Tracing ocular biometry and their heritability in twins in a hospital-based cohort in South India.

PURPOSE: Twin studies, in the background of lack of twin registry in India, are a challenge. We report the response rates in tracing a hospital birth register-based cohort of twins using mail and door to door survey, ocular parameters influencing refractive errors, and their heritability. METHODS: Twins born from 1991 to 1995 in a tertiary hospital in the Vellore District of South India from a database were traced by mail and home survey from March 2011 to September 2013. Consenting live twin pairs who presented to the eye department were examined, including best corrected visual acuity, cycloplegic refraction, slit lamp examination, measurements of intraocular pressure (IOP) by Goldmann Applanation tonometry, axial length (AL) and anterior chamber depth (ACD), central corneal thickness (CCT), specular microscopy for endothelial count (EC), and a dilated fundus examination. Zygosity was determined by a validated zygosity questionnaire. Heritability was determined using the Falconers formula. RESULTS: Postal contact was made in 14%, and a home visit was successful in another 23% of the cohort. Of those presenting for examination, 51.3% were found to be monozygous. Heritability (h2) of IOP was 0.34, that of ACD was 0.88, that of AL was 0.92, that of CCT was 0.96, and that of EC was 0.58. CONCLUSION: Tracing of twins using postal and home visits is challenging. Heritability for AL and CCT was found to be high, similar to that reported in other studies. This implies that a large proportion of variation found in AL and CCT is due to genetic causes as seen in twins from South India.

Comparative evaluation of diabetic retinopathy screening programs in regular ophthalmology clinics versus integrated diabetic clinics within rural health-care services.

BACKGROUND: Robust integration of diabetic retinopathy (DR) screening within health systems is essential to prevent DR-related blindness. This, however, remains a challenge in the developing world. The aim of this study was to evaluate two models of DR screening programs within rural general health-care services. MATERIALS AND METHODS: This was a retrospective observational study from two rural health centers. Demographic and clinical data of patients completing DR screening were analyzed. Patients were screened in regular ophthalmology clinics (ROC) or integrated diabetic clinics (IDC). Referral and treatment completion data were retrieved from the clinical charts at the base hospital. RESULTS: A total of 2535 DR screenings were conducted for 2296 patients. The total population prevalence for any DR was 14.2% (95% confidence interval [CI]: 12.8%-15.6%) and vision-threatening DR (VTDR) was 4.7% (95% CI: 3.8%-5.6%). In the ROC and IDC groups, respectively, the prevalence of any DR was 20.4% and 8.2%, VTDR, 7.8% and 1.7%, and blindness, 1.4% and 0.4% (all P < 0.001). Referral completion rates were higher in the ROC group (44.8% vs. 25.2%, P < 0.001), while treatment completion in both was similar (69.6% vs. 70.6%). Referral and treatment completion rates for referable DR were 61.2% and 48.2%, and for VTDR, 62% and 38.8%, respectively. Only 11.45% of patients completed the repeat screening follow-up. CONCLUSIONS: Patients attending IDCs had a significantly lower prevalence of any DR, VTDR, and blindness demonstrating the advantages of integrated diabetic care in a rural setting. However, referral uptake and DR treatment completion need strengthening.

Correlation between visual acuity at discharge and on final follow-up in patients undergoing manual small incision cataract surgery.

Purpose: The aim of this study was to determine the correlation between visual acuity on discharge and at final follow-up in patients undergoing manual small incision cataract surgery (MSICS) through outreach services of a tertiary care training center. Methods: A prospective observational study was done to determine the correlation between visual acuity on postoperative day 1 and final follow-up (4-8 weeks) among various categories of surgeons and surgical complications in patients who underwent MSICS between January 2018 and March 2018. Proportions of patients benefitting from refractive correction were also analyzed. Results: Of the 924 patients who underwent MSICS through outreach services during the study period 841 were eligible for the study. Follow-up rate at 4-8 weeks was 91%. Mean age was 61.6 (SD 9.2) years, 63% were females and 55% were operated by trainees. There was a positive correlation between visual acuity at day one and final follow-up with a Spearman's correlation coefficient of 0.375 and 0.403 for uncorrected (UCVA) and best corrected visual acuity (BCVA) respectively (P < 0.001). The correlation coefficient, while still positive, was lower for trainees (0.287), as compared to consultants (0.492). At least two lines of improvement in visual acuity on refractive correction were found in 77% of patients. Conclusion: Visual acuity on the day of discharge may be a useful quality indicator of visual outcome for monitoring cataract surgical programs. However, a follow-up at 4-8 weeks is recommended for individual patient benefit and monitoring surgical quality especially in training hospitals.

Acute work-related hazardous eye exposures in a health care environment - An observational study from a tertiary care hospital in South India.

PURPOSE: Healthcare workers (HCW) are exposed to numerous occupation-related eye hazards. We studied the epidemiological distribution, risk factors, and severity of acute work-related hazardous exposure/infection (WRHEI) to the eyes of HCW in a tertiary healthcare institution in Southern India. METHODS: In this prospective observational study, we included HCW who reported acute WRHEI between February 15, 2017 and August 14, 2017 from a total 11,628 HCWs (staff and students). Each HCW underwent a comprehensive eye examination. Information regarding WRHEI was collected by a structured questionnaire. Statistical analysis was performed using SPSS Version 20.0. RESULTS: Cumulative incidence of acute WRHEI in 6 months was 0.8%, 95% CI (0.64-0.96). Among the 94 reporting WRHEI, 82 (87.2%) were staff and 12 (12.8%) students. Mean age was 31.53 ± 8.39 years and 65 (69%) were females. Exposures were reported more commonly among nurses (25.5%), followed by technicians (18%), and housekeeping staff (15.9%). Infectious eye hazards accounted for 50%. Noninfectious eye hazards included exposure to chemicals (28%) and blood and body fluid (8%). Among them, awareness regarding personal protective equipment (PPE) and its usage was present in 44.6 and 27.6%, respectively. Multivariable logistic regression analysis showed that HCWs working in clinical areas (adjusted odd's ratio (AOR): 3.23, 95% CI: 1.12-9.34) and not wearing glasses (AOR: 3.72, 95% CI: 1.33-10.34) had a significantly higher risk of acute WRHEI. CONCLUSION: Cumulative Incidence of WRHEI eye was 8 per 1000 in 6 months. Infectious conjunctivitis is half the burden followed by chemical exposures. Awareness regarding eye safety and usage of PPE was low.

A validated audio-visual educational module on examination skills in ophthalmology for undergraduate medical students in the COVID-19 season - An observational longitudinal study.

PURPOSE: The aim of this study was to assess the impact of an audio visual (AV) teaching module on basic torchlight examination of the eye and direct ophthalmoscopy for undergraduate medical students. METHODS: This observational longitudinal study was done on 33 consecutive medical interns during their Ophthalmology posting from December 2019 to March 2020 at a medical college in South-India. An AV-module was created using animation graphics, narratives, demonstrations on normal individuals and on patients with positive signs. All interns had a pretest consisting of Multiple-choice questions, (MCQs) and an Objective Structured Clinical Examination (OSCE) on torchlight examination and direct ophthalmoscopy (DO). They were then shown the 20-minute AV-module. A posttest was performed immediately and after one week. RESULTS: The mean pretest MCQ score was 5.84 ± 1.98. It improved to 8.81 ± 1.15 in the immediate posttest and 8.87 ± 1.66 in the one-week posttest. The mean pretest OSCE score was 12.21 ± 3.39. It improved to 23.21 ± 3.39 in the immediate posttest and 23.90 ± 3.7 in the one-week posttest. Using Generalized Estimating Equation, MCQ score improved by 2.97 units and 3.03 units and the OSCE score improved by 11 units and 11.69 units in the immediate posttest and one-week posttest respectively when compared to the pretest corresponding to the MCQ score and OSCE score (p < 0.001). CONCLUSION: AV teaching modules-for torchlight examination and DO has a significant benefit in improving knowledge and skill in undergraduate medical students. These significant results have the great translatory capacity in the current COVID-19 pandemic, where physical demonstrations involving close proximity and groups of students are highly risk prone.

Accuracy of Trained Community-based Rehabilitation Volunteers in Identification and Appropriate Referral of Adults with Perceived Visual Disability in an Urban-slum Setting in Southern India.

PURPOSE: The integration of primary eyecare into existing primary healthcare systems requires simple yet effective tools that do not overburden the grass-root level worker. The objective of this study was to test the accuracy of a questionnaire-based tool administered by trained community-based rehabilitation volunteers (CBRVs) in identifying persons with visual disability, proportions accessing referral pathway and barriers to uptake of eyecare services. METHODS: CBRVs working in the urban-slum service area of a teaching hospital were trained in administering a questionnaire-based tool derived from the World Health Organization (WHO) "Training in the community for people with disabilities" to a responsible adult member of the household. Post-training, they screened and referred adults with perceived visual problems. This tool was tested against two reference standards: (i) history of visual disability elicited by ophthalmologist; (ii) pre-set visual acuity and diagnosis criteria. RESULTS: Ten CBRVs screened 950 individuals of whom 805 (84.7%) were examined by an optometrist and ophthalmologist. Sensitivity and specificity of this method were 75% (95% CI 72-78%), 95.8% (95% CI 94-98%) respectively, using history and 60.2% (95% CI 57-63%), 91.8% (95% CI 90-94%) using clinical criteria as reference standard. Referral pathway was used by 91/221 (41.2%) referred individuals. The commonest barriers to accessing eye care were 'did not feel the need' (32.2%) and 'busy with work/household responsibilities' (30.2%). CONCLUSIONS: This questionnaire-based tool administered by grass-root level health workers to a responsible adult member of the family may be a promising screening method for identification and appropriate referral of persons with visual disability in the community.

Facilitating factors in overcoming barriers to cataract surgical services among the bilaterally cataract blind in Southern India: A cross-sectional study.

Purpose: To effectively address cataract blindness, increasing sight-restoring surgeries among the bilaterally blind are essential. To improve uptake of surgical services among this group, evidence regarding the problems of access is vital. Barriers in accessing eye care services have previously been reported but not specific to bilaterally cataract blind patients. Further, there is a gap in knowledge regarding factors facilitating access to eye care. Our aims were to (1) report proportion of bilaterally cataract blind patients undergoing surgery and sight restoration rate (SRR) and (2) analyze barriers and factors enabling access to eye care services among bilaterally cataract blind patients. Methods: Retrospective analysis of interview and clinical data of bilaterally cataract blind patients undergoing surgery through outreach services at the base hospital, from June 2015 to May 2016, was performed. Demographic data, vision, postoperative visual outcomes, barriers, and facilitating factors in accessing cataract surgical services were obtained. Results: Bilateral cataract blindness was present in 196/3178 (6.2%, 95% confidence interval 5.4-7.06) patients. SRR was 6.5%. Fear of surgery (24.2%) and lack of family support/escort (22.9%) were the most common barriers. Neighbors and acquaintances (28.6%), general health workers (20.2%), and persons who had undergone cataract surgery (19.6%) were the most common facilitating factors. Conclusion: Proportion of bilaterally cataract blind people undergoing surgery and consequently SRR were low. The most common barriers were at the individual level while facilitating factors at the community level were instrumental in promoting uptake of services. Interventions involving community-based support for the blind may be useful in overcoming barriers to eye care.

Incorporating primary eye care into primary health care: Piloting a perceived visual disability questionnaire based model in rural southern India - An observational study.

Purpose: Over 20% of the world's visually impaired and blind populations live in India. Integration of primary eye care (PEC) into existing primary health care by trained personnel could address access-related barriers. We piloted an unreported, modified WHO disability questionnaire-based model for community health workers (CHWs) to screen and refer persons with perceived visual impairment instead of the traditional visual acuity model. The objective of the study was (1) to determine the prevalence of perceived visual impairment, rate of follow-up postreferral, distribution of ocular morbidity, visual impairment, and proportion of appropriate referrals and (2) to compare results of this intervention with those of existing services. Methods: CHWs were trained in administering a questionnaire for identification and referral of persons with perceived visual impairment in 7 rural villages and 22 tribal hamlets from the institutional database. In this cross-sectional study, patients screened and referred to PEC services from September 2014 to March 2015 underwent comprehensive ocular examination by an optometrist and ophthalmologist. Data collected from their records were analyzed retrospectively. Results: Of 18,534 individuals screened, 3082 (16.64%, 95% confidence interval: 16.06-17.14) complained of perceived visual impairment and were referred; 463 (15%) of these followed up for examination. Correct referrals were noted in 452 (97.6%) cases. Cataract (52.3%) and refractive error (15.8%) were the most common morbidities. There was a 39.6% increase in uptake of eye care services from baseline. Conclusion: The questionnaire-based screening tool administered by CHWs can lead to appropriate identification and referral of persons with ocular morbidity impacting uptake of eye care services.

Angle-supported phakic intraocular lenses for the correction of myopia: Three-year follow-up.

PURPOSE: To evaluate patient safety and refractive outcomes in eyes with an angle-supported phakic intraocular lens (pIOL), and to assess the correlation between rotation and corneal endothelial cell damage. SETTING: Gimbel Eye Centres, Calgary and Edmonton, Alberta, Canada. DESIGN: Retrospective cohort study. METHODS: This study included patients with moderate to high myopia (range -6.50 to -19.50 diopters [D]) who received the Acrysof Cachet pIOL. Outcome measures included uncorrected distance visual acuity (UDVA), corrected distance visual acuity, manifest refraction spherical equivalent (MRSE), endothelial cell density (ECD), and IOL rotation. RESULTS: This study evaluated 119 eyes of 61 patients. The mean ECD decrease from preoperative measurements was 3.11% (n = 46), with a mean IOL rotation of 10.6 degrees (n = 35) at the 3-year postoperative visit. Of the 49 eyes at the 3-year visit measured for UDVA, 98.0% were 20/40 or better and 77.6% were 20/20 or better. The MRSE improved from a preoperative mean of -9.26 diopters (D) ± 2.43 (SD) (range -19.50 to -5.63 D) to -0.33 ± 0.61 D (range -3.12 to +0.71 D) at the 3-year visit. The residual refractive error was within ±0.50 D of the target refraction for 78.4% and within ±1.00 D for 92.2% of the 51 eyes. The study included one bilateral pIOL removal due to endothelial cell loss, one case of synechia, and one case of subtle pupil ovalization. CONCLUSIONS: No correlation between IOL rotation and ECD decrease was found (R(2) = 0.0143); the pIOL provided promising refractive outcomes and acceptable safety in patients with moderate to high myopia. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Suture refixation and recentration of a subluxated capsular tension ring-capsular bag-intraocular lens complex.

We describe a 3-point ab externo technique to refixate and recenter a subluxated Cionni capsular tension ring (CTR)-intraocular lens (IOL)-capsular bag complex to the sclera. A 9-0 polypropylene suture on a curved needle is looped through the eyelet of the CTR and back through a Hoffman scleral tunnel. Two other sutures passed in a similar fashion through the fibrotic continuous curvilinear capsulorhexis (CCC) edge are used to complete a tripod fixation, which centers and stabilizes the IOL. This surgical approach avoids the surgical trauma of removing and replacing a subluxated CTR-IOL-capsular bag complex, retains the optimal anatomical position, and ensures centration of the IOL.

Reverse optic capture to stabilize a toric intraocular lens.

PURPOSE: To describe a technique for stabilizing a rotationally unstable toric intraocular lens (IOL). METHOD: Case report and literature review. RESULTS: Surgical technique and long-term follow-up for a patient who underwent repositioning and stabilization of a mobile 1-piece acrylic toric IOL using reverse optic capture (ROC) are described. This patient presented with early, more than 70° off-axis rotation. The IOL was repositioned but was very mobile within the bag and tended to rotate off-axis; hence, it was stabilized in the desired position by capturing the optic through the anterior continuous curvilinear capsulorhexis, leaving the haptics in the bag. The immediate and 2-year postoperative follow-up revealed a stable and on-axis IOL with no visual, refractive or ocular complications. CONCLUSIONS: ROC is a useful and safe technique to address the problem of toric IOLs that tend to rotate at the time of surgery or are not stable postoperatively.

Unusual case of a graphite foreign body in the anterior chamber.

Retained intraocular graphite foreign bodies are uncommon. Although they are generally inert, they have been reported to cause severe inflammatory reaction and progressive damage to intraocular structures. We report a case of a six-year-old girl with a retained intraocular graphite pencil lead foreign body in the anterior chamber of the eye and discuss the various considerations in the management of such cases.