Evaluation and model to achieve sex parity in cataract surgical coverage in Theni district, India.

BACKGROUND/AIMS: To propose an approach to determine the target ratio of cataract surgical rates (CSRs) of female to male subpopulations to increase sex parity in cataract surgical coverage (CSC), based on the sex gap in cataract burden and incidence, and demonstrate its application to Theni district, India. METHODS: A population-based longitudinal study between January 2016 and April 2018. We recruited 24 327 participants using random cluster sampling. We conducted detailed eye examinations of 7087 participants aged ≥40 years (4098 females, 2989 males). We fit exponential models to the age-specific and sex-specific cataract burden and estimated annual incidence rates. We developed a spreadsheet-based planning tool to compute the target CSR ratio of female to male subpopulations. RESULTS: Among those aged ≥40 years, cataract burden was 21.4% for females and 17.5% for males (p<0.05). CSC was 73.9% for females versus 78.6% for males (p<0.05), with an effective CSC of 52.6% for females versus 57.6% for males (p<0.05). Treating only incident cataracts each year requires a target CSR ratio of female to male subpopulations of 1.30, while addressing in addition 10% of the coverage backlog for females and 5% for males requires a target CSR ratio of 1.48. CONCLUSIONS: The female population in Theni district, as in many low-income and middle-income countries, bears a higher cataract burden and lower CSC. To enhance sex parity in coverage, both the higher number of annual incident cataracts and the larger backlog in females will need to be addressed.

Comparison of cataract surgery outcomes between a secondary and a tertiary eye hospital in Tamil Nadu, India.

PURPOSE: To examine the difference in post-operative visual outcomes of cataract surgeries between a tertiary and secondary centre at Aravind Eye Hospitals in Tamil Nadu, India. METHODS: Our retrospective cross-sectional study analysed cataract surgeries at a secondary centre and its associated tertiary centre in 2021. Our main outcome measures were postoperative best corrected visual acuity (BCVA), spherical equivalent, and intraoperative and postoperative complications. Two-sample proportion tests and logistic regression analyses were performed. RESULTS: The analysis of 32,302 cataract surgeries in 2021 of which 4357 were performed at the secondary centre and 27,945 were performed at the tertiary centre showed that the tertiary centre operated on more advanced cataract condition (p < 0.001). Intraoperative (p < 0.001) and post-operative complication rates (p < 0.001) were higher in the tertiary centre. The odds of effective outcomes (BCVA > = 6/12) controlling for all covariates are poorer (p < 0.0001) in the tertiary centre for both phacoemulsification (phaco) and manual small incision cataract surgeries (MSICS). CONCLUSION: World Health Organization recommendations for the effective outcome of cataract surgery are met by both the tertiary and secondary centres, but the odds of effective outcomes in the tertiary centre was lower after adjusting for all known factors. Further investigations of the causes of poor vision in both phaco and MSICS in the tertiary centre are needed to improve the situation.

Accuracy of an artificial intelligence-based mobile application for detecting cataracts: Results from a field study.

Purpose: To assess the accuracy of e-Paarvai, an artificial intelligence-based smartphone application (app) that detects and grades cataracts using images taken with a smartphone by comparing with slit lamp-based diagnoses by trained ophthalmologists. Methods: In this prospective diagnostic study conducted between January and April 2022 at a large tertiary-care eye hospital in South India, two screeners were trained to use the app. Patients aged >40 years and with a best-corrected visual acuity <20/40 were recruited for the study. The app is intended to determine whether the eye has immature cataract, mature cataract, posterior chamber intra-ocular lens, or no cataract. The diagnosis of the app was compared with that of trained ophthalmologists based on slit-lamp examinations, the gold standard, and a receiver operating characteristic (ROC) curve was estimated. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were computed. Results: The two screeners used the app to screen 2,619 eyes of 1,407 patients. In detecting cataracts, the app showed high sensitivity (96%) but low specificity (25%), an overall accuracy of 88%, a PPV of 92.3%, and an NPV of 57.8%. In terms of cataract grading, the accuracy of the app was high in detecting immature cataracts (1,875 eyes, 94.2%), but its accuracy was poor in detecting mature cataracts (73 eyes, 22%), posterior chamber intra-ocular lenses (55 eyes, 29.3%), and clear lenses (2 eyes, 2%). We found that the area under the curve in predicting ophthalmologists' cataract diagnosis could potentially be improved beyond the app's diagnosis based on using images only by incorporating information about patient sex and age (P < 0.0001) and best-corrected visual acuity (P < 0.0001). Conclusions: Although there is room for improvement, e-Paarvai app is a promising approach for diagnosing cataracts in difficult-to-reach populations. Integrating this with existing outreach programs can enhance the case detection rate.

Changing operating room practices: the effect on postoperative endophthalmitis rates following cataract surgery.

PURPOSE: To determine whether four new operating room (OR) protocols instituted because of COVID-19 reduced the cataract surgical postoperative endophthalmitis rate (POE). DESIGN: Retrospective, sequential, clinical registry study. METHODS: 85 552 sequential patients undergoing cataract surgery at the Aravind Eye Hospitals between 1 January 2020 and 25 March 2020 (56 551 in group 1) and 3 May 2020 and 31 August 2020 (29 011 in group 2). In group 1, patients were not gowned, surgical gloves were disinfected but not changed between cases, OR floors were not cleaned between every case, and multiple patients underwent preparation and surgery in the same OR. In group 2, each patient was gowned, surgical gloves were changed between each case, OR floors and counters were cleaned between patients, and only one patient at a time underwent preparation and surgery in the OR. RESULTS: Group 1 was older, had slightly more females, and better preoperative vision. More eyes in group 2 underwent phacoemulsification (p=0.18). Three eyes (0.005%) in group 1 and 2 eyes (0.006%) in group 2 developed POE (p=0.77). Only one eye that underwent phacoemulsification developed POE; this was in group 1. There was no difference in posterior capsule rupture rate between the two groups. CONCLUSIONS: Adopting a set of four temporary OR protocols that are often mandatory in the Western world did not reduce the POE rate. Along with previously published studies, these results challenge the necessity of these common practices which may be needlessly costly and wasteful, arguing for the reevaluation of empiric and potentially unnecessary guidelines that govern ophthalmic surgeries.

Embracing technology in cataract surgical training - The way forward.

While ophthalmology as a surgical branch itself has evolved technologically with newer instruments, techniques and procedures; ophthalmic surgical training appears to have stagnated in terms of how it is delivered and how trainees' learning and performance are assessed. This collaborative editorial attempts to identify the lacunae in ophthalmic residency training and highlight how technological tools such as surgical simulators can be incorporated into ophthalmic training even in limited-resource settings with good results.

Quantification of relative afferent pupillary defect by an automated pupillometer and its relationship with visual acuity and dimensions of macular lesions in age-related macular degeneration.

PURPOSE: The occurrence of relative afferent pupillary defect (RAPD) secondary to optic nerve diseases and widespread retinal disorders is well established. However, only very few reports of RAPD in macular disorders exist in the literature. In this study, we used automated pupillometer to evaluate RAPD in eyes with macular lesions. METHODS: It was a prospective cross-sectional study. A total of 82 patients with choroidal neovascular membrane (CNVM) - 65 unilateral and 17 bilateral macular lesions - were enrolled. RAPD was assessed with an automated pupillometer and macular lesions evaluated with optical coherence tomography (OCT). The length of the ellipsoid zone disruption was measured as the longest length of lesion on the horizontal raster scans and the area of macular lesion was measured manually, mapping the affected area of ellipsoid zone on the enface images. RESULTS: : RAPD scores showed good correlation with the intereye difference in length of maximum ellipsoid zone disruption (r-value = 0.84, P value <0.001) and macular lesion area as measured on OCT in all unilateral cases (r-value = 0.84, P value <0.001). Best-corrected visual acuity was also found to have a significant correlation with lesion size on the OCT as well as the length of ellipsoid zone disruption in unilateral cases. CONCLUSION: : RAPD evaluated with an automated binocular pupillometer is a noninvasive and objective method to assess macular lesions in CNVMs; it shows good correlation with structural lesion dimensions on OCT in unilateral cases. Further longitudinal studies are needed to assess the significance of these findings in disease progression as well as correlation with lesion response to treatment.

Seroprevalence of SARS-CoV-2 specific IgG antibodies among eye care workers in South India.

PURPOSE: Health care workers are at higher risk of acquiring the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. This study aims to understand the seroprevalence of anti-SARS-CoV-2 IgG antibody among the eye care workers in South India. METHODS: The participants included eye care workers from the nine eye care centres. All the participants were interviewed with a questionnaire to obtain essential information about socio-demographics, past contact with COVID-19 patients and additional information as recommended by Indian Council of Medical Research, India. Serum samples were tested for anti-SARS-CoV-2 IgG antibodies by ELISA. RESULTS: A total of 1313 workers were included and 207 (15.8%) were positive for the SARS-CoV-2 IgG antibody. The seropositivity was higher in the moderate risk group (19.5%) followed by low (18.6%) and high risk (13.7%) groups. The seropositivity was significantly higher among i) day scholars compared to hostellers (OR - 2.22, 1.56 to 3.15, P â€‹< â€‹0.0001), ii) individuals with history of flu-like illness (4.57, 3.08-6.78, P â€‹< â€‹0.001) or who were symptomatic or in contact with COVID 19 positive cases (2.2, 1.02-4.75, P - 0.043) and iii) individuals with history of systemic illness (2.11, 1.39-3.21, P â€‹< â€‹0.001). Individuals (11.97%) who had no history of contact or any illness were also seropositive. CONCLUSIONS: The effectiveness of the protective measures taken against COVID infection was evident from the lower percentage of seropositivity in the high risk group. The study highlighted the need to create awareness among individuals to follow strict safety measures even in non-work hours and also in social circles.

Addressing the MSICS learning curve: identification of instrument-holding techniques used by experienced surgeons.

AIM: To identify instrument holding archetypes used by experienced surgeons in order to develop a universal language and set of validated techniques that can be utilized in manual small incision cataract surgery (MSICS) curricula. METHODS: Experienced cataract surgeons performed five MSICS steps (scleral incision, scleral tunnel, side port, corneal tunnel, and capsulorhexis) in a wet lab to record surgeon hand positions. Images and videos were taken during each step to identify validated hand position archetypes. RESULTS: For each MSICS step, one or two major archetypes and key modifying variables were observed, including tripod for scleral incision, tripod-thumb bottom for scleral tunnel, underhand-index to thumb grip for side port, index-contact tripod for corneal entry, and tripod-forceps for capsulorhexis. Key differences were noted in thumb placement and number of fingers supporting the instrument, and modifying variables included index finger curvature and amount of flexion. CONCLUSION: Identification of optimal hand positions and development of a formal nomenclature has the potential to help trainees adopt hand positions in an informed manner, influence instrument design, and improve surgical outcomes.

Differences Between Male and Female Residents in Case Volumes and Learning in Cataract Surgery.

OBJECTIVE: It is important that ophthalmology residency programs are structured to provide opportunities for all residents to gain adequate surgical experience. The aim of this study is to examine differences between female and male residents in number of cataract surgeries performed, surgical outcomes, and rate of learning, and to draw implications for the training of ophthalmology residents. DESIGN: In this hospital-based retrospective cohort study we examined the cumulative number of surgeries performed, and the intraoperative complications rate, of male and female residents over time. We used multivariable regression to measure the association between cataract surgery volumes and resident gender, controlling for covariates. We compared the intraoperative complications rates of female and male residents in each quarter of the program and overall, and estimated a multivariable logistic model of intraoperative complications with resident gender, surgical experience, their interaction, and other predictors. SETTING: Three-year residency programs at 5 Aravind Eye Hospitals in India. PARTICIPANTS: Residents entering in 2012, 2013, 2014, or 2015. RESULTS: In our sample of 95 residents (64 females, 31 males), a male resident on average performed 662.2 surgeries, which was 26.9% (p < 0.05) more than the 521.8 surgeries performed by a female resident. The difference in cumulative case volume grew steadily during the residency, and was not explained by the 29 more days of leave taken by female residents. On average a male resident performed 21% more surgeries per surgical turn than a female resident. In each quarter female residents had a lower cumulative rate of intraoperative complications than males, but the differences were not statistically significant. Learning curve analysis showed that the effect of experience on intraoperative complications flattened at about 300 surgeries, and that the curves for male and female residents were not statistically different. CONCLUSION: Female residents performed substantially fewer surgeries than their male counterparts in our data. However, surgical outcomes were comparable between groups with complication rates flattening after 300 surgeries for all trainees.

Seven-year trends in cataract surgery indications and quality of outcomes at Aravind Eye Hospitals, India.

PURPOSE: To report trends in cataract surgery indications, visual acuity outcomes, complication rates and reoperation rates at ten Aravind Eye Hospitals in Tamil Nadu, India. METHODS: In this retrospective database study we analyzed seven years of data of cataract surgeries at Aravind during January 1, 2012 to December 31, 2018. Our main outcome measures were preoperative and 1-month postoperative uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA); and rates of intraoperative complications and reoperations. We performed Cochran-Armitage trend tests. RESULTS: In 1.86 million eyes that underwent cataract surgery, the percentage of eyes undergoing phacoemulsification (PE) showed an increasing trend (p < 0.0001), from 26.8% in 2012 to 33.5% in 2018. The percentage of eyes undergoing manual small incision cataract surgery (SICS) showed a decreasing trend (p < 0.0001), from 70.0% in 2012 to 65.1% in 2018. For SICS, the percentages of eyes with good postoperative UCVA and BCVA showed increasing trends (p < 0.0001 for each), and the percentages of eyes with poor postoperative UCVA and BCVA showed decreasing trends (p < 0.0001 for each). Results for PE surgeries were mixed. For both PE and SICS rates of intraoperative complications showed a declining trend (p < 0.0001 for each) and a slight increasing trend for reoperations (PE p < 0.02; SICS p < 0.0001). CONCLUSIONS: During this seven-year period there were noticeable trends in cataract surgeries performed at Aravind in terms of the mix of surgical procedures, preoperative vision, and cataract surgical outcomes.

Common variants in SOX-2 and congenital cataract genes contribute to age-related nuclear cataract.

Nuclear cataract is the most common type of age-related cataract and a leading cause of blindness worldwide. Age-related nuclear cataract is heritable (h2 = 0.48), but little is known about specific genetic factors underlying this condition. Here we report findings from the largest to date multi-ethnic meta-analysis of genome-wide association studies (discovery cohort N = 14,151 and replication N = 5299) of the International Cataract Genetics Consortium. We confirmed the known genetic association of CRYAA (rs7278468, P = 2.8 × 10-16) with nuclear cataract and identified five new loci associated with this disease: SOX2-OT (rs9842371, P = 1.7 × 10-19), TMPRSS5 (rs4936279, P = 2.5 × 10-10), LINC01412 (rs16823886, P = 1.3 × 10-9), GLTSCR1 (rs1005911, P = 9.8 × 10-9), and COMMD1 (rs62149908, P = 1.2 × 10-8). The results suggest a strong link of age-related nuclear cataract with congenital cataract and eye development genes, and the importance of common genetic variants in maintaining crystalline lens integrity in the aging eye.

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.

Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: Results from 2 million consecutive cataract surgeries.

PURPOSE: To analyze the posterior capsule rupture (PCR) rates among staff and trainee cataract surgeons, and the postoperative endophthalmitis (POE) rates in uncomplicated and complicated eyes both with and without intracameral moxifloxacin prophylaxis (ICMP). SETTING: Ten regional Aravind Eye Hospitals in India. DESIGN: Retrospective multicenter clinical registry within a single hospital network. METHODS: POE rates with and without ICMP were statistically compared for all eyes and separately for trainees versus staff, for phacoemulsification versus manual small-incision cataract surgery (M-SICS), and for a subgroup of eyes complicated by PCR or requiring secondary surgery. RESULTS: All cataract surgeries (2 062 643) performed during the 8-year period from 2011 to 2018 at the 10 regional Aravind Eye hospitals were included in the analysis. With ICMP, the overall POE rate declined from 692 (0.07%) of 993 009 eyes to 185 (0.02%) of 1 069 634 eyes (P < .001). This was independently significant for phacoemulsification and for M-SICS (P < .001). The overall PCR rate was 28 352 (1.37%) of 2 062 643 eyes, and it was statistically higher for trainees irrespective of surgical method (P < .001). Both staff and trainee surgeons had higher PCR rates with phacoemulsification than with M-SICS (P < .001). Absent ICMP, PCR increased the overall POE rate by more than 7-fold to 63 (0.43%) of 14 505 eyes. ICMP reduced the POE rate after PCR to 25 (0.18%) of 13 847 eyes (P = .002). This ICMP benefit was separately significant for both M-SICS (0.54% vs 0.26%, P = .01) and phacoemulsification (0.29% vs 0.06%, P = .005). The POE rate was especially high after secondary IOL implantation (0.90% without ICMP vs 0.34% with ICMP; P = .10). CONCLUSIONS: ICMP reduced the POE rate overall, with phacoemulsification, with M-SICS, and in eyes with PCR.

Predictors of patient compliance with follow-up visits after cataract surgery.

PURPOSE: To identify patient characteristics associated with follow-up compliance and to draw implications for better cataract treatment services. SETTING: Aravind Eye Hospital, Madurai, India. DESIGN: Retrospective case study. METHODS: The data of all cataract surgeries performed in 2015 were analyzed. After each surgery, patients were asked to return for follow-up after 1 month. The follow-up rates were compared between patients with different demographic characteristics, surgical factors, and preoperative and discharge visual acuities. The behaviors of patients who complied with the follow-up advice were analyzed, including the number of days from surgery to follow-up and number of follow-up visits. Multivariate regression models were used to identify predictors associated with these behaviors. RESULTS: The overall follow-up rate for the 86 776 surgeries analyzed was 85.6%. Patients more likely to follow-up were women, younger than 70 years, and paying (versus subsidized or free) and had phacoemulsification rather than manual small-incision cataract surgery (all P < .001). Patients who had complications, reoperations, or poorer visual acuity at discharge were less likely to comply with the follow-up advice (P < .001). CONCLUSIONS: Targeted interventions to boost follow-up rates should be directed to patients with the characteristics found in this study. Furthermore, average measures of visual outcomes at 4 weeks are likely to be overstated relative to the truth.

Effectiveness of Teleretinal Imaging-Based Hospital Referral Compared With Universal Referral in Identifying Diabetic Retinopathy: A Cluster Randomized Clinical Trial.

Importance: Studies in high-income countries provide limited evidence from randomized clinical trials on the benefits of teleretinal screening to identify diabetic retinopathy (DR). Objective: To evaluate the effectiveness of teleretinal-screening hospital referral (TR) compared with universal hospital referral (UR) in people with diabetes. Design, Setting, and Participants: A cluster randomized clinical trial of 8 diabetes clinics within 10 km from Aravind Eye Hospital (AEH), Madurai, India, was conducted. Participants included 801 patients older than 50 years. The study was conducted from May 21, 2014, to February 7, 2015; data analysis was performed from March 12 to June 16, 2015. Interventions: In the TR cohort, nonmydriatic, 3-field, 45° retinal images were remotely graded by a retinal specialist and patients with DR, probable DR, or ungradable images were referred to AEH for a retinal examination. In the UR cohort, all patients were referred for a retinal examination at AEH. Main Outcomes and Measures: Hospital-diagnosed DR. Results: Of the 801 participants, 401 were women (50.1%) (mean [SD] age, 60.0 [7.3] years); mean diabetes duration was 8.6 (6.6) years. In the TR cohort, 96 of 398 patients (24.1%) who underwent teleretinal imaging were referred with probable DR (53 [13.3%]) or nongradable images (43 [10.8%]). Hospital attendance at AEH was proportionately higher with TR (54 of 96 referred [56.3%]) compared with UR (150 of 400 referred [37.5%]). The intention-to-treat analysis based on all patients eligible for referral in each arm showed that proportionately more patients with TR (36 of 96 [37.5]%) were diagnosed with DR compared with UR (50 of 400 [12.5%]) (unadjusted risk ratio [RR], 3.00; 95% CI, 2.01-4.48). These results were little changed by inclusion of covariates (RR, 2.72; 95% CI, 1.90-3.91). The RR was lower in the per-protocol analysis based on all patients who adhered to referral (covariate-adjusted RR, 1.75; 95% CI, 1.12-2.74). Diagnoses of DR were predominantly mild or moderate nonproliferative DR (36 in TR and 43 in UR). In the UR arm, there were 4 cases of severe nonproliferative DR and 2 cases of proliferative DR. Age (RR, 0.98; 95% CI, 0.95-0.99), female sex (RR, 0.79; 95% CI, 0.64-0.98), and hypertension diagnosis (RR, 0.81; 95% CI, 0.68-0.95) were factors associated with lower attendance. Those with higher secondary educational level or more were twice as likely to attend (RR, 2.00; 95% CI, 1.32-3.03). Conclusions and Relevance: The proportionate yield of DR cases was higher in the TR arm, confirming the potential benefit, at least in the setting of eye hospitals in India, of a targeted referral approach using teleretinal screening to identify patients with DR. Trial Registration: ClinicalTrials.gov identifier: NCT02085681.

Visual Acuity Outcomes after Cataract Surgery: High-Volume versus Low-Volume Surgeons.

PURPOSE: The primary objective was to assess associations between annual surgeon case volume and visual acuity outcomes after cataract surgery. Secondary objectives included (1) assessing associations between other case and patient characteristics and visual acuity outcomes and (2) assessing associations between annual surgeon case volume and complication rates. DESIGN: Database study. PARTICIPANTS: All adult eyes that underwent small-incision cataract surgery (SICS) or phacoemulsification cataract extraction (PECE) with intraocular lens placement at the Aravind Eye Hospital, Madurai, India, during 2015. METHODS: Descriptive statistics were used to characterize the study population. Uncorrected visual acuity (UCVA) at follow-up was assessed relative to annual surgeon case volume and other case and demographic factors using bivariate linear regression with random effects modeling. Factors with P values of less than 0.20 on bivariate regression were included in multivariate linear regression with random effects modeling. MAIN OUTCOME MEASURES: Postoperative UCVA after cataract surgery. RESULTS: Of 91 084 surgeries, 35 880 eyes were included in this study. Cases were performed by 69 surgeons, who varied in annual case volume from 76 to 2900 cases during the study period. Increasing annual surgeon case volume was independently associated with a statistically significant but clinically modest improvement in UCVA in PECE but not in SICS. This association was most pronounced when comparing surgeons with case volumes of 350 PECE/year or fewer; surgeons with more than 350 PECE/year had similar results to one another. Similarly, increased annual case volume was associated with significantly lower complication rates, both in PECE and SICS. Younger patient age was independently associated with improved visual acuity outcomes and lower complication rates in both PECE and SICS. Greater surgeon experience was associated with lower complication rates in PECE, but not SICS, and there was no significant association with visual acuity outcomes. CONCLUSIONS: High-volume cataract surgeons showed improved visual acuity outcomes in PECE and lower complication rates in PECE and SICS. These findings further support the benefit of high-output ophthalmology clinics wherein individual surgeons perform a high number of cataract extractions annually, particularly in developing nations where there is a large backlog of untreated cataracts and the cataract patient-to-surgeon ratio is high.

Quantification of RAPD by an automated pupillometer in asymmetric glaucoma and its correlation with manual pupillary assessment.

PURPOSE: The relative afferent pupillary defect (RAPD) is an important sign of asymmetrical retinal ganglion cell damage. The purpose of this study was to quantify RAPD by a pupillometer (RAPiDo, Neuroptics) and assess its correlation with asymmetric glaucoma and manual pupillary assessment. METHODS: A total of 173 subjects were enrolled in the study and categorized into glaucoma, n = 130, and control, n = 43. Subjects were all recruited in the Glaucoma Clinic of the Aravind Eye Hospital in Madurai during their follow-up. They were 18 years and older, with best corrected visual acuity of 6/36 or better. Exclusion criteria included all retinal pathologies, optic atrophies, ocular injuries, severe uveitis, cloudy corneas, dense cataracts, or use of mydriatics or miotic drugs. RAPD was assessed in all subjects using an automated pupillometer and the results were compared with the swinging flash light test conducted on the same subjects by an experienced ophthalmologist. We looked at the correlation between RAPD and the intereye difference in cup-to-disc ratio (CDR), mean deviation (MD) of visual field testing, and retinal nerve fiber layer (RNFL) thickness. Sensitivity and specificity were assessed by area under the receiver operator characteristic (AUROC) analysis. RESULTS: Glaucoma patients had significant RAPD (0.55 ± 0.05 log units) when compared with the controls (0.25 ± 0.05 log units), P < 0.001. Significant intereye differences in CDR, MD, and RNFL between glaucoma and control (P < 0.001) were seen. There was a good correlation between the magnitude and sign of RAPD and these intereye differences in CDR (r = 0.52, P < 0.001), MD (r = 0.44, P < 0.001) and RNFL thickness (r = 0.59, P < 0.001). When compared with the experienced ophthalmologist, AUROC was 0.94, with 89% sensitivity and 91.7% specificity. CONCLUSION: The good correlation between the magnitude of RAPD, as measured by the automated pupillometer, and intereye differences in MD, CDR, and RNFL thickness in glaucomatous, and the good sensitivity and specificity when compared with the experienced ophthalmologist, suggest that pupillometry may be useful as a screening tool to assess asymmetric glaucoma.

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.

Genetic variants in a sodium-dependent vitamin C transporter gene and age-related cataract.

BACKGROUND: Cataract is a major health burden in many countries and a significant problem in India. While observational studies show lower cataract risk with increasing dietary or plasma vitamin C, randomised controlled trials of supplements have been negative. Genetic variants in vitamin C transporter proteins (SLC23A1), especially rs33972313, may provide evidence on a causal association of vitamin C with cataract. METHODS: We used data from a randomly selected population-based study in people aged 60 years and above in north and south India. Of 7518 sampled, 5428 (72%) were interviewed for socioeconomic and lifestyle factors, attended hospital for lens imaging and blood collection and were subsequently genotyped for rs33972313 and rs6596473. Mixed or pure types of cataract were graded by the Lens Opacity Classification System III as nuclear (2404), cortical (494) or posterior subcapsular cataract (PSC) (1026); 1462 had no significant cataract and no history of cataract surgery and 775 had bilateral aphakia/pseudophakia. RESULTS: rs33972313 was associated with cortical (OR 2.16; 95% CI 1.34 to 3.49, p=0.002) and PSC (OR 1.68; 95% CI 1.06 to 2.65, p=0.03) but not with nuclear cataract. In analyses of pure cataracts, associations were found only between rs33972313 and pure cortical cataracts (OR 2.29; 95% CI 1.12 to 4.65, p=0.03) and with a standardised cortical opacity score. There was no association with rs6596473 and any cataract outcomes. CONCLUSIONS: Using an established genetic variant as a proxy for lifetime ascorbate concentrations, our results support a causal association of vitamin C with cataract.