Bhagabat Nayak

Socioeconomics of long-term glaucoma therapy in India

Purpose: To determine the socioeconomic impact of long-term glaucoma therapy. Materials and Methods: One hundred and fifty consecutive glaucoma patients on medical therapy, following up at our glaucoma service for at least 6 months were recruited. A questionnaire regarding monthly income, cost of glaucoma medications prescribed, availability of medications, travel time, time spent in review clinics, compliance, education status, medical insurance and systemic or local side-effects was administered. Results: The patients seen at the tertiary government hospital had an average monthly income of Rs. 10,912/- (range: Rs. 500/- to Rs. 50,000/-) with approximately 56% of the patients having an income of less than Rs. 5000/month. The expenditure on anti-glaucoma medications ranged from 0.3% in high income group to 123% of their monthly gross income in low income group (P < 0.0001). The total expenditure including travel, stay, and loss of wages of patients and accompanying persons ranged from 1.6% in high income group to 137% of the monthly income in low income group (P < 0.0001). Mean time required for a glaucoma clinic visit was 15.66 h, (range: 6–96 h/month). About 2.7% experienced systemic side-effects and 21.3% had complaints of ocular adverse effects. About 90% of the patients were compliant. 92% were not covered by any insurance plan/government reimbursement for their treatment. Conclusions: Medical therapy for glaucoma is an economic burden to many patients and should be individualized, according to the socioeconomic status, availability of drugs and the required distance to travel to reach the specialist clinics.

Visual field loss in primary congenital glaucoma

PURPOSE To assess the visual field defects in primary congenital glaucoma (PCG) and to identify associated risk factors. METHODS In this cross-sectional study visual fields of consecutive PCG patients were examined using Humphery Field Analyzer (HFA) or Goldmann visual field (GVF). All patients had maintained an intraocular pressure (IOP) ≤14 mm Hg on standard care. Mean deviation, pattern standard deviation (PSD), foveal threshold in HFA, and global visual field extent (degrees) in 24 meridians for targets V4e, I4e, I2e in GVF were recorded and evaluated with respect to baseline IOP and age at detection. Statistical analysis was performed by Kruskal Wallis and Mann-Whitney test. Qualitative analysis of GVF and reliable fields in HFA was performed. RESULTS A total of 100 eyes of 77 patients were included: 56 eyes of 47 patients were in the HFA group; 44 eyes of 30 patients, in the GVF group. On HFA, mean deviation detected at ≤1 month of age was significantly lower than eyes detected after 1 year (P < 0.001). On GVF, the global visual field extent for target I4e and I2e was significantly lower for PCG detected at ≤1 month of age compared to those seen at >1 year (I4e, P < 0.001; I2e, P = 0.005). Mean deviation, PSD, and foveal threshold were significantly lower in PCG with baseline IOP of >30 mm Hg than with IOP of 20-25 mm Hg (mean deviation, P < 0.001; PSD, P = 0.002; foveal threshold, P = 0.002). Extent for targets V4e and I4e on GVF were significantly lower in patients with baseline IOP of >30 mm Hg compared to those with baseline IOP of 20-25 mm Hg (V4e, P = 0.002; I4e, P = 0.003). Definitive glaucomatous defects were found in 36 eyes (41%), most ommon being arcuate scotoma (19 eyes [22%]). CONCLUSIONS PCG detected at age ≤1 month and those having a baseline IOP of >30 mm Hg show greater visual field loss.

A novel technique to release sticking haptic of a single-piece hydrophobic acrylic IOL using irrigation-aspiration probe

Purpose To describe a novel technique to release sticking haptic of a single-piece hydrophobic acrylic intraocular lens (IOL) using irrigation-aspiration (I/A) probe. Methods In our technique, the I/A probe is introduced into the anterior chamber on Visco mode. Using the aspiration port of the I/A probe, the sticking haptic is held at its tip and suction force is built up until occlusion is noted. Then the haptic is nudged towards the center of the IOL along its curve. After the haptic is free from optic, the suction is released. Results Several techniques have been described to release the sticking haptic such as squeezing the haptic at the site where it sticks to the IOL or using Sinskey hook for releasing the adhesion. These techniques require extra manipulation of the IOL by introduction of surgical instruments. In our technique, we used the I/A probe itself for separating the sticky haptic successfully. Conclusions This technique allows separation of sticking haptic without any extra instrumentation, thus reducing intraocular maneuvering and total surgery time.

PHACE syndrome with lip haemangioma, microphthalmos and persistent fetal vasculature

An 11-month-old baby girl presented with white reflex in her left eye. On examination, there was a 6.5×5 mm2 haemangioma present over her face involving on her lower lip. Systemic examinations were within normal limits. The left eye was small, with an axial length of 16.08 mm and had a cataract. Ultrasonography of the left eye was suggestive of the presence of a vascular stalk, persistent hyperplasia of a primary vitreous, or persistent fetal vasculature with vitreous haemorrhage. On MRI, the left eye was small with vitreous haemorrhage. Left eye lens aspiration was performed and the bleeding vascular stalk behind the lens was cauterised with diathermy. The right eye was normal. The patient was diagnosed as having PHACE syndrome (Posterior fossa malformations, Hemangiomas, Arterial anomalies, Coarctation of the aorta and other cardiac defects, and Eye abnormalities syndrome). On follow-up, she was able to follow light with her left eye.

Loa loa in the vitreous cavity of the eye

A 25-year-old man presented with painful diminution of vision (20/160), accompanied by redness, pain and floaters, over a period of 2 weeks, in his left eye. On examination, the anterior segment revealed moderate inflammation. Posterior segment examination showed a grade one vitreous haze with a fairly long live worm moving around in a haphazard and relentless manner throughout the vitreous cavity. The media was slightly hazy due to corneal oedema. The worm was clearly visible in the fundus photo taken. So we planned the patient for vitrectomy, and removal of the worm was performed under steroid cover. The worm was sent to the microbiology department for examination and it was found to be the species of Loa loa. The patient was administered a course of diethylcarbamazine and, on follow-up after 2 weeks, his vision had improved to 20/40.

Capsular hook-assisted implantation of modified capsular tension ring

A 16-year-old boy presented with decrease of vision over a period of 2 years. On examination, he was diagnosed to have microspherophakia with lenticular myopia with secondary glaucoma in both eyes. He was treated by lens aspiration and two-point capsular support using a modified capsular tension ring (M-CTR) and capsular tension segment (CTS) sutured to the sclera along with implantation of a foldable intraocular lens inside the bag. Lens aspiration was performed without artificial capsular hook support of the bag, as the lens was soft and vitreous was formed. However, M-CTR rotation into the bag was fraught with repeated adherence of the advancing end of the M-CTR into the loose bag causing simultaneous rotation of the bag with the rotation of the ring resulting in transient increase in bag subluxation. Capsular hooks provided appropriate countertraction to the unsupported bag, thus facilitating easy insertion and rotation of the ring into the bag.

Prevalence of glaucoma and cataract morphology in congenital rubella syndrome

rates of postoperative endophthalmitis (0.296% and 0.422%) than we identified in our study. Also, with the additional use of intracameral antibiotics, the risk for endophthalmitis was 0.062% and 0.047%, respectively, which is still higher than the 0.041% found for cataract surgery in period 3 in our study using povidone–iodine only. Therefore, ophthalmic surgeons should choose the optimum prophylaxis scheme for preventing infectious postoperative endophthalmitis with regard to their specific setting, including diligent povidone– iodine prophylaxis and possibly the use of intracameral antibiotics. However, these data also show that the mere use of intracameral antibiotics does not guarantee better results than the use of povidone–iodine only, which resulted in low rates of infectious endophthalmitis at our institution after intraocular surgery and intravitreal injections. However, as we found an increased risk for postoperative endophthalmitis after eventful cataract surgery in our study population, we recommended considering “the use of intracameral cefuroxime at the end of cataract surgery.if there are intraoperative complications such as posterior capsule rupture or if the surgery takes significantly longer than average.” In conclusion, we very much appreciate the common quest to optimize preoperative and intraoperative prophylactic measures to prevent infectious postoperative endophthalmitis.dMartin M. Nentwich, MD, Herminia Mi~ no de Kaspar, PhD

Anesthetic dilemma in planning bilateral cataract surgery for an infant associated with congenital cardiac anomaly.

In a patient with tetralogy of Fallot (TOF) and pulmonary atresia, treating the cardiac problem or the associated congenital illness is always a challenge. We describe the challenges and successful initial management of bilateral cataract to prevent visual loss in an infant with TOF with pulmonary atresia.

A safe technique for in-the-bag intraocular lens implantation in pediatric cataract surgery.

Purpose To describe a safe technique for in-the-bag intraocular lens (IOL) implantation in pediatric cataract patients who undergo lens aspiration with primary posterior capsulorhexis and anterior vitrectomy. Methods Sixty eyes of 45 consecutive patients with congenital/developmental cataract underwent lens aspiration with primary posterior continuous curvilinear capsulorhexis (PCCC) with anterior vitrectomy and in-the-bag IOL implantation using the described technique of IOL implantation using anterior capsule as support. Results All eyes had stable IOL at the end of surgery and none of the eyes had lens decentration/dislocation in posterior vitreous. Conclusions Implantation of in-the-bag IOL is difficult in children who undergo primary PCCC with anterior vitrectomy. Our technique of implanting IOL by pushing it against the back surface of anterior capsule is a safe method and results in no complications related to faulty IOL implantation.

Bilateral Sturge-Weber and Phakomatosis Pigmentovascularis with Glaucoma, an Overlap Syndrome

Aim. To report a case of bilateral Sturge-Weber and Phakomatosis pigmentovascularis with secondary glaucoma in a child. Method. Case report. Results. A 4-year-old male child was referred to us for control of intraocular pressure (IOP). Sleeping IOP was 36 mm Hg in right eye and 28 mm Hg in the left eye. The sclera of both the eyes showed bluish black pigmentation—melanosis bulbi. Fundus examination of both eyes showed diffuse choroidal hemangiomas with glaucomatous cupping. Nevus flammeus was present on both sides of face along all the 3 divisions of trigeminal nerve with overlying hypertrophy of skin and on left forearm. Nevus fuscocaeruleus was present on upper trunk. All skin lesions were present since birth and were stationary in nature. CT scan of head revealed left-sided cerebral atrophy. Intraocular pressure was controlled after treatment with topical antiglaucoma medications. Pulsed Dye Laser has been advised by dermatologist for skin lesions. Patient has been advised for regular follow-up. Conclusion. The two overlapping dermatological disorders and their association with glaucoma are a rare entity. Management should be targeted both for dermatological and eye conditions.