An Evaluation of the Efficacy and Safety of Timolol Maleate 0.5% Microdrops Administered with the Nanodropper®.

OBJECTIVE OR PURPOSE: Examine if 12.5 µL timolol maleate 0.5% microdrops dispensed with the Nanodropper® Adaptor provide non-inferior intraocular pressure (IOP) reduction compared to conventional, 28 µL drops in open-angle glaucoma (OAG) and ocular hypertension (OHT) patients. DESIGN: Prospective, non-inferiority, parallel, multicenter, single-masked, active-controlled, randomized trial. SUBJECTS, PARTICIPANTS, AND/OR CONTROLS: Treatment-naïve subjects that were recently diagnosed with OAG/OHT at the Aravind Eye Care System. METHODS, INTERVENTION, OR TESTING: Both eyes of subjects received either one commercially available drop or one microdrop of timolol maleate 0.5%. We measured IOP, resting heart rate (HR), and blood pressure (BP) at baseline and 1, 2, 5, and 8 hours after timolol administration. MAIN OUTCOME MEASURES: IOP was the primary outcome measure. Secondary outcomes were resting HR, systolic BP (sBP), and diastolic BP (dBP). RESULTS: Adaptor-mediated microdrops and conventional drops of timolol significantly decreased IOP compared to baseline at all timepoints. Non-inferiority was established at three of four timepoints. HR decreases with Nanodropper were ∼3 bpm less than with conventional drops. CONCLUSIONS: Timolol microdrops appear to be as effective in ocular hypotensive action as conventional drops with a slightly lesser effect on resting HR and BP.

The Environmental Impacts of Electronic Medical Records Versus Paper Records at a Large Eye Hospital in India: Life Cycle Assessment Study.

BACKGROUND: Health care providers worldwide are rapidly adopting electronic medical record (EMR) systems, replacing paper record-keeping systems. Despite numerous benefits to EMRs, the environmental emissions associated with medical record-keeping are unknown. Given the need for urgent climate action, understanding the carbon footprint of EMRs will assist in decarbonizing their adoption and use. OBJECTIVE: We aimed to estimate and compare the environmental emissions associated with paper medical record-keeping and its replacement EMR system at a high-volume eye care facility in southern India. METHODS: We conducted the life cycle assessment methodology per the ISO (International Organization for Standardization) 14040 standard, with primary data supplied by the eye care facility. Data on the paper record-keeping system include the production, use, and disposal of paper and writing utensils in 2016. The EMR system was adopted at this location in 2018. Data on the EMR system include the allocated production and disposal of capital equipment (such as computers and routers); the production, use, and disposal of consumable goods like paper and writing utensils; and the electricity required to run the EMR system. We excluded built infrastructure and cooling loads (eg. buildings and ventilation) from both systems. We used sensitivity analyses to model the effects of practice variation and data uncertainty and Monte Carlo assessments to statistically compare the 2 systems, with and without renewable electricity sources. RESULTS: This location's EMR system was found to emit substantially more greenhouse gases (GHGs) than their paper medical record system (195,000 kg carbon dioxide equivalents [CO2e] per year or 0.361 kg CO2e per patient visit compared with 20,800 kg CO2e per year or 0.037 kg CO2e per patient). However, sensitivity analyses show that the effect of electricity sources is a major factor in determining which record-keeping system emits fewer GHGs. If the study hospital sourced all electricity from renewable sources such as solar or wind power rather than the Indian electric grid, their EMR emissions would drop to 24,900 kg CO2e (0.046 kg CO2e per patient), a level comparable to the paper record-keeping system. Energy-efficient EMR equipment (such as computers and monitors) is the next largest factor impacting emissions, followed by equipment life spans. Multimedia Appendix 1 includes other emissions impact categories. CONCLUSIONS: The climate-changing emissions associated with an EMR system are heavily dependent on the sources of electricity. With a decarbonized electricity source, the EMR system's GHG emissions are on par with paper medical record-keeping, and decarbonized grids would likely have a much broader benefit to society. Though we found that the EMR system produced more emissions than a paper record-keeping system, this study does not account for potential expanded environmental gains from EMRs, including expanding access to care while reducing patient travel and operational efficiencies that can reduce unnecessary or redundant care.

Wound modulation in glaucoma surgery: The role of anti-scarring agents.

Filtration surgery is one of the most frequently performed surgeries in the management of glaucoma, and trabeculectomy is considered the gold standard surgical technique for the same. Though trabeculectomy has been reported to have an excellent initial success rate, about 30% of them fail in 3 years, and nearly 50% of them fail in 5 years. The most significant risk of failure still seems to be wound scarring, especially episcleral fibrosis, leading to bleb failure. As a result, it is essential to explore the role of anti-scarring agents, including mitomycin C, and 5-fluorouracil in wound modulation and improving the bleb survival rate. Since these agents are widely used in trabeculectomy, it is crucial to understand the various modes of application, advantages, and adverse effects of these agents. On an evidence-based approach, all these points have been highlighted in this review article. In addition, the newer agents available for wound modulation and their scope for practical application are discussed.

S-FIX: A sutured way of doing sutureless SFIOL surgeries beyond X-NIT!

BACKGROUND: The video describes a technique in scleral fixation intraocular lens (SFIOL) surgery that is very simple and easily reproducible by any novice surgeon. PURPOSE: This technique may serve as a simple option for tucking the haptic of a multipiece IOL into the sclera without the need for the scleral flap, scleral pocket, forceps, glue, or flange. SYNOPSIS: The two most crucial steps in scleral fixation intraocular lens (SFIOL) surgery are 1) the exteriorization of the haptic, and 2) the fixation of the exteriorized haptic. The first half of the video describes the steps of our previously published technique of extraocular needle-guided haptic insertion technique (X-NIT), which simplifies the exteriorization step by shifting the intraocular hand-shake maneuver to an extraocular site. The second half describes a novel suture-guided haptic fixation (S-FIX) device, which simplifies the fixation step. S-FIX has three components: 1) a 380-micron spatulated needle, 2) a 5-o nylon suture thread, and 3) a polyimide tube. There are four steps involved in S-FIX: 1) docking of the exteriorized haptic into the polyimide tube, 2) pushing the docked polyimide tube into the eye, 3) suture bite starting from the point of sclerotomy, and 4) pulling the suture thread. As the suture thread is being pulled, the haptic along with the polyimide tube comes out and the haptic gets fixed into the narrow suture track. HIGHLIGHTS: The technique enhances the overall safety in SFIOL surgeries by avoiding haptic slips during exteriorization and fixation steps. Most anterior segment and novice surgeons do not perform SFIOL surgeries due to fear of fall of IOL. VIDEO LINK: https://youtu.be/ZoJBiw2SNaU.

Knowledge, attitude, and practice toward mucormycosis among patients discharged from a COVID-19 care tertiary center in South India: A questionnaire-based survey.

Purpose: To study the awareness of mucormycosis among discharged inpatients after receiving treatment for COVID-19 infection at a tertiary COVID care center in south India. Methods: This was a telephone-based survey conducted using a questionnaire consisting of 38 questions in five sections in the month of June-July 2021. COVID-positive inpatients who had been admitted, treated, and discharged from a government medical college were contacted via phones, and their responses were directly entered into the Google Forms platform. Results: A total of 222 participants were included in the study. Among all the participants, a cumulative 66% of participants had some knowledge of mucormycosis and 98/222 (44%) did not have any idea of mucormycosis in spite of being admitted to the hospital. More than 40% of them reported that their prime source of information was through mass communication. Around 81% of the respondents were aware that it can occur after COVID-19 infection. Among them, only 25 knew that systemic steroids were the main risk factor. Sixty-four out of 124 knew that diabetes is a major risk factor. Fifty percent agreed that a vaccine for COVID can prevent mucormycosis. Conclusion: Such knowledge, attitude, and practice (KAP) studies give us an idea of the impact of the measures taken for educating the public. In this study, a cumulative 66% of participants had some knowledge of mucormycosis and 34.7% were diabetics who had better knowledge and practice scores than non-diabetics. Sixty-six point nine percent felt that it was possible to prevent this condition.

4-Flanged intrascleral fixation of an intraocular lens through the dialing hole.

The high prevalence of mature, hypermature, and traumatic cataracts in developing countries, combined with the limited availability of surgical resources and skill by anterior segment surgeons to manage the resultant aphakia, leaves the patient needlessly blind. Relying on posterior segment surgeons, expensive surgical setup, and appropriate lenses for aphakia management limits the number of patients receiving a secondary intraocular lens (IOL). Utilizing the well-acknowledged flanging technique and the readily available polymethyl methacrylate (PMMA) lenses with dialing holes in their optic, a hammock can be created through the dialing holes using a 7-0 polypropylene suture on a straight needle. This 4-flanged scleral fixation through the dialing hole of an IOL makes scleral fixation of PMMA lens possible by even anterior segment surgeons without requiring any specialized equipment or scleral fixated lens with eyelet. This technique was successfully performed in a series of 103 cases with no incidence of IOL decentration.

Evidence from the first Shared Medical Appointments (SMAs) randomised controlled trial in India: SMAs increase the satisfaction, knowledge, and medication compliance of patients with glaucoma.

In Shared Medical Appointments (SMAs), patients with similar conditions meet the physician together and each receives one-on-one attention. SMAs can improve outcomes and physician productivity. Yet privacy concerns have stymied adoption. In physician-deprived nations, patients' utility from improved access may outweigh their disutility from loss of privacy. Ours is to our knowledge the first SMA trial for any disease, in India, where doctors are scarce. In a 1,000-patient, single-site, randomized controlled trial at Aravind Eye Hospital, Pondicherry, we compared SMAs and one-on-one appointments, over four successive visits, for patients with glaucoma. We examined patients' satisfaction, knowledge, intention-to-follow-up, follow-up rates, and medication compliance rates (primary outcomes) using intention-to-treat analysis. Of 1,034 patients invited between July 12, 2016 -July 19, 2018, 1,000 (96.7%) consented to participate, and were randomly assigned to either SMAs (NSMA = 500) or one-on-one appointments (N1-1 = 500). Patients who received SMAs showed higher satisfaction (MeanSMA = 4.955 (SD 0.241), Mean1-1 = 4.920 (SD 0.326); difference in means 0.035; 95% CI, 0.017-0.054, p = 0.0002) and knowledge (MeanSMA = 3.416 (SD 1.340), Mean1-1 = 3.267 (SD 1.492); difference in means 0.149; 95% CI, 0.057-0.241, p = 0.002) than patients who received one-on-one appointments. Across conditions, there was no difference in patients' intention-to-follow-up (MeanSMA = 4.989 (SD 0.118), Mean1-1 = 4.986 (SD 0.149); difference in means 0.003; 95% CI, -0.006-0.012, p = 0.481) and actual follow-up rates (MeanSMA = 87.5% (SD 0.372), Mean1-1 = 88.7% (SD 0.338); difference in means -0.012; 95% CI, -0.039-0.015, p = 0.377). Patients who received SMAs exhibited higher medication compliance rates (MeanSMA = 97.0% (SD 0.180), Mean1-1 = 94.9% (SD 0.238); difference in means 0.020; 95% CI, 0.004-0.036, p = 0.013). SMAs improved satisfaction, learning, and medication compliance, without compromising follow-up rates or measured clinical outcomes. Peer interruptions were negatively correlated with patient satisfaction in early-trial SMAs and positively correlated with patient satisfaction in later-trial SMAs. Trial registration: The trial was registered with Clinical Trials Registry of India (https://ctri.nic.in/) with reference no. REF/2016/11/012659 and registration no. CTRI/2018/02/011998.

A novel transconjunctival, intrascleral, ab-externo, knotless, and double-flanged technique with 6-0 Prolene for iridodialysis repair.

Small traumatic iridodialysis (ID) may be asymptomatic, but large ones usually cause polycoria and corectopia, leading to symptoms like diplopia, glare, and photophobia. The management of ID, including medical and surgical methods, depends upon the patient's symptoms. Mild glare and diplopia can be treated either with atropine, antiglaucoma medications, tinted spectacles, colored contact lens, or corneal tattooing, but extensive IDs require surgical options. The surgical techniques are challenging due to the iris texture and the damage encountered during the primary surgery, the narrow anatomical workspace for repair, and the associated surgical complications. Numerous techniques have been described by several authors in the literature; each has its advantages and disadvantages. All the procedures described previously involve conjunctival peritomy, scleral incisions, and suture knots and are time consuming. Here, we report a novel transconjunctival, intrascleral, knotless, and ab-externo, double-flanged technique for repair of large ID with a 1-year follow-up.

"Dye another day!" - dyes in ophthalmology.

Background: Dyes are substances that are an integral part of ocular procedures and surgeries. In Clinical practice, dyes help in better visualization and aid in diagnoses of ocular surface disorders. In Surgical practice, dyes help in better resolution of the structures that are otherwise naked to the surgeon's eyes. Purpose: To educate ophthalmologists about the importance and uses of dyes. Synopsis: Dyes have become an important part of an ophthalmologists' clinical as well as surgical practice. This video aims at educating the different characteristics, uses, advantages and disadvantages of each dye. Dyes help in identifying the obscure and highlighting the invisible. The indications and contraindications as well as the side effects of each dye are discussed which would help ophthalmologists in the correct usage of these wonder substances. This video will also help the new eye doctors understand and utilize these dyes judiciously which would aid in their learning process and provide better patient care. Highlights: This video highlights the uses, indications, contraindications and side effects of all the dyes used in ophthalmology. Video Link: https://youtu.be/shdV4a6oc20.

Prostaglandin analogs in ophthalmology.

Glaucoma is a major cause of irreversible blindness worldwide. Reducing intraocular pressure (IOP) is currently the only approach to prevent further optic nerve head damage. Pharmacotherapy is the mainstay of treatment for glaucoma patients. In recent years, a significant milestone in glaucoma treatment has been a transition to prostaglandin analogs (PGAs) as the first line of drugs. The rapid shift from traditional ß-blockers to PGAs is primarily due to their excellent efficacy, convenient once-a-day usage, better diurnal control of IOP, and systemic safety profiles. This review article aims to provide information regarding the various PGAs in practice and also the newer promising drugs.

Retrospective analysis of the role of anterior segment optical coherence tomography and outcomes of cataract surgery in posterior polar cataract.

Purpose: To evaluate the visual and surgical outcomes of cataract surgery in patients with posterior polar cataract (PPC) and to evaluate the benefits of preoperative anterior segment optical coherence tomography (AS-OCT). Methods: This was a retrospective, single-center study. Case records of patients diagnosed with PPC who underwent cataract surgery either by phacoemulsification or manual small-incision cataract surgery (MSICS) from January to December 2019 were analyzed. Data collected include demographic details, preoperative best corrected visual acuity (BCVA), AS-OCT, type of cataract surgery, intraoperative and postoperative complications, and visual outcome at 1-month follow-up. Results: One hundred patients were included in the study. Preoperative posterior capsular defect was noted on AS-OCT in 14 patients (14%). Seventy-eight underwent phacoemulsification and 22 underwent MSICS. Intraoperatively, posterior capsular rupture (PCR) was seen in 13 patients (13%) and cortex drop was noted in one among them (1%). Out of 13 PCRs, 12 were found to have posterior capsular dehiscence preoperatively in AS-OCT. The sensitivity of AS-OCT for detecting posterior capsule dehiscence was 92.3% and specificity was 97.7%. The positive predictive value and negative predictive value were 85.7% and 98.8%, respectively. There was no significant difference in the incidence of PCR between phacoemulsification and MSICS (P = 0.475). The mean BCVA at 1 month was found to be better with phacoemulsification than MSICS (P = 0.004). Conclusion: Preoperative AS-OCT has excellent specificity and negative predictive value in identifying posterior capsular dehiscence. It thus helps to plan the surgery and counsel patients appropriately. Both phacoemulsification and MSICS provide good visual outcome with similar complication rates.

Changes in emergency glaucoma care during the COVID-19 pandemic in South India.

Purpose: To assess the differences in the pattern of presentation of glaucoma emergency conditions during the various phases of pandemic-related travel restrictions: first wave-related lockdown, unlock period, and the second wave-related lockdown. Methods: The number of new emergency glaucoma conditions, the various diagnoses, and the total number of all new glaucoma patients presenting to the glaucoma services at five tertiary eye care centers in south India from 24th March 2020 to 30th June 2021 were collected from the electronic medical records and were analyzed. The data were compared with the corresponding time period in the year 2019. Results: In total, 620 patients presented with an emergency glaucoma diagnosis during the first wave-related lockdown as against 1337 during the same period in 2019 (P < 0.0001). During the unlock period, 2659 such patients visited the hospital compared with 2122 in 2019 (P = 0.0145). During the second wave-related lockdown, there were 351 emergency patients compared with 526 patients in 2019 (P < 0.0001). Lens-induced glaucomas (50.4%) and neovascular glaucoma (20.6%) were the most common diagnoses during the first wave-related lockdown. During the unlock period, there was a greater proportion of neovascular glaucoma (P = 0.0123). The second wave-related lockdown had a greater proportion of phacolytic glaucomas (P = 0.005) and acute primary angle closure (P = 0.0397) patients. Conclusion: The study demonstrates that emergency glaucoma care was grossly underutilized by the people during the lockdowns. Trivial conditions like cataracts or retinal vascular diseases if not treated appropriately may progress to become emergencies in the future.

Single haptic iris fixation of posterior chamber intraocular lens.

Single haptic iris fixation technique is used where there is a loss of 6 clock hours anterior capsular support. It helps the anterior segment surgeon to fix the intraocular lens to the iris on the side of absent capsular support and place the other haptic over the capsular support. A 10-0 polypropylene suture on a long-curved needle is only used to take a suture bite on the side of capsule loss. Meticulous automated anterior vitrectomy is done. Then, the suture loop below the iris is taken out and the loops are twirled multiple times around the haptic. The leading haptic is then gently glided behind the iris, and the trailing haptic is gently placed on the other side using forceps. The suture ends are trimmed and internalized into the anterior chamber and then externalized through the paracentesis using a Kuglen hook, and the knot is tied and secured.

Important signs to check posterior capsule integrity.

For beginner surgeons, it is difficult to recognize the posterior capsule during cataract surgery. In the case of brown cataracts with a thin posterior capsule and in cataracts with asteroid hyalosis, it is difficult to identify the capsule before intraocular lens (IOL) implantation even for expert surgeons. Here we illustrate five important signs, which can be practiced in routine cases to make sure the posterior capsule is intact, before IOL implantation.

Comparison of a New Head Mount Virtual Reality Perimeter (C3 Field Analyzer) With Automated Field Analyzer in Neuro-Ophthalmic Disorders.

BACKGROUND: Automated perimetry in neurologically disabled patients is a challenge. We have devised a patient-friendly virtual reality perimeter, the C3 field analyzer (CFA). We aim to assess the utility of this as a visual field-testing device in neuro-ophthalmic patients for screening and monitoring. METHODS: Neuro-ophthalmic patients and controls were selected to participate in the study between September and December 2018. They randomly underwent either the CFA or automated field analyzer (HFA) first followed by the other in an undilated state. The CFA results were compared with the HFA, and the correlation of the pattern of the field defect was assessed by an independent masked physician. RESULTS: In total, 59 eyes of 33 neuro-ophthalmic patients (cases) and another 95 normal individuals (controls) were enrolled. CFA was found to have greater proportion of reliable fields (81.4%) than HFA (59.3%) ( P = 0.009). There were less false negatives ( P < 0.001) and more false positives in CFA ( P < 0.001) among neuro-ophthalmic patients compared with controls. Among neuro-ophthalmology patients, the number of fixation losses was greater with CFA ( P < 0.001), whereas false negatives were greater in HFA ( P < 0.001). On assessing the pattern of the field defects, we found that there was almost 70% correlation of CFA with HFA. Moreover, in classical neurological fields such as hemianopia, the correlation was 87.5%. CONCLUSIONS: The CFA seems to correlate well with HFA in classic neurological fields such as hemianopias and may serve as an alternative in patients unable to perform a standard automated perimetry. Further developments are currently underway to incorporate threshold testing.

Automatic detection of glaucoma via fundus imaging and artificial intelligence: A review.

Glaucoma is a leading cause of irreversible vision impairment globally, and cases are continuously rising worldwide. Early detection is crucial, allowing timely intervention that can prevent further visual field loss. To detect glaucoma an examination of the optic nerve head via fundus imaging can be performed, at the center of which is the assessment of the optic cup and disc boundaries. Fundus imaging is noninvasive and low-cost; however, image examination relies on subjective, time-consuming, and costly expert assessments. A timely question to ask is: "Can artificial intelligence mimic glaucoma assessments made by experts?" Specifically, can artificial intelligence automatically find the boundaries of the optic cup and disc (providing a so-called segmented fundus image) and then use the segmented image to identify glaucoma with high accuracy? We conducted a comprehensive review on artificial intelligence-enabled glaucoma detection frameworks that produce and use segmented fundus images and summarized the advantages and disadvantages of such frameworks. We identified 36 relevant papers from 2011 to 2021 and 2 main approaches: 1) logical rule-based frameworks, based on a set of rules; and 2) machine learning/statistical modeling-based frameworks. We critically evaluated the state-of-art of the 2 approaches, identified gaps in the literature and pointed at areas for future research.