The Aravind Pseudoexfoliation Study: Surgical and First-Year Postoperative Results in Eyes without Phacodonesis and Nonmiotic Pupils.

PURPOSE: To compare intraoperative complication rates, 1-year visual outcomes, and postoperative complication rates over the first postoperative year in eyes with and without pseudoexfoliation undergoing cataract surgery. DESIGN: Prospective, comparative, interventional study. PARTICIPANTS: Nine hundred thirty eyes with cataract and uncomplicated pseudoexfoliation (without phacodonesis, clinically shallow anterior chambers, or pupil size <4 mm) and 476 controls with cataract but without pseudoexfoliation recruited from 4 centers of the Aravind Eye Care System in Southern India. The 2 groups were randomized separately to receive either a single-piece acrylic intraocular lens (IOL; SA60AT; Alcon Laboratories, Fort Worth, TX) or a 3-piece acrylic IOL (MA60AS; Alcon Laboratories). The pseudoexfoliation group also was randomized to receive or not receive a capsular tension ring. METHODS: All eyes underwent phacoemulsification with IOL implantation and were followed up at 1 day, 1 month, 3 months, and 1 year after surgery. MAIN OUTCOME MEASURES: Association of pseudoexfoliation status with intraoperative complication rates, 1-year best-corrected visual acuity, and any other complications. RESULTS: Mean ages were 63.0±6.9 years and 57.9±7.3 years in the pseudoexfoliation and control groups, respectively (P < 0.001). Pseudoexfoliation patients were more likely to be men (P = 0.014), to have a nuclear opalescence grade of more than 4 (P = 0.001), and to have a pupil size of less than 6 mm (P < 0.001) when compared with controls. Intraoperative complication rates were 2.9% and 1.9% in the pseudoexfoliation and control groups, respectively (P = 0.29). One-year postoperative best-corrected visual acuity was comparable (P = 0.09). Complication rates at 1 year were 2.7% and 2.5% in the pseudoexfoliation and control groups, respectively (P = 0.82). Average endothelial cell loss was 14.7% in the pseudoexfoliation group and 12.7% in the control group at 1 year (P = 0.066) when adjusting for age and nuclear opacity. CONCLUSIONS: Pseudoexfoliation eyes without shallow anterior chamber, small pupils, or apparent zonulopathy may represent eyes with lower risks of complications. Despite smaller pupils and denser cataracts, pseudoexfoliation eyes without clinically apparent preoperative zonulopathy were not at a higher risk of intraoperative or postoperative complications or worse visual outcomes after cataract surgery.

Short-term outcomes of Mitomycin-C augmented phaco-trabeculectomy using subconjunctival injections versus soaked sponges: a randomized controlled trial.

OBJECTIVES: To determine whether subconjunctival Mitomycin-C (MMC) injections are as safe and effective as sponge-soaked MMC in phaco-trabeculectomy. METHODS: This prospective, randomized, interventional study was conducted on consecutive patients with visually significant cataract and an uncontrolled primary open-angle glaucoma. One hundred thirty-nine patients were recruited but 15 were ineligible for analysis. The patients were randomized into a sponge/injection group. All participants received a twin-site phaco-trabeculectomy. They were followed up on days 1, 15, 30, 3 months and 6 months post-operatively. A p-value < 0.05 was considered significant. INTERVENTIONS: Participants in the sponge group received an augmentation of their phaco-trabeculectomy with sponges soaked in a mixture of 0.04% MMC and 2% preservative-free Lignocaine in a 1:1 ratio, placed in the subconjunctival space for four minutes. Participants in the injection group received the same mixture as a subconjunctival injection, after surgical draping. RESULTS: There were 62 patients in each group. The groups had no significant differences in their baseline characteristics. The mean IOP at 6 months was significantly lower in the injection group (14.8 ± 3.7 mm Hg) than in the sponge group (17.1 ± 6.4 mm Hg) (p = 0.02). There was no notable difference in the complications or the final post-operative visual outcome but a significantly greater number of patients in the sponge arm required removal of the releasable suture (p = 0.001) and additional anti-glaucoma medications (p = 0.04) at six months post-operatively. CONCLUSIONS: Subconjunctival MMC achieves a lower IOP with fewer anti-glaucoma medications than sponge-soaked MMC at six months for twin-site phaco-trabeculectomy in primary open-angle glaucoma with no additional risks.

Long-term outcomes of Mitomycin-C augmented trabeculectomy using subconjunctival injections versus soaked sponges: a randomised controlled trial.

PURPOSE: To compare the safety and efficacy of subconjunctival injection of Mitomycin C(MMC) with sponge-applied MMC during trabeculectomy. METHODS: This prospective, randomised, interventional study was conducted on consecutive patients with uncontrolled glaucoma. 137 patients were randomised into an Injection group (Group 1, n = 66) and a sponge group (Group 2, n = 71). Trabeculectomy was performed in all patients who were followed up on days 1, 15, 30, 3 months, 6 months, 1 year, 2 years & 3 years postoperatively. Baseline & follow-up visits were compared to find out difference in the number of antiglaucoma medications (AGM), Intraocular pressure (IOP), and Best Corrected Visual Acuity (BCVA). In Group 1, the surgeon used MMC 0.2 mg/ml as subconjunctival injection and two separate semicircular surgical sponges soaked with MMC solution of 0.2 mg/mL were inserted subconjunctivally in Group 2. RESULTS: Mean preop IOP was 34.21 ± 13.3 mmHg & 34.17 ± 10.6 mmHg in group 1 & 2 respectively, which reduced to 11.34 ± 3.7& 12.57 ± 4.7 mmHg(6 months),11.97 ± 4.2 & 13.60 ± 5.3 mmHg(1 year),12.42 ± 4.4 & 11.77 ± 2.8 mmHg (2 years) &11.25 ± 3.2 & 11.81 ± 3.2 mmHg at final visit(P < 0.001 in both groups)with no significant difference between the groups. The mean number of preoperative AGM was 2.32 ± 0.7 & 2.32 ± 0.8 in group1 & 2 respectively which reduced to 0.78 ± 0.9 (P < 0.001) & 1.13 ± 1.1(P = 0.930) at 3 years. Overall success rates were 75.3% in group 1 and 70.7% in group 2 at 3 years(p = 0.512). Postoperative complications and the final post-operative visual outcomes were similar between the groups. CONCLUSION: Subconjunctival Injection of MMC is as safe and effective as sponge application with comparable surgical outcomes and complications in the long term.

Early Outcomes of Combined Phacoemulsification and Ab Interno Tanito Microhook Trabeculotomy in Open-Angle Glaucoma.

PURPOSE: To study the early postoperative efficacy and safety of an Ab Interno microhook trabeculotomy (microLOT) combined with cataract surgery in patients with open-angle glaucoma. METHODS: This prospective, randomized, interventional study was conducted on consecutive patients with visually significant cataract and mild-moderate open-angle glaucoma. One hundred fourteen patients were included for analysis. The patients were randomized to undergo microhook trabeculotomy with phacoemulsification (group 1) or phacoemulsification alone (group 2). All patients were evaluated on postoperative day 1, 15, and 30, as well as 3, 6, and 12 months postoperatively. A P value < 0.05 was considered statistically significant. Baseline and follow-up visits were compared to determine significant differences in the number of antiglaucoma medications (AGMs), intraocular pressure (IOP), and best-corrected visual acuity. RESULTS: There were 57 patients in each group. The baseline characteristics were similar between the 2 groups, except the number of AGMs, which was greater in group 2. The mean preoperative IOP for group 1 (phaco-microLOT) was 26.5 mmHg ± 5.2 and group 2 (phaco-alone group) was 25.3 mmHg ± 3.1 which decreased to 12.5 mmHg ±3.6 (P < 0.001) and 20.0 mmHg ± 2.7(P < 0.001) at 12 months, respectively. Logarithm of the minimum angle of resolution visual acuity improved from 0.48 (interquartile range [IQR], 0.30-0.60) preoperatively to 0.00 (0.00-0.18) postoperatively (P < 0001) in group 1 and improved from 0.30 (IQR, 0.30-0.48) to 0.00 (0.00-0.00) in group 2 (P < 0.001). In group 1, the mean (standard deviation [SD]) AGM used preoperatively was 0.6 (0.9) which was significantly reduced to 0.2 (0.5) at 12 months postoperatively, whereas in group 2, at 12 months, the mean (SD) AGM used was reduced from 1.4 (0.6) to 1.1 (0.9). In group 1, 90.3% of eyes achieved complete success at the end of 1 year. The most common complication was hyphema, noted in 4 patients with 1 eye requiring an anterior chamber washout. CONCLUSION: Ab interno microhook trabeculotomy (microLOT) combined with phacoemulsification in patients with open-angle glaucoma is an efficacious procedure with relatively minimal complications. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Myocilin Mutation N480K Leads to Early Onset Juvenile and Adult-onset Primary Open Angle Glaucoma in a Six Generation Family.

PRCIS: A pathogenic autosomal dominant MYOC mutation N480K detected in 6 generations of an Indian family is primarily responsible for juvenile open angle glaucoma (JOAG) and adult-onset primary open angle glaucoma (POAG), emphasizing the importance of screening this mutation at a younger age. PURPOSE: To screen myocilin mutations in a large South Indian family with early-onset JOAG and adult-onset POAG. METHODS: In a large South Indian family with 20 members, 8 members diagnosed as JOAG, 7 members as POAG, 4 members as JOAG suspect, and 1 member as POAG suspect were screened for myocilin ( MYOC) mutations using Sanger sequencing. Whole exome sequencing was performed on clinically suspected JOAG/POAG individuals. RESULTS: Myocilin gene mutation N480K (c.1440C>G) was detected in 20 family members, including proband, of whom 8 were JOAG and 7 were POAG patients, 3 were JOAG suspects, and 2 were unaffected. Among the unaffected carriers, 1 was less than 5 years old, and another was 25 years old. The earliest to develop the disease was a 10-year-old child. The penetrance of the mutation was 95% over 10 years of age. This family had JOAG/POAG suspects with no N480K MYOC mutation, and they were further screened for other mutations using whole-exome sequencing. Polymorphisms CYP1B1 L432V and MYOC R76K were detected in 3 JOAG/POAG suspects, and among these 3, one had another CYP1B1 polymorphic variant R368H. The presence of the CYP1B1 polymorphism along with an MYOC polymorphic variant among the JOAG/POAG suspects needs additional studies to explore their combined role in the onset of glaucoma. CONCLUSIONS: This study reveals that MYOC mutation is primarily responsible for JOAG and adult-onset POAG in a family, emphasizing the importance of screening for this mutation at a younger age for early treatment.

Glaucoma awareness, anxiety and its impact on patients undergoing visual field testing and optical coherence tomography.

PURPOSE: To assess the effect of Glaucoma awareness, knowledge, and anxiety on patients under visual field analysis by Humphrey's visual field analyzer (HFA) and optical coherence tomography(OCT). METHODS: This prospective comparative cohort study included glaucoma patients undergoing HFA (Group A)(n = 150) and OCT(Group B) (n = 150). Each group consisted of 75 newly diagnosed patients and 75 patients who were on follow-up. Participants completed State trait anxiety inventory form Y2(STAI) before and after the test to assess pre-test and intra-test anxiety. Another validated and structured questionnaire was used to assess patient awareness and knowledge of glaucoma. Anxiety scores were used to make correlations and comparisons between the two groups and also against visual field reliability indices. The impact of awareness on anxiety scores and its correlation with reliability indices were also determined. RESULTS: Overall pretest and intratest anxiety scores in patients undergoing HFA were 52.39(9.5) and 52.45(8.6)and OCT 53.04(8.0) and 53.83(8.2) respectively.Pretest anxiety was less in follow-up patients of both groups(Group A-51.04,Group B-52.72).There was no statistically significant difference between the groups(pretest p = 0.52,Intratest p = 0.15). Anxiety score was found to be significantly high in female participants(54.07,p = 0.01)and those without awareness(p < 0.001). Patients with education of graduation and above in group B had significantly lower anxiety scores(p = 0.007). CONCLUSION: Anxiety levels induced by both diagnostic modalities HFA and OCT appear to be similar and it does not affect the reliability indices.Anxiety score was higher in female participants and participants lacking disease awareness.

Comparative study of surgical outcomes of twin-site phacotrabeculectomy with mitomycin C in primary open-angle glaucoma versus primary angle-closure glaucoma.

Purpose: To compare the surgical outcomes of twin-site phacotrabeculectomy with Mitomycin C (MMC) in primary open-angle glaucoma (POAG) versus primary angle-closure glaucoma (PACG). Methods: Prospective, comparative, observational study. Patients with visually significant cataract and primary glaucoma were divided into two groups: POAG and PACG. They underwent twin-site phacotrabeculectomy with MMC and followed up on days 1, 15, 1 month, 6 months, and 12 months. Baseline and follow-up visits were compared to find the differences in intraocular pressure (IOP), antiglaucoma medications (AGM), success rates, anterior chamber depth (ACD), and axial length (AXL). Results: There were 50 eyes each in POAG and PACG groups. Mean IOP reduction from baseline to 12 months (21.22 ± 6.0 to 11.40 ± 2.8-POAG group vs 24.16 ± 7.6 to 12.42 ± 3.2-PACG group) was statistically significant in both groups (P < 0.001), but no significant difference between groups (P = 0.095). There was a statistically significant decline in the number of AGM in POAG [1.66 (0.7) to 0.38 (0.7), P < 0.001] and PACG [2.10 (0.7) to 0.70 (0.8), P < 0.001]; the decline was more in POAG (P = 0.012) at last visit. Probability of overall (complete and qualified) success at 12 months postop was 72.0% [95% confidence interval (CI): 57.4-82.4] in PACG and 84.0% (95% CI: 70.5-91.7) in POAG group. There was a significant increase in ACD and a decrease in AXL in both groups (P < 0.001). More interventions were required in the PACG group (38, P = 0.012). Conclusion: Phacotrabeculectomy with MMC causes a significant reduction in IOP and improvement in biometric parameters in both POAG and PACG. Patients with PACG required more postoperative interventions, while a lesser number of antiglaucoma medications were needed in POAG patients.

Comparison of the effect of audiovisual and verbal instructions on patient performance while performing automated Humphrey visual field testing.

Purpose: To compare the effect of audiovisual and verbal instructions on patient performance while performing automated Humphrey visual field testing. Methods: This was a prospective study. A total 120 patients divided into groups of 40 each were recruited from the glaucoma outpatient department (OPD). All patients were aged 35-75 years with no previous experience of performing HFA. Patients with hearing impairment, any other cognitive impairment, and best-corrected visual acuity (BCVA) ≤6/36 on Snellen's visual acuity were excluded. The first two groups were given strict (conservative) and lenient (liberal) verbal instructions. The instructions were adapted from those listed in the manufacturer's instruction. and the third group was shown a standard video depicting in detail how perimetry was to be performed. A questionnaire was given to each patient before and after the test to assess the patient's performance. Results: Patients diagnosed with glaucoma during testing in each group were 29 (72.50%), 30 (75.0%), and 33 (82.5%) in the video instructed, strictly verbal, and leniently verbal groups, respectively. The overall mean deviation (MD) in the right eye (RE) was of - 3.38 (-4.9 to 1.9) and in the left eye (LE) was - 3.96 (-6.4 to - 1.9). Reliable field was slightly higher for the video instructed group (47.5%) and lowest for the strictly verbal group (22.5%) (P = 0.033). A higher number of patients were very motivated in the video instructed group (27%) (P = 0.041). Post-test questionnaires showed that 40% of patients felt they have performed the test with 100% accuracy in video group with less guessing. A higher number of patients in the video instructed group (85%) felt instruction was helpful in performing the test (P = 0.001). Conclusion: The video groups were more motivated and had better confidence to perform the test with less anxiety and stress and with probably better understanding of the procedure due to visual effects enhancing their understanding.

Transconjunctival flap sutures: A novel technique to combat hypotony.

BACKGROUND: Hypotony secondary to overfiltration is a recognized complication following trabeculectomy. Persistent hypotony requires intervention . PURPOSE: We describe a modified version of placing conjunctival compression sutures directly over the scleral flap. SYNOPSIS: A 70-year-old male patient diagnosed with primary open angle glaucoma in both eyes underwent combined surgery in the right eye. On the tenth post-operative day, the patient presented with severe hypotony with 360ª choroidal detachment. He was treated with corticosteroids and cycloplegics but developed hypotony maculopathy on the subsequent follow-up. Hence, he was further managed surgically by trans-conjunctival flap sutures to which he responded favorably with resolution of choroidal detachment and improvement in intraocular pressure and visual acuity. HIGHLIGHTS: Transconjunctival suturing of the scleral flap is an effective and minimally invasive treatment to prevent visual loss from hypotony maculopathy for an overfiltering bleb following trabeculectomy. ONLINE VIDEO LINK: https://youtu.be/BJtUZcyQZ-w.

Winning the battle of refractory hypotony.

BACKGROUND: Trabeculectomy, a mainstay in the management of glaucoma is associated with various complications, the most dreaded being hypotony. PURPOSE: We present a challenging case of late-onset refractory hypotony following trabeculectomy. SYNOPSIS: : A 64-year-old male patient diagnosed with primary open angle glaucoma in the right eye underwent combined surgery. Three weeks later, he presented with hypotony which responded well with medical management and then he was lost to follow-up. Two years later, he presented with severe hypotony with shallow choroidal detachment in the right eye, which failed to respond to medical management. Compression sutures were placed over the bleb which also failed to work. Subsequently bleb repair was done with corneal patch graft, which helped resolve the bleb leak, with an improvement in visual acuity and intraocular pressure. HIGHLIGHTS: This video highlights the importance of prompt and timely intervention of an overfiltering bleb in preventing irreversible visual loss. VIDEO LINK: https://youtu.be/8DrxzqQ4qP4.

Early outcomes of 21-gauge needle-guided ab interno tube sulcus placement of a non-valved implant in pseudophakic eyes.

We report the early outcomes and describe an ab interno 21-G needle technique of sulcus placement of the Aurolab aqueous drainage implant (AADI) tube in nine pseudophakic eyes. IOP reduced from a preoperative mean (SD) of 28.33 (9.80) to 11.56 (2.65) mm Hg and the mean (SD) number of preoperative medications reduced from 3.0 (0.7) to 0.4 (0.9) at 3 months. There were no intraoperative complications noted. This technique of sulcus placement of the AADI tube is a precise technique of tube insertion. It may be an alternative to existing ab externo procedures of tube sulcus placement, limiting multiple blind entries.

Clinical profile and long term outcomes of eyes with choroidal detachment following trabeculectomy.

Purpose: To assess the long-term outcomes of choroidal detachments (CDs) in eyes following trabeculectomy. Methods: Retrospective comparative case series. Data of patients with CDs following trabeculectomy (5-year period) with or without cataract surgery with a minimum of 3 months of follow-up were included. Results: In total, 45 patients with CDs following trabeculectomy were included. The mean age was 63.27 ± 8.68 years, (M:F = 2:1); 29 of 45 eyes (64.4%) had a baseline IOP of >24 mm Hg. Patients had a median follow-up of 22.2 (IQR: 16.2-30.5) months. Further, 10 of 45 eyes (22.2%) had CDs following suture lysis. The median onset of choroidal detachment from the time of surgery was 16.0 (IQR: 11-36) days. The mean BCVA improved from 0.62 ± 0.28 to 0.24 ± 0.27 (P < 0.001) and mean IOP increased from 4.07 ± 2.66 to 11.20 ± 5.31 (P < 0.001) at last visit. The cumulative success rates were 76.4% (95% CI: 48.4-90.5) in POAG eyes and 79.3% (95% CI: 62.8-89.1) in PACG eyes (P = 0.547). Medical management was the mainstay in all patients. Four of 45 (8.88%) patients underwent subsequent choroidal drainage. Conclusion: Choroidal detachment following modern-day trabeculectomy has favorable long-term visual acuity and IOP outcomes. There was no difference in the long-term surgical success of trabeculectomy with choroidal detachments in primary angle-closure and open-angle glaucoma eyes. Long-term follow-up is essential to prevent chronic hypotony and trabeculectomy failure.

Outcomes and favourable prognostic factors in patients of phacomorphic and phacolytic glaucoma managed by manual small-incision cataract surgery: A retrospective study.

Purpose: To evaluate the outcomes and identify favorable prognostic factors in patients of phacomorphic (PMG) and phacolytic glaucoma (PLG) managed by manual small-incision cataract surgery (MSICS). Methods: The medical records of patients with PMG/PLG who had undergone MSICS in a tertiary eye hospital between September 2014 and August 2018 were retrospectively reviewed. Regression analyses were conducted to identify the predictors associated with intraoperative or postoperative complications and a favorable final outcome at 1 month, namely, a best-corrected visual acuity (BCVA) of 6/18 or better and an intraocular pressure (IOP) of <21 mm Hg. P < 0.05 was considered statistically significant. Results: The records of 209 patients with PMG and 279 patients with PLG were eligible for the review. The mean preoperative IOP for PMG and PLG were 43.15 ± 12.9 and 40.05 ± 12.0 mm Hg, respectively (P = 0.006). A younger age (<60 years) was associated with a lower risk of severe postoperative inflammation in both PMG and PLG [OR = 0.45 (0.21-0.99); P = 0.047 and OR = 0.44 (0.23-0.83); P = 0.011, respectively]. There was no significant difference in the final mean logMAR BCVA (P = 0.21) and IOP (P = 0.36) in the two groups. The likelihood of a final IOP of <21 mm Hg was significant for symptoms less than a week [OR = 3.52 (1.2-10.2); P = 0.02] in PMG and for absence of vitreous disturbance [OR = 35.0 (3.8-325.7); P = 0.002] in PLG. A BCVA of 6/18 or better was strongly associated with symptoms for less than a week [OR = 1.58 (1.0-2.4); P = 0.043] and absence of vitreous disturbance [OR = 23.53 (5.1-108.0); P < 0.001]. Conclusion: Early diagnosis and management can translate to good outcomes in PMG and PLG.

Visual outcomes and complications of manual small-incision cataract surgery in patients with pseudoexfoliation.

Purpose: Pseudoexfoliation is an age-related fibrillopathy characterized by the deposition of fibrillar material in the eye with an increased risk of complications during cataract surgery. Aim was to study visual outcomes and complications in patients with pseudoexfoliation undergoing manual small-incision cataract surgery (MSICS). Methods: Prospective observational study was performed on 152 patients with pseudoexfoliation above 50 years undergoing MSICS in a tertiary hospital from December 2016 to November 2017. Intraoperative and postoperative complications were documented with follow-up on postoperative day 1, 1st week, 1st month, and 3rd month. Results: Preoperative small pupil was noted in 49 eyes (32.2%), and 19 (12.5%) required intraoperative measures. Intraocular complications noted were zonular dialysis in five (3.3%), posterior capsular rupture in one (0.7%), and iridodialysis in one (0.7%). On postoperative day 1, the most common complication was corneal edema in 134 patients but clinically significant in only 23 (15.1%). Postoperative complications at 3 months were irregular pupil in 17 cases and decentered IOL in three cases. Intraocular pressure decreased with each visit [preoperative mean: 14.39 (±3.4) and 13.37 (±2.0) 12.53 (±1.4) mm Hg at 1 and 3 months, respectively]. There was a significant improvement in vision from the first day mean pinhole vision of 0.26 (±0.24) to mean best corrected visual acuity (BCVA) of 0.09 (±0.22) and 0.07 (±0.22) at 1 and 3 months, respectively. Mean endothelial cell loss was 193.16 (7.79%) and 266.01 (10.68%) at 1 and 3 months, respectively. Conclusion: Pseudoexfoliation has an increased risk of complications during cataract surgery. MSICS gives good outcomes in terms of visual recovery and postoperative outcomes.

Pars plana Aurolab aqueous drainage implantation for refractory glaucoma: Outcome of a new modified technique.

PURPOSE: To report the outcomes of pars plana insertion of Aurolab aqueous drainage implant (AADI) in adults with refractory glaucoma by the novel technique of making scleral tunnel instead of patch graft to cover the tube to prevent its migration. METHODS: A retrospective study was done between April 2016 and April 2018 on patients with ≥12 months of follow-up. The main outcome measure was a surgical failure at 12 months. The failure was defined as intraocular pressure (IOP) >18 mmHg or IOP ≤5 mmHg on two consecutive follow-up visits after 3 months, reoperation for glaucoma, loss of light perception vision, or implant explantation. Alternate definitions of failure including IOP >21 and IOP >15 mmHg were also considered. RESULTS: : The study included 32 eyes of 32 patients. The mean age was 46.2 ± 17.5 years. The most common etiology is traumatic glaucoma (12 eyes, 37.5%). The mean preoperative IOP and anti-glaucoma medications were 43.3 ± 10.3 and 3.4 ± 0.5 mmHg, respectively; both the parameters at the final follow-up were reduced to 15.2 ± 8.1 and 1.6 ± 0.5 mmHg. The Kaplan-Meier survival estimates demonstrated that the cumulative probability of failure was 15.6% (95% CI; 6.8-33.5%) at 3 months, 18.7% (95% CI; 8.9-37.0%) at 6 months, and 25.0% (95% CI; 13.4-43.8%) at 12 months. CONCLUSION: Pars plana AADI implantation with a newer modification technique is a useful procedure in reducing IOP and the number of anti-glaucoma medications in the eyes with refractory glaucoma. The visual acuity may be stabilized with the concurrent treatment of posterior segment pathology.

An Infectious Cause of Congenital Pupillary-Iris-Lens Membrane With Secondary Angle Closure Glaucoma in an Infant.

PURPOSE: The aim of the study was to report an infectious cause of congenital pupillary-iris-lens membrane with secondary angle closure glaucoma in an infant. DESIGN: This was a case report. METHODS: Institutional review board exemption for this report was obtained from the Institutional Ethics Committee, Aravind Eye Hospital, Tirunelveli. Informed consent was obtained.A 3-month-old female infant presented to us with congenital pupillary-iris-lens membrane, iris bombe and raised intraocular pressure in the left eye. She underwent trabeculotomy and trabeculectomy along with membranectomy for the same. An aqueous tap performed a month later was suggestive of coexisting Toxoplasma gondii infection detected by polymerase chain reaction. RESULT: The study provides a description of the course of management of angle closure glaucoma secondary to congenital pupillary-iris-lens membrane with an associated infection. Intraocular pressure reduced from 40 to 20 mm Hg in the left eye. CONCLUSION: This condition is a rare entity of unknown etiology with an increased risk of glaucoma and visual loss. A multidisciplinary approach is needed for the management of these eyes. Infectious associations with these membranes should be ruled out by an aqueous tap with polymerase chain reaction and a close postoperative follow-up is mandatory.

Novel device to contain aerosols during phacoemulsification.

We herein describe a novel device to contain droplets and aerosols during phacoemulsification. We modified the silicon phaco test chamber into an aerosol containment chamber (ACC) by shortening the chamber and making a pear-shaped opening at one aspect of its tip. The ACC was fitted over phaco tip such that 4-5 mm of phaco tip and sleeve was exposed. When the phaco tip and irrigation port are inside the anterior chamber during phacoemulsification, the portion of the modified chamber remains around the clear corneal tunnel in an enclosing manner that contains aerosols and droplets.

Aurolab aqueous drainage implant in the vitreous cavity: Our modifications over the conventional technique of glaucoma implant surgery.

Glaucoma drainage devices (GDDs) are used for managing refractory glaucoma due to failed trabeculectomy, neovascular glaucoma, traumatic glaucoma, and secondary glaucoma post keratoplasty. Aurolab aqueous drainage implant (AADI) is a nonvalved drainage implant conventionally implanted with the tube placed in the anterior chamber. Studies about the outcome of the various aqueous drainage devices implanted in the anterior chamber have reported complications such as tube extrusion, migration, blockage, erosion, and corneal decompensation. We propose modifying the conventional GDD implantation technique by placing the tube in the vitreous cavity, thereby negating the risk of anterior segment complications in patients with refractory glaucoma whose anterior segment is already compromised. Another novel approach implemented in this technique was making a scleral tunnel instead of using a scleral or corneal patch graft to cover the tube to prevent its migration. This article describes the surgical steps of this technique and its advantages, along with a surgical video.

Diabetes mellitus in the Tamil Nadu State-Noncommunicable diseases nurse model in diabetic retinopathy screening.

Tamil Nadu is one of the states in India, where the diabetic retinopathy (DR) project was implemented in the Tirunelveli District. Aravind Eye Hospital, Tirunelveli was the mentoring institution and ophthalmology department of Tirunelveli Medical College and Hospital (TVMCH) was the implementing partner. The objective of the project was to develop a district level model for building capacity at the government health system for effective screening, diagnosis and management (primary to tertiary) of diabetic retinopathy. The DR screening, counseling, referral and follow-up tasks were included in the scope of Non- Communicable Disease (NCD) nurses at the respective Community Health Centres and Primary Health Centres using the tele-medicine platform. During the project period (December 2016 to June 2019), 8,574 people with diabetes were registered at the 18 CHCs/PHCs. 6,462 (75.4% of those registered) were screened by NCD staff. The government has agreed to scale up services in 3 more districts.

The Aravind Pseudoexfoliation Study: 5-Year Postoperative Results. The Effect of Intraocular Lens Choice and Capsular Tension Rings.

PURPOSE: We compared rates of intraocular lens (IOL) decentration, neodymium-doped yttrium aluminum garnet capsulotomy for posterior capsule opacification (PCO), and visual acuity (VA) in eyes with and without pseudoexfoliation (PEX) 5 years after undergoing cataract surgery. DESIGN: Prospective comparative interventional study. METHODS: This multicenter study population included 1 eye of both 930 cataract patients with and 470 cataract patients without uncomplicated PEX (no small pupils or phacodonesis) all undergoing phacoemulsification by experienced Aravind Eye Care System surgeons. Eyes were randomized to either 1- or 3-piece intraocular lenses (IOLs). PEX eyes were also randomized to either receive or not receive a capsule tension ring. The main outcome measures included IOL decentration and PCO. Secondary outcomes included postoperative best-corrected VA. RESULTS: Follow-up was 86.2% in the PEX group and 86.7% in the control group at 5 years. The PEX group was older (P < .001) and had more men (P = .01). IOL decentration at 5 years was equally prevalent in PEX and control eyes (1.0% vs 1.1%, respectively, P = .8). Neodymium-doped yttrium aluminum garnet posterior capsulotomy rates for PCO were similar in the PEX group when compared with control subejcts (5.3% compared with 3.2%, respectively, P = .07). Best corrected VA was better at baseline and years 2 and 3 in the control group (P = .0001, P = .0005, and P = .02); however, there was no difference in BCVA at years 1, 4, and 5 between the PEX and control groups (P = .09, P = .29, and P = .5). CONCLUSION: In a large-scale, long-term, prospective comparative study of cataract surgery in eyes with uncomplicated PEX, the risks of IOL decentration and PCO were low and comparable to that in control subjects. When approaching cataract surgery in eyes with relatively uncomplicated PEX, neither IOL choice (1- vs 3-piece acrylic IOL) nor the presence/absence of a capsule tension ring affects outcomes at 5 years.