An Evaluation of the Efficacy and Safety of Timolol Maleate 0.5% Microdrops Administered with the Nanodropper.

PURPOSE: To examine if 12.5 µl timolol maleate 0.5% microdrops dispensed with the Nanodropper Adaptor provide noninferior intraocular pressure (IOP) reduction compared with conventional 28 µl drops in patients with open-angle glaucoma (OAG) and ocular hypertension (OHT). DESIGN: Prospective, noninferiority, parallel, multicenter, single-masked, active-controlled, randomized trial. PARTICIPANTS: Treatment-naïve subjects who were recently diagnosed with OAG and OHT at the Aravind Eye Care System. METHODS: Both eyes of subjects received 1 commercially available drop or both eyes of subjects received 1 microdrop of timolol maleate 0.5%. We measured IOP, resting heart rate (HR), and blood pressure (BP) at baseline and 1, 2, 5, and 8 hours after timolol administration. MAIN OUTCOME MEASURES: The IOP was the primary outcome measure. Secondary outcomes were resting HR, systolic BP (sBP), and diastolic BP (dBP). RESULTS: Adaptor-mediated microdrops and conventional drops of timolol significantly decreased IOP compared with baseline at all timepoints. Noninferiority was established at 3 of 4 timepoints. Heart rate decreases with Nanodropper were approximately 3 beats per minute (bpm) less than with conventional drops. CONCLUSIONS: Timolol microdrops appear to be as effective in ocular hypotensive action as conventional drops with a slightly attenuated effect on resting HR and BP. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

The Environmental Impacts of Electronic Medical Records Versus Paper Records at a Large Eye Hospital in India: Life Cycle Assessment Study.

BACKGROUND: Health care providers worldwide are rapidly adopting electronic medical record (EMR) systems, replacing paper record-keeping systems. Despite numerous benefits to EMRs, the environmental emissions associated with medical record-keeping are unknown. Given the need for urgent climate action, understanding the carbon footprint of EMRs will assist in decarbonizing their adoption and use. OBJECTIVE: We aimed to estimate and compare the environmental emissions associated with paper medical record-keeping and its replacement EMR system at a high-volume eye care facility in southern India. METHODS: We conducted the life cycle assessment methodology per the ISO (International Organization for Standardization) 14040 standard, with primary data supplied by the eye care facility. Data on the paper record-keeping system include the production, use, and disposal of paper and writing utensils in 2016. The EMR system was adopted at this location in 2018. Data on the EMR system include the allocated production and disposal of capital equipment (such as computers and routers); the production, use, and disposal of consumable goods like paper and writing utensils; and the electricity required to run the EMR system. We excluded built infrastructure and cooling loads (eg. buildings and ventilation) from both systems. We used sensitivity analyses to model the effects of practice variation and data uncertainty and Monte Carlo assessments to statistically compare the 2 systems, with and without renewable electricity sources. RESULTS: This location's EMR system was found to emit substantially more greenhouse gases (GHGs) than their paper medical record system (195,000 kg carbon dioxide equivalents [CO2e] per year or 0.361 kg CO2e per patient visit compared with 20,800 kg CO2e per year or 0.037 kg CO2e per patient). However, sensitivity analyses show that the effect of electricity sources is a major factor in determining which record-keeping system emits fewer GHGs. If the study hospital sourced all electricity from renewable sources such as solar or wind power rather than the Indian electric grid, their EMR emissions would drop to 24,900 kg CO2e (0.046 kg CO2e per patient), a level comparable to the paper record-keeping system. Energy-efficient EMR equipment (such as computers and monitors) is the next largest factor impacting emissions, followed by equipment life spans. Multimedia Appendix 1 includes other emissions impact categories. CONCLUSIONS: The climate-changing emissions associated with an EMR system are heavily dependent on the sources of electricity. With a decarbonized electricity source, the EMR system's GHG emissions are on par with paper medical record-keeping, and decarbonized grids would likely have a much broader benefit to society. Though we found that the EMR system produced more emissions than a paper record-keeping system, this study does not account for potential expanded environmental gains from EMRs, including expanding access to care while reducing patient travel and operational efficiencies that can reduce unnecessary or redundant care.

Comparison of a New Head Mount Virtual Reality Perimeter (C3 Field Analyzer) With Automated Field Analyzer in Neuro-Ophthalmic Disorders.

BACKGROUND: Automated perimetry in neurologically disabled patients is a challenge. We have devised a patient-friendly virtual reality perimeter, the C3 field analyzer (CFA). We aim to assess the utility of this as a visual field-testing device in neuro-ophthalmic patients for screening and monitoring. METHODS: Neuro-ophthalmic patients and controls were selected to participate in the study between September and December 2018. They randomly underwent either the CFA or automated field analyzer (HFA) first followed by the other in an undilated state. The CFA results were compared with the HFA, and the correlation of the pattern of the field defect was assessed by an independent masked physician. RESULTS: In total, 59 eyes of 33 neuro-ophthalmic patients (cases) and another 95 normal individuals (controls) were enrolled. CFA was found to have greater proportion of reliable fields (81.4%) than HFA (59.3%) ( P = 0.009). There were less false negatives ( P < 0.001) and more false positives in CFA ( P < 0.001) among neuro-ophthalmic patients compared with controls. Among neuro-ophthalmology patients, the number of fixation losses was greater with CFA ( P < 0.001), whereas false negatives were greater in HFA ( P < 0.001). On assessing the pattern of the field defects, we found that there was almost 70% correlation of CFA with HFA. Moreover, in classical neurological fields such as hemianopia, the correlation was 87.5%. CONCLUSIONS: The CFA seems to correlate well with HFA in classic neurological fields such as hemianopias and may serve as an alternative in patients unable to perform a standard automated perimetry. Further developments are currently underway to incorporate threshold testing.

Access to eye care during the COVID-19 pandemic, India.

OBJECTIVE: To study the impact of the coronavirus disease 2019 (COVID-19) pandemic on outpatient visits to eye care facilities in south India. METHODS: We used data on 7.69 million outpatient visits to primary (i.e. vision centres), secondary and tertiary Aravind Eye Care System's centres between January 2019 and June 2021. We compared outpatient numbers and outpatients' age and sex between the pandemic period and the pre-pandemic period in 2019 for all centres, whereas vision and ophthalmic assessments were compared for vision centres only. FINDINGS: During the first wave, the number of outpatient visits at tertiary, secondary and vison centres was 39% (647 968/1 656 296), 60% (170 934/283 176) and 73% (180 502/246 282) respectively, of 2019 levels. During the second wave, outpatient visits at tertiary, secondary and vision centres were 54% (385 092/710 949), 73% (88 383/121 739) and 79% (121 993/154 007), respectively, of 2019 levels. The proportion of outpatients who were female or younger than 20 years or older than 60 years was significantly lower during the first and second waves than in 2019 (P < 0.0001 for all). The proportion of outpatients whose worse eye vision was poorer than 5/60 or who required referral was significantly higher (P < 0.0001 for both). CONCLUSION: Restrictive measurements led to declines in outpatient visits, however the decline was less at secondary and vision centres than at tertiary centres. Easy access to specialized ophthalmic care via telemedicine and the relative proximity of these centres to communities helped reduce barriers to access.

The Utility of Routine Fundus Photography Screening for Posterior Segment Disease: A Stepped-wedge, Cluster-randomized Trial in South India.

PURPOSE: To assess whether routine fundus photography (RFP) to screen for posterior segment disease at community eye clinics (vision centers [VCs]) in India increases referral to centralized ophthalmolic care. DESIGN: Stepped-wedge, cluster-randomized trial. PARTICIPANTS: Patients aged 40 to 75 years and those aged 20 to 40 years with a known history of hypertension or diabetes mellitus presenting to 4 technician-run VCs associated with the Aravind Eye Care System in India. METHODS: VCs (clusters) were randomized to standard care or RFP across five 2-week study periods (steps). Patients in each cluster received standard care initially. At the start of each subsequent step, a randomly chosen cluster crossed over to providing RFP to eligible patients. All clusters took part in RFP during the last step. Standard care involved technician eye exams, optional fundus photography, and teleconsultation with an ophthalmologist. RFP involved eye exams, dilation and 40-degree fundus photography, and teleconsultation with an ophthalmologist. MAIN OUTCOME MEASURES: Standard care and RFP clusters were compared by the proportion of patients referred for in-person evaluation by an ophthalmologist because of fundus photography findings and urgency of referral (urgently in ≤ 2 weeks vs. nonurgently in > 2 weeks). Generalized linear mixed models adjusting for cluster and step were used to estimate the odds of referral due to fundus photography findings compared with standard care. RESULTS: A total of 1447 patients were enrolled across the VCs, including 737 in the standard care group and 710 in the RFP group. Compared with standard care, the RFP group had a higher proportion of referrals due to fundus photography findings (11.3% vs. 4.4%), nonurgent referrals due to fundus photography (9.3% vs. 3.3%), and urgent referrals due to fundus photography (1.8% vs. 1.1%). The RFP intervention was associated with a 2-fold increased odds of being referred because of photography findings compared with standard care (odds ratio, 2.07; 95% confidence interval, 0.98-4.40; P = 0.058). CONCLUSIONS: Adding RFP to community eye clinics was associated with an increased odds of referral compared with standard care. This increase in referral was mostly due to nonurgent posterior segment disease.

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.

Comparison of New Visual Disturbances after Superior versus Nasal/Temporal Laser Peripheral Iridotomy: A Prospective Randomized Trial.

PURPOSE: To determine whether laser peripheral iridotomy (LPI) location affects postoperative dysphotopsia symptoms. DESIGN: Multicenter, randomized, prospective, single-masked trial. PARTICIPANTS: Five hundred fifty-nine South Indian patients 30 years of age or older diagnosed as primary angle-closure suspects (PACSs) or with primary angle closure (PAC) or primary angle-closure glaucoma (PACG) in both eyes. METHODS: Patients were randomized to either bilateral superior or bilateral nasal/temporal LPI. Occurrence of new visual disturbances was evaluated before and 2 weeks after LPI using a questionnaire based on the 7-item dysphotopsia symptoms described by Spaeth et al. MAIN OUTCOME MEASURES: New-onset dysphotopsia symptoms. RESULTS: Superior LPI (n = 285) and nasal/temporal LPI (n = 274) patients were matched for age (P = 0.6), gender (P = 0.7), and distribution of PACS versus PAC or PACG (P = 0.7). Similar initial laser energy settings were used in both groups (P = 0.3), although superior LPIs required more shots (P = 0.006) and greater total energy (P < 0.001) than nasal/temporal LPIs. No significant differences in postoperative anterior chamber reaction (P = 0.7) or LPI area (P = 0.9) were noted between the 2 groups. No group differences were noted regarding the proportion of patients demonstrating 1 or more dysphotopsia symptoms before LPI (15.8% for superior vs. 13.9% for nasal/temporal; P = 0.1) or any individual dysphotopsia symptom (P > 0.2 for all). After LPI, 8.9% of all patients reported 1 or more new symptoms, the most common consisting of linear dysphotopsias, glare, and blurring in 2.7%, 4.3%, and 4.3% of patients, respectively. Patients undergoing superior LPI were not more likely to describe the new onset of 1 or more dysphotopsia symptoms as compared with patients undergoing nasal/temporal LPI (8.4% vs. 9.5%; P = 0.7), nor did the frequency of any new individual symptoms differ by group (P ≥ 0.3 for all). In multivariate logistic regression analysis, neither LPI location nor LPI area nor total laser energy predicted higher odds of new postoperative dysphotopsias (P > 0.1 for all). CONCLUSIONS: Laser peripheral iridotomy likely is safe with respect to visual dysphotopsias regardless of location, LPI size, and amount of laser energy used.

Evaluation of Primary Angle-Closure Glaucoma Susceptibility Loci in Patients with Early Stages of Angle-Closure Disease.

PURPOSE: To investigate whether newly identified genetic loci for primary angle-closure glaucoma (PACG) are associated with early stage angle-closure disease defined as primary angle closure suspect (PACS). DESIGN: Case-control study. PARTICIPANTS: A total of 1397 PACS patients and 943 controls of Chinese ethnicity from Singapore and 604 PACS patients and 287 controls of Indian ethnicity. METHODS: The 8 PACG single nucleotide polymorphisms (SNPs; rs11024102 at PLEKHA7, rs3753841 at COL11A1, rs1015213 located between PCMTD1 and ST18 son chromosome 8q, rs3816415 at EPDR1, rs1258267 at CHAT, rs736893 at GLIS3, rs7494379 at FERMT2, and rs3739821 mapping in between DPM2 and FAM102A) were genotyped by Taqman assays. The association between SNP genotypes and PACS status was measured using logistic regression. A P value of 0.006 was set to account for the testing of 8 genetic loci using a Bonferroni correction. A meta-analysis was conducted to calculate the overall P value and accompanying per-allele odds ratios for each SNP analyzed. MAIN OUTCOME MEASURES: Association of PACG loci with PACS status. RESULTS: The PACS patients were significantly older in both cohorts (Chinese, P < 0.001; Indian, P = 0.002), and there were also more women (P < 0.001, both Chinese and Indian cohorts). In the Chinese cohort, significant evidence of association was noted at 3 SNPs: rs1015213 [A] in PCMTD1-ST18 (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.36-4.11; P = 0.002), rs3816415 [A] in EPDR1 (OR, 1.49; 95% CI, 1.19-1.85; P < 0.001), and rs3739821 [G] in DPM2-FAM102A (OR, 1.40; 95% CI, 1.18-1.65; P < 0.001). Only PCMTD1-ST-18 was replicated modestly in the Indian population (P = 0.056). Meta-analysis showed significant evidence of association for PCMTD1-ST-18 (OR, 1.55; 95% CI, 1.18-2.04; P = 0.002) and DPM2-FAM102A (OR, 1.27; 95% CI, 1.12-1.45; P = 0.0002). CONCLUSIONS: In this study, 2 of 8 PACG-associated loci were associated significantly with PACS status, the earliest stage in the angle-closure glaucoma disease course. The association of these PACG loci with PACS status suggests that these loci may confer susceptibility to a narrow angle configuration.

Predictors of Photographic Quality with a Handheld Nonmydriatic Fundus Camera Used for Screening of Vision-Threatening Diabetic Retinopathy.

PURPOSE: To analyze predictors of image quality for a handheld nonmydriatic fundus camera used for screening of vision-threatening diabetic retinopathy. METHODS: An ophthalmic photographer at an Aravind Eye Hospital obtained nonmydriatic and mydriatic fundus images from 3 fields in 275 eyes of 155 participants over 13 months using a Smartscope camera (Optomed, Oulu, Finland) and a Topcon tabletop fundus camera (Topcon, Tokyo, Japan). Two fellowship-trained retina specialists graded the images. Repeated-measures logistic regression assessed predictors of the main outcome measure: gradability of the fundus images. RESULTS: Of 2,475 images, 76.2% of the Smartscope nonmydriatic images, 90.1% of the Smartscope mydriatic images, and 92.0% of the Topcon mydriatic images were gradable. Eyes with vitreous hemorrhage (OR = 0.24, p < 0.0001) or advanced cataract (OR = 0.08, p < 0.0001) had decreased odds of image gradability. Excluding eyes with cataract or vitreous hemorrhage, nonmydriatic macular image gradability improved from 68.4% in the first set of 55 eyes to 94.6% in the final set of 55 eyes. CONCLUSION: With sufficient training, paraprofessional health care staff can obtain high-quality images with a portable nonmydriatic fundus camera, particularly in patients with clear lenses and clear ocular media.

Intraocular Pressure Reduction after Phacoemulsification versus Manual Small-Incision Cataract Surgery: A Randomized Controlled Trial.

PURPOSE: To compare reduction in intraocular pressure (IOP) and change in anterior chamber angle configuration between eyes undergoing phacoemulsification versus those undergoing manual small-incision cataract surgery (MSICS). DESIGN: Prospective, randomized, double-masked, parallel assignment clinical trial. PARTICIPANTS: Five hundred eyes of 500 participants 40 to 70 years of age with normal IOP, gonioscopically open angles, and age-related cataract. METHODS: Eyes underwent phacoemulsification or MSICS after a 1:1 randomization and allocation code. Best-corrected vision, IOP, comprehensive slit-lamp evaluation, and anterior segment (AS) optical coherence tomography (OCT) were performed at baseline and at 1, 3, and 6 months follow-up. MAIN OUTCOME MEASURES: Change in IOP (ΔIOP) and AS OCT parameters between baseline and 6 months after surgery. RESULTS: Six months, similar IOP reduction was observed in eyes undergoing phacoemulsification (ΔIOP = 2.7±2.9 mmHg) and MSICS (ΔIOP = 2.6±2.6 mmHg; P = 0.70). Widening of the angle opening distance (AOD) 500 µm from the scleral spur (median ΔAOD500 = 103 µm; interquartile range = 39-179 µm) was also similar in both groups (P = 0.28). Multivariate linear regression analysis showed that eyes with higher baseline IOP experienced significantly greater reduction in IOP at 6 months (ΔIOP = 0.46-mmHg reduction for every 1-mmHg increment in baseline IOP; 95% confidence interval [CI], 0.4-0.5 mmHg; P < 0.001). After adjusting for covariates, the magnitude of widening of AOD500 was not associated significantly with reduction in IOP (1.33-mmHg reduction for every 1-mm increment in AOD500; P = 0.07). Baseline AOD500 (ß = -0.60-mm change/1-mm increment of baseline AOD; 95% CI, -0.67 to -0.53 mm) and anterior chamber depth (ß = 0.07-mm change/1-mm increment of baseline anterior chamber depth; 95% CI, 0.04-0.1 mm) were significant predictors of AOD500 widening at 6 months. CONCLUSIONS: Both phacoemulsification and MSICS led to significant and similar IOP reductions 6 months after surgery, and both surgeries produced similar changes in anterior chamber and angle parameters. Higher baseline IOP was associated with greater IOP reduction; IOP reduction also can be attributed partly to changes in angle and anterior chamber configuration, although these parameters were unable to predict significantly predict IOP drop at 6 months.

Changes in Anterior Segment Morphology and Predictors of Angle Widening after Laser Iridotomy in South Indian Eyes.

PURPOSE: To compare anterior segment optical coherence tomography (ASOCT) angle morphology before and after laser peripheral iridotomy (LPI) in a cohort of South Indian subjects with primary angle-closure suspect (PACS) or primary angle-closure/primary angle-closure glaucoma (PAC/PACG) and to examine baseline parameters associated with angle widening. DESIGN: Prospective observational study. PARTICIPANTS: A total of 244 subjects aged ≥30 years with PACS or PAC/PACG in at least 1 eye. METHODS: The ASOCT images and angle gonioscopic grades were analyzed for all subjects at baseline and 2 weeks after LPI. Multivariable linear and logistic regression models were used to determine predictors of angle widening (change in mean angle opening distance [AOD750]) and angle opening (all 4 quadrants with trabecular meshwork [TM] visible on gonioscopy after LPI). MAIN OUTCOME MEASURES: Change in ASOCT parameters with LPI and baseline predictors of angle widening. RESULTS: Laser peripheral iridotomy resulted in angle widening on ASOCT with significant increases in AOD750, angle recess area, and trabecular iris surface area (P < 0.05 for all). Gonioscopically, 44.7% of all subjects had open angles in all 4 quadrants after LPI, with a greater percentage of angles open in the PACS group compared with the PAC/PACG group (52.4% vs. 36.4%; P = 0.01). In multivariable regression analyses, greater postoperative angle widening as defined by change in AOD750 was associated with shorter baseline AOD750 and axial length, and greater baseline anterior chamber depth, iris curvature, and lens vault (P ≤ 0.002 for all). Gonioscopic angle opening after LPI was more common with wider baseline angle width (modified Shaffer grade) and lower cup-to-disc ratio (P < 0.001 for both). CONCLUSIONS: In a South Indian population with PACS or PAC/PACG, LPI results in significant anterior chamber angle widening seen on both ASOCT and gonioscopy, although some degree of persistent iridotrabecular contact was present in approximately half of PACS eyes and approximately two thirds of PAC/PACG eyes on gonioscopy. The greatest widening by ASOCT was observed in eyes with features most consistent with greater baseline pupillary block.

Carbon footprint and cost-effectiveness of cataract surgery.

PURPOSE OF REVIEW: This article raises awareness about the cost-effectiveness and carbon footprint of various cataract surgery techniques, comparing their relative carbon emissions and expenses: manual small-incision cataract surgery (MSICS), phacoemulsification, and femtosecond laser-assisted cataract surgery. RECENT FINDINGS: As the most commonly performed surgical procedure worldwide, cataract surgery contributes significantly to global climate change. The carbon footprint of a single phacoemulsification cataract surgery is estimated to be comparable to that of a typical person's life for 1 week. Phacoemulsification has been estimated to be between 1.4 and 4.7 times more expensive than MSICS; however, given the lower degree of postoperative astigmatism and other potential complications, phacoemulsification may still be preferable to MSICS in relatively resource-rich settings requiring high levels of visual function. Limited data are currently available regarding the environmental and financial impact of femtosecond laser-assisted cataract surgery; however, in its current form, it appears to be the least cost-effective option. SUMMARY: Cataract surgery has a high value to patients. The relative environmental impact and cost of different types of cataract surgery should be considered as this treatment becomes even more broadly available globally and as new technologies are developed and implemented.

Family history is a strong risk factor for prevalent angle closure in a South Indian population.

PURPOSE: To compare the prevalence of angle closure among siblings of patients with open angles (OAs), suspect angle closure (PACS), and either primary angle closure (PAC) or PAC glaucoma (PACG). DESIGN: Cross-sectional, clinical study. PARTICIPANTS: A total of 303 South Indian sibling pairs, including 81 OA probands, 143 PACS probands, and 79 PAC/PACG probands. METHODS: Probands and siblings underwent a clinical examination, including gonioscopy by a masked grader, applanation tonometry, slit-lamp biomicroscopy, optic nerve evaluation, and A-scan ultrasonography. Probands and siblings were classified into 1 of 3 groups based on the phenotype of the more severely affected eye: OA, PACS, or PAC/PACG. Multivariable regression models were used to estimate the odds of prevalent angle closure in PACS or PAC/PACG siblings compared with OA siblings. MAIN OUTCOME MEASURES: Prevalence and relative prevalence of angle closure and PAC/PACG among OA, PACS, and PAC/PACG siblings. RESULTS: Mean sibling age was 49.7 ± 8.7 years, and 56.6% of siblings were females. Angle closure was more prevalent in both PACS siblings (35.0%) and PAC/PACG siblings (36.7%) compared with OA siblings (3.7%; P < 0.001). There was PAC/PACG present in 11.4% of PAC/PACG siblings compared with 4.9% of PACS siblings (P = 0.07) and 0% of OA siblings (P = 0.002). In multivariable models adjusting for sibling age and sex, the odds of angle closure was 13.6 times greater in angle closure (PACS or PAC/PACG) siblings compared with OA siblings (95% confidence interval [CI], 4.1-45.0; P < 0.001). Sibling angle-closure risk was also greater in female (odds ratio [OR], 2.3; 95% CI, 1.3-4.0; P = 0.005) and older siblings (OR, 1.5 per 10-year increment; 95% CI, 1.1-2.0; P = 0.02). Siblings of PAC/PACG probands had a 2.3-fold greater odds (95% CI, 0.8-6.5) of having PAC/PACG compared with siblings of PACS probands, although the association was not significant (P = 0.13). CONCLUSIONS: In the South Indian population screened, siblings of angle-closure patients had a >1 in 3 risk of prevalent angle closure, whereas siblings of PAC/PACG patients had a >10% risk of prevalent PAC/PACG. Screening siblings of angle-closure patients is likely to be of high yield in finding undetected angle closure.

Wound modulation in glaucoma surgery: The role of anti-scarring agents.

Filtration surgery is one of the most frequently performed surgeries in the management of glaucoma, and trabeculectomy is considered the gold standard surgical technique for the same. Though trabeculectomy has been reported to have an excellent initial success rate, about 30% of them fail in 3 years, and nearly 50% of them fail in 5 years. The most significant risk of failure still seems to be wound scarring, especially episcleral fibrosis, leading to bleb failure. As a result, it is essential to explore the role of anti-scarring agents, including mitomycin C, and 5-fluorouracil in wound modulation and improving the bleb survival rate. Since these agents are widely used in trabeculectomy, it is crucial to understand the various modes of application, advantages, and adverse effects of these agents. On an evidence-based approach, all these points have been highlighted in this review article. In addition, the newer agents available for wound modulation and their scope for practical application are discussed.

S-FIX: A sutured way of doing sutureless SFIOL surgeries beyond X-NIT!

BACKGROUND: The video describes a technique in scleral fixation intraocular lens (SFIOL) surgery that is very simple and easily reproducible by any novice surgeon. PURPOSE: This technique may serve as a simple option for tucking the haptic of a multipiece IOL into the sclera without the need for the scleral flap, scleral pocket, forceps, glue, or flange. SYNOPSIS: The two most crucial steps in scleral fixation intraocular lens (SFIOL) surgery are 1) the exteriorization of the haptic, and 2) the fixation of the exteriorized haptic. The first half of the video describes the steps of our previously published technique of extraocular needle-guided haptic insertion technique (X-NIT), which simplifies the exteriorization step by shifting the intraocular hand-shake maneuver to an extraocular site. The second half describes a novel suture-guided haptic fixation (S-FIX) device, which simplifies the fixation step. S-FIX has three components: 1) a 380-micron spatulated needle, 2) a 5-o nylon suture thread, and 3) a polyimide tube. There are four steps involved in S-FIX: 1) docking of the exteriorized haptic into the polyimide tube, 2) pushing the docked polyimide tube into the eye, 3) suture bite starting from the point of sclerotomy, and 4) pulling the suture thread. As the suture thread is being pulled, the haptic along with the polyimide tube comes out and the haptic gets fixed into the narrow suture track. HIGHLIGHTS: The technique enhances the overall safety in SFIOL surgeries by avoiding haptic slips during exteriorization and fixation steps. Most anterior segment and novice surgeons do not perform SFIOL surgeries due to fear of fall of IOL. VIDEO LINK: https://youtu.be/ZoJBiw2SNaU.