Antibiotic prophylaxis for cataract surgery - Practice patterns amongst Indian Ophthalmologists

Purpose: To assess the current trends in use of perioperative antibiotic prophylaxis, especially intracameral antibiotics (ICAB), for cataract surgery in India. Methods: This was an E?survey using a previously validated questionnaire carried out by the All India Ophthalmological Society (AIOS) in August 2022. An E?mail invitation to complete an online 40?point survey was sent to all members of the AIOS using a digital E?mail service (Survey Monkey) and social media platforms. Results: Out of 1804 total respondents, 58% (n = 1022) reported using routine ICAB prophylaxis. Of those using ICAB, 89% (n = 909) reported using it for all cases, whereas the rest used it for specific indications such as post?PC rent (n = 43), one eyed patient (n = 19), and high?risk cases (n = 50). Commercially available moxifloxacin was by far the commonest agent used for ICAB (n = 686, 67%). Eighty respondents (8%) reported noticing occasional toxic reactions and nontoxic corneal edema (n = 64, 6%) with ICAB. Surgeons with >10 years� experience especially practicing in medical colleges used fewer ICAB (OR = 0.52, 95%CI = 0.38 � 0.72, P < 0,001) compared to younger surgeons (<5?year experience) in solo clinics. The commonest reason for nonadoption of IC antibiotics was 搖nconvinced of the need to use it in my setting� (n = 296, 52% of those who answered this question). Conclusion: IC antibiotic prophylaxis for cataract surgery has significantly increased in India from 40% in 2017 to 58% in 2022. Commercially available moxifloxacin was preferred by the majority users. Intraocular inflammation may occur occasionally and needs safer formulations to avoid this

Correlation between different retinal layers with visual acuity in diabetic retinopathy patients with clinically significant macular edema

Purpose: To study the corelation between outer retinal layer thickness (ORL), outer photoreceptor segment thickness (PROS), and central macular thickness (CMT) with best?corrected visual acuity (BCVA) in patients having clinically significant macular edema (CSME) and compare these parameters with normal patients. Methods: This was a prospective, nonrandomized, observational, comparative study done during the period of January to May 2019. The study included 60 eyes of 36 patients. The patient population was segregated into two Groups: Group ? (30 normal eyes of 15 normal patients) and Group ?? (30 eyes of 21 diabetic patients) with CSME. The comparison between ORL, PROS, and CMT was made between both the groups, and the correlation between ORL thickness, PROS thickness, and CMT with BCVA in Group ?? was studied. Results: The mean age in Group I was 52.6+10.66 years, and 53.42+8.15 years in Group II. The male/ female ratio was 1.1:1 in Group I and 4:3 in Group II. The mean CMT was greater in Group ?? (330.13 ± 37.01) than in Group ? (222.20 ± 12.30). The mean ORL thickness was greater in Group ? (97.73 ± 6.92) than in Group ?? (80.63 ± 9.03). The PROS thickness was statistically significant in Group ? (35.05 ± 3.4) than in Group ?? (28.57 ± 3.53). There was a strong correlation between BCVA and ORL thickness (r = ?0.580, P < 0.001) and more strong correlation between BCVA and PROS thickness in Group ?? (r = ?0.611, P < 0.000). There was a moderate correlation between BCVA and CMT (r = 0.410, P < 0.025), and all results were statistically significant. Conclusion: Both ORL and PROS thickness were greater in healthy normal eyes than in eyes with CSME. BCVA was strongly correlated with PROS and ORL thickness and moderately associated with CMT.

Cataract surgical training among residents in India: Results from a survey

Purpose: To assess the quantum of cataract surgical training opportunities for trainees enrolled in ophthalmology residency programs in India. Methods: An anonymous online survey was sent across to resident ophthalmologists across India through various social media platforms. The results were tabulated and analyzed. Results: A total of 740 resident ophthalmologists participated in the survey. In all, 40.1% (297/740) were independently performing cataract surgeries. Of those who were not performing independent cataract surgeries, 62.5% (277/443) were in the third year of residency. A significantly higher proportion of trainees who were not operating independent cataract surgeries were enrolled in MD/MS programs as compared with DNB courses (65.6% vs. 43.7%; P < 0.0001). Of those who were operating independent cases; 97.1% had exposure to manual small incision cataract surgery (MSICS), whereas only 14.1% performed phacoemulsification. It was noted that 31.3% of residents reported that on an average a trainee in their training program performed less than 100 independent cataract surgeries throughout the residency. Apart from cataract surgery, the most performed surgeries by residents were pterygium excision (85.3%), followed by enucleation/ evisceration (68.1%). When it came to training aids, 47.2% (349/740) of the respondents reported no access to wet lab, animal/cadaver eyes, or surgical simulators for training. Conclusion: The amount of surgical exposure in terms of cataract surgery across residency programs in India is low with most of the ophthalmology residents who participated in this survey not operating cataracts independently; even in their final year of residency. Exposure to phacoemulsification in residency programs is very limited across the country. Although some programs do provide well?rounded surgical exposure to trainees, such centers are scarce; the stark variations in infrastructure, training opportunities, and surgical numbers warrant an overhaul in the structure and curriculum of residency programs in India

Assessment of optic disk by disk damage likelihood scale staging using slit-lamp biomicroscopy and optical coherence tomography in diagnosing primary open-angle glaucoma

Purpose: The current study was aimed at assessment of optic disk by disk damage likelihood scale (DDLS) staging using slit?lamp biomicroscopy and optical coherence tomography (OCT) in diagnosing primary open?angle glaucoma (POAG) patients. Methods: This was a cross?sectional observational study of 106 POAG patients, which was conducted from April 2017 to April 2018. All patients underwent slit?lamp fundoscopy with a +78 D lens and high?definition (HD)?OCT, and the vertical cup disk ratios (VCDRs) were recorded. Disk size and neuroretinal rim assessment were done, and the disk was then staged using the recent version, which stages the optic nerve head (ONH) from 1 to 10 as read from the DDLS nomogram table. DDLS scores >5 indicate glaucomatous damage. Pearson coefficient was used to correlate the DDLS staging by slit?lamp biomicroscopy with best?corrected visual acuity (BCVA), intraocular pressure (IOP), disk size, and VCDR and VCDR, mean deviation, and DDLS staging by HD?OCT. Results: The mean age of the patients was 59.54 ± 6.61 years. The male: female ratio was 2:1. The mean IOP was 16.04 ± 1.97 mmHg, and BCVA was 0.72 ± 0.13 LogMAR units. The mean VCDR on 78 D slit?lamp biomicroscopy was 0.76 ± 0.09 (standard deviation [SD]) (range 0.1–0.77), whereas on HD?OCT, the mean VCDR was 0.81 ± 0.09 (SD) (range 0.07–0.81). The mean deviation on visual field testing in decibels was ?14.43 ± 3.31 (SD). The correlation coefficient between DDLS staging by slit?lamp biomicroscopy and DDLS staging by HD?OCT parameters was r = 0.96. Conclusion: There is a positive correlation between the DDLS system of optic disk evaluation on slit?lamp biomicroscopy and most of the HD?OCT evaluation parameters

One step beyond tomorrow; Ranjan manual small-incision cataract surgery (MSICS) marker - Welcome to the topical, flapless and astigmatism-free MSICS era

The prevalence of blindness in India is 14.9 per 1000. Cataract causes 80% of this blindness. Most of these blinds are in the rural areas while the surgical service delivery channels are concentrated in the urban areas. This situation has many social impacts like loss of productivity, breakdown of interpersonal relationships, depressive manifestations, loss of self-esteem, and isolated humiliating life. Manual small-incision cataract surgery (MSICS; also SICS) is a low-cost, small-incision, high-valued cataract surgery that is principally employed in the developing world. In poor settings, MSICS also has several distinct advantages over phacoemulsification, including shorter operative time, less need for technology, and lower cost. Ranjan MSICS Marker is a tool which enables MSICS to be done under topical anesthesia easily with more precise and safe incision making along with more control on surgery induced astigmatism.

Fish hook technique for nucleus management in manual small-incision cataract surgery: An Overview

Manual small-incision cataract surgery (MSICS) preserves its utility as a cost-effective and efficient strategy for mitigating cataract-associated blindness. Numerous techniques of nucleus delivery in MSICS have been described in the literature. The fish hook technique of nucleus extraction was advocated in 1997 and has been popular for high-volume surgery in limited pockets of the world. This article describes in detail the steps involved in the construction of a fish hook, tips of nucleus extraction with the help of a fish hook, and the pros and cons of fish hook-based MSICS through text, diagram, and video supplement.

Comparison of corneal endothelial cell loss during manual small-incision cataract surgery using viscoelastic-assisted nucleus removal versus continuous balanced salt solution plus technique - Randomized controlled trial

Purpose: The purpose of this study was to compare and analyze the endothelial cell loss during manual small-incision cataract surgery (MSICS) using the viscoelastic-assisted nucleus removal versus basal salt solution plus technique. Methods: This was a prospective randomized trial of 204 patients who underwent MSICS using viscoelastic-assisted nucleus removal (Group 1- OVD) versus basal salt solution plus technique (Group 2- BSS) at a tertiary eye care hospital in North India from January 2018 to 2021. Of these 204 patients, 103 (50.5%) and 101 (49.5%) were allocated to Group 1 and 2, respectively. The parameters assessed were detailed history, demographics, and anterior and posterior segment details. Visual acuity, intraocular pressure (IOP), keratometry, pachymetry, and endothelial cell density were evaluated preoperatively and postoperatively on day 1 and 30. Results: The mean age of the patients was 64.5 � 8.2 years (range 48� years). There were 129 (63.2%) males and 75 (36.8%) females. The mean LogMAR visual acuity for both groups on day 1 (Group 1- 0.3 � 0.1, Group 2- 0.5 � 0.2) and day 30 (Group 1- 0.1 � 0.2, Group 2- 0.1 � 0.1) was statistically significant (P < 0.001), and the mean IOP value showed a statistically significant value (P < 0.009) on day 1 in Group 2 (15.0 � 2.4 mmHg) and on day 30 (P < 0.001) in both the groups (Group 1- 13.6 � 1.8 mmHg, Group 2- 13.5 � 2 mmHg). The horizontal and vertical k values also showed a statistically significant difference on day 1 and day 30 (P < 0.001). The mean percentage change of central corneal thickness (CCT) in Group 1 was 17.7% and in Group 2 was 17.4% on day 1, and it was 1.1% on day 30 in both the groups, which was statistically significant (P < 0.001) compared to preoperative values. The percentage change in endothelial cell density on day 1 was 9% in Group 1 and 4.6% in Group 2, which was statistically significant (P < 0.001). On day 30, it was 9.7% and 4.8%, respectively, which was statistically significant (P < 0.001). Conclusion: Our study highlights statistically significant endothelial cell loss with viscoelastic-assisted nuclear delivery compared to BSS-assisted nuclear delivery during MSICS in a short follow-up of 1 month. The CCT values showed a slight increase, and the keratometry and IOP were unaffected compared to the preoperative parameters in both the groups

Early postoperative astigmatism in 2-mm manual small incision cataract surgery with phacofracture

Purpose: India’s cataract surgery rate has been hovering around a creditable 6000 per million population but the coverage is variable across the geography and demography with sharp urban rural divide. Smaller incisions in manual small incision cataract surgery (MSICS) with phacofracture have been credited with lower astigmatism and faster recovery, which is especially useful for patients traveling for surgeries. Methods: In this retrospective chart analysis based observational study of 66 eyes, we describe the early postoperative results with 2 mm MSICS with phacofracture. Results: The mean spherical equivalent of the autorefractor measured astigmatic error changed marginally to ?0.51 diopters (SD = 0.58) from ?0.44 diopters (SD = 0.42) (t = ?8.410, P = 0.0) translating to mean change in astigmatism of 0.14 DCyl when the axis was ignored. The keratometric difference between steepest and flattest axis of the anterior surface of the central 3 mm zone of the cornea changed from a mean of 0.89 diopters (SD = 0.55) to 1.39 diopters (SD = 1.03). The visual acuity improved to mean logarithm of the minimum angle of resolution (logMAR) score of 0.27 (SD = 0.33) at 1 week and 0.007 (SD = 0.04) which corresponds to 6/6P on Snellen’s acuity at 1 month or more. Conclusion: A 2 mm MSICS with phacofracture can deliver low astigmatism and good visual recovery in cataract surgery. The study underlines the need for considering the refraction at anterior and posterior corneal interfaces when the triplanar incision with separate interfaces is used.

Prevalence of incidental and total human immunodeficiency virus, hepatitis B and hepatitis C seropositivity among patients posted for cataract surgery at a tertiary care center in India

Purpose: To study the prevalence of human immunodeficiency virus (HIV), hepatitis B (HBV), and hepatitis C (HCV) viral seropositive among the patients posted for cataract surgery at a tertiary care center in north India. Methods: It was a cross?sectional study done for 30 months duration. All the patients posted for cataract surgery underwent comprehensive ophthalmic evaluation followed by routine hematological workup, including viral markers for HIV, Hepatitis B surface antigen (HBsAg), and anti?HCV. Data were analyzed by the Statistical Package for Social Science (SPSS Version 20). Results: A total of 7,316 individuals underwent cataract surgery from Jan 2016 to August 2018, 4,073/7,316 (55.7%) were males. The prevalence for HIV was 58/7,316 (0.8%), HBsAg was 151/7,316 (2.1%), and HCV was 11/7,316 (0.1%); 28/58 (48.3%) HIV positives were unaware of their seropositivity till testing, as were 37/151 (24.5%) of HBsAg positives, and 4/11 (36.4%) HCV positives. There was a significant relationship between the mean age in the patients with HIV (P = 0.002) and anti?HCV (P = 0.045). A majority of the seropositive patients were found to be illiterate (45.6%), followed by educated up to high school level (29.1%), and graduate (25.0%). Conclusion: Viral seropositivity was significant among the patients posted for cataract surgery. The eye care providers could refer these patients for counseling and further management for the patient’s and their caretaker’s benefit

Incidence of Pterygium in Teenagers -A Clinical Study

Aim: The aim of our study was to evaluate increasing occurrence of pterygium in young individuals and to suggest methods for its prevention. Methods: This was a hospital based prospective observational study carried out for a period of one year. A total of 30 eyes of 25 patients were taken who were diagnosed to have pterygium on slit lamp examination. All patients were less than 20 years of age. Patients who presented with complaints of irritation, redness and mass in the eyes were included in our study. Patients with history of trauma and chemical injuries were excluded in this study. All selected patients underwent detailed ophthalmic examination including visual acuity, refraction, slit lamp examination and fundus evaluation. The side, progression, position, autorefractometry and keratometry were noted in each and every patient. Results: A total of 30 eyes of 25 patients were included in our study among which 21 (84.0%) were males and rest 4 (16.0%) females. All of our patients belonged to age group 11-20 yrs. The complaint of pterygium was found more in patients who belonged to rural background (18, 72.0%). 5 (20.0%) patients had bilateral pterygium and rest 20 (80.0%) had complaint in only one eye. Majority of our patients had pterygium on nasal side (21, 84.0%), 3 of them on temporal side (12.0%) and one on both sides (4.0%). Majority of them had concern with cosmesis followed by diminution in vision and irritation in the eyes. Almost all of them (24, 96.0%) spent their time outdoors while work and play. Pterygium was graded as grade 1 when it just touched the limbus, grade 2 when pterygium was at half the distance between the limbus and pupillary margin, grade 3 when pterygium reached the pupillary margin and grade 4 when it crossed the visual axis to the other side. All of our patients had grade 1 and 2 pterygium. Conclusion: The prevalence of pterygium has been on a rise in these recent years in young individuals. Hence, adequate precautions like wearing protective glasses, hooded caps, brimmed hats etc. should be advised to young individuals in order to prevent them from pterygium. All of them should be educated for safety measures in order to prevent pterygium and hence to lead a good quality of life.

Evaluation of Changing Axial Length in Eyes after Paediatric Cataract Surgery

Background: Evaluation of changing axial length in eyes after paediatric cataract surgery. Aim – To assess the change in axial length of eye after paediatric cataract surgery which will help us to determine the amount of under-correction required in IOL power with increase in age. Methods: 32 patients were divided in three age groups; 0-2 years, 2-5 years and 5-10 years. Post cataract surgery, in all the patients axial length measurement, intraocular pressure recording and cycloplegic refraction was done at 6month, 1 year and after 2year of surgery. An unpaired T-test was performed to check the significance of study. Results: The change in axial length in first group(0-2 years) was higher at the end of 2 years (1.82mm) than second (1.74mm) and the third group (0.85mm). The mean axial growth of aphakic eye was higher (1.65mm) than the pseudophakic eyes of the same age group. Maximum growth rate (40-56% of the total growth) was observed in the first 6months of surgery in all the three groups. Myopic eyes in group 2 had higher mean axial growth (2.28) than the non-myopic eyes (1.28) of the same study group. Myopic eyes in the other group also had higher growth rate. Conclusion: Paediatric eye is a growing system with an eminent myopic shift which necessitates the required adjustment in IOL power to achieve emmetropia at adult age. As the rate of growth in axial length is maximum between 0-2 years of age, the required reduction in IOL power is more in this group to achieve the final status of emmetropia.

Changes in the Central Corneal Thickness in Diabetes Mellitus Patients with age and Gender Matched Healthy Controls in North Indian Population

Background: Since diabetes mellitus affects the all part of body including ocular structures so we planned a study to compare the central corneal thickness in diabetes mellitus patients with age and sex matched healthy controls in North Indian population. The aim of our study was to compare the central corneal thickness in diabetes mellitus patients with age and sex matched healthy controls in North Indian population. Methods: It was a prospective clinical study done at tertiary care centre on two hundred patients. Out of them 100 were diabetic and 100 were healthy subjects. The CCT measurement was done in enrolled patient using a non contact ultrasonic pachymeter probe gently placed in the mid pupillary axis of the cornea in undilated eye. All CCT and IOP recordings were done between 12- 2 pm keeping in mind the diurnal fluctuations. Data was analysed by SPSS Software version16. Results: CCT was higher in diabetics having duration > 10 years than those having duration < 10 years.Central corneal thickness values increased from patients with no diabetic retinopathy to those with proliferative retinopathy. Conclusion: The cornea of diabetics is significantly (P≤0.001) thicker than normal healthy subjects.

Management of Descemet’s Membrane Detachment by Intra Cameral Air Injection.

Background: Descemet’s membrane detachment (DMD) is an uncommon but serious complication of intraocular surgery. It requires prompt intervention to prevent corneal decompensation. Intracameral injection of air is the most commonly practiced and most successful modality of management in such circumstances. Aim and Objective: To analyze the possible causes of Descemet’s membrane detachment (DMD), evaluate the efficacy of intracameral air injection in its management, analyze when to do other interventions & to evaluate the outcome of patients after successful management. Methods: After Ethical committee approval, clinical data of 50 eyes of 50 patients during the period April 2014 to April 2016, who developed DM detachment after cataract surgery were noted. Study area: - IGIMS, Patna, Bihar, India. Study population: - 50 eyes of 50 post cataract surgery patients developing intra-operative DMD in the period of April 2014 to April 2016. Results: Patients were within the age group 54 to 82 years, mean was 65.38 ± 7.11. Sex distribution was 24 male and 26 female patients. Majority of the patients (n=37, 74%), had severe corneal edema. 8% had mild and 18% had moderate corneal edema. Descemet’s membrane detachment as noted from the ASOCT was, Range 10% to 95%, Mean 46.20, SD 24.065. Only air was sufficient to re-attach DMD ranged from 10% to 55%, mean = 36.50 and SD = 14.815. Visual acuity of patients on Post-Op (Day 1) versus Post-Op (1 week), c2 = 22.1 and P = 0.00019144, which was a significant improvement. Conclusion: Intra Cameral injection of air is demonstrated as a safe and efficacious option for the repair of Descemet's membrane detachment. Use of Isoexpansile 14% C3F8 is an effective and promising alternative for cases not resolving with repeated intra cameral air injection.

Acute myeloid leukemia with t(4;12)(q12;p13): A morphological dilemma.

Cytogenetics has a pivotal role in risk stratification of acute myeloid leukemia (AML). We report a case of AML with a t(4;12)(q12;p13). To the best of our knowledge, there are about 24 cases of t(4;12) reported in AML which are usually misdiagnosed as lymphoproliferative disorders on morphological assessment. This case showed specific clinical, morphological, and immunophenotypic features such as (1) pseudo lymphoid morphology, (2) dysplasia in granulocytic series, (3) an immature immunophenotype with positivity for CD34 and CD117, and (4) poor treatment response.

Loss of chromosome Y in acute lymphoblastic leukemia: Age related or neoplastic phenomenon.

Loss of chromosome Y (LOY) in the bone marrow has long been considered as an age-related phenomenon with an incidence of more than 25% in males beyond the age of 80 years. Though reported as an acquired abnormality in myeloid neoplasms, it has rarely been described in B-lymphoblastic leukemia which primarily is a disease of the young. We describe here in three cases of pediatric B-lymphoblastic leukemia with LOY. Conventional cytogenetic studies and fluorescence in situ hybridization studies using centromeric probes for chromosome X and Y on peripheral blood samples ruled out constitutional LOY in all the three cases favoring it to be a neoplastic phenomenon.

Celiac disease: association with adult-onset Still's disease: apropos of a clinical case.

Adult-onset Still's disease (AOSD) is a rheumatic disorder of unknown etiology characterized by a triad of fever, polyarthritis and evanescent rash. We present a case report of a 28-year-old female who presented with complaints of fever, joint pains, rash, weakness for the past 4 years and diarrhea for the past 2 years. On investigation the patient was diagnosed to be a case of AOSD. Duodenal biopsy report was suggestive of celiac disease with a positive IgA tissue transglutaminase and anti-endomysial antibody. The patient was started on weekly methotrexate and gluten-free diet and her symptoms gradually improved. The patient remains in our follow-up and is doing well.