Effect of intravenous sedation on patients' visual experience and vital signs during cataract surgery under topical anesthesia: A randomized controlled trial

Purpose

Effect of intravenous sedation on patients' visual experience and vital signs during cataract surgery under topical anesthesia: a randomized controlled trial.

Design

Prospective, double masked, randomized controlled trial.

Methods

150 eyes of 150 patients undergoing phacoemulsification and IOL implantation under topical anesthesia were randomized to receive either intravenous midazolam (0.015 ​mg/kg) or normal saline. The patients' experience was evaluated using a questionnaire. Vital signs including blood pressure and heart rate were measured before, during and after surgery. Mean arterial pressure (MAP) was calculated.

Results

Both groups were comparable except that fewer patients in the control group were pseudophakic in the fellow eye (25.3% vs. 41.3%). More patients in the control group perceived hand movements (p ​< ​0.01), surgeon/medical staff (p ​= ​0.04) and sudden increase in vision during surgery (p ​< ​0.01) compared to midazolam group. More control group patients experienced fear (p ​< ​0.001), pain (p ​= ​0.06) and unpleasant surgical experience (20.3% vs. 1.3%, p ​< ​0.001). They also experienced greater fluctuation in MAP (16.9 ​± ​7.9 vs.7.2 ​± ​5.3, p ​< ​0.001) and this was accentuated in hypertensives. After adjusting for age, gender, hypertension status and other eye lens status, multivariable logistic regression analysis revealed that subjects in the control arm (OR ​= ​11.7, 95% [CI] ​= ​1.3-108, p ​= ​0.03), had a longer duration of surgery, experienced pain and more likely to report unpleasant experience. Adjusting for similar covariates, multivariable linear regression analysis showed that control group patients (β ​= ​8.5 ​mmHg, 95% CI ​= ​6.2-10.8, p ​= ​0.03) had hypertension, experienced fear during surgery and greater fluctuations in the MAP.

Conclusions

A sedative dose of intravenous midazolam during phacoemulsification under topical anesthesia significantly reduces patients' visual experience, fear and fluctuations in MAP and improves overall surgical experience.

A Delphi method based consensus statement for surgical management of proliferative diabetic retinopathy in India

Purpose

To derive consensus statements for surgical management of proliferative diabetic retinopathy (PDR) for vitreoretinal (VR) surgeons.

Methods

Thirteen prolific VR surgeons representing all regions of India were invited to participate in a 42-point questionnaire based on the Delphi methodology describing various surgical scenarios commonly encountered in PDR. Consensus was derived using predefined robust analytics. Scenarios that returned a moderate consensus in round 1 were taken to round 2 as per the Delphi methodology. After considering all inputs, the final consensus criteria were developed.

Results

A strong consensus was derived about waiting for 4 weeks before considering vitrectomy. In treatment-naïve eyes with fresh vitreous hemorrhage (VH), the wait time was slightly shorter for extramacular tractional retinal detachment (2-4 weeks) and longer (4-6 weeks) for eyes treated previously with laser or anti-VEGF agents. The expert panel recommended using preoperative anti-VEGF only in eyes with large membranes requiring extensive dissection. For post vitrectomy VH, while a conservative approach was recommended for the first episode of VH, experts recommended immediate vitreous lavage for recurrent episodes of VH. In eyes with iris neovascularization, the panel recommended immediate anti-VEGF injection followed by early vitreous lavage in nonresponsive eyes. A strong consensus was derived for stopping antiplatelet agents before surgery, while there was only a moderate consensus for performing vitrectomy for recalcitrant macular edema unresponsive to anti-VEGF injections in the absence of traction.

Conclusion

This study provides valuable consensus on managing the different scenarios encountered during surgical management of PDR and should help guide the VR surgeons in clinical decision-making.

Outcomes of preoperative bevacizumab in diabetics with nonclearing vitreous hemorrhage without tractional detachment - A quasi-randomized retrospective study

Purpose:

To assess whether preoperative bevacizumab (BVZ) in treatment-naïve eyes with proliferative diabetic retinopathy (PDR) and vitreous hemorrhage (VH) without tractional retinal detachment (TRD) leads to lesser macular edema and better visual outcome compared to eyes that do not receive BVZ.

Methods:

This quasi-randomized retrospective study included 217 treatment-naïve eyes with nonclearing VH without TRD that had vitrectomy with or without BVZ and had a minimum 6-months follow-up. Postoperative variables, including visual acuity (BCVA), central macular thickness (CMT) at 1 month, and need for additional anti-VEGF injections till 6 months follow-up, were recorded for analysis.

Results:

Of the 217 eyes, 107 eyes (49%) received preoperative BVZ and 110 (51%) did not. Groups were comparable in terms of preoperative characteristics. At 1 month, mean CMT was significantly higher in eyes without BVZ (310 ± 33 μ vs. 246 ± 34μ; P < 0.001). The likelihood of developing center-involving DME at 1 month after vitrectomy was 67% lower if the eye received preoperative BVZ (OR = 0.33, 95%CI = 0.18–2.54, P = 0.56). Though BCVA improved significantly in both groups at 1 month, it was 1/3^rd of a line better in the BVZ group (β coefficient = −0.035 logMAR, 95%CI = −0.04 to −0.008 logMAR, P = 0.01).

Conclusion:

Preoperative BVZ in treatment-naïve eyes with PDR and VH but without TRD lead to better macular status and marginally improved vision at 1 month, which was maintained at 6 months. In view of these results, patients may be offered BVZ only when it is readily affordable to them.

Socio-economic variations in the clinical presentation, etiology and outcome of infective endocarditis in the ESC-EORP EURO-ENDO (European Infective Endocarditis) registry: a prospective cohort study

Background

Infective endocarditis (IE) is a life threatening disease associated with high mortality and morbidity worldwide. We sought to determine how socio-economic factors may influence variations in epidemiology, clinical presentation, investigation and management (and their consequence upon clinical outcomes) in a large international multi-centre registry.

Methods

The ESC-EORPEURO-ENDO registry comprises a prospective cohort of 3116 adult patients admitted to 156 hospitals in 40 countries with IE between January 2016 and March 2018. We analysed the complete dataset to assess potentially important determinants of variation according to World Bank economic stratification (high income (Group 1) [73.8%]; upper-middle income (Group 2) [17.1%]; lower-middle income (Group 3)[9.1%]).

Results

Patients in Group 3 were younger (median age [IQR]: Group 1 - 66 [54–75] years; Group 2 - 57 [40–68] years; Group 3 - 33 [26–43] years; p&lt;0.001) with a higher prevalence of smoking, intravenous drug use and human immunodeficiency virus (HIV) infection (all p&lt;0.001). Group 3 patients with IE presented later (median [IQR) days since symptom onset: Group 1 - 12 [3–35]; Group 2 - 20 [6–51]; Group 3 - 31 [12–62]; p&lt;0.001) and were more likely to develop congestive heart failure (13.6%; 11.3%; and 22.6%, respectively; p&lt;0.001), septic shock (8.3%; 11.1%; 13.4%; p=0.007), and persistent fever for greater than 7 days (9.6%; 14.4%; 27.9%; p&lt;0.001) following hospital admission. Surgery was performed less frequently in Group 3 (75.4%, 76.8% and 51.3% in Groups 1, 2 and 3, respectively; p&lt;0.001) and mortality was highest in the poorest countries (14.6%; 23.6% and 23.7%, respectively; p&lt;0.001).

Conclusion

Socio-economic factors influence the clinical profile of patients presenting with IE across the world. Despite being younger, patients from the poorest countries presented with more frequent complications and higher mortality associated with delayed diagnosis and less frequent use of surgery.

Funding Acknowledgement

Type of funding sources: None.

Peak atrial longitudinal strain predicts exercise tolerance in heart failure with preserved ejection fraction

Purpose

The present study i) determined left atrial (LA) and left ventricular (LV) strains at rest and in response to exercise in patients with heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF), and ii) assessed the relationship between LA and LV strains and exercise tolerance.

Methods

Forty HFpEF patients (age 59±7 yrs; 25 females), 40 stable HFrEF patients (age 57+6 yrs, 15 females) and 20 controls (age 56+6 yrs, 13 females) underwent baseline clinical and biochemical assessment, resting and exercise stress transthoracic echocardiography using modified Bruce protocol. Speckle-tracking echocardiography was performed to define peak atrial longitudinal strain (PALS) and left ventricular global longitudinal strain (LVGLS). LA stiffness index and LV stiffness index were also derived.

Results

Compared to healthy controls, HFpEF and HFrEF showed significantly lower PALS at rest (34.03±1.85 vs. 23.06±4.69 vs. 11.51±1.44%, p&lt;0.01) and after exercise (34.41±1.24 vs. 18.48±3.51 vs 10.47±1.49, p&lt;0.01 for both). In response to exercise, the PALS significantly reduced in HFpEF by 26%, but only 8% in HFrEF and remained unchanged in controls. LA stiffness index was higher in HFpEF and HFrEF compared to healthy controls at rest (0.57±0.22 vs. 1.19±0.63 vs. 0.27±0.06, p&lt;0.01) and in response to exercise (0.83±0.46 vs. 1.37±0.63 vs. 0.33±0.04, p&lt;0.01). Compared to healthy controls, HFpEF and HFrEF demonstrated significantly lower LVGLS at rest (−20.27±0.98 vs. −15.89±2.72 vs.-11.14±3.40%, p&lt;0.01) and after exercise (−19.9±0.8 vs.-15.5±3.18 vs.-11.01±2.6%, p&lt;0.01). LV stiffness index was significantly higher in HFpEF and HFrEF compared to healthy controls at rest (0.16±0.05 vs. 0.14±0.07 vs. 0.11±0.02, p&lt;0.01) and in response to exercise (0.18±0.07 vs. 0.15±0.06 vs. 0.13±0.02, p&lt;0.01). Exercise tolerance i.e. exercise duration was significantly lower by 28% and 30% in HFpEF and HFrEF compared with controls (363±152 vs. 352±91 vs. 505±42, p&lt;0.01). There was a significant relationship between peak atrial longitudinal strain and exercise tolerance in HFpEF (r=0.32, p=0.04).There was no significant relationship between exercise tolerance and LVGLS (r=0.058, p=0.72), LA stiffness (r=−0.17, p=0.3), LV stiffness (r=0.88, p=.59). There was no significant relationship between exercise tolerance and PALS (r=0.021, p=0.89) or LVGLS (r=0.12, p=0.48) in HFrEF.

Conclusion

HFpEF and HFrEF are associated with reduced left atrial and left ventricular strains and increased arial and ventricular stiffness.Peak atrial longitudinal strain is a significant determinant of exercise tolerance in HFpEF but not in HFrEF.

Funding Acknowledgement

Type of funding sources: None.

Work From Home, Mental Health and Employee Needs: A pilot study in selected information technology organizations in India

Introduction: The Coronavirus (COVID-19) pandemic has impacted the economy and has resulted in changes to the working arrangements of employees who are based at home and may continue to work from home (WFH). Organizations are expected to develop an inclusive policy for their employees to promote mental health whilst working from home. The aim of this study was to document the impact of WFH on mental health and determine the expectations of employees from their organizations regarding occupational health policy. Methodology: A cross-sectional study was conducted on the impact of work from home on mental health and to document the mental health support needs of employees. Google form was floated through social media platform to receive the responses. A total of 74 responses were received. Descriptive analysis was conducted using Microsoft Excel, while qualitative answers were manually analysed. Results: About 67% employees (n=45) mentioned that their workload has increased significantly during work from home. Thirty five percent (n=26) felt lonely and lost and 47% (n= 34) felt disconnected from the real world, indicating the mental health impact of work from home. Fifty three percent employees (n=40) mentioned that there were no efforts made by their organization to reduce the mental health impact of work from home. Conclusion: The results of this study indicate that there is an urgent need to create a comprehensive occupational health and safety policy inclusive of strategies to improve mental health by the organizations in light of “work from home” as a “new-normal”.

Epidemiology, clinical profile, management, and outcome of COVID-19-associated rhino-orbital-cerebral mucormycosis in 2826 patients in India - Collaborative OPAI-IJO Study on Mucormycosis in COVID-19 (COSMIC), Report 1

Purpose

COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM) has reached epidemic proportion during India's second wave of COVID-19 pandemic, with several risk factors being implicated in its pathogenesis. This study aimed to determine the patient demographics, risk factors including comorbidities, and medications used to treat COVID-19, presenting symptoms and signs, and the outcome of management.

Methods

This was a retrospective, observational study of patients with COVID-19-associated ROCM managed or co-managed by ophthalmologists in India from January 1, 2020 to May 26, 2021.

Results

Of the 2826 patients, the states of Gujarat (22%) and Maharashtra (21%) reported the highest number of ROCM. The mean age of patients was 51.9 years with a male preponderance (71%). While 57% of the patients needed oxygen support for COVID-19 infection, 87% of the patients were treated with corticosteroids, (21% for > 10 days). Diabetes mellitus (DM) was present in 78% of all patients. Most of the cases showed onset of symptoms of ROCM between day 10 and day 15 from the diagnosis of COVID-19, 56% developed within 14 days after COVID-19 diagnosis, while 44% had delayed onset beyond 14 days. Orbit was involved in 72% of patients, with stage 3c forming the bulk (27%). Overall treatment included intravenous amphotericin B in 73%, functional endoscopic sinus surgery (FESS)/paranasal sinus (PNS) debridement in 56%, orbital exenteration in 15%, and both FESS/PNS debridement and orbital exenteration in 17%. Intraorbital injection of amphotericin B was administered in 22%. At final follow-up, mortality was 14%. Disease stage >3b had poorer prognosis. Paranasal sinus debridement and orbital exenteration reduced the mortality rate from 52% to 39% in patients with stage 4 disease with intracranial extension (p < 0.05).

Conclusion

: Corticosteroids and DM are the most important predisposing factors in the development of COVID-19-associated ROCM. COVID-19 patients must be followed up beyond recovery. Awareness of red flag symptoms and signs, high index of clinical suspicion, prompt diagnosis, and early initiation of treatment with amphotericin B, aggressive surgical debridement of the PNS, and orbital exenteration, where indicated, are essential for successful outcome.

Anatomical and functional outcomes one year after vitrectomy and retinal massage for large macular holes

Purpose

The aim of this study was to report results of macular hole closure, visual benefit and longitudinal changes in foveal architecture over 1 year following macular hole surgery with retinal massage.

Methods

Records of patients with full thickness macular hole (FTMH) with minimum basal diameter of 550 μ who underwent vitrectomy, internal limiting membrane (ILM) peeling and retinal massage were drawn up. Retinal massage was performed after dye assisted ILM peeling, using a 27G flute needle with a long and soft silicone tip under air in a centripetal direction around the FTMH. At the end, 10% C₃F₈ gas was used as tamponade. The foveal contour at 1 year follow up was recorded based on its cross sectional appearance on OCT and was classified into U, V and irregular types of closure as previously described.

Results

Forty-one eyes of 41 patients with a mean age of 70.4 ± 6.9 years were included. The mean preoperative vision was 0.99 ± 0.07 logMAR and mean maximum basal diameter of the FTMH was 835 ± 208 μ. Macular hole closure was seen in all patients at 1-month follow up. The BCVA improved to 0.5 ± 0.1 log MAR at 6 months (P < 0.001) and then stabilized. The U shaped closure was the commonest pattern (n = 22, 54%), followed by V-shaped closure (n = 16, 39%) while irregular closure was seen in 3 eyes (7%).

Conclusion

Retinal massage after ILM peeling is a very simple, and as yet under-utilized manoeuvre that may improve hole closure rates and lead to potentially greater improvement in vision compared to existing techniques for large holes.

Proportion of diabetic retinopathy among diabetics presenting for the first time to a tertiary eye institute in South India

PURPOSE

To detect the proportion of diabetic retinopathy (DR) among diabetics visiting a tertiary eye care institute and correlate presenting symptoms to clinical diagnosis.

METHODS

The study recruited 1000 eyes of 1000 diabetics visiting a tertiary eye care institute in South India for the first time. Along with basic demographic data and systemic history, details of presenting complaints and clinical diagnosis were noted.

RESULTS

Data from 956 cases were analyzed. There were 29 (3%) newly diagnosed diabetics and 927 (97%) known diabetics. The commonest reason for the hospital visit was diminution of vision (66%) followed by "visiting for a routine checkup" (22.3%). Diabetic retinopathy was seen in 492 (51.5%), cataract in 161(17%) and refractive error in 240 patients (79.2%). Vision-threatening DR was present in 216 cases (22.59%) and clinically significant macular edema in 73 cases (7.63%) at first presentation itself.

CONCLUSION

The cohort from a tertiary eye care institute has higher proportion of diabetic retinopathy, with vision-threatening DR at presentation. These data emphasize the need for more robust screening for DR, along with population awareness programs.

Brain and Lung Imaging Correlation in Patients with COVID-19: Could the Severity of Lung Disease Reflect the Prevalence of Acute Abnormalities on Neuroimaging? A Global Multicenter Observational Study

PURPOSE

Our aim was to study the association between abnormal findings on chest and brain imaging in patients with coronavirus disease 2019 (COVID-19) and neurologic symptoms.

MATERIALS AND METHODS

In this retrospective, international multicenter study, we reviewed the electronic medical records and imaging of hospitalized patients with COVID-19 from March 3, 2020, to June 25, 2020. Our inclusion criteria were patients diagnosed with Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection with acute neurologic manifestations and available chest CT and brain imaging. The 5 lobes of the lungs were individually scored on a scale of 0-5 (0 corresponded to no involvement and 5 corresponded to >75% involvement). A CT lung severity score was determined as the sum of lung involvement, ranging from 0 (no involvement) to 25 (maximum involvement).

RESULTS

A total of 135 patients met the inclusion criteria with 132 brain CT, 36 brain MR imaging, 7 MRA of the head and neck, and 135 chest CT studies. Compared with 86 (64%) patients without acute abnormal findings on neuroimaging, 49 (36%) patients with these findings had a significantly higher mean CT lung severity score (9.9 versus 5.8, P < .001). These patients were more likely to present with ischemic stroke (40 [82%] versus 11 [13%], P < .0001) and were more likely to have either ground-glass opacities or consolidation (46 [94%] versus 73 [84%], P = .01) in the lungs. A threshold of the CT lung severity score of >8 was found to be 74% sensitive and 65% specific for acute abnormal findings on neuroimaging. The neuroimaging hallmarks of these patients were acute ischemic infarct (28%), intracranial hemorrhage (10%) including microhemorrhages (19%), and leukoencephalopathy with and/or without restricted diffusion (11%). The predominant CT chest findings were peripheral ground-glass opacities with or without consolidation.

CONCLUSIONS

The CT lung disease severity score may be predictive of acute abnormalities on neuroimaging in patients with COVID-19 with neurologic manifestations. This can be used as a predictive tool in patient management to improve clinical outcome.

Medios- An offline, smartphone-based artificial intelligence algorithm for the diagnosis of diabetic retinopathy

Purpose:

An observational study to assess the sensitivity and specificity of the Medios smartphone-based offline deep learning artificial intelligence (AI) software to detect diabetic retinopathy (DR) compared with the image diagnosis of ophthalmologists.

Methods:

Patients attending the outpatient services of a tertiary center for diabetes care underwent 3-field dilated retinal imaging using the Remidio NM FOP 10. Two fellowship-trained vitreoretinal specialists separately graded anonymized images and a patient-level diagnosis was reached based on grading of the worse eye. The images were subjected to offline grading using the Medios integrated AI-based software on the same smartphone used to acquire images. The sensitivity and specificity of the AI in detecting referable DR (moderate non-proliferative DR (NPDR) or worse disease) was compared to the gold standard diagnosis of the retina specialists.

Results:

Results include analysis of images from 297 patients of which 176 (59.2%) had no DR, 35 (11.7%) had mild NPDR, 41 (13.8%) had moderate NPDR, and 33 (11.1%) had severe NPDR. In addition, 12 (4%) patients had PDR and 36 (20.4%) had macular edema. Sensitivity and specificity of the AI in detecting referable DR was 98.84% (95% confidence interval [CI], 97.62–100%) and 86.73% (95% CI, 82.87–90.59%), respectively. The area under the curve was 0.92. The sensitivity for vision-threatening DR (VTDR) was 100%.

Conclusion:

The AI-based software had high sensitivity and specificity in detecting referable DR. Integration with the smartphone-based fundus camera with offline image grading has the potential for widespread applications in resource-poor settings.

Perspectives of physicians in general and ophthalmologists in particular about restarting services post-COVID-19 lockdown

PURPOSE

To assess the perspectives of physicians in general and ophthalmologists in particular about restarting elective out-patient (OP) and operating (OT) services after relaxation of lockdown for COVID-19.

METHODS

An online survey, containing 31 questions, was conducted among medical doctors using a secure Google forms link. The survey was open for 48 hours from 16th-18th April 2020.

RESULTS

Responses were received from 556 physicians (including 266 ophthalmologists). About a third (n = 205) wanted to start OP immediately after lockdown. In OP, mask of any kind for patient (60.8%), 3-ply for assistants (52.7%) and N95 for doctors (72.7%) were most common preferences. In OP, 31.5% and 46.6% felt full PPE and gloves alone were sufficient respectively. Ophthalmologists were more likely to start immediately after lockdown compared to other specialists (P = 0.004). Among 299 surgeons, an almost equal number (27%) wanted to start routine OT services immediately and 2 weeks post lockdown. A large majority (76.9%) would mandate COVID-19 tests before elective surgeries. In OT, 34.1% wanted N95 for surgical team and 3-ply for patient, 23.4% wanted 3-ply masks for everyone. 40.5% felt additional personal protective equipment (PPE) is not required and 33.1% felt that full PPE is required for everyone in OT. Ophthalmic surgeons preferred 3-ply masks and were less inclined to use full PPE (P < 0.001).

CONCLUSION

Perspectives of doctors vary, especially with regarding to timing of restarting services and precautions to be taken in the OT. Ophthalmologists may tend to err on the side of taking lesser stringent precautions when restarting services post lockdown.

All India Ophthalmological Society - Indian Journal of Ophthalmology consensus statement on preferred practices during the COVID-19 pandemic

The COVID-19 pandemic has taken tragic proportions and has disrupted lives globally. In the wake of governmental lockdowns, ophthalmologists need practical and actionable guidelines based on advisories from national health departments on how to conduct their duties during nationwide lockdowns and after these are lifted. In this paper, we present a preferred practice pattern (PPP) based on consensus discussions between leading ophthalmologists and health care professionals in India including representatives from major governmental and private institutions as well as the All India Ophthalmological Society leadership. In this document, the expert panel clearly defines the range of activities for Indian ophthalmologists during the ongoing lockdown phase and precautions to be taken once the lockdown is lifted. Guidelines for triage, governmental guidelines for use of personal protective equipment from ophthalmologists' point of view, precautions to be taken in the OPD and operating room as well as care of various ophthalmic equipment have been described in detail. These guidelines will be applicable to all practice settings including tertiary institutions, corporate and group practices and individual eye clinics and should help Indian ophthalmologists in performing their professional responsibilities without being foci of disease transmission.