SWOT analysis of ortho-K practice in India.

PURPOSE: Orthokeratology (ortho-K) has been well established as a methodology for myopia correction and control its progression. A SWOT analysis serves as a strategic planning tool for intervention hence the purpose of this study to establish and implement ortho-K practice in India. METHOD: The study was conducted between December 2020 and June 2021. A prospective questionnaire-based study was conducted to elicit the responses in the SWOT study. Based on focus group discussion a set of five statements under strengths, weaknesses, opportunities and threats were identified. These were closed ended questions were based on a 5-point likert scale. The Content Validation Index (CVI) was computed for each item taking those answers relevant with a score of three and four on the Likert scale and omitting those with a score of one and two on the Likert scale as non-relevant. RESULTS: Strengths: 'Ortho-K is an excellent option for myopia control' was agreed by more than 50% of respondents. 67% of respondents agreed that advanced topographers has made ortho-K lens fitting easier. Weakness: More than 60% agreed that Ortho-K practice involves investment in instrumentation like topographers and trial lenses. 50% agreed that due to multiple follow up patients may be lost to follow up. OPPORTUNITY: 'Pandemic has necessitated the need for optometrists to explore myopia control options such as ortho-K' was agreed by more than 50%. Threats: 'Reluctance from adults and parents to try overnight contact lenses for myopia correction/control' was agreed by more than 50% of respondents. 62% agreed that atropine is perceived as an effective myopia control option by majority of the Indian ophthalmologists. CONCLUSION: Ortho-K as an emerging modality for Myopia management in India through SWOT analysis, allows practitioners as well as CL industry to approach Ortho-K appropriately with novel designs and practice patterns that suits the market needs.

Posterior capsular opacification and Nd:YAG capsulotomy rates in patients implanted with square-edged and non-square-edged intraocular lenses in manual small-incision cataract surgery: A randomized controlled study.

Purpose: To study posterior capsular opacification (PCO) and neodymium-doped yttrium aluminum garnet (Nd:YAG) capsulotomy rates in patients implanted with square-edged and non-square-edged intraocular lenses (IOLs) in manual small-incision cataract surgery (MSICS). Setting: Tertiary eye care center. Design: Prospective, comparative, and randomized controlled study. Methods: This study included patients with senile cataracts scheduled for MSICS and IOL implantation. One eye of each patient was randomized to the implantation of square-edged (S group) or non-square-edged IOL (NSQ group). An independent observer analyzed PCO at 6, 12, 18, and 24 months under slit-lamp illumination. Results: A total of 104 eyes were included in this study. The mean age of the participants in the two groups was 63.2 (±8.2) years, and there were 65 (62.5%) men and 39 women (37.5%). The mean best-corrected visual acuity (BCVA) values at 6, 12, and 18 months were 0.157 (±0.10), 0.11 (±0.12), and 0.12 (±0.11), respectively, in the S group and 0.17 (±0.10), 0.17 (±0.12), and 0.20 (±0.17), respectively, in the NSQ group. At 12 (P = 0.03) and 18 months (P = 0.01) follow-up, the BCVA of the S group was significantly better than that of the NSQ group. Four eyes in the NSQ group and one eye in the S group required Nd:YAG. Conclusion: Evaluation of PCO and Nd:YAG capsulotomy rates showed that the 360° square of the posterior IOL edge plays a role in the prevention of PCO. Owing to the low cost of the material and the easy availability of IOLs manufactured from it, square-edged IOL has a definite role in the prevention of PCO in MSICS.

The complication rate following Neodymium-doped Yttrium Aluminum Garnet laser posterior capsulotomy for posterior capsular opacification in patients with and without comorbidities.

Purpose: To study the complication rate following Nd: YAG posterior capsulotomy posterior capsular opacification (PCO) in patients with and without comorbid conditions. Methods: This was a prospective, interventional, comparative, and observational study. A total of 80 eyes, consisting of 40 eyes without ocular comorbidities (group A) and 40 eyes with ocular comorbidities (group B) that were being treated with Nd: YAG capsulotomy for PCO, were included. Visual outcome and complications of Nd: YAG capsulotomy were studied. Results: The mean age of group A patients was 61.65 ± 8.85 years and that of group B patients was 63 ± 10.46 years. Of the total, 38 (47.5%) were men and 42 (52.5%) were women. In group B, the ocular comorbidities were moderate nonproliferative diabetic retinopathy (NPDR) (n = 14 eyes; 14/40 = 35%), subluxated intraocular lens (IOL; <2 clock hours of subluxation; n = 6), age-related macular degeneration (ARMD; n = 6), post-uveitic eyes (having old signs of uveitis, no episode of uveitis since the last 1 year; n = 5), and operated cases of traumatic cataract (n = 4). The mean energy required in groups A and B was 46.95 ± 25.92 and 42.62 ± 21.85 mJ, respectively (P = 0.422). The average energy requirement in Grade 2, Grade 3, and Grade 4 PCO was 22.30, 41.62, and 79.52 mJ, respectively. An increase in intraocular pressure (IOP) of >5 mmHg from pre-YAG levels was observed in one patient in each group on day 1 postprocedure, for which medical treatment was given to both patients for 7 days. One patient in each group had IOL pitting. No patient had any other complications attributable to ND:YAG capsulotomy. Conclusion: Nd:YAG laser posterior capsulotomy is a safe procedure for PCO in patients with comorbidities. Visual outcomes were excellent after Nd:YAG posterior capsulotomy. Although a transient increase in IOP was noted, the response to treatment was good and a long-term increase in IOP was not observed.

To study the learning curve of capsulorhexis in manual small incision cataract surgery among postgraduate residents in central India.

PURPOSE: To evaluate the learning curve of continuous curvilinear capsulorhexis (CCC) and to assess the number of surgeries required to master it among residents in a postgraduate teaching institute. METHODS: The present prospective observational study was based on the completion time and complication rates related to CCC performed using various techniques by 10 students in the 2nd (JR2) and 3rd-year (JR3) of residency. CCC was performed either by a cystotome or capsulorhexis forceps or by a combined method in 253 eyes, of which 160 eyes (63.2%) were operated by JR3 and 93 (36.8%) by JR2. The complication rates were studied with respect to the number of capsular extensions, posterior capsular rent (PCR), zonular dehiscence, need for senior surgical assistance, and nucleus drop. RESULTS: The average time required for the completion of CCC was 412 ± 90.5 s. The average number of times residents required to fill the anterior chamber with viscoelastic was 6.9 ± 1.4. The average size of CCC was 7 ± 0.66 mm. Extended CCC was the most common complication. JR2 required assistance from a senior surgeon in 47 eyes (50.5%), whereas JR3 required assistance in 39 eyes (24.4%) (P = 0.0001). The rate of PCR was not significantly different in JR2 (7.5%) and JR3 (8.8%). CONCLUSION: CCC is a difficult step to master in the trainee. Focusing and practicing on this step will help to reduce the complications and maximize proficiency. Approximately 6-eight surgeries are required to master CCC.

Comparative evaluation of an automated preloaded delivery system with a non-preloaded system.

Purpose: To evaluate a single surgeon's experience with an automated preloaded intraocular lens (IOL) delivery system and a nonpreloaded system. Methods: This was a prospective, observational case series. Phacoemulsification was performed under topical anesthesia by creating a temporal clear corneal incision. Patients were consecutively assigned to either the Clareon group (n = 50; the IOL was injected into the capsular bag by using an automated injector system) or the AcrySof group (n = 50; the IOL was injected into the capsular bag by using a conventional injector system). The main outcome measures were ease of implantation, intraoperative complications, postoperative centration, and visual acuity. Results: Additional manipulation in the anterior chamber was not required in 38 (74%) eyes in the Clareon group and 41 (82%) eyes in the AcrySof group. However, seven eyes in the Clareon group and one eye in the AcrySof group required trailing haptic dislodgement from the optic. Furthermore, two eyes in the Clareon group and five eyes in the AcrySof group required injector rotation (varying from 10° to 90°) in the wound. Moreover, in two eyes of the Clareon group, the silicon plunger of the injector system crossed over the optic. None of the patients developed iris trauma and PCR during IOL manipulation. All the IOLs were centered in the capsular bag. Conclusion: The automated IOL delivery system enables the controlled delivery of an IOL in the capsular bag. The effect of carbon footprints created by plastic generated from the delivery system and the implications of the CO2 cylinder on the environment should be addressed.

Complete Occlusion of Anterior Capsular Opening in Patient Operated for Cataract With Penetrating Keratoplasty.

A 68-year-old female underwent a full-thickness penetrating keratoplasty (PK) and developed a mature cataract for which she was operated on using the phacoemulsification technique with the implantation of polymethyl methacrylate lens. The patient developed diminished vision one month after the cataract surgery. The patient had a contraction of the anterior capsular opening. Neodymium-doped yttrium aluminum garnet laser (ND:YAG) anterior capsulotomy was performed to create an opening in the anterior capsule, following which the patient regained her vision. To the best of our knowledge, this is the first report of early anterior capsular contraction in a patient operated for PK.

Causes for Rejection of Keratorefractive Surgery in a Central Indian Population.

Aim To identify the reasons for refusing refractive surgery in patients visiting for spectacle-free vision. Methodology Medical records of 296 patients who presented for keratorefractive surgery (KRS) from June 2017 to April 2020 at a tertiary eye care center in central India (Government Medical College and Hospital, Nagpur, Maharashtra, India) were reviewed. Demographic details of all the patients and parameters obtained during workup of a case presented for KRSs were captured in an Excel® sheet and analyzed statistically. Results Of the 296 patients who presented for KRS during the study period, 86 (29.1%) patients were denied KRS. The mean pachymetry in the right eye was 505 µm ± 10 µm (range 520-485 µm) and 502 µm ± 7 µm (511-490 µm) in the left eye. Suboptimal corneal thickness (n = 28, 32.6%) was the most common reason for rejection. Other reasons for not recommending the procedure were high myopia (n = 20, 23.3%), spectacle not stable (n = 16, 18.6%), and keratoconus (n = 11, 12.8%). Collagen vascular diseases (n = 3, 3.5%) and anxiety about the procedure (n = 2, 2.3%) were causes unrelated to the procedure. No correlation was observed between corneal thickness and degree of myopia (r = 0.014, p = 0.66). Conclusion Patients presenting for KRS exhibit various problems. Meticulous preoperative evaluation is most important for long-term visual outcome. Suboptimal corneal thickness, high myopia, unstable spectacle correction, and keratoconus were the common reasons for not performing KRS in the study population.

Rotation versus non-rotation of intraocular lens for prevention of posterior capsular opacification.

Purpose: To study the effect of rotation of intraocular lens (IOL) on posterior capsular opacification (PCO) in eyes with phacoemulsification. Methods: This was a prospective, comparative, randomized case series. One eye of each patient was randomized to one of two groups. The 360-degree rotation of IOL was carried out after its placement in the capsular bag (rotation group). The control group had no rotation of IOL. PCO was analyzed by an independent observer on EPCO computer analysis system at 6, 12, 24, and 36 months. Results: The study included 50 patients (100 eyes) with senile cataracts scheduled for phacoemulsification and IOL implantation. The median age in 2 groups was 66 years. 25% quartile age in both the group was 62 years (P = 0.06). There were 30 males, and 20 females. The median PCO score at 6, 12 and 24 months was significantly low in the rotation group (0.15, 0.13, 0.22) compared to the control group (0.22, 0.23, 0.25). There was no significant difference in PCO score between the two groups from 24-36 months. The median PCO score at 36 months was 0.2 in both the groups. At the end of three years, 4 eyes (8%) in the rotation group, and 10 eyes (20%) in the control group needed Nd:YAG capsulotomy (P = 0.04). Conclusion: Rotation of IOL in the capsular bag decreases PCO and Nd:YAG capsulotomy rate.

Frequency and surgical difficulties associated with pseudoexfoliation syndrome among Indian rural population scheduled for cataract surgery: Hospital-based data.

PURPOSE: To study the frequency and intraoperative difficulties associated with pseudoexfoliation (PXF) syndrome at a tertiary eye care center in a rural central India. METHODS: This study included patients scheduled for cataract surgery who were diagnosed with PXF syndrome. All patients underwent a complete ophthalmologic evaluation, including slit-lamp examination, tonometry, gonioscopy, and ophthalmoscopy before the surgery. Cataract surgeries were performed by a single surgeon who reported the intraoperative difficulties. RESULTS: In total, 1022 phakic eyes of 1823 patients were evaluated, 226 of whom (22.1%) were diagnosed with PXF syndrome. Most eyes (n = 81, 35.8%) with PXF syndrome were ≥81 years old. Eighty-six eyes (38.1%) had bilateral involvement, whereas 70 (30.9%) had right or left eye involvement. Further, PXF material was distributed on the iris, pupil, and lens in 70 eyes (30.9%) and on the pupillary margin in 36 eyes (15.9%). The mean pupillary dilation was 5.1 (±1.4) mm in patients with PXF syndrome compared with 7.2 (±1.6) mm in those without it (P = 0.03). Grade VI cataract was observed in 93 eyes (41.2%) and hypermature cataract was the most commonly observed cataract stage. Twenty-one eyes (9.3%) had increased intraocular pressure. Intraoperative difficulties were encountered in 62 eyes (27.4%) with poor pupillary dilation being the most common problem (32 eyes, 14.2%), followed by zonular dehiscence (18 eyes, 8%). CONCLUSION: This hospital-based study showed that PXF syndrome is common in Indian rural population and that the intraoperative complication rate in these patients is high.

Phaco-emulsification in completely vitrectomized eyes: Intraoperative analysis of modified phaco sleeve.

PURPOSE: The purpose was to evaluate the results of modified sleeve in phacoemulsification of cataract in completely vitrectomised eyes, Materials and Methods: Twenty-five previously completely vitrectomized eyes of 23 patients having visually significant cataract were included. After through evaluation they underwent phaco-emulsification by phaco chop with a modified sleeve via temporal clear corneal incision. The modified sleeve was made by creating a small round port of approximate 1 × 1 mm size at the proximate end of the sleeve in line with the already existing ports. This port faced the posterior capsule while performing phacoemulsification. Patients were observed for any intraoperative complications. RESULT: The most common indication for pars plana vitrectomy in our study group was vitreous hemorrhage due to diabetic retinopathy [13 out of 25 eyes (52%)]. Intraoperative findings included miosis [seen in 3 (12%) eyes] and posterior capsular plaque [seen in 2(8%) eyes]. No other significant intraoperative complications (posterior capsular tear, dropped nucleus) were observed. Average effective phaco time was 33 sec. (±15.11). CONCLUSION: Though cataract surgery in postvitrectomized eyes is a challenging situation, modified sleeve prevents anterior chamber fluctuation and avoids complications arising out of it, making the surgery safe.

Recurrent iridocyclitis due to cotton fiber in anterior chamber.

BACKGROUND: Cotton is commonly used during ophthalmic surgical procedure. Cotton fibers may get attracted to the instruments due to electrostatic forces and become adhered to the surface. With the introduction of these instruments during the surgical procedure cotton fiber may get entry into the eye. In the literature they have been infrequently reported due to insignificant effect on the ocular structures. We present a case of recurrent iridocyclitis due to cotton fiber in the anterior chamber. Patient was relived of his symptoms after removal. CASE: A 78-year-old male presented with pain, redness and blurring of right eye vision since last six months. The patient had undergone phacoemulsification with implantation of hydrophilic intraocular lens (IOL) six years earlier. Postoperative follow up was uneventful from his records till last 6 months. Slit-lamp examination revealed a cotton fiber in the anterior chamber touching the endothelium. Keratic precipitates were seen on the endothelium. Removal of the cotton fiber resulted in subsidence of inflammation. CONCLUSION: We recommend use of plastic eye and trolley drapes, lint free instrument wipes and use of needle cap to support the globe during creation of side port while performing phacoemulsification instead of cotton buds to avoid entry of cotton fiber into the anterior chamber.

Posterior capsular calcification without opacification of intraocular lens.

BACKGROUND: Posterior capsular clarity is important for long-term visual gain. Postoperative visual acuity could be reduced due to posterior capsular or intraocular lens opacification, which occur months or years after cataract surgery. We report early occurrence of posterior capsular calcification without opacification of intraocular lens. CASE: We report the case of a 78-year-old male who had undergone phacoemulsification with implantation of hydrophilic intraocular lens (IOL) in the left eye for cataract. The patient was non-diabetic, and the surgical procedure was uneventful. On the third postoperative day, fine granular deposits were found on the mid-peripheral part of the posterior capsule. No deposits were found on IOL. The patient presented with diminished vision four months after surgery. Slit-lamp examination revealed distinct areas of calcification with an early opacification of the posterior capsule and no IOL calcification. Neodymium doped: YAG capsulotomy was done to clear posterior capsular opacification, and the patient regained visual acuity of 20/20. To the best of our knowledge, this report is the first to investigate posterior capsular calcification without opacification of IOL in a patient without any known etiological factors. CONCLUSION: This case is reported to stimulate future study on the use of BSS plus and the development of posterior capsular or IOL calcification.

Study of referral pattern to ophthalmology outpatient department from various departments in the medical college.

The study was aimed at finding out the pattern of referrals to ophthalmology outpatient department (OPD) in a teaching hospital and to provide guidelines for the improvement. Patients referred from various departments of a medical college situated in central India for ophthalmic evaluation were scrutinised for age, sex, diagnosis and the referring OPD. Out of 730 patients referred, 350 (47.95%) were males and 380 (52.02%) were females. The highest referral was found in the age group 45-64 years (22.60%). The highest referral was from the medicine OPD (58.22%) and the lowest was from psychiatry (2.05%). Maximum patients were referred for fundus examination (27.40%). While there were 280 patients (38.36%) who had refractive error, no diagnosis was established in 147 cases (20.14%). Ophthalmic opinion definitely helped patients as well as physician in the management of the patients. The study also stresses on some areas deficient, when unnecessary referrals could be avoided by arranging short annual refreshers courses to acquire basic skills in ophthalmology like visual acuity testing, colour vision, ophthalmoscopy and the diagnosis of common ocular conditions. We believe this kind of activity will help to make our services more efficient and cost effective.