Customized incision cataract surgery: Astigmatism modulation techniques in manual small-incision cataract surgery.

Advanced instrumentation and intraocular lenses (IOL) allow great refractive and visual outcome control to permit excellent correction of refractive aberrations. Residual astigmatism can be modified to provide depth of focus using an appropriate incision in the steepest meridian in manual small-incision cataract surgery (MSICS). The authors describe the nomogram for surgically correcting astigmatism (SCA). This technique can handle preoperative astigmatism of about 2.25 DCyl with the standard incisions-straight incision of 5, 6, and 7 mm in length, the minimally curved frown incision, the frown incision, the frown incision with an accentuated frown, and the U incision placed on the steep axis in the superior or the temporal quadrant depending on the axis of pre-operative astigmatism.

Closed chamber manual phacofragmentation in manual small-incision cataract surgery.

Manual small-incision cataract surgery (MSICS) has existed as an alternative to conventional phacoemulsification since its inception. The size of the incision has been becoming smaller in MSICS to reduce the surgically induced astigmatism. Smaller incisions go hand in hand with nucleus debulking and fragmenting techniques which have been practiced over almost four decades. Such techniques have a learning curve and require meticulous execution. The authors describe a technique to achieve nucleus bisection or trisection or debulking in a closed anterior chamber. This technique has been in use for a long time; it has shown excellent results and has a shorter learning curve. Since it is done in a closed chamber, the risk to the corneal endothelium is minimized as the anterior chamber remains deep throughout the procedure. Sudden escape of the viscoelastic and shallowing of the chamber are prevented, and the corneal endothelium is well protected. It uses iris as support and reference. The specially designed chopper is an inexpensive addition to the instruments. Fragmentation is achieved in the proximal half of the chamber where control over instruments is maximum. Pristine clear cornea on day 1 is the rule rather than the exception with this technique. This is a safe and repeatable technique for phacofragmentation in cataract extraction.

Endoexpression technique of nucleus delivery in manual small-incision cataract surgery.

Manual small-incision cataract surgery (MSICS) is a cost-effective alternative to phacoemulsification and extracapsular cataract extraction (ECCE) for cataract surgery. The surgical technique in MSICS is heterogeneous, and the maximum variation exists in incision and nucleus delivery techniques. Many studies on various incisions are available, and most of them are dedicated to surgically induced astigmatism (SIA), utility, and visual outcomes. The nucleus delivery techniques have less-extensive literature available. They can be divided into "pulling" techniques like phacosandwich technique, fish hook technique, and vectis delivery and "pushing" techniques like viscoexpression or hydroexpression with irrigating vectis/Blumenthal's MiniNuc technique. Postoperative surgical-induced astigmatism is comparable in all techniques. The authors describe a pushing technique which does not raise the pressure of the anterior chamber and can be utilized with variable-sized and irregularly shaped nuclear fragments. It has universal application, especially when the size of the incision is getting smaller in MSICS and phacofragmentation is being used as an adjunct to reduce the incision size. It can be used in situations like posterior polar cataracts, where pressure variations in the anterior chamber can be dangerous.

Health economics and manual small-incision cataract surgery: An illustrative mini review.

Cataract extraction is one of the most common surgical procedures performed worldwide. Manual small-incision cataract surgery (MSICS) is a popular technique of cataract extraction. Full economic evaluation of different techniques is of value to policy makers. This was a systematic review of published literature to present a brief overview of evidence available in respect of economic evaluation measures like cost effectiveness, cost utility, and cost parameters in cataract patients regarding MSICS. The data on these was sparse and heterogeneous. Direct costs of MSICS were lower than phacoemulsification (PE): $25.55 (PE) to $17.03 (MSICS) in India, $15 (MSICS) to $70 (PE) in Nepal, and $62.25 (MSICS) to $104.15 (PE) in Thailand. The cost utility analysis for MSICS demonstrated savings of $79.57 (INR6175) per gain in LogMAR BCVA, $8.91 (INR691) per QALY gained and $1.42 (INR110) per VF 14 score increment in India. Incremental cost-effectiveness ratio (ICER) $368.20 (13,215.50 Baht) for MSICS was better than $489.30 (17,561.70 Baht) for PE in Thailand. ICER for femto laser-assisted cataract surgery (FLACS) compared to was €10,703 in femtosecond laser-assisted versus phacoemulsification cataract surgery (FEMCAT) study. The corrected ICER for PE against MSICS is €146.50. The limited data available demonstrates that MSICS is the most cost-effective technique among FLACS, PE, and MSICS. MSICS scores over other existing alternatives of cataract extraction from cost-effectiveness and cost-minimization approaches. Further research is required in this area.

Posterior polar cataract: Hydrodissection and nucleus rotation in manual small-incision cataract surgery not a taboo with proper fluidics.

A posterior polar cataract is a discoid posterior polar plaque-like cataract with a thin and fragile to absent posterior capsule with adherent acellular opacity to the capsule reported in the literature. It is a stationary or slowly progressive opacity. A higher risk of complications such as posterior capsular tear and nucleus drop makes this a challenging surgery. The techniques described in the literature include bimanual irrigation aspiration, leaving the plaque for later Yag, bimanual micro phaco, Lambda technique with dry aspiration, Phaco if opacity <4 mm and soft nucleus, pars plana vitrectomy (PPV), pars plana lensectomy (PPL) if opacity >4 mm and soft nucleus, intra-capsular cataract extraction (ICCE) and scleral fixated intraocular lens (IOL) if opacity >4 mm with the hard nucleus, viscodissection, 3 ports PPL, PPV, low parameters phaco, modified epinucleus removal, inverse horse-shoe technique, standard phacoemulsification, chip and flip for soft cataracts, stop and chop for hard cataracts, layer-by-layer phacoemulsification, standard lens aspiration, pars plicata posterior vitrecto-rhexis, manual small-incision cataract surgery, and conventional extracapsular extraction. A posterior capsule rupture rate of 0 to 36% is reported in different series for cataract extraction. To prevent this dreaded complication, surgeons used many modifications. Minimal hydrodissection in posterior polar cataract extraction was described by Fine et al. The authors describe a technique of low flow manual small-incision cataract surgery with minimal hydrodissection and nucleus rotation with no associated posterior capsule rent. This demonstrates that if the fluidics is understood and corrected, then minimal hydrodissection and nucleus rotation is not taboo in posterior polar cataract extraction by manual small-incision cataract surgery.

Tunnel-floor entry continuous curvilinear capsulorhexis technique: Rhexis in a controlled and stable anterior chamber always.

Continuous circular capsulorhexis (CCC) was demonstrated independently by Thomas Neuhann, Kimiya Shimizu, and Howard Gimbel in the 1980s and it finds mention in the landmark paper by Gimbel and Neuhann. The authors describe a technique of achieving the rhexis in a stable, viscoelastic-filled anterior chamber using the tunnel floor as the entry. This gets covered by the roof of the tunnel postoperatively and, therefore, does not leak. There is no oar-locking or striae even when cystitome goes beyond the edge of the tunnel. As there is no escape of the viscoelastic substance, there is no change in the pressure or shallowing of the anterior chamber. It is a useful technique for beginners. It is of great help in difficult cases like intumescent cataracts, shallow anterior chambers, hyperopes, nanophthalmos, pseudoexfoliation, small non-dilating pupils, intraoperative floppy iris syndrome (IFIS), and phacomorphic glaucoma.

State of the nation survey on cataract surgery in India.

Purpose: To study the knowledge, attitudes, and practices of the ophthalmologists in India regarding cataract extraction practices. Methods: A prospective, online, descriptive study was conducted from January 2022 to April 2022 using a self-developed validated questionnaire attached which was administered through a generated link. Results: The mean age of these 153 respondents was 47.02 (SD = 11.53) years with a male preponderance (70.59%). The majority (52.9%) had completed a fellowship after their post-graduation, and 56.20% provided sub-specialty services. Comprehensive ophthalmology (69.93%) and anterior segment (50.32%) practice were the most popular. Although 76.47% of respondents used a mix of techniques, 11.11% surgeons used only phaco-emulsification and 9.8% used only manual small-incision cataract surgery (MSICS) as the lone cataract treatment modality. Roughly 38% felt that outcomes were comparable for phaco-emulsification and MSICS, whereas about 44% opined that the outcomes of phaco-emulsification were better. MSICS outcomes were reported to be better by approximately 15%. The frown incision (53.59%), the straight incision (19.60%), and the straight incision with back cuts (10.45%) were popular. The majority (71.24%) of the respondents were willing to train fellow ophthalmologists and youngsters in MSICS. Standalone practices and family practices (42.48%), private eye institutes (10.45%), medical colleges (12.41%), and government non-teaching hospitals (11.11%) were the major service providers. 4% were working in rural hinterland. Conclusion: The majority of the surgeons use a mix of cataract extraction operative techniques. A large, willing talent pool of manual small-incision cataract surgeons exists. India can be a global hub for MSICS delivery and training.

Artificial intelligence in ophthalmology and healthcare: An updated review of the techniques in use.

Artificial intelligence (AI) refers to "the ability of a digital machine or computer to accomplish tasks that traditionally have required human intelligence." These days, artificial intelligence is becoming popular in healthcare and more so in ophthalmology. It has shown promising results in diabetic retinopathy detection and referral. Recently, Indian data has depicted that the new algorithms can be generalized to the Indian population as well. An increased understanding of the tools is required especially by the practitioners and medical researchers so that they can contribute meaningfully to the development of the technology and not become mere data providers and data labelers. While AI is extensively being used by finance, marketing and travel industry, its application is more recent in medicine. The applications based on artificial intelligence have the potential to benefit all stakeholders in the healthcare industry.

Applications of Machine Learning in Pediatric Hydrocephalus: A Systematic Review.

INTRODUCTION: Annually, hydrocephalus affects nearly 7 children per 10,000 live births around the world. It significantly impairs the quality of life of such children and is associated with increased morbidity and mortality The high cost of treatment and post-intervention complications add to the burden of disease. Deployment of machine learning (ML) models in actual clinical settings have led to improved outcomes. OBJECTIVE: The aim of this systematic review is to analyze the utility as well as acknowledge the achievements of AI/ML in HCP decision making. METHODOLOGY: PubMed and Cochrane databases were used to perform a systematic search with proper terminology to include all the relevant articles up to May 2021. RESULTS: Fifteen studies that described the use of ML models in the diagnosis, treatment, and prognostication of pediatric hydrocephalus were identified. The median accuracy of prediction by the ML model in various tasks listed above was found to be 0.88. ML models were most commonly employed for ventricular segmentation for diagnosis of hydrocephalus. The most frequently used model was neural networks. ML models attained faster processing speeds than their manual and non-ML-based automated counterparts. CONCLUSION: This study attempts to evaluate the important advances and applications of ML in pediatric hydrocephalus. These methods may be better suited for clinical use than manual methods alone due to faster automated processing and near-human accuracy. Future studies should evaluate whether the use of these models is feasible in the future for patient care and management in field settings.