Ajai Kumar

Transcanalicular laser dacryocystorhinostomy using low energy 810 nm diode laser

Background: Hypertrophic scarring may be a cause of failure after transcanalicular laser dacryocystorhinostomy (DCR) surgery. This hypertrophic scarring results from tissue charring and excessive coagulation, which may be caused by the high laser energy. We have evaluated the use of low energy settings to prevent hypertrophic scarring, for a successful outcome. Aims: To perform and evaluate transcanalicular laser DCR using low energy 810 nm diode laser. Design: Interventional, non-comparative, case series. Materials and Methods: Patients with nasolacrimal duct obstruction and chronic dacryocystitis, who needed DCR, and were fit for surgery under local anesthesia, were recruited to undergo transcanalicular laser DCR using a 810 nm diode laser. The outcome was measured by the patency of the lacrimal passage, as indicated by the relief in the symptoms and the patency on syringing at the last follow-up. The surgical time and surgical complications were noted. Statistical Analysis Used: Descriptive analysis. Results: The study included 94 patients. The average age was 30.1 years (range 15 - 69 years). Seventy (74.4%) patients were female. Eight patients had failed external DCR. Per-operative patency of the passage was obtained in all the patients. Average surgical time was seven minutes (5 – 18 minutes). At the end of the study period of one year, a successful outcome was seen in 85 patients (90.5%). There were eight patients of previous failed DCR surgeries, and six of them achieved a cure at the end of follow-up. Conclusions: Transcanalicular Laser DCR can be safely performed using a low power 810 nm diode laser. The surgery is elegant, minimally invasive, allows fast rehabilitation, and has an excellent success rate.

Cataract surgery under topical anesthesia using 2% lignocaine jelly and intracameral lignocaine: Is manual small incision cataract surgery comparable to clear corneal phacoemulsification?

A prospective comparative study was undertaken to compare the patients’ pain experience, surgical outcome and surgeon’s experience in phacoemulsification and manual small incision cataract surgery (MSICS) under topical anesthesia supplemented with intracameral lignocaine (TASIL). In Group 1 (n=88) phacoemulsification was done and in Group 2 (n=92) MSICS was done. Pain scores were marked by the patients on a Visual analog scale (VAS) after the surgery. The surgical experience was noted on a questionnaire by the operating surgeon. Descriptive analysis and one-tailed Mann-Whitney test were used to draw results. The average VAS score in Group 1 was 0.65 (SD 1.31) and in Group 2 it was 0.90 (SD 1.22). This difference in the average was not statistically significant with P=0.09. The study demonstrates that MSICS and phacoemulsification both can be done safely under TASIL with acceptable patient comfort, and the pain experienced by the patients during the procedures is comparable.

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.

Topical Anesthesia in High Volume Cataract Surgery: Pain Evaluation andFeasibility Study

Context: This study was undertaken to evaluate the use of topical anesthesia for Manual small incision cataract surgery in high volume cataract surgery setup. Aims: The primary aim was to evaluate the pain experience of the patients undergoing Manual Small Incision Cataract Surgery (MSICS) under topical anesthesia using 2% lignocaine jelly in high volume cataract surgery setup. Secondary aims were to study any relation between the pain experience and education status, gender and age of the patients. Settings and Design: The study was an Interventional case series conducted at a tertiary care eye hospital. Methods and Material: Patients screened at the peripheral field camps were transported to base hospital and underwent MSICS under topical anesthesia using lignocaine 2% jelly and intracameral 0.5% lignocaine solution. Demographic data and pain experience of the patients during the surgery was recorded and analyzed. Statistical analysis: Statistical analysis was done using MedCalc® version 12.2.1.0 software for Windows 7. Descriptive analysis, Mann-Whitney test, Kruskal-Wallis test, and Spearman’s rho coefficient were used to analyze the data. Results: The study included 270 patients, with average age 62.7 years. Average pain score was 1.6 units (SD ± 0.72, scale 1-5) with ~85% patients reporting comfortable experience. Pain perception had no relation to gender, education status or age. Conclusions: Manual Small Incision Cataract Surgery under topical anesthesia using lignocaine 2% jelly and intracameral lignocaine, in high volume cataract surgeries safe and comfortable to majority of patients and is unaffected by gender, age or educational status of the patients.

Query to the author of retinoblastoma: Achieving new standards with methods of chemotherapy

Dear Sir, We have read the symposium article titled “Retinoblastoma: Achieving new standards with methods of chemotherapy” by Kaliki and Shields [1] with great interest and appreciate their effort to summate the present status of chemotherapy for retinoblastoma. We noticed that the Fig. 2 depicted in the article on page number 105 of the journal, claims that the systemic chemotherapy reduces the size of orbital retinoblastoma as per the attached legend “Treatment of the orbital retinoblastoma with intravenous chemotherapy (a) Orbital retinoblastoma of the left eye confirmed on (b) computed tomography scan of the orbit. (c and d) Nine cycles of high-dose chemotherapy resulted in phthisis bulbi facilitating enucleation. No residual tumor was noted on histopathology. The patient subsequently underwent left orbit external beam radiotherapy and further three cycles of high-dose chemotherapy.” The figure depicts the change in retinoblastoma tumor of single patient over a period of time after systemic chemotherapy. However, it is obvious that the images depicted are of two separate patients and the one labeled (a) with advanced tumor is of a patient with older age, darker iris, and a mole on the left slope of the nasal bridge. The image (c) of Fig. 2 is a different patient with lighter iris and no mole at the mentioned site. We would like to thank the authors for explaining the anomaly. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Trojan horse anaesthesia: A novel method of anaesthesia for pars plana vitrectomy

CONTEXT: Topical anesthesia has been used for pars plana vitrectomy (PPV) with limited patient comfort. Thus, augmenting topical anesthesia with intracameral anesthesia (Trojan horse anesthesia) will provide pain-free experience during PPV. AIMS: This study was undertaken to evaluate the patient comfort and surgical safety using 2% lignocaine jelly augmented with intracameral 1.0% lignocaine solution for anesthetizing the eyes undergoing PPV. SETTINGS AND DESIGN: This was a prospective interventional case series at tertiary care hospital. SUBJECTS AND METHODS: Patients planned for PPV for indications other than retinal detachment were included in the study. The pain perception of the participants undergoing PPV under Trojan horse anesthesia was evaluated using visual analog scale (VAS). STATISTICAL ANALYSIS USED: Data analysis was done using descriptive statistics and nonparametric analysis with level of significance at P < 0.05. RESULTS: There were 114 eyes of 114 patients in the study out of which 68.4% (n = 78) were males. The mean age was 42.31 years (range 14–80 years, standard deviation [SD] 18.7). The mean surgical time was 34.0 min (range 13–80 min, SD 14.2). The pain perception on VAS scale averaged 3.0 (range 0–8, SD 1.59, median 3.0). Pain scores were not affected by the age (Pearson correlation = 0.098, P = 0.3), gender (P = 0.44), or the educational status of the participant (P = 0.28). The pain scores were not affected by the indications of surgery (P = 0.58) or the use of silicone oil (P = 0.07). CONCLUSIONS: Trojan horse anesthesia provides adequate analgesia for comfortable and safe 23-gauge PPV with high patient acceptability.

Survival and outcome of retinoblastoma treated by neo-adjuvant chemotherapy in India

Retinoblastoma is the most common intraocular malignancy during infancy and childhood. The survival rate for children with retinoblastoma has improved significantly in developed countries; however, the outcome of the disease in developing countries remains dismal. Neoadjuvant chemotherapy is useful in this clinical scenario and can improve the survival of these children in the developing and underdeveloped countries.

Temporary complete vision loss after intracameral lignocaine in a post-vitrectomy eye: A single case report

We report a case of temporary complete vision loss in a phakic patient after intracameral lignocaine solution injection percolated to the posterior segment of the eye and anesthetized the retina. The main reason of this seepage of lignocaine solution from the anterior chamber to the posterior segment was presumably the hypotony and absence of the vitreous body as the patient had undergone pars plana vitrectomy for intravitreal cysticercus. Once the duration of anesthesia effect of lignocaine elapsed, the patient gained good vision with no obvious retinal damage as seen on fundus imaging and ocular coherence tomography. Thus, one should keep the possibility of intracameral medications to reach the posterior segment in therapeutic/toxic concentrations, especially in postvitrectomy eyes with hypotony.

Query to the author of 'comparison of different techniques of cataract surgery in bacterial contamination of the anterior chamber in diabetic and non-diabetic population'.

Sir, We have read the article published in the current issue of IJO, titled “Comparison of different techniques of cataract surgery in bacterial contamination of the anterior chamber in diabetic and non-diabetic population.”[1] We have the following observations and would like to have authors comments on them. Side port in phacoemulsification surgery is understandable, but irrigation of the anterior chamber using the side port in MSICS indicates that a side port was made in MSICS patients also. However this is not mentioned in the MSICS steps. Kindly clarify, when was that made and the purpose served by the side port. Sub-conjunctival injection at the end of surgery was not given. As we see it, this is a usual practice in cataract surgery that a sub-conjunctival injection of steroid and antibiotics is given just before patching the eye in surgery under local anesthesia. Apart from a depot of antibiotic and steroid, sub-conjunctival injection helps in reposition of the conjunctival flap. Why this deviation from the routine practice? Only an antibiotic solution drop was instilled at the end of surgery. Was there any specific reason for not instilling steroid solution? As mentioned, the eye patch was opened after 6 h of surgery. Again we would consider this as a deviation from routine practice as the dressing is opened on the next day. Any advantage of not giving sub-conjunctival injection of antibiotic steroid solution and then early opening of the eye dressing to start topical medication? Kindly clarify. The eye drop regimen after opening the eye dressing was too aggressive. One hourly instillation of antibiotic steroid eye drop is not justified routinely without any evidence of excessive inflammation or infection. Kindly comment. The antibiotic steroid combination was started at one hourly frequency and later tapered to once daily. It is incorrect to taper the dose of any antibiotic. The antibiotics should be used in adequate dosage and stopped immediately, with no tapering, to prevent emergence of acquired bacterial resistance. Tapering of antibiotics is not justified at all. Author should have used separate antibiotic and steroid drops if they wanted to taper the steroid drop dosage instead of using fixed dose combination of steroid and antibiotic. It is ironical that the authors have condemned the use of antibiotics in irrigating solution for possibility of inducing resistance and at the same time indulged in tapering the dosage of antibiotic eye drop which itself is capable of inducing resistance by exposing the bacteria to sub-minimal lethal dosage.