Preoperative COVID-19 Testing for Elective Ophthalmological Procedure in a Tertiary Health Care Centre: Our Experience During the Pandemic.

BACKGROUND: To study the prevalence of coronavirus infection among asymptomatic patients requiring eye surgery and the role of screening in prevention of spread of infection among the healthcare workers. DESIGN: The prospective observational study was conducted in the Ophthalmology department of a tertiary care center in Delhi from September 2020 to December 2020. SETTING: Patients requiring elective ophthalmological procedures in a tertiary care hospital were screened for coronavirus using the RT-PCR method. Testing methods and results were documented. RESULTS: Among the 218 asymptomatic patients posted for elective surgery in that period, 16 (7.3%) were found to be positive for COVID-19. Those who tested positive were advised home isolation and surgery was postponed for the next 14 days. No complications were reported in these patients. One health-care worker also tested positive for COVID-19 during our study period. CONCLUSION: In our study, 1 out of 14 asymptomatic patients were found to be carriers for the novel virus. Asymptomatic COVID-infected patients may lead to transmission of the virus inside the hospital among the visiting patients and hospital staff while they have no adverse effect on the surgery and its outcome.

Optic perineuritis.

Optic perineuritis (OPN) is a rare inflammatory disorder in which the inflammation is confined to optic nerve sheath. It can be idiopathic or secondary to underlying systemic autoimmune disorder. It usually presents with unilateral progressive diminution of vision with pain on eye movements and optic disc oedema. Hence, clinically OPN mimics optic neuritis resulting in delayed diagnosis and suboptimal treatment. In contrast to optic neuritis, patients with OPN are usually of older age group and more likely show sparing of central vision. MRI is an important tool for diagnosis of OPN apart from optic nerve sheath biopsy. Perineural enhancement on MRI is diagnostic of OPN. Oral corticosteroid therapy gives dramatic and rapid improvement in signs and symptoms. Rapid tapering of steroids increases the risk of relapse. Overall, prognosis of OPN is generally good if adequate treatment is given timely.

Topical vs Peribulbar Anesthesia: Comparison of Anterior Chamber Depth and the Resultant Visual Outcome After Phacoemulsification.

PURPOSE: To compare anterior chamber depth and postoperative visual outcome in patients undergoing phacoemulsification under topical vs peribulbar anesthesia. MATERIALS AND METHODS: Prospective, randomized, comparative observational study.Sample size: 110 eyes with 55 eyes each. Group I: Patients undergoing phacoemulsification under topical anesthesia.Group II: Patients undergoing phacoemulsification under peribulbar anesthesia.Once patients were selected, baseline a standard ophthalmic examination was done including best-corrected visual acuity (BCVA), refraction, IOP by NCT, anterior segment evaluation with slit lamp biomicroscopy, keratometry, axial length, and ACD measurement by IOL master. Post-operatively, the patients were reviewed at day 1, week 1, week 6 for the same parameters.Statistics:Quantitative variables: Paired and unpaired t-test.Qualitative variables: Chi square test.A P-value of <0.05 was considered statistically significant. RESULTS: Inter-group comparisons of post-operative change in ACD at 1-week post-op (P-value<0.001) and 6-week post-op (P-value<0.001) were statistically significant when compared to the pre-op values. The mean spherical equivalent in group I was 0.27±0.26 d and that in group II was 1±0.32 d at 1-week post-op. The mean spherical equivalent in group I was 0.23±0.20 d, while that in group II was 0.85±0.64 d at 6-week post-op. This difference was statistically significant both at 1-week post-op (P-value=0.002) and 6-week post-op (P-value<0.001). CONCLUSION: Post-phacoemulsification, the ACD is more after peribulbar anesthesia as compared to topical anesthesia. Post-op refractive outcome is better with the use of topical anesthesia.

Forceps-assisted, 10-0 monofilament nylon, suture-guided capsular tension ring insertion in subluxated cataracts.

Capsular tension ring (CTR) and iris hooks have proved to be useful devices in cataract surgery in cases of zonular weakness and dialysis. We would like to describe the use of monofilament 10-0 nylon (MFN)- guided CTR insertion in a subluxated cataractous lens. Here, the MFN is passed through the distal trailing eyelet of the CTR (simple or Morcher's depending on the size of the defect and subluxation) for controlled insertion of the distal eyelet of the CTR beneath the anterior capsulorhexis margin and safe retrieval of CTR in case of an iatrogenic posterior capsular tear during CTR insertion or phacoemulsification.

Retro-intraocular Lens Irrigation-aspiration to Prevent Capsular Block Syndrome at the Hands of Novice Surgeons.

Retro-intraocular lens (IOL) irrigation-aspiration is of paramount importance in order to remove the viscoelastic substance from the retro-IOL space and to prevent any early post-operative capsular block syndrome. However, manoeuvring the IOL to reach the retro-IOL space may be difficult at the hands of novice surgeons despite the use of coaxial or bimanual irrigation-aspiration probes. We describe a simpler and safer technique in order to facilitate the removal of this retro-IOL viscoelastic substance using a 26-Gauge bent-cannula mounted on a 2-ml syringe. The fluid is injected forcefully along with sideways movement of cannula in a single-plane to displace the viscoelastic substance.

Megaloblastic anemia and bilateral disc edema: An enigma Have we figured it out yet?

A 28-year-old male presented with insidious-onset, painless, progressive diminution of vision in both eyes. He denied any other ocular symptoms. On examination, visual acuity in both eyes was 6/60. Color vision and contrast sensitivity were maintained in both eyes. Direct ophthalmoscopy revealed that the optic discs were bilaterally hyperemic and congested, with blurring of all the disc margins and loss of spontaneous venous pulsations. Besides this bilateral disc edema, rest of the clinical examination was normal. Primary intensive search for any intracranial space-occupying lesions returned negative on computed tomography scan imaging. Blood investigations revealed a hemoglobin level of 9.2 g/dl, leukocyte count of 7000 cells/mm3, and serum Vitamin B12 level of 155 pg/ml (200-835 pg/ml). Serum homocysteine and methylmalonic acid levels were done and were found to be elevated. After 4 weeks, visual acuity improved to 6/6 in both the eyes, and laboratory investigations showed no signs of Vitamin B12 deficiency. Nonsurgical causes for papilledema should be considered in the differential diagnosis. Early diagnosis and prompt treatment is the key to a good prognosis in Vitamin B12-deficient optic neuropathy, which has shown to have a good prognosis if treatment is initiated in the first few months after the onset of symptoms.

Intraoperative capsular marking for toric intraocular lens placement.

Preoperatively, the surgeon instills two drops of 0.5% proparacaine and then marks the 0° and 180° points at the limbus using a Gentian violet marker and 26G needle edge. Intraoperatively, after phacoemulsification and irrigation and aspiration of the cortex are complete, the surgeon inspects the previously marked 0°-180° points on the limbus. In case the steeper astigmatic meridian needs to be marked, a Mendez Ring is used and the meridian is marked using a Gentian violet marker and 26G needle edge. The desired markings (2 mm in length only) on the anterior lens capsule can be made using 26G needle bent at the bevel or using micro-vitreoretinal scissors. The toric intraocular lens (IOL) is then rotated in the bag in the desired meridian (customized-toric IOL in 0°-180° meridian and noncustomized toric IOL in steeper marked meridian), viscoelastic substance is aspirated and corneal wounds are hydrated.

Role of trabeculectomy in advanced glaucoma: Whether we stand to consider it a bane or a boon today?

PURPOSE: To elucidate the role of trabeculectomy in advanced glaucoma. MATERIALS AND METHODS: Only patients with primary open-angle glaucoma were selected. All patients who had cup-disc ratio of 0.9 or a near-total cupping were given a trial of aggressive maximum medical therapy for IOP control for at least 4 weeks. Target IOP was defined as ≤ 12 mm Hg. Patients who showed progression were included in the study. A total of 10 patients were selected. Trabeculectomy was performed using limbal-based conjunctival flap. Patients were followed up for a period of 2 years for visual acuity, intraocular pressure, visual fields, slit-lamp biomicroscopy and bleb morphology. RESULTS: Mean preoperative intraocular pressure on five drugs was 21.7 ± 3.8 mm Hg (range 18-27 mm Hg) on maximum medical therapy. Mean post-operative intraocular pressure was 11 ± 1.78 mm Hg (range 9-13 mm Hg) and 11 ± 1.92 mm Hg (range 9-14 mm Hg) at 1 month and 6 months post-operatively, respectively. Post-operatively, the visual acuity remained stable in 17 patients. It dropped by 1 Snellen line in 2 patients and 2 Snellen lines in 1 patient, respectively, over a period of 6 months and later improved to 6/6P following cataract surgery. There was no defined visual field progression in any of the 20 patients. CONCLUSION: Besides being a cost-effective alternative to medical management, trabeculectomy not only provides a better IOP control but also has a high safety profile when performed by an experienced surgeon.

BKC and CME: Is benzalkonium chloride hindering our efforts to achieve the desired postoperative visual acuity?

PURPOSE: To evaluate and compare the change in postoperative central macular thickness in patients receiving benzalkonium chloride (BKC)-preserved and BKC-free medications after uneventful phacoemulsification. SETTING: V.M.M.C & Safdarjung Hospital, New Delhi (a tertiary health care hospital). STUDY DESIGN: Prospective randomized comparative observational study. MATERIALS AND METHODS: Once patients were selected, the baseline standard ophthalmic examination was done. SAMPLE SIZE: 140 eyes were enrolled and randomly divided into two groups. (a) Group I: receive BKC-preserved topical medications and (b) Group II: receive BKC-free topical medications of same constituents postoperatively. Group I patients received topical BKC-preserved moxifloxacin 0.5% + dexamethasone 0.1% eye drops six times a day, timolol maleate 0.5% twice daily, tropicamide 0.8% + phenylephrine 5% once a day for 6 weeks, and Group II received same BKC-free topical eye drops for 6 weeks. Postoperatively, the patients were reviewed at day 1, week 1, week 6 for same parameters. STATISTICS: Quantitative variables: paired and unpaired t test. p value < 0.05 was considered statistically significant. RESULTS: The mean CMT in µm at 1 week in Group I was 269.39 ± 14.56 and in Group II was 270.04 ± 6.56. The mean CMT in µm at 6 weeks in Group I was 270.39 ± 17.18 and in Group II was 270.90 ± 7.00. CONCLUSION: Neither do BKC-preserved topical medications have any independent role in increasing the central macular thickness after uneventful surgery nor do they have any role in causing pseudophakic CME.

Comparative analysis of coaxial phacoemulsification with 2.2- and 2.8-mm clear corneal incisions.

PURPOSE: To compare the intraoperative efficiency and postoperative visual outcome of coaxial phacoemulsification using 2.2- and 2.8-mm clear corneal incision coaxial phacoemulsification. SETTING: The study was conducted at Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi which is a tertiary health care centre. STUDY DESIGN: This is a prospective, randomized, comparative interventional study. MATERIALS AND METHODS: A total of 140 eyes of patients undergoing cataract surgery were enrolled according to the inclusion-exclusion criteria and randomly divided in two groups of 70 such that Group I-Patients underwent phacoemulsification through 2.8-mm clear corneal incision. Group II-Patients underwent phacoemulsification through 2.2-mm clear corneal incision.Postoperative assessment was done at 1 day, 1 and 6 weeks to note best-corrected visual acuity (BCVA), ophthalmic examination, corneal topography, central corneal thickness and corneal endothelial cell count. STATISTICS: 1. Quantitative variables were compared using Mann-Whitney test and Wilcoxon ranked-sum test. 2. Qualitative variables were compared using Fisher's exact test. p value of <0.05 was considered statistically significant. RESULTS: There is steady trend in decrease in postoperative astigmatism with time, more so in 2.8 mm group; however, differences were not found to be statistically significant. 2.2 mm group had larger increase in CCT and ECC compared to 2.8 mm group which was not statistically significant (p = 0.296). CONCLUSION: Reducing the incision size from 2.8 to 2.2 mm does not result in any significant reduction in the amount of surgically induced astigmatism. Also, both the incision sizes have similar intraoperative efficacy when compared in terms of postoperative decrease in corneal endothelial cell count and increase in central corneal thickness.

Suture-guided sulcus implantation of a single-piece foldable acrylic intraocular lens after posterior capsule rupture.

We describe a technique for suture-guided sulcus implantation of a foldable acrylic posterior chamber IOL (PC IOL). A 10-0 monofilament nylon suture is used to control insertion of the PC IOL over the ciliary sulcus and enable safe retrieval if the PC IOL drops during insertion, stabilization, or centration. In this technique, the 10-0 monofilament nylon suture acts as a guy rope to hold onto the PC IOL, enabling the surgeon to inject the IOL into the sulcus, unfold it in the iris plane, dial it in the appropriate meridian, and stabilize it.

Management of glaucoma in pregnancy: risks or choices, a dilemma?

The treatment of glaucoma in and around pregnancy offers the unique challenge of balancing the risk of vision loss to the mother as against the potential harm to the fetus or newborn. Most anti-glaucoma drugs (i.e. beta-blockers, prostaglandin analogues, carbonic anhydrase inhibitors topical and systemic, cholinergics, anticholinesterases, and apraclonidine) are considered category C agents and ophthalmologists are usually limited to treating patients with the category B drugs of brimonidine and dipivefrin. Brimonidine is generally the preferred first-line drug in the first, second and early third trimester. Late in the third trimester, brimonidine should be discontinued because it can induce central nervous system depression in newborns wherein topical carbonic anhydrase inhibitors may be the optimal choice. Glaucoma surgery can be performed with caution in second and third trimester if the patients have a strong indication for the procedure. However, anesthetics, sedative agents, and antimetabolites still have potential risk for the fetus. Argon laser trabeculoplasty (ALT) or selective laser trabeculoplasty (SLT) is an alternative treatment that can be performed in all trimesters. Carbonic anhydrase inhibitors and ß-blockers are certified by the American Academy of Pediatrics for use during nursing. However, low doses of these medications should be considered when used in the breast feeding period. Optimum treatment for glaucoma in pregnancy must not be withheld so as to prevent any further deterioration in progressive vision loss and quality of life.

Intraoperative intracameral pilocarpine after capsular tension ring and capsule/iris hook insertion in pediatric eyes with subluxated cataract.

UNLABELLED: Capsular tension rings and iris hooks have proved to be useful devices in cataract surgery in cases of zonular weakness and dialysis. We describe the use of intracameral pilocarpine-induced pupillary miosis to couple the iris and the capsulorhexis edge with iris hooks during phacoemulsification in pediatric cases with posttraumatic subluxated cataractous lens. The coupled iris and capsule act as a single unit, eliminating the space between them and significantly reducing the possibility of vitreous or ophthalmic viscosurgical device passing through the zonular defect. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

26-G needle-assisted sutureless glueless intrascleral haptic fixation for secondary ciliary sulcus implantation of three-piece polymethylmethacrylate intraocular lens during penetrating keratoplasty.

After tenotomy adjoining 3 o'clock and 9 o'clock limbus, 3-mm-wide partial-thickness scleral tunnels are created at these two diametrically opposite points 3 mm from the limbus such that they reach up to a distance of 1.5 mm from the limbus. Two ab externo sclerotomies are created using 26-G needles on the bed of these partial-thickness scleral tunnels. Precaution is taken to ensure that the positions of the sclerotomies are diagonally opposite each other. A scleral niche is made using a 26-G needle to accommodate the intraocular lens (IOL) haptic later. A 7.5-mm trephine is used to excise the corneal button, and anterior vitrectomy is performed. The haptic of a three-piece polymethylmethacrylate IOL is docked in a bent 26-G needle. It is then pulled out under the partial-thickness scleral tunnel and placed securely in the scleral niche opposite to the haptic. An 8-mm donor corneal button is sutured in place using 16 equidistantly placed 10-0 nylon interrupted sutures.

Deep anterior lamellar keratoplasty with phacoemulsification.

PURPOSE: To evaluate the technique and outcomes of deep anterior lamellar keratoplasty (DALK) combined with phacoemulsification for corneal opacity with coexisting cataract. SETTING: Cornea Service, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. DESIGN: Cohort study. METHODS: Eyes with cataract of varied nucleus grade and with different corneal pathologies were selected. Modified triple procedures were performed in all eyes. RESULTS: Twenty eyes were evaluated. The corrected distance visual acuity (CDVA) after 3 months was 20/60 or better in 18 eyes. One eye had 20/80 CDVA as a result of perioperative and postoperative complications. One graft became opaque after postoperative infection. CONCLUSION: Simultaneous DALK with phacoemulsification was feasible in eyes with coexisting corneal and lenticular pathology, and the outcomes were encouraging. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Atypical Duane's retraction syndrome: congenital adduction palsy with synergistic divergence in association with aberrant trigeminal innervation and facial hypoplasia.

The authors describe the atypical and unique features of trigeminal-oculomotor synkinesis in a 6-year-old boy with left congenital adduction palsy and synergistic divergence with facial hypoplasia. Adducting movements of the left eye were also seen on mastication. To the best of the authors' knowledge, a case of this nature has not previously been reported. This case illustrates the absence of changes in palpebral aperture and globe retraction on attempted adduction and also the complete absence of any abduction deficit of the involved eye. Additionally, presence of adducting movements on mastication suggests a trigemino-oculomotor synkinesis. Hypothesis favors an anomalous innervation of the medial rectus muscle from the motor branch of the trigeminal nerve that innervates the external pterygoids.

The efficacy of postenucleation saline wash and the effect of different antimicrobial agents on microbial contamination of donor eyes.

OBJECTIVES: To evaluate the efficacy of postenucleation saline wash and the effect of different antimicrobial agents on the microbial contamination of donor eyes. METHODS: Two hundred donor eyes were given saline wash and treated with any one of the following 5 randomly selected antimicrobial solutions: 1% povidone-iodine for 3 min, 0.3% gentamycin for 10 min, 0.3% ciprofloxacin for 10 min, a combination of neomycin 1,700 IU, gramicidin 0.025% and polymyxin B 5,000 IU (Neosporin(R)) for 10 min and a combination of 0.3% amikacin for 10 min, followed by 2.5% cefazolin for 10 min. Limbal swabs were sent for culture before and after saline wash and after treatment with antimicrobial agents. RESULTS: On culture of the pretreatment swabs, 77.5% were positive for growth with 75.5% bacterial and 11.5% fungal. Coagulase-negative Staphylococcus (29.1%) was the most common bacterial contamination followed by Pseudomonas aeruginosa (18.5%), Acinetobacter sp. (18.5%) and Alcaligenes faecalis (13.2%). A 20-ml sterile saline wash resulted in a 20% decrease (p < 0.01) in the amount of contamination. The maximum antimicrobial effect with regard to bacterial decontamination was achieved with povidone-iodine (64% decrease in the amount of contamination, p < 0.01) followed by ciprofloxacin (47.6% decrease, p < 0.05), the combination of cefazolin and amikacin (42.5%, p < 0.05), Neosporin (38.5%, p < 0.05) and then gentamycin (21.7%, p = NS). CONCLUSIONS: A thorough saline wash and treatment with 1% povidone-iodine for 3 min is a more effective method for the decontamination of donor eyes as compared to most currently available and frequently used antibiotics.

Visual outcome after intravenous dexamethasone therapy for idiopathic optic neuritis in an Indian population: a clinical case series.

PURPOSE: To evaluate the clinical profile, response to dexamethasone treatment and visual function outcome in Indian patients with acute optic neuritis. MATERIALS AND METHODS: We conducted an observational study of patients with acute optic neuritis who were treated with intravenous dexamethasone (100 mg in 250 ml of 5% dextrose over 1-2 hours daily, for three consecutive days) and had completed at least two years of follow-up. Parameters assessed included visual acuity, contrast sensitivity, color vision, visual fields, relative afferent pupillary defect (RAPD) and visually evoked potentials. Out of 40 patients studied, 26 patients (33 eyes) had all visual function parameters assessed. Twenty three patients (28 eyes) had completed two years of follow-up and were included for statistical analysis. RESULTS: Improvement in visual acuity was statistically significant for distance after 24 hours of the first dose (P = < 0.001) and for near vision after 24 hours of the second dose (P = 0.006); improvement in color and contrast sensitivity was statistically significant 24 hours after the third dose (P = < 0.001 for color vision and P = 0.013 for contrast sensitivity). Significant improvement in RAPD and visual fields were seen by 1 month (P = 0.005). Recurrence was seen in 4 eyes of 4 patients. No serious side effects were observed. At two years, 82.14% (23 out of 28) eyes had visual acuity > 20/40. CONCLUSION: Treatment with intravenous pulsed dexamethasone led to rapid recovery of vision in acute optic neuritis, without any serious side effects.

Use of the Unfolder Silver/Sapphire system to inject capsular tension ring during phacoemulsification in cases with subluxated cataract.

Capsular tension rings (CTRs) have proved to be useful devices in cataract surgery in cases of zonular weakness and dialysis. They can be inserted with the help of forceps or commercially available injection systems. We describe use of the Unfolder Silver/Sapphire Series implantation system (Advanced Medical Optics, Inc.) to inject a CTR into the capsular bag during phacoemulsification in cases with subluxated cataract. The implantation system used for CTR insertion can subsequently be used for implantation of a foldable intraocular lens.