Ripasudil Endgame: Role of Rho-Kinase Inhibitor as a Last-Ditch-Stand Towards Maximally Tolerated Medical Therapy to a Patient of Advanced Glaucoma.

PURPOSE: To elucidate the use of Ripasudil in patients of advanced glaucoma on maximally tolerated medical therapy who could not be offered the option of surgery due to the global pandemic lockdown. MATERIALS AND METHODS: Only patients with primary open angle glaucoma (POAG), who had a cup-disc ratio (CDR) of 0.9 or a near total cupping on maximum tolerated medical therapy for at least 4 weeks and yet could not meet the target IOP were included. Target IOP was defined as ≤12 mm Hg. A total of 30 patients were enrolled. All patients in study cohort were started on E/D Ripasudil BD. Patients were followed up at 1 week, 2 weeks, 4 weeks and then monthly for 6 months for their best corrected visual acuity (BCVA), intraocular pressure (IOP), disc changes (slit lamp biomicroscopy), perimetry, and retinal nerve fibre layer analysis using optical coherence tomography (OCT-RNFL). RESULTS: Mean pre-treatment IOP on five drugs was 18.3 ± 2.1 mm Hg (range 14 to 22mmHg) on maximally tolerated medical therapy. At 1 week follow-up, mean post-treatment IOP was 15.1 ± 1.7 mm Hg (range 12 to 18mmHg) and at 2 week follow-up, mean post-treatment IOP was 12.5 ± 1.9 mmHg (range 10 to 16mmHg). Thus, target IOP ≤12mmHg was attained in 28 patients at 2 weeks. This target IOP was maintained throughout the 6 months of follow-up period. Of the 2 patients who could not meet target IOP, 1 patient needed rearrangement of their fixed-drug-combinations to achieve target IOP at 4 weeks. The second patient required unfixing of all fixed-drug-combinations to achieve target IOP at maximally tolerated medical therapy at 6 weeks. CONCLUSION: Ripasudil not only provides a better IOP control but also has a high safety profile even when started as an add-on drug to already-existing yet inadequate maximally tolerated medical therapy.

Capsular bag phimosis.

A 60year old male presented with insidious onset, gradually progressive, painless diminution of vision in the right eye since a year. He was operated for cataract about 7 years ago. However, details of surgery or intraocular lens (IOL) were unavailable. Fellow eye was unremarkable. Examination revealed a visual acuity of FC at 5 mts. Slit-lamp examination revealed a quiet anterior chamber without any cells-flare nor any posterior synechiae. Co-axial retro-illumination revealed an in-the-bag IOL, having both haptics folded on the optic with scarring and contraction of the capsular bag, most apparent in the centre. Fundus examination with indirect ophthamoloscopy was difficult owing to the media haze due to capsular scarring but retina was unremarkable as far as could be seen. A diagnosis of "Capsular Bag Phimosis"1,2,3,4 was made. An ASOCT demonstrated such severe moulding of the IOL that a simple YAG capsulotomy may have increased visual acuity but would have lead to severe image distortion, metamorphopsia and resultant aniseikonia. IOL was explanted alongwith the phimosed capsular bag and a Scleral-fixated IOL was placed to achieve a final BCVA 20/20P Snellen.

Modified bandage-contact-lens used as a guide-marker for performing continuous-curvilinear-capsulorhexis by a first-year-post-graduate-ophthalmology-resident.

PURPOSE: To define the use of modified bandage-contact-lens as a guide-marker for performing continuous-curvilinear-capsulorhexis by a first-year-post-graduate-ophthalmology-resident. OBSERVATION: Phacoemulsification has now become the standard cataract surgery in which anterior capsulorhexis is the first and most crucial step. A perfect capsulorhexis is difficult to learn and even more difficult to master with a steep learning curve when performed free-hand especially by a first-year post-graduate ophthalmology-resident. There is paucity of simple, single-use, easily portable, cost-effective and affordable devices designed especially for performing CCCs in a safe and reproducible way.In our technique, the bandage contact lens (BCL) is trephined using a 6mm corneal trephine. After topical or peribulbar block (as the case may be), the 6mm-guide-marker (trephined BCL) is placed on the cornea. The CCC is then completed using the edge of the contact-lens as a guide for CCC. CONCLUSION: AND IMPORTANCE: CCC with contact-lens-guide-marker is expected to yield better results in carrying out the procedure more accurately being closer to the target in terms of size, circularity and centration as compared to contact-lens-unassisted conventional CCC. This would eventually facilitate better surgical outcomes and we recommend this to be applied as the standard protocol for first-year post-graduate ophthalmology-resident performing the surgery.

Idiopathic Isolated Acquired Steroid Dependent SO Palsy: A Rare Case Report.

15-year-old boy presented with sudden onset, stable, nonprogressive painless diplopia (greatest in right gaze and inferior field of view) and hyperdeviation of left eye for a year. On ophthalmic examination, the patient had uncrossed diplopia with tilt and separation maximum in dextrodepression. On Park's three step test, left eye hypertropia increased on right gaze and left tilt suggestive of left superior oblique (SO) palsy. On prism bar cover test (PBCT), deviation was more than 25 PD base-down over the left eye for both distance and near in all gazes. MRI head and orbit revealed a normal study while the myasthenia and inflammatory work-up was unremarkable. A provisional diagnosis of "Idiopathic Acquired Left Superior Oblique Palsy" was made and the patient was given trial of oral steroids at 1 mg/kg body weight. At 6 weeks, patient's diplopia resolved and PBCT neutralised at 6PD. Oral steroids were gradually tapered off by 10 mg per week with weekly follow-up. Upon decreasing the dose of prednisolone to 5 mg, intermittent diplopia and 18 PD left hypertropia reappeared. When patient was again restarted on oral steroids at 1 mg/kg body weight, diplopia-hypertropia disappeared at 10 mg OD prednisolone only to reappear at 5 mg OD dosage, leading to the final diagnosis of a "Steroid Dependent Isolated Superior Oblique Palsy". Presently, the patient is maintained on a daily dose of 10 mg oral prednisolone.

Spontaneous levitation of dropped nucleus on first post-operative day.

A 60-year-old male patient presenting with gradual painless progressive diminution of vision was diagnosed with nuclear sclerosis grade III (LOCS). Intra-operatively, there was a nuclear drop into the vitreous cavity. The patient was left aphakic and was deferred for further vitreoretinal procedure the next day. On first post-op day, the nucleus fragment (of roughly the same size that had dropped into the vitreous) was seen in the anterior chamber. A gentle ultrasonography B-Scan done for posterior segment evaluation was anechoic. Incision was enlarged and viscoexpression of the nucleus fragment was done followed by thorough anterior vitrectomy. Post-operatively, dilated full fundus examination showed clear vitreous cavity without any evidence of retinal tear or detachment. This was later confirmed by an anechoic ultrasonography B-Scan. After 2 weeks, three-piece foldable IOL was placed in the sulcus with posterior optic capture and the patient attained a best-corrected visual acuity of 6/9P.

Modified Krimsky test for irregular scarred corneas.

The measurement of the amount and nature of deviation is the essence of diagnostic workup of a patient with strabismus and also has important therapeutic implications while planning the amount of surgery or prescribing therapeutic prisms. Although Krimsky test is a useful method, it cannot be used to measure deviation in patients with scarred and irregular cornea with an anechoic posterior segment making it difficult to see the corneal reflex. We hereby take the opportunity to present a modification of the original Krimsky test which is extremely helpful in determining the deviation in patients with irregular opaque corneas.

Strategies to Improve Glaucoma Compliance Based on Cross-Sectional Response-Based Data in a Tertiary Healthcare Center: The Glauco-Jung Study.

PURPOSE: To elucidate compliance rates among glaucoma patients in a tertiary healthcare center, reasons for noncompliance and response-based-solutions to improve compl iance in the same cohort. MATERIALS AND METHODS: In the Glauco-Jung study, a cross-sectional descriptive epidemiological one, information was obtained from 500 patients from 1st January, 2014 to 30th June, 2014. Patients were intercepted at entry point where they get their intraocular pressure (IOP) checked, wherein they were asked to fill an exhaustive questionnaire. At the same setting, they were also asked to demonstrate how they (or their relatives or helpers) instill eyedrops, following which any irregularities were brought to notice and corrected. Finally, they were also asked any suggestions to improve compliance to medications. Noncompliance rates were determined based on the number of patients who did not instill anti-glaucoma medications as per prescribed dosage or frequency schedule. Noncompliance rates were then evaluated by the Chi-square test for any association with distributions based on various parameters. RESULTS: In case of a positive association, correlation coefficient was further calculated to know the strength of this association. No association was observed in distributions based on diet, associated co-morbidities, daily dosage frequency and side-effects experienced by patients. Positive association was noted in distributions based on age, sex, duration of treatment, social structure and number of medications (p < 0.05); but correlation coefficients were very weak (c < 0.3). Cost of medications not only had positive association but also had a very strong correlation coefficient (c = 0.9188), proving that cost of medications had a modest bearing on compliance rates. CONCLUSION: The Glauco-Jung study concluded that besides availability of medications at reasonable cost, simplification of treatment regimen and interactive health education appear to be the most important factors for improving compliance so that patients do not feel guilty or inadequate because they have problems while administering their eyedrops. How to cite this article: Gupta VS, Sethi H, Naik M. Strategies to Improve Glaucoma Compliance Based on Cross-Sectional Response-Based Data in a Tertiary Healthcare Center: The Glauco-Jung Study. J Curr Glaucoma Pract 2015;9(2):38-46.