Hook and flip technique: for phacoemulsification in non-rotating nuclei and posterior polar cataracts.

PURPOSE: We put forward a physical levitation method to hook and flip the chopped nuclear fragments that could not be solely drawn by vacuum during phacoemulsification, due to various reasons such as a non-rotating nuclei or posterior polar cataracts where hydrodissection was unsuccessful or contra-indicated, respectively. METHOD: A Sinskey hook is insinuated through the crack of the divided nuclei into a plane behind the nuclear pie to 'hook and flip' the chopped piece, heading it towards the phacoemulsification probe. This simple step disassembles the nuclear chunk, thereby creating space to facilitate the dismantling of the rest of the fragments. The remnant epinuclear cushion guards the posterior capsule, mitigating the chances of serious intra-operative complications. RESULT: We have employed this technique in 17 eyes during similar situations. No specific intra-operative complications were observed; all surgeries were uneventful. A Sinskey hook utilised for this step ensures safety and familiarity, none encountered posterior capsular rent. This technique not only eases the surgery, but also decreases the anticipated intra-operative and post-operative complications. CONCLUSION: 'Hook and flip technique' thus proves useful whenever dismantling difficulties are encountered during phacoemulsification.

Corneal tomography and biomechanics in primary pterygium.

PURPOSE: To study the Scheimpflug's imaging and corneal biomechanics in primary pterygium. METHODS: A prospective observational study of 55 patients with unilateral primary nasal pterygium was done. The normal fellow eyes of patients with pterygium were taken as controls. Clinical parameters noted included visual acuity, values of corneal curvature by doing Scheimpflug imaging, wavefront aberrations in terms of higher and lower-order aberrations and corneal hysteresis (CH) as well as corneal resistance factor (CRF) values by using ocular response analyzer. RESULTS: Of the total 55 patients, mean age was 43.0 + 11.4 years (range: 20-72 years). Mean LogMar uncorrected visual acuity in pterygium eyes and control eyes was 0.21 + 0.20 and 0.12 + 0.15, respectively (p = 0.016). On Scheimpflug imaging the mean anterior corneal curvature values (Ka1/Ka2 D) were 41.09 + 3.38/44.33 + 2.29 in pterygium eyes, 43.13 + 1.79/43.98 + 2.17 in control eyes (p < 0.0005) and mean posterior corneal curvature (Kp1/Kp2 D) values were 6.14 + 0.39/6.53 + 0.43 in pterygium eyes and 6.13 + 0.28/6.46 + 0.47 in control eyes (p > 0.05). Analysis of corneal aberrations showed significantly higher corneal wavefront aberrations in pterygium eyes. Highest correlation of corneal astigmatism was noted with corneal area encroached by pterygium (ρ = 0.540 for LOA and 0.553 for HOA) and distance from pupillary center (ρ = 0.531 for LOA and 0.564 for HOA). Corneal biomechanical parameters including CH and CRF were found to be lower in the pterygium eyes, though not statistically significant (p value 0.60 and 0.59, respectively). CONCLUSION: Pterygium leads to deterioration of visual performance not only by causing refractive and topographic changes but also by causing a significant increase in corneal wavefront aberrations.

Biometric evaluation of myopic eyes without posterior staphyloma: disproportionate ocular growth.

PURPOSE: To evaluate changes in the anterior segment of myopic eyes and assess anterior biometry as a function of axial length (AL). DESIGN: Retrospective investigational study. PARTICIPANTS: Patients evaluated for phakic intraocular lens surgery at a tertiary eye care centre. METHODS: Patients with corrected visual acuity > 20/40 and AL > 24.5 mm were included in the study. Posterior staphyloma and maculopathy were ruled out in all the patients, and 176 eyes were included for analysis. AL was measured with partial coherence interferometry, while keratometry, central corneal thickness (CCT), anterior chamber depth (ACD), and horizontal white to white (WTW) were measured with slit-scanning topography. Group 1 included 55 eyes with AL < 26.5 mm, group 2 had 57 eyes with AL between 26.5 and 28.5 mm while group 3 had 64 eyes with AL > 28.5 mm. MAIN OUTCOME MEASURE: Correlation of AL with anterior biometry. RESULTS: The mean AL of the study eyes was 27.88 + 2.14 mm. The mean values of ACD (2.99 mm), CCT (0.52 mm), WTW (11.68 mm), and keratometry (43.62 D) were within the normal range. Overall, very weak correlations could be established between AL and CCT (R = 0.17, p = 0.02), AL and keratometry (R = - 0.28, p < 0.001), and AL and WTW (R = 0.22, p = 0.002), while ACD did not relate to AL significantly. The ACD and CCT did not relate significantly to AL in any of the three groups. Keratometry had a weak negative relation with AL in groups 1 and 2, while WTW had a weakly positive relation with AL in group 2 only. No variable had any significant relation with AL in group 3. CONCLUSION: There is disproportionate elongation of the eyeball in myopic patients with very weak or no correlation between anterior biometry and AL. This discord is more in longer eyes. Such a scenario can be challenging to a refractive surgeon treating highly myopic eyes and needs further evaluation.

Evaluation of Autograft Characteristics After Pterygium Excision Surgery: Autologous Blood Coagulum Versus Fibrin Glue.

PURPOSE: To compare graft outcomes following pterygium excision and conjunctival autograft fixation using patient's in situ autologous blood or standard fibrin glue-assisted conjunctival autograft adhesion. METHODS: Outcomes of 23 consecutive eyes which underwent pterygium excision and conjunctival autograft with autologous in situ blood coagulum (group I) were compared with historical case controls (20 eyes) that had undergone fibrin glue-assisted conjunctival autograft (group II). Primary outcome measure was graft stability. Secondary outcome measure was severity of graft inflammation at day 1, day 7, 3 months, and 6 months. RESULTS: The two groups were similar regarding age, gender, uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), refractive error, tear function tests, and pterygium size. Mean surgical time was similar for the two groups (14.2±2.74 min, group I; 12.25±1.88 min, group II; P=0.1); with the mean difference in operative time being 1.95 min (95% CI, 0.48-3.42 min). Postoperatively, there was a statistically significant reduction in astigmatism and improvement in UCVA, BCVA, and spherical equivalent in all eyes. No difference was found in mean epithelial defect healing time, UCVA, BCVA, astigmatism, tear film break-up time, and Schirmer I and II at 6 months between the two groups. Initial graft stability was better for group II at 1 month (P=0.001) but was similar for both groups at 6 months. Median score of graft inflammation was significantly more for group II during the first week (P<0.05; Wilcoxon rank-sum test). CONCLUSION: Autologous blood may be used as an effective alternative with lesser postoperative inflammation in comparison to glue-assisted autograft fixation.

Risk factors for intra-operative complications during phacoemulsification performed by residents.

The purpose of this study was to determine the risk factors for occurrence of intra-operative complications during phacoemulsification performed by residents. One hundred fifty patients with cataract who underwent phacoemulsification by residents, with an experience of five or more phacoemulsification surgery, at a tertiary care centre were included in this study. The pre-operative data of these patients were collected from the hospital records. Surgeons were interviewed immediately after the surgery regarding the surgeon experience, phacoemulsification technique, machine factors, and intra-operative complications. Statistical analysis was done to determine pre-operative and intra-operative risk factors. The overall surgical complication rate in resident-performed phacoemulsification was 37 % of which major and minor complications were 21 and 16 %, respectively. Success in terms of placement of intraocular lens in capsular bag was 84 %. The most common major and minor complications found were posterior capsular tear and irregular capsulorhexis, respectively. Systemic and ocular features of patients as well as type of machine (longitudinal versus torsional longitudinal) had no significant association in terms of complication rate. Increase in success rate was seen with increase in semester and number of surgeries performed. Patient factors including general physical condition, systemic diseases, and anatomical factors do not influence success in resident-performed phacoemulsification. With increase in semester of residents, there is a significant decrease in intra-operative complications. Minor complications in the beginning of case lead to increase in major complications later on during the case and decrease in success rate by junior-semester residents.

Microincision versus Standard Corneal Incision Phacoemulsification: Visual Outcome.

PURPOSE: To compare the visual outcome of microincision (2.2 mm) with standard (2.75 mm) corneal incision phacoemulsification. METHODS: In this prospective, randomized comparative study, patients with senile cataract and less than 1 diopter (D) of astigmatism were divided into two groups. Group 1 included patients undergoing phacoemulsification with 2.2 mm clear corneal incision and group 2 included those undergoing phacoemulsification with 2.75 mm incision. The steep axis measured on keratometry was marked preoperatively. Phacoemulsification was performed through clear corneal incision on this steep axis. Assessment of visual acuity (distance and near), keratometry, keratometric cylinder, contrast sensitivity by Functional Acuity Contrast Test, and surgically induced astigmatism (SIA) was performed at 1 day, 1 week, and 1, 3, and 6 months. RESULTS: Fifty eyes of 50 patients were included in the study (29 were male). There were 25 patients in each group. The mean (±SD) SIA calculated by vector analysis method (Holladay-Cravy-Koch) using keratometry value, at the end of 6 months, was 0.54 (±0.18) D and 0.58 (±0.14) D in groups 1 and 2, respectively (p = 0.27). No significant differences were found in the distance and near uncorrected visual acuity, mean keratometry, keratometric cylinder, contrast sensitivity, and SIA at any follow-up visit between two groups. CONCLUSIONS: In patients with less than 1 D astigmatism undergoing phacoemulsification, both 2.2-mm and 2.75-mm clear corneal incisions result in similar postoperative visual outcome in terms of SIA, keratometry, and contrast sensitivity.

Air-assisted implantation of anterior chamber intraocular lens.

PURPOSE: We describe a technique of air-assisted anterior chamber intraocular lens (ACIOL) implantation. METHODS: Lens aspiration and ACIOL implantation was performed in patients with progressive subluxation of lenses associated with systemic disorders. RESULTS: Surgery was performed in nine eyes of six patients. No intraoperative adverse events were noted. There was air leak from the main port in three patients while inserting the intraocular lens; however the ACIOL was successfully implanted after re-injecting air from the side port. The mean best-corrected visual acuity improved from 0.67 to 0.25 log of minimal angle of resolution at 6-month follow-up. Mean intraocular pressure preoperatively was 14.54+1.38 mm Hg and 15.16+1.15 mm Hg at 6-month follow-up. Mean corneal endothelial count was 3,151+240.49 cells per square millimeter in the preoperative period and 2,947+194.9 cells per square millimeter at 6-month follow-up. CONCLUSIONS: Air-assisted ACIOL implantation seems to be a safe and effective technique for implantation of ACIOL in cases with progressive lens subluxation.

Corneal Polishing After Pterygium Excision With Motorized Diamond Burr: A Randomized Control Trial.

PURPOSE: To evaluate outcomes of motorized diamond burr polishing versus manual polishing after pterygium excision. SETTING: Dr. Rajendra Prasad Center for Ophthalmic Sciences, New Delhi. DESIGN: A randomized, interventional observer-masked controlled trial. METHODS: Forty consecutive eyes underwent pterygium excision with fibrin, glue-assisted conjunctival autograft. In group 1 (20 eyes), polishing of the corneal bed was done using a crescent blade, and in group 2 (20 eyes), using a motorized diamond burr. RESULTS: There was no difference in the 2 groups with respect to mean age (P=0.08), gender (P=0.3), preoperative uncorrected visual acuity (UCVA) (P=0.45), best spectacle-corrected visual acuity (BCVA) (P=0.52), spherical equivalent (P=0.5), mean astigmatism (P=0.7), tear function tests like tear break-up time, tear film meniscus height, Schirmer I and II (P=0.6, 0.5, 0.7, 0.9 respectively), pterygium dimension (P=0.4), and conjunctival autograft size (P=0.24). Mean intraoperative surgical time was significantly more in group 1 (16.9 ± 2.85 min) as compared with 12.25 ± 1.88 min in group 2 (P=0.0001). Postoperatively, there was a statistically significant reduction in astigmatism and improvement in UCVA, BCVA, spherical equivalent in all eyes. No difference was found in mean epithelial defect healing time, UCVA, BCVA, astigmatism, tear film break-up time, Schirmer I and II, and tear meniscus height at 6 months between 2 groups; however, significantly better UCVA was found in group 2 at 3 months (P=0.04). Surgically induced astigmatism (SIA) was significantly more in group 2 as compared with group 1 at 6 months (P=0.0006). CONCLUSIONS: Motorized diamond burr polishing of the corneoscleral bed during primary pterygium excision in comparison with manual polishing requires significantly lesser surgical time with better UCVA, decreased astigmatism, and greater SIA at 6 months, which indicates greater astigmatic correction.

Two-step technique for posterior optic buttonholing of intraocular lens.

PURPOSE: This study aims to describe a two-step surgical technique for placement of a posterior chamber intraocular lens (IOL) in cases with crystalline lens subluxation resulting from non-progressive zonular dialysis. METHODS: The first stage entails a phacoemulsification with creation of a 4-mm posterior capsular opening using an automated vitrector. The second stage performed 6 weeks later includes an anterior vitrectomy and injection of a foldable three-piece IOL in the sulcus. The haptics of IOL are positioned in the sulcus while the optic is pushed behind the posterior capsular opening therefore "buttonholing" the IOL. RESULTS: Seven eyes of seven patients with posttraumatic zonular dialysis were operated using this technique. Follow-up of all cases revealed a well-centered IOL with good postoperative visual acuity (20/20 to 20/80). CONCLUSIONS: Our two-stage surgical technique precludes the insertion of capsular tension ring in cases with non-progressive zonular dialysis. The technique is recommended in the presence of less than or equal to 6 clock hours of zonular dialysis with preexisting posterior capsular tear or herniation of vitreous in the anterior chamber.

A case of decentered IOL managed with optic buttonholing.

We describe an unusual case which presented with late lateral IOL decentration secondary to bag subluxation in the presence of a posterior capsular defect. Instead of approaching the case with the usual IOL exchange with iris-fixated or anterior chamber IOL or by fixating it to the sclera, a relatively non-invasive sutureless method of IOL re-centration was performed by buttonholing the optic into the posterior capsular defect. It enabled a perfect IOL centration with minimal incidence of astigmatism, inflammation, macular edema, secondary glaucoma, or corneal decompensation.

Iridodialysis repair: stroke and dock technique.

Iridodialysis needs to be repaired if it is symptomatic. We describe a new bimanual technique for repair of iridodialysis where a bent 26 gauge (G) needle is used to lift the peripheral iris first. The bevel of the needle then acts as a platform for the 9-0 prolene suture with a straight needle to enable unfolding of the curled up iris by stroking before finally docking the suture needle into the bevel of the 26 G needle. This technique ensures precise scleral fixation.

Epidemiology of traumatic lenticular subluxation in India.

To study the epidemiological and clinical profile of patients with traumatic subluxated lenses at a tertiary care center in India. Ours was a non-comparative descriptive case series. Evaluation of 71 eyes of 71 consecutive patients presenting to the lens clinic over a period of 2 years with traumatic lenticular subluxation was done. Demographic and clinical profile of patients was acquired, followed by a biomicroscopic examination of the cornea, anterior chamber, iris, lens, angles, zonules, anterior vitreous and fundus. Most of the patients were adolescents and belonged to lower socioeconomic status. The mean time lag before presenting was 33.6 months (range 5 days to 40 years) and mean visual acuity in the affected eyes was 1.67 + 0.56 logMAR. Blunt trauma (63/71) was nine times more common than penetrating trauma in the etiology of manifest subluxation. Injury while playing accounted for the highest rate of injury; sports-related injury with a gulli danda or a cricket bat and ball were the most common mode of blunt trauma while bow and arrow injury was the commonest cause of injury in the penetrating trauma subgroup. Cataract was the most frequent ocular association (53.5 %). All eyes had broken zonules and most presented with inferior subluxation (46 %). Traumatic lenticular subluxation, a unilateral cause of zonulolysis usually occurs while playing with a gulli danda, bow and arrow, or cricket bat and ball in Northern India. It is a major cause of severe visual loss and a modification in risk factors is mandatory to decrease ocular morbidity from trauma.

Shifting bubble-guided sutureless technique for performing descemetorhexis for retained Descemet's membrane after penetrating keratoplasty.

We describe the use of anterior segment optical coherence tomography in the diagnosis of inadvertent retention of Descemet's membrane (DM) after penetrating keratoplasty, and a novel technique for its removal in a case of congenital hereditary endothelial dystrophy. In this technique, we use a modification of the shifting bubble technique, commonly used in deep anterior lamellar keratoplasty where a viscocohesive ophthalmic viscosurgical device is injected into the false anterior chamber which causes migration of the central air bubble placed in the anterior chamber peripherally and helps in confirming the correct space. The DM is then peeled in a circular fashion with the help of 23-G vitreoretinal micro forceps.

Management of traumatic incomplete lacerating rectus muscle injuries using multimodal imaging approach (ASOCT and CT/MRI).

Purpose: To describe the pathophysiology, importance of multimodal imaging approach, and the clinical outcomes of incomplete lacerating rectus muscle injuries. Methods: A retrospective review was conducted to identify patients with ocular deviation secondary to rectus muscle injuries. Between 2019 and 2022, a total of 30 patients were identified, amongst whom eleven patients had incompletely lacerated rectus muscles (secondary to penetrating adnexal trauma and sino-orbital surgeries). Patients' demography, nature of injury, computed tomography/magnetic resonance imaging, anterior segment optical coherence tomography features, intra-operative findings, and post-operative outcomes were reviewed. Results: The mean age of 11 patients was 31.36 ± 14.38 years. All patients had external trauma which severed the muscle in its anterior portion. Five patients had isolated inferior rectus muscle injury (45.45%), three had inferior and medial rectus muscle injuries together (27.27%), two had isolated lateral rectus muscle injury (18.18%), and one remaining patient had isolated medial rectus muscle injury (9.05%). In ten patients (90.90%) CT/MRI revealed features suggestive of muscle injury, however details with respect to muscle insertion and scleral course were lacking. In this difficult scenario, ASOCT filled these lacunae in nearly 90% of the patients by providing surgically useful details. Moreover, when CT/MRI-ASOCT imaging features were combined, the management and outcomes were even more predictable. Conclusions: Penetrating rectus muscle injuries can be better identified as incompletely lacerated muscle using multimodal imaging approach. This simple image correlation process customizes the treatment approach and hence the clinical outcomes.

Visual axis opacification after pediatric cataract surgery - An analysis of morphology and etiology.

PURPOSE: To investigate the morphological types and delineate the clinical and surgical variables associated with VAO in children undergoing pediatric cataract surgery. METHODS: We included 33 eyes of 28 children who developed clinically significant visual axis opacification (VAO) after congenital or developmental cataract surgery. All eyes underwent a comprehensive examination under anesthesia followed by a membranectomy to clear the visual axis. We classified VAO into three subgroups: fibrotic, proliferative, and combined morphologies. We reviewed and analyzed the retrospective data and the findings during membranectomy to identify the etiological variables associated with various morphologies of VAO. RESULTS: The median age at primary surgery was 7 (2-96) months. The median interval from primary surgery to the first documentation of VAO was 6 (1-22) months. Younger children developed VAO sooner than older children. VAO was fibrotic in 11 eyes (33%), proliferative in 18 eyes (54.5%), and combined in four eyes (12.12%). Most children with fibrotic VAO belonged to economically disadvantaged sections of society ( P = 0.04). CONCLUSION: Lower age at primary surgery was the predominant risk factor for the development of VAO. Besides primary posterior capsulotomy and adequate anterior vitrectomy, a strict adherence to anti- inflammatory measures and follow up in necessary to prevent the occurrence of VAO. A close follow-up facilitates early detection and management, which can prevent the onset of visually impairing amblyopia.

Clinical outcomes of topography-guided versus wavefront-optimized LASIK for correction of myopia and compound myopic astigmatism.

PURPOSE: To compare the safety, efficacy, and visual outcomes of topography-guided (TG) LASIK ablation versus advanced ablation algorithm (AAA) on Zeiss Mel 90 on virgin eyes. SETTING: A tertiary care hospital in north India. DESIGN: A retrospective comparative study. METHODS: Case sheets of 30 patients who underwent TG LASIK and 45 patients who underwent AAA LASIK between January 2021 and September 2022 were retrieved and reviewed. The TG group included 60 eyes of 30 patients, and the AAA group included age- and sex-matched 90 eyes of 45 patients. Both groups were compared for visual outcomes, residual refraction, and root-mean-square higher-order aberrations (rms HOA) at 1 week, 1 month, 3 months, and 6 months postoperatively and using unpaired t -test and Mann-Whitney U test. RESULTS: The mean preoperative spherical equivalent in the TG group and AAA group was - 3.12 (1.67) and - 3.19 (1.61), respectively. The safety and efficacy of the treatment were 100% in both groups. The postoperative increase in rms HOA was comparable in both groups ( P = 0.55). The ablation duration was significantly longer in topo-guided LASIK ( P = 0.001). CONCLUSION: AAA LASIK on MEL 90 is comparable to topography-guided LASIK for the management of low myopia and myopic astigmatism.

Bimanual phacoemulsification for subluxated cataractous lens.

Bimanual phacoemulsification has been established as a safe and efficacious means of nuclear emulsification in the past. This case report presents the use of this technique in a man in his early forties, who had subluxated cataractous lenses in both eyes. The technique allowed for effective nuclear emulsification within a closed chamber, providing better control over intraocular events. The report emphasizes the safety and effectiveness of bimanual phacoemulsification in cataract extraction, even in challenging cases like a subluxated lens.

Molecular and structural analysis of genetic variations in congenital cataract.

OBJECTIVE: To determine the relative contributions of mutations in congenital cataract cases in an Indian population by systematic screening of genes associated with cataract. METHODS: We enrolled 100 congenital cataract cases presenting at the Dr. R. P. Centre for Ophthalmic Sciences, a tertiary research and referral hospital (AIIMS, New Delhi, India). Crystallin, alpha A (CRYAA), CRYAB, CRYGs, CRYBA1, CRYBA4, CRYBB1, CRYBB2, CRYBB3, beaded filament structural protein 1 (BFSP1), gap function protein, alpha 3 (GJA3), GJA8, and heat shock transcription factor 4 gene genes were amplified. Protein structure differences analysis was performed using Discovery Studio (DS) 2.0. RESULTS: The mean age of the patients was 17.45±16.51 months, and the age of onset was 1.618±0.7181 months. Sequencing analysis of 14 genes identified 18 nucleotide variations. Fourteen variations were found in the crystallin genes, one in Cx-46 (GJA3), and three in BFSP1. CONCLUSIONS: Congenital cataract shows marked clinical and genetic heterogeneity. Five nucleotide variations (CRYBA4:p.Y67N, CRYBB1:p.D85N, CRYBB1:p.E75K, CRYBB1:p.E155K, and GJA3:p.M1V) were predicted to be pathogenic. Variants in other genes might also be involved in maintaining lens development, growth, and transparency. The study confirms that the crystallin beta cluster on chromosome 22, Cx-46, and BFSP1 plays a major role in maintaining lens transparency. This study also expands the mutation spectrum of the genes associated with congenital cataract.