Surgical trends in glaucoma management: The current Indian scenario.

OBJECTIVES: To assess the current trend in the surgical management of glaucoma in India. METHODS: An anonymous online survey evaluating the preferred choices in the surgical management of glaucoma was circulated among the members of Glaucoma Society of India (GSI). Survey responses were compared to prior survey among GSI members in 2013 and members of American Glaucoma Society (AGS), 2016. RESULTS: A total of 175 of 879(20%) GSI members participated in the survey of which 75.3% of the survey participants were practicing in the private sector. Trabeculectomy with or without augmentation with Mitomycin C(MMC) was the first-choice glaucoma incisional surgery for 96.6% of the survey participants. Of the participants doing tube surgery, use of valved GDD was the preferred choice (83.4%). Re-trabeculectomy was the preferred approach (60.7%) in case of trabeculectomy failure. For paediatric glaucomas, combined trabeculotomy with trabeculectomy was the preferred surgical approach for both hazy cornea (84.5%) as well as clear cornea (66%). For a POAG patient without prior incisional surgery and presenting with visually significant cataract, phacoemulsification with trabeculectomy was the preferred management approach by 58.7% of the participants. CONCLUSION: Trabeculectomy continues to be the clear winner for the Indian glaucoma surgeon because of its cost effectiveness, lack of expensive instrumentation, and a more robust surgical training for trabeculectomy during residency programs. A higher proportion of angle closure disease precludes the use of minimally invasive glaucoma surgery and very often tube shunts also. Economics, ease of access and follow-up made a combined cataract and glaucoma surgery a preferred choice among Indian surgeons.

Breaking bad news about glaucoma: a SPIKES strategy primer.

PURPOSE: Most ophthalmic physicians are not formally trained for breaking the news of having sight threatening diseases, requiring lifelong therapy. This study aims to ascertain physician practices and patients' experiences regarding delivery of bad news. METHODS: An online, anonymous questionnaire was sent to 400 ophthalmologists practising glaucoma to gather information as to how they deliver bad news to their patients. A parallel survey was also conducted amongst 100 established glaucoma patients to know whether how their doctor had delivered the diagnosis of glaucoma to them. After this, resident doctors were trained in SPIKES strategy and the patient survey was repeated in 100 new patients. RESULTS: Two hundred and eighteen out of 400 ophthalmologists responded to our survey resulting in a survey yield of 54.5%. About 56.5% ophthalmologists dealt with disclosing the diagnosis >20 times a month; 70% of responders always discussed about the true severity of disease up-front. Only 8.70% respondents had formal training for breaking the bad news. Results of first phase of patient survey revealed that nearly one-third of patients (27%), felt that their doctor used incomprehensible medical terminology and 42% patients said that their doctor downplayed their diagnosis. Only 12% provided information to their patients about reliable sources to gather additional information. After the resident doctors were trained in SPIKES strategy, the second phase of patient survey had marked positive change in the way information was delivered. CONCLUSION: The current study shows that despite years of clinical experience, many ophthalmologists face difficulty in delivering bad news for a sight threatening disease such as glaucoma. Therefore, SPIKES strategy or a similar protocol must be taught to practising ophthalmologists at all levels, to alleviate worries of patients suffering from chronic, visually debilitating diseases.

Management of multi-surface ocular burns caused by molten iron.

Ocular thermal burns are medical emergencies that require immediate intervention before the standard management protocol, which involves obtaining a detailed history and performing an ophthalmic examination. In this case report, we report the clinical manifestations of ocular burns caused by molten iron and the steps taken for good clinical outcomes. The patient presented with an inferior epithelial defect and limbal and lower lid ischemia at four hours post-injury. Over the course of treatment, due to non-resolving epithelial defect and increased superior lid notching, amniotic membrane transplantation (AMT) and lid repair by pentagon wedge excision were performed. Following AMT, the corneal surface completely healed with residual opacity and neovascularization. Additionally, limbal ischemia was significantly reduced with the restoration of normal lid anatomy. Corneal burns initiate a cascade of inflammatory reactions disrupting the balance between pro- and anti-angiogenic factors, leading to corneal neovascularization. The eyelid damage can lead to necrosis of tissues with eschar formation and eventually quantitative tissue loss. Therefore, timely intervention is the key to the successful management of ocular burns.

Architectural design and development of an upper-limb rehabilitation device: a modular synthesis approach.

PURPOSE: Enormous assistance is required during rehabilitation activities, which might result in a variety of complications if performed manually. To solve this issue, several solutions in the form of assistive devices have been presented recently. Another issue highlighted is the lack of kinematic compatibility in low degrees-of-freedom (dof) systems. The proposed approach of developing a human-motion-oriented rehabilitation device deals with the problem through hybrid architectures. A novel modular synthesis approach is used for the purpose to induce generality in the design process. MATERIALS AND METHODS: Using a modular strategy, three planar hybrid configurations are generated for two-dof mechanisms for supporting flexion/extension motion. Three such architectures are optimally synthesised and kinematically analysed over the entire workspace. A Genetic Algorithm (GA) is used to synthesise the architecture parameters optimally. Moreover, the outcomes are evaluated against a set of seven poses and posture locations of the wrist to choose the most suitable configuration among the others. Subsequently, kinematic compatibility is analysed for the coupled system - formed by the selected architecture and the human arm - while wearing the proposed mechanism. RESULTS: According to the findings of optimal synthesis, workspace and singularity analysis, configuration-III is capable of achieving the optimal postures for all task space locations (TSLs). Further, the work modifies the design by attaching additional three revolute passive joints for correcting misalignment concerns using coupled mobility analysis. CONCLUSION: The modular strategy for hybrid architectures and the subsequent mobility analysis provides an algorithmic framework for synthesising a task-based rehabilitation device.IMPLICATIONS OF REHABILITATIONManual physiotherapy is reported as repeated task, expensive and time-consuming, and considered stressful for the therapist or assistants to provide one-on-one physiotherapy to each patient in the traditional method. Robotic rehabilitation is, therefore, a viable option.In the several reported works on robotic rehabilitation exoskeletons, misalignment of the exoskeleton and the human motion is considered an open challenge. Normally, it is being managed through large number of degrees of freedom, which is certainly expensive and complex in control. The proposed approach of developing a human-motion-oriented rehabilitation device deals with the problem through hybrid architectures and modular strategy to develop them.While focusing upon the emulation of natural human motion trajectory, the compatibility of orthotic joint and human joint motion needs attention. As biological joint possesses complex kinematic characteristics, closed-loops are used in the design.Overall, a complete framework of a cost effective low-dof rehabilitation device is proposed and detailed through coupled analysis.

Change in contrast sensitivity and OCT parameters in idiopathic intracranial hypertension.

Background: Deterioration in peripheral contrast sensitivity (CS) can be an indicator to detect progressive deterioration of visual function in patients with idiopathic intracranial hypertension (IIH). Objectives: The aim of this study was to evaluate the changes in central and peripheral CS and optical coherence tomography (OCT) parameters and in patients with IIH. Design and Methods: In this pilot observational study, data of 20 eyes of 10 'treatment-naïve' IIH patients were analyzed. Detailed ocular examination was performed including CS assessment using both Pelli-Robson (PR) test and Spaeth-Richman Contrast Sensitivity Test (SPARCS) along with the OCT for macular and optic nerve head (ONH) parameters. A comparative analysis was done for CS and OCT parameters from baseline to a follow-up visit > 12 months (range: 18-24 months). Results: The study population had a female preponderance (80%, n = 8), and mean age at diagnosis was 31.9 ± 10.3 years. Mean follow-up period was 21.2 months (range: 15-24 months). At presentation, 6/6 visual acuity was noted in 75% eyes (n = 15) while all eyes had 6/6 vision at the last follow-up. Average PR score increased from 1.96 ± 0.36 to 2.30 at the last visit (Wilcoxon test: V = 0.0, p ⩽ 0.001) while average SPARCS score (total) increased from 71.85 ± 9.10 to 77.55 ± 6.20 (Paired t-test: t = -2.3, p = 0.035). Change in SPARCS score was significant in average total score (p = 0.035), and quadrant-wise score in superonasal (p = 0.014), inferonasal (p = 0.001), and inferotemporal (p = 0.021) quadrants. Same trend in SPARCS scores was observed when eyes with and without recurrence were analyzed. Statistically significant difference in retinal nerve fiber layer (RNFL) thickness (p = 0.007) and macular thickness (MT) in nasal quadrant (p = 0.006) was seen between the eyes with recurrence and without recurrence. Conclusion: Peripheral CS showed significant difference in all eyes over time. It showed significant change in eyes with recurrence, even in the presence of intact visual acuity and preserved central CS. Changes in RNFL thickness and nasal MT could differentiate eyes which developed recurrence from normal eyes.

Impact of moderate and severe primary open-angle glaucoma on quality of life due to activity limitation.

PURPOSE: To study the impact of moderate and severe primary open-angle glaucoma (POAG) on the quality of life (QoL) due to activity limitation using glaucoma-specific questionnaires. METHODS: This cross-sectional study enrolled 122 participants, 50% (n = 61) being controls and 50% were diagnosed cases of moderate/severe POAG. Three orally administered glaucoma-specific QoL instruments were used: Glaucoma Activity Limitation (GAL-9), Glaucoma Quality of Life (GQL-15), and Viswanathan questionnaires. The questions related to activity limitation were identified and analyzed for each questionnaire separately. RESULTS: The mean age of the participants was 61.04 ± 9.88 years and a majority were males (64.8%, n = 79). The mean scores in controls, moderate glaucoma, and severe POAG patients for GAL-9 questionnaire were 9.77 ± 1.36 (P = 0.44), 13.75 ± 4.76 (P < 0.001), and 23.45 ± 5.62 (P < 0.001), for GQL-15, these were 16.39 ± 2.18 (P = 0.5), 22.75 ± 7.89 (P < 0.001), and 39.34 ± 9.42 (P < 0.001), respectively, while for the Viswanathan questionnaire, they were 9.49 ± 0.94 (P = 0.38), 7.91 ± 1.59 (P < 0.001), and 4.41 ± 2.20 (P < 0.001), respectively. The GQL-15 and GAL-9 questionnaires concluded that activity limitation pertaining to dark adaptation-related tasks affected the QoL the most in moderate as well as severe POAG (P < 0.001). Using the Viswanathan questionnaire, it was observed that the peripheral vision-related activity limitation was most significant for the decrease in QoL in moderate POAG while near vision-related activity limitation affected the QoL the most in severe POAG (P < 0.001). CONCLUSION: All three questionnaires concluded that the activity limitation due to moderate and severe glaucoma has a negative impact on the QoL. The limitation of the tasks involving dark adaptation/glare and peripheral vision has the most significant impact on the QoL in moderate glaucoma. As the disease progresses to a severe category, the limitation of activities requiring central and near vision causes the most significant worsening in QoL.

Contrast sensitivity assessment for early detection of hydroxychloroquine toxicity.

INTRODUCTION: Hydroxychloroquine (HCQ), is known to cause visual dysfunction during its prolonged course of administration. Optical Coherence Tomography (OCT) and field tests are the commonly used screening tests. Not much is known about the role of contrast sensitivity (CS) as method for early detection of HCQ toxicity. This pilot study was designed to study the change in central and peripheral contrast sensitivity for detecting early signs of HCQ toxicity. DESIGN: Prospective study conducted at Government Medical College & Hospital, Chandigarh, India. PARTICIPANTS: Twenty eyes of 10 treatment naïve, autoimmune patients. METHODS: All patients underwent functional tests, contrast sensitivity tests: Pelli Robson and Spaeth Richman Contrast Sensitivity (SPARCS). Average and quadrant wise SPARCS score; Pelli Robson score and structural parameters viz., macular OCT parameters were compared at baseline, 3- and 6-month post treatment with HCQ. MAIN OUTCOME MEASURES: Change in CS using SPARCS and Pelli Robson were recorded at each visit and compared with the baseline. Structural and functional parameters were correlated. RESULTS: The average SPARCS scores at baseline, 3-month post HCQ and at 6-month post HCQ were 82.37 ± 8.40, 73.17 ± 9.63 and 70.37 ± 10.08, respectively. Quadrant wise change from first visit to third visit was statistically significant only in superotemporal (p = 0.002), inferotemporal (p = 0.02) and central (p = 0.01) quadrants. There was no correlation between SPARCS and Pelli Robson (S = 0.1454, p = 0.466). Similarly, there was no significant correlation between the structural and functional parameters. CONCLUSIONS: HCQ affect the CS by virtue of its action on bipolar and ganglion cells. Decrease in central and peripheral CS as measured by SPARCS can be a sign of early visual dysfunction, hence must be considered as an early indicator of HCQ toxicity.

Kinematic modeling of a 7-degree of freedom spatial hybrid manipulator for medical surgery.

The prime objective of this work is to deal with the kinematics of spatial hybrid manipulators. In this direction, in 1955, Denavit and Hartenberg proposed a consistent and concise method, known as D-H parameters method, to deal with kinematics of open serial chains. From literature review, it is found that D-H parameter method is widely used to model manipulators consisting of lower pairs. However, the method leads to ambiguities when applied to closed-loop, tree-like and hybrid manipulators. Furthermore, in the dearth of any direct method to model closed-loop, tree-like and hybrid manipulators, revisions of this method have been proposed from time-to-time by different researchers. One such kind of revision using the concept of dummy frames has successfully been proposed and implemented by the authors on spatial hybrid manipulators. In that work, authors have addressed the orientational inconsistency of the D-H parameter method, restricted to body-attached frames only. In the current work, the condition of body-attached frames is relaxed and spatial frame attachment is considered to derive the kinematic model of a 7-degree of freedom spatial hybrid robotic arm, along with the development of closed-loop constraints. The validation of the new kinematic model has been performed with the help of a prototype of this 7-degree of freedom arm, which is being developed at Council of Scientific & Industrial Research-Central Scientific Instruments Organisation Chandigarh to aid the surgeon during a medical surgical task. Furthermore, the developed kinematic model is used to develop the first column of the Jacobian matrix, which helps in providing the estimate of the tip velocity of the 7-degree of freedom manipulator when the first joint velocity is known.

Adaptive neuro-fuzzy inference system-based path planning of 5-degrees-of-freedom spatial manipulator for medical applications.

Over the last few decades, medical-assisted robots have been considered by many researchers, within the research domain of robotics. In this article, a 5-degrees-of-freedom spatial medical manipulator is analyzed for path planning, based on inverse kinematic solutions. Analytical methods have generally employed for finding the inverse kinematic solutions in earlier studies. However, this method is only appreciable in case of closed-form solutions. The unusual joint configurations of considered manipulator result in more complexity to attain the closed-form solutions, analytically. To overcome with shortcomings of analytical method, a non-traditional approach named adaptive neuro-fuzzy inference system is proposed under the class of artificial intelligent techniques. This article presents this neuro-fuzzy approach for desired path generation by 5-degrees-of-freedom manipulator. The estimation of percentage error between actual path and adaptive neuro-fuzzy inference system-generated path is done with respect to x, y, and z directions, respectively. Furthermore, the error between actual and predicted values regarding joint parameters is calculated for a certain arm matrix. The prototype of 5-degrees-of-freedom medical-assisted manipulator is developed at CSIR-CSIO Laboratory Chandigarh, which is also termed as patient-side manipulator to be utilized in robot-assisted surgery. Through the simulation runs, in this work, it is found that the results from adaptive neuro-fuzzy inference system approach are quite satisfactory and acceptable.

Impact of moderate and severe primary open-angle glaucoma on quality of life due to activity limitation

Purpose: To study the impact of moderate and severe primary open?angle glaucoma (POAG) on the quality of life (QoL) due to activity limitation using glaucoma?specific questionnaires. Methods: This cross?sectional study enrolled 122 participants, 50% (n = 61) being controls and 50% were diagnosed cases of moderate/ severe POAG. Three orally administered glaucoma?specific QoL instruments were used: Glaucoma Activity Limitation (GAL?9), Glaucoma Quality of Life (GQL?15), and Viswanathan questionnaires. The questions related to activity limitation were identified and analyzed for each questionnaire separately. Results: The mean age of the participants was 61.04 ± 9.88 years and a majority were males (64.8%, n = 79). The mean scores in controls, moderate glaucoma, and severe POAG patients for GAL?9 questionnaire were 9.77 ± 1.36 (P = 0.44), 13.75 ± 4.76 (P < 0.001), and 23.45 ± 5.62 (P < 0.001), for GQL?15, these were 16.39 ± 2.18 (P = 0.5), 22.75 ± 7.89 (P < 0.001), and 39.34 ± 9.42 (P < 0.001), respectively, while for the Viswanathan questionnaire, they were 9.49 ± 0.94 (P = 0.38), 7.91 ± 1.59 (P < 0.001), and 4.41 ± 2.20 (P < 0.001), respectively. The GQL?15 and GAL?9 questionnaires concluded that activity limitation pertaining to dark adaptation?related tasks affected the QoL the most in moderate as well as severe POAG (P < 0.001). Using the Viswanathan questionnaire, it was observed that the peripheral vision?related activity limitation was most significant for the decrease in QoL in moderate POAG while near vision?related activity limitation affected the QoL the most in severe POAG (P < 0.001). Conclusion: All three questionnaires concluded that the activity limitation due to moderate and severe glaucoma has a negative impact on the QoL. The limitation of the tasks involving dark adaptation/glare and peripheral vision has the most significant impact on the QoL in moderate glaucoma. As the disease progresses to a severe category, the limitation of activities requiring central and near vision causes the most significant worsening in QoL.