Posterior keratometry changes after steep axis phacoemulsification: a prospective study.

Purpose: To measure changes in posterior corneal curvature after steep axis phacoemulsification and investigate the possibility of its effect on SIA. Methods: This was a prospective longitudinal study on 60 consecutive eyes of age-related cataract with regular astigmatism and absence of co-morbidities undergoing uneventful cataract surgeries with main incision at steep meridian. Preoperative and 4 weeks postoperative measurements of anterior and posterior corneal curvatures using Scheimpflug based corneal topographer were performed. Posterior corneal curvature was assessed at 3, 5- and 7-mm diameters. Results: The study found a statistically significant change in posterior corneal K1, K2 and mean astigmatism in all zones (3, 5 and 7 mm) at 4 weeks postoperative, when compared to preoperative readings. Conclusion: Posterior keratometry is likely to be an important determinant of Surgically Induced Astigmatism (SIA) and should be factored in for refractive cataract surgery.

Evaluation of primary Ahmed Glaucoma valve implantation in post-traumatic angle recession glaucoma in Indian eyes.

PURPOSE: To highlight the efficacy of primary Ahmed glaucoma valve implantation in angle recession glaucoma following blunt ocular trauma in Indian eyes. DESIGN: A retrospective analytical study. MATERIALS AND METHODS: This study included 52 patients of angle recession glaucoma, who presented between Mar 2006 to Feb 2016, out of which 38 patients had undergone primary AGV implantation, while the rest were managed with topical anti-glaucoma medications. Preoperative data included age, sex, type and mode of injury, duration of injury, assessment of best-corrected visual acuity (BCVA) and intraocular pressure (IOP). The extent of angle recession was observed by gonioscopy. The intraocular pressure, visual acuity, and the number of anti-glaucoma medications were measured postoperatively. The success of this technique was analyzed by using a Kaplan-Meier cumulative survival curve. RESULTS: Following AGV implantation, the mean IOP was significantly reduced to 8.7 ± 2.2 at 1st day, 10.1 ± 2.2 at 7th day, 14.2 ± 3.4 at 3rd month, 15.6 ± 3.7 at 1 year, and 15.6 ± 3.6 at 3rd-year follow-up showing statistically significant values (p < 0.001) at each visit. The IOP was successfully controlled at the last follow-up without topical treatment. Mean BCVA at 3 years -post-AGV was 0.144 (0.151) (LogMAR) which was statistically significant (p < 0.001) as compared to the mean BCVA of 0.898 (± 0.205) LogMAR units at presentation. The success rate by Kaplan-Meier survival curve analysis was 90% at the mean follow-up duration of 29.47 ± 3.39 months. Overall surgical complications were noted in the form of prolonged hypotony, hyphema in 7 patients (13.5%). CONCLUSIONS: In medically uncontrolled post-traumatic angle recession glaucoma, primary AGV Implantation is a safe and effective surgical procedure with lesser complication rates providing long-term IOP control in a younger population.

Effect of complicated ocular surgery in stress-related parameters: A novel outlook into surgeon's health.

PURPOSE: To assess the stress-related physiological parameters of ophthalmic surgeons during complicated cataract surgery and compare them with uncomplicated routine cataract surgery. METHODS: In this cross-sectional observational study, 110 patients of various types of cataract were divided into two groups: Group 1 included 55 patients with simple cataract (Grade ≤3) with no ocular or systemic comorbidities, whereas Group 2 included 55 patients with complicated cataracts (Grade >3) and ocular/systemic comorbidities. All patients underwent phacoemulsification with intraocular lens implantation in the right eye only. The outcome measures were systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), and saturation of peripheral oxygen (SpO2). RESULTS: The average SBP, DBP, MAP, and HR were significantly higher in the surgeon operating Group 2 (complicated cataract) compared with Group 1 (uncomplicated cataract; P < 0.05). The average SBP of the surgeon while operating Group 1 patients preoperatively and postoperatively was 125.42 ± 2.49 mmHg and 122.45 ± 2.10 mmHg, respectively, whereas in Group 2, the average SBP of the surgeon taken preoperatively and postoperatively was 145.98 ± 3.80 mmHg and 137.44 ± 3.45 mmHg, respectively (P < 0.05). The surgeon's SpO2 showed no significant difference between the two groups. CONCLUSION: There is a significant level of increase in stress-related parameters of operating surgeons while doing complicated cataract surgery.

Ahmed valve implantation in childhood glaucoma associated with Sturge-Weber syndrome: our experience.

PURPOSE: To evaluate the efficacy and safety of Ahmed valve implantation in childhood glaucoma associated with Sturge-Weber syndrome (SWS). METHODS: A retrospective chart review of patients who underwent primary Ahmed valve implantation in childhood glaucoma associated with SWS. The outcome measures were success rate (Intraocular pressure (IOP) >5 and <21 mm Hg without additional surgical maneuver), and operative complications. RESULTS: Twenty-four eyes of 18 patients were analyzed. Mean IOP (26.21 ± 3.52 to 12.27 ± 1.27 mm Hg) and mean number of anti-glaucoma medicines (3.92 ± 0.28 to 1.5 ± 1) reduced significantly after the surgery at the mean follow-up of 2.12 ± 0.87 years (P = < 0.05). The cumulative probability of success rate was 75% (Confidence Interval 95%, 60 to 100%) by Kaplan-Meier survival curve analysis. Failed eyes [6 (25%)], hyphema [4 (16.67%)], hypotony [3 (12.5%)], choroidal detachment [3 (12.5%)], tube-cornea touch [2 (8.33%), and visually significant cataract [4 (16.67%)] were the complications observed in post-operative period. CONCLUSION: Primary Ahmed valve implantation may provide a safe and effective option in the management of childhood glaucoma associated with SWS.

Leprosy Presenting with Iridocyclitis: A Diagnostic Dilemma.

PURPOSE: To report a case of lepromatous iridocyclitis that posed a diagnostic challenge. CASE REPORT: A 50-yeasr-old male developed profound loss of vision in the right eye, while he was in the hospital with septicemia presenting with fever, dysuria, and abdominal swelling. He also developed erythema nodosum on the legs. Skin incisional biopsy section, upon dermatology consultation, showed a granulomatous nodule in the dermis. The anterior chamber aspirate demonstrated lepra bacilli, which confirmed the diagnosis of lepromatous leprosy with type II reaction. The patient was treated with multidrug therapy and oral and topical steroids. CONCLUSION: This case highlights that the lepromatous iridocyclitis, a serious vision-threatening disorder requires a high index of suspicion for prompt diagnosis in atypical cases particularly in endemic areas. Examination of the aqueous humor can also be helpful in diagnosis.

Endogenous Nocardial Endophthalmitis in an Immunosuppressed Patient: A Serious Warning of an Underlying Life Threatening and Blinding Disorder.

PURPOSE: To report a case of bilateral endogenous nocardial endophthalmitis with central nervous system involvement in an immunocompromised individual with an extremely poor outcome. CASE REPORT: A 35-year-old man with a history of long-term, prescribed oral steroid use for membranoproliferative glomerulonephritis presented with profound bilateral vision loss. Patient's diagnosis of bilateral endogenous nocardial endophthalmitis was delayed. Nocardia was finally isolated from a brain biopsy after a repeat magnetic resonance imaging revealed a brain abscess. With anti-nocardia therapy, patient improved systemically, but the visual outcome was poor, with no light perception in both eyes. CONCLUSION: Ocular nocardiosis is a serious vision and life threatening disorder, particularly in patients on immunosuppressive therapy. A high index of suspicion is required for successful treatment.

Pars Plana-Modified versus Conventional Ahmed Glaucoma Valve in Patients Undergoing Penetrating Keratoplasty: A Prospective Comparative Randomized Study.

PURPOSE: To compare the outcome of pars-plana-modified Ahmed glaucoma valve (AGV) versus limbal-based conventional AGV into the anterior chamber, in patients undergoing penetrating keratoplasty (PK) for glaucoma with coexisting corneal diseases. METHOD: In this prospective randomized clinical trial, 58 eyes of 58 patients with glaucoma and coexisting corneal disease were divided into two groups. Group 1 (29 eyes of 29 patients) included patients undergoing limbal-based conventional AGV into the anterior chamber (AC) along-with PK and group 2 (29 eyes of 29 patients) included those undergoing pars-plana-modified AGV along-with PK. Outcome measures included corneal graft clarity, intraocular pressure (IOP), number of antiglaucoma medications, and postoperative complications. Patients were followed up for a minimum period of 2 years. RESULTS: Out of 58 eyes (58 patients), 50 eyes (50 patients: 25 eyes of 25 patients each in group 1 and group 2) completed the study and were analyzed. Complete success rate for AGV (group 1: 76%; group 2: 72%; p = 0.842) and corneal graft clarity (group 1: 68%; group 2: 76%; p = 0.081) were comparable between the two groups at 2 years. Graft failure was more in conventional AGV (32%) as compared to pars plana-modified AGV (24%) but not statistically significant (p = 0.078) at 2 years. CONCLUSION: Though both procedures were comparable in various outcome measures, pars-plana-modified AGV is a viable option for patients undergoing PK, as it provides a relatively better corneal graft survival rate and lesser complications that were associated with conventional AGV.

Efficacy of Bevacizumab Compared to Mitomycin C Modulated Trabeculectomy in Primary Open Angle Glaucoma: A One-Year Prospective Randomized Controlled Study.

PURPOSE: To compare the efficacy of bevacizumab over mitomycin C (MMC) modulated trabeculectomy in cases of primary open angle glaucoma (POAG). METHOD: In this prospective randomized controlled study, 80 eyes of 80 patients with uncontrolled POAG or intolerant to antiglaucoma medications were randomized to two groups: Group 1 (n = 40) patients underwent trabeculectomy modulated with MMC (0.2 mg/ml), whereas Group 2 (n = 40) patients underwent trabeculectomy modulated with bevacizumab (1.25 mg/0.05 ml). The outcome measures were best corrected visual acuity (BCVA), intraocular pressure (IOP), number of glaucoma medications and bleb morphological features based on Moorfields Bleb Grading System (MBGS). All patients were followed up for one year post trabeculectomy. RESULTS: The mean preoperative IOP in the bevacizumab group improved from 22.41 ±1.08 mm Hg with 3.2 ± 0.9 glaucoma medications to 13.68 ± 0.79 mm Hg with 0.11 ± 0.32 glaucoma medications at one year (P < 0.001). The mean preoperative IOP in the MMC group improved from 22.64 ± 0.90 mm Hg with 3.1 ± 0.8 glaucoma medications to 13.84 ± 0.73 mm Hg with 0.17 ± 0.38 glaucoma medications at one year (P < 0.001). IOP was comparable between two groups at one year (P = 0.43). No significant differences were found in bleb morphological features based on MBGS regarding central bleb area, peripheral bleb area, height and central vascularity between the two groups at six months and one year. However, there was a statistically significant difference in peripheral bleb vascularity and peripheral non-bleb vascularity with bevacizumab group exhibiting a low degree of vascularity at one year (P = 0.029 and 0.004, respectively). CONCLUSION: Adjunctive bevacizumab in trabeculectomy is effective and comparable to MMC for controlling IOP in POAG patients for the first year.

Allogenic cultivated limbal stem cell transplantation versus cadaveric keratolimbal allograft in ocular surface disorder: 1-year outcome.

PURPOSE: To compare the outcome of allogenic ex vivo cultivated limbal stem cell transplantation (LSCT) versus cadaveric keratolimbal allograft in patients with limbal stem cell deficiency (LSCD). METHODS: In this prospective interventional study from Army Hospital Research and Referral in New Delhi, 50 eyes of 40 patients with ocular surface disorder having LSCD underwent either cultivated LSCT (group 1: 25 eyes of 20 patients) or keratolimbal allograft transplantation (group 2: 25 eyes of 20 patients). The outcome measures were gain of two or more lines of best-corrected visual acuity (BCVA), absence of conjunctival vascularization over cornea, corneal neovascularization regression, regression of visually significant corneal opacity (iris details poorly visible), Schirmer's 1 ≥10 s, tear break-up time (TBUT) ≥10 s, and absence of fluorescein staining. RESULTS: At 1 year of follow-up, both groups experienced significant improvement in all outcome measures, but there was no significant difference between both groups in improvement of two or more lines of BCVA (P = 0.841), absence of conjunctival vascularization over cornea (P = 0.812), corneal neovascularization (P = 0.074), visually significant corneal opacity (P = 0.075), Schirmer's 1 ≥10 s (P = 0.814), TBUT ≥10 s (P = 0.382), or absence of fluorescein stain (P = 1.00). CONCLUSION: Both allogenic ex vivo cultivated LSCT and cadaveric keratolimbal allograft transplantation are comparable in terms of visual gain and ocular surface restoration.

Phacoemulsification at high-altitude Himalayan region: comparison.

PURPOSE: To compare phacoemulsification parameters at different high-altitude regions as well as between peristaltic and Venturi-based machines. METHODS: In this prospective, nonrandomized clinical study, 160 eyes of 160 patients with senile cataract underwent phacoemulsification using either peristaltic or Venturi system at a high-altitude Himalayan region (>10,000 feet). Patients (n = 200, including 100 each with either peristaltic or Venturi system) operated at mean altitude of 1115 feet (Delhi) were included as controls (group 1). At Leh (11,203 feet), 110 patients were operated with peristaltic (62) or Venturi (48) system (group 2), whereas 50 patients (group 3) (peristaltic = 37; Venturi = 13) were operated either with peristaltic (37) or Venturi (13) system at Tangtse (14,106 feet). Intraoperative parameters-i.e., bottle height (BH), vacuum (V), and flow rate (FR)-were compared for different phacoemulsification steps-i.e., central chopping (CC), segment removal (SR), epinucleus removal (ER), and cortex removal (CR)-between all groups and between peristaltic and Venturi pump-based machines in each group. RESULTS: Mean BH, V, and FR for CC, SR, ER, and CR significantly increased with the increment in altitude of surgery (p = 0.000). Venturi and peristaltic-based phacoemulsification showed higher values of the mean BH and V, respectively, for CC, SR, ER, and CR at Leh as well as Tangtse. CONCLUSIONS: At the high-altitude region, the higher setting of BH, FR, and V is required in phacoemulsification.