To assess the efficacy of vertical muscle surgery for management of hypotropia in monocular elevation deficiency type II.

AIM: To assess the efficacy of vertical muscle surgery for management of hypotropia in monocular elevation deficiency (MED) type II. Knapp's is described as standard procedure for management of MED type II. However, it is not graded and has unpredictable amount of correction. Besides this, there is drift towards overcorrection with time and limitation of movements in extreme adduction and abduction. MED is a vertical misalignment for which vertical muscle surgery is also described but limited literature is available. METHODS: Thirteen fresh cases of MED type II with hypotropia >20 PD and age >4 years were included in our interventional study. All cases underwent superior rectus resection and inferior rectus recession (vertical R&R) depending upon amount of preoperative deviation. Success was defined as hypotropia <5 PD at 1-year follow-up. RESULTS: Twelve patients (92.30 %) were aligned to within 5 PD. Six patients (46.15 %) had gain in elevation. Bell's phenomenon was improved in six patients (46.15 %). There was no limitation in down gaze in any patient. None gained stereopsis. CONCLUSION: Vertical R&R is a good alternative for MED type II with predictable amount of correction especially in patients with higher preoperative deviation. It spares horizontal muscles for correction of any associated horizontal deviation.

Comparative evaluation of nebulized versus intravenous dexmedetomidine on intubating conditions during awake fiberoptic nasotracheal intubation.

BACKGROUND: There is a search for an ideal agent to facilitate awake fiberoptic intubation (AFOI). Dexmedetomidine is a selective α2 agonist which can be administered through intravenous, intramuscular, buccal, intranasal & inhalational routes. It provides good intubation conditions without oxygen desaturation but may cause hypotension and bradycardia when administered intravenously. Hence, alternative routes of administering dexmedetomidine which may improve its safety profile are worth exploring. METHODS: In this randomised, controlled, double-blind trial, 46 ASA I/II adult participants scheduled for elective ENT surgery were randomly allocated to Group ND (Nebulised Dexmedetomidine) (n = 23) to receive nebulisation with dexmedetomidine 1µg.kg-1 and Group ID (Intravenous Dexmedetomidine) (n = 23) to receive intravenous dexmedetomidine 1µg.kg-1 before AFOI. All the patients received injection midazolam 1 mg i.v. as premedication before anaesthesia was initiated. The primary outcome was the cough score. The secondary outcomes were the RSS, SAYGO boluses, post-intubation score, hemodynamic parameters, recall of the procedure, patient satisfaction score and any side effects. RESULTS: The cough score was significantly lower in nebulized group (2.43 ± 0.992 vs 3.52 ± 1.082) with p = 0.001. RSS(3.30 ± 0.926 vs 4.22 ± 1.126; p = 0.004), number of SAYGO boluses required (2.74 ± 0.864 vs 3.57 ± 1.161; p = 0.009) & the post intubation score (1.48 ± 0.593 vs 2.17 ± 0.778; p = 0.001) were also significantly lower in nebulized group. CONCLUSIONS: Nebulisation with dexmedetomidine results in desirable degree of sedation and better tolerance of the procedure with adequate attenuation of the haemodynamic responses to intubation.

Safety of removal of ProSeal laryngeal mask airway in children in the supine versus lateral position in a deep plane of anesthesia: A randomized controlled trial.

Importance: When a ProSeal laryngeal mask airway (PLMA) is removed with the child in a deep plane of anesthesia, the upper airway muscle tone and protective upper airway reflexes may be obtunded. Objective: To determine whether the supine or lateral position is safer for the removal of a PLMA in deeply anesthetized children by comparing the incidence of upper airway complications. Methods: This randomized single-blind comparative trial was conducted at a tertiary care hospital between January 2020 and September 2020. Forty children of the American Society of Anesthesiologists class I/II of ages 1-12 years age undergoing surgery under general anesthesia with PLMA used as the definitive airway device were recruited. Patients were randomly allocated to lateral group or supine group for PLMA removal in a deep plane of anesthesia in the lateral or supine position. The primary outcome was the number of patients experiencing one or more upper airway complications and the secondary outcomes were incidence of individual respiratory adverse effects and of severe airway complications. Results: The incidence of airway complications was 30% in the supine group and 20% in the lateral group (P = 0.6641). Incidence of laryngospasm, immediate stridor, and excessive secretions were similar. Early stridor and oxygen desaturation were higher in the supine group (P = 0.0374, P = 0.0183 respectively). Interpretation: The overall incidence of upper airway complications was similar with the removal of a PLMA in the supine or lateral position in deeply anesthetized children. The incidence of oxygen desaturation and stridor were higher with PLMA removal in the supine as compared to the lateral position.

Validation of In-House Kit-Like Synthesis of 68Ga-Trivehexin and Its Biodistribution for Targeting the Integrin αvß6 Expressing Tumors.

Background: Integrin αvß6 has become an extremely promising theranostic target for precise delineation of fast-growing malignant cells in the recent years. The aim of the study was to validate the in-house kit-like synthesis of 68Ga-Trivehexin (integrin αvß6) and to evaluate its uptake in patients with integrin αvß6 expressing head and neck and pancreatic cancer. Materials and Methods: 68Ga-Trivehexin was synthesized by adding the variable amount of integrin αvß6 (30-50 µg) to full volume (4-5 mL) Ga-68 in 0.05 M HCl and heating the reaction mixture at 90°C for 12 min at pH 3.5-4 to obtain the radiotracer with high radiochemical purity (RCP) and high yield. Quality control procedures were done to assess the RCP, stability, pyrogenicity and sterility of the radiotracer. 68Ga-Trivehexin was then administered in patients who met the eligibility criteria. Whole body PET/CT scans were done at variable time points post intravenous (i.v.) injection of 84-185 MBq of 68Ga-Trivehexin to assess its biodistribution and maximum uptake time. Results: 0.2 mCi of 68Ga/µg of Trivehexin at 90°C for 12 min was the optimal parameter to obtain 85%-88% of noncorrected yield and 99% of RCP. The 68Ga-Trivehexin showed in vitro stability upto 6 h and was also found to be sterile and pyrogen free. Intense radiotracer uptake was noticed in the tumor and no uptake was noticed in healthy tissues. PET/CT imaging at 60 min post injection was found to be the optimal time for imaging the tumors with 68Ga-Trivehexin. Conclusion: The protocol for in-house kit-like labeling of 68Ga-Trivehexin was safe, reproducible, and cost-effective. 68Ga-Trivehexin is an extremely promising agent for noninvasive molecular imaging of integrin αvß6 expressing tumors.

Retropupillary iris claw lens versus Gore-Tex assisted scleral fixated intraocular lens in children with large lens subluxations.

Purpose: To compare the functional outcome of retropupillary iris claw lenses (RPIC-IOL) and scleral fixated intraocular lenses (SFIOL) in children with large lens subluxations. Methods: Sixty eyes of patients between 6 and 18 years of age having >7 clock hour lens subluxation were included and equally divided into group A (RPIC-IOL implantation) and group B (Gore-Tex sutured SFIOL implantation). Cases with anterior and posterior segment abnormalities, trauma and glaucoma were excluded. Primary outcome was improvement in best-corrected visual acuity (BCVA) at 1.5 years. Secondary outcomes were assessment of intraocular lens (IOL) tilt, mean change in astigmatism at 1.5 years, and median operating time. All surgeries were performed by the same surgeon. Results: The mean improvement in BCVA in group A was 0.28 ± 0.41 logMAR and group B was 0.44 ± 0.45 logMAR (P = 0.3). Significant IOL tilt was seen in 4 eyes in group A (13.33%) and 5 eyes in group B (16.66%) (P = 0.120). Mean change in astigmatism was 4.38 ± 5.9D in group A and 4.91 ± 4.4D in group B (P = 0.299). The median operating time was 40 min in group A and 90 min in group B (P < 0.001). No significant posterior segment complications were seen in either technique. Conclusion: Both procedures had comparable visual outcomes. RPIC-IOL implantation was relatively quick and comparatively easier; it may be preferred in cases with high risk of retinal detachment.

Orbital tumour or a retained foreign body? An uncommon case of missed diagnosis.

We report a case who presented with decreased vision, significant hypotropia, proptosis and gross limitation of extraocular motility for one year. Suspecting an orbital tumour, we asked for a computed tomography of the orbit which revealed a mass lesion in the inferior orbit. However, incisional biopsy reported inflammatory infiltration. Diagnosing it as orbital inflammatory disease, a course of oral steroids was given for four weeks. It was only after the reduction in inflammation that a foreign body was palpable in the inferior fornix. Surgical exploration revealed a large wooden foreign body measuring 3.3 × 1 × 0.3 cm. Though intraorbital foreign bodies are not rare, ambiguous history, delayed presentation and nonspecific CT findings made this case diagnostically challenging.

Designing and Comparing Performances of Image Processing Pipeline for Enhancement of I-131-metaiodobenzylguanidine Images.

OBJECTIVE: An image processing pipeline can have more than one image processing technique in sequence, and the output of the first technique becomes input for the next technique and so on. In this study, we have designed and compared the performances of image processing pipelines for enhancement of I-131-metaiodobenzylguanidine (mIBG) images. MATERIALS AND METHODS: Five different image processing pipelines (A [Gaussian filter, normalization], B [histogram specification (image 1), Gaussian filter, normalization], C [histogram specification (image 2), Gaussian filter, normalization], D [{histogram specification (image 3), Gaussian filter, and normalization], and E [histogram specification (image 4), Gaussian filter, normalization]) were designed and their performances were evaluated on I-131-mIBG images (n = 122). The image quality was assessed objectively using Perception-based Image Quality Evaluator (PIQE) score and subjectively (on scale 1-4) by two nuclear medicine physician. Sign test was applied to find the statistically significant difference between the image quality obtained using image processing pipelines. We applied test of proportion to compute difference in proportion of image quality score assigned to images obtained using image processing pipelines. RESULTS: Based on PIQE score, the quality of images obtained using all the five image processing pipelines were significantly better than that of input images (P < 0.001). The highest image quality score (=4) was assigned maximum number of times (n = 90) to the images obtained using image processing pipeline D and was significantly different from that of the second best image processing pipeline E (P = 0.015). CONCLUSIONS: The image processing pipeline D was found to be better for enhancement of I-131-mIBG images.

Fuzzy logic-based moving average filters for reducing noise from Tc-99m-sestamibi parathyroid images.

INTRODUCTION: The objective of the study was to use fuzzy logic-based moving average filters for reducing noise from Tc-99m-sestamibi parathyroid images and to compare its performance with classical moving average filters. METHODS: Sixty-eight Tc-99m-sestamibi parathyroid images (33 image zoom 1.0, 35 images zoom 2.0) were filtered using symmetric triangular fuzzy filters with the moving average (TMAV), asymmetric triangular fuzzy filters with the moving average (ATMAV) and classical moving average filter (MAV) with moving average within a square window of dimension N × N pixels (N=3,5,7,9,11). The relative filtering performance was compared both objectively (using Brisque score) and subjectively [by two nuclear medicine physicians on a 4-point scale (1 = nondiagnostic; 2 = diagnostic; 3 = good; and 4 = excellent image quality)]. The nonparametric two-sample Kolmogorov-Smirnov test was applied to find the statistically significant difference between the quality of input and their corresponding filtered images. RESULTS: The Brisque score assigned to MAV filtered zoom 2.0 images (MAV_3, median = -0.61) were significantly smaller than that of their input images (median = 53.84, at P = 1) and fuzzy filtered images (TMAV_3, median = 0.44, at P = 0.89 and ATMAV_3, median =8.26, at P = 0.97). The sum of average subjective image quality score for input, MAV_3, TMAV_3, TMAV_5, ATMAV_3, and ATMAV_5 were 148, 221, 221.5, 198,171,253 and 237.5, respectively. CONCLUSION: On the basis of subjective assessment, the performance of ATMAV_3 fuzzy filter was found to be better compared to the classical moving average filter in reducing noise from Tc-99m-sestambi parathyroid images.

Evaluation of functional outcome and stability of sutureless scleral tunnel fixated IOLs in children with ectopia lentis.

AIM: To evaluate functional outcome of sutureless scleral tunnel intraocular lens (SSTIOL) in children with crystalline lens subluxation of more than 7 clock hours. METHODS: A prospective interventional study was conducted consisting of 45 eyes of 44 children in age group 6-18y having >7 clock hours of lens subluxation who underwent lensectomy-vitrectomy followed by SSTIOL implantation. Primary outcome was improvement in best corrected visual acuity (BCVA) and secondary outcomes were assessment of intraocular lens (IOL) tilt using ultrasound biomicroscopy (UBM), mean change in astigmatism at last follow-up of 1y and associated complications. RESULTS: The mean preoperative and postoperative BCVA was 1.05±0.28 and 0.64±0.45 (logMAR) respectively (P=0.001) at last follow-up. The mean astigmatism preoperatively and postoperatively was -4.17±2.69 D and -1.86±1.25 D respectively (P=0.011). Significant IOL tilt (>5 degrees) was present in 5 cases. The mean percentage endothelial loss was 3.65%±1.92%. The most serious complication encountered was retinal detachment seen in 2 cases. CONCLUSION: SSTIOL implantation provides efficient visual rehabilitation in children provided there is stringent case selection. We recommend caution in children having white-to-white distance >12 mm and presence of peripheral retinal degenerations.

Surgical outcomes of plication versus resection in basic type of intermittent exotropia.

OBJECTIVES: To compare the surgical outcomes of plication versus resection in basic type of intermittent exotropia. DESIGN: Prospective interventional study. PARTICIPANTS: 60 patients above 6 years of age with diagnosis of basic type of intermittent exotropia. METHODS: A randomized study was conducted in 60 patients above 6 years of age with diagnosis of basic type of intermittent exotropia. They were equally divided in two groups by computer generated random number table. Group A underwent recession and plication (RP) and group B underwent recession and resection (RR) based on post patch deviation with constant 8 mm lateral rectus recession in both groups. Parameters assessed were postoperative alignment, cosmetic outcome, improvement in binocularity & stereoacuity and dose effect. Successful outcome was defined as post patch deviation ≤ 10 Prism diopters (PD) of exophoria/exotropia to < 5 PD of esophoria/esotropia at 12 months follow up. RESULTS: The mean preoperative and postoperative deviation was 44.67 ± 4.5 PD and 10.13 ± 3.6 PD respectively in group A and 43.17 ± 4.8 PD and 9.40 ± 3.3 PD respectively in group B (p = 0.423). The exodrift at 12 months follow up was 4.4 ± 2.8 PD in group A and 4.67 ± 3.29 PD in group B. There was statistically no significant difference in outcomes between the two groups. Mean effect of MR plication at last follow up was 5.91 PD/mm and MR resection was 5.5 PD/mm (p = 0.877). CONCLUSION: Both procedures achieved acceptable ocular alignment and had a comparable dose effect. Plication has certain added advantages over resection hence may be preferred as an alternate tightening procedure.

Comparison of conventional and Hang-back methods of inferior oblique recession in V-pattern strabismus with inferior oblique overaction.

AIM: To compare outcomes of conventional and Hang-back methods of inferior oblique (IO) recession in V-pattern strabismus with inferior oblique overaction (IOOA). METHODS: Comparative randomized study was conducted consisting of 50 patients, age 6 to 35y having V-pattern strabismus [>15 prism diopter (PD)] with IOOA. They were divided equally in two groups and underwent IO recession, group A by conventional method and group B by Hang-back method. Parameters evaluated were reduction in V-pattern and IOOA, shift in torsion, improvement in binocular status. Success was a residual V-pattern of less than 10 PD at 1y of follow up. RESULTS: The mean V-pattern preoperatively and postoperatively at 1y was 24±5.4 PD and 4.2±3.51 PD in group A and 23.44±6.44 PD and 5.76±3.8 PD in group B respectively. The mean reduction in V-pattern was 20±6.78 PD in group A and 18.2±5.48 PD in group B. The mean correction of IOOA was 18.48±3.13 PD in group A and 16±2.93 PD in group B. Mean shift in extorsion was 3.08±1.8 degree in group A and 3.72±2.14 degree in group B. CONCLUSION: Both the procedures achieve a significant and comparable reduction in V-pattern and IOOA. Hang-back recession being a landmark free surgery eliminates the need for intrascleral suturing thereby reducing the risk of scleral perforation with possible postoperative adjustment of muscle. It may be considered as a good alternative for IO recession in patients of V-pattern strabismus with mild to moderate amount of IOOA.

Comparison of adjustable sutures versus nonadjustable sutures in intermittent exotropia.

PURPOSE: To compare adjustable sutures versus nonadjustable sutures for intermittent exotropia. METHODS: In this randomized prospective interventional study, 40 adult patients with intermittent exotropia were randomly divided into 2 equal groups. Both groups underwent bilateral lateral rectus recession. In group A, adjustable suture recession was performed, and in group B, nonadjustable suture recession was performed. Patients were followed up for 6 months and outcome measures were residual deviation, binocular status, and need for resurgery. RESULTS: Success was defined as alignment of 2 eyes <10 prism diopters (PD) of deviation at the end of 12 weeks. Need for resurgery in a 12-week follow-up period was considered to be failure. At the end of the study, 90% of the patients in group A and 85% of the patients were within 10 prism diopters of orthophoria (p = 0.316). At the end of 6 months, mean deviation in group A was 6.20 PD and in group B it was 5.60 PD (p = 0.31). No patient underwent resurgery. CONCLUSIONS: Adjustable hang-back recession has no definite added advantage over nonadjustable hang-back recession in intermittent exotropia.