Phacoemulsification in angle-closure glaucoma: A 360° evaluation.

PURPOSE: To evaluate the effect of phacoemulsification on intraocular pressure (IOP) and anterior chamber angle (ACA) morphology in primary angle-closure glaucoma (PACG). SETTING AND DESIGN: A hospital-based, prospective pre- and post-interventional study was carried out in 40 PAC and PACG eyes post patent PI with visually significant cataracts. METHODS: All patients underwent phacoemulsification and were evaluated for IOP control, ACA widening, and disease progression for a minimum of 6 months. Failure was defined as an IOP of >21 mmHg necessitating another intervention, including trabeculectomy and/or an increase in the required number of antiglaucoma medications (AGMs) by >1. RESULTS: A highly statistically significant reduction of IOP (P < 0.0001) was seen with an overall reduction of 42.2% over 6 months and a mean reduction of 8.9 ± 3.59 mmHg, with the requirement of AGMs reducing from 39/40 patients preoperatively to 1/38 postoperatively. Success was seen in 95% of cases, with two patients not achieving target IOP and requiring trabeculectomy. Angle widening was documented in all cases by both gonioscopy and AS-OCT, and none of the patients showed any progression in disc damage and visual field changes. CONCLUSION: Early cataract surgery in ACG not only helps to control IOP and disease progression by widening angles and improving aqueous outflow but also improves visual acuity and reduces the economic burden of AGMs. It also helps in better evaluation of disease progression by both structural and functional analysis, as was documented by the improved and more reliable visual field indices.

Recurrence of gigantic overhanging bleb post excision: a case report.

Purpose: To report the case of an extremely large overhanging bleb, extending from superior fornix to limbus, in a 57-year-old poorly controlled diabetic, six years after trabeculectomy for an uncontrolled primary open angle glaucoma (POAG) with recurrence, months after complete excision. Methods: An overhanging bleb is defined as a filtering cicatrix which has been massaged downward over the cornea by eyelid action. It has been linked to anti-metabolite use during glaucoma filtering surgery. Despite being functional, these blebs result in patient discomfort ranging from foreign body sensation and lacrimation to dysphotopsia. A 57-year-old male presented with complaints of reduced vision, foreign body sensation, watering, and difficulty in eye closure in the left eye (OS) for past 6 months. He had undergone trabeculectomy with mitomycin C 6 years ago for advanced primary open-angle glaucoma with no follow-up beyond the initial one 4 weeks post-surgery. Results: At presentation, he had a giant multi-loculated, cystic filtering bleb (15 mm x 8 mm x 4-5 mm), which was carefully excised. Amniotic membrane was used as an anti-fibrotic as well to cover the defect. Seven months after surgery, there was recurrence of this overhanging cystic bleb when it was again excised with debulking of the conjunctiva done and cryotherapy applied to its margins. Conclusion: Although multiloculated cystic overhanging blebs have been documented before, such a large (posterior extent till fornix), thick-walled multiloculated bleb with histopathological evidence of chronic inflammatory process has not been reported prior.

Clinically relevant colour album test for the colour defective medical student.

Purpose: To evaluate the impact of color vision deficiency (CVD) in medical undergraduates by a more clinically applicable test. Methods: Cross-sectional study of 31 students with CVD (Ishihara diagnosed) asked to identify subject-specific signs/tests requiring color identification on a customized medical multispecialty designed color album test (CAT). They were further subjected to Farnsworth D-15 testing. Results: The error score of CVD students (4 ± 3.2) on 39 plates of color album test was highly significant as compared to the error score of color normal (0.3 ± 0.6). The CAT depicted linear correlation with Farnsworth D-15 and emerged as a valid tool of assessment. Ishihara interpretation did not correlate with the clinical impact of CVD. Nature of error suggests that CVD students can anticipate problems in dermatology, pathology, hematology, microbiology, and biochemistry. Conclusion: Color album test is a more clinically relevant test for CVD doctors to identify specialties where they can anticipate difficulties.

Merits of conjunctival frill incision in reducing trabeculectomy-induced astigmatism and patient discomfort.

Purpose: To compare results of a novel "conjunctival frill/smile incision" on surgically induced astigmatism (SIA) and patient discomfort vs conventional trabeculectomy in the initial postoperative period. Methods: Sixty trabeculectomy cases were subjected to either conjunctival frill incision, performed 1.5-2.0 mm from the limbus (study group) or conventional fornix-based conjunctival flap (control group). Corneal astigmatism and suture-induced discomfort were assessed by keratometry and a self-devised patient questionnaire, respectively. Results: Both groups generated a "with the rule" SIA, which was 1.77 vs 2.42 at 1 week and reduced to 1.27 vs 1.8 in the study vs control group, after removal of sutures - both scleral flap releasable and conjunctival at 1 month. Patient discomfort score revealed enhanced comfort in 37% of patients (study group) vs 17% (control group) during the early postoperative period. After 1 month of surgery, good comfort was regained in all cases. Conclusion: This novel suturing technique results in reduced SIA, patient discomfort during the 1st month after trabeculectomy.

Iris clues in ACG.

Primary angle closure glaucoma is a major cause of visual morbidity in Asia, which hosts 80% of the worldwide cases. In India, primary angle closure glaucoma (PACG) comprises almost 50% of adult glaucomas in hospital setting with its asymptomatic presentation predominating at 80%. Early diagnosis is critical to prevent the blinding trajectory of this disease, which is purported to cause twice as much blindness compared to open angle glaucoma. Traditional screening methods to identify PACG range from van Herick and flashlight test (relatively poor predictors) to gonioscopy (gold standard). Altered iris morphology are intrinsic to PACG, resulting in specific iris patterns. Iris appraisal could emerge as a method to screen underlying PACG. This would not only be specific, objective, but also easily performed at the peripheral level by a trained personnel and used in the era of tele-medicine for mass screening by AI softwares. This article seeks to detail these iris changes.

Congenital ectropion uveae (CEU) with refractory glaucoma: Early trabeculectomy saves vision.

We report the case of congenital ectropion uveae in a 10-year-old boy with intractable unilateral glaucoma but no systemic association. Glaucoma in congenital ectropion uveae is often poorly responsive to medial therapy and requires surgical intervention. Satisfactory results are possible if diagnosis is established early and timely surgery performed, as was the case in our patient.

Orthokeratology in Moderate Myopia: A Study of Predictability and Safety.

PURPOSE: Literature is relatively silent on safety profile and predictability of orthokeratology lenses in terms of myopia correction and prevention of further progression, especially in semi-tropical countries; this study was designed to fill this gap. METHODS: This prospective, intervention case series enrolled 30 eyes of 30 patients with myopia up to -5.5 diopters (D). Patients were randomized into two groups of 15 each; the study group was prescribed overnight orthokeratology (OK) lenses, while the control group used daily wear conventional soft contact lenses. Follow-up examinations were performed after 1 h and 6 h, and then at 1, 7, 15, 30 days, and 4 months post lens wear. Uncorrected visual acuity (UCVA), contrast sensitivity, keratometry, central corneal thickness (CCT), and tear film break up time (TBUT) were evaluated at each follow-up examination. RESULTS: All patients attained a visual acuity of 0.00 Logarithm of the Minimum Angle of Resolution (logMAR) after one week of lens use, which was maintained throughout the study period. While patients allotted to the study group had a gain of 8.1 Snellen lines (UCVA), those in the control group gained 8.9 lines (BCVA) at the end of follow-up period. In the OK group, cornea showed a flattening of 0.8 D (mean keratometry) after single overnight usage of OK lens and overall flattening of 1.2 D compared to baseline, at the end of four months. The change in contrast sensitivity, corneal endothelial specular count, axial length and tear film status was not significant in either group. CONCLUSION: Orthokeratology is an effective and safe modality to correct moderate myopia in motivated young adults. No side effects were encountered after a short-term follow-up in participants who resided in semi-tropical environments.

Bilateral Phacomatosis Pigmentovascularis in a Young Male with Developmental Glaucoma and Varicose Veins.

AIM: To report a case of bilateral phacomatosis pigmentovascularis (PPV), in a young male,presenting with developmental glaucoma and high myopia along with systemic features of klippel trenanauy weber (KTW) syndrome. BACKGROUND: The co-existence of oculodermal melanocytosis (ODM)and port-wine stain was termed PPV by Ota. Port-wine stain presents as part of Sturge-Weber syndrome (SWS). KTW presents with varicose veins and tissue hypertrophy alongwith port-wine stain. CASE DESCRIPTION: A 22-year-old male presented with decreased vision owing to high myopia and advanced glaucoma. Incidental findings noted were pigmentary naevi along with facial port-wine stain, which collectively comprises PPV. Also noted were bilateral varicose veins which are usually seen in association with KTW. In view of advanced visual field damage and inability to control intraocular pressures (IOP) on topical medications, he underwent Glaucoma filtration surgery in both eyes. Intra-operatively care was taken to avoid sudden decompression by controlled anterior chamber paracentesis, and scleral flap closure with releasable sutures was done to prevent hypotony related complications in the immediate postoperative period. Such precautions lead to an uneventful postoperative recovery, and even at 3 years' follow-up, the patient is maintaining IOP in early teens along with a stable visual acuity and visual fields. CONCLUSION: This case highlights the overlapping features of congenital conditions like oculodermal melanocystosis (ODM), SWS, KTW; presenting in a young male. Systemic features reported less frequently with PPV, included palatal pigmentation and palatal vascular malformations. CLINICAL SIGNIFICANCE: This case re-emphasizes a common origin of these entities, PPV and KTW, from the neural crest cells. Early recognition of the systemic features and timely surgical intervention under appropriate precautions, can be vision salvaging in such cases of developmental glaucoma.How to cite this article: Singh K, Dangda S, Mutreja A, Bhattacharyya M, Jaisingh K. Bilateral Phacomatosis Pigmentovascularis in a Young Male with Developmental Glaucoma and Varicose Veins. J Curr Glaucoma Pract 2018;12(2):94-98.

Trabeculectomy with subconjunctival collagen implant in Indian eyes: Long-term results.

PURPOSE: To report long-term safety and efficacy of trabeculectomy with collagen implant in Indian population. METHODS: All cases of trabeculectomy with Ologen® Collagen Matrix implant performed over a 7-year period from May 2008 through April 2015 at a tertiary referral institute were reviewed. A total of 30 eyes of 28 patients were included in the study with two patients undergoing bilateral trabeculectomy. Outcomes measured included intraocular pressure (IOP) control, number of antiglaucoma medications used, bleb morphology, and complications/reoperations. RESULTS: Trabeculectomy resulted in reduction in IOP from 36.46 to 11.65 mm Hg in the immediate postoperative period (day 1), a 68% decrease to 15.18 mm Hg at 84 months (58% decrease). The mean IOP reduction decreased over time from 63% in the first year to 55% after 5 years of follow-up. Fourteen eyes attained a follow-up of 5 years and eight eyes a follow-up of ≥7 years. No sight-threatening complication such as hypotony, bleb leak, and bleb-related endophthalmitis was observed in our series, and only intervention required was 5-fluorouracil needling in one case. CONCLUSION: Ologen-augmented trabeculectomy is effective in controlling IOP over a long-term follow up from minimal 3 to maximal 7 years. No untoward events jeopardizing bleb safety were noted at any time. This modality is a viable alternative for patients with contraindications to use of antimetabolites.

Alterations in contact lens fitting parameters following cross-linking in keratoconus patients of Indian ethnicity.

BACKGROUND: Most studies have either excluded patients using contact lens or not taken their effect while analyzing post-collagen cross-linkage (CXL) changes. This study aims to study impact of CXL on lens fit in both quantitative and qualitative manner. OBJECTIVE: To evaluate changes in CL fit post-CXL and to correlate these changes with alterations in corneal topographic parameters. STUDY DESIGN: Prospective intervention study on 20 keratoconic eyes of 14 patients (age > 18 years), with mean follow-up of 6 months. METHODS: Preoperative evaluation included UCVA, BCVA, corneal topography, AS-OCT and contact lens fit. Patients were evaluated at 2 weeks, 1, 3, 4 and 6 months post-CXL; contact lens trial with standard rigid gas permeable (RGP) lens performed at 3 and 6 months. MAIN OUTCOME MEASURE: Changes in objective and subjective parameters of lens fit. RESULTS: Over 6-month follow-up post-CXL, improvement in visual acuity by one Snellen line, both UCVA and BCVA, and decrease in flat/mean/apical K by 0.8 D, 0.8 D and 1.3 D, respectively, resulted in significant improvement in RGPCL fit. Almost 20% increase in near-ideal fit, 100% acceptable fit, 65% improved subjective comfort with 8 h/day increase in duration of comfortable CL wear were observed. CONCLUSION: Despite no statistically significant change in objective parameters of lens fit, a tendency for flatter lens fit along with contact lens induced further flattening of the ectatic cornea which resulted in marked improvement in both objective and subjective contact lens fit.

Ocular Decompression Retinopathy : A Case Series.

INTRODUCTION: Ocular decompression retinopathy (ODR) is a relatively rare entity with variable prognosis depending on extent and pre-existing condition. This article describes profile of two cases with a brief review of the condition. CASE REPORT: Case 1 highlights extensive choroidal detachment with subhyaloid haemorrhage and multiple intra-retinal hemorrhages in the posterior pole seen on first post-operative day in a 6 year old child with congenital glaucoma who underwent Trab & Trab. Case 2 describes multiple intraretinal hemorrhages seen at posterior pole on second post-operative day in a 24 year old pregnant lady with post traumatic cataract and secondary glaucoma who underwent cataract extraction with Cionni ring. Both patients had complete resolution of the haemorrhages with topical steroids. CONCLUSION: Ocular decompression retinopathy is mostly seen after operations on cases with advanced glaucoma and those with vulnerable blood flow fluidics. Adequate precautions to prevent this entity should be adopted during surgery and management of the manifest entity is conservative with good prognosis.

Diode laser cyclophotocoagulation paves way to a safer trabeculectomy in eyes with medically uncontrollable intraocular pressure.

High intraocular pressure (IOP) not responding to systemic and topical anti-glaucoma medications renders the eye at risk for both intra- and post-operative complications of glaucoma filtration surgery. Laser cyclophotocoagulation is able to lower IOP in such refractory glaucoma eyes and may make the surgical event safer. This study assessed diode laser cyclophotocoagulation (DLCP) when used as a temporary measure for lowering IOP prior to performing trabeculectomy. This study is a  retrospective analysis of cases planned for trabeculectomy surgery, uncontrolled on maximally tolerable systemic anti-glaucoma medications. They were analysed for response to DLCP in terms of IOP control, vision-related complications, increased inflammation, post-trabeculectomy hypotony and chances of phthisis and ciliary shutdown. Twelve eyes of ten patients aged 35-65 years were identified and all followed up for at least 2 years. One week following DLCP, the IOP (mean ± SD) declined by 51 % from 46.8 ± 5.4 to 22.8 ± 3.3 mmHg. The IOP was further reduced to 15.4 ± 2.7 mmHg at 4 weeks after trabeculectomy; it remained in the mid-teens for a minimum of 2 years in all cases. The mean (±SD) visual acuity improved from 1.4 ± 0.4 to 0.8 ± 0.4 LogMAR equivalents following trabeculectomy. In four eyes, phacoemulsification was performed 5-7 months after trabeculectomy with improvement in best-corrected visual acuity. One patient developed transient hypotony, post-trabeculectomy, which resolved by 6 days. There were no other complications like increased inflammation, prolonged hypotony or suprachoroidal haemorrhage. DLCP is, thus, effective and safe for temporarily controlling IOP; thereby trabeculectomy can be performed in a quieter ocular milieu.

Using Role-plays as an Empathy Education Tool for Ophthalmology Postgraduate.

PURPOSE: To assess the role of an "empathy sensitizing module" (ESM) in ophthalmology postgraduates in promoting effective empathetic communication. METHODOLOGY: Thirty-nine ophthalmology postgraduates were taught effective empathetic communication using specially designed module, comprising of five illustrative role-plays. We evaluated the impact of the training by (a) self-assessment of empathy quotient by residents using Jefferson Scale of Empathy (JSE scale) before and 6 weeks after ESM training and (b) nonparticipant observation (NPO) by trained faculty in real-life settings over the next 4 months. A peer-validated, self-designed checklist was used for NPO. The change in score was analyzed using Student's paired t-test. The faculty observed the use of empathy in real-life patient encounters of the trainees over the next 6 months. In addition, secondary qualitative data were collected and analyzed to assess the impact of the module on other stakeholders such as the role-playing undergraduate students and core faculty. RESULTS: Pretraining assessment revealed that concept of empathy during patient communication was understood by only 10% students. PostESM training, the self-rated mean empathy score, on JSE, significantly increased from 95.9 to 106.7 (of a maximum of 140). This was also confirmed by a significant improvement in externally rated empathy and soft skills scores (from 29.3 to 39.1; of a maximum of 55) using the NPO tool. Focus group discussion was done on the continued display of empathy by the trainees in real-life situation over 6 months of observation by the faculty. The group agreed that there was a gradual attrition of initial gain in empathy behavior over the observation period of 6 months. The spillover benefits of the training process were observed among the role-playing undergraduates as well. A thematic analysis of their reflections on the process revealed a substantial change with an improved understanding of effective communication. CONCLUSIONS: There is a definite scope for introducing empathetic communication in medical training. Empathetic communication can be improved by effective training in a contextual manner with a need for regular reinforcement. Sensitization at all levels including the faculty is required to implement effective communication skills in medical profession.