Endoilluminator-aided cataract surgery in eyes with corneal opacity - A modified surgical approach.

Background: Cataract and corneal blindness continue to be leading causes of reversible blindness in India. These can co-exist in a multitude of pathologies such as trauma, healed keratitis (old herpetic scar), chronic degenerative changes such as labrador keratopathy, bullous keratopathy, corneal dystrophies etc. Phacoemulsification in such eyes is rewarding to the patient in terms of minimal intervention, less risk of complications owing to reduced open sky time (as in case of combined keratoplasty), and better predictable visual outcomes. Approach to such eyes with poor visualisation is highly challenging. Purpose: We illustrate a modified surgical technique of chandelier illumination through pars plana for cataract surgery in eyes with corneal opacity of varying grades. Synopsis: Five patients with dense cataract and small pupils, associated with corneal opacity (leucomatous and macular grade) are described. Closed chamber phacoemulsification with intraocular lens with or without pupil expanders was performed assisted by 23 or 25 gauge pars plana chandelier illumination introduced in the vitreous cavity through a sclerotomy wound made prior to phacoemulsification in the inferotemporal quadrant. Highlights: Chandelier illumination aids in reducing the light scatter that occurs due to corneal opacity. Ease of visualisation of lens structures and of performing cataract surgery was noticed. One case was combined with penetrating keratoplasty with reduced open sky time. This assisted technique has advantages such as enhancing visualisation intraoperatively and allowing working in closed chamber. Its self-retaining nature aids bimanual manipulation. No complications were encountered. The video highlights the utility, advantages and practicality of chandelier retroillumination in patients with corneal opacities of varying degree undergoing phacoemulsification. Video Link: https://youtu.be/I3z6QG-_wD8.

Subconjunctival Dirofilariasis presenting as orbital cellulitis.

Background: Dirofilariasis is an emerging zoonosis in India. Most of the cases from India have been reported from the states of Kerala, coastal Karnataka and Maharashtra, and a few from the North India, Orissa and Assam. Dogs, cats, foxes and other wild animals are definitive hosts for dirofilaria. Human ocular parasitosis is prevalent in geographical areas where environmental factors and poor sanitary conditions favor parasitism between humans and animals. However, in recent years, migrating population have facilitated the spread of certain parasitic diseases from endemic to non-endemic areas. We report a case of subconjunctival dirofilariasis in a 91-year-old man, who presented with features of orbital cellulitis. An intact live worm, measuring 13.5 cm, was extracted from the subconjunctival space, following which there was prompt resolution of symptoms. Purpose: Given the increase in the frequency of dirofilariasis in humans in recent years, medical practitioners should bear in mind the possibility of ocular dirofilariasis when a patient presents with an ocular or orbital inflammatory lesion. Synopsis: This video illustrates various presentations of ocular dirofilaria and surgical extraction of a live worm from the subconjunctival space. Highlights: Lifecycle and human ocular manifestations of dirofilaria ared elucidated. Rare presentation of subconjunctival dirofilariasis as orbital cellulitis and its resolution following removal of the live worm has been demonstrated. Video link: https://youtu.be/Nj8unz0S85M.

A scalable, self-sustaining model for screening and treatment of diabetic retinopathy in rural Karnataka.

The Indian health infrastructure is struggling to handle the burgeoning number of people with diabetes. Managing the complications of diabetes in an organized manner through the government health programs is still a distant reality. Here, we describe a program aimed at addressing the problem of diabetic retinopathy in rural areas of Tumkur district in Karnataka. By amalgamating telescreening and our own novel distributive care model, we were able to screen 85% of the registered diabetics in the Government noncommunicable disease clinics and treat 95% of those needing laser therapy. We also describe the importance of using electronic medical records in public health programs which not only increase the efficiency in screening for disease but help in increasing uptake of treatment by tracking defaulters.

Seroprevalence of Lymes disease in the Nagarahole and Bandipur forest areas of South India.

Purpose: The aim of this study was to determine the seroprevalence of Lymes disease in a population at risk in south India. Methods: Prospective ongoing study and included screening of forest workers and staff of Nagarahole and Bandipur forest ranges in South India for Lymes disease. Screening included a detailed questionnaire for Lymes disease, complete ocular and systemic examination by an ophthalmologist and infectious disease specialist and blood collection. ELISA for IgM and IgG antibodies for Borrelia burgdorferi were performed on the collected sera samples. Western blot confirmation was done on the seropositive samples. Ticks were also collected from these forest areas for future studies to detect if they harbor B. burgdorferi. Results: Seroprevalence of 19.9% was noted by ELISA. Western blot confirmation was seen in 15.6% of the seropositive samples. There was significant correlation between seropositivity and exposure to tick bites (P = 0.023). Conclusion: There is a high seroprevalence of infection with B. burgdorferi in the forest areas of Nagarahole and Bandipur ranges in south India.

Older Drivers and Glaucoma in India: Driving Habits and Crash Risks.

PRéCIS:: In India, older drivers with glaucoma show greater driving difficulty but are not involved in higher number of on-road accidents. To achieve balance between safety aspects and independence for drivers with glaucoma is important. PURPOSE: The purpose of this study was to analyze driving habits of patients with glaucoma and to compare their driving behavior, driving difficulties, and accident rates with nonglaucoma controls. PATIENTS: Patients with glaucoma aged older than 40 years were recruited. Subjects with best-corrected visual acuity ≤6/24 in the better-seeing eye and those having primary eye disorder other than glaucoma were excluded. Age-matched nonglaucoma controls were recruited. Subjects with clinically significant cataract and/or with best-corrected visual acuity ≤6/24 in both eyes were excluded. All cases and controls were legally licensed to drive. MATERIALS AND METHODS: In this study, Driving Habits Questionnaire was used. Collected data were statistically analyzed using SAS, version 9.2 (GLM procedure), and IBM SPSS, version 22. P-values <0.05 were considered statistically significant. RESULTS: All controls and 84% (n=84/100) of cases were current drivers. Among them, 16% (n=16/100) cases had stopped driving, of which 31.25% (n=5/16) had stopped because of self-reported ocular causes. Cases drove lesser number of days per week (P=0.001) and had more driving dependence on other drivers (44%, n=37/84) compared with controls. Glaucoma was significantly associated with driving difficulty in the rain, in rush-hour traffic, and at night. Comparing driving difficulty scores and visual field index within glaucoma group showed statistical significance [F(1,82)=22.12, P<0.001]. Composite scores of driving difficulty (P<0.001) and driving space (P=0.003) between the 2 groups showed strong statistical significance. Controls had higher number of self-reported accidents (P<0.001). CONCLUSIONS: Patients with glaucoma show greater driving difficulty, self-regulate their driving behavior, and restrict their driving. Older patients with glaucoma in India are not involved in higher rates of on-road crash risks compared with nonglaucoma drivers.

Subconjunctival Dirofilariasis Presenting as Orbital Cellulitis.

Human ocular Dirofilariasis is a relatively rare, zoonotic disease, caused by a filarial nematode, Dirofilaria repens. This parasitic infestation usually presents as a subconjunctival nodule with hyperemia. The authors present a case of subconjunctival dirofilariasis in a 91-year-old gentleman, who presented with manifestations of orbital cellulitis. The live worm was surgically removed and identified to be D. repens.

Renewal of driving license in India and glaucoma: A study of prevalent practice and its lacunae.

PURPOSE: Glaucoma affects different aspects of vision including visual field. This prospective observational study aims to collect details of driving license (DL) renewal procedure (in an urban metro in India) among patients with diagnosed glaucoma and the method of reporting of vision-related requirements during renewal. METHODS: One-hundred patients with diagnosed glaucoma above 40 years, having valid DL (with at least one renewal cycle), were included. Patients with other ocular comorbidities were excluded. Driving Habits Questionnaire and a questionnaire about license renewal were administered. Driving eligibility was compared to international guidelines. RESULTS: Study population included patients with 69% early, 29% moderate, and 2% advanced glaucoma. Sixteen percent of patients had stopped driving. Legal license renewal procedure was bypassed by 45%. Form-1 was not submitted by 43% and 49% did not submit Form-1A at the time of renewal. Only 7.01% mentioned about glaucoma in the self-declaration form. None were asked about their visual field during renewal. Among 61 patients who submitted a medical certificate, the undersigning doctor was an ophthalmologist in only six patients. Thirty percent patients with valid Indian DL would not have satisfied International College of Ophthalmologists guidelines. Driving difficulties were experienced by 44%, more so in advanced glaucoma (F (1, 82) = 22.12, P < 0.001). CONCLUSION: Vision-related testing at the time of renewal of DL is inadequate in India. Chronic eye diseases such as glaucoma are commonly not self-declared or detected at pre-renewal testing. Clear-cut guidelines about visual requirements and implementation are required to prevent road traffic events because of vision-related errors.

Femtosecond laser-assisted cataract surgery versus 2.2 mm clear corneal phacoemulsification.

PURPOSE: Phacoemulsification is the surgical procedure of choice for cataract, providing excellent visual and safety outcomes. Femtosecond laser-assisted cataract surgery (FLACS) is an addition to the surgical armamentarium. The study aims to compare the outcomes of FLACS using LenSx™ (Alcon Inc., USA) to standard 2.2 mm clear corneal phacoemulsification. Prospective case-control, comparative, interventional study was conducted in a tertiary care center. METHODS: In each group, 55 eyes of 55 patients underwent cataract surgery using either FLACS or conventional phacoemulsification (control group). The primary outcome variables, uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), specular microscopy, pachymetry, mean absolute error (MAE), and anterior chamber depth (ACD) were compared between two groups at 4 weeks postoperatively. Intraoperative effective phaco time (EPT), postoperative circularity of the rhexis, capsular overlap over the edge of the intraocular lens (IOL), and decentration of the IOL were the secondary variables which were compared. RESULTS: No significant difference was found between the groups for UCVA, pachymetry, MAE, and ACD at 4 weeks postoperatively. The FLACS group had better BCVA (P = 0.0294). Circularity of capsulorrhexis (P = 0), circular overlap over the edge of IOL (P = 0), and centration of IOL (P = 0.002) at 4 weeks postoperatively were better in the FLACS group. EPT was lower in FLACS for similar grade of cataract (P = 0). Endothelial cell loss in FLACS group was 4.2% more (P = 0.032). CONCLUSIONS: FLACS is superior to conventional phaco in the circularity of rhexis, capsular overlap, and centration of the IOL and uses less EPT. However, conventional phacoemulsification is equivalent to FLACS in most other parameters.

Proteomics of human aqueous humor.

The aqueous humor is a colorless, transparent fluid that fills the anterior chamber of the eye. It plays an important role in maintaining the intraocular pressure and providing nourishment to the lens and cornea. The constitution of the aqueous humor is controlled by the blood-aqueous barrier. Though this ocular fluid has been extensively studied, its role in ocular physiology is still not completely understood. In this study, aqueous humor samples were collected from 250 patients undergoing cataract surgery, subjected to multiple fractionation strategies and analyzed on a Fourier transform LTQ-Orbitrap Velos mass spectrometer. In all, we identified 763 proteins, of which 386 have been identified for the first time in this study. Sorbitol dehydrogenase (SORD), filensin (BFSP1), and phakinin (BFSP2) are some of the proteins that have not been previously reported in the aqueous humor. Gene Ontology analysis revealed 35% of the identified proteins to be extracellular, with a majority of them involved in cell communication and signal transduction. This study comprehensively reports 386 novel proteins that have important potential as biomarker candidates for future research into personalized medicine and diagnostics aimed towards improving visual health.

Chronic endophthalmitis due to Pyrenocheta romeroi in an immunocompetent host--a case report from southern India.

PURPOSE: Endophthalmitis due to Pyrenochaeta romeroi has not been reported in literature (PubMed, Medline). We report an interesting case of P. romeroi causing chronic endophthalmitis in an immunocompetent lady. METHODS: Retrospective interventional case report. A 25-year-old immunocompetent lady presented with pain and redness in the left eye of 1-month duration. Her best-corrected visual acuity was 6/6 and 6/18 in the right and the left eyes, respectively. Slit-lamp examination of the left eye showed a corneal stromal scar, fibrinlike material in the anterior chamber, few retrolental cells, and normal fundus examination. RESULTS: Aqueous taps on two occasions were negative for bacteria and fungi on routine smear, culture, and nested polymerase chain reaction. As inflammation recurred despite intravitreal voriconazole and amikacin injections, a lensectomy with vitrectomy was done. During vitrectomy, dense flocculent material was seen in the pars plana with only scleral indentation. The flocculent material grew a rare filamentous fungus called P. romeroi. The left eye underwent retinal detachment surgery with silicone oil insertion for a giant retinal tear at 2 months of follow-up. At 6 months of follow-up, her vision in the left eye was stable at 6/24 (Snellen) with no ocular inflammation. CONCLUSION: P. romeroi may need to be added in the list of rare fungi, which cause chronic endophthalmitis.

Proteomic analysis of human vitreous humor.

BACKGROUND: The vitreous humor is a transparent, gelatinous mass whose main constituent is water. It plays an important role in providing metabolic nutrient requirements of the lens, coordinating eye growth and providing support to the retina. It is in close proximity to the retina and reflects many of the changes occurring in this tissue. The biochemical changes occurring in the vitreous could provide a better understanding about the pathophysiological processes that occur in vitreoretinopathy. In this study, we investigated the proteome of normal human vitreous humor using high resolution Fourier transform mass spectrometry. RESULTS: The vitreous humor was subjected to multiple fractionation techniques followed by LC-MS/MS analysis. We identified 1,205 proteins, 682 of which have not been described previously in the vitreous humor. Most proteins were localized to the extracellular space (24%), cytoplasm (20%) or plasma membrane (14%). Classification based on molecular function showed that 27% had catalytic activity, 10% structural activity, 10% binding activity, 4% cell and 4% transporter activity. Categorization for biological processes showed 28% participate in metabolism, 20% in cell communication and 13% in cell growth. The data have been deposited to the ProteomeXchange with identifier PXD000957. CONCLUSION: This large catalog of vitreous proteins should facilitate biomedical research into pathological conditions of the eye including diabetic retinopathy, retinal detachment and cataract.

Comparison of profile of retinopathy of prematurity in semiurban/rural and urban NICUs in Karnataka, India.

PURPOSE: To identify and compare the profile of retinopathy of prematurity (ROP) in premature babies in urban and semiurban neonatal intensive care units (NICUs). METHODS: A prospective study of babies admitted to NICUs of two urban and seven semiurban centres. They were <36 weeks of gestational age and were subjected to fundus photography with a RetCam shuttle camera. Photos and NICU details were uploaded on a secure website. Photographs were read by a single observer. Infants were followed till retinal vascularisation was complete, or 45 weeks post conceptional age. Babies developing severe ROP were lasered. RESULTS: 500 babies were screened (243, urban group; 257, semiurban group). Incidence of ROP in the urban and semiurban groups was 16.5% (40) and 14.8% (38) respectively. Mean gestational age was 30.90 weeks and 31.53 weeks respectively. Mean birth weight was 1344 g and 1375 g respectively. 28 babies were lasered, 15 and 13 from each group respectively. There was no statistically significant difference between any of the parameters compared. Level of significance was fixed at 0.05. CONCLUSIONS: The magnitude of the burden of ROP is comparable between urban and semiurban NICUs stressing the need for effective screening strategies in semiurban and rural areas as well.

Mobile diabetes eye care: experience in developing countries.

The prevalence of diabetes in developing countries is on the increase and along with it the need to provide structured care to avoid the feared long term complications among them loss of vision and blindness due to diabetic retinopathy (DR). The biggest hurdle facing most developing countries is the lack of resources and trained manpower to both screen and treat the large number of people with DR. Countries also face the additional problem of unequal distribution of resources between the urban and rural areas. To overcome these challenges models of mobile diabetic retinopathy screening and treatment aided by the use of telemedicine have been introduced and demonstrated to be popular and effective. The aim of this review article is to describe different mobile diabetic retinopathy screening and treatment models developed in India, which can be readily replicated in developing countries presented with similar difficulties.

Neuroretinitis as a manifestation of Lyme disease in South India: a case report.

PURPOSE: To report a rare case of Lyme disease with neuroretinitis from South India. MATERIALS AND METHODS: Retrospective case report. A 45-year-old lady who hails from the Nagarhole forest in South India presented with a history of tick bite followed by diminution of vision in the left eye. Fundus evaluation of the left eye showed neuroretinitis. Mantoux test, Treponema pallidum hemagglutination test, serum angiotensin converting enzyme, and ELISA for toxoplasmosis and rickettsial infections were negative. ELISA for Lyme disease was positive for IgM antibodies. This was confirmed by Western blot test. RESULTS: Ocular inflammation resolved with a course of doxycyline and oral steroids. The species of the tick was also identified. CONCLUSION: This case highlights the need to consider Lyme disease, though rare in India, in the differential diagnosis of neuroretinitis especially if the patient hails from a forest area.

A study of the efficacy of endoscopic cyclophotocoagulation for the treatment of refractory glaucomas.

BACKGROUND: Endoscopic cyclophotocoagulation (ECP) is a relatively new method of cyclodestruction which can be used in the management of refractory glaucomas. AIM: To evaluate the safety and efficacy of ECP in the management of refractory glaucomas. SETTINGS AND DESIGN: Prospective interventional non-comparative study. MATERIALS AND METHODS: Fifty eyes of 50 patients with refractory glaucoma, whose intraocular pressures (IOP) were not under control with maximal medical therapy underwent ECP, by the anterior, or pars plana route. IOP, best corrected visual acuity (BCVA), and the number of anti-glaucoma medications, were compared postoperatively to preoperative values. Success was defined as IOP pound 22 mmhg, with or without use of medications. STATISTICAL ANALYSIS USED: Student's t test and repeated measures ANOVA were used to evaluate change in IOP and Student's t test, for comparison of BCVA. Kaplan Meier survival curve was plotted. Wilcoxon signed rank test was used to evaluate reduction in medications. RESULTS: Patients were followed for an average of 12.27 months (3-21months). IOP decreased significantly from 32.58 +/- 9.16 mmHg to 13.96 +/- 7.71 mmHg at last follow-up ( P < 0.001, student's t test). BCVA was significantly improved in the postoperative period ( P < 0.001, student's t test). The average number of antiglaucoma medications decreased from 2.51 +/- 0.97 to 1.09 +/- 1.16 ( P < 0.001, Wilcoxon signed rank test). ECP had a success rate of 82.2%. CONCLUSION: Endoscopic cyclophotocoagulation is an effective procedure in this subset of refractory glaucomas.