Comparison of cycloplegia with atropine 1% versus cyclopentolate 1.

PURPOSE: Cycloplegic refraction is mandatory for children to know the eye's refractive status. In this study, we compared cycloplegia induced by cyclopentolate 1% to that induced by atropine 1% by means of retinoscopy. METHODS: In this parallel-designed interventional study, we included 67 children aged between 4 and 17 years. After the initial retinoscopy under cyclopentolate 1% (used twice in each eye), we repeated it a week later under atropine ointment 1% (used twice a day for 3 days); both were done by the same trained optometrist masked to the drug. Each eye's refraction was converted to spherical equivalents (SEs), and the values averaged between the two eyes of each child under each drug. We compared SE with paired t-test (JASP 16.4). In addition, we performed correlational analysis, and looked for agreement using the Bland-Altman plot. Significance was set at P < 0.05. Wherever possible, 95% confidence intervals (CIs) are quoted. RESULTS: The mean SE with atropine was +1.93 ± 2.0 D, compared to +1.75 ± 1.95 D under cyclopentolate. On average, atropine induced greater cycloplegia by a mere 0.18 D (95% CI: 0.07 to 0.29 D, P value 0.002). The two cycloplegic refractions correlated significantly (Pearson's r: 0.975, P < 0.001). The Bland-Altman plot revealed the limits of agreement as 1.06 and -0.71 D. CONCLUSION: Our study suggests that cyclopentolate works for the most part as well as atropine to attain cycloplegia. Atropine may be considered for children less than 15 years of age with greater than 5.0 D of hyperopia. Cycloplentolate, with its advantages of quick action and short duration, should form the first go-to topical cycloplegic in busy outpatient clinics.

Ocular morbidity and co-morbidities in children attending a nodal district early intervention center in Uttar Pradesh.

Purpose: To obtain epidemiological data on children with ocular morbidity attending a nodal district early intervention center (DEIC). Methods: : After parental consent, we recruited children with ocular morbidity. After detailed history and clinical evaluation, along with pediatric consultation and relevant neuro-radiological and ancillary investigation, information was entered in a pretested proforma: especially looking for perinatal morbidity, including developmental delay (DD). Visual acuity (VA) was assessed by age-appropriate means by an ophthalmic assistant trained to work with children with special needs. We diligently looked for strabismus and performed dilated ophthalmoscopy. Using JASP, we summarized data as means and proportions and reported 95% CIs. We explored the association of disability percentage with possible predictor variables using regression. Results: We enrolled 320 children, with a mean age of 34.43 ± 31.35 months; two-thirds were male; one-third belonged to lower socioeconomic status (36%), with most parents being illiterate. The mean presenting VA was 1.8 logMAR for both eyes, range: 0 to 3. Sixty-one percent were hyperopic and 27% were myopic. High refractive error, (>±6D) occurred in nine; anisometropia in one; strabismus in 149, mostly esotropia; congenital cataract in 25, whereas 63 had abnormal fundus. Seventy-six received a diagnosis of cerebral visual impairment (CVI). On multivariate linear regression (MLR), younger age, presence of DD, and CVI significantly predicted a higher disability percentage. Logistic regression revealed that statutory disability is likely associated with DD (odds ratio [OR]:13.43); whereas older age was protective (OR: 0.977). Conclusion: Our study suggests that in DEIC children with ocular morbidity, younger children, and the presence of DD significantly predict both greater disability and the likelihood of statutory levels.

Half Minimally Invasive Strabismus Surgery (MISS): A single para-muscular approach to horizontal muscle strabismus surgery.

PURPOSE: Minimally invasive surgeries are gaining popularity. We compared two different approaches to rectus muscles: namely the standard para limbal (SPL) and the single para-muscular (SPM). METHODS: Thirty-six patients planned for monocular horizontal strabismus surgery were block randomized to SPL and SPM approach. SPM approach involved a single para-muscular 10-mm conjunctival incision levelled at the inferior border of rectus muscle. We compared the post-operative grades of redness, congestion, chemosis, foreign body sensation, and drop intolerance at day 1, 2 weeks, and 6-8 weeks; scar visibility and success rates at 6-8 weeks and operation duration in minutes. We compared the results using Mann-Whitney U-test for inflammatory grades, Fisher's exact test for proportions, and t-test for parametric measures. Significance was set at P < 0.05. RESULTS: On postoperative follow-up at any time point, no significant difference was found on comparing inflammatory grades, scar visibility, and success rates. In terms of duration, SPL approach was on an average 21.5 minutes quicker than SPM (P = <0.001). CONCLUSION: The SPM is comparable to the SPL approach in terms of postoperative comfort and appearance, but takes significantly longer to accomplish.

Economizing strabismus surgery: Using half the double-armed suture for horizontal muscles.

In a developing country like India, both availability and affordability of medical care are obstacles, leading to delay in seeking timely treatment. To reduce the cost incurred to the patients for strabismus surgery, we used half of a 6-0 polyglactin suture for performing common muscle weakening and strengthening procedures: a fixed and hang back recessions with plication and resection. We cut the 45-cm-long double-armed 6-0 polyglactin sutures in two halves, and with a modified approach, used one-half in each of two patients planned for monocular two horizontal muscles surgeries: fixed recession-plication and hang back recession-resection. By devising an intuitive manner of threading a single armed 22.5 cm suture we successfully carried out horizontal extraocular muscle surgeries on each of two patients of exotropia. We believe in the long run, this will reduce the cost to individual patients and sponsoring groups, and suggest that strabismus surgeons consider adopting this option.

Self-regurgitation on pressure over lacrimal sac in cases of primary-acquired nasolacrimal duct obstruction: Correlation with physician examination and patients' perceptions.

PURPOSE: To analyze the correlation between patient-reported regurgitation on pressure over lacrimal sac (ROPLAS) with the physician's examination in diagnosing primary-acquired nasolacrimal duct obstruction (PANDO). METHODS: A cross-sectional study was done over 5 months (March-July 2018). All cases diagnosed as PANDO were included in the study. The maneuver of pressing over the lacrimal sac area and noticing the egress of mucoid or clear fluid from the surrounding area by the patient was termed as self-ROPLAS. A specific patient history of performance of this maneuver was compared with a clinician-performed ROPLAS and subsequent objective lacrimal drainage evaluation. The various reasons for performing self-ROPLAS by the patients were documented. RESULTS: A total of 134 patients were included in the study, out of which 59 (44.02%) were males and 75 (55.9%) were females. History of self-ROPLAS was present in 64 (47.8%) of the patients, whereas the physician examination revealed ROPLAS to be positive in 92 (68.6%) of the patients. All patients (100%) with a positive history of self-ROPLAS had nasolacrimal duct obstruction on subsequent examination. The most common reason for performing self-ROPLAS was for emptying the discharge from the medial canthal region to reduce the painless swelling. CONCLUSION: Self-ROPLAS is highly suggestive of an obstructed nasolacrimal duct and can be used as a screening tool by the primary physician to triage the patients toward ophthalmic plastic clinics or consult.

Saving space: Comparing mini - logMAR with standard logMAR visual acuity.

Purpose: Assessing visual acuity (VA) is the cornerstone of an ophthalmic workup and needs VA charts in a four or six meters space. The objective of this study was to compare the performance of distant VA (DVA) on one meter mini-logMAR (MLM) with a standard six meter logMAR (SLM) chart. Methods: We developed a MLM chart to be used at 1 m with +1.0 D spectacles, by reducing the SLM chart designed for 6 meters, to 1/6th its size, using AutoCAD version 2014. On an initial cohort, we obtained DVA on the two charts by optometrist trainees, masked to the outcomes on the different tests. We performed regression and checked agreement between the two measurements. Subsequently, on a new cohort, we validated the performance of the MLM. Results: Of the 56 initial subjects, mean DVA with SLM was 0.44 ± 0.13 and with MLM was 0.45 ± 0.13; mean difference of -0.01 ± 0.02, 95%CI: 0.007 to 0.018; P < 0.0001 on paired t-test. There was a significant correlation: r = 0.99; r2 = 0.98, P < 0.0001. On an average, DVA with MLM was less than a letter worse than with SLM. The regression formula obtained: SLM DVA = -0.1312 + 1.0014 x (MLM DVA). The validation study revealed no significant difference (P = 0.29) between the predicted standard DVA calculated by the regression formula and the actual standard. Conclusion: We suggest that we can deduce distance logMAR VA from a mini-logMAR chart as devised and used by us. This will take less space, be portable and allow congenial interaction with patients.

Do all children need a cycloplegic refraction? A comparison of Mohindra's versus cycloplegic refraction.

PURPOSE: In 1-12 years old children, we assessed correlation, regression, and agreement between spherical equivalents (SE) obtained on Mohindra's near retinoscopy (MNR) and the post cycloplegic refraction (PCRef), performed 72 h after a cycloplegic refraction (CRef) using cyclopentolate 1% drops. METHODS: In this prospective comparative study, Mohindra's near retinoscopy (MNR) was performed on 202 eyes of 101 children, from 50 cm with a streak retinoscope, in a dimly lit room, subtracting 1.25 from the trial lens used for neutralization, to obtain the final refraction. Subsequently we undertook CRef, half-hour after instilling 1% cyclopentolate, with a PCRef 72 h later. All refractive data were converted to SE for evaluation. We compared the SEs using correlation, linear regression, and agreement (Bland-Altman graphic analysis) and paired t-test. Significance was set at P ≤ 0.05. RESULTS: The mean SE on MNR was 1.71 ± 2.49 D compared to 1.43 ± 2.42 D on PCRef. A significant correlation with r = 0.97 (r2= 0.94, P < 0.001) existed. Agreement analysis suggested that MNR overestimates hypermetropia and underestimates myopia each by 0.3 D than the standard procedure of CRef-PCRef. The regression analysis suggested that SE on PCRef is 95% of that on MNR, less 0.20. CONCLUSION: Our study suggests that MNR offers single point refraction very similar to CRef-PCRef, and may be considered as a viable option more often.

Gain beyond cosmesis: demonstration of psychosocial and functional gains following successful strabismus surgery using the adult strabismus questionnaire adult strabismus 20.

BACKGROUND: Strabismus adversely affects psychosocial and functional aspects; while its correction impacts positively. AIM: The aim was to evaluate the gains in scores: Overall scores (OASs), psychosocial subscale scores (PSSs) and functional subscale scores (FSSs) following successful surgical alignment. SETTINGS AND DESIGN: We evaluated changed scores in the adult strabismus 20 (AS-20) questionnaire, administered before and after successful surgery. MATERIALS AND METHODS: Thirty adults horizontal strabismics, were administered the AS-20, at baseline, and at 6-week and 3-month. Group-wise analysis was carried out based on gender, strabismus type (esotropia [ET] or exotropia [XT]), back-ground and amblyopia. STATISTICAL ANALYSIS: We used Wilcoxon, and Mann-Whitney U-tests. Significance was set at P ≤ 0.05. RESULTS: At baseline, there were no significant differences within the groups, except that those with amblyopia significantly scored less than nonamblyopes in OAS (median scores: 53.8 vs. 71.3; P = 0.009) and FSS (56.3 vs. 85.3; P = 0.009). OAS, PSS and FSS showed significant gains at 6-week and 3-month (all Wilcoxon P < 0.001). Compared with males, females showed significantly more gain at 3-month (OAS: 37.9 vs. 28.7; P = 0.02), on account of PSS gain (49.6 vs. 37.5; P = 0.01). The ET performed better than XT only on the FSS at 6-week (28.7 vs. 15.0; P = 0.02). Vis-à-vis the nonamblyopes, the amblyopes showed significantly more benefit at 6-week alone (OAS: 18.7 vs. 28.7; P = 0.04), largely due to gains in PSS. CONCLUSIONS: Successful strabismus surgery has demonstrated significant gains in psychosocial, functional and overall functions. There is some evidence that gains may be more in females; with a trend to better outcomes in ET and amblyopes up to 6-week.

Minimally invasive strabismus surgery versus paralimbal approach: a randomized, parallel design study is minimally invasive strabismus surgery worth the effort?

INTRODUCTION: Minimal access surgery is common in all fields of medicine. We compared a new minimally invasive strabismus surgery (MISS) approach with a standard paralimbal strabismus surgery (SPSS) approach in terms of post-operative course. MATERIALS AND METHODS: This parallel design study was done on 28 eyes of 14 patients, in which one eye was randomized to MISS and the other to SPSS. MISS was performed by giving two conjunctival incisions parallel to the horizontal rectus muscles; performing recession or resection below the conjunctival strip so obtained. We compared post-operative redness, congestion, chemosis, foreign body sensation (FBS), and drop intolerance (DI) on a graded scale of 0 to 3 on post-operative day 1, at 2-3 weeks, and 6 weeks. In addition, all scores were added to obtain a total inflammatory score (TIS). STATISTICAL ANALYSIS: Inflammatory scores were analyzed using Wilcoxon's signed rank test. RESULTS: On the first post-operative day, only FBS (P = 0.01) and TIS (P = 0.04) showed significant difference favoring MISS. At 2-3 weeks, redness (P = 0.04), congestion (P = 0.04), FBS (P = 0.02), and TIS (P = 0.04) were significantly less in MISS eye. At 6 weeks, only redness (P = 0.04) and TIS (P = 0.05) were significantly less. CONCLUSION: MISS is more comfortable in the immediate post-operative period and provides better cosmesis in the intermediate period.

Beyond photography: evaluation of the consumer digital camera to identify strabismus and anisometropia by analyzing the Bruckner's reflex.

Amblyopia screening is often either costly or laborious. We evaluated the Canon Powershot TX1 (CPTX1) digital camera as an efficient screener for amblyogenic risk factors (ARF). We included 138 subjects: 84-amblyopes and 54-normal. With the red-eye-reduction feature off, we obtained Bruckner reflex photographs of different sized crescents which suggested anisometropia, while asymmetrical brightness indicated strabismus; symmetry implied normalcy. Eight sets of randomly arranged 138 photographs were made. After training, 8 personnel, marked each as normal or abnormal. Of the 84 amblyopes, 42 were strabismus alone (SA), 36 had anisometropia alone (AA) while six were mixed amblyopes (MA). Overall mean sensitivity for amblyopes was 0.86 (95% CI: 0.83-0.89) and specificity 0.85 (95% CI: 0.77-0.93). Sub-group analyses on SA, AA and MA returned sensitivities of 0.86, 0.89 and 0.69, while specificities were 0.85 for all three. Overall Cohen's Kappa was 0.66 (95% CI: 0.62-0.71). The CPTX1 appears to be a feasible option to screen for ARF, although results need to be validated on appropriate age groups.

Multi-use of single use unims: Does economic burden outweigh contamination risk?

Aim: To assess if residual drops of unims can be used after single use to cut down economic load. Setting: Laboratory setting. Materials and Methods: This study was done to determine the possibility of multi-use of such unims. Ten unims of Acuvail (ketorolac tromethamine 0.45%) were opened simultaneously to culture a single drop from each unim daily for 7 days and growth was studied at 24 h (group 1); a similar study was done taking extra aseptic precautions (group 2), and with another set of 10 unims, with one drop twice a day for 3 days (group 3). Results: 20% unims showed growth on the 1st day and 60% on the 6th day. The growth consisted of Staphylococcus aureus. No growth was found in the second part of the study. Two drops per day arm showed incremental growth from the 3 rd dose (2 nd day). Conclusion: Even though unims contain more than one drop, patients should be strictly instructed for single use of such vials because there is potential risk of transmitting pathogens and a serious threat to post-cataract surgery patients.

Cut and paste: a novel method of re-attaching rectus muscles with cyanoacrylate during recessions in strabismus.

AIM: Bio-adhesives like cyanoacrylate offer an alternative to sutures to attach tissues, including in ophthalmology. This prospective trial evaluated the suitability and bio-tolerance of iso-amyl cyanoacrylate in rectus muscle recession surgery for strabismus. MATERIALS AND METHODS: We randomized one eye in each of 10 cases of bilateral horizontal rectus recessions to 6/0 polyglactin and the other to iso-amyl-cyanoacrylate. We compared time to reattachment (from disinsertion), complications and inflammatory scores (0 to +3: nil, mild, moderate and severe) on Day One, at two and at four to six weeks post surgery. RESULTS: There were no significant group differences in inflammatory scores (Wilcoxon, all values of P>0.05). All attachments held firm. Gluing took significantly longer by 5.24+/-1.91 min (95% CI for difference: 3.87-6.61). There were no complications. CONCLUSION: We feel that although it takes marginally longer, iso-amyl cyanoacrylate offers an effective and safe alternative to sutures for muscle recession in strabismus surgery. Since it is cheaper (vs. polyglactin) and offers multi-use possibility it may also prove to be cost-effective.

Gains beyond cosmesis: Recovery of fusion and stereopsis in adults with longstanding strabismus following successful surgical realignment.

We evaluated recovery of binocularity in 15 chronically strabismic, non-fusing (with neutralizing prisms) adults following successful surgical alignment. We included > or =12-year-olds, with best corrected visual acuity (BCVA) > or =20/60, and excluded those with: anisoacuity> 2 lines-Snellen; failed realignment judged by> 10 prism diopters (PD) horizontal and> 4 PD vertical. Six-week outcomes were: fusion by Worth Four-Dots (WFDT) and Bagolini striated glasses (BSG) and stereopsis by Titmus test and the Netherlands organisation for applied scientific research (TNO) test. Baseline data in medians (range): age 18 (12-40) years, strabismus 45 (19-95) PD, duration 14 (0.5-24) years, 12 females; 12 exotropes, three esotropes; visual acuity was 20/20 in 10, while none had BCVA < 20/60. Postoperative strabismus measured 6 PD (range:0-10). By six weeks none suppressed: WFDT findings showed eight fused at distance and 13 at near; and on BSG figures were 10 and 13 respectively. Stereopsis was demonstrated by 13 on Titmus and by 10 on TNO tests. It is concluded that longstanding strabismic adults with good vision can recover fusion and stereopsis following successful squint surgery.

Orbital amelanotic melanoma in xeroderma pigmentosum: a rare association.

Xeroderma pigmentosum (XP) is an autosomal recessive genetic disorder of DNA repair in which the body's normal ability to repair damage caused by ultraviolet light is deficient. This leads to a 1000-fold increased risk of cutaneous and ocular neoplasms. Ocular neoplasms occurring in XP in order of frequency are squamous cell carcinoma, basal cell carcinoma and melanoma. Malignant melanomas occur at an early age in patients with XP. We report a case of XP with massive orbital melanoma in an eight-year-old boy which is unique due to its amelanotic presentation confirmed histopathologically.

Topical diclofenac versus dexamethasone after strabismus surgery: a double-blind randomized clinical trial of anti-inflammatory effect and ocular hypertensive response.

BACKGROUND: Compared to steroids non-steroidal anti-inflammatory drugs offer comparable anti-inflammatory action without ocular side-effects. AIM: To compare the anti-inflammatory effect and effect on IOP (Goldmann) of topical diclofenac 0.1% with dexamethasone 0.1% after strabismus surgery. DESIGN: Prospective, randomized, double-blind, single-center, clinical trial. MATERIALS AND METHODS: Forty-three cases of constant horizontal strabismus, qualifying for standard uniocular recession-resection surgery on two horizontal rectus muscles were randomized to either the dexamethasone or diclofenac group. They were excluded if they had previous ocular surgery, recently used anti-inflammatory drugs and had a neurological, systemic or an ocular inflammatory condition. In addition all received ciprofloxacin 0.3% four times daily. Assessment was done on the first postoperative day and at two and four weeks. The inflammatory characteristics graded from nil (0) to severe (3) were: discomfort, chemosis, injection, discharge and drop-intolerance. Their sum provided the total inflammatory score (TIS). RESULTS: Dexamethasone group (n=21) was comparable in age, gender, preoperative IOP, strabismus, anesthesia administered and baseline IOP, to diclofenac (n=22). There were no significant differences in the inflammatory characteristics and TIS. The dexamethasone group had IOP significantly higher at two weeks (95% CI 0.17 to 3.25) and four weeks (95% CI 1.09 to 4.24) compared to diclofenac group and the net change of IOP at four weeks (95% CI 0.60 to 3.14). Compared to the baseline IOP. CONCLUSION: Topical diclofenac is comparable to dexamethasone in providing anti-inflammatory and analgesic effect with the advantage of significantly lesser IOP rise and should be preferred after strabismus surgery.