Use of 30 gauge needle to prevent hypotony during silicone oil removal.

Silicone oil (SO) is used as an intraocular tamponade after complex vitreoretinal surgeries because of its properties such as transparency, inertness, high surface tension, and interfacial tension with water. The only disadvantage of SO tamponade is the need for a second surgery for its removal. However, there is a risk of ocular hypotony soon after the removal of the infusion cannula, especially in retinal vascular conditions, such as diabetic retinopathy. We hereby present a silicone oil removal (SOR) technique using a 30 G needle that prevents intraocular hypotony during SOR.

Toxic anterior segment syndrome (TASS): A review and update.

Toxic anterior segment syndrome (TASS) is an acute, sterile, postoperative inflammatory reaction of the anterior segment without vitreous involvement, following an uncomplicated and uneventful ocular surgery, having broad and multiple etiologies. The symptoms of decreased visual acuity and ocular discomfort generally occur within the first 12-48 h after intraocular surgery. The clinical signs include prominent limbus-to-limbus corneal edema, anterior chamber cells, aqueous flare, fibrinous inflammation, and/or keratic precipitates. There can be sight-threatening complications of TASS, such as permanent corneal decompensation, intractable glaucoma, and cystoid macular edema. The causes of TASS are emerging and being reported, so are the newer treatment options for managing the inflammation and its complications. Prevention guidelines for TASS are being updated, and a traceability system for surgical instruments and intraocular fluids used during the surgery is being perpetually developed. It is important to recognize TASS and start treatment on an immediate effect. Hereby, we review the literature on TASS, emphasizing its etiology, pathophysiology, management, prognosis, complications, and the importance of prevention as well as prompt recognition.

Efficacy of a single injection of brolucizumab in neovascular age-related macular degeneration on visual acuity and micromorphometry.

Purpose: To assess short-term efficacy of a single injection of brolucizumab in neovascular AMD. Methods: This was a multicenter, retrospective chart review of 25 eyes of 25 patients who received a single injection of brolucizumab. Visual acuity (VA) and optical coherence tomography (OCT) features such as central subfield thickness (CSFT), subretinal fluid (SRF), intraretinal fluid, and pigment epithelial detachment (PED) were recorded at baseline, first month, and third month. Results: Of the 25 eyes, 14 eyes were treatment-naïve and 11 eyes had received previous injections. VA improved from 0.68 ± 0.59 log MAR at baseline to 0.31 ± 0.43 log MAR at the end of 3 months. SRF height in first and third month was significantly reduced from baseline (P < 0.001). Subretinal hyperreflective material height significantly reduced from baseline (P value 0.008 at first month and 0.01 at third month, respectively). CSFT was 464.16 ± 247.97 microns at baseline and showed a significant reduction in first month (P < 0.001) and third month (P < 0.001). There was a significant reduction of PED height from baseline at both follow-ups. None of the eyes showed a recurrence of fluid at the end of 3 months. Conclusion: Our study demonstrated sustained improvement in VA and OCT parameters after a single injection of brolucizumab at 3 months. A longer follow-up may demonstrate even farther effects of a single injection.

The Need for Culturally Appropriate Food Allergy Management Strategies: The Indian Milk Ladder.

BACKGROUND: Cow's milk allergy (CMA) is one of the most common and complex food allergies affecting children worldwide and, with a few exceptions, presents in the first few months of life. Baked-milk-containing diets are well tolerated in the majority of milk-allergic children and allow dietary restrictions to be relaxed. In addition, the early introduction of tolerated forms of allergenic foods to an infant's diet in small amounts may enhance the outgrowth of their milk allergy through oral tolerance induction. The methods of milk introduction vary widely across the globe. METHODS: We convened an expert group to develop a comprehensive milk ladder based on the calculated milk protein content of Indian foods. To validate the milk ladder, the foods chosen for the ladder were analyzed and the ladder was re-evaluated based on the cooked milk protein content. RESULTS: Combining expert consensus and validation of milk protein content, we created the world's first milk ladder containing Indian foods. This is the first ladder that provides information on the timing and temperature of cooking, with validated milk protein content. CONCLUSIONS: This is the first milk ladder based on the unique features of Indian food habits built by the consensus of Indian experts along with international collaboration with laboratory quantification of milk protein in each step. We believe the "The Indian Milk Ladder" will be a very helpful tool for pediatricians helping manage CMA in children as well as their parents and caregivers, not only in India, but in countries world-wide where these foods are commonly consumed.

Antibiotic prophylaxis for cataract surgery - Practice patterns amongst Indian Ophthalmologists.

Purpose: To assess the current trends in use of perioperative antibiotic prophylaxis, especially intracameral antibiotics (ICAB), for cataract surgery in India. Methods: This was an E-survey using a previously validated questionnaire carried out by the All India Ophthalmological Society (AIOS) in August 2022. An E-mail invitation to complete an online 40-point survey was sent to all members of the AIOS using a digital E-mail service (Survey Monkey) and social media platforms. Results: Out of 1804 total respondents, 58% (n = 1022) reported using routine ICAB prophylaxis. Of those using ICAB, 89% (n = 909) reported using it for all cases, whereas the rest used it for specific indications such as post-PC rent (n = 43), one eyed patient (n = 19), and high-risk cases (n = 50). Commercially available moxifloxacin was by far the commonest agent used for ICAB (n = 686, 67%). Eighty respondents (8%) reported noticing occasional toxic reactions and nontoxic corneal edema (n = 64, 6%) with ICAB. Surgeons with >10 years' experience especially practicing in medical colleges used fewer ICAB (OR = 0.52, 95%CI = 0.38 - 0.72, P < 0,001) compared to younger surgeons (<5-year experience) in solo clinics. The commonest reason for nonadoption of IC antibiotics was "unconvinced of the need to use it in my setting" (n = 296, 52% of those who answered this question). Conclusion: IC antibiotic prophylaxis for cataract surgery has significantly increased in India from 40% in 2017 to 58% in 2022. Commercially available moxifloxacin was preferred by the majority users. Intraocular inflammation may occur occasionally and needs safer formulations to avoid this.

Prevention and management of childhood progressive myopia: National consensus guidelines.

Myopia is a major public health problem worldwide, including India, with the global prevalence of myopia increasing rapidly over decades. The clinical and socioeconomic impact of myopia is also expected to rise with rising prevalence. Therefore, the focus has now been shifted to prevent the incidence and progression of myopia. However, there is lack of any standardized guidelines for myopia management. This document aims to generate a national-level expert consensus statement on the management of childhood myopia in the Indian scenario. The expert panel of pediatric ophthalmologists consisted of 63 members who met in a hybrid meeting. A list of topics deliberating discussion in the meeting was provided to the experts in advance and they were instructed to provide their opinions on the matter during the meet. The panel of experts then gave their views on each of the items presented, deliberated on different aspects of childhood myopia, and reached a consensus regarding the practice patterns in the Indian scenario. In case of opposing views or lack of a clear consensus, we undertook further discussion and evaluated literature to help arrive at a consensus. A written document is prepared based on recommendations explaining definition of myopia, refraction techniques, components and methods of workup, initiation of anti-myopia treatment, type and timing of interventions, follow-up schedule, and indications for revised or combination treatment. This article formulates evidence-based guidelines for progressing myopes and pre-myopes and also establishes uniformity in the management of childhood myopia in the country.

Development of a Community Hospital Medicine Affiliated Inpatient Rotation for Family Medicine Residents-A Collaborative Success.

Background: Hospitalists perform key roles as inpatient educators for family medicine residents. For the past decade, Duke University Family Medicine Residency Program had its inpatient family medicine resident rotation at non-Duke facilities. Objective: The authors describe the steps taken in 2020 to develop an inpatient Duke family medicine rotation at a North Carolina community hospital, Duke Regional Hospital, and provide outcomes data. Methods: Duke Family Medicine Residency and Duke Regional Hospital Medicine collaborated in addressing key issues to develop an inpatient rotation for family medicine residents. Performance metrics of patients cared for by both the family medicine inpatient resident team and internal medicine teams were compared. Resident satisfaction survey results were reviewed. Results: Retrospective cohort evaluation comparing the two inpatient services (internal medicine and family medicine) revealed the family medicine resident inpatient service performed comparatively in length of stay and 30-day readmission rates. Resident evaluation surveys of the family medicine inpatient rotation showed overall satisfaction with learning objectives. Conclusions: This new family medicine inpatient rotation has benefitted all parties. Key quality performance metrics such as LOS and readmissions are comparable to internal medicine, hospitalists have more teaching opportunities, and Duke family medicine has its residents training in a Duke-affiliated community hospital for their core inpatient rotation.

Lactobacillus rhamnosus GG Evaluation in Acute Diarrhea (LEAD): An Observational Study.

Background and objective Probiotics with documented efficacy such as Lactobacillus rhamnosus GG(LGG) and Saccharomyces boulardii might be utilized as adjuncts to rehydration for the management of acute gastroenteritis (AGE) in children. In this study, we aimed to evaluate the potential role of LGG in acute diarrhea in the Indian pediatric population. Methods An observational, cross-sectional study [Lactobacillus rhamnosus GG Evaluation in Acute Diarrhea (LEAD)] was conducted among children aged one month to 12 years with acute watery diarrhea. In addition to standard management of diarrhea, LGG was given as an adjuvant treatment at the discretion of treating physicians based on their routine practice. Observations were documented on days one, three, and five. Outcomes such as frequency and duration of diarrhea, time to change in consistency of stools, Bristol Stool Chart (BSC) reading, and global assessment by healthcare practitioners (HCPs) and patients were also recorded. Results Of the 2,080 patients enrolled, 1,900 completed the five-day follow-up. There was marked improvement observed in the number of incidences of loose stools from day one (mean: 7.33) to day five (mean: 1.6). The mean time to improvement in stool consistency was 34 hours. The mean duration of diarrhea was 44.63 hours. A relatively shorter duration of diarrhea was reported among participants in this study. There was also a significant improvement in the number of vomiting episodes. Most patients and HCPs reported the product to be excellent/very good on the global assessment scale. No adverse effects were noted in any of the groups. Conclusion Based on our findings, LGG supplementation may be a beneficial adjuvant treatment in reducing the severity and duration of acute diarrheal episodes.

Transparency in Admissions and Personalized Learning Through Resident Patient Selection.

Background: Adult learning (andragogy) posits that adult learners have an improved educational experience when engaged in self-directed learning. The decision to allocate patients to the teaching service vs a nonresident service varies according to institution. Previously, our institution focused on faculty perception of learning value as the deciding factor in patient assignment. We hypothesized that transitioning to a process in which adult learners (residents) select patients for their teams based on their own identified learning needs could improve the educational experience without adversely impacting the workflow for nonteaching teams. Methods: A new patient assignment model focused on learner-driven identification of patients for their own inpatient service, consistent with the principle of andragogy, was created. This patient assignment strategy was tested during a 1-month pilot period followed by a 5-month implementation period with 20 senior residents and 31 hospitalists. Both residents and hospitalists were surveyed after the intervention. Results: Sixteen of 20 residents completed the paper survey, and 100% of the respondents indicated "yes" when asked if they were able to direct cases to their team that were in line with their learning goals and if the new process should continue. Twenty-one of 31 hospitalists responded to the electronic survey; 81% of responding hospitalists reported a slightly positive to very positive impact on the hospitalist workflow, and 76% felt the new process should continue. The new patient assignment model had no negative impact on case mix index or length of stay. Conclusion: Restructuring patient assignment processes based on educational theory may improve resident education and improve hospitalist workflow.

All India Ophthalmological Society (AIOS) Task Force guidelines to prevent intraocular infections and cluster outbreaks after cataract surgery.

Infectious endophthalmitis is a serious and vision-threatening complication of commonly performed intraocular surgeries such as cataract surgery. The occurrence of endophthalmitis can result in severe damage to the uveal and other ocular tissues even among patients undergoing an uncomplicated surgical procedure. If the infections result from common factors such as surgical supplies, operative or operation theater-related risks, there can be a cluster outbreak of toxic anterior segment syndrome (TASS) or infectious endophthalmitis, leading to several patients having an undesirable outcome. Since prevention of intraocular infections is of paramount importance to ophthalmic surgeons, the All India Ophthalmological Society (AIOS) has taken the lead in the formation of a National Task Force to help ophthalmic surgeons apply certain universal precautions in their clinical practice. The Task Force has prepared a handy checklist and evidence-based guidelines to minimize the risk of infectious endophthalmitis following cataract surgery.

Diabetic macular edema treatment guidelines in India: All India Ophthalmological Society Diabetic Retinopathy Task Force and Vitreoretinal Society of India consensus statement.

Diabetic macular edema (DME) is a common cause of moderate visual impairment among people with diabetes. Due to the rising number of people with diabetes in India, the absolute numbers of people with DME are significant. There are several treatment options for DME, and the choice of treatment is based on the availability of retinal specialists and infrastructure for the delivery of treatment. A major challenge is the out-of-pocket expenditure incurred by patients as most treatment options are costly. Treatment also varies based on the associated ocular and systemic conditions. The All India Ophthalmology Society (AIOS) and the Vitreo-Retinal Society of India (VRSI) have developed this consensus statement of the AIOS DR task force and VRSI on practice points of DME management in India. The objective is to describe the preferred practice patterns for the management of DME considering the different presentations of DME in different clinical scenarios.

The All India Ophthalmological Society - Academic and Research Committee pan-India diabetic retinopathy project "Fixing the missing link": Prevalence data from West Bengal.

PURPOSE: The aim of this study was to determine the prevalence of diabetic retinopathy (DR) and its risk factors among diabetic patients in rural and urban West Bengal (WB). METHODS: Patients were screened in the physician's clinic by a team of ophthalmologist, optometrist and counsellor. Demographic details, diabetic control, compliance to eye checkup, awareness regarding diabetic blindness, and visual acuity were recorded using a questionnaire. DR was graded both by indirect ophthalmoscopy and fundus photo taken with a portable fundus camera. RESULTS: A total of 1553 subjects were screened over 39 camps across 14 districts of WB over 17 months. The prevalence of DR was 21.51%, with a significant difference between rural (26.55%) and urban (13.89%) areas (P < 0.01). No significant difference with gender was seen (P = 0.99). Presence and grade of DR were related to age, loss of vision, diabetic age, diabetic control, awareness of diabetic blindness and last eye checkup. CONCLUSION: This study provides the first major prevalence data from WB, and gives valuable insight regarding modifiable risk factors for DR. It is also the first DR study in India to be conducted in the physician's clinic. The study results emphasise the need to "fix the missing link" between ophthalmologists and treating physicians to win the battle against DR.

The perceived impact of webinars during the COVID.19 pandemic: A survey of ophthalmology trainees from India.

OBJECTIVE: The objective of the study was to assess the perceived utility and the impact of web-based teaching programs being conducted following the COVID-19 pandemic. METHODS: An online survey was sent to trainee ophthalmologists across India through various social media platforms. The responses were tabulated and analyzed. RESULTS: A total of 768 valid responses were recorded. Majority of respondents (52.2%) felt that the ideal duration for webinars was 1 hour or less. Factors that helped trainees in choosing a webinar were the topic (95.1%), the timing (53.6%), and the speaker list (42.4%). Residents indicated a preference for webinars to attend aimed at postgraduate residency training, more specifically clinical problem-solving. Further questions were answered using a 1-10 Likert scale (1: least useful and 10: extremely useful). The median score when asked for overall usefulness of the webinars in general was 8 (interquartile range/IQR: 2). The median response when asked about utility of webinars in enhancing theoretical knowledge was 8 (IQR: 2) and the median for utility of webinar-based teaching programs in enhancing practical knowledge/surgical learning was also 8 (IQR: 2). The median score when asked about the utility of the webinar programs in acquiring skills for writing research papers/thesis was 7 (IQR: 3). Connectivity issues, audio/voice issues, and the long duration of webinars were some of the problems faced while attending webinars. CONCLUSIONS: Ophthalmology trainees in India found online teaching programs and webinars to be useful in enhancing their theoretical knowledge and practical skills/surgical learning. Administrators and educational institutes should tailor online teaching programs as per the needs and preferences of the residents.

Microincision phacoemulsification combined with sutureless transpupillary passive silicone oil removal.

PURPOSE: To evaluate the outcomes of combined microincision phacoemulsification with sutureless transpupillary silicone oil (SO) removal using an irrigation probe of bimanual irrigation/aspiration. METHODS: We conducted a single-center retrospective study, including patients who had undergone phacoemulsification with transpupillary removal of SO, which had been used for intraocular tamponade after a previous pars plana vitrectomy. Outcome measures were corrected distance visual acuity (CDVA), refractive error, intraocular pressure (IOP), and endothelial cell count (ECC) evaluated preoperatively and postoperatively at 3-month follow-up. Any intraoperative or postoperative complications, duration of surgery, and final retinal status at 3 months were also noted. RESULTS: Seventy-four eyes (74 patients) were analyzed. The mean interval between SO placement and cataract surgery was 4.73 months (standard deviation [SD]: 1.02). CDVA improved in 66 (89.2%) eyes and remained the same in 8 (10.8%) eyes (P < 0.001). The mean postoperative spherical equivalent was -0.96D (SD: 0.75) at 3 months (P < 0.001). There was a significant drop in IOP from 15.08 mmHg (SD: 2.67) preoperatively to 11.64 mmHg (SD: 2.02) postoperatively (P < 0.001). The average ECC loss was only 5.7% at 3 months postoperatively. The mean surgical duration was 17.20 min (SD: 7.02). One patient had retinal redetachment and required resurgery. At 3 months, the retina was attached in all patients. CONCLUSION: Combined microincision phacoemulsification with transpupillary passive SO removal using irrigation probe of bimanual irrigation/aspiration is a safe, effective, and less invasive technique that offers the main advantage of reduced surgical trauma, and should be reserved for patients with a stable retina, not requiring additional surgical intervention.

Impact of COVID-19 pandemic on income and opportunities of ophthalmologists in India: Ophthalmologists' Workplace Expectations and Satisfaction Survey (OWESS) Report 1.

Purpose: To evaluate the impact of COVID-19 pandemic on the income and surgical training opportunities among the ophthalmologists in India and their opinion on salary reduction during this period. Methods: A questionnaire in the form of a Google survey was sent to ophthalmologists across India on May 1, 2021. The data collected until May 11, 2021 was analyzed. Results: A total of 1057 ophthalmologists all over India participated in the survey. Of the respondents, 559 (52.9%) were women and 730 (69.1%) were young ophthalmologists (below the age of 40 years). Salary reduction was reported by 569 (53.8%) of the respondents. The categories suffering the maximum salary reduction were - young ophthalmologists (407, 55.8%) (P < 0.001), women (304, 54.4%) (P < 0.001), and private sector employees (457, 67%) (P < 0.001). More women ophthalmologists (438, 78.4%) felt it was unfair to reduce the salary during the pandemic, as compared to men (330, 66.3%) (P < 0.001). A reduction in surgical training opportunities was reported by 689 (65.2%) of ophthalmologists. The categories who suffered the maximum loss of surgical training opportunities were young ophthalmologists (565, 77.4%) (P < 0.001), women ophthalmologists (415, 74.2%) (P < 0.001), and ophthalmologists in the government sector (147, 82.6%) (P < 0.001). Conclusion: Ophthalmologists in India, especially women and the younger professionals, had to face salary reduction and loss of surgical training opportunities during the COVID-19 pandemic. Most ophthalmologists in India do not favor a reduction in salary. There is a need to formulate policies to safeguard ophthalmologists, especially women and younger generation from future crises in training, employment, and income.

Ophthalmology residency trainers' perspective on standardization of residency training in India.

Purpose: The aim of this study was to study the perception of residency trainers about an optimum residency program. Methods: A survey, using a pre-validated questionnaire, was conducted by the Academic and Research Committee of the All India Ophthalmological Society, in 2019-20 with questions directed to teachers in medical colleges and national board of examination's ophthalmology residency programs on demography, teaching experience, imparting clinical and surgical skills, ideal academic schedule and dissertation in the post-graduate residency program. Results: The response rate in the survey was 47.6%. Valid responses were obtained from 309 residency trainers. Of these, 132 of 309 (42.7%) were females. The mean age was 45.3 ± 9.5 years, range 26-68 years. The trainers believed that on a scale of 0-10, clinical skills teaching should be taught, mean ± SD: slit lamp 9.8 ± 0.7; indirect ophthalmoscopy 9.3 ± 1.3; gonioscopy 9.2 ± 1.5; perimetry 8.9 ± 1.5; OCT 8.4 ± 1.9; applanation tonometry 9.5 ± 1.2 and orthoptic evaluation 8.1 (±1.9). A resident should ideally perform independently surgeries (median, inter-quartile range IQR): SICS 50 (IQR 40-100); phaco 50 (20-60); pterygium excision 20 (10-40); DCR 10 (5-20); chalazion 20 (10-50), trabeculectomy 7 (5-15); strabismus 5 (2-10), LASIK and retinal detachment 0. Ideally there should be four lectures, four seminars, four case presentations, five journal clubs and four wet labs every month. Conclusion: Teachers expected their wards to become competent professionals. There was near unanimity about the content of clinical skills training, non-medical skills and academics, but there was a significant variation on extent of surgical training that should be imparted to the residents.

Clinical efficacy and safety of Razumab® (CESAR) study: Our experience with the world's first biosimilar Ranibizumab.

Purpose: : The aim of this study was to evaluate the efficacy and safety of Razumab (the biosimilar Ranibizumab by Intas Pharmaceuticals Ltd.) for the treatment of chorioretinal vascular diseases such as diabetic macular edema (DME), choroidal neovascular membrane (CNVM), and macular edema secondary to retinal vein occlusion (RVO). Methods: : We conducted a single-center, retrospective study, including patients with DME, CNVM, and RVO, who had received treatment with Razumab® between October 2018 and September 2019. Primary outcome measures were the changes in corrected distance visual acuity (CDVA) and central foveal thickness (CFT) from baseline to 1 month and 3 months. Secondary outcome measures included intraocular pressure (IOP) at day 1, any signs of ocular inflammation or systemic adverse events during the follow-up. Results: : One hundred and fifty-three eyes of 141 patients were analyzed. The indications included DME in 70 (45.8%) eyes, CNVM in 70 (45.8%) eyes, and RVO in 13 (8.4%) eyes. Mean CDVA improved from baseline (0.62 ± 0.44) to month 1 (0.45 ± 0.42) and maintained till 3 months (0.42 ± 0.44; P < 0.001). Mean CFT showed significant reduction from baseline (405.68 ± 192.422 µm) to month 1 (286.08 ± 118.36 µm) and month 3 (271 ± 104.24 µm; P < 0.001). None of the eyes recorded IOP >20 mmHg on day 1. No evidence of ocular toxicity or systemic adverse event was noted. Conclusion: : Razumab® showed a rapid improvement in CDVA and CFT in most of the eyes with efficacy observed as early as 1 month and maintained till 3 months. The biosimilar Ranibizumab can be a safe and effective low-cost drug for treating macular diseases.

Essentials of setting up a wet lab for ophthalmic surgical training in COVID-19 pandemic.

Wet labs are an extremely important training tool, especially in times of a global COVID-19 pandemic, where surgical training can be minimal. They help the trainee learn and practice in a risk-free environment, without an imminent of a complication or failure, also allowing them the chance to execute the steps of a surgery repeatedly. We summarize all the key ingredients required from setting up a wet lab to improve the surgical skill of the trainees. The review also discusses various eyeball fixating devices, preparation of the eye for various types of ocular surgeries, and the role of simulation-based training in today's scenario.