Eyeball simulator for extraocular muscles

Learning about human eye movements broadens our comprehension of the visuomotor system and aids in the effective management of strabismus. One's clinical practice is improved by a dynamic simulation of human eye movements using physical models of the extraocular muscles (EOMs). We use our eyeball model to teach the basics of strabismus to undergraduate students and ophthalmology residents. In Listing's plane, extraocular movements of each muscle and the angle demonstration are being used to familiarize students with their knowledge. The degree of the residents' understanding of strabismus is significantly influenced by the eyeball strabismus simulator. This model is an inexpensive, Do It Yourself (DIY) model that is simple to build.

Outcomes of manual small incision cataract surgery in hypermature/morgagnian cataract

PURPOSE

To evaluate the visual outcome and complication rate of manual small incision cataract surgery (MSICS) in hypermature morgagnian cataract (HMC).

SETTING

Aravind Eye Hospital, Pondicherry, India.

DESIGN

Retrospective, single center study.

METHODS

Case records of patients diagnosed with HMC and who underwent MSICS from January to December 2019 were retrospectively collected. Data were analyzed for demographic details, preoperative risk factors, intraoperative/postoperative complications, and visual outcome at 1-month follow-up.

RESULTS

105 patients were included in the study. Preoperative risk factors like dense pseudoexfoliation were seen in 6 patients (5.7%), phacolytic glaucoma in 7 patients (6.7%), lens induced uveitis in 5 (4.7%), and phacodonesis in 30 patients (28.5%). Overall intraoperative complication rate was 14.3%, which included posterior capsular rent (n = 4), zonular dialysis (n = 7), and whole bag removal (n = 4). Due to poor posterior capsular bag support, 7 patients (6.6%) did not receive intraocular lens implantation in primary surgery. Both the intraoperative and postoperative complication rate were high in those with risk factors, and this difference was statistically significant ( P < .001 and .0005, respectively). On the first postoperative day, 70 patients (66.7%) had a corrected distance visual acuity (CDVA) better than 20/40, and at 1 month, 98 patients (93.3%) had a CDVA of 20/60 or better of which 89.5% had CDVA of ≥20/40.

CONCLUSIONS

MSICS for hypermature cataract is relatively safe and yields adequate visual outcome. Preoperative risk factors, in addition to hypermaturity, increase the complication rate.

Topical 0.1% Nepafenac versus 0.09% Bromfenac Eye Drops for Inflammation after Laser Peripheral Iridotomy: A Randomized Controlled Trial

PURPOSE

To assess the safety and efficacy of 0.1% nepafenac versus 0.09% bromfenac eye drops in controlling inflammation after neodymium yttrium-aluminum-garnet (YAG) laser peripheral iridotomy (LPI).

DESIGN

Single-masked, single-center, randomized controlled trial.

PARTICIPANTS

One hundred and sixty eyes of patients with primary angle-closure suspect (PACS) and primary angle closure (PAC) undergoing bilateral LPI.

METHODS

Patients were randomized in a 1:1 ratio to receive 0.1% nepafenac thrice daily or 0.09% bromfenac eye drops twice daily for 2 weeks after neodymium YAG LPI. Assessment was performed by masked investigators at 2 weeks after LPI. A Glaucoma Symptom Scale (GSS) questionnaire was administered both at baseline and 2 weeks after LPI. Subjective comfort scores to the study medications were assessed on the basis of a Likert scale at 2 weeks after LPI. In patients with bilateral PACS or PAC, the right eye was analyzed, and in asymmetrical disease (i.e., when one eye had PACS and the other eye had PAC), the eye with PAC was analyzed.

MAIN OUTCOME MEASURES

The primary outcome (end point) was uncontrolled inflammation, defined as symptomatic inflammation within 1 week after LPI, the presence of anterior chamber cells at 2 weeks, or rebound inflammation after medication discontinuation. The secondary outcome was patient-reported comfort levels with study medications based on the GSS and Likert scale.

RESULTS

At 2 weeks after LPI, 7 patients (6 with PACS and 1 with PAC) in the nepafenac group and 2 patients with PACS in the bromfenac group achieved the primary end point, without a difference between the medication groups (P = 0.09). Post-LPI burning, smarting, and stinging was more common in the bromfenac group (P = 0.01), which also had a higher comfort score on the Likert scale (P = 0.004). The need for repeat LPI was comparable (10.0% in the nepafenac group vs. 15.4% in the bromfenac group; P = 0.22). A multivariate analysis revealed that a greater number of laser shots was associated with the need for repeat LPI (odds ratio, 1.05; 95% confidence interval, 1.00-1.10; P = 0.04).

CONCLUSIONS

Topical 0.09% bromfenac is noninferior to 0.1% nepafenac in controlling inflammation after LPI in eyes with PACS and PAC. Nepafenac may be associated with higher patient-reported comfort.

Radiation-induced neovascular glaucoma: A devastating disease

Neovascular glaucoma (NVG) is a potentially blinding form of secondary glaucoma, with radiation being one of the rare causes. This report is aimed to discuss a case of NVG caused secondary to radiotherapy (RT) given for a nasal malignancy. A 50-year-old male presented with enophthalmos, dry eye, and NVG 3 years after receiving RT for chondrosarcoma of nasal and paranasal cavities. He was given topical antiglaucoma medications, retinal laser, and intravitreal bevacizumab injection and thus prevented the eye from becoming a painful blind eye. The radiation oncologist and ear, nose, and throat specialists have to liaise closely with ophthalmologist when patients receive radiation involving the eye in the treatment field to prevent, diagnose, and treat this devastating condition.

Comparison of central corneal thickness using non-contact tono-pachymeter (Tonopachy) with ultrasound pachymetry in normal children and in children with refractive error

Purpose

To compare the central corneal thickness (CCT) measured by non-contact tono-pachymeter [Tonopachy (TP)] with the gold standard ultrasound pachymetry (UP) in normal children and in children with refractive error.

Methods

This cross-sectional study involved 95 normal children (190 eyes) and 123 children with refractive error (246 eyes), a total of 218 children (436 eyes) aged 7-15 years. After refraction and complete ophthalmic evaluation, axial length was measured with IOLMaster 700, CCT was measured with TP followed by UP. The correlation between the CCT measurements obtained with the two methods was analysed by Intraclass correlation coefficient (ICC) and the limits of agreement were assessed with Bland-Altman analysis plot.

Results

Mean CCT measured with TP was 537.46 ± 36.41 μm and by UP was 537.17 ± 39.80 μm in normal children (P = 0.79) and in refractive error group, the mean CCT was 533.50 ± 34.91 μm by TP and 531.60 ± 36.30 μm by UP (P = 0.04). The 95% limits of agreement between TP and UP ranged from -19.2 to + 21.6 μm (mean = 1.20) for total children, -20.8 to + 21.4 μm (mean = 0.29) for normal group and -18.0 to + 21.8 μm (mean = 1.90) for refractive error group. ICC for CCT measurement between TP and UP was 0.980 for total children and refractive error group and 0.981 for normal group.

Conclusion

The CCT measurement obtained by TP showed an excellent agreement with UP. Hence non-contact TP can be used to assess CCT in children above seven years of age.

Validation of a portable, non-mydriatic fundus camera compared to gold standard dilated fundus examination using slit lamp biomicroscopy for assessing the optic disc for glaucoma

Purpose

To evaluate the sensitivity and specificity of a portable non-mydriatic fundus camera to assess the optic disc for glaucoma.

Methods

We conducted a single-site, cross-sectional, observational, instrument validation study. Non-mydriatic fundus photographs centred at the optic disc were obtained from 276 eyes of 68 glaucoma and 70 normal patients, using a portable fundus camera (Smartscope, Optomed, Oulu, Finland). A senior Glaucoma consultant, masked to the patient’s study participation, performed a gold standard dilated fundus examination to make the diagnosis of glaucoma. Following this, a mydriatic photograph was taken by a standard table-top fundus camera. All the images were digitalized and de-identified by an independent investigator and presented to two remote graders, masked to the patients, their diagnoses, and photographic modality. Based on individual disc characteristics, a diagnosis of screening positive or negative for glaucoma was made. In the end, the independent investigator re-identified the images. Sensitivity and specificity to detect glaucoma with the undilated Smartscope camera was calculated compared to dilated fundus examination.

Results

Grading remote images taken with the portable non-mydriatic fundus camera showed a sensitivity of 96.3% (95% confidence interval (CI): 91.6–98.8%) and 94.8% (95% CI: 89.7–97.9%) and a specificity of 98.5% (95% CI: 94.9–99.8%) and 97.8% (95% CI: 93.9–99.6%) for the two graders respectively as compared to gold standard dilated fundus examination.

Conclusion

The non-mydriatic Smartscope fundus images have high sensitivity and specificity for diagnosing glaucoma remotely and thus may be an effective tool for use in community outreach programs.

A case series of topiramate-induced angle closure crisis – an ophthalmic emergency

Background

Topiramate is a drug commonly used by physicians. However, it has various systemic and ocular adverse effects. Bilateral angle closure crisis is a potentially blinding adverse reaction that is seldom reported in non-ophthalmic journals.

Objective

This article aims to report a case series of topiramate-induced angle closure crisis in the eyes.

Methods and material

Most patients presented to us with blurred vision and high intra-ocular pressure within days of starting topiramate tablet for headache. However, the attack resolved in those who presented early with prompt treatment, which included stopping topiramate.

Conclusions

Physicians prescribing topiramate must be well aware of this potentially blinding adverse effect. Educating the patient about this possible side effect is important. Timely referral and treatment can prevent blindness in these individuals.

The Effectiveness of Intracameral Moxifloxacin Endophthalmitis Prophylaxis for Trabeculectomy

PURPOSE

To analyze the effectiveness of intracameral moxifloxacin prophylaxis in reducing acute postoperative endophthalmitis after trabeculectomy and combined trabeculectomy plus cataract extraction.

DESIGN

Retrospective clinical registry analysis.

PARTICIPANTS

Patients undergoing either trabeculectomy or trabeculectomy plus cataract extraction at Aravind Eye Hospitals (AEH) between 2009 and 2018 (inclusive).

METHODS

Electronic health records data were analyzed before and after implementation of routine intracameral moxifloxacin, and acute postoperative endophthalmitis rates were compared. During 2015, routine intracameral moxifloxacin prophylaxis was added in a step-wise fashion throughout AEH. Date of implementation was used to create group 1 (without intracameral moxifloxacin prophylaxis) and group 2 (with intracameral moxifloxacin prophylaxis).

MAIN OUTCOME MEASURES

The primary outcome was the difference in acute (≤6 weeks) postoperative endophthalmitis between groups 1 and 2. Review of culture results, visual acuity, and intraocular pressure also was performed for patients with endophthalmitis.

RESULTS

Thirty-eight thousand nine hundred eyes (group 1) did not receive intracameral moxifloxacin, whereas 19 086 eyes (group 2) did. Although the rate of noninfectious postoperative complications was not significantly different (0.81% vs. 0.67%; P = 0.07), a significantly lower rate of acute postoperative endophthalmitis was found in group 2 versus group 1 (0.03% vs. 0.08%; P = 0.03). Patients receiving intracameral moxifloxacin showed approximately 2.5-times lower odds of infection (odds ratio, 0.39 for group 2 vs. group 1; 95% confidence interval, 0.16-0.95) and almost 4-times lower odds after adjustment for covariates (odds ratio, 0.26 for group 2 vs. group 1; 95% confidence interval, 0.09-0.74). The rate of early postoperative infection after intracameral moxifloxacin introduction was lower for patients undergoing both trabeculectomy alone (0.09%-0.03%; P = 0.27) and combined trabeculectomy plus cataract extraction (0.08%-0.03%; P = 0.06). Although most cultures yielded no growth, no Staphylococcus or gram-negative growth was found for patients in group 2, who received intracameral moxifloxacin.

CONCLUSIONS

Intracameral moxifloxacin prophylaxis was associated with a nearly 4-fold lower rate of early postoperative endophthalmitis in patients undergoing trabeculectomy or combined trabeculectomy plus cataract extraction.

Safety and Efficacy of 0.1% Nepafenac versus 1% Prednisolone Acetate Eye Drops after Laser Peripheral Iridotomy: A Prospective, Randomized Trial

PURPOSE

To compare 0.1% nepafenac, a topical nonsteroidal anti-inflammatory drop, with 1% prednisolone acetate in controlling inflammation after neodymium:yttrium-aluminum-garnet laser peripheral iridotomy (LPI) in primary angle-closure suspects (PACS).

DESIGN

Randomized controlled trial.

PARTICIPANTS

One hundred fifty-two PACS undergoing bilateral LPI.

METHODS

Patients were randomized to 0.1% nepafenac or 1% prednisolone acetate eye drops in both eyes. Medications were given 4 times daily for 7 days, then twice daily for additional 7 days. Investigators were masked to the type of medication. Right eyes in patients with bilateral PACS and the PACS eye in asymmetrical disease (primary angle closure in fellow eye) were analyzed.

MAIN OUTCOME MEASURES

Noninferior control of inflammation, defined as absence of cell in the anterior chamber at 2 weeks and absence of rebound iritis with medication discontinuation, was the primary outcome, whereas difference in the rise in intraocular pressure (IOP) was a secondary outcome.

RESULTS

Both groups were comparable in baseline characteristics, including IOP and total laser energy. Nepafenac was noninferior to prednisolone with regard to inflammation control, with 1 nepafenac-treated eye (1.3%) not meeting the primary end point because of 1+ anterior chamber cell at 2 weeks and 4 prednisolone-treated eyes (5.4%) failing to meet the primary end point because of rebound iritis (P < 0.001). A greater increase in IOP from baseline to 2 weeks was observed in the prednisolone group compared with the nepafenac group (+2.6 mmHg vs. +0.6 mmHg; P = 0.004), although at 4 weeks, IOP was not significantly different than baseline in either group (P > 0.05 for both). Two weeks after LPI, 3 nepafenac-treated eyes and 10 prednisolone-treated eyes demonstrated a 6- to 15-mmHg IOP elevation from baseline (P = 0.10), whereas 2 prednisolone-treated eyes and no nepafenac-treated eyes showed IOP elevation of more than 15 mmHg (P = 0.20). Four weeks after LPI, more prednisolone-treated eyes showed IOP elevation of 6 to 15 mmHg as compared with nepafenac-treated eyes (6 eyes vs. 1 eye; P = 0.04); no eyes showed IOP elevation of more than 15 mmHg.

CONCLUSIONS

Nepafenac was noninferior to prednisolone in controlling inflammation after LPI in PACS.

Acute angle closure glaucoma secondary to polypoidal choroidal vasculopathy - a devastating complication

Acute angle closure glaucoma (ACG) in the setting of polypoidal choroidal vasculopathy (PCV) is a catastrophic complication that has been documented infrequently in literature. Ours is the second only report that describes hemorrhagic choroidal detachment as an event leading to acute angle closure glaucoma in PCV patients and the first one to describe the use of diode cyclophotocoagulation (CPC) for this condition. The purpose of this article is to familiarize readers with this entity that has an extremely dismal visual prognosis. Ours is a descriptive case report of two patients with PCV complicated by sudden onset hemorrhagic choroidal detachment (CD) and acute ACG. Both patients had severe pain with no perception of light at presentation with an acute angle closure attack. Both underwent diode CPC for pain relief and control of intraocular pressure (IOP). Both our patients did not regain any vision, but their pain was relieved by diode CPC. Both eyes eventually became phthisical. Acute ACG following massive hemorrhagic CD is a rare but grave complication of PCV, not amenable to treatment. Diode CPC is an effective palliative modality of management to achieve pain relief in such cases.

Visual experience during phacoemulsification under topical versus retrobulbar anesthesia: results of a prospective, randomized, controlled trial

PURPOSE

To compare the subjective visual experience of cataract patients during phacoemulsification and intraocular lens implantation under topical anesthesia (TA) vs retrobulbar anesthesia (RA).

DESIGN

Prospective, randomized, controlled trial.

METHODS

Three hundred six cataract patients eligible for phacoemulsification and intraocular lens implantation were randomized to receive either TA or RA during surgery by one of three surgeons. The surgeons were familiar with both anesthetic techniques and operated on the patients using the technique to which the patients were randomized. A masked interviewer conducted in-person interviews with the patients using a standardized questionnaire about their intraoperative visual experience and their reaction to their visual experience between 30 minutes and 4 hours after the surgery.

RESULTS

Two patients (one in each group) had intraoperative posterior capsule rupture and were excluded from analysis. There was no statistically significant difference between TA (n = 154) and RA (n = 150) groups, except that more males compared with females had TA (P = .03). More patients who had TA reported perception of light (P < .001) and colors (P < .001) and a change (either increase or decrease) in light brightness during the course of the surgery (P < .001). There was no statistically significant difference in the proportions of patients who saw movements, flashes, instruments, or the surgeon or medical staff during the operation and who found their visual sensations frightening in the two groups. However, 10.4% in the TA group and 9.3% in the RA group found their visual experience frightening.

CONCLUSIONS

More patients undergoing cataract surgery under TA compared with RA reported perception of light, colors, and a change in light brightness. A significant proportion of patients in both groups found the visual experience frightening.