Air bubble guide for adequacy of ophthalmic viscosurgical device during phacoemulsification.

Phacoemulsification in hard cataracts is a challenge. The use of dispersive ophthalmic viscosurgical devices (OVDs) to protect the endothelium is a routine step in such scenarios. However, as OVD is transparent, it is difficult to spot within the anterior chamber. Therefore, surgeons may not be aware when the OVD coating of the endothelium disappears during surgery. Consequently, there may be too frequent OVD injections, resulting in a waste of resources. On the contrary, the surgeon may fail to inject OVD at an appropriate time, leading to greater endothelial damage. We propose a novel technique of using an air bubble as a guide that helps in identifying the time when OVD disappears from the anterior chamber, thereby suggesting the surgeon to reinject before proceeding further.

Toxic anterior segment syndrome following trabeculectomy with mitomycin C.

Objective: Toxic anterior segment (TASS) is a rare acute sterile anterior segment inflammation that typically develops within 12 to 24 hours after an anterior segment surgery. The purpose of this case report is to alert surgeons to the possibility of this complication following any anterior segment surgery, including trabeculectomy, and to highlight the possible etiologies and measures to prevent it. Patient and method: A 58-year-old male glaucoma patient was initially managed medically for primary open angle glaucoma with antiglaucoma medications. There was rapidly progressive glaucomatous optic nerve damage in his left eye within the following year, despite the use of antiglaucoma medications, hence the need for trabeculectomy. Result: The post-operative condition of the patient's eye was stormy with diffuse limbus-to-limbus corneal edema and profound Descemet's membrane folds, among other features of TASS, with associated deteriorating visual acuity. Conclusion: Although there is no documented report of TASS following trabeculectomy with mitomycin C, surgeons should be alerted to this possibility. Preventive measures include extreme care to avoid errors while preparing and administering diluted solutions, especially medications that are administered into the intracameral space.

4-Flanged intrascleral fixation of an intraocular lens through the dialing hole.

The high prevalence of mature, hypermature, and traumatic cataracts in developing countries, combined with the limited availability of surgical resources and skill by anterior segment surgeons to manage the resultant aphakia, leaves the patient needlessly blind. Relying on posterior segment surgeons, expensive surgical setup, and appropriate lenses for aphakia management limits the number of patients receiving a secondary intraocular lens (IOL). Utilizing the well-acknowledged flanging technique and the readily available polymethyl methacrylate (PMMA) lenses with dialing holes in their optic, a hammock can be created through the dialing holes using a 7-0 polypropylene suture on a straight needle. This 4-flanged scleral fixation through the dialing hole of an IOL makes scleral fixation of PMMA lens possible by even anterior segment surgeons without requiring any specialized equipment or scleral fixated lens with eyelet. This technique was successfully performed in a series of 103 cases with no incidence of IOL decentration.

Retrospective analysis of the role of anterior segment optical coherence tomography and outcomes of cataract surgery in posterior polar cataract.

Purpose: To evaluate the visual and surgical outcomes of cataract surgery in patients with posterior polar cataract (PPC) and to evaluate the benefits of preoperative anterior segment optical coherence tomography (AS-OCT). Methods: This was a retrospective, single-center study. Case records of patients diagnosed with PPC who underwent cataract surgery either by phacoemulsification or manual small-incision cataract surgery (MSICS) from January to December 2019 were analyzed. Data collected include demographic details, preoperative best corrected visual acuity (BCVA), AS-OCT, type of cataract surgery, intraoperative and postoperative complications, and visual outcome at 1-month follow-up. Results: One hundred patients were included in the study. Preoperative posterior capsular defect was noted on AS-OCT in 14 patients (14%). Seventy-eight underwent phacoemulsification and 22 underwent MSICS. Intraoperatively, posterior capsular rupture (PCR) was seen in 13 patients (13%) and cortex drop was noted in one among them (1%). Out of 13 PCRs, 12 were found to have posterior capsular dehiscence preoperatively in AS-OCT. The sensitivity of AS-OCT for detecting posterior capsule dehiscence was 92.3% and specificity was 97.7%. The positive predictive value and negative predictive value were 85.7% and 98.8%, respectively. There was no significant difference in the incidence of PCR between phacoemulsification and MSICS (P = 0.475). The mean BCVA at 1 month was found to be better with phacoemulsification than MSICS (P = 0.004). Conclusion: Preoperative AS-OCT has excellent specificity and negative predictive value in identifying posterior capsular dehiscence. It thus helps to plan the surgery and counsel patients appropriately. Both phacoemulsification and MSICS provide good visual outcome with similar complication rates.

Comparison of the outcomes of phacoemulsification and manual small-incision cataract surgery in posterior polar cataract - A retrospective study.

Purpose: To compare the visual outcomes and intraoperative complications between phacoemulsification and manual small-incision cataract surgery (MSICS) in cases of posterior polar cataract (PPC). Methods: A retrospective study was carried out involving 142 patients (164 eyes) with PPC who underwent cataract surgery between January and December 2017. Data collected include the demographic details, preoperative uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), type of cataract, intraocular pressure, anterior and posterior segment findings, type of surgery performed, intraoperative complications, postoperative UCVA on the first day, UCVA and BCVA at 1 month after surgery, complications, and resurgery details. Results: In total, 90 patients (107 eyes) underwent phacoemulsification, and 52 patients (57 eyes) underwent MSICS. There was no significant difference in the mean age, sex, and type of PPC between the two groups (P = 0.326, 0.852, and 0.220, respectively). Patients who underwent phacoemulsification had significantly better preoperative BCVA (P = 0.002). The BCVA on first postoperative day and 1 month after surgery was better in the phacoemulsification group than in the MSICS group (P < 0.001 and 0.002, respectively). The overall incidence of posterior capsular rupture (PCR) was 11.6%, which included the 10.3% in phacoemulsification and 14.0% in MSICS. There was, however, no significant difference in the rates of PCR between the two groups (P = 0.506). Conclusion: Phacoemulsification delivered better postoperative visual outcomes than MSICS in PPC patients, whereas the complication rates were similar between the two groups.

Vacuum-assisted cortex removal - A novel change to the tradition.

In developing countries, manual small-incision cataract surgery (MSICS) has surfaced as the cost-effective alternative to phacoemulsification. The Simcoe irrigation-aspiration cannula was developed nearly 40 years ago and is still the most frequently employed tool for cortex aspiration. Although it stands unsurpassed, here we attempt to introduce an addition to the existing Simcoe cannula to achieve a dynamic and controlled vacuum with the added advantage of less physical strain and an effective volume of aspiration. The vacuum-assisted cortex removal device is based on a simple spring action mechanism, where the relaxation of the spring pushes the plunger up and thereby generates a controlled vacuum.

Short-term surgical outcomes of twin-site combined phaco-emulsification and mitomycin-C augmented trabeculectomy in pseudo-exfoliation glaucoma versus primary open-angle glaucoma.

Purpose: To compare the short-term outcomes of combined phaco-emulsification with posterior chamber intra-ocular lens and mitomycin augmented trabeculectomy in patients with pseudo-exfoliation glaucoma (PXFG) versus primary open-angle glaucoma (POAG). Methods: A total of 144 eyes of 144 patients were enrolled in this prospective interventional comparative study, 72 each of which had PXFG and POAG, respectively. All patients underwent twin-site combined phaco-trabeculectomy at a tertiary eye center in India between December 2017 and December 2018 and were followed up for a period of 12 months. The main outcome measures were intra-ocular pressure (IOP), best corrected visual acuity (BCVA), total surgical time, rate of intra-operative and post-operative complications, and the number of ocular hypotensive medications needed. Success rates were determined via Kaplan-Meier survival analysis. Results: The mean age was 63.9 ± 7.9 years in the POAG group and 66.4 ± 6.8 years in the PXFG group (P - 0.04). The baseline BCVA, IOP, and cup-disc ratio were comparable between two groups. Intra-operative complications and post-operative outcomes were comparable between the two groups. There was a significant drop in anti-glaucoma medications in both groups. Six patients, three (4.2%) in each group, were lost to follow-up after 6 months. Three patients (4.2%) in PXFG needed additional glaucoma intervention for controlling IOP, one patient needed a non-valved glaucoma drainage device, and two patients required diode cyclo-photocoagulation within the follow-up period. Conclusion: Patients with PXFG had a longer surgical time than POAG. Similar success and complication rates were observed following combined twin-site phaco-trabeculectomy in both POAG and PXFG at 1 year. Combined glaucoma surgery resulted in good IOP control, improvement in BCVA, and lower requirement of ocular hypotensives in both the groups.

Artificial intelligence in glaucoma.

Background: Artificial Intelligence (AI) is an area of computer science that encompasses the creation of intelligent machines that work and react like humans. It deals with the development algorithms that seek to simulate human brain and also mimic cognitive functions typically associated with the human mind such as learning and problem solving. Purpose: Do we need artificial intelligence in Glaucoma? Glaucoma is the second most common cause of blindness in the world. Its prevalence was over 60 million in 2010 and over 80 million by 2020. It is so common, yet so easily overlooked. More importantly, about 50% of patients in developed countries and 90% in developing countries are unaware of having glaucoma. Early detection can delay the progression of glaucoma. Hence the time is ripe to advovate glaucoma screening. Synopsis: The application of AI in ophthalmology mainly concentrates on the diseases with a high incidence, such as diabetic retinopathy, age-related macular degeneration, glaucoma, retinopathy of prematurity, age-related or congenital cataract etc AI involves mainly 1. machine learning that are algorithms with the ability to learn without being explicitly programmed and 2. deep learning in which artificial neural networks adapt and learn from vast amounts of data. But there are limitations to screening - such as disparity between ophthalmologist:patient ratio and also the availability of the specialty services. The large amount of data acquired from patients makes it nearly impossible for ophthalmologists to screen them with equal efficacy and consistency. Highlights: AI in glaucoma aims at including factors such as clinical data, genomic data, life style behaviors, risk factors, and medical history to predict the risk of developing glaucoma, help customise the most appropriate management protocol for a given patient, and estimate prognosis and surgical success. Video Link: https://youtu.be/IwYS7wDMhkY.

Formalin-assisted training eyes for ophthalmic wet lab practice.

The foundation of an ophthalmologists' microsurgical career begins in the wet lab. Training on donor cadaveric, animal like goat or pig eyes provide the most realistic surgical environment, however, the availability of a donor's eyes for practice is limited. This scarcity is further escalated in this current coronavirus disease 2019 pandemic where eye donations have decreased. Even among those eyes which find their way into the wet lab, quite a few would have collapsed significantly making training difficult. Therefore, we looked at ways to salvage these collapsed globes. We describe a novel way of salvaging the collapsed eyeballs by injecting formalin in slow boluses into the vitreous cavity. The longer maintenance of the globe integrity without necessitating repeated injections facilitates better quality of surgical training and optimal utilization of these eyes.

Piggyback miLOOP-assisted phacoemulsification combined with intraocular lens scaffold in hypermature cataracts.

Hypermature cataracts with liquified cortex pose a higher risk for capsular complications due to a distended capsular bag, floppy posterior capsule, and absence of any cushioning epinucleus. Disassembly of a brunescent nucleus is more difficult because of the thickened, leathery posterior plate. Relying on mechanical forces, miLOOP nucleotomy reduces ultrasound time and is assured of bisecting the posterior nuclear plate. However, using this instrument with brunescent nuclei might impart significant stress on the zonular fibers and posterior capsule, particularly if there is no epinuclear shell. Evacuating the liquefied cortex and prolapsing one nuclear pole through capsulorhexis with ophthalmic viscosurgical devices create enough space to implant an intraocular lens (IOL) into the capsular bag beneath the undivided nucleus. This IOL scaffold shields the floppy posterior capsule and stabilizes the nucleus and zonular fibers during miLOOP nucleotomy. Combining and piggybacking these 2 techniques successfully avoided capsular and corneal complications in a series of 32 cases.

Predicting zonular strength based on maximum pupillary mydriasis in patients with pseudoexfoliation syndrome.

Pseudoexfoliation Syndrome (PXFS) is considered a systemic disorder with significant ocular manifestations ranging from corneal decompensation, non-dilating pupil, zonular weakness, subluxated lens, and glaucoma. PXFS may lead to increased complications during routine cataract surgery. Zonular dialysis is a common complication during or after cataract surgery in such patients. However, not all patients with pseudoexfoliation are at a higher risk. We hypothesize that there is an inverse correlation between the maximum pupillary dilation and the degree of zonular disintegration. Available evidence supporting the hypothesis is discussed. We propose a new clinical classification for predicting the zonular strength based on the maximum pupillary dilation so that it can serve as a guide to identify PXFS patients who are at high risk of complications during or after cataract surgery.

Intraocular lens-sling technique: A safe approach for lens implantation in complicated cataract surgery and secondary intraocular lens implantation.

Among 20 million cataract surgeries being performed worldwide every year, approximately 5% are being complicated by posterior capsule rent or zonular dialysis. Intraocular lens (IOL) implantation in such cases with intraoperative complications is quite challenging. Our next course of action is to place the IOL in the ciliary sulcus, however, there is a risk of IOL drop into the vitreous in cases of inadequate support. We have described a novel idea of using a suture material through the dialling hole of a three-piece rigid IOL which can be used as a leash to reduce the risk of IOL drop during implantation in such cases. This technique could also be used during sutureless scleral fixated IOL and retro-pupillary iris claw lens implantation. We found that in 90 consecutive patients where this technique was used, there was no incidence of IOL drop or retinal detachment.

The Impact of Routinely Measuring IOP in Younger Adults to Screen for Glaucoma in a Large Eye Hospital.

PRECIS: Intraocular pressure (IOP) screening in adults 18 to 40 years of age identified 1 in 535 young adults with or at risk for developing glaucoma in India with a cost of about Indian rupee 596 (USD 8) per patient diagnosed. PURPOSE: The purpose of this study was to evaluate the outcomes of routine noncontact tonometry as a screening modality for glaucoma in young adults receiving an eye examination at Aravind Eye Hospital, Pondicherry, India. METHODS: Retrospective chart review of adults 18 to 40 years of age screened for IOP from November 2017 to June 2018. The diagnoses were determined by a glaucoma specialist using gonioscopy, dilated fundus examination, and occasionally, Humphrey Field Analyzer, and/or optical coherence tomography. Analyses include detection of glaucoma, ocular hypertension (OHT), angle closure, and calculation of the yield of this screening paradigm. RESULTS: A total of 28,369 younger adults were screened and 296 (1.05%) were referred to the glaucoma unit, 84 for an IOP >21 mm Hg and 208 for other reasons. The hypertensive group had a mean screening IOP of 29.3±8.4 mm Hg and the following diagnoses: OHT (19%), secondary raised IOP (14%), glaucoma (26%), angle closure (4%), healthy (11%) and need for further examination (26%). Fifty-five percent of those with glaucoma were previously undiagnosed. In comparison, the normotensive group had a mean IOP of 16±2.5 mm Hg and the following diagnoses: OHT (1%), glaucoma (5%), occludable angles (8%), healthy (47%) and need of further examination (33%). Nearly 40% of these patients with glaucoma were previously undiagnosed. CONCLUSIONS: One of every 535 young adults screened had both IOP >21 mm Hg and angle closure, OHT, secondary raised IOP or glaucoma. Given their young age and the potential to treat and delay progression, the benefits seem to outweigh the low cost of this screening.

A retrospective study on the incidence of post-cataract surgery Descemet's membrane detachment and outcome of air descemetopexy.

PURPOSE: To study the anatomic and functional outcome of air descemetopexy in postcataract surgery Descemet's membrane detachment (DMD). DESIGN: Retrospective study. METHODS: Setting: Institutional. STUDY POPULATION: Records of 112 patients who underwent air descemetopexy for postcataract surgery sight-threatening DMD at Aravind Eye Hospital, Pondicherry, between January 2013 and December 2015 were studied. MAIN OUTCOME MEASURES: Anatomical outcome refers to reattachment of the Descemet's membrane (DM). Functional outcome was given by the best-corrected visual acuity. RESULTS: The mean age was 66.47±8.46 (SD) years, the male to female ratio was 45:67. The incidence of DMD was more in extracapsular cataract extraction (0.26%) and manual small incision cataract surgery (0.11%) than phacoemulsification (0.04%) (p=0.005 and p<0.0001). DMD was more common among surgical trainees (0.17%) than consultants (0.07%) (p≤0.0001). After primary air descemetopexy, 78 (71%) out of the 110 patients had DM reattachment. The complications noted after descemetopexy include persistent DMD (21.8%), corneal decompensation (7.3%), appositional angle closure (18%), pupillary block with air (2.7%) and uveitis (2.7%). Age, sex and timing of intervention did not influence the reattachment rate. Fifteen patients underwent repeat air descemetopexy for persistent DMD among whom nine (60%) had successful reattachment. Almost 75% of patients had vision better than 6/18 1 month after anatomically successful descemetopexy. CONCLUSION: Air descemetopexy is a safe and efficient modality of treatment of DMD and should be tried even in patients with severe DMD before planning a major surgery like endothelial keratoplasty.