Patterns of risk for diabetic retinopathy in the Mumbai slums: The Aditya Jyot Diabetic Retinopathy in Urban Mumbai Slums Study (AJ-DRUMSS) Report 3.

Diabetes onset precedes diabetic retinopathy (DR) by 5-10 years, but many people with diabetes remain free of this microvascular complication. Our aim was to identify risk factors for DR progression in a unique and diverse population, the slums of Mumbai. We performed a nested case-control study of 1163 diabetics over 40 years of age from slums in 18 wards of Mumbai. Data was collected on 33 variables and assessed for association with DR using both univariate and multivariate analyses. Stratified analyses were also performed on males and females, separately. Among hypertensive individuals we also assessed whether duration of hypertension associated with DR. Of 31 non-correlated variables analysed as risk factors for DR, 15 showed evidence of significant association. The most prominent included sex, where being a female associated with decreased odds of DR, while longer duration of diabetes and poor glycaemic control associated with increased odds. The duration of diabetes effect was partially, but significantly, mediated by age of diabetes diagnoses (8.6% of variance explained, p = 0.012). Obesity as measured by several measures, including body mass index (BMI) and measures of central obesity had a negative association with DR; increased measures of obesity consistently reduced odds of DR. As in most earlier studies, DR was associated with the duration of diabetes and glycaemic control. However, other factors, especially obesity related measures were associated with DR, in ways that contrast with most prior studies. These results indicated that the overall pattern of association in the Mumbai slums was novel. Thus, in previously uncharacterized populations, such as the slums that we examined, it is important to evaluate all risk factors de novo to appropriately assess patterns of association as the patterns of association with DR can be complex and population specific.

Impact of individual counseling on the knowledge and attitudes of type 2 diabetics regarding diabetic retinopathy: The Aditya Jyot Diabetic Retinopathy in Urban Mumbai Slums Study - Report 3.

Purpose: Baseline knowledge and attitudes regarding diabetic retinopathy (DR) have not been previously reported for type 2 diabetes mellitus adults (T2DM) in Dharavi, one of the largest slums in Mumbai. Furthermore, a pre- and post-intervention survey study regarding this topic has not been conducted to date in Dharavi. This pre- and post-intervention survey study analyzes the impacts of DR counseling sessions administered individually on the knowledge and attitudes of T2DM participants recruited from Dharavi. Methods: Potential subjects (>30 years old) from Dharavi were enrolled by community workers and screened for T2DM. Those with confirmed T2DM were each registered for an individual DR counseling session. A survey was distributed to participants before the counseling session to determine their baseline knowledge and attitudes. The same survey was distributed after the counseling session, and changes in pre- and post-survey responses were analyzed. Results: Exactly 1718 T2DM study participants were given pre- and post-surveys. Before the counseling, T2DM participants showed low baseline knowledge and attitudes regarding DR, with only 30.8% (530/1718) participants being aware that diabetes can affect the eye. Participants showed significant improvements after the counseling session, with more participants showing willingness to attend DR screenings (pre: 38.3.%, post: 56.8%; P < 0.0001) and more becoming aware that diabetes can affect the eye (90.4%, 1553/1718; P < 0.0001). Conclusion: Targeted educational interventions for T2DM individuals from the slums of western India, such as Dharavi, can lead to significant improvements in knowledge and attitudes, representing a promising avenue in tackling the burden of avoidable blindness caused by DR in India.

A Multisite Longitudinal Investigation of Psychological Outcomes Following Cataract Surgery in India.

Background: Systematic data on mental health issues among adults with cataracts are not available from India. This study explored the impact of cataract surgery on depressive and generalized anxiety (GA) symptoms in an adult Indian sample. Methods: A multicenter, prospective, longitudinal cohort study was conducted. Subjects were recruited from four tertiary eye hospitals to assess depression, GA, and associated risk factors. A follow-up survey was carried out at 6 (n = 273, group 1), 12 (n = 198, group 2), or 18 months (n = 105, group 3) post-cataract surgery. Variations in the intensity of depression and GA were assessed using multiple classification analysis (MCA). Results: A total of 576 patients completed both baseline and follow-up assessments. The mean (SD) depression score was 25.6 (8.5) before surgery and 8.6 (7.7), 9.9 (7), and 9.8 (6.8), respectively, post-surgery for the three groups on the Center for Epidemiologic Studies Depression scale (CES-D). The mean GA score was 6.7 (4.2) at baseline and 1.1 (2.3), 1 (1.8), and 0.6 (1.3) after surgery on the Generalized Anxiety Disorder scale (GAD-7). MCA showed that factors with the highest impact on the mean change scores for both depressive and GA symptoms were restoration of vision post-surgery (ß = 0.381 and 0.185) in group 1, regaining functional independence and female sex in group 2 (ß = 0.192 and 0.23), and the presence of ocular comorbidities in the fellow eye (ß = 0.36 and 0.315) in group 3. Conclusion: Mental health symptoms improved significantly post-cataract surgery across the three groups. The urgent need to invest in strategies that enable early cataract case detection and treat ocular anomalies in the fellow eye is highlighted.

Depressive and generalized anxiety symptoms in adults awaiting cataract surgery in India.

Background Systematic data on mental health issues among adults awaiting cataract treatment are not readily available in India. We explored the prevalence and predictors of depressive and generalized anxiety (GA) symptoms in a cohort of adults awaiting cataract surgery. Methods Our study is based on data from baseline assessments which were conducted as part of a multicentre prospective, longitudinal cohort study. Subjects were recruited from four eye hospitals to assess depression and GA and associated risk factors using standardized scales, i.e. Center for Epidemiologic Studies-Depression Scale (CES-D) and Generalised Anxiety Disorder (GAD-7). Variation in the intensity of depression and GA was assessed using multiple classification analysis (MCA). Results A total of 813 adults awaiting cataract surgery participated, of whom 456 (56.1%) were men. The mean (SD) CES-D and GAD-7 scores were 24.6 (7.8) and 6.3 (SD 4.2) for men and 25.8 (8.9) and 6.9 (4.4) for women, respectively. The overall prevalence of depression score of >16 was 87.4% (95% confidence interval [CI] 84.7%- 89.6%), and GA score of >10 was 57.1% (95% CI 53.5%-60.7%). The prevalence of comorbid depressive and anxiety symptoms was 56.6% (95% CI 52.9%- 60.2%). MCA showed that being neglected and mistreated by family/friends because of vision condition and facing difficulty and requiring help with daily tasks had the highest effect on the intensity of both depression (beta=0.254 and 0.238, respectively) and GA (beta=0.219 and 0.211, respectively). Conclusion The majority of adults with untreated cataract had both depressive and GA symptoms. These findings could be used for planning mental health interventions for adults awaiting cataract surgery.

Use of offline artificial intelligence in a smartphone-based fundus camera for community screening of diabetic retinopathy.

PURPOSE: The aim of the study was to analyse the reliability of an offline artificial intelligence (AI) algorithm for community screening of diabetic retinopathy. METHODS: A total of 1378 patients with diabetes visiting public dispensaries under the administration of the Municipal Corporation of Greater Mumbai between August 2018 and September 2019 were enrolled for the study. Fundus images were captured by non-specialist operators using a smartphone-based camera covering the posterior pole, including the disc and macula, and the nasal and temporal fields. The offline AI algorithm on the smartphone marked the images as referable diabetic retinopathy (RDR) or non-RDR, which were then compared against the grading by two vitreoretinal surgeons to derive upon the sensitivity and specificity of the algorithm. RESULTS: Out of 1378 patients, gradable fundus images were obtained and analysed for 1294 patients. The sensitivity and specificity of diagnosing RDR were 100% (95% CI: 94.72-100.00%) and 89.55% (95% CI: 87.76-91.16%), respectively; the same values for any diabetic retinopathy (DR) were 89.13% (95% CI: 82.71-93.79%) and 94.43% (95% CI: 91.89-94.74%), respectively, with no false-negative results. CONCLUSION: The robustness of the offline AI algorithm was established in this study making it a reliable tool for community-based DR screening.

Diagnostic Accuracy of Community-Based Diabetic Retinopathy Screening With an Offline Artificial Intelligence System on a Smartphone.

IMPORTANCE: Offline automated analysis of retinal images on a smartphone may be a cost-effective and scalable method of screening for diabetic retinopathy; however, to our knowledge, assessment of such an artificial intelligence (AI) system is lacking. OBJECTIVE: To evaluate the performance of Medios AI (Remidio), a proprietary, offline, smartphone-based, automated system of analysis of retinal images, to detect referable diabetic retinopathy (RDR) in images taken by a minimally trained health care worker with Remidio Non-Mydriatic Fundus on Phone, a smartphone-based, nonmydriatic retinal camera. Referable diabetic retinopathy is defined as any retinopathy more severe than mild diabetic retinopathy, with or without diabetic macular edema. DESIGN, SETTING, AND PARTICIPANTS: This prospective, cross-sectional, population-based study took place from August 2018 to September 2018. Patients with diabetes mellitus who visited various dispensaries administered by the Municipal Corporation of Greater Mumbai in Mumbai, India, on a particular day were included. INTERVENTIONS: Three fields of the fundus (the posterior pole, nasal, and temporal fields) were photographed. The images were analyzed by an ophthalmologist and the AI system. MAIN OUTCOMES AND MEASURES: To evaluate the sensitivity and specificity of the offline automated analysis system in detecting referable diabetic retinopathy on images taken on the smartphone-based, nonmydriatic retinal imaging system by a health worker. RESULTS: Of 255 patients seen in the dispensaries, 231 patients (90.6%) consented to diabetic retinopathy screening. The major reasons for not participating were unwillingness to wait for screening and the blurring of vision that would occur after dilation. Images from 18 patients were deemed ungradable by the ophthalmologist and hence were excluded. In the remaining participants (110 female patients [51.6%] and 103 male patients [48.4%]; mean [SD] age, 53.1 [10.3] years), the sensitivity and specificity of the offline AI system in diagnosing referable diabetic retinopathy were 100.0% (95% CI, 78.2%-100.0%) and 88.4% (95% CI, 83.2%-92.5%), respectively, and in diagnosing any diabetic retinopathy were 85.2% (95% CI, 66.3%-95.8%) and 92.0% (95% CI, 97.1%-95.4%), respectively, compared with ophthalmologist grading using the same images. CONCLUSIONS AND RELEVANCE: These pilot study results show promise in the use of an offline AI system in community screening for referable diabetic retinopathy with a smartphone-based fundus camera. The use of AI would enable screening for referable diabetic retinopathy in remote areas where services of an ophthalmologist are unavailable. This study was done on patients with diabetes who were visiting a dispensary that provides curative services to the population at the primary level. A study with a larger sample size may be needed to extend the results to general population screening, however.

BILATERAL METASTATIC CUTANEOUS MELANOMA TO RETINA AND VITREOUS AFTER IPILIMUMAB TREATED WITH PARS PLANA VITRECTOMY AND RADIOTHERAPY.

PURPOSE: To report a patient with bilateral metastatic cutaneous melanoma to the retina and vitreous presenting as a right panuveitis. METHODS: A 63-year-old woman with metastatic malignant cutaneous melanoma treated with ipilimumab and prolonged high-dose steroids presented with a right panuveitis and right blurred vision. Dilated fundus examination revealed bilateral, off-white, large, globular vitreous opacities and bilateral retinal lesions. These retinal lesions had a pale yellow appearance with a cuff of haemorrhage. The unpigmented appearance of the vitreous opacities raised the suspicion of candida endophthalmitis. RESULTS: Bilateral, sequential pars plana vitrectomy with pathomorphologic examination of the vitreous specimen demonstrated metastatic melanoma. Ocular radiotherapy followed by cataract surgery resulted in the regression of retinal lesions in both eyes and no recurrence of the vitreous metastases. CONCLUSION: The development of vitreous and retinal metastases despite a systemic response to ipilimumab identifies the challenge of immunotherapy in an immune privileged site. Treatment is challenging, and outcomes are variable. A local approach of bilateral pars plana vitrectomy, external beam radiotherapy, and subsequent bilateral cataract surgery provided an excellent visual result with no recurrence at 12 months.

Comparison of the Endosaver with noninjector techniques in Descemet's stripping endothelial keratoplasty.

PURPOSE: Minimal loss of corneal endothelial cells during corneal transplantation is a major target but remains a point of controversy among specialists. Hence, the available method to best achieve this continues to stir progress in the field. The aim of this study is to evaluate the use of the Endosaver injector device for graft insertion in Descemet's stripping endothelial keratoplasty (DSEK) and compare the visual outcomes and endothelial cell survival between the Endosaver injector and Goosey grasping forceps insertion techniques. METHODS: This was a retrospective, interventional, consecutive case series undertaken at the University of Southampton Eye Department to assess outcomes of DSEK using the Endosaver injector device compared to noninjector DSEK insertion. Postoperative specular microscopy alongside manifest refraction at 6 and 12 months was evaluated and compared. Mann-Whitney U-test was employed for the statistical analysis of data. RESULTS: Both the Endosaver and Goosey forceps groups showed an improvement in best corrected visual acuity. No significant statistical difference was found in preoperative and postoperative best-corrected visual acuity between the Endosaver and non-Endosaver insertion groups. Mean preoperative endothelial cell count was 2660 (±130) for the Endosaver group and 2608 (±66) for the non-Endosaver group. Postoperative endothelial counts at 6 and 12 months showed a significant difference between the Endosaver: 2104 (±199)-1896 (±226) and the non-Endosaver: 1492 (±207)-1314 (±224) (P < 0.005) groups, respectively. CONCLUSION: The Endosaver injection device is associated with less trauma to endothelium during graft insertion due to the minimal touch technique employed. A smaller insertion wound of 4.0 mm compared to noninjector cases enabled a more stable system during surgery with no or minimal anterior chamber shallowing. The combination of a stable host with minimal endothelial graft handling and subsequent trauma potentially leads to higher endothelial cell counts when the Endosaver injection device is used compared to forceps insertion.

Infiltrative local anesthesia with articaine is equally as effective as inferior alveolar nerve block with lidocaine for the removal of erupted molars.

AIM: The aim of this study is to assess the efficacy of 4% articaine with 1:100,000 adrenaline given as buccal and lingual infiltration in adult patients undergoing erupted mandibular first and second molar teeth extraction versus inferior alveolar nerve block technique using 2% lignocaine with 1:80,000 adrenaline. MATERIALS AND METHODS: A total of 100 patients undergoing extraction of mandibular posterior teeth were divided into two equally matched groups for the study, out of which 50 patients were given 4% articaine with 1:100,000 adrenaline as buccal and lingual infiltration and 50 patients were given 2% lignocaine with 1:80,000 adrenaline using classic direct inferior alveolar nerve block with lingual and buccal nerve block. Efficacy of anesthesia was determined using a numeric analog scale (NAS) ranging from 0 indicating no pain to 10 indicating the worst pain imaginable. The NAS was taken by a different operator to avoid bias. RESULTS: The pain scores in both groups were analyzed using the Mann-Whitney U test, and a p value of 0.338 was obtained which is not statistically significant. Hence, no significant difference in the pain score was established between both groups. The adverse effects of both the local anesthetics if any were noted. CONCLUSION: From this study, we concluded that the use of 4% articaine with 1:100,000 adrenaline is as effective as inferior alveolar nerve block with lignocaine but without the risk of attendant adverse effects of inferior alveolar nerve block technique.

Retrospective evaluation of airway management with blind awake intubation in temporomandibular joint ankylosis patients: A review of 48 cases.

AIM: The aim was to determine the morbidity or mortality associated with the blind awake intubation technique in temporomandibular ankylosis patients. SETTINGS AND DESIGN: A total of 48 cases with radiographically and clinically confirmed cases of temporomandibular joint (TMJ) ankylosis were included in the study for evaluation of anesthetic management and its complications. MATERIALS AND METHODS: Airway assessment was done with standard proforma including Look externally, evaluate 3-3-2 rule, Mallampati classification, Obstruction, Neck mobility (LEMON) score assessment in all TMJ ankylosis patients. The intubation was carried out with the standard departmental anesthetic protocol in all the patients. The preoperative difficulty assessment and postoperative outcome were recorded. RESULTS: Blind awake intubation was done in 92% of cases, 6% of cases were intubated by fiberoptic awake intubation, and 2% patient required surgical airway. Ninety-eight percent of the patients were cooperative during the awake intubation. The frequent complications encountered during the blind awake intubation were epistaxis and sore throat. CONCLUSION: In an anesthetic setup, where fiberoptic intubation is not available, blind awake intubation could be considered in the anesthetic management algorithm.

Immunosuppression for ipilimumab-related toxicity can cause pneumocystis pneumonia but spare antitumor immune control.

Ipilimumab is a standard therapy for advanced melanoma. Severe immune related adverse events occur in up to 30% of patients and require treatment with immunosuppressants such as steroids or the anti-TNFα antibody, infliximab. We describe two patients with advanced melanoma treated with ipilimumab. Both suffered from severe immune related side effects and required prolonged immunosuppression with steroids and/or infliximab. Both patients recovered and in spite of the immune suppression, demonstrate clinical evidence of tumor control. This argues that distinct immunological effector functions control nosocomial infection and tumor, respectively. To our knowledge, these are also the first two case reports of pneumocystis pneumonia in this setting.

VITREOMACULAR TRACTION AFFECTS ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR TREATMENT OUTCOMES FOR EXUDATIVE AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To evaluate the effect of vitreomacular traction (VMT) on visual acuity outcomes and central retinal thickness (CRT) measurements after intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy for treatment of exudative age-related macular degeneration (AMD). METHODS: In this retrospective series, the authors evaluate the clinical records and optical coherence tomography of 34 eyes of 32 patients, with VMT confirmed on optical coherence tomography at baseline, to assess the effects of VMT on anti-VEGF therapy for newly diagnosed exudative wet AMD. Best-corrected visual acuity at baseline, 1, 3, 6, 9, and 12 months and CRT at baseline, 3, 6, and 12 months were assessed. Comparison was made with a control group of 29 eyes of 28 patients with wet AMD and no VMT on optical coherence tomography and with key variable-dosing studies for anti-VEGF in exudative AMD (CATT, HARBOR, PrONTO, SUSTAIN, and Gupta et al). RESULTS: Best-corrected visual acuity results showed a visual acuity improvement that peaked at 3 months with 2.47 letters, well below other variable-dosing studies for anti-VEGF therapy in exudative AMD. This was then followed by a steady decline with mean best-corrected visual acuity at 12 months ending below the baseline level (-1.00 letters) compared with a gain of 9.39 letters in the control group at 12 months. Comparison of the mean CRT in the VMT group between baseline and 12 months showed no significant difference (P = 0.67), whereas the PrONTO study and control groups showed a highly significant difference at 12 months compared with baseline (P < 0.001). Mean CRT values at 6 months and 12 months were essentially at baseline levels (0.26 µm, -0.62 µm, respectively). CONCLUSION: Vitreomacular traction at baseline, existing concurrently with newly diagnosed exudative AMD treated with intravitreal anti-VEGF therapy on a variable-dosing regime, was associated with poorer visual outcomes and a decreased response to reduction in CRT, compared with a control group of wet AMD without VMT and compared with major variable-dosing studies for intravitreal anti-VEGF in exudative AMD.

Evaluation of the efficacy of tranexamic acid on blood loss in orthognathic surgery. A prospective, randomized clinical study.

The purpose of this prospective, randomized, double blind study was to assess the effect of tranexamic acid on blood loss, quality of surgical field and duration of surgery in adolescent orthognathic surgery patients. 50 consecutive patients, scheduled for orthognathic surgery were included. The study group (n=25) received tranexamic acid 10mg/kg as a bolus preoperatively followed by 1mg/kg as a maintenance dose intra operatively; the control group (n=25) received placebo (normal saline). All patients received moderate hypotensive anaesthesia with nitroglycerin and had surgery according to a standard protocol. Intra operative blood loss, duration of surgery, quality of surgical field, blood transfusion and complications, if any, were recorded. The mean total blood loss was 166.1±65.49ml in the study group and 256.4±77.80ml in the control group. The results showed statistically significant reduction in blood loss (p<0.001) and improved quality of surgical field (p<0.001) in the study group. There was no significant difference in duration of surgery and transfusion requirements between the two groups. In conclusion, preoperative and intra operative administration of the antifibrinolytic agent, tranexamic acid, is effective in controlling blood loss and improving the quality of the surgical field.

Submacular haemorrhage after intravitreal bevacizumab compared with intravitreal ranibizumab in large occult choroidal neovascularization.

BACKGROUND: Submacular haemorrhage may occur following intravitreal bevacizumab injection for large occult choroidal neovascularization (CNV) in age-related macular degeneration (AMD). We report the occurrence of submacular haemorrhage following intravitreal ranibizumab compared with intravitreal bevacizumab for large occult CNV in AMD. METHODS: Retrospective, comparative evaluation of two interventional case series. Evaluation of consecutive patients with occult CNV > or = 15 mm(2) treated with intravitreal bevacizumab (n = 14) and intravitreal ranibizumab (n = 22) over a 2-year period within a single institution. Postoperative submacular haemorrhage, Early Treatment Diabetic Retinopathy Study-derived visual acuity, preoperative blood pressure and anticoagulant use were noted. The two groups were compared using Fisher's exact test. RESULTS: The mean surface area of occult CNV at presentation was 20.9 +/- 5.4 mm(2) in the bevacizumab group and 24.0 +/- 11.0 mm(2) in the ranibizumab group. Fresh submacular haemorrhage was seen in 4 out of 14 patients following bevacizumab compared with 0 out of 22 patients following ranibizumab (P = 0.017, odds ratio = 19.29). Mean preoperative blood pressures were very similar between the groups. 28.6% of patients in the bevacizumab group were on oral anticoagulants compared with 31.8% in the ranibizumab group. None of the patients who developed postoperative haemorrhage were on anticoagulants. CONCLUSIONS: Acute submacular haemorrhages appear to be a significant adverse event following intravitreal bevacizumab in occult CNV > or = 15 mm(2). Intravitreal ranibizumab appears to have a significantly lower incidence of postoperative submacular haemorrhage in occult CNV > or = 15 mm(2). Larger studies are required to identify the most appropriate agent for the treatment of large occult CNV.