Ophthalmic surgical training in Karnataka and Southern India: Present status and future interests from a survey of final-year residents

Settings and Design:

This study documents a survey of final-year ophthalmology postgraduates on the subject of their surgical training and their future plans after residency.

Purpose:

This survey aimed to answer the question, What is the present status of surgical training in ophthalmic training centers? by obtaining information from students about (1) various methods used in surgical training (2) numbers and types of surgeries performed by them in the training centers (3) their plans after residency.

Materials and Methods:

A questionnaire containing 21 questions was distributed to 155 students attending an intensive 4-day teaching program. The questions related to orientation training, wet lab training, facilities for training, free surgical camps and detailed information about numbers and types of surgeries observed and performed. Completed questionnaires were collected, and responses analyzed.

Results:

One hundred and seven completed responses were analyzed. The majority had not received formal orientation training. More than half had undergone wet lab training. Most residents performed their first ophthalmic surgery during the 1^st year of residency and went to the operation theatre multiple times a week. Most of the students planned to undergo further training after residency. More than half of the students found their surgical training to be fair or satisfactory.

Conclusions:

The number and frequency of ophthalmic surgeries done by residents appear satisfactory, but further efforts from trainers on enhancing the quality and range of surgical training would benefit students and improve their satisfaction.     

Episcleral plaque brachytherapy using 'BARC I-125 Ocu-Prosta seeds' in the treatment of intraocular tumors: a single-institution experience in India

Context:

To analyze the results of episcleral plaque brachytherapy using indigenous Bhabha Atomic Research Centre (BARC) Iodine-125 Ocu-Prosta seeds for the management of intraocular tumors from a single institute.

AIM:

To report our initial experience and learning curve on the use of ‘BARC I-125 Ocu-Prosta seeds’ for the management of intraocular tumors such as choroidal melanomas, retinoblastomas and vasoproliferative tumors (VPT).

Materials and Methods:

We retrospectively reviewed 13 eyes of 13 patients who underwent ophthalmic brachytherapy between May 2008 to March 2012. Nine cases had choroidal melanomas; three had retinoblastomas while one case had VPT.

Results:

For choroidal melanomas the average apical diameter before brachytherapy was 7.6 mm and average largest basal diameter was 12.1 mm, respectively, which reduced to 4.2 mm and 7.7 mm after the procedure at an average follow-up of 24 months (range 10-43 months). Retinoblastoma and VPT also showed good regression after brachytherapy.

Conclusion:

Plaque radiotherapy using ¹²⁵I seeds can be performed under peribulbar anesthesia and provides a viable option for the management of intraocular cancer with minimal invasiveness and surgical complications. Patients in our studies experienced excellent local tumor control. With the availability of indigenous ‘BARC I-125 Ocu-Prosta seeds’ locally, cost effective ophthalmic brachytherapy can be performed in India.     

Effect of dacryocystorhinostomy on systemic adverse effects of topical timolol maleate

Purpose:

To evaluate whether transformation of the naso-lacrimal passage as happens after dacryocystorhinostomy (DCR) operation has any effect on the systemic adverse effects of topically administered timolol maleate.

Materials and Methods:

Fifty otherwise healthy adult patients without any prior history of cardiac or pulmonary problems scheduled for elective DCR surgery received a drop of timolol maleate 0.5% on the healthy eye. This eye served as a control. Six weeks after successful DCR surgery, the operated eye received the same medication. Parameters compared included intraocular pressure (IOP), pulse rate, blood pressure and forced expiratory volume in the first second (FEV1) findings.

Observations:

Post DCR patients showed an increased incidence of reduced pulse rate and FEV1.

Conclusion:

Timolol maleate ophthalmic preparation should be used with caution in post-DCR patients.     

Surgeon point-of-view recording: Using a high-definition head-mounted video camera in the operating room

Objective:

To study the utility of a commercially available small, portable ultra-high definition (HD) camera (GoPro Hero 4) for intraoperative recording.

Methods:

A head mount was used to fix the camera on the operating surgeon''s head. Due care was taken to protect the patient''s identity. The recorded video was subsequently edited and used as a teaching tool. This retrospective, noncomparative study was conducted at three tertiary eye care centers. The surgeries recorded were ptosis correction, ectropion correction, dacryocystorhinostomy, angular dermoid excision, enucleation, blepharoplasty and lid tear repair surgery (one each). The recorded videos were reviewed, edited, and checked for clarity, resolution, and reproducibility.

Results:

The recorded videos were found to be high quality, which allowed for zooming and visualization of the surgical anatomy clearly. Minimal distortion is a drawback that can be effectively addressed during postproduction. The camera, owing to its lightweight and small size, can be mounted on the surgeon''s head, thus offering a unique surgeon point-of-view. In our experience, the results were of good quality and reproducible.

Conclusions:

A head-mounted ultra-HD video recording system is a cheap, high quality, and unobtrusive technique to record surgery and can be a useful teaching tool in external facial and ophthalmic plastic surgery.     

Scleral fixation of one piece intraocular lens by injector implantation

Aim of Study:

With an ab-interno technique of transscleral suturing of current one-piece posterior chamber intraocular lenses (PC IOLs) by injector implantation in the absence of capsular support, we aimed to demonstrate the possibility of the implantation of one-piece acrylic PC IOLs that might be produced in the future for only scleral fixation through small clear corneal incision.

Materials and Methods:

Case report and literature review.

Results:

This procedure has been performed in eight aphakic eyes with four different types of IOLs. Good centration was achieved with minimal technical effort. All patients had well-centered and stable lenses postoperatively during 9-18 months follow-up.

Conclusion:

We managed to decrease the risks of surgical trauma and intricate surgical maneuvers requirement. With this technique, excessive fluid leakage and consecutive hypotony can be minimized.     

Effectiveness of using teachers to screen eyes of school-going children in Satna district of Madhya Pradesh, India

Aim:

To assess the effectiveness of teachers in a vision screening program for children in classes 5th to 12th attending school in two blocks of a district of north central India.

Materials and Methods:

Ophthalmic assistants trained school teachers to measure visual acuity and to identify obvious ocular abnormalities in children. Children with visual acuity worse than 20/30 in any eye and/or any obvious ocular abnormality were referred to an ophthalmic assistant. Ophthalmic assistants also repeated eye examinations on a random sample of children identified as normal (approximately 1%, n=543) by the teachers. Ophthalmic assistants prescribed spectacles to children needing refractive correction and referred children needing further examination to a pediatric ophthalmologist at the base hospital.

Results:

Five hundred and thirty teachers from 530 schools enrolled 77,778 children in the project and screened 68,833 (88.50%) of enrolled children. Teachers referred 3,822 children (4.91%) with eye defects for further examination by the ophthalmic assistant who confirmed eye defects in 1242 children (1.80% of all screened children). Myopia (n=410, 33.01%), Vitamin A deficiency (n=143, 11.51%) and strabismus (n=134, 10.79%) were the most common eye problems identified by the ophthalmic assistant. Ophthalmic assistants identified 57.97% referrals as false positives and 6.08% children as false negatives from the random sample of normal children. Spectacles were prescribed to 39.47% of children confirmed with eye defects.

Conclusions:

Primary vision screening by teachers has effectively reduced the workload of ophthalmic assistants. High false positive and false negative rates need to be studied further.     

Morphological and functional changes in spectral domain optical coherence tomography and microperimetry in macular microhole variants: spectral domain optical coherence tomography and microperimetry correlation

Purpose:

To evaluate the relationship between the morphology and retinal function of macular microhole (MMH) variants.

Materials and Methods:

We evaluated 12 eyes of 11 patients with defects in the IS/OS junction of photoreceptor layer with SD-OCT. All patients underwent comprehensive ophthalmic examination including spectral domain optical coherence tomography (SD-OCT) and microperimetry.

Results:

The mean logMAR visual acuity in the affected eye was 0.15 ± 0.17 (range 0.00–0.5). Mean horizontal diameter of the MMH was 163 ± 99 μm; the mean retinal sensitivity in the area corresponding to the MMH was 13.79 ± 4.6 dB. Negative correlation was found between the MMH diameter and the retinal sensitivity (r = -0.65, p = 0.02). Three morphological patterns of MMH variants were recognized on SD-OCT, which did not differ in retinal sensitivities.

Conclusion:

We described and classified the MMH variants and made an assessment on the physiological functions using microperimeter.     

Prevalence and causes of low vision and blindness in an urban population: The Chennai Glaucoma Study

Aim:

To evaluate the prevalence and causes of low vision and blindness in an urban south Indian population.

Settings and Design:

Population-based cross-sectional study. Exactly 3850 subjects aged 40 years and above from Chennai city were examined at a dedicated facility in the base hospital.

Materials and Methods:

All subjects had a complete ophthalmic examination that included best-corrected visual acuity. Low vision and blindness were defined using World Health Organization (WHO) criteria. The influence of age, gender, literacy, and occupation was assessed using multiple logistic regression.

Statistical Analysis:

Chi-square test, t-test, and multivariate analysis were used.

Results:

Of the 4800 enumerated subjects, 3850 subjects (1710 males, 2140 females) were examined (response rate, 80.2%). The prevalence of blindness was 0.85% (95% CI 0.6–1.1%) and was positively associated with age and illiteracy. Cataract was the leading cause (57.6%) and glaucoma was the second cause (16.7%) for blindness. The prevalence of low vision was 2.9% (95% CI 2.4–3.4%) and visual impairment (blindness + low vision) was 3.8% (95% CI 3.2–4.4%). The primary causes for low vision were refractive errors (68%) and cataract (22%).

Conclusions:

In this urban population based study, cataract was the leading cause for blindness and refractive error was the main reason for low vision.     

Principal components' analysis of multifocal electroretinogram in retinitis pigmentosa

Aims:

To determine waveforms of multifocal electroretinogram (mfERG) in patients with retinitis pigmentosa (RP) contributing significantly to the overall retinal response by using principal components’ analysis.

Settings and Design:

Prospective, non-randomized, single-visit, observational, case-control study from a single tertiary ophthalmic center.

Materials and Methods:

Patients with various forms of RP underwent mfERG testing for a period of one year. The first-order kernel responses of RP cases were compared with concurrently recruited healthy controls.

Statistical Analysis Used:

Parametric data was analyzed using the unpaired t test for differences between the implicit time and amplitudes of cases and controls. Principal components’ analysis was done for each implicit time and amplitude in cases with RP using the Varimax rotation method.

Results:

From March 2006 to March 2007, 24 cases with typical RP (56%, 47 eyes) were included in the final analysis. Their mean age was 33.7 years (19-69 ± 15.5 years). Comparison of latencies and amplitudes among RP cases with log MAR acuity ≤ 0.18 and those > 0.18, revealed significant difference in the implicit time (P1) in Ring 2 only (P=0.028). Two components (predominently from Ring 1 and 2) each contributing 66.8% and 88.8% of the total variance in the data for latencies and amplitudes respectively, were seen.

Conclusions:

The first two rings of the mfERG contributed to the variance of waveforms in RP, irrespective of the visual acuity and poor visual field results.     

A new surgical technique using steel suture for trans-scleral fixation of posterior chamber intraocular lenses

Background:

A new emerging complication of trans-scleral fixation of posterior chamber (PC) intraocular lens (IOL) with polypropylene suture is high rates of spontaneous dislocation of the IOL due to disintegration or breakage of suture.

Materials:

We report a new surgical technique of trans-scleral fixation of posterior chamber intraocular lens (SF PCIOL) with steel suture to eliminate the complication of dislocation of IOL fixed with polypropylene suture in one adult and a child.

Results:

We successfully achieved stable fixation and good centration of IOL after SF PCIOL with steel suture in these patient having inadequate posterior capsular support. Both eyes achieved best corrected visual acuity 20/40 at 18 months follow-up.

Conclusions:

Steel suture is a viable option for trans-scleral fixation of posterior chamber intraocular lens.     

Phacoemulsification without preoperative topical mydriatics: Induction and sustainability of mydriasis with intracameral mydriatic solution

Context:

Intracameral mydriatic solution can eliminate the disadvantages of repeated eye drop instillation regimen and provide adequate mydriasis for phacoemulsification with added advantages.

Aims:

Evaluating the role of intracameral irrigating solution (0.5% lignocaine + 0.001% epinephrine) in initiating and maintaining the pupillary mydriasis during phacoemulsification. Secondary aims were to observe the effect of surgical time, nucleus density and ultrasound time on mydriasis during the procedure.

Settings and Design:

The study is a prospective interventional case series, conducted at tertiary care institution.

Materials and Methods:

Thirty patients underwent phacoemulsification under topical anesthesia for visually significant cataract. Pupillary dilatation was achieved by intracameral irrigation of mydriatic solution alone. Pupillary diameter was measured serially during surgery and ultrasound time and total surgical time were noted.

Statistical Analysis Used:

Paired samples student–t test was done to compare means. Spearman correlation coefficient was used to study the effect of various parameters on mydriasis.

Results:

Thirty eyes completed the study. The pupil size increased from 2.1 mm (Range 2-3.5 mm SD ± 0.32) to 6.9 mm (Range 5-9 mm SD ± 1.02) in 30 seconds time after intracameral mydriatic solution delivery, and was 7.0 mm (Range 3.5 - 9 mm SD ± 0.20) at the end of surgery. Duration of surgery, grade of nucleus and ultrasound time had statistically insignificant effect on mydriasis.

Conclusions:

Intracameral solution containing 0.5% lignocaine and 0.001% epinephrine provides rapid mydriasis which is adequate for safe phacoemulsification and is unaffected by other parameters.     

The effect of anterior transposition of the inferior oblique muscle on eyelid configuration and function

Purpose:

To evaluate the alteration of lower lid configuration and function with anterior transposition surgery of the inferior oblique (IO) muscle.

Patients and Methods:

A prospective clinical trial was conducted on a consecutive series of patients underwent anterior transposition of the IO as a sole operation. All patients received a thorough ophthalmic examination 1 day before and 3 months after surgery. Output parameters were consisted of palpebral fissure, margin reflex distance 1–2, lower lid function, hertel value, and lower lid crease. The differences of the collected data were calculated for statistical significance by using the Wilcoxon test.

Results:

A total of 19 eyes of 16 consecutive patients were included. The median preoperative grade of IO overaction was 3.5 (ranging from 3 to 4), which decreased to 0 (ranging from 0 to 2) postoperatively (P < 0.05). No significant change was observed in all parameters 3 months postoperatively (P > 0.05).

Conclusion:

In this study, no significant effect on lower lid configuration and function was observed following IO anterior transposition in which the disinserted muscle was placed posterior to inferior rectus insertion.     

A comparison of scientometric data and publication policies of ophthalmology journals

Purpose:This retrospective database analysis study aims to present the scientometric data of journals publishing in the field of ophthalmology and to compare the scientometric data of ophthalmology journals according to the open access (OA) publishing policies.Methods:The scientometric data of 48 journals were obtained from Clarivate Analytics InCites and Scimago Journal & Country Rank websites. Journal impact factor (JIF), Eigenfactor score (ES), scientific journal ranking (SJR), and Hirsch index (HI) were included. The OA publishing policies were separated into full OA with publishing fees, full OA without fees, and hybrid OA. The fees were stated as US dollars (USD).Results:Four scientometric indexes had strong positive correlations; the highest correlation coefficients were observed between the SJR and JIF (R = 0.906) and the SJR and HI (R = 0.798). However, journals in the first quartile according to JIF were in the second and third quartiles according to the SJR and HI and in the fourth quartile in the ES. The OA articles published in hybrid journals received a median of 1.17-fold (0.15–2.71) more citations. Only HI was higher in hybrid OA; other scientometric indexes were similar with full OA journals. Full OA journals charged a median of 1525 USD lower than hybrid journals.Conclusion:Full OA model in ophthalmology journals does not have a positive effect on the scientometric indexes. In hybrid OA journals, choosing to publish OA may increase citations, but it would be more accurate to evaluate this on a journal basis.     

Prevalence of amblyopia in children undergoing nasolacrimal duct irrigation and probing

Purpose:

To investigate ambylopia and amblyopia risk factors of children who underwent nasolacrimal duct (NLD) irrigation and probing for congenital nasolacrimal duct obstruction (CNLDO).

Materials and Methods:

The medical records of patients who had undergone NLD irrigation and probing for CNLDO at an age of 3 years or younger were reviewed, and 51 of the patients were recalled between October 1 and December 31, 2011 for a detailed ophthalmic examination to determinate amblyopia or amblyopia risk factors. Amblyopia was accepted as difference in visual acuity of two or more Snellen lines between the two eyes or visual acuity of 20/30 or worse in either eye.

Results:

The median age of the 51 patients to whom NLD irrigation and probing were attempted for CNLDO was 23 months. CNLDO affected a total of 70 eyes. All patients were reviewed for best-corrected visual acuity, refractive errors, and strabismus at a median age of 70.5 months (range 31-95 months). Amblyopia or amblyopia risk factors were identified in 14 patients (27.5%). One child (7.15%) had only strabismus, six children (42.8%) had only amblyogenic refractive errors, two (14.3%) had a combination of two, one child (7.15%) had a family history for amblyopia, but four children (28.6%) had no amblyopia risk factors but had amblyopia.

Conclusion:

Amblyogenic risk factors are found higher in patients with CNLDO and patients undergoing NLD irrigation and probing in comparison to normal population. Therefore, we recommend these children to routinely undergo cycloplegic refractions and full ophthalmic examinations.     

Diurnal variation in central corneal thickness and intraocular pressure in eyes with pseudoexfoliation syndrome without glaucoma

Aim:

The aim was to ascertain if any differences exist in diurnal central corneal thickness (CCT) and intra-ocular pressure (IOP) between eyes with pseudoexfoliation (PXF) syndrome without glaucoma and eyes with no ocular pathology. A secondary aim was to determine whether there was a significant relationship between CCT and IOP.

Settings and Design:

This study was a prospective design conducted within a hospital setting.

Materials and Methods:

The experimental group consisted of seven participants with bilateral PXF (14 eyes) and the control group comprised of 15 participants (30 eyes). Testing included CCT and IOP measured at four different times on one given day (8.00 a.m.; 11 a.m.; 2 p.m. and 5 p.m.).

Statistical Analysis:

The data were analyzed with the generalized linear latent mixed model.

Results:

PXF eyes displayed a significantly thinner overall mean CCT (520 μm) compared to controls (530 μm). Furthermore, a significant reduction in CCT and IOP occurred in the PXF group from 8 a.m. to 5 p.m. The mean overall IOP in PXF eyes was significantly lower than the control group. A significant association between IOP and CCT was also found in PXF eyes.

Conclusions:

Displaying a significantly thinner mean CCT highlights the importance of measuring CCT in an ophthalmic clinical setting as to avoid falsely underestimated IOP measurements in such a high-risk glaucoma population. Furthermore, a statistically significant correlation between IOP and CCT in PXF eyes suggests that the reduction in CCT that occurred in PXF eyes between 8 a.m. and 5 p.m. may be partly responsible for the reduction in IOP measurements.     

Papilledema in the setting of x-linked hypophosphatemic rickets with craniosynostosis

Purpose

Introduction to the ophthalmic literature of an unusual cause of papilledema and subsequent optic atrophy: X-linked hypophosphatemic rickets (XLH).

Methods

Case report of a 3-year-old female presenting with papilledema resulting from craniosynostosis secondary to XLH.

Results

Early intervention with craniofacial surgery prevented the development of optic atrophy.

Conclusion

Children with XLH should be screened for ophthalmic evidence of elevated intracranial pressure to aid early intervention and prevention of permanent loss of vision.Key words: Papilledema, Optic atrophy, Rickets, Craniosynostosis     

Ocular morbidity prevalence among school children in Shimla, Himachal, North India

Background

Data on eye diseases among school children is not readily available. Considering the fact that one-third of India''s blind lose their eyesight before the age of 20 years and many of them are under five when they become blind, early detection and treatment of ocular morbidity among children is important.

Aim

To estimate the prevalence of ocular morbidity among school children of age 6-16 years.

Settings

Government and private coeducational schools in urban area of Shimla.

Design

Cross-sectional

Materials and Methods

Government and private coeducational schools selected by stratified random sampling. About 1561 school children, studying in elementary through secondary class in these schools were examined from August 2001 to January 2002 in Shimla. A doctor did visual acuity and detailed ophthalmic examination.

Statistical analysis

The Chi-square test was used to test differences in proportions. Differences were considered to be statistically significant at the 5% level.

Results

Prevalence of ocular morbidity was 31.6% (CI=29.9-32.1%), refractive errors 22% (CI=21.1-22.8%), squint 2.5% (CI=2.4-2.6%), color blindness 2.3% (CI=2.2-2.4%), vitamin A deficiency 1.8 % (CI=1.7-1.9%), conjunctivitis 0.8% (CI=0.79-0.81%). Overall prevalence of ocular morbidity in government and private schools did not show any statistical significant difference. Prevalence of conjunctivitis was significantly (P<0.5) more in government schools.

Conclusion

A high prevalence of ocular morbidity among high-school children was observed. Refractive errors were the most common ocular disorders.