Short-term outcomes of Mitomycin-C augmented phaco-trabeculectomy using subconjunctival injections versus soaked sponges: a randomized controlled trial.

OBJECTIVES: To determine whether subconjunctival Mitomycin-C (MMC) injections are as safe and effective as sponge-soaked MMC in phaco-trabeculectomy. METHODS: This prospective, randomized, interventional study was conducted on consecutive patients with visually significant cataract and an uncontrolled primary open-angle glaucoma. One hundred thirty-nine patients were recruited but 15 were ineligible for analysis. The patients were randomized into a sponge/injection group. All participants received a twin-site phaco-trabeculectomy. They were followed up on days 1, 15, 30, 3 months and 6 months post-operatively. A p-value < 0.05 was considered significant. INTERVENTIONS: Participants in the sponge group received an augmentation of their phaco-trabeculectomy with sponges soaked in a mixture of 0.04% MMC and 2% preservative-free Lignocaine in a 1:1 ratio, placed in the subconjunctival space for four minutes. Participants in the injection group received the same mixture as a subconjunctival injection, after surgical draping. RESULTS: There were 62 patients in each group. The groups had no significant differences in their baseline characteristics. The mean IOP at 6 months was significantly lower in the injection group (14.8 ± 3.7 mm Hg) than in the sponge group (17.1 ± 6.4 mm Hg) (p = 0.02). There was no notable difference in the complications or the final post-operative visual outcome but a significantly greater number of patients in the sponge arm required removal of the releasable suture (p = 0.001) and additional anti-glaucoma medications (p = 0.04) at six months post-operatively. CONCLUSIONS: Subconjunctival MMC achieves a lower IOP with fewer anti-glaucoma medications than sponge-soaked MMC at six months for twin-site phaco-trabeculectomy in primary open-angle glaucoma with no additional risks.

Trident technique of safe nuclear emulsification in posterior polar cataracts.

The common complications associated with a posterior polar cataract (PPC) with deficient or weak posterior capsules (PCs) are posterior capsular rupture (PCR), vitreous loss, and luxation of lens material into the vitreous. Often the commonly used technique of hydrodelineation in such cataracts can lead to accidental hydrodissection, and even the slightest nucleus rotation during phacoemulsification can cause the PC to give way. We describe a modified relatively safe technique (Trident technique) for managing the nucleus in PPCs which does not involve any hydroprocedure or nucleus rotation.

Outcomes and favourable prognostic factors in patients of phacomorphic and phacolytic glaucoma managed by manual small-incision cataract surgery: A retrospective study.

Purpose: To evaluate the outcomes and identify favorable prognostic factors in patients of phacomorphic (PMG) and phacolytic glaucoma (PLG) managed by manual small-incision cataract surgery (MSICS). Methods: The medical records of patients with PMG/PLG who had undergone MSICS in a tertiary eye hospital between September 2014 and August 2018 were retrospectively reviewed. Regression analyses were conducted to identify the predictors associated with intraoperative or postoperative complications and a favorable final outcome at 1 month, namely, a best-corrected visual acuity (BCVA) of 6/18 or better and an intraocular pressure (IOP) of <21 mm Hg. P < 0.05 was considered statistically significant. Results: The records of 209 patients with PMG and 279 patients with PLG were eligible for the review. The mean preoperative IOP for PMG and PLG were 43.15 ± 12.9 and 40.05 ± 12.0 mm Hg, respectively (P = 0.006). A younger age (<60 years) was associated with a lower risk of severe postoperative inflammation in both PMG and PLG [OR = 0.45 (0.21-0.99); P = 0.047 and OR = 0.44 (0.23-0.83); P = 0.011, respectively]. There was no significant difference in the final mean logMAR BCVA (P = 0.21) and IOP (P = 0.36) in the two groups. The likelihood of a final IOP of <21 mm Hg was significant for symptoms less than a week [OR = 3.52 (1.2-10.2); P = 0.02] in PMG and for absence of vitreous disturbance [OR = 35.0 (3.8-325.7); P = 0.002] in PLG. A BCVA of 6/18 or better was strongly associated with symptoms for less than a week [OR = 1.58 (1.0-2.4); P = 0.043] and absence of vitreous disturbance [OR = 23.53 (5.1-108.0); P < 0.001]. Conclusion: Early diagnosis and management can translate to good outcomes in PMG and PLG.

Agreement of findings of glaucoma screening between trained vision center technicians and glaucoma specialists at a tertiary hospital in South India.

Purpose: To study the agreement of findings of glaucoma screening between trained vision center (VC) technicians and glaucoma specialists in patients referred from VC to the glaucoma services of a tertiary eye care hospital in south India. Methods: This was a retrospective study comparing the findings of the VC technicians and the specialists of the glaucoma services in the base hospital, in patients referred from 13 VCs between January and June 2019. Medical records of 277 referred patients (out of 533 referrals) who attended the glaucoma clinic were analyzed. Results: Of the 277 patients, 111 (40%) were confirmed having glaucoma, 133 (48%) were suspects, 29 (10.4%) were normal, and four (1.4%) had other pathology. The mean age of the patients was 59.7 ± 13 years and 60.6% were females. There was no statistically significant difference between the mean intraocular pressure (IOP) measured (17 ± 7.2 mmHg at the VC and 18 ± 8.7 mmHg at the clinic, p = 0.16) and the cup-to-disc ratio (CDR) (0.7 ± 0.13 at the VC and 0.6 ± 0.18 at the clinic, p = 0.57). Bland-Altman plots with 95% limits of agreement supported that mean differences were close to zero, and the intraclass correlation coefficient at 95% CI showed good consistency between the measurement of IOP (0.78 [0.74 to 0.81]) and CDR (0.90 [0.88 to 0.92]) at the base hospital and vision center. Conclusion: There is good agreement between the findings of VC technicians and glaucoma specialists. VC technicians can help in detecting glaucoma in the community.

The Aravind Pseudoexfoliation Study: 5-Year Postoperative Results. The Effect of Intraocular Lens Choice and Capsular Tension Rings.

PURPOSE: We compared rates of intraocular lens (IOL) decentration, neodymium-doped yttrium aluminum garnet capsulotomy for posterior capsule opacification (PCO), and visual acuity (VA) in eyes with and without pseudoexfoliation (PEX) 5 years after undergoing cataract surgery. DESIGN: Prospective comparative interventional study. METHODS: This multicenter study population included 1 eye of both 930 cataract patients with and 470 cataract patients without uncomplicated PEX (no small pupils or phacodonesis) all undergoing phacoemulsification by experienced Aravind Eye Care System surgeons. Eyes were randomized to either 1- or 3-piece intraocular lenses (IOLs). PEX eyes were also randomized to either receive or not receive a capsule tension ring. The main outcome measures included IOL decentration and PCO. Secondary outcomes included postoperative best-corrected VA. RESULTS: Follow-up was 86.2% in the PEX group and 86.7% in the control group at 5 years. The PEX group was older (P < .001) and had more men (P = .01). IOL decentration at 5 years was equally prevalent in PEX and control eyes (1.0% vs 1.1%, respectively, P = .8). Neodymium-doped yttrium aluminum garnet posterior capsulotomy rates for PCO were similar in the PEX group when compared with control subejcts (5.3% compared with 3.2%, respectively, P = .07). Best corrected VA was better at baseline and years 2 and 3 in the control group (P = .0001, P = .0005, and P = .02); however, there was no difference in BCVA at years 1, 4, and 5 between the PEX and control groups (P = .09, P = .29, and P = .5). CONCLUSION: In a large-scale, long-term, prospective comparative study of cataract surgery in eyes with uncomplicated PEX, the risks of IOL decentration and PCO were low and comparable to that in control subjects. When approaching cataract surgery in eyes with relatively uncomplicated PEX, neither IOL choice (1- vs 3-piece acrylic IOL) nor the presence/absence of a capsule tension ring affects outcomes at 5 years.

The Aravind Pseudoexfoliation Study: Surgical and First-Year Postoperative Results in Eyes without Phacodonesis and Nonmiotic Pupils.

PURPOSE: To compare intraoperative complication rates, 1-year visual outcomes, and postoperative complication rates over the first postoperative year in eyes with and without pseudoexfoliation undergoing cataract surgery. DESIGN: Prospective, comparative, interventional study. PARTICIPANTS: Nine hundred thirty eyes with cataract and uncomplicated pseudoexfoliation (without phacodonesis, clinically shallow anterior chambers, or pupil size <4 mm) and 476 controls with cataract but without pseudoexfoliation recruited from 4 centers of the Aravind Eye Care System in Southern India. The 2 groups were randomized separately to receive either a single-piece acrylic intraocular lens (IOL; SA60AT; Alcon Laboratories, Fort Worth, TX) or a 3-piece acrylic IOL (MA60AS; Alcon Laboratories). The pseudoexfoliation group also was randomized to receive or not receive a capsular tension ring. METHODS: All eyes underwent phacoemulsification with IOL implantation and were followed up at 1 day, 1 month, 3 months, and 1 year after surgery. MAIN OUTCOME MEASURES: Association of pseudoexfoliation status with intraoperative complication rates, 1-year best-corrected visual acuity, and any other complications. RESULTS: Mean ages were 63.0±6.9 years and 57.9±7.3 years in the pseudoexfoliation and control groups, respectively (P < 0.001). Pseudoexfoliation patients were more likely to be men (P = 0.014), to have a nuclear opalescence grade of more than 4 (P = 0.001), and to have a pupil size of less than 6 mm (P < 0.001) when compared with controls. Intraoperative complication rates were 2.9% and 1.9% in the pseudoexfoliation and control groups, respectively (P = 0.29). One-year postoperative best-corrected visual acuity was comparable (P = 0.09). Complication rates at 1 year were 2.7% and 2.5% in the pseudoexfoliation and control groups, respectively (P = 0.82). Average endothelial cell loss was 14.7% in the pseudoexfoliation group and 12.7% in the control group at 1 year (P = 0.066) when adjusting for age and nuclear opacity. CONCLUSIONS: Pseudoexfoliation eyes without shallow anterior chamber, small pupils, or apparent zonulopathy may represent eyes with lower risks of complications. Despite smaller pupils and denser cataracts, pseudoexfoliation eyes without clinically apparent preoperative zonulopathy were not at a higher risk of intraoperative or postoperative complications or worse visual outcomes after cataract surgery.