Aurolab aqueous drainage implant implantation made easy: A video-based step-by-step guide

Background: Glaucoma is one of the major causes of irreversible blindness in the world, with trabeculectomy still being the primary surgical modality for the management of glaucoma. Glaucoma drainage devices (GDDs) have been conventionally used for the treatment of refractory glaucoma and are found to be beneficial in eyes with prior unsuccessful filtration surgeries and primary choice of surgery in certain glaucoma. Aurolab aqueous drainage implant (AADI) is a nonvalved device useful in refractory glaucoma to achieve low intraocular pressure (IOP). The device has been commercially available in India since 2013 and is like the Baerveldt glaucoma implant in design and function. AADI being the most economical and effective GDD in controlling IOP is becoming a popular choice among ophthalmologist in developing countries. AADI surgery has steep learning curve due to large end?plate surface area which needs a rigorous conjunctival dissection, muscle hooking, meticulous plate fixations, and careful tube ligations and insertion. There are different techniques of performing AADI surgery, but the authors have tried to simplify the complex surgery for easy and catchable learning of the procedure by novice surgeon with their experience and have elaborated a step?wise most effective way of performing surgery. Purpose: This video?based skill transfer depicts steps of AADI surgery with compilation of various modifications and authors’ tips and tricks to novice surgeons. Synopsis: This video depicts detailed steps of AADI surgery with micro?points and authors experience. Video also shows various tailor?made modifications of surgical techniques for different case scenarios. Highlights: Steps of AADI surgery, modifications, and surgical pearls.

Refractive profile of children treated with intravitreal bevacizumab for retinopathy of prematurity

Purpose: To study the refractive profile of children after they received intravitreal injection of bevacizumab for retinopathy of prematurity (ROP). Methods: The study was conducted at a tertiary eye care hospital in South India. ROP patients of more than 1 year of age, presenting to the Pediatric Ophthalmology Clinic and Retina Clinic and having history of treatment for type ? ROP with intravitreal bevacizumab (IVB) or intravitreal bevacizumab and laser photocoagulation were included in the study. Cycloplegic refraction was done, and the refractive status was evaluated. The refractive status of age?matched, full?term children with uneventful perinatal and neonatal history was also recorded and compared to the study group. Results: Among 134 eyes of 67 study subjects, the major refractive error was myopia in 93 eyes (69.4%; spherical equivalent [SE] = ?2.89 ± 3.1, range = ?11.5 to ?0.5 D). There were 75 eyes (56%) with low?to?moderate myopia; high myopia was seen in 13.4%, emmetropia in 18.7%, and hypermetropia in 11.9% of eyes. The majority of them (87%) had with?the?rule (WTR) astigmatism. In 134 eyes, the SE was ?1.78 ± 3.2 (range = ?11.5 to 4 D); the SE of the 75 eyes with low?to?moderate myopia was ?1.53 ± 1.2 (range = ?0.50 to ?5 D). In the control group, the majority had emmetropia (91.8%). There was no significant association between the age at which IVB had been injected and the development of refractive errors (P = 0.078). The prevalence of low?to?moderate myopia was more than high myopia in patients with zone ? and zone ? ROP before treatment (60.0% and 54.5%, respectively). Conclusion: Myopia was the major refractive error seen in post?IVB pediatric patients. WTR astigmatism was more commonly seen. The age at which IVB injection had been given had no effect on the development of refractive errors

Assessment of parental awareness about pediatric visual problems by Knowledge-Attitude-Practice survey in South India

Purpose: To find out parents’ knowledge, attitude, and treatment practice (KAP) toward pediatric eye problems and to assess the effect of demographic factors such as gender, age, educational status, and number of children on KAP. Methods: A cross?sectional descriptive study was conducted in a hospital setting. Two hundred parents were randomly selected for the questionnaire. All parents had children who were included in Systematic Pediatric Eye Care Through Sibling Screening Strategies (SPECSSS) study. A survey with 15 questions on KAP of pediatric eye diseases was prepared and administered to parents coming to a tertiary eye hospital with varied experience and education qualifications. Results: The mean age of 200 patients was 9.6 (3.4) years, with the majority of them male (n = 110; 55.0%). The majority of the children (n = 91, 45.5%) were between the age group of 6–10 years. Knowledge of visual problems among parents was of a good grade in 9% only. The attitude of the parents toward the visual problem was positive at 17%, and the responses regarding the practice were of excellent grade at 46.5% and good at 26.5%. Analysis suggests that the level of knowledge and practice were not significantly associated with the demographic factors (p > 0.05). The positive attitude toward the visual problems of the children was associated with education of the parents (p < 0.05) and the father occupation (p < 0.05). Conclusion: Knowledge about pediatric eye diseases was poor among parents and it was significantly affected by education and occupation of parents. The parents have positive attitude toward enhancing their attitude in treatment.

Non-compliance for wearing spectacles: Prevalence and determinants in school-going children in South India

Purpose: To study the prevalence and determinants of compliance with spectacle wear among school?age children in South India who were given spectacles free of charge under a school vision screening program. Methods: A cross?sectional, descriptive study was performed. The participants were recruited from the school from Tirunelveli and Tuticorin districts of Tamil Nadu, where a school vision screening camp was conducted between January 2012 and October 2012. The school screening was performed under “Lavelle Pediatric Eye Care Project”. Of the 129,720 children examined of 249 schools, 4253 of children had refractive error and 3333 were prescribed and dispensed spectacles. A total of 683 children were interviewed, who were not wearing glasses on follow?up. Results: About 20% of the participants (683/3333) were not wearing their spectacles at examination. The most common reasons given for non?wear were lost (44.9%) or broken (35.3%) spectacles. There was no gender preference on compliance to spectacles. Conclusion: Compliance with spectacle wear is less even when spectacles are provided free of cost, particularly in children among the age group of 5–15 years. Because factors such as type of school, area (urban or rural), parent’s income, occupation, and their education were not significantly affecting the compliance of spectacle wear, proper encouragement and counseling of the parents and the child become extremely important.

Comparison of the effect of audiovisual and verbal instructions on patient performance while performing automated Humphrey visual field testing

Purpose: To compare the effect of audiovisual and verbal instructions on patient performance while performing automated Humphrey visual field testing. Methods: This was a prospective study. A total 120 patients divided into groups of 40 each were recruited from the glaucoma outpatient department (OPD). All patients were aged 35–75 years with no previous experience of performing HFA. Patients with hearing impairment, any other cognitive impairment, and best?corrected visual acuity (BCVA) ?6/36 on Snellen’s visual acuity were excluded. The first two groups were given strict (conservative) and lenient (liberal) verbal instructions. The instructions were adapted from those listed in the manufacturer’s instruction. and the third group was shown a standard video depicting in detail how perimetry was to be performed. A questionnaire was given to each patient before and after the test to assess the patient’s performance. Results: Patients diagnosed with glaucoma during testing in each group were 29 (72.50%), 30 (75.0%), and 33 (82.5%) in the video instructed, strictly verbal, and leniently verbal groups, respectively. The overall mean deviation (MD) in the right eye (RE) was of ? 3.38 (?4.9 to 1.9) and in the left eye (LE) was ? 3.96 (?6.4 to ? 1.9). Reliable field was slightly higher for the video instructed group (47.5%) and lowest for the strictly verbal group (22.5%) (P = 0.033). A higher number of patients were very motivated in the video instructed group (27%) (P = 0.041). Post?test questionnaires showed that 40% of patients felt they have performed the test with 100% accuracy in video group with less guessing. A higher number of patients in the video instructed group (85%) felt instruction was helpful in performing the test (P = 0.001). Conclusion: The video groups were more motivated and had better confidence to perform the test with less anxiety and stress and with probably better understanding of the procedure due to visual effects enhancing their understanding.

Identification of potential barriers for timely access to pediatric sibling eye check-up in a tertiary eye care hospital

Purpose: To identify socio?economic, demographic, and clinical factors that may be associated with sibling access to ophthalmic check?up. Methods: A cross?sectional, descriptive study investigated children in the age group of 0–15 years under a project on Systematic Pediatric Eye Care Through Sibling Screening Strategies (SPECSSS project). The siblings of pediatric patients (proband) with refractive errors, strabismus, cataract, glaucoma, and retinal pathologies were given a referral card for ophthalmic check?up. If parents do not bring siblings for check?up within 1 month of initial information and even after 2 SMS reminders, it was considered as failure to uptake of services. On follow?up later, they were provided a questionnaire. A questionnaire was given to the parent by interview through a project coordinator, and details were obtained from the parents or caretaker. Parents who were willing for telephonic interview were asked to respond to the questionnaire over phone on the scheduled date. The sibling details, parent?related details, and data from questionnaire forms were entered and analyzed. Results: The mean age of 300 siblings was 9.3 ± 4.0 years with the majority of them being female (158). The most common reasons quoted by parents in the rural area compared with the urban area for not bringing siblings for eye exams were the travel distance from home to the hospital (n = 118, 83.7%), the travel time from home to the hospital (n = 109, 77.3%), more than one vehicle required to change (n = 111, 78.7%), and the transportation cost more than rupees 100 (INR) (n = 89, 63.1%) (p < 0.05). Unable to leave work responsibilities (n = 126, 79.3%) was stated more frequently by urban parents compared to rural (p = 0.039). Conclusion: Our study suggests that the financial factor, the distance factor, and social belief play an important role in timely uptake of sibling eye check?up. Targeting siblings with treatable pediatric eye diseases could help in reducing the burden of refractive error, strabismus, and cataract in the pediatric population.

Potpourri of retinopathies in rare eye disease – A case series

This case series describes the ocular and retinal manifestations of rare eye diseases in systemic syndromes. This observational case series consists of five patients with varied ophthalmic manifestations and documentation of imaging in rare pediatric and adult retinopathies. Two patients had Kearns Sayre syndrome (KSS) based on the classical triad of external ophthalmoplegia, pigmentary retinopathy, and onset before 20 years of age. In one patient of KSS, the mitochondrial retinopathy was seen in an asymmetric pattern, and the second patient presented with KSS after being mis-diagnosed as myasthenia gravis elsewhere. A case of Senior Loken syndrome in pediatric age is described in this series with varied ophthalmic manifestations ranging from retinitis pigmentosa to orbital abscess. This series also enlightens features of Hallervorden Spatz syndrome presenting with bull’s eye maculopathy and a case of spino-cerebellar ataxia type 7 presenting with pigmentary retinopathy.

Clinical profile and long term outcomes of eyes with choroidal detachment following trabeculectomy

Purpose: To assess the long?term outcomes of choroidal detachments (CDs) in eyes following trabeculectomy. Methods: Retrospective comparative case series. Data of patients with CDs following trabeculectomy (5?year period) with or without cataract surgery with a minimum of 3 months of follow?up were included. Results: In total, 45 patients with CDs following trabeculectomy were included. The mean age was 63.27 ± 8.68 years, (M:F = 2:1); 29 of 45 eyes (64.4%) had a baseline IOP of >24 mm Hg. Patients had a median follow?up of 22.2 (IQR: 16.2–30.5) months. Further, 10 of 45 eyes (22.2%) had CDs following suture lysis. The median onset of choroidal detachment from the time of surgery was 16.0 (IQR: 11–36) days. The mean BCVA improved from 0.62 ± 0.28 to 0.24 ± 0.27 (P < 0.001) and mean IOP increased from 4.07 ± 2.66 to 11.20 ± 5.31 (P < 0.001) at last visit. The cumulative success rates were 76.4% (95% CI: 48.4–90.5) in POAG eyes and 79.3% (95% CI: 62.8–89.1) in PACG eyes (P = 0.547). Medical management was the mainstay in all patients. Four of 45 (8.88%) patients underwent subsequent choroidal drainage. Conclusion: Choroidal detachment following modern?day trabeculectomy has favorable long?term visual acuity and IOP outcomes. There was no difference in the long?term surgical success of trabeculectomy with choroidal detachments in primary angle?closure and open?angle glaucoma eyes. Long?term follow?up is essential to prevent chronic hypotony and trabeculectomy failure

Bleb revision with bleborhexis and clear corneal lamellar patch graft for overhanging cystic bleb

Background: Trabeculectomy is associated with several complications. One of the common complications with mitomycin assisted trabeculectomy is thin cystic bleb leading to bleb leak, hypotony and infections. Various technique of bleb repair and reconstruction have been described, such as conjunctival advancement, or scleral, pericardial or corneal patch graft. Purpose: To demonstrate bleb revision by bleborhexis and clear corneal lamellar patch graft for a patient with thin cystic leaking bleb leading to hypotony and decreased vision. Synopsis: This was a 75-year-old one-eyed lady, diagnosed with primary angle-closure glaucoma in both eyes with absent light perception in the left eye, had undergone a combined trabeculectomy and cataract surgery in the right eye 6 years ago. She presented with diminution of vision (6/18p), introacular pressure (IOP) of of 6 mmHg, thin cystic leaking overhanging bleb, and dysesthesia. Bleb repair by bleborhexis with lamellar corneal patch graft was performed. Bleborhexis is a technique in which the overhanging fibrosed thin cystic conjunctival bleb is peeled off the cornea smoothly to leave a uniform clear corneal surface. Clear cornea, uniform diffuse bleb, well-formed anterior chamber with and IOP of 15 mmHg was noted on the first post-operative day, with a vision of 6/12p. This procedure helped meticulous reconstruction of the bleb, early recovery of vision, maintanance of normotensive eye, and save the eye from potential infections. Highlights: Bleborhexis with lamellar corneal patch graft provides for an easy and a elegant surgical technique with minimal corneal tissue damage, faster healing and patient comfort. It could be the favored technique in patients with thin overhanging clebs.

Transconjunctival flap sutures: A novel technique to combat hypotony

Background: Hypotony secondary to overfiltration is a recognized complication following trabeculectomy. Persistent hypotony requires intervention . Purpose: We describe a modified version of placing conjunctival compression sutures directly over the scleral flap. Synopsis: A 70-year-old male patient diagnosed with primary open angle glaucoma in both eyes underwent combined surgery in the right eye. On the tenth post-operative day, the patient presented with severe hypotony with 360? choroidal detachment. He was treated with corticosteroids and cycloplegics but developed hypotony maculopathy on the subsequent follow-up. Hence, he was further managed surgically by trans-conjunctival flap sutures to which he responded favorably with resolution of choroidal detachment and improvement in intraocular pressure and visual acuity. Highlights: Transconjunctival suturing of the scleral flap is an effective and minimally invasive treatment to prevent visual loss from hypotony maculopathy for an overfiltering bleb following trabeculectomy.

Early outcomes of 21-gauge needle-guided ab interno tube sulcus placement of a non-valved implant in pseudophakic eyes

We report the early outcomes and describe an ab interno 21?G needle technique of sulcus placement of the Aurolab aqueous drainage implant (AADI) tube in nine pseudophakic eyes. IOP reduced from a preoperative mean (SD) of 28.33 (9.80) to 11.56 (2.65) mm Hg and the mean (SD) number of preoperative medications reduced from 3.0 (0.7) to 0.4 (0.9) at 3 months. There were no intraoperative complications noted. This technique of sulcus placement of the AADI tube is a precise technique of tube insertion. It may be an alternative to existing ab externo procedures of tube sulcus placement, limiting multiple blind entries.

Unilateral acquired Brown’s syndrome in systemic scleroderma: An unusual cause for diplopia.

Brown’s syndrome can be congenital or acquired with multiple causes. It has been described as a ocular complication in various rheumatic and nonrheumatic diseases. We describe a case of 27‑year‑old female patient with 5 years old history of systemic scleroderma who developed vertical diplopia, a left head tilt, and restriction of left eye on elevation in adduction. The patient responded to systemic steroids with resolution of diplopia.

Retinal nerve fiber layer thickness in normal Indian pediatric population measured with optical coherence tomography.

Purpose: To measure the peripapillary retinal nerve fiber layer (RNFL) thickness in normal Indian pediatric population. Subjects and Methods: 120 normal Indian children ages 5-17 years presenting to the Pediatric Clinic were included in this observational cross‑sectional study. RNFL thickness was measured with stratus optical coherence tomography (OCT). Children with strabismus or amblyopia, with neurological, metabolic, vascular, or other disorders and those with abnormal optic discs were excluded. One eye of each subject was randomly selected for statistical analysis. The effect of age, refraction and gender on RNFL thickness was investigated statistically. Result: OCT measurements were obtained in 120 of 130 (92.3%) subjects. Mean age was 10.8 ± 3.24 years (range 5-17). Average RNFL thickness was (± SD) 106.11 ± 9.5 μm (range 82.26‑146.25). The RNFL was thickest inferiorly (134.10 ± 16.16 μm) and superiorly (133.44 ± 15.50 μm), thinner nasally (84.26 ± 16.43 μm), and thinnest temporally (70.72 ± 14.80 μm). In univariate regression analysis, age had no statistical significant effect on RNFL thickness (P = 0.7249) and refraction had a significant effect on RNFL thickness (P = 0.0008). Conclusion: OCT can be used to measure RNFL thickness in children. Refraction had an effect on RNFL thickness. In normal children, variation in RNFL thickness is large. The normative data provided by this study may assist in identifying changes in RNFL thickness in Indian children.

Visual prognosis, intraocular pressure control and complications in phacomorphic glaucoma following manual small incision cataract surgery.

Aims: To evaluate intraocular pressure (IOP) control, visual prognosis and complications following manual small incision cataract surgery among eyes with phacomorphic glaucoma. Materials and Methods: This prospective, non-randomized interventional consecutive case series included all patients with phacomorphic glaucoma who presented to a tertiary eye care referral center in South India between March 2006 and April 2007. All patients underwent slit-lamp bio-microscopy, applanation tonometry and gonioscopy of the other eye to rule out angle closure. Small incision cataract surgery with intraocular lens implantation was performed in all affected eyes. Complete ophthalmic examination was done at each follow-up visit. Results: A total of 74 eyes with phacomorphic glaucoma were included in this study. The preoperative mean IOP was 38.4±14.3 mmHg and mean IOP at last follow-up was 12.7±2.4 mmHg. There was a statistically significant difference between IOP at presentation and IOP at last follow-up (P< 0.001). None of the eyes required long-term antiglaucoma medication. No significant intraoperative complications were noted. The final postoperative best corrected visual acuity was 20/40 or better in 51 patients. Eighteen eyes had corneal edema and 36 eyes had anterior chamber inflammation. Both conditions resolved with standard medical therapy. Conclusion: Manual small incision cataract surgery is safe and effective in controlling IOP and achieving good functional visual acuity with minimal complications in the management of phacomorphic glaucoma in developing countries.