UNASSIGNED: We describe a novel method of digital, virtual-reality based binocular indirect ophthalmoscopy which allows for simultaneous stereoscopic recording of the examination with the potential of real-time anatomic correction of the retinal view.
UNASSIGNED: A provisional prototype of the all-digital, binocular, indirect virtual stereo video ophthalmoscope was designed consisting of a generic LED light source and two synchronized closely spaced side-by-side minicameras which are connected to a processor, storage media (a Samsung note-9 android smartphone in the current provisional prototype), and a virtual reality set (VISIONHMD Bigeyes H1 3D Video Glasses, in the current prototype). A custom designed android application was developed to capture the examination media and allow optional real-time anatomical correction of the examination view. Binocular stereoscopic indirect ophthalmoscopy was attempted on 15 eyes of 15 patients without and with digital real-time anatomic correction of the examination view.
UNASSIGNED: Binocular, video, stereo ophthalmoscopic media could be successfully obtained in all 15 patients. Anatomic correction of the examination view as well as a collateral observer\'s view could be achieved in all 15 patients.
UNASSIGNED: An all-digital, binocular, stereo, video indirect ophthalmoscopy is a feasible alternative for conventional binocular indirect ophthalmoscopy and provides stereoscopic video documentation identical to what the examiner sees. The examination video can be streamed in the real-time of the examination for educational or telemedicine purposes.

Premature neonates require regular ophthalmological examination, generally indirect ophthalmoscopy, to screen for retinopathy of prematurity (ROP). Conventional analgesia is provided with topical anesthetic eyedrops and oral sugar solution, but neonates still experience significant pain. Here, the literature base was examined to evaluate the usefulness of other pharmacological analgesics.
A systematic review was undertaken, adhering to a PROSPERO preregistered protocol in accordance with PRISMA guidelines (identifier CRD42022302459). Electronic databases were searched for primary research articles on pharmacological pain interventions used for ROP screening in neonates. The primary outcome measure was pain scores recorded using validated pain scoring tools, with and without pharmacological interventions in neonates during eye examination. For analysis, studies were separated into two categories: topical anesthesia and alternative pharmacological treatments.
Eleven studies met the inclusion criteria. Topical analgesia, oral paracetamol, and intranasal fentanyl were found to be effective in reducing the pain of eye examination. Oral morphine and inhaled nitrous oxide had no significant effect on premature infant pain profile (PIPP) scores during indirect ophthalmoscopy.
In addition to topical anesthesia, premedication with oral paracetamol is recommended during screening examination for ROP. The routine use of fentanyl is not recommended due to the risk of potential side effects. Non-pharmacological measures, such as sweet oral solutions and comfort techniques should also be employed. Further research is required to determine whether the use of nitrous oxide has a role, and to develop a safe and effective analgesic strategy to fully ameliorate the pain of ROP screening.

Comparison of patient satisfaction with red-free (green) versus yellow light using binocular indirect ophthalmoscope for retinal examination.
This is an observational questionnaire-based study of 100 myopes in the age group of 18-40 years coming for a routine check-up or for refractive surgery workup. The examination was done using an indirect ophthalmoscope and a 20D lens with green or yellow light and was assigned in two groups randomly using the coin toss method, following which, a questionnaire was used to assess the following parameters: a) level of comfort, b) any complaints of discomfort during examination, d) preference of the used light source in future, e) grading of discomfort on a linear scale, and f) patient cooperation and duration of examination.
Patients were randomized for observation with IDO using either green light (n = 55) or yellow light (n = 45) filter. In the study, 46 patients (83.6%) were very comfortable and only 9 patients (16.4%) experienced mild discomfort when using red-free (green) light, while only 3 patients (6.7%) were very comfortable and 31 (68.9%) had mild discomfort when using yellow light. The complaints of watering with yellow and green light were noted in 36 patients (80.0%) and 15 patients (27.3%), pain in 13 patients (28.9%) and 3 patients (5.5%), light sensitivity in 29 patients (64.4%) and 4 patients (7.3%), respectively, all being significantly more in yellow light category (P < 0.001). The time of examination was significantly more in yellow light category with 83 ± 10.75 seconds (P < 0.001).
Retinal examination using the green filter of indirect ophthalmoscope is more comfortable in examining the patients as compared to routine yellow light with decreased number of complaints, lesser examination time, and better patient cooperation.

To explore the factors affecting the linear magnification of the intermediate fundus image during indirect ophthalmoscopy with a slit-lamp biomicroscope.
A simple paraxial model, based on a \'reduced\' eye and a \'thin\' ophthalmoscopy lens, is used to develop equations showing the effects of the power and ametropia of the eye, and the equivalent power and position of the ophthalmoscopy lens on fundus magnification. Predicted magnifications are compared with practical results found in earlier published experimental studies, which used Volk ophthalmoscopy lenses in conjunction with physical model eyes with adjustable levels of axial ametropia.
The model\'s magnification predictions, as a function of the eye\'s ametropia, are in good agreement with previous experimental measurements, provided that the equivalent powers of the Volk lenses are used rather than their labelled nominal powers. Magnification values typically change by approximately ±10% over the practical range of each parameter if other parameters are held constant. In particular, normal variations in the equivalent power of the adult emmetropic eye result in magnifications which range from about 90-120% of the nominal value given for an eye power of +60.00 D. It is demonstrated that the recommended working distances for different powers of Volk ophthalmoscopy lenses approximate optimal matching between the various pupils of the eye-Volk lens-slit-lamp biomicroscope system.
All the parameters considered have marked effects on magnification. The magnification values quoted by manufacturers can be regarded as only approximations of those which may be found in practice. Better estimates of magnification can be obtained by inserting the appropriate parameter values into the equations derived in this paper, using, where appropriate, the equivalent power of the indirect ophthalmoscopy lens, rather than the lens\' labelled, \'nominal\' power.

Retinoblastoma, an intraocular cancer primarily affecting children, interacts with surrounding intraocular and extraocular structures in the development and progression. Subretinal and vitreous seeds are characteristic features of retinoblastoma, which result from the interaction between the tumor and its environment at the levels of tissue and microenvironment. The retina and vitreous affect the disease course and responses to treatment options. Also, neighboring cells in the retina and physicochemical properties of the tumor microenvironment are related to the biological activities of retinoblastoma tumors. Researches focusing on the tumor environment of retinoblastoma will lead to the development of more effective treatment options, which can revolutionize the prognosis of patients with retinoblastoma.

Neurofibromatosis Type I (NF1), also termed von Recklinghausen disease, is a rare genetic disorder that is transmitted by autosomal dominant inheritance, with complete penetrance and variable expressivity. It is caused by mutation in the NF1 gene on chromosome 17 encoding for neurofibromin, a protein with oncosuppressive activity, and it is 50% sporadic or inherited. The disease is characterized by a broad spectrum of clinical manifestations, mainly involving the nervous system, the eye and skin, and a predisposition to develop multiple benign and malignant neoplasms. Ocular diagnostic hallmarks of NF1 include optic gliomas, iris Lisch nodules, orbital and eyelid neurofibromas, eyelid café-au-lait spots. Choroidal nodules and microvascular abnormalities have recently been identified as additional NF1-related ocular manifestations. The present study was designed to describe the features and clinical significance of a new sign related to the visual apparatus in NF-1, represented by hyperpigmented spots (HSs) of the fundus oculi.
HSs were detected in 60 (24.1%) out of 249 patients with NF1, with a positive predictive value of 100% and a negative predictive value of 44.2%. None of the healthy subjects (150 subjects) showed the presence of HSs. HSs were visible under indirect ophthalmoscopy, ultra-wide field (UWF) pseudocolor imaging and red-only laser image, near-infrared reflectance (NIR)-OCT, but they were not appreciable on UWF green reflectance. The location and features of pigmentary lesions matched with the already studied NF1-related choroidal nodules. No significant difference was found between the group of patients (n = 60) with ocular HSs and the group of patients (n = 189) without ocular pigmented spots in terms of age, gender or severity grading of the disease. A statistically significant association was demonstrated between the presence of HSs and neurofibromas (p = 0.047), and between the presence of HSs and NF1-related retinal microvascular abnormalities (p = 0.017).
We described a new ocular sign represented by HSs of the fundus in NF1. The presence of HSs was not a negative prognostic factor of the disease. Following multimodal imaging, we demonstrated that HSs and choroidal nodules were consistent with the same type of lesion, and simple indirect ophthalmoscopy allowed for screening of HSs in NF1.

Surgical skill of the surgeon can be improved by surgical simulation. Especially in ophthalmology, it is impossible to use real human/non-human primate eyes for ophthalmology surgery practice. However, surgical practice is most important for ophthalmologist. The retina laser surgery is one of the ophthalmology surgeries and it requires more surgical practice for surgeons to use the laser beam precisely to coagulate and fuse small areas of tissue. Dealing with the prospect of vision reduction or vision loss presents a peculiar problem and that can be highly stressful and frustrating for both doctors and patients. In this regard, training for indirect ophthalmoscopy and retinal photocoagulation is undergone using model eyes instead of real eyes. Properties and functioning of an existing model eye are huge and they differ from real human eye such as casings are completely rigid and focusing of retinal fundus is not completely covered. Therefore, this research concentrates to develop a model eye that assimilates close to the human eye by focussing on the maximum viewing area that is not done at the moment. Finally, the design and development of re-engineered model eye for retina laser is fabricated by additive manufacturing. Compared to existing plastic model eye, viewing area and viewing angle of the re-engineered model eye is increased by 16.66% and 6.14%, respectively. Due to design modifications and elimination of the insert, it can be reduced by 18.99% and 13.95% of height and weight of the top casing respectively. Developed re-engineered model eye will improve the surgical and diagnostic skill of the surgeon and increase their confidence and proficiency. It also augments the effective use of essential ophthalmic instruments. Additionally, it can reduce the surgical error and meet the existing demand of actual eyes for surgical practices.

We read with interest the article \"Role of Ultra-widefield Imaging in Eales\' Disease: A Case Series\" by Agarwal et al. We would like to congratulate the authors for their nice work and make few observations.We noted few discrepancies between the results and conclusions. Results revealed disease activity in 10/57 (17.5%), 20/57 (35%), and 29/57 (50.9%) patient visits with clinical examination, UWF Optos imaging, and wide-field FFA respectively. However, authors conclude that \"ultra-widefield imaging is a very helpful tool in the management of a patient with Eales\'disease.\" This is in spite of the fact that widefield FA resulted in better documentation in 56% of the patient visits in their series. Widefield FA detected significantly more number of active vasculitis as compared to Optos, and alteration in the treatment plan was done in 18/57 (31.6%) patient visits based on FA.

To assess the variability of assessing the ocular torsion on fundus photographs among strabismus surgeons.
This was a prospective, noninterventional, clinical trial involving 16 trained and experienced squint surgeons participated in the study. Two videos were prepared of a total of 10 fundus pictures with or without lines for disc foveal angle. The first video had a 4 s viewing time for each fundus image. The second video had the disc foveal lines drawn and a similar 4 s viewing time for each image. The participants were asked to grade the torsion. The primary outcome measure was to assess the agreement between the raters for ocular torsion measurement. Difference in the response of observers from the standard response was the secondary outcome measure.
A 4 s viewing time was given to mimic the exposure time in the clinic while assessing torsion in a patient. Large variability was found among the responses. The kappa test was done for comparing the agreement between various observers which ranged from slight to fair (<0.40). There was no difference in torsion grading in 30.6% and 26.3% responses in the first and second video from the standard response, respectively. When a limit of ±1 grade was taken as acceptable for the responses, 66.2% for the first and 68.7% for the second video respectively were similar to standard response.
There is wide variability in assessing ocular torsion by fundus photography. The level of accuracy does increase with marking the line on photographs but still remains unreliable.

OBJECTIVE: To describe and appraise the latest simulation models for direct and indirect ophthalmoscopy as a learning tool in the medical field.
METHODS: The present review was conducted using four national and international databases - PubMed, Scielo, Medline and Cochrane. Initial set of articles was screened based on title and abstracts, followed by full text analysis. It comprises of articles that were published in the past fifteen years (2002-2017).
RESULTS: Eighty-three articles concerning simulation models for medical education were found in national and international databases, with only a few describing important aspects of ophthalmoscopy training and current application of simulation in medical education. After secondary analysis, 38 articles were included.
CONCLUSIONS: Different ophthalmoscopy simulation models have been described, but only very few studies appraise the effectiveness of each individual model. Comparison studies are still required to determine best approaches for medical education and skill enhancement through simulation models, applied to both medical students as well as young ophthalmologists in training.