fixation, DVD, inferior oblique overaction, any associated neurological problem or developmental delay. Cycloplegic refraction to rule out any refractive error or any accommodative component. Glasses- if hyperopia > +2.50D/ Anisometropia>+1.50D /myopia >-4.00D and astigmatism of >0.50D. Amblyopia treatment if present.

atleast 2 reproducible measurements (measurements agree within a range of 5counsel about >1 surgery and the importance of fusion restoration to possible extent Surgery bimedial recession with / without LR resection. Botox injection has been suggested for small angle deviations.

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Accomodative ETage of onset, usual intermittent nature initially, and amount of deviation (both distance and near) Cycloplegic refraction & calculation of AC/A ratio (methods to calculate AC/A ratio) Treatment -Hyperopic correction (usually full cycloplegic correction followed by modifications as per vision and residual ET with glasses) & Bifocals if large AC/A. Rarely contact lenses or miotics are prescribed. Homatropine for a week while starting glasses , executive type bifocals , amblyopia treatment if present. Counsel partial accommodative & decompensated accommodative surgery for residual deviation Surgery bilateral MR recession usually (unilateral recession resection if severe visual deficit in one eye) Monofixation syndromeSensory state- often arising as result of non-operative management of preLack of central fusion but presence of peripheral fusion. Can be diagnosed by cover-uncover test, also central suppression scotoma To rule out Sensory causes of ET, previous surgery for XT, cyclic ET (rare) Heavy eye syndrome (HES) / Strabismus fixus convergence

Hypertropia has also been described.

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Limitation of abduction & elevation Etiology Diagnosis- history, recent onset diplopia, neuroimaging mostly MRI with attention to the path of muscles. Complications Differentials especially sagging eye syndrome (SES) Treatment: Loop myopexy, concurrent MR recession at times of loop myopexy, Recession-resection (less successful)

EXOTROPIA Classification of exotropia (XT) Intermittent XT (IXT)Age of onset, duration of XT at home, use of glasses- squint status with same Check CSM , Newcastle score & control for Distance (D) & Near (N), deviation for D and N (with glasses if any) prolonged occlusion (one eye should always remain covered during measurement following occlusion) +3.0D lens for AC/A ratio. Classify as basic/ divergence excess/ convergence insufficiency to decide on type of surgery needed. Cycloplegic refraction (IXT may hv myopia)- glasses and amblyopia treatment if present Surgery- depends on type of IXT and the angle for D and N. Bilateral recession, unilateral recession & resection Rule out any cause of sensory XT/ consecutive XT

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PATTERN DEVIATION Classification & definition Etiology Evaluation- motor testing, rule out pseudo A & V pattern, ocular rotation examination, torsion and sensory testing. Surgical options depend on etiology- muscle transposition, SO- & IO- weakening Complications of surgery.

DUANE S RETRACTION SYNDROME Classification Mechanism & pathogenesis of DRS . Features of Duanes Grading of globe retraction & overshoots. Ocular and systemic associations Surgical approach with respect to eso- or exotropic DRS/ Y overshoot/ Recession of co-contracting muscles for globe retraction

split for

DISSOCIATED STRABISMUS COMPLEX Definition Components dissociated vertical (DVD), horizontal (DHD) & torsional (DTD) Usually non fixing eye, best seen with translucent occluder Symptoms & AHP Classification Evaluation- Prism Under Cover Test, Bielchowsky s phenomenon, Red glass test

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Differential- IOOA Surgical management- indications-surgeries for comitant/ incomitant DVD, DHD, DTD.

MONOCULAR ELEVATION DEFICIT (MED) Definition Features of MED-restriction of upgaze in straight up, adduction & abduction, ptosis, pseudoptosis or both, Marcus Gunn Jaw winking & AHP. Subtypes of MED with etiology and differentiating features . Acquired causes & Differentials. Management-non-surgical management refractive correction & amblyopia treatment. Surgical management indications and types. IR restriction present- IR recession, Horizontal muscle transposition for elevation deficit- full tendon, half tendon, full tendon with posterior fixation suture, unilateral horizontal muscle transposition, Modified Nishida s procedure. Ptosis surgery if required done post squint surgery

BROWN S SYNDROME Definition Congenital & Acquired Brown s and underlying pathology Types & characteristics Grades of Brown s Evaluation- proper history, strabismus evaluation, any coexisting amblyopia Management- refractive error & amblyopia correction, treatment of any underlying systemic diseases causing Brown s syndrome. Surgical managementSO tenotomy

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Complication

CRANIAL NERVE PALSIES All cranial nerve palsies require evaluation of other cranial nerve palsies 3RD CRANIAL NERVE PALSYEtiology Clinical characteristics- Total check pupil involvement (congenital cases aberrant regeneration of 3rd nerve)/ Partial- superior or inferior division, Isolated muscle palsy / other cranial nerve palsies +/Evaluation- prism cover testing (primary and secondary), fusion, ocular rotation & muscle function. Investigations- MRI of brain and orbit or CT scan as per age and etiology Differentials - restrictive causes, Myasthenia, early CPEO Management- Acute cases observation for initial 6months, diplopia if present treated with occlusion / prisms/ botox injection. Surgical management- as per muscle involvement and secondary contracture. Aim- straight eyes with BSV in primary gaze 4th CRANIAL NERVE PALSY OR SUPERIOR OBLIQUE PALSY- (fallen eye syndrome) Congenital or Acquired- etiology , muscle anatomy, facial asymmetry (mostly congenital cases) & AHP. Clinical evaluation- measurement of deviation , Parks 3step test, torsion (subjective and objective), Versions, always check for Bilateral SO palsy. Family album Tomography (FAT scan), Imaging to rule out SOL and check muscle status, rare instances edrophonium test to rule out myasthenia Differentials

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Management- usually surgical- intraoperative Exaggerated traction testing (lax SO) & traditional traction testing (SR contracture) Surgery is based on angle of deviation in primary position +/- IOOA, associated SO laxity, SR contracture if with IOOA- IO weakening, if not ipsilateral SO tucking (lax SO muscle)/ SR recession (SR contracture) or contralateral IR recession - if with IOOA- IO weakening + a combination of SO tuck/ SR recession (ipsilateral) or contralateral IR recession - Harada Ito procedure otherwise correction of V pattern and diplopia in side gazes Post-op complication- Iatrogenic Brown s syndrome. 6TH CRANIAL NERVE PALSYHistory to determine etiology & recurrence- adults & children Clinical evaluation-face turn, horizontal diplopia, horizontal incomitance in unilateral cases, pattern strabismus, deviation in AHP, forced primary and lateral gaze, vertical deviations if any. Diplopia charting, Forced duction & force generation testing, saccadic velocity testing if needed, MRI in appropriate cases & also to rule out concomitant SO or other cranial nerve involvement Treatment- occlusion, prisms, Botox injection to MR, surgery after deviation has stabilised.

NYSTAGMUS CEMAS classification, Alexander Law, null point Features of INS/FMNS/ Spasmusnutans

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Mechanism for stable eye movements Acquired nystagmus Nystagmus evaluation- direction, plane, intensity, normal eye movements, conjugacy, associations, cover, convergence Extensive workup- visual acuity, pupils, anterior and posterior segment, VEP, ERG, NAFX score, eye movement recording, neuroimaging , other speciality Treatment nonsurgical- glasses based on cycloplegic refraction, prisms and Botox injection. Surgical correction for (i) Nystagmus (ii) AHP (iii) AHP with strabismus (iv) other surgical procedures SURGICAL TECHNIQUES Pre-op evaluation- assessment of vision, refraction & Amblyopia treatment, measurement of deviation, intraoperative tests- FDT, exaggerated FDT for obliques. Deviation under general anaesthesia Weakening procedures for rectiRecession- conventional/ hang back / hemi-hangback/ adjustable- sliding noose & half knot/ vertical transposition of horizontal recti/ slanting recession Retro-equatorial myopexy (Faden s) Marginal myotomy Myectomy Freetenotomy or disinsertion Strengthening procedures for rectiResection Advancement Tucking

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Transposition of adjacent muscles Weakening procedures for ObliquesInferior oblique Generalised weakening:

Selective weakening:

Recession/ myectomy/ disinsertion/ Denervation/ Extirpation

Anteropositioning with recession/ pure anteropositioning (without recession)/ total anteropositioning/ recession of anterior fibres.

Superior oblique Generalised weakening:

Selective weakening:

Tenotomy (temporal/ nasal approach) / Tenectomy/ Recession/ Translational recession/ L-lengthening/ Silicone expander

Posterior tenotomy or tenectomy / Recession of anterior fibres/ Anteropositioning

Strengthening procedure for obliques: Inferior Oblique Generalised strengthening:

Selective strengthening:

Advancement / Resection &/or double breasting

Advancement of anterior fibres

Superior Oblique Generalised strengthening:

Selective strengthening:

Tucking

Harada Ito procedure

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Complications of Strabismus surgery: Intraoperative & postoperative Anaesthesia related Special importance- slipped or lost muscle, Anterior segment ischemia

REFERENCES: 1.Rosenbaum AL , Santiago AP. Clinical Strabismus Management- Principles and Surgical Techniques 2.Sharma P. Strabismus Simplified. 2nd Edn

Dr. Smita Ghosh completed her Diploma in Ophthalmology from RIO, Medical College and Hospital, Kolkata followed by a post Diploma DNB from Sankara Nethralaya, Chennai. She is currently pursuing Fellowship in Pediatric Ophthalmology, Strabismus and Neuro-ophthalmology from Sankara Nethralaya, Chennai. You can reach her at smitaghosh210@gmail.com

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Pediatric Ophthalmology Resources for Residents and Fellows For many Residents, Pediatric Ophthalmology education is limited to a few classes in the curriculum and a few months of posting in paediatric ophthalmology department if they are lucky to have a separate and dedicated paediatric ophthalmology department at their training institute.

For fellows duration is limited and therefore they should be prepared to work hard in order to make the most of it . Only working hard is not sufficient. As said by William Osler

He who studies medicine without books

sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.

All medicos must update themselves with latest advances in their field. Traditional way of earning knowledge via books and hard copies is changing now, especially post COVID. Online resources have brought a revolutionary change in education, not only because they are convenient and accessible, but also they make the entire process of teaching and learning more interesting and memorable

While Google makes it easy to search for specific topics, sometimes it s also nice to have a list on hand. Here are some websites that I ve found extremely helpful for reviewing paediatric ophthalmology topic.

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American Association for Pediatric Ophthalmology and Strabismus (AAPOS) The American Academy of Ophthalmology (AAO) offers an interactive simulator designed to teach and allow practice of basic strabismus evaluation. Simple comitant deviations are demonstrated in the current model. Visit the AAO website to learn more:https://aapos.org/education/educational-resources

Cybersight Cybersight offers free online courses in ophthalmology, developed and delivered by international ophthalmology experts, on various topics of, pediatric ophthalmology and strabismus. All courses are optimized for mobile devices. Visit :-https://cybersight.org/online-learning/

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Tim root ophthalmology https://timroot.com/ One of the easiest way to learn ophthalmology is Dr. Timothy Root s website. He has simplied ophthalmology by his quirky illustrations in the form of cartoons,videos, podcasts and flash cards. If you are looking to learn about the eye, you are in the right place!Dr.Root created this website to get your ophthalmology/optometry knowledge up to speed as quickly as possible. On this site you ll find: Video Lectures about eye anatomy and eye diseases Books (some of them free) that are written at a beginner level Extra learning material such as flashcards, audio podcasts, and software to help you learn about ocular disease. This site provides an easy access to general and pediatric ophthalmology as well.Plus, if you enjoy corny jokes and fun facts, then your learning will be sprinkled with a few chuckles along the way.

EyeWiki https://eyewiki.org/Main_Page A platform where ophthalmologists and other physicians can get an access to articles written by ophthalomogists , covering

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various categories of eye disorders ranging from cataract / anterior segment diseases to neuro-ophthalmology and pediatric ophthalmology and strabismus. It delivers a very comprehensive coverage of common and uncommon eye conditions. Definitely a go to resource for learning more about rare cases and advances in ophthalmology.

Healio Ophthalmology The Healio is an educational website which covers all branches of modern medicine at https://www.healio.com/. In ophthalmology, the Education lab is available at https://www.healio.com/ophthalmology/education-lab. It is designed to provide an in-depth specialty clinical information. It delivers dynamic multimedia, question-and-answer columns, CME and other educational activities in a variety of formats, quick reference content, blogs, peer-reviewed journals and a full line of popular book titles.

eOphtha It is an online portal, which has bundle of information on ophthalmology including online text books, presentation slides, blog, links to useful websites and more.

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eOphtha remains an excellent resource for information in the field of ophthalmology and boasts of users not just from India but world over. The website has become a go to resource, especially amongst the trainees. Pedaitric ophthalmology is widely covered on eOphtha. The creativity of the information provided on the website has made it popular amongst practising ophthalomogists and also residents and fellows.

YOUNG OPHTHALMOLOGISTSOCIETY OF INDIA The YOSI is created by young ophthalmologists belonging to India as a platform to share ideas and knowledge in all specialties of ophthalmology (http://www.yosi.in/home.html). For the young trainee, it offers numerous educational tools such as the YOSI flash notes, YO Times that contains articles that pertain to requirements of the young ophthalmologists in the modern era, YoTube which is the official you tube channel of YOSI that aims to serve as a preferred medium of education for Young Ophthalmologists globally (https://www.youtube.com/channel/UC7c0oitsACPG0ug2gMi_StQ), and YO Central that consists of eBooks, CME

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All India Ophthalmological Society The AIOS website, www.aios.org provides additional academic materials in the form of webinars and AIOS YouTube channel. The webinars cover diverse range of topics in Pediatric ophthalmology and other subspecialties. There is also a subsection on surginars which are surgical educational programs for the trainees. Additionally, member can access the Indian journal of Ophthalmology (IJO) journal through the website.

International Council of Ophthalmology ICO offers conferences, courses, curricula, and online resources to anyone involved in ophthalmic education. To help enhance the quality of ophthalmic education worldwide, the ICO has defined curricula for training ophthalmology residents, medical students, and allied eye care providers. The ICO has got an elearning module on their website www.http://www.icoph.org/.

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We are grateful to Dr. Kunal Shinde, Dr. Ankit Ahir and Dr. Riddhi Raichura (DNB Residents Sri Sankaradeva Nethralaya, Guwahati )for compiling the Pediatric Ophthalmology online resources.

Dr. Kunal Shinde

Dr. Ankit Ahir

Dr.Riddhi Raichura

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Established in the year 2016, Dr. Agarwal's Eye Hospital in Anna Nagar East, Chennai is a top player in the category Eye Hospitals in the Chennai. This wellknown establishment acts as a one-stop destination servicing customers both local and from other parts of Chennai. Over the course of its journey, this business has established a firm foothold in it s industry. The belief that customer satisfaction is as important as their products and services, have helped this establishment garner a vast base of customers, which continues to grow by the day. This business employs individuals that are dedicated towards their respective roles and put in a lot of effort to achieve the common vision and larger goals of the company. In the near future, this business aims to expand its line of products and services and cater to a larger client base. In Chennai, this establishment occupies a prominent location in Anna Nagar East. It is an effortless task in

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commuting to this establishment as there are various modes of transport readily available. It is at 2nd Avenue, Opposite Nagappa Motors, Next to Apollo Medical Center, which makes it easy for first-time visitors in locating this establishment. The popularity of this business is evident from the 1100+ reviews it has received from Justdial users. It is known to provide top service in the following categories: Eye Hospitals, Hospitals, General Physician Doctors, Ophthalmologists, Eye Surgeon Doctors, Cataract Operation Doctors, Paediatric Ophthalmologist Doctors, Eye Lens Implant Doctors.

1. Name and contact details (phone number/ email ID) of the academic coordinator: Mr. John, Ph- 9445003890, email- fellowship@dragarwal.com

2. Type of fellowship offered and duration: Long term 1 year fellowship (no short term observerships) Number of seats offered: 2 seats per session Number of sessions: 2 sessions/year Dates for application: Application can be mailed all year round Starting date of fellowship: April and October

3. Process of application and selection: CV to be emailed- followed by interview at the centre 4. Any course fee for the same: No course fee Stipend paid: Rs 30, 000 per month Post fellowship work bond associated (if any): W are extremely grateful to Mr. John for providing us with the necessary details

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Aravind Eye Hospital

Aravind Eye Hospitals is a hospital chain in India. It was founded by Dr. Govindappa Venkataswamy (popularly known as Dr. V) at Madurai, Tamil Nadu in 1976. It has grown into a network of eye hospitals and has had a major impact in eradicating cataract related blindness in India. As of 2012, Aravind has treated nearly 32 million patients and performed 4 million surgeries. The model of Aravind Eye Care hospitals has been applauded and has become a subject for numerous case studies across the world.

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1. Name and contact details (phone number/ email ID) of the academic co-ordinator: Dr. P. Vijayalakshmi Chief, Pediatric Ophthalmology and strabismus Dept., Aravind Eye Hospital, Madurai. Email id: p.vijayalakshmi@aravind.org Contact person- Ms. Chandra, Ph- 045 24356100. Emailpaediatricsecretary@aravind.org

2. Type of fellowship offered, and duration- short term observership/ long term fellowship/ both A) Long term fellowship : Duration - 24 months at Pondicherry 18 months at Coimbatore, Tirunelveli & Tirupati

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18 months & 24 months at Madurai 18 months posting detail: (General OPD posting for a period of 4 months & Paediatric ophthalmology for 14 months) 24 months posting details: General ophthalmology for 10 months at one of our peripheral centres and Paediatric ophthalmology for 14 months) Course duration will depend on the surgical skills in managing adult cataract. B) Short term Observership: 2 months duration (no hands-on training) 3. Number of seats offered per session/ number of sessions/ dates for application/ starting date of fellowship Pediatric ophthalmology fellowship course is available at Aravind Eye Care system: Madurai, Coimbatore, Pondicherry and Tirunelveli Seats offered per session 4 Total position per year -19 (AEH-all centres) Number of sessions - Quarterly ; Staring date: 1st of the month Dates for application - 2 -3 months prior to the session 4. Type of exposure : At Out-patient department - Exposure to paediatric refraction, orthoptic evaluation and management, tackling all paediatric eye diseases. Operation theatre Exposure to surgery cases; Assisting followed by surgery under supervision and finally individual surgeries. Posting also include pediatric retina including ROP, Orbit &oculoplasty, Low vision clinic and Neuro-ophthalmology

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5. Names of the present Paediatric Ophthalmology faculty at your institute: Madurai - Dr. Shashikant Shetty, Dr.Rupa ,Dr.Sahithya & Dr.Janani Coimbatore Dr. Kalpana, Dr. Sandra Ganesh, Dr. Sasikala Elizebeth, Dr. Amruthasindhu, Dr.S hilparao, Dr.Parthpatil , Dr. Vanathi , Dr. Srushti and Dr. Krishnababu Tirunelveli - Dr. Meenakshi, Dr. NeelamPawar, Dr. Fathima, Dr. Anuraag Gandhi & Dr. Sabaya Sachi Chakravarthy Pondicherry Dr. Veena K, Dr. Fredrick Moutappa, Dr. AnjaliKhadia Tirupathi Dr. Sathya T Ravilla 6. Process of application and selection Apply through online portal (link given below) with all the certificates. http://www.aurovikas.co.in/web_lterm_onlineapplicationform_instr uction.aspx?enc=7UvMY9WwUxsByRyQJDXunpSmLyqwEHFwg5BYwv PwWms2RooDkk8dgq32NS0TZlCL After receiving the application form, it will be reviewed by the concerned team and an interview will be fixed, if the candidate is found to be acceptable. The interview consists of an oral and written examination process. The candidate suitable for the institute will be selected and informed accordingly. 7. Any course fee for the same, Stipend paid, post fellowship work bond associated (if any) No course fee (only Application fee is applicable: INR 1000 +18%GST) Stipend paid yes Post fellowship bond - NIL 8. Number of sanctioned leaves during the tenure 15 days per year

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9. Names and contact details of 3 present or past (within 2 years) fellows: Dr. AnshuleeSood -anshuleesood@gmail.com Dr. ChancalGadodiya chanchal2gadodiya@gmail.com Dr. SnehalGanatra - snehal1989@gmail.com We are extremely grateful to Ms. Chandra for providing us with the necessary details.

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BB EYE FOUNDATION

The seed of B B Eye Foundation was sown by Dr Pradeep Kumar Bakshi in 1989, as a centre for cataract surgery. In the last two decades it has grown from strength to strength and today it is a landmark for total Eye Care in Eastern India. Dr. Bakshi is one of the most experienced surgeon in the country, who revolutionized eye surgery in Eastern India, with IOL implantation in the eighties and phacoemulsification in the nineties. Living up to this tradition, we are amongst one of the first to do microphaco, use customized IOLs, equip the Glaucoma Services with the newest of technologies, perform the most advanced vitreo retinal, strabismus and pediatric cataract surgeries, and offer highest quality of cornea services with the turn of the century. B B Eye Foundation is spread over three floors with three composite units The Clinic Section, The Surgery Centre and The Diagnostic Centre. The Clinic Section is equipped with examination rooms, where experts in all subspecialties of Ophthalmology are available to see patients, aided by an optometry section where highly skilled technicians are at work. Optometrists also undergo Internship training programs for a year. B B Eye Foundation has three fully functional Operation Rooms with Leica and Zeiss microscopes, Alcon Infinity and AMO Signature Phacoemulsification systems

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and Alcon Vitrectomy equipment. The Diagnostic Section is equipped with the latest state of the art equipments at par with the best centers in the world. We are one of the select group of practices that are continually involved in clinical research and have presented scientific papers and chaired sessions at National and International levels of Ophthalmic CME programs. Relevant to say , that surgeons from the Foundation have delivered talks and Instruction courses at the highest level of Ophthalmic platforms like the American Academy of Ophthalmology and the All India Ophthalmological Society. The surgery centre is one of the most modern and complete eye care facilities in the country. The operating suites have state of the art equipments and are well supported by the in house Physicians and Anesthesiologists. The Diagnostic Centre is complete with the latest equipments in Lasers, DFA, Biometry, Perimetry, Dynamic Contour Tonometry, Specular microscopy, Pachymetry, Ultrasonography and OCT3.

1. Name and contact details (phone number/ email ID) of the academic coordinator: Dr. Lav Kochgaway (Director), email- lav.kochgaway@gmail.com

2. Type of fellowship offered and duration: Long term 1 year Fellowship

3. Number of seats offered per session: 1(one)/session Number of sessions: 1 session /year Dates for application/ starting date of fellowship

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4. Process of application and selection: CV to be emailed- followed by Interview

5. Any course fee for the same: none Stipend paid: Rs 25,000 pm Post fellowship work bond associated (if any): none

We are extremely grateful to Dr. Lav Kochagaway for providing us with the necessary details. Dr. Lav Kochagaway is an Executive Director and Consultant at B. B. Eye Foundation, VIP, Senior Consultant at B B Eye Foundation, Director SLR Eye and Retina Surgeons. He is Consultant Pediatric Ophthalmology, Strabismus, Cataract, Squint, Lasik and Ocular Trauma. He was privileged to be the first candidate to graduate from the now illustrious Sankara Nethralaya Orbis Pediatric Ophthalmology Learning and Training Center.

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To have a major impact on blindness and deafness eradication in India, especially among poor, by building an accessible, self-sufficient model institution, that has internationally approved performance standards, and is focused on quality, excellence and patient-care. Founded in 1926, Dr. Shroff's Charity Eye hospital is a non-commercial, non-profit trust setup enabling people from all sections of the society to receive quality eye care. SCEH has a strong 75-year old tradition of eye care, and more recently, ear, nose and throat care. The hospital has been known for both its high-quality as well as the compassionate treatment it has offered its patients. The Eicher group started providing substantial assistance to this hospital in 1996, both in terms of funds and expertise. And gradually, this hospital started to

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emerge as one of the finest ophthalmic and ENT hospitals in Delhi owing to its international standards and adherence to hygiene and quality. SCEH's long-term goal is to provide care approaching that of international standards for all patients, while at the same time increase the treatment of poor people at minimal or no cost, thereby becoming a true center of excellence. SCEH is now following a combination of the very successful models used by three outstanding Indian eye hospitals with international quality standards L.V Prasad Eye Institute in Hyderabad, Sankara Nethralaya in Chennai, and Aravind Eye Hospitals in Madurai. During recent years, SCEH has expanded its services, which include: A new Vision Enhancement Centre, which provides vision-enhancing devices and advice to severely visually impaired or blind patients and for whom a little more can be done surgically or medically. A School Screening Programme wherein teachers in schools are given necessary training to identify the students who are having some visual impairment. These students are treated in SCEH and return to school with improved capacities. An aggressive Outreach Programme which connects people who need financial assistance and live in less accessible locations, and those who are poorly informed about the solutions of their unnecessary blindness. The main outreach is its satellite clinic in Alwar, Rajasthan. It has also introduced high-quality educational conferences, a Quality Assurance Programme, and an intensive medical and patient-focused skills enhancement agenda. Over the years, SCEH has made tremendous strides towards excellence and is currently expanding and upgrading its services and reach.

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1. Name and contact details (phone number/ email ID) of the academic coordinator: Ms. Kalpana Gupta, (training Executive).Ph: 011-43524444 / 8888. Email: training@sceh.net 2. Type of fellowships offered and duration- short term observership2months -long term 2yearsfellowship 3. Number of seats offered per session/ number of sessions/ dates for application/ starting date of fellowship: 2sessions/year Short term- 2 seats/ session, session commences January and August Long term- 1-2 seats/session, session commences June and December 4. Type of exposure: Clinical + surgical 5. Names of the present Pediatric Ophthalmology faculty at your institute Dr Suma Ganesh, HOD of Pediatric Ophthalmology 6. Process of application and selection: Application and CV to be emailed. Selection is based on merit 7. Any course fee for the same, Stipend paid, post fellowship work bond associated (if any): 8. Number of sanctioned leaves during the tenure: One per month We are extremely grateful to Ms. Kalpana Gupta for providing us with the necessary details.

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H. V. DESAI EYE HOSPITAL

The Pune Blind Men s Association (PBMA) established the HV Desai Eye Hospital, located in Maharashtra, India in 2000. PBMA is a center committed to the socioeconomic rehabilitation of people who are blind and has been active for the past 60 years. The eye hospital has examined more than 2.7 million patients and completed more than 400,000 eye surgeries since it was established 15 years ago. Approximately 60% of patients are treated absolutely free through a sustainable

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fee system where paying patients cover the cost of services for non-paying patients.

HV Desai operates a tertiary center in Pune and has two secondary centers. It also operates 7 vision centers in and around Pune. In recent years, they have completed almost 10,000 surgeries annually. The Chief Medical Director of HV Desai, Dr. Col. M Deshpande, also served as the President of VISION2020 India for a number of years.

HV Desai offers postgraduate and paramedical ophthalmic training and has emerged as a leading comprehensive eye care center in the region and works with mentees to build the capacity of hospital staff and increase economic sustainability. Seva works with HV Desai to spread their model through the Global Sight Initiative and provides subsidized direct service support through Focusing Philanthropy s World Sight Day campaigns and outreach and school screenings through the Bio Eyes Buy a Frame, Help a Child to See program.

1. Name and contact details (phone number/ email ID) of the academic coordinator: Mrs. Sangeeta Patil, Ph- 020-26970144, emaildesaieyehospital@hvdeh.org, training@hvdei.org 2. Type of fellowship offered, and duration- short term observership/ long term fellowship: Short term 3 months, Long term 15 months. 3. Number of seats offered per session/ number of sessions/ dates for application/ starting date of fellowship: Short term- 2 seats per 3 months, long term fellowship- 3seats/year.

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4. Type of exposure: Long term fellowship-Observing Pediatric examination and evaluation initially, followed by handling Pediatric Clinics individually. -Orthoptic evaluation in children and adults, Vision Assessment in children of all ages. -Amblyopia assessment and treatment protocols for amblyopia therapy. -Assisting and observing speciality surgeries like Pediatric Cataract surgeries, Strabismus, nystagmus surgeries, Vertical strabismus . -Hands on training in strabismus and pediatric cataract surgery in a step by step manner. -Minimum number of squint surgeries -25 ( assisted and supervised by senior Consultants). -Pediatric cataract surgeries- Number would depend on the surgical skill of the fellow. The fellow will be able to perform pediatric cataract surgery with Primary posterior Capsulorhexis in a confident manner. -The fellow will be doing adult SICS cataract surgeries every week to keep in touch with the skill set.A basic number of adult Phaco surgeries will be given in the last 3 months of fellowship. -They get exposed to Uvea and ROP quite extensively and in a limited way to Retinoblastoma and Ocular Oncology. We have a separate department of oculoplastics and ocular oncology. Short Term Observership-

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-Paid Observership wherein the short term fellow can participate in examination of children in the clinics and evaluate strabismus, nystagmus and amblyopia. -Can learn the important techniques of refraction in children of all ages including infants, and in post cataract surgery refraction. -No hands on surgical training

5. Exposure to research and expectations by the institute in research: Fellows are expected to participate in ongoing research projects during the term of their fellowship They also get to attend classes to improve research skills (Preparing a project proposal, ethics in medical research, skills for literature search, basics of biostatistics etc) 6. Names & positions of Faculties: Dr Nikhil Rishikeshi DOMS, FPOS Dr Sudhir Taras , Chief Orthoptist and Pediatric Optometrist Dr Anukul Dixit, MS, FPOS Dr Mahesh Thikekar MS, FPOS 7. Process of application and selection: CV to be emailed- followed by a short questionnaire and interview at the centre 8. Selection procedure in brief including probable dates (Interview & Joining): Candidates are required to appear for interview at H V DESAI EYE HOSPITAL where candidates approach towards case diagnosis and management is tested. They are administered a short questionnaire before interview to gauge their experience, clarity of thoughts and attitude.

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9. Most important points that you consider in a CV -Previous academic achievements -Qualifications -Attitude and motivation which is assessed in written questionnaire) -We give importance to where (Hospital/city/place) the fellow would finally work after the fellowship (It gives us insight into how the fellowship training would get utilised) . -Research aptitude of the candidate -Conference presentations and publications 10.Number of permitted leaves There are 8 fixed leaves during the long term fellowship. Fellows are encouraged to be regular and take minimum leaves during the period. 11.Any peripheral centres for compulsory rotation and duration of the same Nandurbar and Jalgaon satellite centres where fellows may be posted for patient care services if required. 12.Any course fee for the same, Stipend paid, post fellowship work bond associated (if any): Fee to be paid in short term observership. Long term- stipend Rs15,000 /month (accommodation charges deducted, if applicable) No bond. We are extremely grateful to Mrs. Sangeeta Patil for providing us with the necessary details.

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JYOTIRMAY EYE CLINIC

Jyotirmay eye clinic was established in the megapolis of Thane and Mumbai in the year 2005 initially with the aim of providing best eye treatment for children. Comprehensive eye care for adults was added in the year 2019. State of the art infrastructure for pediatric eye care was laid down and a pediatric ophthalmologist (children s eye specialist), a pediatric optometrist (children s optometrist), a pediatric-anesthetist and a pediatrician (child specialist) came together to provide skillful treatment for kids eye problems. Jyotirmay became the first dedicated hospital for children s eye treatment in western India and Dr Mihir Kothari led the team. In addition to providing pediatric eye care, advanced setup was established for the treatment o f squint in children and squint treatment in adults. The clinic has kept its promise by adding newer technologies and evidence based treatment protocols to provide the latest treatment in its pursuit of providing best pediatric ophthalmology and strabismus services to its fellow citizens. In the year 2012, Jyotirmay eye clinic added first of its kind nystagmus treatment center in India after the installation of Intellinext, video-nystagmography system from Eyedentify Inc. USA. Nystagmus or shaking of eyes is a common eye problem in children and affects neurologically affected adults for which not much medical help was available. Our medical director underwent special training and contributed immensely towards increasing the awareness regarding the problems

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and management of nystagmus among other kid eye doctors by conducting several education programmes (CME, workshops etc), presenting the research papers and writing book chapters on nystagmus and nystagmography. In the year 2015, a modern children s spectacle dispensing unit was commenced at Jyotirmay eye clinic. The eye treatment for children became easy with better spectacle frames and lens dispensing technology. A silver medal was awarded to us for a seminal research on the quality of spectacles in the children in India. The pediatric eye specialists in India are welcome to contact us for cost effective optical needs of their patients. In the year 2016, orthoptic (eye exercises) department was started to provide evidence based and latest treatment for lazy eye correction and correction of crossed eyes using the dichoptic therapy/binocular eye exercises. In the year 2019 Jyotirmay eye clinic reached new dimensions in the quality and safety of eye care for children and adults. The clinic received accreditation from the quality council of India, NABH, under the category of eye care organisation (ECO) which that simply means the standards of treatment of kids eye problems and squint treatment offered in Jyotirmay eye clinic meets international standards. An organisation is defined by its values. We value our patients and we exist for providing services to them. We believe in a fair, value based, efficient, scientific and compassionate health care delivery system. Our vision is to create a state of the art and unparalleled pediatric eye care facility incorporating comprehensive eye care for adults. Our core values include Commitment to quality Patient satisfaction Mutual respect Strive for excellence Friendly work atmosphere Continual education Societal commitment

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1. Name and contact details (phone number/ email ID) of the academic coordinator: Dr. Mihir Kothari, 932037173/drmihirkothari@gmail.com

2. Type of fellowship offered, and duration- short term observership/ long term fellowship/ both: Both (observership, 3 months and 4 months training, 1 year fellowship)

3. Number of seats offered per session: 3 per session - one long term and 2 short term Number of sessions:2 sessions / year Dates forapplication: first week of September and first week of April every year Starting date of fellowship: 1st Oct and 1st May

4. Type of exposure: The course would include training in following diagnostic and management skills. DIAGNOSTIC SKILLS: Vision assessment and refraction in infants and children. Vision screening in children. Diagnostic approach to common Pediatric ophthalmic disorders. Screening for the retinopathy of prematurity. Evaluation of patients with diplopia. Evaluation of binocularity, stereopsis, fusional amplitudes and accommodative amplitudes. Practical approach to the diagnosis of strabismus. Paddle tests (Cover Test, Uncover TEST, simultaneous prism cover test etc). Use of prisms to quantitate

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the deviation, Hess charting, Forceps tests, Evaluation of versions, vergencesduction, saccades and ocular torsion. Working up the cases of nystagmus and other ocular motility disorder. Tensilon / Prostigmine test for myaesthenic. Evaluation of congenital epiphora. Evaluation of congenital ptosis etc Eye movement recording for nystagmus and other relevant motility disorders. Forced duction and force generation tests using Scott force forceps.

MANAGEMENT SKILLS: NON-SURGICAL: Therapeutic approach to common Paediatric disorders. Principles of spectacle correction in strabismic and non-strabismic children. Ophthalmic prism dispensing. Examination under sedation. Vision therapy, low vision rehabilitation and management of cerebral vision impairment. YAG laser posterior capsulotomy.

SURGICAL: Conventional and fornix incision strabismus surgery. Adjustable suture technique. Nystagmus surgeries. Muscle Transposition Surgeries. Endoscopic probing and lacrimal sac surgery in children. Paediatric Cataract surgery. Trabeculotomy/ Trabeculectomy, Ahmed Galucoma Valve implantation, Goniotomy. Management of Pediatric eye trauma.

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Enucleation and orbital implant. Surgeries for Congenital Ptosis etc.

Hands on skill transfer policy: Hands on training is done at variable frequency. We conduct camps at Bhiwandi, Girgaon and outstation. The surgical cases can vary as per the patient load. Research by Fellows: By default, a fellow will be engaged in all / any ongoing research work of the clinic.

5. Names of the present Pediatric Ophthalmology faculty at your institute Dr Mihir Kothari, Dr Ashwin Sainani, Dr Neepa Thacker, Dr Shalini Kaul, Dr Siddharth Kesarwani, Dr AshishDoshi, Dr Prachi Agashe, Dr Shruti Mittal as part of Group of Pediatric Ophthalmologists and Strabismologists of Mumbai.

6. Process of application and selection: Please send your CV, recent photograph, Adhar card and a copy of your MBBS as well as MS/DNB/DO/CPS certificate through e mail. Application to be forwarded to drmihirkothari@gmail.com only in the first week of September and first week of April every year. It is compulsory to take professional indemnity of 50 lakhs, medical fitness certificate, TT and HBSAg immunisation before joining the fellowship program. It is desirable that the trainees bring their direct ophthalmoscope, indirect ophthalmoscope with 28D/20D lens and prisms. The candidates will have to take care of their own accommodation, travel and food.

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Observers are also welcome.

7. Any course fee for the same, Stipend paid, post fellowship work bond associated (if any): None 8. Number of sanctioned leaves during the tenure: One per month 9. Names and contact details of 3 present or past (within 2 years) fellows Dr Meghna Solanki, solankimeghna@gmail.com, 9928289198 Dr Shairin Jahan , jahanshairin@gmail.com, 9304350424 Dr Prolima Thacker, dr.prolima@gmail.com, 9911471600

We are extremely grateful to Dr Mihir Kothari for providing us the above details. He is the Director, Jyotirmay Eye Clinic, OCULAR MOTILITY LAB and Pediatric Low Vision Center. MS, DNB, FPOS, FAICO, Diploma in Pediatric Ophthalmology and Strabismus (USA) Fellowship in Pediatric Neuroophthalmology (USA)

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LV Prasad Eye Institute (LVPEI)

Established in 1987, L V Prasad Eye Institute (LVPEI) is a comprehensive eye health facility with its main campus located in Hyderabad, India. A World Health Organization Collaborating Centre for Prevention of Blindness, the Institute offers comprehensive patient care, sight enhancement and rehabilitation services and high-impact rural eye health programs. It also pursues cutting edge research and offers training in human resources for all levels of ophthalmic personnel. LVPEI is the first major eye institute in India to receive accreditation from the National Accreditation Board for Hospitals and Healthcare providers (NABH). The Institute's Kallam Anji Reddy campus in Hyderabad, Shri MithuTulsi Chanrai Campus in Bhubaneswar and the GMR Varalakshmi campus in Visakhapatnam are NABH accredited. LVPEI focuses on economically disadvantaged groups in rural and urban geographies and extends its services to them through its network of satellite clinics and rural affiliates. The LVPEI network comprises a Centre of Excellence in Hyderabad, three tertiary centres in Bhubaneswar, Visakhapatnam and Vijayawada, 16 secondary and 158 primary care centres that cover the remotest rural areas in the four states of Telangana, Andhra Pradesh, Odisha and Karnataka.

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1. Name and contact details (phone number/ email ID) of the Academic Co-ordinator: Ms. Snigdha (Assistant Director, Academy for Eye Care Education), Ph 040-68102164, email- snigdha@lvpei.org 2. Type of fellowship offered: short term observership / long term fellowship Duration: Short term 3 month observership Long term 3 years fellowship 3. Number of seats offered per session:2-3 seats Number of sessions: 2 sessions Dates for application: joining in January and August Starting date of fellowship: -Do4. Process of application and selection: CV to be emailed- online written mock test- MCQ test at the centre- interview 5. Any course fee for the same: Course fee Rs. 1,20,000 for short term, Application fee of Rs. 5,000 for long term Stipend paid: Stipend not disclosed. Post fellowship work bond associated (if any): none We are extremely grateful to Ms. Snigdha for providing us with the necessary details.

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MM JOSHI EYE HOSPITAL

M. M. JOSHI EYE INSTITUTE , also known as PADMA NAYANALAYA is the biggest exclusive, ophthalmic super specialty Eye care Hospital in Hubbali (North Karnataka). It was founded in 1967 by Dr. M. M. Joshi and since its inception, it has been an icon of advanced ophthalmic care, being the major referral hospital in this part of the country, with its catchment area comprising of entire North Karnataka, Goa, Southern Maharashtra & adjoining Andhra Pradesh. M. M. Joshi Eye Institute is a High-Tech Eye Hospital offering comprehensive Eye Care facilities and also a Postgraduate training Institute of Ophthalmology. Childhood blindness relief is one of the flagship programs of M M Joshi Eye Institute and many community pediatric ophthalmology initiatives are underway covering entire North Karnataka. This includes Anganwadi Screening, School

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Screening activities along with sight restoring pediatric surgeries providing ample hands on training for the fellows.

1. Name and contact details (phone number/ email ID) of the academic coordinator Dr. R Krishnaprasad (Head, Department of Pediatric Ophthalmology and Strabismsus) Ph- 9243288246, Dr. Deepti Joshi Ph- 7829909811 2. Type of fellowship offered, and duration- short term observership - Long term 1 year fellowship 3. Number of seats offered per session: 2 seats/ session Number of sessions: 1 session/year Dates for application: Interview in last week of June Starting date of fellowship course commencement on 1st July 4. Type of exposure: Pediatric cataract, pediatric cornea, pediatric glaucoma, pediatricoculoplasty, adult and pediatric strabismus and ROP.In addition, as a part of community service fellows get a chance to operate community SICS and phacoemulsification cases. 5. Names of the present Pediatric Ophthalmology faculty at your institute: Dr. R. Krishnaprasad, Dr. Deepti Joshi & Dr. AnjanaKuri. 6. Process of application and selection: Online application (on institute website)- written test and personal interview. 7. Any course fee for the same, Stipend paid, post fellowship work bond associated (if any): No post fellowship bond.

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8. The latest 3 fellows to complete pediatric ophthalmology and strabismus are: Dr Ohm Patel- 9925645844 Dr Lakshmi K S- 9480012862 Dr Anusha K L- 7411080944 We are extremely grateful to Dr. Deepti Joshi for providing us with the necessary details.

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Sitapur Eye Hospital

Sitapur Eye Hospital has been a leading Tertiary care eye institute of India since 1947. Established in 1927, it has been serving the people of India for more than 90 years. Founded by Dr. M.P. Mehray Padma Bhushan, Padma Shree Rai Sahib, Rai Bahadur DR BC Roy Awardee in a small town called Khairabad, where patients were served in small huts and tents.Later on if has shifted to the present location in the year 1947. Sitapur Eye Hospital (SEH) serves more than 32 cities and towns in the states of Uttrakhand and Uttar Pradesh. Today the base hospital in Sitapur is a 500 bed facility and has more than 1500 beds amongst the rest of its 32 branches all over. Invariably appreciated by various Leaders of the nation before and after independence from pre independence era of India, the hospital has been a center of great pride and excellence, which continues to serve the poor and rich with cost effective services and enthusiasm that remains unmatched. The history of this hospital has seen, great personalities such as Pandit Jawaharlal Nehru, Smt. Indira Gandhi, Rajmata of Nepal, Shri Lal Bahadur Shastri, Dr. Radha Krishnan, Sri V.V. Giri, Sir John F. Wilson amongst others visitors and appreciate the great work, being done by the institute. The hospital is equipped with world class facilities equipment and instruments and continues to provide the international quality eye care at the lowest price possible in India. At its nucleus center alone in Sitapur, it serves more than 200000 patients every year and more than 4 lac patients between all its branches in the two state of UP and Uttrakhand This is besides the various Camps that the hospital organizes for the poor & underprivileged in various villages and districts, in order to bring awareness and service for better Eye Health. The hospital also houses Nehru Institute of Ophthalmology & Research, which was

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The hospital also houses Nehru Institute of Ophthalmology & Research, which was established keeping in mind the growing consciousness of the people in the matter of specialized treatment and the need for more qualified personnel, in Ophthalmology. The foundation stone of this institute was laid in 1964, by the then President of India, Sri Dr. S. Radha Krishnan. In the year 1981, it was upgraded to regional institute of ophthalmology by govt.ofindia 1. Name and contact details (phone number/ email ID) of the academic coordinator: Mohammad Najaf 7607033333 hr@sitapureyehospital.org 2. Type of fellowship offered, and duration: Short Term Observership(1-3 months) Long Term Fellowship (18 months) 3. Long Term Fellowship: Number of seats offered: 1 seat per session for long term fellowship Number of sessions: Yearly session Dates for application: Application can be mailed between December February Starting date of fellowship:1stApril Short TermObservership:1 seat on monthly & quarterly basis. Application can accept but training slot can allot on the queue basis or on the availability of seat. And session of training period is January to December. 4. Type of exposure: A wide range of pediatric cases in clinics. Focus on skill development to evaluate and examine pediatric patients. Adult Cataract Surgery (SICS & Phacoemulsification), Strabismus Surgery & Pediatric Cataract Surgery. 5. Names of the present Pediatric Ophthalmology faculty at your institute: Dr. Ketaki Shashank Subhedar Dr. Subhajit Bhattachaarya

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6. Process of application and selection: Based on Application & Interview. 7. Any course fee for the same, Stipend paid, post fellowship work bond associated (if any): Short Term Fellowship (01 or 03 Months) - Paid Rs. 10,000/ month Long Term Fellowship on Stipend (1st year Rs. 25,000/ month and 2nd year Rs. 50,000/ month) 8. Number of sanctioned leaves during the tenure: C L - 14 days & S L - 07 days 9. Names and contact details of 3 present or past (within 2 years) fellows: NA

We are extremely grateful to Mohammad Najaf for providing us with the necessary details.

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Sadguru Netra Chikitsalaya

Shri Sadguru Seva Sangh Trust (SSSST) founded by Param Pujya Ranchhoddas ji Maharajis a humanitarian organization, established in 1968 on the premise of selfless service to mankind. Sadguru Netra Chikitsalaya (SNC) is a pair of rural hospitals that perform high volume eye surgeries in Chitrakoot and Anandpur, India. SNC has been partners with Seva since 2001. SNC was founded in the 1950s by Param Pujya Gurudev Shri Ranchoddas ji Mahara with the mission to provide food for the hungry, clothes for destitute and sight for the blind. To attain this mission, he formulated the Charitable Sadguru Seva Sangh Trust, under which the hospital functions today. It endeavors to provide quality eye care services to all sections of society, emphasizing the economically underserved.

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Sadguru Netra Chikatsalaya, Chitrakoot delivers state-of-the-art eye care and is recognized worldwide as the largest rural eye care provider of high quality comprehensive eye care. The institute provides six specialty fellowships vitreo retina and uveitis, pediatric ophthalmology and strabismus, glaucoma, cornea, oculoplasty and cataract and intra ocular lens implantation. Sadguru Netra Chikatsalaya runs an integrated pediatric centre called Children Eye Care Centre (CECC). Under one roof all pediatric eye specialties are provided. Sadguru provides two fellowships in pediatric ophthalmology of variable duration - two years and three years. Both the fellowship programs in pediatric ophthalmology and strabismus endow competence to practice independently.

Name and contact details (phone number/ email ID) of the academic coordinator: Dr. Devindra Sood. Head Academics, Research and Training E mail: sood@sadgurutrust.org Mobile: 8800200423

Type of fellowship offered and duration: -Short term fellowship/ observership of 2 months -2 & 3 year pediatric ophthalmology and strabismus fellowships respectively

Number of seats offered per session: -Short term fellowship / observership of 2 months 6 seats per year -2 year pediatric ophthalmology and strabismus fellowship 3 per year -3 year pediatric ophthalmology and strabismus fellowship 4 per year Number of sessions: 2 session per year

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Dates for application: December and June of each year Starting date of fellowship: February 1 and August 1 of each year 4.

Type of exposure: At CECC different eye specialties converge to provide integrated pediatric eye care. Fellows rotate amongst consultant s focusing on pediatric ophthalmology, strabismus, cataract, retina and uveitis, ROP, cornea, oculoplasty and glaucoma. In a step by step manner, surgical exposure is provided so that one operates independently squints, cataracts, glaucoma and oculoplasty. Currently performing an independent combined trabeculectomy and trabeculotomyabexterno are not a part of the pediatric ophthalmology and strabismus fellowship. Our model does not work on providing a fixed number of procedures. Depending on the performance of fellow s opportunities keep increasing. Overall adequate exposure is provided to make the ophthalmologist competent in pediatric eye care.

Academic pursuits include participation in weekly case presentations, journal clubs and a pediatric ophthalmology class with the entire hospital in the mornings. Pediatric ophthalmology case presentations, journal clubs and discussions are also an integral part of the evening departmental academic activities. Research activities are also encouraged and fellows participate in guided retrospective and prospective studies and case reports. 5.

Names of the present Pediatric Ophthalmology faculty at your institute

Dr PradhnyaSen (Head) Dr Amit Mohan

Pediatric ophthalmology, strabismus, cataract, trauma Strabismus, cataracts and pediatric ophthalmology

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Dr Chintan Shah

Trauma, cataract, strabismus and pediatric ophthalmology Dr EashaRamawat Cataract, strabismus, trauma and pediatric ophthalmology Dr GauravKohli Retinopathy of Prematurity Dr SachinShetty Retina and Uveitis Dr NarendraPatidar Oculoplasty Dr Gautam Singh Parmar Cataract Dr DevindraSood Glaucoma 6. Process of application and selection: Applications are accepted through the year but the process of selection happens twice a year (January and July first week) The selection process involvesa) An MCQ examination in the morning of the interview b) Panel interview in the afternoon for selected candidates 7.

Any course fee for the same, Stipend paid, post fellowship work bond associated (if any) The stipend paid is INR 30,000 in first 12 months, INR 40,000/- (13-24 months) and INR 60,000/- in the last 12 months. In the short term fellowship/ observership of 2 months a course fee of INR 40,000/- is payable. Cost of accommodation and food is subsidized, but chargeable from each candidate. Bond: Nil

8. Number of sanctioned leaves during the tenure: 20 days per year 9. Names and contact details of 3 present or past (within 2 years) fellows a) Dr Swapnil Kumar Jain 9581471241 b) Dr. Amrita Tiwari -7089322792 c) Dr MansiKshetraPal -9685578060 We are extremely grateful to Dr. Devindra Sood for providing us with the necessary details.

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Sankara Eye Foundation

Sankara Eye Foundation is a US-based non-profit organization that works toward eliminating curable blindness in India. Sankara brings quality timely eye care to the doorsteps of rural India through its award-winning Gift of Vision rural outreach program. Equipped with most modern facilities & knowledgeable dedicated specialists and highly motivated staff, the SEF is committed to clinical excellence, personalized patient care, and best eye care services at all times to all our patients. One of the unique features of the Sankara Eye Hospitals is the self-sustainability model. The hospitals work on 80:20 model where 20% of the paid surgeries fund 80% of the free surgeries. This model ensures that hospitals fund themselves once the selfsufficiency is reached.

1. Name and contact details (phone number/ email ID) of the academic coordinator: Ms. Radhika, Ph- 9666677505, email- careers.sefi@sankaraeye.com

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2. Type of fellowship offered, and duration- short term observership/ long term fellowship: Short term observership 1 month, long term 2 years. 3. Number of seats offered per session:3seats/ session Number of sessions: 2 sessions/ year Dates for application: Applications to be sent by June and December Starting date of fellowship: Course commencement in July and January 4. Type of exposure- cataract, paediatric and squintsurgical & theory 5. Names of the present Pediatric Ophthalmology faculty at your institute Dr. KaushikMurali, Dr. Sowmya Murthy, Dr. Kavitha, Dr. Sairani, Dr. Rajesh Prabhu 6. Process of application and selection: Online application- written exam- panel interview- counselling and seat allotment as per merit list 7. Number of sanctioned leaves during the tenure: 12 days and 10 declared holidays 8. Any course fee for the same, Stipend paid, post fellowship work bond associated (if any): Application fee only. No course fee/ bond. Stipend given. 9. Names and contact details of 3 present or past (within 2 years) fellows: Dr. Nivedita (St John's Medical College Bangalore), Dr Smita Kapoor (Vision Eye Centre Delhi) and Dr Sneha Mungarwadi We are extremely grateful to Ms. Radhika for providing us with the necessary details.

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Sankara Nethralaya

Sankara Nethralaya is a not-for-profit missionary institution for ophthalmic care (i.e., an eye hospital) headquartered in Chennai, India. In the name "Sankara Nethralaya", "Sankara" is a reference to AdiShankaracharya and "Nethralaya" means "The Temple of the Eye". Sankara Nethralaya receives patients from India and abroad. Nani A. Palkivala, former Indian ambassador to United States, described Sankara Nethralaya as the "Best managed charitable organization in India". Sankara Nethralaya has over 1000 employees and serves around 1500 patients per day, performing over 100 surgeries per day. Patient safety and well-being shall always be our top priority. We shall strive for continuous quality improvement and comply with international standards to implement quality systems. To maintain the quality of ophthalmic services on par with international standards. Optimum utilization of infrastructural facilities, including manpower. To ensure continued patient satisfaction through delivery of high class Medicare

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with a personal touch. To ensure high levels of staff satisfaction and motivation and facilitate continuous enhancement of knowledge and skills through constant learning and training initiatives.

1. Name and contact details of the academic co-ordinator Dr. S. Meenakshi Director Academics Email :drms@snmail.org Mobile No: 9840143813 Mr. N. Sivakumar Academic officer Email :nsk@snmail.org; academic@snmail.org Mobile No: 9840800146 2. Types of fellowship, duration, eligibility, number of seats per session & no. of sessions Short term Observership and Long term fellowship Duration : 18 months Eligibility : Ophthalmology PG Degree in MD, MS, DNB recognized by the Medical Council of India, New Delhi Seats : 2 per year Conducting Fellowship Interviews in the month of February & August There are 2 sessions in a year (April & October batch) Deadline dates for application form April session 31st January October session 31st July Starting date of fellowship programme : 1st April and 1st October

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3. Type of Exposure : Clinical Responsibilities The objective of the fellowship is to provide training in comprehensive clinical evaluation of children as well as adult strabismus which includes diagnosis and management Fellows will have rotations with faculty in the department as well as rotations in oculoplasty, Neurophthalmology and retina . In the last few months of fellowship as senior residents they will examine patients independently in OPD. Fellows are expected to actively participates in clinics as well as in surgery. They will have hands on experience in allied special services like low vision service, contact lens clinic and binocular vision clinic and special children clinic. Institute has a ROP screening programme and fellows are encouraged to participate in the screening .Sankara Nethralaya runs community outreach programme in schools. Fellows will be required to participate in this programme as and when needed Hands on surgical training The fellows will have opportunity to assist and perform steps in surgical procedures in the initial part of the fellowship. Independent surgical opportunities will depend on individual skill as determined by the mentor or the attending surgeon They will have Limited surgical exposure in pediatric oculoplasty as well as Pediatric oncology

4. Names of the Present Pediatric Ophthalmology faculty at our institute : Director: Dr. T S Surendran, DO. M. Phil, FRCS Deputy Director: Dr. Sumita Agarkar, MS, DNB Senior Consultant: Dr. S Meenakshi, MS (AB) Consultant: Dr. Kavitha Kalaivani, DO Associate consultant: Dr. V Akila Ramkumar, MS, DNB, FICO Associate consultant: Dr. Muthumeena Muthumalai, MS

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5. Process of application and selection: The details of application process and selection will be displayed in SankaraNethralaya website https://www.sankaranethralaya.org/education-fellowship.html 6. No course fees for fellowship programme Stipend for fellowship: Rs 25,000/No bond for post fellowship 7. Number of sanctioned leaves during the tenure 14 days 8. Names and contact details of 3 present or past (within 2 years) fellows :

1. Dr. Nisha D.S

Mobile No: 9986240152 (present fellow) Email Id : drna@snmail.org 2. Dr. Swathi W M Mobile No : 8007478507 , Email Id:smailankody@gmail.com (past fellow) 3. Dr. Sujay Nayak Mobile No: 8056109587 , Email Id : drsujay25nayak@gmail.com

We are extremely grateful to Mr. N. Sivakumar for providing us the necessary details.

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Sri Sankaradeva Nethralaya was established on 14th October 1994, named after the great Vaishnavite Saint of the region, Srimanta Sankardev. It is a non-profit service organization registered under the charitable trust of Sri Kanchi Sankara Health and Educational Foundation. Sri Sankaradeva Nethralaya is the only stateof-the-art ophthalmic centre as well as postgraduate training institute in the entire northeast India. The hospital was established out of public donations, bank loans, and with a team of dedicated doctors & staff. It is a professional institution rendering quality eye care services with highest moral, legal and ethical standards. The Pediatric Ophthalmology department of the institute has been exclusively attending to the eye care needs of the children and conducted various projects under the NPCB and the global initiative of Vision 2020. It had also collaborated with Orbis India to conduct various community-based and school screening programmes in the difficult terrains of the region. As an outgrowth of this unit, the Myopia Control Clinic and Neurovision Clinic were developed as a model for correction of myopia and amblyopia. 1. Name and contact details (phone number/ email ID) of the academic coordinator:

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Dr. Sumita Sarma Borthakur, Ph- 09864206177, Email - ssnsecretary@gmail.com 2. Type of fellowship offered, and duration- short term observership/ long term fellowship: Short term 3 month observership, long term 18 months fellowship 3. Number of seats offered per session: 1 seat/ session Number of sessions: 1 session/ year Dates for application: Applications to be sent by July Starting date of fellowship: Course commencement in August 4. Type of exposure: Fellows rotate amongst consultant s focusing on pediatric ophthalmology, strabismus, cataract, retina and uveitis, ROP, cornea, oculoplasty and glaucoma. 5. Names of the present Pediatric Ophthalmology faculty at your institute Dr. Damaris Magdalene, Dr. Nilutparna Deori 6. Process of application and selection: Online application- written exam- panel interview- counselling and seat allotment as per merit list 7. Number of sanctioned leaves during the tenure: 14 days 8. Any course fee for the same, Stipend paid, post fellowship work bond associated (if any): No course fee/ bond. Stipend of INR 30,000/month Short term observership- course fee of INR 45,000 is payable We are extremely grateful to Dr. Sumita Sarma Borthakur for providing us with the necessary details.

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Susrut Eye Foundation & Research Centre

The beginnings and the journey till now In the year 1998, Dr. Sunil Chandra Bagchi and Dr. Ratish Chandra Paul founded Susrut Eye Foundation & Research Centre with a vision to eradicate blindness and make this world a beautiful place to those who are still in darkness. They realized the necessity of a team, an organization to overcome the insurmountable load of blindness in our country. Today, we are a leading non-profit organization dedicated to providing eye care and rehabilitate people of all ages suffering from ophthalmic problems. In this journey, Susrut Eye Foundation has proved itself as one of the best tertiary eye care institutes in Eastern India. In the year 1999, Susrut Eye Foundation and Research Centre used to serve only 80 to 90 patients in the outpatient department, whereas in 2006 it inaugurated a

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9 storied building, adjacent to the first building in Salt Lake, to accommodate more patients. The first building was converted into inpatient department (ward and operation theatre). As of June 2019, we are serving on an average 1500 patients in OPD and 120 patients in IPD per day. Susrut Eye Foundation & Research Centre s strength lies in its human resources; we have a self-driven team of passionate, skilled and efficient Ophthalmologists, Optometrists, dedicated nurses and staffs. We have a state-of-the-art infrastructure, which complies with the international standards. We also have a very strong teaching and training component as a part of our comprehensive ophthalmic service commitment. We are training ophthalmologists (postgraduate DNB, fellowships in all ophthalmic subspecialties and international trainees), optometrists and ophthalmic assistants.

4. Name and contact details (phone number/ email ID) of the academic coordinator: Ms. Munmum Das and Mr Amit Pal, Ph- 9153330883, emailtraining@susrut.org

5. Type of fellowship offered and duration: -Short term pediatric ophthalmology training/ Long term 1 year fellowship -Overseas Pediatric Ophthalmology Observership: 1 month, 2 months, 3 months and 6 months -Overseas Pediatric Ophthalmology Fellowship: 6 months, 1 year 6. Number of seats offered per session/ number of sessions/ dates for application/ starting date of fellowship: As per requirement (for more details contact the above mentioned). 7. Type of exposure: Hands-on Training & Observation

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8. Names of the present Paediatric Ophthalmology faculty at your institute Dr. Anuradha Chandra Chief Faculty of Pediatric Ophthalmology Dr. Asmita Ray Faculty of Pediatric Ophthalmology

9. Number of sanctioned leaves during the tenure 15 Days per Year Only in Long Term Fellowship Only Emergency leave is allowed in Short Term. 10.Process of application and selection: CV to be emailed and via interview.

11.Any course fee for the same, Stipend paid, post fellowship work bond associated (if any) Yes (for more details contact the above mentioned). Post fellowship contract period- 3years.

We are extremely grateful to Ms. Munmun Das and Mr. Amit Pal for providing us with the necessary details.

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