Abadan K Amitava

Gains beyond cosmesis: recovery of fusion and stereopsis in adults with longstanding strabismus following successful surgical realignment.

We evaluated recovery of binocularity in 15 chronically strabismic, non-fusing (with neutralizing prisms) adults following successful surgical alignment. We included > or =12-year-olds, with best corrected visual acuity (BCVA) > or =20/60, and excluded those with: anisoacuity> 2 lines-Snellen; failed realignment judged by> 10 prism diopters (PD) horizontal and> 4 PD vertical. Six-week outcomes were: fusion by Worth Four-Dots (WFDT) and Bagolini striated glasses (BSG) and stereopsis by Titmus test and the Netherlands organisation for applied scientific research (TNO) test. Baseline data in medians (range): age 18 (12-40) years, strabismus 45 (19-95) PD, duration 14 (0.5-24) years, 12 females; 12 exotropes, three esotropes; visual acuity was 20/20 in 10, while none had BCVA < 20/60. Postoperative strabismus measured 6 PD (range:0-10). By six weeks none suppressed: WFDT findings showed eight fused at distance and 13 at near; and on BSG figures were 10 and 13 respectively. Stereopsis was demonstrated by 13 on Titmus and by 10 on TNO tests. It is concluded that longstanding strabismic adults with good vision can recover fusion and stereopsis following successful squint surgery.

Topical diclofenac versus dexamethasone after strabismus surgery: a double-blind randomized clinical trial of anti-inflammatory effect and ocular hypertensive response.

BACKGROUND Compared to steroids non-steroidal anti-inflammatory drugs offer comparable anti-inflammatory action without ocular side-effects. AIM To compare the anti-inflammatory effect and effect on IOP (Goldmann) of topical diclofenac 0.1% with dexamethasone 0.1% after strabismus surgery. DESIGN Prospective, randomized, double-blind, single-center, clinical trial. MATERIALS AND METHODS Forty-three cases of constant horizontal strabismus, qualifying for standard uniocular recession-resection surgery on two horizontal rectus muscles were randomized to either the dexamethasone or diclofenac group. They were excluded if they had previous ocular surgery, recently used anti-inflammatory drugs and had a neurological, systemic or an ocular inflammatory condition. In addition all received ciprofloxacin 0.3% four times daily. Assessment was done on the first postoperative day and at two and four weeks. The inflammatory characteristics graded from nil (0) to severe (3) were: discomfort, chemosis, injection, discharge and drop-intolerance. Their sum provided the total inflammatory score (TIS). RESULTS Dexamethasone group (n=21) was comparable in age, gender, preoperative IOP, strabismus, anesthesia administered and baseline IOP, to diclofenac (n=22). There were no significant differences in the inflammatory characteristics and TIS. The dexamethasone group had IOP significantly higher at two weeks (95% CI 0.17 to 3.25) and four weeks (95% CI 1.09 to 4.24) compared to diclofenac group and the net change of IOP at four weeks (95% CI 0.60 to 3.14). Compared to the baseline IOP. CONCLUSION Topical diclofenac is comparable to dexamethasone in providing anti-inflammatory and analgesic effect with the advantage of significantly lesser IOP rise and should be preferred after strabismus surgery.

Minimally invasive strabismus surgery versus paralimbal approach: A randomized, parallel design study is minimally invasive strabismus surgery worth the effort?

Introduction: Minimal access surgery is common in all fields of medicine. We compared a new minimally invasive strabismus surgery (MISS) approach with a standard paralimbal strabismus surgery (SPSS) approach in terms of post-operative course. Materials and Methods: This parallel design study was done on 28 eyes of 14 patients, in which one eye was randomized to MISS and the other to SPSS. MISS was performed by giving two conjunctival incisions parallel to the horizontal rectus muscles; performing recession or resection below the conjunctival strip so obtained. We compared post-operative redness, congestion, chemosis, foreign body sensation (FBS), and drop intolerance (DI) on a graded scale of 0 to 3 on post-operative day 1, at 2-3 weeks, and 6 weeks. In addition, all scores were added to obtain a total inflammatory score (TIS). Statistical Analysis: Inflammatory scores were analyzed using Wilcoxons signed rank test. Results: On the first post-operative day, only FBS (P =0.01) and TIS (P =0.04) showed significant difference favoring MISS. At 2-3 weeks, redness (P =0.04), congestion (P =0.04), FBS (P =0.02), and TIS (P =0.04) were significantly less in MISS eye. At 6 weeks, only redness (P =0.04) and TIS (P =0.05) were significantly less. Conclusion: MISS is more comfortable in the immediate post-operative period and provides better cosmesis in the intermediate period.

Orbital amelanotic melanoma in xeroderma pigmentosum: a rare association.

Xeroderma pigmentosum (XP) is an autosomal recessive genetic disorder of DNA repair in which the body′s normal ability to repair damage caused by ultraviolet light is deficient. This leads to a 1000-fold increased risk of cutaneous and ocular neoplasms. Ocular neoplasms occurring in XP in order of frequency are squamous cell carcinoma, basal cell carcinoma and melanoma. Malignant melanomas occur at an early age in patients with XP. We report a case of XP with massive orbital melanoma in an eight-year-old boy which is unique due to its amelanotic presentation confirmed histopathologically.

Cost-effectiveness analysis should continually assess competing health care options especially in high volume environments like cataract surgery

Context: Cost-effectiveness analysis should continually assess competing health care options especially in high volume environments like cataract surgery. Aims: To compare the cost effectiveness of phacoemulsification (PE) versus manual small-incision cataract surgery (MSICS). Settings and Design: Prospective randomized controlled trial. Tertiary care hospital setting. Subjects and Methods: A total of 52 consenting patients with age-related cataracts, were prospectively recruited, and block randomized to PE or MSICS group. Preoperative and postoperative LogMAR visual acuity (VA), visual function-14 (VF-14) score and their quality-adjusted life years (QALYs) were obtained, and the change in their values calculated. These were divided by the total cost incurred in the surgery to calculate and compare the cost effectiveness and cost utility. Surgery duration was also compared. Statistical Analysis Used: Two group comparison with Students t-test. Significance set at P < 0.05; 95% confidence interval (CI) quoted where appropriate. Results: Both the MSICS and PE groups achieved comparative outcomes in terms of change (difference in mean [95% CI]) in LogMAR VA (0.03 [−0.05−0.11]), VF-14 score (7.92 [−1.03−16.86]) and QALYs (1.14 [−0.89−3.16]). However, with significantly lower costs (INR 3228 [2700–3756]), MSICS was more cost effective, with superior cost utility value. MSICS was also significantly quicker (10.58 min [6.85–14.30]) than PE. Conclusions: MSICS provides comparable visual and QALY improvement, yet takes less time, and is significantly more cost-effective, compared with PE. Greater push and penetration of MSICS, by the government, is justifiably warranted in our country.

Gain beyond cosmesis: Demonstration of psychosocial and functional gains following successful strabismus surgery using the adult strabismus questionnaire adult strabismus 20

Background: Strabismus adversely affects psychosocial and functional aspects; while its correction impacts positively. Aim: The aim was to evaluate the gains in scores: Overall scores (OASs), psychosocial subscale scores (PSSs) and functional subscale scores (FSSs) following successful surgical alignment. Settings and Design: We evaluated changed scores in the adult strabismus 20 (AS-20) questionnaire, administered before and after successful surgery. Materials and Methods: Thirty adults horizontal strabismics, were administered the AS-20, at baseline, and at 6-week and 3-month. Group-wise analysis was carried out based on gender, strabismus type (esotropia [ET] or exotropia [XT]), back-ground and amblyopia. Statistical Analysis: We used Wilcoxon, and Mann-Whitney U-tests. Significance was set at P ≤ 0.05. Results: At baseline, there were no significant differences within the groups, except that those with amblyopia significantly scored less than nonamblyopes in OAS (median scores: 53.8 vs. 71.3; P = 0.009) and FSS (56.3 vs. 85.3; P = 0.009). OAS, PSS and FSS showed significant gains at 6-week and 3-month (all Wilcoxon P < 0.001). Compared with males, females showed significantly more gain at 3-month (OAS: 37.9 vs. 28.7; P = 0.02), on account of PSS gain (49.6 vs. 37.5; P = 0.01). The ET performed better than XT only on the FSS at 6-week (28.7 vs. 15.0; P = 0.02). Vis-à-vis the nonamblyopes, the amblyopes showed significantly more benefit at 6-week alone (OAS: 18.7 vs. 28.7; P = 0.04), largely due to gains in PSS. Conclusions: Successful strabismus surgery has demonstrated significant gains in psychosocial, functional and overall functions. There is some evidence that gains may be more in females; with a trend to better outcomes in ET and amblyopes up to 6-week.

Assessment of a modification of Bruckner's test as a screening modality for anisometropia and strabismus.

Background: Current amblyopia screening methods are not cost effective. Aim: To evaluate the diagnostic capability of a modified Brückner test (MBT) for amblyopiogenic risk factors. Materials and Methods: We applied the MBT using the streak retinoscope to identify anisometropia and strabismus by noting an inter-ocular difference in movement and glow, from children who failed 6/9 Snellen on community vision screening, followed by comprehensive eye examination. Statisitics: Data were analyzed by 2 × 2 tables for diagnostic test parameters (95% CI). Results: From 7998 children vision-screened, 392 failed 6/9 VA and were referred. Since 34 failed to reach the centers, and 15 were excluded due to poor/ no glow, data from 343 was analyzed. The prevalence of anisometropia of 0.5D was 17%, of 1D was 11% and of strabismus 5%. For the MBT the accuracy was ≥ 90% (95%CI 89% to 97%) over the three outcomes. The sensitivity, specificity, NPV and +LR for anisometropia of 0.5D were: 0.57 (0.48, 0.64), 0.97 (0.95, 0.98), 0.92 (0.90, 0.93) and 18 (9.7, 35); for 1D: 0.74(0.60, 0.82), 0.95 (0.94, 0.97), 0.97 (0.95, 0.98) and 16 (9.3, 28); and for strabismus: 0.5 (0.32, 0.66), 0.98 (0.97, 0.98), 0.97 (0.96, 0.98) and 20 (9.1, 42). Conclusion: Our data suggests that the MBT is highly accurate and useful for ruling in anisometropia and strabismus in children who fail 6/9 Snellen. The MBT needs further validation, both by different care givers and on differing populations. It offers an affordable, portable, and clinically useful tool to detect anisometropia and strabismus. We suggest that performing an MBT prior to uniocular retinosocpy should be a routine practice.

Beyond photography: evaluation of the consumer digital camera to identify strabismus and anisometropia by analyzing the Bruckner's reflex.

Amblyopia screening is often either costly or laborious. We evaluated the Canon Powershot TX1 (CPTX1) digital camera as an efficient screener for amblyogenic risk factors (ARF). We included 138 subjects: 84-amblyopes and 54-normal. With the red-eye-reduction feature off, we obtained Bruckner reflex photographs of different sized crescents which suggested anisometropia, while asymmetrical brightness indicated strabismus; symmetry implied normalcy. Eight sets of randomly arranged 138 photographs were made. After training, 8 personnel, marked each as normal or abnormal. Of the 84 amblyopes, 42 were strabismus alone (SA), 36 had anisometropia alone (AA) while six were mixed amblyopes (MA). Overall mean sensitivity for amblyopes was 0.86 (95% CI: 0.83-0.89) and specificity 0.85 (95% CI: 0.77-0.93). Sub-group analyses on SA, AA and MA returned sensitivities of 0.86, 0.89 and 0.69, while specificities were 0.85 for all three. Overall Cohens Kappa was 0.66 (95% CI: 0.62-0.71). The CPTX1 appears to be a feasible option to screen for ARF, although results need to be validated on appropriate age groups.

Changes in central retinal artery blood flow after ocular warming and cooling in healthy subjects

Context: Retinal perfusion variability impacts ocular disease and physiology. Aim: To evaluate the response of central retinal artery (CRA) blood flow to temperature alterations in 20 healthy volunteers. Setting and Design: Non-interventional experimental human study. Materials and Methods: Baseline data recorded: Ocular surface temperature (OST) in °C (thermo-anemometer), CRA peak systolic velocity (PSV) and end diastolic velocity (EDV) in cm/s using Color Doppler. Ocular laterality and temperature alteration (warming by electric lamp/cooling by ice-gel pack) were randomly assigned. Primary outcomes recorded were: OST and intraocular pressure (IOP) immediately after warming or cooling and ten minutes later; CRA-PSV and EDV at three, six and nine minutes warming or cooling. Statistical Analysis: Repeated measures ANOVA. Results: (n = 20; μ ± SD): Pre-warming values were; OST: 34.5 ± 1.02°C, CRA-PSV: 9.3 ± 2.33 cm/s, CRA-EDV: 4.6 ± 1.27 cm/s. OST significantly increased by 1.96°C (95% CI: 1.54 to 2.37) after warming, but returned to baseline ten minutes later. Only at three minutes, the PSV significantly rose by 1.21 cm/s (95% CI: 0.51to1.91). Pre-cooling values were: OST: 34.5 ± 0.96°C, CRA-PSV: 9.7 ± 2.45 cm/s, CRA-EDV: 4.7 ± 1.12 cm/s. OST significantly decreased by 2.81°C (95% CI: −2.30 to −3.37) after cooling, and returned to baseline at ten minutes. There was a significant drop in CRA-PSV by 1.10cm/s (95% CI: −2.05 to −0.15) and CRA-EDV by 0.81 (95% CI: −1.47 to −0.14) at three minutes. At six minutes both PSV (95% CI: −1.38 to −0.03) and EDV (95% CI: −1.26 to −0.02) were significantly lower. All values at ten minutes were comparable to baseline. The IOP showed insignificant alteration on warming (95% CI of difference: −0.17 to 1.57mmHg), but was significantly lower after cooling (95% CI: −2.95 to −4.30mmHg). After ten minutes, IOP had returned to baseline. Conclusion: This study confirms that CRA flow significantly increases on warming and decreases on cooling, the latter despite a significant lowering of IOP.

Comment on: cut and paste: a novel method of re-attaching rectus muscles with cyanoacrylate during recessions in strabismus.

Aim: Bio-adhesives like cyanoacrylate offer an alternative to sutures to attach tissues, including in ophthalmology. This prospective trial evaluated the suitability and bio-tolerance of iso-amyl cyanoacrylate in rectus muscle recession surgery for strabismus. Materials and Methods: We randomized one eye in each of 10 cases of bilateral horizontal rectus recessions to 6/0 polyglactin and the other to iso-amyl-cyanoacrylate. We compared time to reattachment (from disinsertion), complications and inflammatory scores (0 to +3: nil, mild, moderate and severe) on Day One, at two and at four to six weeks post surgery. Results: There were no significant group differences in inflammatory scores (Wilcoxon, all values of P>0.05). All attachments held firm. Gluing took significantly longer by 5.24±1.91 min (95% CI for difference: 3.87-6.61). There were no complications. Conclusion: We feel that although it takes marginally longer, iso-amyl cyanoacrylate offers an effective and safe alternative to sutures for muscle recession in strabismus surgery. Since it is cheaper (vs. polyglactin) and offers multi-use possibility it may also prove to be cost-effective.