Graefe's Archive for Clinical and Experimental Ophthalmology (2021) 259:1695–1701

https://doi.org/10.1007/s00417-020-05063-2

RETINAL DISORDERS

Clinico-demographic profile and outcomes of 25-gauge vitrectomy

in advanced stage 5 retinopathy of prematurity
Renu P. Rajan 1 & Naresh Babu Kannan 1 & Sagnik Sen 1 & Lavanya C 1 & Soumya Jena 1 & Karthik Kumar 1 &
P. Vijayalakshmi 2 & Kim Ramasamy 1

Received: 12 May 2020 / Revised: 6 October 2020 / Accepted: 21 December 2020 / Published online: 6 January 2021
# The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature 2021

Abstract
Background Stage 5 retinopathy of prematurity is a difficult condition to treat despite technological advances in vitreous surgery.
Methods A retrospective chart review of all consecutive cases of stage 5 ROP was performed between December 2016 and
December 2018, and 21 babies were included for assessment of surgical outcomes using a modified vitrectomy technique. Data
extracted from documents included demography, ROP screening status, preoperative prophylactic therapy, clinical presentation,
surgery performed, and postsurgical outcomes.
Results Out of the 21 babies, ophthalmologist screening was done in 42.9%. Mean birth weight was 1185 ± 222.4 g with a
mean gestational age of 29.86 ± 2.0 weeks and mean post-menstrual age of 44.55 ± 9.82 weeks. Lesser than stage 5 disease
was seen in 16.7% of eyes and they were managed accordingly. Seventy percent of babies had bilateral disease. 21 eyes
underwent 25-gauge pars plicata vitrectomy using a modified technique. After an average follow-up duration of 6.33 ± 2.18
months, the final macular attachment rate was 19%. Anteriorly closed-posteriorly closed type configuration of retinal
detachments had a poorer outcome. Fix and follow visual acuity was achieved in 23.8% of eyes, while 57.1% of eyes
had a perception of light.
Conclusions Management of stage 5 ROP is mostly surgical; however, the risk of ending up with a poor vision or vision loss is
high, irrespective of whether surgery is performed. The modified surgical technique with a spacer described in this study may
help in better manipulation of instruments inside the vitreous cavity.

Keywords ROP . Stage 5 ROP . Pars plana vitrectomy

Key messages:

A lot of stage 5 ROP babies in developing countries might not have undergone ROP screening, due to lack of
accessibility to healthcare and the outcomes of stage 5 ROP have been recorded to be poor.

The pattern of ROP in developing countries like India is different from the west, with older and heavier babies
presenting with more severe and advanced disease.

This paper describes a novel method of vitreoretinal surgery in Stage 5 ROP eyes, however the final anatomical
success after surgery is comparable to what has been described from the west.

* Sagnik Sen Introduction

riksag@gmail.com
Retinopathy of prematurity (ROP) has gained the status of an
Extended author information available on the last page of the article epidemic in developing nations. Survival of preterm infants
1696
has increased because of improvement in neonatal care.
However, proper protocol-based screening of ROP still does
not reach all neonates in need. This can be attributed to various
factors like lack of awareness regarding disease, lack of acces-
sibility to the nearest ophthalmic care center, and failure of
screening chain and follow-up. In Asian countries, ROP might
begin at higher gestational age (GA) than in the West [1]. India
also faces a challenge of heavier babies developing progressive
ROP, with threshold ROP occurring in babies with birth weight
(BW) > 2000 g, while US studies report minimal treatable ROP
in babies with BW > 1500 g at birth [1–3]. Authors have ob-
served that in India, aggressive posterior ROP may also be
common in heavier BW babies with almost 16% of babies
developing APROP having BW > 1500 g. (Shah et al.: mean
BW—1554 g, mean GA—31.75 weeks; Sanghi et al.: mean
BW—1260 g, mean GA—29.75 weeks) [4, 5]. Some studies
have found that APROP may occur even in larger preterm
babies with mean BW of 1500–2000 g, mostly because of
unblended oxygen therapy [4]. Recently, Dwivedi et al. have
observed that 16.6% of babies screened had advanced ROP
(stages 4 and 5), with mean GA of 31 weeks and BW 1340 g,
and almost 10% of severe ROP babies had GA > 34 weeks [6].
Most developing countries do not have a well-established
national program targeting ROP. Hence, a large proportion of
babies at risk never get screened for ROP, and many eyes with
preventable disease may progress to advanced stages. Proper
neonatal care and protocol-based screening can help reduce
the incidence of any stage of ROP, treatable disease, and ag-
gressive posterior ROP [7]. Although most cases ideally
should resolve with observation or laser photocoagulation
therapy, it is not uncommon to find infants presenting with
advanced and complicated stages of ROP (namely stages 4
and 5) in developing nations. At these stages, laser therapy
does not hold much importance and surgical modalities need
to be considered.
Surgery for ROP has evolved over the years, with scleral
buckling being an important surgical modality initially.
However, buckling was seen to be associated with secondary
effects like axial length elongation, along with chances of
amblyopia later, and hence slowly decreased in popularity.
For the past decade, microincision vitrectomy surgery
(MIVS) has revolutionized the outcomes, more so for stage
4 ROP. Stage 5 ROP eyes do not seem to perform well with
surgical management, with or without the removal of the lens
[8, 9]. Hence, management of these eyes is a major challenge
for developing nations today.
This study was designed to evaluate the risk factors, out-
comes, and factors predictive of surgical outcome of stage 5
ROP eyes. With stage 5 ROP being a rare disease, not many
surgical series are available from this subcontinent. Moreover,
the stage 5 ROP eyes seen in the developing nations may
behave differently than those described in the west, due to
development in older and heavier babies or more aggressive
Graefes Arch Clin Exp Ophthalmol (2021) 259:1695–1701
patterns of disease and association with aggressive posterior
ROP (APROP). With advances in surgical technology and
techniques, outcomes of surgery may also differ or improve,
and in this respect, our study may be considered crucial.
Methods
Retrospectively, the medical records of all consecutive cases
of stage 5 ROP presenting to our tertiary care ophthalmic
center from December 2016 to December 2018 were
reviewed. The study strictly followed the principles of the
Declaration of Helsinki and was cleared by the Institutional
Ethics Committee. The data collected included details on GA,
gender, BW, age and weight at presentation, referral/screening
details, history of neonatal intensive care unit (NICU) stay,
oxygen therapy, mechanical ventilation, and treatment sought
until presentation. The data entered included the details re-
corded in the neonatal and/or ophthalmic screening records
and parental recall. Also, the data related to the surgical man-
agement of these eyes, intraoperative and postoperative
follow-up details were recorded.
Ophthalmic examination
All infants underwent anterior and posterior segment exami-
nation. Anterior segment examination involved careful
checking for the corneal clarity, anterior chamber depth, pu-
pillary and iris status, and clarity of the crystalline lens.
Posterior segment examination was performed using both in-
direct ophthalmoscopy with a + 28-D/+ 20-D lens and Retcam
III (Clarity Medical Systems Inc., Pleasanton, CA, USA)
when possible. Dilatation was achieved using phenylephrine
2.5% and tropicamide 0.4% eye drops, put twice 15 min apart.
Eyelid skin of all babies was carefully cleaned after drop in-
stillation, to reduce systemic absorption. All infants were ex-
amined by a retina specialist well-experienced in ROP screen-
ing, who documented zone, stage, and extent of ROP in terms
of clock hours and the presence of pre-plus or plus disease,
according to the international classification of ROP [10].
Ultrasonography
Ultrasonography (A and B scans) was performed in all stage 5
ROP eyes by a trained professional and confirmed by a trained
ophthalmologist and the three best images taken were record-
ed. The following types of retinal detachment (RD) were de-
fined: anteriorly open-posteriorly closed, anteriorly open-
posteriorly open, anteriorly closed-posteriorly open, and ante-
riorly closed-posteriorly closed.
Graefes Arch Clin Exp Ophthalmol (2021) 259:1695–1701
Protocol for pars plana vitrectomy
All eyes deemed fit for surgery underwent standard three-port
25-gauge vitrectomy by any one of two experienced surgeons
(N.B.K. and R.P.R.). Sclerotomies were made 0.5 to 1.0 mm
posterior to the limbus through pars plicata. In all surgeries, a
spacer (2-mm × 2-mm piece of #42 silicone encircling band,
1.25-mm thickness) was used between the sclera and the base
of the 25-gauge surgical cannulas. This was done to maximize
the space for surgical manipulation inside small infant eyes
[11]. Surgeries were performed under a binocular indirect
ophthalmic microscope (BIOM) with a Constellation 25-
gauge vitrectomy instrument (Alcon, TX, USA), at intraocular
pressure of 15 mm Hg and cutting speed of 5000 per minute.
The goal of the surgery was to relieve the traction between the
ridge and ciliary body, lens, and optic disk.
Lensectomy was performed for cases in which the retina
with attached membranes was very close to the posterior sur-
face of the lens where manipulation was difficult. Anterior
membrane dissection was initiated with microvitreoretinal
blade and segmentation attempted using MIVS scissors, for-
ceps, and cutter after identifying a dissection plane. Limited
vitrectomy was performed to release tractional elements.
Viscocohesive agent was injected at the end of the surgery
to aid in the further opening of the funnel. Complete reattach-
ment at the end of surgery was not attempted and
endotamponade with silicone oil or endolaser was not per-
formed in any of the cases. During the postoperative period,
a topical antibiotic and steroid combination drop was used
four times a day, tapered over 1 month.
Follow-up
All operated infants were followed up routinely on day 1 after
surgery, at 1 week, 1 month, and as needed thereafter. All
babies, including non-operated cases were referred to the pe-
diatric ophthalmology department for low vision rehabilita-
tion. Anatomical success was measured as the percentage of
eyes that attained posterior pole attachment on ultrasound at
the final follow-up. Functional outcomes were measured as
the presence of perception of light, “fixes and follows” visual
acuity, or “central-steady-maintained” fixation, etc.
Data analysis
Data were entered into Microsoft Office Excel 2013
(Microsoft, Redmond, WA) and analyzed using Stata (Stata
Statistical Software: College Station, TX, Stata Corp LP).
Variables were compared using chi-square or Fisher exact test,
Student t test, or Mann Whitney test wherever applicable. A
two-tailed p value of < 0.05 was considered statistically
significant.
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Results
Demography
Twenty-one babies presented to our clinic with advanced
stage 5 ROP in at least one eye from December 2016 to
December 2018. Sixteen babies (76.2%) were born in the state
of Tamil Nadu, 1 (4.8%) in Andhra Pradesh, 2 (9.5%) in
Pondicherry, and 2 (9.5%) in Kerala.
Of the 21 ROP babies, 7 (35%) were male and 14 (65%)
were female. Mean GA overall was 29.86 ± 2.0 weeks (range,
26–33 weeks; median = 29 weeks) and BW was 1185 ±
222.4 g (range, 990–1700 g). Overall, 2 infants (9.5%) had
> 1500 g BW, 2 infants (9.5%) had > = 32-week GA, and 2
infants (9.5%) were just completing 32 weeks of gestation.
Only 1 infant had both > 1500 g BW and > 32-week GA.
None of our cases had a BW of > 1750 g or GA of > 34 weeks.
Mean post-menstrual age (PMA) was 44.55 ± 9.82 weeks
(range, 34–71 week; median = 42 weeks) and the babies were
brought to our center after a mean duration of 15.05 ± 11.49
weeks (range, 4–43 weeks; median = 12 weeks) after birth.
NICU care
Seventeen babies out of a total of 21 had received NICU care
and out of these, 12 babies were referred for ROP screening.
The rest 4 babies did not receive NICU care or ophthalmolo-
gist referral and presented to us directly with stage 5 ROP. Out
of 17 babies who received NICU care, 9 (52.9%) babies were
screened by an ophthalmologist outside. The rest 8 (47.1%)
babies were directly referred to us from the NICUs. The aver-
age number of days in NICU was 35.3 ± 19.4 days (range, 7–
90 days). Moreover, they were given oxygen supplementation
for a mean duration of 22.9 ± 14.5 days (range, 3–45 days).
Only 1 child had received laser treatment outside, while 1
child was lost to follow-up after screening. The commonest
complaints by the parents of 12 babies who directly came to
our center without prior screening (8 who received NICU care
and 4 who did not) were inability to fix at the mother’s face
(10/12), whitish reflex (6/12), and abnormal eye movements
(5/12).
Clinical presentation
A total of 35 eyes had stage 5 ROP. Fourteen babies (67%)
had bilateral stage 5 ROP (28 eyes). In the 7 babies having
unilateral stage 5 disease, three fellow eyes had stage 3 ROP
and four fellow eyes had stage 4A ROP. Of the 35 eyes with
stage 5 ROP, 17 eyes (48.5%) presented with leukocoria, 3
eyes (8.6%) had a corneal opacity, 20 eyes (57.1%) had a
shallow anterior chamber, 6 eyes (17.1%) had posterior
synechiae to the lens, and 4 eyes (11.4%) had
microphthalmos. Sixteen eyes (45.7%) presented with
1698
nystagmus. The fundus could not be assessed clinically in
sixteen eyes because of poorly dilating pupils and/or posterior
synechiae in 10 eyes (28.6%) and corneal opacity in 6 (17.1%)
eyes. The types of retinal detachment detected were anteriorly
closed-posteriorly open (8.6%), anteriorly open-posteriorly
closed (31.4%), and anteriorly closed-posteriorly closed
(57.1%).
Fourteen eyes (40%) were judged unfit for surgical interven-
tion. Among them, 50% of eyes had anteriorly closed-posteriorly
closed configuration of the retinal detachment and 35.7% had
anteriorly open-posteriorly closed configuration. Three of these
eyes (20%) had corneal opacities, 9 (60%) had shallow anterior
chambers, 5 (33.3%) eyes had posterior synechiae to the lens,
and 3 (20%) eyes had microphthalmos. One eye had an associ-
ated organized vitreous hemorrhage along with anteriorly closed-
posteriorly closed configuration of RD.
Surgical details
Of the 35 eyes, 21 eyes (60%) underwent surgery (Table 1).
Five babies (23.8%) underwent bilateral surgeries. In 4 babies
with bilateral stage 5 ROP, only one eye was considered for
surgical management, since the fellow eyes were found to
have advanced and untreatable disease. The average age at
presentation for the 21 operated eyes was 40.0 ± 5.3 weeks
PMA against an average of 46.8 ± 8.06 weeks PMA in the
unoperated eyes. Fourteen eyes underwent lensectomy simul-
taneously during vitrectomy. Three babies had a non-
advanced ROP stage (stage 3 and below) in the fellow eye,
for which photocoagulation was done with close observation.
In 4 others, the fellow eyes had stage 4A ROP, for which
necessary surgical management was performed. None of the
eyes developed any iatrogenic hole during surgery. Two eyes
developed intraoperative bleeding during membrane
Table 1 Surgical management of the ROP study population
Number Percentage
Total number of eyes with ROP 42
Total number of eyes with stage 5 ROP 35/42 83.3
No intervention 14/35 40
Intervention
Pars plana vitrectomy 21/35 60
Pars plana vitrectomy with lensectomy 14/21 66.7
Surgery along with bevacizumab injection 5/21 23.8
Fellow eyes—other than stage 5 ROP 7/42 16.7
Zone 3 disease less than/equal to stage 3/7 42.8
3 without plus
Stage 4a disease 4/7 57.1
Eyes with stage 5 ROP and plus disease 5/35 14.3
Graefes Arch Clin Exp Ophthalmol (2021) 259:1695–1701
dissection, which was controlled by temporarily increasing
the intraocular pressure and aspiration of the blood.
Postoperative outcomes
The average duration of postoperative follow-up was 6.33 ± 2.18
months (range, 3–12 months; median = 6 months). None of the
eyes developed postoperative bleeding. Table 2 summarizes the
retinal reattachment status after surgery at the immediate and
final follow-ups. Although 50% of eyes with anteriorly closed-
posteriorly open configuration showed anteriorly open-
posteriorly closed configuration at immediate postoperative fol-
low-up, both these eyes had anteriorly closed-posteriorly closed
configuration at final follow-up. Eyes having anteriorly open-
posteriorly closed RD preoperatively ended up with 50% having
anteriorly open-posteriorly closed configuration and 50% having
attached macula (on ultrasound) at final follow-up. Eleven eyes
having anteriorly closed-posteriorly closed configuration ended
up in 54.5% having anteriorly open-posteriorly closed configu-
ration. The final macular attachment rate was 19%. On functional
evaluation at final follow-up, 12/21 (57.1%) eyes achieved a
vision of perception of light, 5/21 (23.8%) eyes achieved good
fixation and following movements, and 4/21 (19%) ended in no
perception of light. Three eyes (60%) that achieved good fixation
and following movements had attached macula at final follow-
up. All 4 eyes which had no perception of light had closed-closed
configuration (Table 2).
Discussion
Retinopathy of prematurity is a challenging disease for oph-
thalmic practitioners worldwide, not only because of its com-
plexity in pathogenesis but also because of associated medical
issues, including prematurity and low birth weight. Although
the majority of ROP regresses spontaneously, advanced stages
(4 and 5) seem to be much more prevalent in the developing
countries, reported as the third epidemic of ROP [12, 13].
Although the incidence of ROP is rising worldwide due to
improved perinatal care, safe and effective laser treatment of
non-advanced ROP has reduced end-stage ROP incidence in
developed countries like the USA [14–16]. Providing metic-
ulous medical management in NICUs, with timely screening
as per protocol, can reduce the occurrence of ROP.
Lack of knowledge and awareness regarding the prevention
and treatment of ROP among parents plays a major role in
health-seeking behavior and compliance. In our series, the chil-
dren were brought after a mean period of almost 2 months after
birth and the longest period was 10 months. The number of girl
children suffering from stage 5 ROP in our series was more than
males and this may reflect an underlying social trend of preferred
attention to the male child, which is common in rural parts of the
country. Outcomes of ROP depend on early detection and
Graefes Arch Clin Exp Ophthalmol (2021) 259:1695–1701 1699

Table 2 Anatomical outcomes of retinal detachment surgery of stage 5 ROP eyes

Preoperative Total Operated Unoperated Postoperative retinal status Postoperative functional-status

retinal detachment at final follow-up
configuration Immediate Final follow-up
postoperatively

Anteriorly Anteriorly Anteriorly Anteriorly Attached

open- closed- open- closed- posterior
posteriorly posteriorly posteriorly posteriorly pole
closed closed closed closed

Anteriorly 2 2 0 1 1 0 2 0 No PL = 1 with close-close

closed-- configuration
posteriorly PL+ = 1 with close-close
open configuration
Anteriorly 12 8 4 6 2 4 0 4 Fixation and following
open-- movements = 3 with attached
posteriorly macula, 2 with open-close
closed configuration
PL+ = 1 with attached macula, 2
with open-close
configuration
Anteriorly 21 11 10 7 4 6 5 0 PL+ = 6 with open-close
closed-- configuration, 2 with
posteriorly close-close configuration
closed No PL = 3 with close-close
configuration –
Total 35 21 14 14 7 10 7 4 No PL = 4
PL+ = 12
Fixing and following
movements = 5

PL, perception of light

effective management and follow-up of babies, which is highly
reliant on a strong collaboration between pediatricians, ophthal-
mologists, and paramedical personnel. Prior laser photocoagula-
tion seems very important for earlier stages of surgical ROP
cases, e.g., stage 4 ROP, by helping in the stabilization of periph-
eral retina and halting/regressing RD. Among our babies, only 1
(5.2%) had received laser photocoagulation. Prior treatment was
given in 10.4% in the series described by Gopal et al. and 22% in
the Cusick et al. study [9, 17].
Management of stage 5 ROP is mostly surgical; howev-
er, such babies are at a high risk of losing vision, irrespec-
tive of surgery. Determining the appropriate time for sur-
gery in stage 5 ROP eyes is debatable. In our series, sur-
geries were performed at a median duration of 42 weeks,
which is comparable to the international data [9]. Surgery
is generally restricted to limited dissection of membranes
and vitreous. In this regard, 25-gauge instruments offer a
wide range of flexibility and easy manipulation in small
pediatric eyes. The technique of using a piece of #42 band
as a spacer helped increase the field of movement inside
small eyes by reducing the shaft of the 25G cutter and
increased the rigidity of the instrument [11].
It is apparent from the results of our series and also from
previous literature that ROP stage 5 eyes may show very poor
likelihood of reattachment, making the overall long-term suc-
cess rate of surgery poor [8, 9, 18]. Preoperative configuration
of RD may be a prognostic factor for final attachment [19]. In
our series, we found that the outcomes of anteriorly closed-
posteriorly closed RD were poorer than for the other configu-
rations, similar to observations by Cusick et al. (Table 2) [9].
The number of eyes in the current series is not high enough to
strongly suggest this association, and the same may be evalu-
ated more effectively in larger longitudinal studies. In contrast
to Cusick et al.’s retrospective analysis of surgical outcomes
over 25 years of evolving vitrectomy techniques, our study
evaluated a single advanced technique of microincision vit-
rectomy done over 2 years. Outcomes of 20-G rigid instru-
ment surgeries and 23–25-G MIVS are expected to be differ-
ent, with the latest generation instruments being more efficient
[16]. In this series, we avoided creating iatrogenic breaks due
to limited length and movement of instruments inside the eye
and achieved adequate membrane dissection; however, the
final anatomical success rate was 19%. The success rate of
surgery in stage 5 eyes ranges from 13% as reported by
Choi et al. to 28% reported by Cusick et al. [20]. Kondo
et al. observed that even after successful reattachment of the
retina, a repeat detachment would occur in 22% of stage 5
eyes [18].
1700
In our series, 23.8% of eyes achieved higher than percep-
tion of light visual acuity. Cusick et al. noted that 85% of stage
5 ROP eyes ended up with no perception of light, 14% of eyes
could achieve form visual perception, while only 4% of eyes
achieved visual acuity better than 5/200 [9]. Among the eyes
which had attached macula, only 16% had visual acuity better
than 5/200 and 11% could not perceive light. Choi et al. found
perception of light present in 48% of stage 5 ROP eyes after
vitrectomy [20]. In the series by Karacorlu et al., 65% of eyes
achieved visual acuity only in the range of perception of light,
no perception or fixing and following vision [21]. This overall
poor functional improvement reflects the poor prognosis of
stage 5 ROP in spite of achieving surgical reattachment, prob-
ably because of photoreceptor damage and/or retrolental
membrane formation [22]. Moreover, associated complica-
tions like corneal opacity, cataracts, glaucoma, and amblyopia
may worsen the prognosis. Modification of surgical technique
in the current study did not seem to affect the final outcomes
much. However, the technique may help avoid injuring the
anteriorly displaced retina and also help in the easier cutting of
the anterior vitreous [11].
A limitation of this study is that it is retrospective in nature,
with small number of patients and a comparatively smaller
duration of follow-up. Moreover, comparison of results of this
study with literature may not be proper, because the nature and
severity of stage 5 ROP is heterogeneous in different geo-
graphic areas. However, for developing countries like India,
understanding outcomes of management of stage 5 ROP in
older babies is of prime importance, and better primary care-
based referral systems for earlier detection of such cases
should be developed.
In summary, the prevention of stage 5 ROP is the best
strategy. Once ROP eyes progress to stage 5, the anatomical
and functional prognosis even after surgery are grim, and nov-
el surgical approaches do not appear to improve the poor
prognosis much. The current study observed that the preoper-
ative configuration of RD is associated with the final out-
comes. Effective social measures with organizational efforts
and logistic support at different levels of healthcare are needed
to tackle this huge health burden.
Author contributions RPR: concept design, data collection and analysis,
final approval; NBK: concept design, data collection and analysis, final
approval; SS: data collection and analysis, drafting manuscript, final ap-
proval; LC: concept design, data collection and analysis, final approval;
SJ: data collection and analysis, final approval; KK: concept design, final
approval; VP: final approval; KR: final approval
Data availability Data will be made available on request.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Graefes Arch Clin Exp Ophthalmol (2021) 259:1695–1701
Institutional review board statement This study was reviewed and ap-
proved by the ethics committee of the Aravind Eye Hospital.
Informed consent statement Patients were not required to give in-
formed consent to the study because the analysis used anonymous clinical
data that were obtained after each patient agreed to treatment by written
consent.
Consent for publication All authors have given their consent for publi-
cation and authorship.
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Affiliations
Renu P. Rajan 1 & Naresh Babu Kannan 1 & Sagnik Sen 1 & Lavanya
P. Vijayalakshmi 2 & Kim Ramasamy 1
1 2
Department of Vitreo-Retina, Aravind Eye Hospital, Madurai, India
1701
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Korean J Ophthalmol 25:305–310
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functional results following vitrectomy for advanced retinopathy
of prematurity. Br J Ophthalmol 101:730–734
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tional claims in published maps and institutional affiliations.
C 1 & Soumya Jena 1 & Karthik Kumar 1 &
Department of Pediatric Ophthalmology, Aravind Eye Hospital,
Madurai, India