Ophthalmology

"Indovation" in ophthalmology – The potential power of frugal innovations Santosh G Honavar Indian Journal of Ophthalmology 2019 67(4):447-448

Papilledema or pseudopapilledema? Lin Liu, Michael D Yu, Carol L Shields Indian Journal of Ophthalmology 2019 67(4):449-449

Techniques of anterior capsulotomy in cataract surgery Bhavana Sharma, Robin G Abell, Tarun Arora, Tom Antony, Rasik B Vajpayee Indian Journal of Ophthalmology 2019 67(4):450-460 Optimal outcomes of a cataract surgery largely depend on the successful performance of an anterior capsulotomy. It is one of the most important steps of modern cataract surgery which reduces the risk of capsular tears and ensures postoperative stable intraocular lens (IOL). Anterior capsulotomy is considered ideal if it is round, continuous, well-centered, and overlaps the implanted IOL around its circumference. If any of these features is missing, it can be a cause of impedance for desired surgical and visual outcomes. Manual can opener and manual capsulorhexis are the routine standard techniques employed for manual extracapsular cataract extraction and phacoemulsification, respectively. Recent increasing use of femtosecond laser cataract surgery has allowed cataract surgeons to obviate inherent inaccuracies of manual anterior capsulotomy techniques. There is an ongoing quest to find an ideal, risk free, and surgeon-friendly technique of anterior capsulotomy that can be employed for surgery in all types of cataracts.

Consensus statement and guidelines for use of dilute atropine sulphate in myopia control Siddharth S Kesarwani, Mumbai Group of Paediatric Ophthalmologists and Strabismologists  Indian Journal of Ophthalmology 2019 67(4):461-463 Purpose: To develop a consensus statement for use of dilute atropine in control of myopia progression in children based on review of existing literature, opinions and suggestions of the members of the Group of Paediatric Ophthalmologist and Strabismologists, Mumbai (GPOS). Methods: Literature review, group discussions, questionnaire study and consensus building by supermajority voting. Results: About 65% of paediatric ophthalmologists in Mumbai have started prescribing atropine sulphate 0.01% as routine in their patients showing myopia progression. Majority of the respondents who have used it for >1 year in their patient population are extremely happy with the results. About 47% respondents expressed concerns regarding some yet unknown side effects of long-term use in our patient population. Majority of the respondents agree that it is safe and have rarely encountered side effects with its use. Conclusion: Atropine sulphate 0.01% is a safe and effective treatment for myopia control. Most trained paediatric ophthalmologists recommend its use in children with progressive simple myopia.

Oral azithromycin and oral doxycycline for the treatment of Meibomian gland dysfunction: A 9-month comparative case series Giacomo De Benedetti, Agostino S Vaiano Indian Journal of Ophthalmology 2019 67(4):464-471 Purpose: To compare the efficacy and safety profile of oral azithromycin with that of doxycycline over 9 months in patients experiencing failure with conservative and topical treatment for Meibomian gland dysfunction (MGD), to assess recurrence of MGD, and to determine the number of treatments required. Methods: This is a randomized controlled trial with a cross-over design at a tertiary care center. In all, 115 consecutive patients underwent a complete ophthalmological examination before being randomly assigned to oral treatment with doxycline (4 g for 30 days) or azithromycin (1.25 g for 5 days). Patients were evaluated at 3, 6, and 9 months. Therapy was switched or conservative management maintained according to signs and symptoms. Results: In the azithromycin group, 83.25% of the patients were stable after one treatment, 16.5% needed a further one or two treatments (some had previously been switched to doxycycline), and 5.77% did not improve despite treatment. In the doxycycline group, 33.79% of patients were stable after one treatment, 66.21% needed a further one or two treatments (some had previously switched to azithromycin), and 29.41% did not improve despite treatment (P < 0.05). Minimal gastrointestinal adverse effects (nausea, diarrhea, abdominal cramp, and decreased appetite) were reported, mostly unchanged at the follow-up visits. At the first visit, more adverse effects were reported in the doxycycline group (14/51, 24%) than in the azithromycin group (3/52, 6%; P < 0.005). Conclusion: Both antibiotics were effective and safe for treating patients with persistent MGD, although azithromycin was superior when the reduced dose and the shorter course of therapy (5 days vs. 4 weeks) were taken into consideration. Given the chronic nature of the disease and the improvement in some signs with minimal adverse effects, a shorter therapy seems a safer and more logical alternative to longer regimens.

Human amniotic membrane as a drug carrier – An in-vitro study using fortified cefazolin ophthalmic solution Sajeev Hitha Sara, Namperumalsamy Venkatesh Prajna, Srinivasan Senthilkumari Indian Journal of Ophthalmology 2019 67(4):472-475 Purpose: Our previous study demonstrated the drug reservoir function of human amniotic membrane (HAM) using stable moxifloxacin as a model drug. The purpose of the present study is to evaluate whether HAM can be used as a drug carrier for extended release of extemporaneous preparation of cefazolin. Methods: HAM Buttons (1 Control, 5 Test) were incubated in a freshly prepared (1 ml) sterile topical solution of cefazolin 5% (w/v) for 3 h and 24 h at two different temperatures. The groups were designated as follows: Group IA: Soaking duration 3 h at 4°C; Group IB: Soaking duration 3 h at room temperature; Group IIA: Soaking duration 24 h at 4°C; and Group IIB: Soaking duration 24 h at room temperature. The release kinetics of cefazolin from different groups of drug-laden HAM was studied for a period of 5 days. Samples were assayed for estimation of cefazolin content at different time intervals by High Performance Liquid Chromatography (HPLC) with Photodiode array (PDA) detector. Results: Three-hour cefazolin treatment with HAM at 4°C caused high drug entrapment (24%) compared to room temperature (11%; P < 0.005); however, the release kinetics was not significantly different between Group IA and IB as well as Group IIA and IIB up to the study period. Increase in drug treatment duration did not show increase in entrapment, but caused two-fold (IA Vs IIA) and 1.6-fold (IB Vs IIB) less drug entrapment at 4°C and room temperature, respectively. Conclusion: The results reveal that HAM may be a suitable drug carrier for extended delivery of fortified formulations without compromising stability.

Commentary: The human amniotic membrane: Fortifying nature's gift to ophthalmology Swapna S Shanbhag, Pragnya Rao Donthineni, Vivek Singh, Sayan Basu Indian Journal of Ophthalmology 2019 67(4):476-476

The prevalence and risk factors for cataract in rural and urban India Sumeer Singh, Shahina Pardhan, Vaitheeswaran Kulothungan, Gayathri Swaminathan, Janani Surya Ravichandran, Suganeswari Ganesan, Tarun Sharma, Rajiv Raman Indian Journal of Ophthalmology 2019 67(4):477-483 Purpose: To report the prevalence and risk factors of cataract and its subtypes in older age group. Methods: A total of 6617 subjects were recruited from both rural and urban areas. A detailed history including data on demographic, socioeconomic and ocular history was obtained. Lens opacity was graded according to the Lens Opacity Classification System III (LOCS III). Results: Cataract was present in 1094 of the rural and 649 subjects in the urban population. Monotype subtype cataracts were found in 32% and 25% in rural and urban population and 12.68% and 18.6% were mixed cataracts in the rural and urban groups. In baseline characteristics history of diabetes, alcohol intake and presence of age-related macular degeneration were the risk factors in urban group. On multivariate analysis, the only significant risk factors for any cataract in subjects ≥60 years were increasing age in both rural [odds ratio (OR), 1.07] and urban (OR, 1.08) population, and HbA1c (OR, 1.14) in rural population. Overweight (OR, 0.6) was found to be a protective factor, and lower social economic status (OR, 1.52) a risk factor for cataract in urban population. A significant urban–rural difference was found in the prevalence of cataract and its subtypes (P ≤ 0.05). Conclusion: We found the risk factors for any cataract in older age group to be increasing age and HbA1c in rural group. Age and lower social economic status were found to be the risk factors in urban arm. A statistically significant difference was found on comparison of the prevalence of cataract and its subtypes between the rural and urban population.

Accuracy of the refractive prediction determined by intraocular lens power calculation formulas in high myopia Dong Zhou, Zhuo Sun, Guohua Deng Indian Journal of Ophthalmology 2019 67(4):484-489 Purpose: Our study was conducted to evaluate and compare the accuracy of the refractive prediction determined by the calculation formulas for different intraocular lens (IOL) powers for high myopia. Methods: This study reviewed 217 eyes from 135 patients who had received cataract aspiration treatment and IOL implantation. The refractive mean numerical error (MNE) and mean absolute error (MAE) of the IOL power calculation formulas (SRK/T, Haigis, Holladay, Hoffer Q, and Barrett Universal II) were examined and compared. The MNE and MAE at different axial lengths (AL) were compared, and the percentage of every refractive error absolute value for each formula was calculated at ±0.25D, ±0.50D, ±1.00D, and ±2.00D. Results: In all, 98 patients were recruited into this study and 98 eyes of them were analyzed. We found that Barrett Universal II formula had the lowest MNE and MAE, SRK/T and Haigis formulas arrived at similar MNE and MAE, and the MNE and MAE calculated by Holladay and Hoffer Q formula were the highest. Barrett Universal II formulas have the lowest MAE among different AL patients, whereas it reached the highest percentage of refractive error absolute value within 0.5D in this study. The MAE of each formula is positively correlated with AL. Conclusion: Barrett Universal II formula rendered the lowest predictive error compared with SRK/T, Haigis, Holladay, and Hoffer Q formulas. Thus, Barrett Universal II formula may be regarded as a more reliable formula for high myopia.

Long-term outcomes of cataract surgery in children with uveitis Sonam Yangzes, Natasha Gautam Seth, Ramandeep Singh, Parul Chawla Gupta, Jitender Jinagal, Surinder Singh Pandav, Vishali Gupta, Amod Gupta, Jagat Ram Indian Journal of Ophthalmology 2019 67(4):490-495 Purpose: To evaluate the long-term outcomes of cataract surgery in children with uveitis. Methods: Retrospective, noncomparative review of medical records of children (≤16 years) with uveitic cataract who had undergone cataract surgery between January 2001 and December 2014 at a tertiary care center was done. The main outcome measures were visual acuity and postoperative complications. Results: We recruited 37 children (58 eyes) who were diagnosed with uveitic cataract and underwent cataract surgery. The etiology of uveitis included juvenile idiopathic arthritis (n = 19), presumed intraocular tuberculosis (n = 8), idiopathic (n = 4), Behçet's disease (n = 2), Vogt–Koyanagi–Harada syndrome (n = 2), human leukocyte antigen B-27 associated uveitis (n = 1), and toxocariasis (n = 1). Phacoemulsification with intraocular lens (IOL) implantation was performed in 17 patients (27 eyes; 46.55%), while 20 patients (31 eyes; 53.44%) were left aphakic after pars plan lensectomy and vitrectomy. At an average follow-up of 3.69 ± 7.2 (SD) years, all cases had significant improvement in corrected distance visual acuity post cataract extraction; visual acuity of 20/40 or more was achieved in 32 eyes (55.17%). The most common complication was capsular opacification (37.93%). Incidence of secondary procedures as well as glaucoma was not statistically different in patients undergoing IOL implantation from those who were aphakic. Conclusion: Even though number of secondary procedures was more in pseudophakic group, meticulous choice of surgical technique and adequate immunosuppression lead to a modest gain of visual acuity in children undergoing IOL implantation in uveitis. However, scrupulous case selection and aggressive control of pre- and postoperative intraocular inflammation are the key factors in the postoperative success of these patients.