Comparison of Bent Ab-interno Needle Goniectomy and Goniotomy in Primary Congenital Glaucoma: A Randomized Controlled Trial.

PURPOSE: Primary Congenital Glaucoma (PCG) is a potentially blinding disease, and the search for the best surgical option always remains. This study investigated the efficacy of Bent Ab-interno Needle Goniectomy (BANG) compared to the established standard of traditional goniotomy. DESIGN: Parallel group Randomized Controlled Trial PARTICIPANTS: Infants with PCG aged one month to one year with similar clinical features in both eyes. INTERVENTION: The two eyes of eligible patients were randomized to either goniotomy or BANG using a 25-gauge needle bent as a reverse cystitome, and the surgeries were done on the same day in both eyes. Postoperatively each infant was followed up for a minimum period of one year. MAIN OUTCOME MEASURES: The primary outcomes measured were intraocular pressure (IOP) control and the requirement for antiglaucoma medications (AGMs). The secondary outcome measures included corneal clarity enhancement, axial length stability, incidence of surgical complications or the need for repeat surgery. RESULTS: Eight infants with both eyes eligible, were included. In each infant, one eye was randomized to BANG and the other to conventional goniotomy. The mean age was 7.6±3.6 months. There was no significant difference in the mean preoperative IOP (16.8 +8.87 mm Hg versus 17+6.0 mm Hg; p=0.48) in eyes randomized to goniotomy or BANG. The mean number of AGMs (1.7±1.11 versus 2+0.81 respectively; p=0.26) were similar in both groups. Postoperatively, the IOP at 6 months (14.05 + 4.1 vs 16.2+4.07; p=0.22) and one year (15.3 ± 3.4 versus 17.1 + 3.0; p=0.15) were similar in eyes that underwent goniotomy or BANG respectively. Both procedures demonstrated significant improvements in corneal clarity and maintained normal axial length growth. However, the BANG group required slightly more AGMs than the goniotomy group. There were no serious complications in either group. Both eyes of one patient required repeat surgery for IOP control and underwent a combined trabeculotomy with trabeculectomy at nine months and one year post-operatively, respectively. CONCLUSIONS: This study indicates that goniotomy remains an effective surgical treatment for PCG. The absence of discernible superiority in IOP control or overall outcomes implies that the added complexity of excising the trabecular meshwork in BANG may not confer additional benefits over the established approach.

Intracameral anaesthetic mydriatic versus topical mydriasis in Pediatric Cataract Surgery: a randomised control study.

PURPOSE: To compare the pupil dynamics using premixed intracameral anaesthetic mydriatic combination (ICAM) of phenylephrine (0.31%), tropicamide (0.02%) and lidocaine (1%) vs topical mydriatics (TM) constituting Tropicamide 0.8% Phenylephrine 5% combination and cyclopentolate 0.5% drops in pediatric cataract surgery. METHODS: Design: Randomised, Masked, Fellow-Eye Controlled Trial SETTING: Tertiary eye care facility STUDY POPULATION: Children aged ≤ 12 years with bilateral cataracts planned for surgery. One eye was randomised to receive ICAM and the other eye(control) topical mydriatics INTERVENTION: Commercially available ICAM which was injected at the beginning of surgery or TM three times at an interval of 30 minutes, one hour before the scheduled time of surgery. The other treatment was administered for the second eye cataract surgery. MAIN OUTCOME MEASURE: Pupil dynamics at various points of surgery were studied by a masked observer. RESULTS: Sixty three patients(126 eyes) were randomised to receive ICAM in one eye (Group 1) and topical drops (Group 2) in the other. The mean age of the study children was 15.7 ± 24.3 months (range 3 months-5 years). Adequate mydriasis with single injection was achieved in 93.5% in Group 1 and 88.8% in Group 2 without additional pharmacotherapy or intervention. The mean pupillary diameter increased from 1.78 mm to 5.1 mm after injection of one unit of ICAM and from 1.75 mm to 6.06 mm with topical mydriatics (p < 0.0001). Maximum pupillary dilation achieved was 6.06 ± 1.17 in Group 1 and 6.75 ± 1.07 mm in Group 2 (p=0.004). The average change in pupillary size from injection of drug till end of surgery was positive in Group 1 (0.75 ± 0.98 mm) and negative in Group 2 (-0.3348 ± 2.57), i.e. there was a relative miosis in Group 2 towards the end of surgery (p=0.001). CONCLUSIONS: Topical drugs achieved larger maximum pupil size as compared to ICAM. However, Intracameral mydriatic anaesthetic combination provided adequate and stable mydriasis without need for augmentation as compared to topical drops in children undergoing cataract surgery.

Anterior segment optical coherence tomography (AS-OCT) in strabismus following trauma.

We describe 3 cases of ocular trauma that presented with strabismus. Anterior segment optical coherence tomography was used to delineate the morphology of extraocular muscle insertions and proved helpful in diagnosis and management.

Cataract surgery in children using intracameral mydriatic.

PURPOSE: To study the pupil dynamics with premixed intracameral anesthetic mydriatic combination of phenylephrine (0.31%), tropicamide (0.02%), and lidocaine (1%) in pediatric cataract surgery. METHODS: Consecutive children aged ≤12 years planned for cataract surgery were recruited. A commercially available premixed combination of phenylephrine (0.31%), tropicamide (0.02%), and lidocaine (1%) was injected at the beginning of surgery without any topical/infusion drugs for mydriasis. Pupil sizes at various points of surgery were studied. RESULTS: We recruited 75 patients with a mean age of 24.3 ± 33.4 months (range: 1 month-11 years). Adequate mydriasis with a single injection was achieved in 93.5% (n = 73 eyes of 70 patients) without additional pharmacotherapy or intervention. The mean pupillary diameter increased from 1.8 ± 0.79 to 6.1 ± 1.4 mm after injection (mean change of 4.2 ± 1.25 mm from baseline). The mean variability in pupillary diameter was 0.73 ± 1.3 mm. In five eyes, good dilatation was not possible even after repeat injection. CONCLUSION: Fixed-dose premixed intracameral injection is effective in pupil dilatation. It alleviates the need for any topical dilators or additional intraoperative supplementation for pediatric cataract surgery.

Topical Steroid-Induced Cushing's Syndrome in a Newborn Following Goniotomy for Glaucoma.

Iatrogenic Cushing's syndrome is a life-threatening condition which requires an early diagnosis multidisciplinary approach. Despite reports of iatrogenic Cushing's syndrome following nasal or inhaled steroids, its development after topical betamethasone eye drops for a short duration is a less frequently reported or anticipated condition. We describe a 6-week-old infant who developed exogenous Cushing's syndrome following topical steroids after bilateral goniotomy for newborn glaucoma. The child was kept under observation and managed with a physiological dose of hydrocortisone. Parental counselling regarding the proper method of eye drop instillation and signs of steroid toxicity is of vital importance in all cases of pediatric ocular surgeries, especially where bilateral surgeries are undertaken.

MULTICOLOR CONFOCAL SCANNING LASER OPHTHALMOSCOPE IMAGING IN POSTERIOR UVEITIS.

PURPOSE: To study the utility of MultiColor confocal scanning laser ophthalmoscope imaging (MCI) in identifying the morphology of uveitic lesions compared with conventional color fundus photography (CFP) in patients with posterior uveitis. METHODS: In this prospective observational study, subjects with posterior uveitis underwent MCI and CFP. The images obtained by the two modalities were analyzed by two independent reviewers for vitreoretinal surface abnormalities, retinal fluid and hemorrhages, and depth/location of lesions. These findings were compared with the clinical findings and other imaging techniques. RESULTS: Sixty-nine eyes of 43 patients (25 men) with mean age of 33.5 ± 13.9 years were studied. MultiColor imaging had better sensitivity and specificity in detecting vitreoretinal interface abnormalities, such as epiretinal membrane and inner retinal striae, compared with CFP. MultiColor imaging failed to detect retinochoroiditis lesions in 5 of 6 eyes (83%) and choroiditis in 9 46 eyes (20%), which were detected on CFP and clinical examination. Also, MCI showed a high false-positive rate of 34% in detecting intraretinal hemorrhages. CONCLUSION: Retinochoroidal lesions in posterior uveitis may be poorly identified on MCI compared with CFP and clinical examination. One must exercise caution in commenting on disease morphology based on MCI alone.