Aravind Haripriya

Complication rates of phacoemulsification and manual small-incision cataract surgery at Aravind Eye Hospital.

PURPOSE: To analyze the rate of intraoperative complications, reoperations, and endophthalmitis with phacoemulsification, manual small‐incision cataract surgery (SICS), and large‐incision extracapsular cataract extraction (ECCE). SETTING: Aravind Eye Hospital, Madurai, India. DESIGN: Retrospective cohort study. METHODS: This study comprised consecutive cataract surgeries performed during a 12‐month period. All surgical complications and endophthalmitis cases were tabulated and analyzed for each of 4 surgeon groups (staff, fellows, residents, visiting trainees). Within each surgeon group, complication rates with phacoemulsification, manual SICS, and ECCE were compared. RESULTS: The surgical distribution was 20 438 (26%) phacoemulsification, 53 603 (67%) manual SICS, and 5736 (7%) ECCE. The overall intraoperative complication rate was 0.79% for staff, 1.19% for fellows, 2.06% for residents, and 5% for visiting trainees. Extracapsular cataract extraction had the highest overall rate of surgical complications (2.6%). The overall complication rate was 1.01% for manual SICS and 1.11% for phacoemulsification. However, the combined complication rate for trainees was significantly higher with phacoemulsification (4.8%) than with manual SICS (1.46%) (P<.001). The corrected distance visual acuity was better than 6/12 in 96% after phacoemulsification complications and 89% after manual SICS complications (P<.001). There were 27 cases (0.04%) of endophthalmitis but no statistical differences between surgical methods or surgeon groups. CONCLUSIONS: For staff surgeons experienced with both phacoemulsification and manual SICS, intraoperative complication rates were comparably low. However, for trainee surgeons, the complication rate was significantly higher with phacoemulsification, suggesting that manual SICS may be a safer initial procedure to learn for inexperienced cataract surgeons in the developing world. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Efficacy of Intracameral Moxifloxacin Endophthalmitis Prophylaxis at Aravind Eye Hospital

PURPOSE To compare the rate of postoperative endophthalmitis before and after initiation of intracameral (IC) moxifloxacin for endophthalmitis prophylaxis in patients undergoing cataract surgery. DESIGN Retrospective, clinical registry. PARTICIPANTS All charity and private patients (116 714 eyes) who underwent cataract surgery between February 15, 2014, and April 15, 2015, at the Madurai Aravind Eye Hospital were included. Group 1 consisted of 37 777 eyes of charity patients who did not receive IC moxifloxacin, group 2 consisted of 38 160 eyes of charity patients who received IC moxifloxacin prophylaxis, and group 3 consisted of 40 777 eyes of private patients who did not receive IC moxifloxacin. METHODS The electronic health record data for each of the 3 groups were analyzed, and the postoperative endophthalmitis rates were statistically compared. The cost of endophthalmitis treatment (groups 1 and 2) and the cost of IC moxifloxacin prophylaxis (group 2) were calculated. MAIN OUTCOME MEASURES Postoperative endophthalmitis rate before and after initiation of IC moxifloxacin endophthalmitis treatment cost. RESULTS Manual, sutureless, small incision cataract surgery (M-SICS) accounted for approximately all of the 75 937 cataract surgeries in the charity population (97%), but only a minority of the 40 777 private surgeries (21% M-SICS; 79% phacoemulsification). Thirty eyes in group 1 (0.08%) and 6 eyes in group 2 (0.02%) were diagnosed with postoperative endophthalmitis (P < 0.0001). The group 3 endophthalmitis rate was 0.07% (29 eyes), which was also higher than the second groups rate (P < 0.0001). There were no adverse events attributed to IC moxifloxacin in group 2. The total cost of treating the 30 patients with endophthalmitis in group 1 was virtually identical to the total combined cost in group 2 of routine IC moxifloxacin prophylaxis and treatment of the 6 endophthalmitis cases. CONCLUSIONS Routine IC moxifloxacin prophylaxis achieved a highly significant, 4-fold reduction in postoperative endophthalmitis in patients undergoing M-SICS. Compared with previous studies, having such a high volume of patients undergoing surgery during a relatively short 14-month time period strengthens the conclusion. This study provides further evidence that moxifloxacin is an effective IC prophylactic antibiotic and suggests that IC antibiotics should be considered for M-SICS and phacoemulsification.

Cataract surgery and intraocular lens manufacturing in India.

Purpose of review Cataract surgery in India has seen exponential growth in the past decade. This leap was possible due to cost-effective cataract surgery with intraocular lenses. The purpose of this review is to update the reader regarding the Indian scenario of cataract surgery and intraocular lens manufacturing. Recent findings India performed an estimated 0.5 million cataract surgeries in 1981–1982; this increased to 4.8 million in 2006 with 90% intraocular lens acceptance. There has been a sustained shift from sutured extracapsular cataract surgery to small-incision cataract surgery. Phacoemulsification with foldable lenses is becoming the surgical choice in the urban setting. The Indian intraocular lens industry is maturing from a low-cost manufacturer to a quality-conscious, technology-driven and value-priced industry to meet present and future market needs. Summary The burden of cataract blindness is a major challenge for all developing countries. India has managed to improve its cataract surgical rate by an amalgam of factors such as low surgical costs, low-cost indigenous eye-care consumables, infrastructure development and enhanced training. The findings from this review will be useful to develop strategies to enhance the uptake of cataract surgery in developing countries.

A Proposed Minimum Standard Set of Outcome Measures for Cataract Surgery

IMPORTANCE Aligning outcome measures for cataract surgery, one of the most frequently performed procedures globally, may facilitate international comparisons that can drive improvements in the outcomes most meaningful to patients. OBJECTIVE To propose a minimum standard set of outcome measures for cataract surgery that enables global comparisons. DESIGN, SETTING, AND PARTICIPANTS A working group of international experts in cataract outcomes and registries was convened, along with a patient advocate, to agree on a consensus of outcome measures for cataract surgery. In a modified Delphi process, the group met regularly between November 10, 2012, and November 21, 2013, to discuss which outcomes to include in a standard set. Included factors were based on extant literature, existing registries, and the experience of group members. Similarly, a series of consensus discussions were held to determine a set of risk factors to be gathered for each patient. The final shortlist was compiled into a standard set. Analysis was performed from November 22, 2013, to April 5, 2014. MAIN OUTCOMES AND MEASURES Development of a recommended standard set encompassing preoperative metrics including patient risk factors, intraoperative factors including surgical complications, and postoperative cataract surgery outcomes. RESULTS The recommended standard set encompasses all patients treated for cataracts by 1 of 4 surgical approaches (phacoemulsification, sutured manual extracapsular cataract extraction, sutureless manual extracapsular cataract extraction, or intracapsular cataract extraction). The recommended metrics to be recorded preoperatively include demographics, ocular history and comorbidities, preoperative visual acuity, and patient-reported visual function. The recommended outcomes were split into intraoperative and postoperative metrics. Intraoperative outcomes include capsule-related problems, dislocation of lens nucleus fragments into the vitreous, and other complications. Postoperative outcomes include visual acuity, refractive error, patient-reported visual function, and early and late complications of surgery. The suggested follow-up for collection of postoperative outcomes is up to 3 months. CONCLUSIONS AND RELEVANCE A minimum standard set of outcome measures for cataract surgery is important for meaningful comparison across contexts. The proposed data set is a compromise between all useful data and the practicalities of data collection.

Bimanual microphaco for posterior polar cataracts

&NA; We describe a technique in which bimanual microphacoemulsification technique through 2, 1.4 mm incisions is performed for posterior polar cataract extraction. The low‐infusion and low‐vacuum system provides good anterior chamber stability and followability. The irrigation and aspiration handpieces are interchangeable, enabling removal of the lens fragments without hydrodissection or nucleus rotation. Only 1 (12.5%) of the 8 cases presented here was complicated by posterior capsule rupture. This occurred after epinucleus removal without any vitreous disturbance. The bimanual microphacoemulsification technique appears to minimize the risk for complications, allowing posterior polar cataract extraction to be performed more safely.

Lysyl Oxidase–Like 1 Gene in the Reversal of Promoter Risk Allele in Pseudoexfoliation Syndrome

IMPORTANCE This study was necessary to establish the association between common genetic variants in the lysyl oxidase-like 1 (LOXL1) gene with pseudoexfoliation (PEX) syndrome and emphasize the reversal of promoter risk allele in a South Indian population. OBJECTIVE To investigate the potential association of genetic variants across the LOXL1 gene in South Indian patients with PEX syndrome and glaucoma. DESIGN, SETTING, AND PARTICIPANTS A case-control study of individuals from Madurai, India, with PEX syndrome and glaucoma as well as healthy people serving as controls. Three hundred unrelated people with PEX syndrome and 225 age- and ethnically matched controls were recruited for genetic analysis. MAIN OUTCOMES AND MEASURES Four single-nucleotide polymorphisms in LOXL1 (rs16958477, rs1048661, rs3825942, and rs2165241) were genotyped by direct sequencing in all participants. Regulatory regions and 7 coding exons of LOXL1 were directly sequenced in 50 patients and 50 controls. A case-control association analysis was performed using the Golden Helix SVS suite. RESULTS An association between 4 LOXL1 single-nucleotide polymorphisms with PEX syndrome and glaucoma was observed (rs16958477, P = 4.77 × 10-6 [odds ratio, 0.50]; rs1048661, P = 4.28 × 10-5 [1.79]; rs3825942, P = 4.68 × 10-30 [9.19]; and rs2165241, P = 1.98 × 10-15 [2.88]). Sequencing of 7 exons and regulatory regions of LOXL1 identified 11 additional sequence variants; only rs41435250 showed an association (P = 3.80 × 10-5 [0.49]) with PEX syndrome and glaucoma. CONCLUSIONS AND RELEVANCE Genetic variants in LOXL1 are associated with PEX syndrome and glaucoma in the South Indian population. To our knowledge, this is the first study to demonstrate the association of rs41435250 with PEX as well as reversal of the promoter risk allele. Understanding the role of the LOXL1 gene in PEX pathogenesis will facilitate early detection in individuals at risk for this condition.

Effect of preoperative counseling on fear from visual sensations during phacoemulsification under topical anesthesia

PURPOSE: To determine whether preoperative counseling on possible intraoperative visual perceptions during cataract surgery helps reduce the patients’ fear during surgery. SETTING: Aravind Eye Hospital, Madurai, India. DESIGN: Randomized masked clinical trial. METHODS: Patients having phacoemulsification under topical anesthesia were randomized to receive additional preoperative counseling or no additional preoperative counseling on potential intraoperative visual perceptions. After surgery, all patients were interviewed about their intraoperative experiences. RESULTS: Of 851 patients, 558 (65.6%) received additional preoperative counseling and 293 (34.4%) received no additional counseling. A lower proportion of patients in the counseled group were frightened than in the group not counseled for visual sensation (4.5% versus 10.6%, P<.001). Analyzed separately by specific visual sensations, similar results were found for light perception (7/558 [1.3%] versus 13/293 [4.4%], P=.007), colors (P=.001), and movement (P=.020). The mean fear score was significantly lower in the counseled group than in the not‐counseled group for light perception (0.03 versus 0.12, P=.002), colors (P=.001), movement (P=.005), and flashes (P=.035). Preoperative counseling was a significant factor affecting fear after accounting for age, sex, operated eye, and duration of surgery (multivariate odds ratio, 4.3; 95% confidence interval, 1.6‐11.6; P=.003). CONCLUSION: Preoperative counseling on possible visual sensations during cataract surgery under topical anesthesia significantly reduced the mean fear score and the proportion of patients reporting being frightened. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Single and Multidose Ocular Kinetics and Stability Analysis of Extemporaneous Formulation of Topical Voriconazole in Humans

Purpose: The purpose of the present study was to evaluate the kinetics of single and multiple doses of topical, non-preserved voriconazole (VZ) in human eyes. Methods: For single dose kinetics, 119 patients undergoing cataract surgery were divided into group I and group II and each group received a single drop (30 µl) of either 1% or 0.1% VZ formulation. Aqueous humor was collected at designated time intervals. For multidose kinetics, a single drop of 1% VZ was instilled 5 times either hourly or every 2 hr. The aqueous humor was tested for VZ at the 5th hr and 9th hr, respectively, after initial instillation. The stability and efficacy of the reconstituted VZ formulations were also evaluated after 30 days. Results: Single dose ocular kinetics of 1% VZ resulted in a maximum mean aqueous concentration of 3.333 ± 1.61 µg/ml in 30 min whereas 0.1% showed a maximum mean aqueous concentration of 0.817 ±.36 µg/ml. In the multidose kinetic study, hourly and bi-hourly dosing resulted in mean aqueous concentrations of 7.47 ± 2.14 µg/ml and 4.69 ± 2.7 µg/ml, respectively. The reconstituted VZ formulations were stable at all studied temperatures, and their efficacy was maintained throughout the study period. Conclusion: The present study showed that the achieved mean concentration of VZ in both single dose and multi dose kinetic studies satisfactorily met the MIC90 for almost all causative fungal organisms. The frequency of instillation may be designed for an “every 2 hr regimen” to maintain a therapeutic concentration for successful therapy.

Phacoemulsification with toric IOL implantation in Alport syndrome with anterior lenticonus having spontaneously ruptured anterior capsule

Purpose To report the outcome of phacoemulsification with toric intraocular lens (IOL) implantation in Alport syndrome with spontaneously ruptured capsule. Methods Case report and literature review. Results A 2.2-mm clear corneal phacoemulsification with toric lens implantation was done in anterior lenticonus with spontaneously ruptured anterior capsule. The toric IOL was well-centered with good visual outcome. Conclusions Safe phacoemulsification with toric IOL implantation is possible in cases with spontaneous rupture of anterior lens capsule. Ability to achieve compact and complete capsulorhexis is one of the key steps to achieve favorable results.

A case of endophthalmitis associated with limbal relaxing incision

Limbal relaxing incisions (LRIs) are considered a relatively safe procedure with rapid stabilization and absence of infectious complications. Do we need to readdress this last impression? We report a case of nocardia endophthalmitis associated with an exudate at the site of an LRI in a patient who underwent routine cataract surgery. This case, to the best of our knowledge, is the first report of its kind, stressing the need for a cautious approach to the adoption of this method of astigmatic correction.