Comparison of the safety and efficacy of Mitomycin C 0.02% used intra-operatively by subconjunctival injection versus direct scleral application using sponges in phacotrabeculectomy: A prospective randomized controlled trial.

PURPOSE: To compare the safety and efficacy of subconjunctival injection (MMC: 0.02%) to those with subconjunctival application of sponges soaked in Mitomycin C (MMC: 0.02%) intra-operatively in patients who underwent phacotrabeculectomy. METHODS: A total of 68 patients undergoing phacotrabeculectomy were randomized into two groups; the sponge group received 0.02% MMC-soaked sponges (n = 38), and the injection group received subconjunctival injection of 0.02% MMC (n = 30). The primary outcome was post-operative mean intra-ocular pressure reduction (IOP). The secondary outcomes were bleb morphology using Indiana Bleb Appearance Grading Score (IBAGS) and anterior segment optical coherence tomography (AS-OCT), post-operative use of 5-fluorouracil, and complications rates. These were compared at 1 week and 1, 3, and 6 months post-operatively. Complete success was defined as ≥30% reduction in IOP without anti-glaucoma medications. RESULTS: In sponge and injection groups, the mean pre-operative IOP was 29.1 ± 8.1 and 29.8 ± 8.8 mmHg, respectively. At 6 months, IOP in sponge and injection groups reduced by 52% (14 ± 3.6 mmHg, P < 0.001) and 50% (15.2 ± 4.1 mmHg, P < 0.001), respectively. Complete success was observed in 90.9% in the sponge group and 95.83% in the injection group. Both groups had diffuse, shallow, relatively avascular blebs at 6 months using IBAGS and AS-OCT. A few complications were seen in the sponge group during this period, which were not vision-threatening. CONCLUSION: Subconjunctival MMC injection is an effective, safe, convenient, and time-saving alternative to sponge-soaked delivery of MMC in phacotrabeculectomy.

Low vision device requirements among children from two schools for the blind in Tamil Nadu.

PURPOSE: To identify children with low vision from two local schools for the blind, to provide low vision devices (LVD) to those who may benefit from it, and to encourage them to learn print. METHODS: A prospective study was conducted among children from two local schools for the blind. Best-corrected visual acuity (BCVA) was done using the Snellen chart. Children with BCVA of counting finger (CF) 1/2 meter or more in the better eye underwent low vision assessment. Distant vision was assessed using the Feinbloom chart and near vision was assessed using the Lea symbol chart. Low vision devices (LVD) were prescribed as required. RESULTS: Among 185 children enrolled, 31 children had BCVA of >CF ½ meter. Using a telescope, distant vision was better than 3/36 in 48.4%, 3/36-3/12 in 16.2%, and 3/9.5 to 3/3 in 35.4%. Among 23 children who read 1M at <10 cm, 22.6% could read 0.6-0.8M, and 25.8% could read 1M using LVD. CONCLUSION: Regular screening of children in schools for the blind could identify children who might benefit from LVD. A review of protocols for the entry of children in schools for the blind by screening these children by a specialist team prior to admission should be made mandatory.

Anti-vascular endothelial growth factor for neovascular glaucoma.

BACKGROUND: Neovascular glaucoma (NVG) is a potentially blinding, secondary glaucoma. It is caused by the formation of abnormal new blood vessels, which prevent normal drainage of aqueous from the anterior segment of the eye. Anti-vascular endothelial growth factor (anti-VEGF) medications are specific inhibitors of the primary mediators of neovascularization. Studies have reported the effectiveness of anti-VEGF medications for the control of intraocular pressure (IOP) in NVG. OBJECTIVES: To assess the effectiveness of intraocular anti-VEGF medications, alone or with one or more type of conventional therapy, compared with no anti-VEGF medications for the treatment of NVG. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register); MEDLINE; Embase; PubMed; and LILACS to 22 March 2019; metaRegister of Controlled Trials to 13 August 2013; and two additional trial registers to 22 March 2019. We did not use any date or language restrictions in the electronic search for trials. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of people treated with anti-VEGF medications for NVG. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the search results for trials, extracted data, and assessed risk of bias, and the certainty of the evidence. We resolved discrepancies through discussion. MAIN RESULTS: We included four RCTs (263 participants) and identified one ongoing RCT. Each trial was conducted in a different country: China, Brazil, Egypt, and Japan. We assessed the trials to have an unclear risk of bias for most domains due to insufficient information. Two trials compared intravitreal bevacizumab combined with Ahmed valve implantation and panretinal photocoagulation (PRP) with Ahmed valve implantation and PRP. We did not combine these two trials due to substantial clinical and statistical heterogeneity. One trial randomised participants to receive an injection of either an intravitreal anti-VEGF medication or placebo at the first visit, followed by non-randomised treatment according to clinical findings after one week. The last trial randomised participants to PRP with and without ranibizumab, but details of the study were unavailable for further analysis. Two trials that examined IOP showed inconsistent results. One found inconclusive results for mean IOP between participants who received anti-VEGF medications and those who did not, at one month (mean difference [MD] -1.60 mmHg, 95% confidence interval [CI] -4.98 to 1.78; 40 participants), and at one year (MD 1.40 mmHg, 95% CI -4.04 to 6.84; 30 participants). Sixty-five percent of the participants with anti-VEGF medications achieved IOP ≤ 21 mmHg, versus 60% without anti-VEGF medications. In another trial, those who received anti-VEGF medications were more likely to reduce their IOP than those who did not receive them, at one month (MD -6.50 mmHg, 95% CI -7.93 to -5.07; 40 participants), and at one year (MD -12.00 mmHg, 95% CI -16.79 to -7.21; 40 participants). Ninety-five percent of the participants with anti-VEGF medications achieved IOP ≤ 21 mmHg, versus 50% without anti-VEGF medications. The certainty of a body of evidence was low for this outcome due to limitations in the design and inconsistency of results between studies. Post-operative complications included anterior chamber bleeding (3 eyes) and conjunctival hemorrhage (2 participants) in the anti-VEGF medications group, and retinal detachment and phthisis bulbi (1 participant each) in the control group. The certainty of evidence is low due to imprecision of results and indirectness of evidence. No trial reported the proportion of participants with improvement in visual acuity, proportion of participants with complete regression of new iris vessels, or the proportion of participants with relief of pain and resolution of redness at four- to six-week, or one-year follow-up. AUTHORS' CONCLUSIONS: Currently available evidence is uncertain regarding the long-term effectiveness of anti-VEGF medications, such as intravitreal ranibizumab or bevacizumab or aflibercept, as an adjunct to conventional treatment in lowering IOP in NVG. More research is needed to investigate the long-term effect of these medications compared with, or in addition to, conventional surgical or medical treatment in lowering IOP in NVG.

Ocular Pulse Amplitude in Non-Diabetic Patients with End Stage Renal Disease and Normal Individuals Using Dynamic Contour Tonometry.

INTRODUCTION: Ocular Pulse Amplitude (OPA) is the fluctuation of IOP with the cardiac cycle which is equal to the difference between systolic and diastolic IOP. These variations in IOP are thought to be caused by the blood volume that is pumped into the eye, mainly the choroidal bed during each cardiac cycle. In patients with end stage renal disease (ESRD), Choroidal perfusion has been found to be reduced as determined by Indocyanine Green Angiography (ICG) which is an invasive procedure. OPA is recorded by Dynamic Contour Tonometer (DCT) which represents a potential new technology for measuring choroidal blood flow indirectly & non-invasively especially in patients with suspected compromise in perfusion as in ESRD. In this study we postulate that measurement of OPA can be used to assess the choroidal perfusion inpatients with ESRD. OBJECTIVES: To measure OPA in non-diabetic patients with ESRD on hemodialysis and to compare it with that of OPA in age matched normal individuals. MATERIALS & METHODS: It was a prospective Cross-sectional study and was done in a clinical set up during the period of January 2013 to October 2013. OPA among 44exposed and 44 non exposed individuals were measured using Dynamic Contour Tonometry (DCT) and analysis done. RESULTS: The mean OPA in non diabetic patients with ESRD was 1.945mm Hg (CI:1.847 - 2.043) and the mean OPA in age matched normals was 2.16mm Hg (CI: 2.08- 2.24). CONCLUSION: OPA in non diabetic ESRD patients was statistically significantly lower than that of age matched normals (p=0.03). There was no correlation between OPA and other parameters like age, gender, intraocular pressure, blood pressure or serumcreatinine levels.

Does the ISNT Rule Apply to the Retinal Nerve Fiber Layer?

PURPOSE: To determine whether the ISNT rule (Inferior>Superior>Nasal>Temporal) or the "IST" rule (Inferior>Superior>Temporal) can be applied to the peripapillary retinal nerve fiber layer (RNFL) thickness as measured using Heidelberg Retinal Tomography (HRT) and Optical Coherence Tomography (OCT). MATERIALS AND METHODS: This was a cross-sectional study of 189 normal and 42 glaucomatous eyes. RNFL thicknesses measured in different quadrants using HRT and OCT were compared to determine the percentage of eyes obeying the ISNT and IST rule. RESULTS: The HRT-measured mean RNFL thickness in normal eyes showed that 25.9% obeyed the ISNT rule and 70.4% conformed to the "IST" rule. The "IST" rule was able to identify normal eyes better (P=0.040), but had a poor sensitivity (45%) and specificity (70%) to diagnose glaucoma. The OCT-measured average RNFL thickness showed that 47.1% of normal eyes obeyed the ISNT rule and 58.7% conformed to the "IST" rule. Exclusion of the nasal sector also increased the number of glaucomatous eyes conforming to the IST rule (31% obeyed the ISNT rule and 50% obeyed the IST rule). Sensitivities and specificities of the ISNT and the IST rules for OCT-quantified RNFL ranged from 42% to 77%. CONCLUSIONS: A larger number of normal eyes obeyed the IST rule compared with the ISNT rule for the RNFL thickness measured by HRT and OCT. Exclusion of the nasal sector from the analysis (IST rule) marginally improved the specificity in diagnosing glaucoma at the cost of the sensitivity, making neither of these parameters (ISNT and IST) likely to be useful clinically.

Anti-vascular endothelial growth factor for neovascular glaucoma.

BACKGROUND: Neovascular glaucoma (NVG) is a potentially blinding secondary glaucoma. It is caused by the formation of abnormal new blood vessels which prevent normal drainage of aqueous from the anterior segment of the eye. Anti-vascular endothelial growth factor (anti-VEGF) agents are specific inhibitors of the primary mediators of neovascularization. Studies have reported the effectiveness of anti-VEGFs for the control of intraocular pressure (IOP) in NVG. OBJECTIVES: To compare the IOP lowering effects of intraocular anti-VEGF agents to no anti-VEGF treatment, as an adjunct to existing modalities for the treatment of NVG. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 12), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to January 2013), EMBASE (January 1980 to January 2013), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to January 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov/) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 11 January 2013. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and quasi-RCTs of people treated with anti-VEGF agents for NVG. DATA COLLECTION AND ANALYSIS: Two authors independently assessed the search results for trials to be included in the review. Discrepancies were resolved by discussion with a third author. Since no trial met our inclusion criteria, no assessment of risk of bias or meta-analysis was undertaken. MAIN RESULTS: No RCTs were found that met the inclusion criteria for this review. Two RCTs of anti-VEGF agents for treating NVG were not included in the review due to the heterogeneity and uncontrolled assignment of adjunct treatments received by the study participants. AUTHORS' CONCLUSIONS: Currently available evidence is insufficient to evaluate the effectiveness of anti-VEGF treatments, such as intravitreal ranibizumab or bevacizumab, as an adjunct to conventional treatment in lowering IOP in NVG. Well designed RCTs are needed to address this issue, particularly trials that evaluate long-term (at least six months) benefits and risks since the effects of anti-VEGF agents may be short-term only. An RCT comparing anti-VEGF agents with no anti-VEGF agents taking into account the need for co-interventions, such as panretinal photocoagulation (PRP), glaucoma shunt procedures, cyclodestructive procedures, cataract surgery, and deep vitrectomy, could be of use to investigate the additional beneficial effect of anti-VEGF agents in treating NVG. Since decisions for when and which co-interventions should be used are based on clinical criteria, they would not be appropriate for randomization. However, the design of a study on this topic should aim to balance groups by stratification of co-intervention at time of randomization or by enrolling a sufficient number of participants to conduct subgroup analysis by co-interventions (ideally 15 participants per treatment group for each subgroup). Alternatively, the inclusion criteria for a trial could limit participants to those who receive the same co-intervention.

The effect of smoking on the ocular surface and the precorneal tear film.

BACKGROUND: Smoking, both active and passive, creates a plethora of health-related problems, which primarily affect the cardiovascular and respiratory systems. There is very little evidence on the effects of tobacco smoke on the eye, especially regarding anterior ocular surface related pathology. This study was undertaken to determine the effects of smoking on the ocular surface and the tear film in smokers. METHODS: A total of 51 (102 eyes) smokers and 50 (100 eyes) age-and gender-matched healthy non-smokers were included in this study. The ocular surface was evaluated by measuring tear film break-up time, surface staining with fluorescein, and corneal and conjunctival sensitivities, and by completing the Schirmer's II test. Data was analysed using Statistical Package for Social Sciences (SPSS) version 11.5. A p value less than 0.05 was considered statistically significant. RESULTS: The smoker group had significantly lower tear film break-up time, and corneal and conjunctival sensitivity than the nonsmoker group. Punctate staining was significantly higher in the smoker group than the non-smoker group. There was no statistically significant difference in Schirmer's II test results between the smoker and non-smoker group. CONCLUSION: Smoking caused adverse effects on the precorneal tear film and there was strong association between smoking and tear film instability. Although a causative relationship could not be determined, there is a need for further longitudinal studies.

Correlation between ocular parameters and amplitude of accommodation.

AIM: To study the relationship between ocular parameters and amplitude of accommodation (AA) in the peri-presbyopic age group (35-50 years). MATERIALS AND METHODS: Three hundred and sixteen right eyes of consecutive patients in the age group 35-50 years, who attended our outpatient clinic, were studied. Emmetropes, hypermetropes and myopes with best-corrected visual acuity of 20/20, J1 in both eyes were included. The AA was calculated by measuring the near point of accommodation. The axial length (AL), central anterior chamber depth (CACD) and lens thickness (LT) were also measured. RESULTS: There was moderate correlation (Pearson's correlation coefficient r = 0.56) between AL and AA as well as between CACD and AA (r = 0.53) in myopes in the age group 35-39 years. In the other age groups and the groups taken as a whole, there was no correlation. In hypermetropes and emmetropes, there was no correlation between AA and the above ocular parameters. No significant correlation existed between LT and AA across different age groups and refractive errors. CONCLUSION: There was no significant correlation between AA and ocular parameters like anterior chamber depth, AL and LT.

Corneal thickness and intraocular pressure in a nonglaucomatous Burmese population: the Meiktila Eye Study.

OBJECTIVE: To determine correlates of central corneal thickness (CCT) and its relationship to intraocular pressure (IOP) in a Burmese population. METHODS: We performed a population-based survey of inhabitants 40 years or older in Myanmar; of 2076 participants, data from 1909 nonglaucomatous subjects who underwent ultrasound pachymetry and Goldmann applanation tonometry were analyzed. Linear mixed effects models adjusting for nonindependence of right and left eye data were constructed. RESULTS: Mean (SD) CCT was 521.9 (33.3) microm, and the mean (SD) IOP was 14.5 (3.4) mm Hg. Intraocular pressure and spherical equivalent were significant predictors of CCT (P < .001 and P = .01, respectively). Age, sex, body mass index, and corneal curvature were not significant predictors. Central corneal thickness was the only significant predictor of IOP (ie, an increase of 100 microm in CCT predicted an increase of 1.3 mm Hg in IOP). The Spearman correlation between CCT and IOP for the right and left eyes was highly significant (P < .001), but the Spearman rank correlation values (R(2) = 0.016 and R(2) = 0.017, respectively) were weak. CONCLUSIONS: The CCT in this Burmese population was significantly associated with IOP and spherical equivalent. The weak association between CCT and IOP is consistent with that of other population-based studies. Other corneal factors are likely to influence Goldmann applanation tonometry.

The clinical applications of fluorouracil in ophthalmic practice.

Fluorouracil (5-fluorouracil, 5-FU) is a pyrimidine analogue that was originally known for its widespread use as an anticancer drug. The ability of 5-FU to reduce fibroblastic proliferation and subsequent scarring has made it an important adjunct in ocular and periorbital surgeries. It is used in primary glaucoma filtering surgeries and in reviving failing filtering blebs, in dacryocystorhinostomy, pterygium surgery, and in vitreoretinal surgery to prevent proliferative vitreoretinopathy. In addition, 5-FU is also gaining recognition in the treatment and surgical management of ocular surface malignancies like ocular surface squamous neoplasia; however, the specific action of the drug on highly proliferating cells limits its use in primary acquired melanosis of the conjunctiva. When applied topically, this drug has a low rate of sight-threatening adverse effects, is inexpensive, and is easy to administer, making it an important tool in enhancing the success rate in ophthalmic surgery and in reducing the recurrence of ocular surface neoplasia.

Mitomycin: clinical applications in ophthalmic practice.

Mitomycin (mitomycin C; MMC) is an antibiotic isolated from Streptomyces caespitosus. The drug is a bioreductive alkylating agent that undergoes metabolic reductive activation, and has various oxygen tension-dependent cytotoxic effects on cells, including the cross-linking of DNA. It is widely used systemically for the treatment of malignancies, and has gained popularity as topical adjunctive therapy in ocular and adnexal surgery over the past 2 decades. In ophthalmic medicine, it is principally used to inhibit the wound healing response and reduce scarring of surgically fashioned ostia. Hence, it has been used as adjunctive therapy in various ocular surgeries, such as glaucoma filtering surgeries, dacryocystorhinostomy, corneal refractive surgery and surgeries for ocular cicatrisation. In addition, it has been used as an adjunct in the surgical management of pterygia, ocular surface squamous neoplasia, primary acquired melanosis with atypia and conjunctival melanoma. In many of these surgeries and ophthalmic pathologies, MMC showed a significant beneficial effect.

Amplitude of accommodation and its relation to refractive errors.

AIMS: To evaluate the relationship between amplitude of accommodation and refractive errors in the peri-presbyopic age group. MATERIALS AND METHODS: Three hundred and sixteen right eyes of 316 consecutive patients in the age group 35-50 years who attended our outpatient clinic were studied. Emmetropes, hypermetropes and myopes with best-corrected visual acuity of 6/6 J1 in both eyes were included. The amplitude of accommodation (AA) was calculated by measuring the near point of accommodation (NPA). In patients with more than +/- 2 diopter sphere correction for distance, the NPA was also measured using appropriate soft contact lenses. RESULTS: There was a statistically significant difference in AA between myopes and hypermetropes (P < 0.005) and between myopes and emmetropes (P < 0.005) in the 35-39 year age group. In the 40-44 year age group, there was a significant difference in AA between emmetropes and hypermetropes (P < 0.0001), emmetropes and myopes (P < 0.01) and hypermetropes and myopes (P < 0.0001). In patients above 45 years of age there was no significant difference (P > 0.5). CONCLUSION: Our study showed higher amplitude of accommodation among myopes between 35 and 44 years compared to emmetropes and hypermetropes.

Comparison between latanoprost and brimonidine efficacy and safety in Indian eyes.

PURPOSE: To compare the short-term efficacy and safety of topical latanoprost and brimonidine in Indian eyes. MATERIALS AND METHODS: Twenty-eight patients with ocular hypertension, primary open-angle, pseudoexfoliation or pigmentary glaucoma were enrolled. Following baseline measurements, latanoprost was applied topically once daily in the evening for 12-weeks. After a washout period, brimonidine was applied twice daily in all patients for 6 weeks; 16 patients continued for 12 weeks. Patients were examined at 2, 6 and 12 weeks. The primary outcome measure was the difference in mean intra ocular pressure (IOP) reduction at 6 and 12 weeks. The mean diurnal variation of IOP at baseline and at 12 weeks was also compared. RESULTS: Twenty-six of 28 enrolled patients completed the study. One randomly selected eye of each patient was used for analysis. At 6 weeks, the mean IOP reduction was 11.2 mm Hg (+/- 2.9 mmHg) with latanoprost and 6 mmHg (+/- 3.3 mmHg) with brimonidine. At 12 weeks this was 10.8 mmHg (+/- 2.8 mmHg) and 6.9 mmHg (+/- 3.1 mmHg) respectively. At 6 weeks 85.7% (24) eyes obtained more than 25% reduction in IOP with latanoprost compared to 13 (46.4%) with brimonidine. IOP reduction was maintained with both drugs throughout the study period. Two eyes did not show any response to brimonidine. Latanoprost reduced the diurnal variation of IOP from 5.10 to 2.90 mmHg; brimonidine reduced it from 4.70 to 3.90 mmHg. Conjunctival hyperaemia was present in one patient on latanoprost and three patients on brimonidine. Two patients experienced drowsiness with brimonidine. Neither drug produced side effects necessitating withdrawal from the study. CONCLUSION: In this short-term study, both latanoprost and brimonidine effectively reduced IOP and stabilised the diurnal curve in Indian eyes. Latanoprost was more effective than brimonidine.