Correction of pre-existing astigmatism by on-axis incision size modulation in manual small-incision cataract surgery

Purpose:To study the effect of wound size modulation on pre-existing astigmatism by on-axis placement of incision in manual small-incision cataract surgery (MSICS).Methods:In this prospective interventional study conducted at a tertiary care centre, 40 eyes of 40 consecutive senile cataract patients with 1.00–3.00 D corneal astigmatism were enrolled for the study. MSICS by modified Blumenthal’s technique was performed through 6.0, 6.5, and 7.0 mm on-axis incision in 1.0–1.49 D (group A), 1.50–1.99 D (group B), and 2.00–3.00 D (group C) astigmatism, respectively. Surgically induced astigmatism (SIA) was calculated by vector analysis and double angle plots (DAP) at 12 weeks postoperatively.Results:There were 22 males and 18 females with mean age of 58.12 ± 1.18 years. The mean SIA at 12 weeks was 0.85 ± 0.28 D in group A (17 eyes), 1.32 ± 0.65 D in group B (10 eyes), and 1.91 ± 0.69 D in group C (13 eyes). The overall median uncorrected visual acuity was 0.18 (IQR = 0 to 0.2). The mean astigmatism decreased from 1.95 ± 0.74 D to 1.04 + 0.57 D (P = 0.00) in superior incision and from 1.70 + 0.50 D to 0.92 ± 0.45 D (P = 0.00) in temporal incision group with central shift of centroid in all cases.Conclusion:The customization of on-axis external incision size can be used to manage pre-existing corneal astigmatism of less than 3.00 D using both temporal and superior incisions effectively.     

Comparison of different endophthalmitis prophylactic measures in cataract surgery - An analysis of 2.4 lakh cases

Purpose:To compare different endophthalmitis prophylaxis methods adopted in cataract surgery (manual small-incision cataract surgery and phacoemulsification) between the years 2013 and 2021 in the community eye care section of a tertiary eye care hospital in South India and report their outcomes.Methods:All cataract surgeries performed from January 2013 to December 2021 (2,46,874 surgeries) at a single center were included in this retrospective study. The different endophthalmitis rates with each regimen were analyzed and evaluated.Results:70,081 surgeries were performed from January 2013 to February 2015, where Tobramycin was added to Balanced Salt Solution (BSS) (Group A). From March 2015 to January 2017, 63,245 surgeries were performed when intracameral Moxifloxacin was given (Group B). From February 2017 to December 2021, 1,13,548 surgeries were performed were Amikacin was added to BSS (Group C). In total, 42 cases of postoperative endophthalmitis were reported during the study period (0.02%). There was no significant difference in the endophthalmitis rates between groups A and B (P = 0.4152); however, there was a significant decrease in endophthalmitis rates in group C when compared with group A (P = 0.04) and group B (P = 0.006).Conclusion:There was a significant reduction in the rates of endophthalmitis following the addition of amikacin in irrigating BSS. Nocardia was one of the predominant organisms isolated from these endophthalmitis patients. This is the first single-center study to report a comparative analysis of different endophthalmitis prophylactic measures in a community eye care set up with a high incidence of Nocardia endophthalmitis prevented with amikacin in BSS irrigating solution.     

Central macular thickness and subfoveal choroidal thickness changes on spectral domain optical coherence tomography after cataract surgery in pediatric population

Purpose:To evaluate the central macular thickness (CMT) and subfoveal choroidal thickness (SFCT) changes on spectral domain optical coherence tomography (SD-OCT) after cataract surgery with intraocular lens (IOL) implantation in a pediatric population.Methods:This was a longitudinal, prospective, interventional study which included 90 pediatric patients who underwent cataract extraction with IOL implantation. Serial SD-OCT scans were done at postoperative day 1, 1-month, and 3-month follow-up. CMT and SFCT were measured at each visit.Results:A statistically significant increase in CMT was noted at 1 month (from 199.3 µm to 210.04 µm) post surgery, which declined over a 3-month period (202.70 µm, P = 0.0001). In case of SFCT, a constant increase was observed for over 3 months of follow-up (baseline: 296.52 µm; 1 month: 309.04 µm; and 3 months: 319.03 µm, P = 0.0001). The traumatic cataract group showed more pronounced changes in CMT and SFCT than the non-traumatic cataract group. No significant difference was observed regarding these parameters between those who underwent primary posterior capsulotomy (PPC) versus those who did not. None of the patients in the study group developed cystoid macular edema. These posterior segment–related anatomical changes did not affect the final visual outcomes.Conclusion:Cataract surgery induces potential inflammatory changes in the macula and choroid in pediatric patients. Such changes are more pronounced in trauma-related cases; however, they are not significant enough to affect the visual outcomes. Similarly, the additional surgical step of PPC does not induce significant anatomical or functional changes.     

Long-term real-world outcomes in retinal vein occlusions: How close are we to the trials?

Purpose:To assess and analyze the visual outcomes of patients with retinal vein occlusions in a real-world setting with a long-term follow-up of more than 5 years.Methods:Retrospective analysis of 56 patients having retinal vein occlusions from a tertiary eye center, with a mean follow-up of 7 years was performed. Primary outcome measures were mean change in best-corrected visual acuity (BCVA) from baseline at 6 months, 1 year, 2 years, 3 years, and final visit (≥5 years), proportion of patients having BCVA better than 20/40 and worse than 20/200, and mean number of injections. Secondary outcome measures were change in central macular thickness (CMT), development of subsequent retinal vein occlusion (RVO) in same eye or the other eye, and development of neovascular complications.Results:The mean change in letter score was + 11.84 in branch RVO (BRVO), +7.14 in non-ischemic central RVO (CRVO), and −9.5 in ischemic CRVO at 1 year, which changed to + 8.57, −5 and − 24, respectively, at the end of follow-up. CMT had improved from 506 ± 98.8 µm, 576.44 ± 149 µm, and 618 ± 178.27 µm, respectively, at baseline to 267 ± 94 µm, 345.20 ± 122.61 µm, and 265.50 ± 107.75 µm, respectively, in BRVO, non-ischemic, and ischemic hemi RVO (HRVO)/CRVO groups. The total mean number of injections given in BRVO, non-ischemic CRVO, and ischemic CRVO groups were 4.6, 6.6, and 4.1, respectively. None of the patients with BRVO developed neovascular glaucoma (NVG). Non-ischemic to ischemic HRVO/CRVO conversion was noted in 4/11 eyes at a mean duration of 12.6 months. NVG was noted in 7/9 eyes (77.8%) in initial ischemic CRVO/HRVO group and 3/4 (75%) converted eyes.Conclusion:Patients with BRVO have good visual outcomes with anti-VEGF, while in CRVO results may vary considerably owing to patient compliance and treatment burden on long-term follow-up in a real-world setting.     

A comparative analysis of surgical outcome in uveitic and non-uveitic steroid–induced glaucoma in children

Purpose:To compare outcomes of surgical management of uveitic glaucoma (UG) and steroid-induced glaucoma (SIG) in children in terms of intraocular pressure (IOP) control, visual acuity, and associations for failure.Methods:This was a retrospective case–control study of consecutive UG (cases) and non-uveitic SIG (controls) in children <18 years of age who underwent surgery between January 2005 and December 2017.Results:Primary trabeculectomy with mitomycin C (MMC) was performed in 12 cases (mean age: 9.2 ± 4.3 years) and 40 controls (mean age: 10.4 ± 3.7 years) (P = 0.33). Primary phaco-trabeculectomy with MMC was performed in 11 cases (mean age: 11.4 ± 4.7 years) and 16 controls (mean age: 10.4 ± 3.4 years) (P = 0.57). IOP control (P = 0.26), visual acuity (P = 0.97), number of glaucoma medications (P = 0.06), and survival rates (49% cases vs. 68% controls at 5 years; P = 0.22) were similar between the two groups following trabeculectomy. Survival rates in the phaco-trabeculectomy group at 5 years were 68% cases vs. 69% controls (P = 0.71). IOP was higher (P = 0.008) and visual acuity was worse (P = 0.02) in cases at the last visit. Associations for failure (univariate analysis) were younger age (OR: 6.29, 95% CL: 1.43, 27.67; P = 0.03) and male gender (OR: 4.79, 95% CL: 1.09, 20.97; P = 0.04). On multivariate analysis, younger age (OR: 11.985, 95% CL: 1.071, 134.153; P = 0.04) remained significant. Preoperative number of uveitic attacks was protective on univariate (OR: 0.75, 95% CL: 0.48, 1.15; P = 0.1) and multivariate analyses (OR: 0.49, 95% CL: 0.24, 0.09; P = 0.04).Conclusion:Outcomes of trabeculectomy between cases and controls were similar in our series. However, phaco-trabeculectomy in pediatric uveitic eye group fared worse than eyes with SIG.     

☆Comparison of transcutaneous laryngeal ultrasound with video laryngoscope for assessing the vocal cord mobility in patients undergoing thyroid surgery

ObjectiveWe evaluated the accuracy and feasibility of transcutaneous laryngeal ultrasonography as an alternative to videolaryngoscopy for assessing vocal cord mobility to rule out recurrent laryngeal nerve injury following thyroidectomy.MethodsForty-five adult patients scheduled to undergo elective thyroidectomy under general anesthesia were included. Preoperatively, indirect laryngoscopy and transcutaneous laryngeal ultrasonography was done for assessing vocal cord mobility. Intraoperatively, following induction, patients were intubated using videolaryngoscope. On completion of the surgical procedure, one anesthetist performed videolaryngoscopy so as to record vocal cord mobility while the patients were being extubated in deep plane of anesthesia. Simultaneously another anesthesiologist performed transcutaneous laryngeal ultrasonography.Vocal cord mobility, changes in hemodynamics and total time duration for the two procedures was recorded. Indirect laryngoscopic assessment and flexible fiberoptic laryngoscopy was done on postoperative day 1 and 7 respectively.ResultsPostoperative videolaryngoscopy picked up bilaterally mobile vocal cords in 88.8% cases. Transcutaneous laryngeal ultrasonography could correctly identify 39(86.6%) of these patients, with 1(2.5%) patient being misdiagnosed as having bilaterally immobile vocal cords. Further, videolaryngoscopy identified 5 patients of vocal cord palsy, of which transcutaneous laryngeal ultrasonography correctly identified 3 (60%) patients. Hence, in comparison to videolaryngoscopy, the sensitivity, specificity, positive predictive value, and negative predictive value of transcutaneous laryngeal ultrasonography for assessment of vocal cords was 75%, 95.1%, 60%, and 97.5% respectively.ConclusionIn patients undergoing thyroidectomy, transcutaneous laryngeal ultrasonography can serve as a non-invasive, bedside screening tool for assessing vocal cord palsy postoperatively.     

Tricuspid regurgitant jet velocity and myocardial tissue Doppler parameters predict mortality in a cohort of patients with sickle cell disease spanning from pediatric to adult age groups ‐ revisiting this controversial concept after 16 years of additional evidence

Sickle cell disease (SCD) is a monogenic hemoglobinopathy associated with significant morbidity and mortality. Cardiopulmonary, vascular and sudden death are the reasons for the majority of young adult mortality in SCD. To better understand the clinical importance of multi‐level vascular dysfunction, in 2009 we assessed cardiac function including tricuspid regurgitant jet velocity (TRV), tissue velocity in systole(S′) and diastole (E′), inflammatory, rheologic and hemolytic biomarkers as predictors of mortality in patients with SCD. With up to 9 years of follow up, we determined survival in 95 children, adolescents and adults with SCD. Thirty‐eight patients (40%) were less than 21 years old at initial evaluation. Survival and Cox proportional‐hazards analysis were performed. There was 19% mortality in our cohort, with median age at death of 35 years. In the pediatric subset, there was 11% mortality during the follow up period. The causes of death included cardiovascular and pulmonary complications in addition to other end‐organ failure. On Cox proportional‐hazards analysis, our model predicts that a 0.1 m/s increase in TRV increases risk of mortality 3%, 1 cm/s increase in S′ results in a 91% increase, and 1 cm/s decrease in E′ results in a 43% increase in mortality. While excluding cardiac parameters, higher plasma free hemoglobin was significantly associated with risk of mortality (p=.049). In conclusion, elevated TRV and altered markers of cardiac systolic and diastolic function predict mortality in a cohort of adolescents and young adult patients with SCD. These predictors should be considered when counseling cardiovascular risk and therapeutic optimization at transition to adult providers.     

Gas Bubbles: A Persistent Problem with Immunotherapy

Digestive Diseases and Sciences -