key: cord-0889136-8lk2gth6 authors: Ramesh, Prasanna V; Ramesh, Shruthy V; Ray, Prajnya; Aji, K; Ramesh, Meena K; Rajasekaran, Ramesh title: The curious cases of incorrect face mask positions in bowl-type perimetry versus enclosed chamber perimetry during the COVID-19 pandemic date: 2021-08-03 journal: Indian J Ophthalmol DOI: 10.4103/ijo.ijo_805_21 sha: f51d99cc02506fb6f9cb9a8afaecf8bf03c7fce2 doc_id: 889136 cord_uid: 8lk2gth6 nan Dear Editor, Face masks have become mandatory in everyone's life. [1] Despite being designed to completely cover the patient's nose and mouth [ Fig. 1 ], there seems to be an innate urge among most of the Indian patients to pull down their masks before ophthalmic chin rest examination and investigations, as a sign of respect to the doctor or due to a feeling of not being heard when spoken. [2] This behavior poses risk of aerosol-mediated infection to transmit, especially while using bowl-type perimeters (Humphrey and Octopus), where inadvertent aerosols from nostrils enter into the bowl of perimeter [ Fig. 2 ] contaminating it. The aerosolized SARS-CoV-2 particles can remain active in the air within the bowl-type perimeter up to Letters to the Editor Figure 1 : (a-c) Image showing common incorrect ways of wearing face masks like the neck-beard configuration, the tickler configuration, and the overshooting masker (i.e., wearing mask with the upper end of it, covering up to the inferior aspect of the eye), respectively. (d) The image shows correct face mask configuration, but with a gap near the nasal bridge (yellow asterisk), which would be a source of aerosol spread during visual field testing. (e) A proper method of wearing face mask with the superior strip of mask pinched down on the nose (red arrow) and adhesive tape covering the entire length of the superior border to prevent aerosol contamination b c d a e Image showing visual field perimetry bowl getting exposed to aerosols, emitted from the subject being tested, due to improper mask wearing (red arrow) b a and time consuming. Hence, it is advisable to use a bowl-type perimeter only where it is absolutely necessary, considering what added value using that equipment would provide for that particular patient. On the contrary, with an enclosed chamber virtual reality perimeter [ Fig. 3 ] (Advanced Vision Analyzer, Elisar), the nostrils are always present outside the testing chamber [ Fig. 4 ], making the chances of contamination of the insides of it almost impossible. Also they are much easier to disinfect than a bowl-type perimeter. Though one can argue that a proper wearing technique [ Fig. 1e ] could theoretically prevent displacement of the mask during examination, in reality this practice is difficult for the patient, from comfort and fatigue point of view, while performing the test. [3] [4] [5] With the visual field examination results of virtual reality perimetry, showing good promise and high correlation with Humphrey perimeter; this newer method can be a possible substitute for clinical use, at least till the pandemic gets over, for incorrect mask wearers or patients, who have mask intolerance while performing visual fields. [6] Despite maximum efforts being emphasized for correct technique of mask wearing while performing visual fields, there are still many who do not. On the flip side, there are also many over shooters [ Fig. 1c ]. They possess another major disadvantage [Fig. 5] in the form of mask-induced artifacts mimicking inferior arcuate glaucomatous defects. [7] [8] [9] This erroneous way of mask wearing is also autocorrected, when the enclosed chamber perimeter is snug fitted over the periorbital region to provide dark room effect, exteriorizing the mask outside the chamber preventing mask-induced artifacts. Though fighting against wrong mask wearing can feel like a never-ending battle, it is one worth fighting for. Periodical awareness and constant reinforcements can prevent both aerosol-mediated infections and mask-induced artifacts from bowl-type perimetry. [10] However, for the time being, it seems appropriate to use an enclosed chamber perimeter for assessing glaucoma patients, at least until the pandemic gets over, The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Nil. There are no conflicts of interest Dear Editor, We read with great interest the recent editorial, "Code Mucor" [1] published in Indian Journal of Ophthalmology. We appreciate the author for enlightening the fraternity and the general population about red flag symptoms of COVID-19-associated mucormycosis which is the need of the hour. Looking at the upsurge of rhino-orbital-cerebral (ROCM) in India, it has now been declared as an epidemic in many states of India. We have never come across in many years with such elaborative staging of ROCM. [1] Earlier it was classified into three clinical stages. Stage-I involving sino-nasal area, stage-II involving sino-orbital infection, and stage-III involving intracranial compartment. [2] The clinical assessment alone might not justify the extent of staging, as the radiological findings might surprise us. The proposed staging by the author with adjunct radiology to the clinical acumen helps in better assessment of the stage of the disease. Our department is performing diagnostic nasal endoscopy (DNE) with contrast-enhanced magnetic resonance imaging (CEMRI) in high-risk patients with alarming symptoms. We hereby report the staging of 15 patients of ROCM by clinical assessment/DNE and comparing it with radiological derived staging [ Table 1 ]. In eight patients, the clinical and radiological staging were the same, while in seven patients, we observed that MRI has upstaged the disease. Two patients of stage 1 were upstaged to stages 2b and 2c, while five patients upstaged in subcategories of the same stage. This upstaging helped us in proper evaluation and management. With the numbers rising, we have a dedicated mucor ward with almost 60 patients. We are now witnessing patients of ROCM with only Perspective of ophthalmologists providing direct care to COVID-19 positive patients at JIPMER, Puducherry Wetlab training during COVID-19 era; an ophthalmology resident's perspective Adoption of newer teaching methods to overcome challenges of training in ophthalmology residency during the COVID-19 pandemic A systematic review of simulation-based training tools for technical and non-technical skills in ophthalmology Surgical simulators in cataract surgery training Influence of surgery simulator training on ophthalmology resident phacoemulsification performance Simulation training in vitreoretinal surgery: A systematic review Efficacy of surgical simulator training versus traditional wet-lab training on operating room performance of ophthalmology residents during the capsulorhexis in cataract surgery Virtual reality training improves wet-lab performance of capsulorhexis: Results of a randomized, controlled study Royal college of ophthalmologists' National ophthalmology database study of cataract surgery: Report 6. 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