Bharat Patil

Evaluating eye drop instillation technique in glaucoma patients.

AimTo evaluate the technique of eye drop instillation in glaucoma patients. MethodsSeventy patients with primary open-angle glaucoma or primary angle-closure glaucoma, self-administering topical antiglaucoma medications for at least 6 months were evaluated. All patients instilled a tear substitute in 1 eye using the same technique they used for instilling antiglaucoma medications at home. The parameters that were recorded included time taken to instill the first drop, number of eye drops instilled, drop contact location, any contact with the tip of the bottle, and closure of the eyelids or tear duct after drop instillation. ResultsThe mean age of the patients was 54.1±10.0 years. The mean time taken to instill the first drop was 14.8±3.7 seconds (range, 8.7 to 23.5 s). The mean number of drops squeezed from the bottle per instillation was 1.8±1.2 drops (range, 1 to 8 drops). In 22 patients (31.43%), the eye drops fell on the eyelids or cheek. Fifty-three patients (75.7%) touched the tip of the bottle to the globe or periocular tissue. Twenty patients (28.57%) closed eyes after instilling drops and 4 patients (5.7%) occluded the punctum. Only 6 patients (8.57%) were able to correctly instill the eye drops (squeeze out 1 drop and instill it into the conjunctival sac without bottle tip contact). ConclusionsNearly, 9 of 10 glaucoma patients were unable to instill eye drops correctly. This may be an important cause of unintentional noncompliance in glaucoma medical therapy.

Corneal Changes in Childhood Glaucoma

OBJECTIVE To study the clinical features and topography of the cornea in eyes with childhood glaucoma. DESIGN Cross-sectional, observational study. PARTICIPANTS Fifty-eight eyes with childhood glaucoma and 28 eyes of age-matched controls. METHODS Clinical and topographic corneal changes were evaluated. MAIN OUTCOME MEASURES Corneal topographic changes were evaluated on Orbscan (Orbscan Topography System II; Bausch & Lomb, Salt Lake City, UT) in eyes with childhood glaucoma and those changes were compared with the control eyes. RESULTS Fifty-eight eyes with childhood glaucoma and 28 eyes of age-matched controls were evaluated. Thirty-six eyes (62.1%) were classified as having primary childhood glaucoma and 22 eyes (37.94%) as having childhood glaucoma with associated ocular anomalies. The corneas in 18 of 58 eyes (31.0%) with childhood glaucoma were clear, whereas 24.1% of eyes (14/58 eyes) had some corneal opacification. Haabs striae were noted in 44.8% of eyes (26/58 eyes) and were most frequently present between 3 and 5 mm from the optical axis. The mean posterior elevation recorded in eyes with childhood glaucoma controlled with medication or surgery was significantly higher than that in control eyes: 0.043 ± 0.027, 0.042 ± 0.017, and 0.018 ± 0.058 μm, respectively (P < 0.0001). The presence of Haabs striae was correlated significantly with a higher posterior elevation (P = 0.0396) and poor vision. The mean anterior elevation in eyes with childhood glaucoma (0.022 ± 0.015 μm) and in control eyes (0.015 ± 0.078 μm) was comparable (P = 0.08). Corneal astigmatism in eyes with childhood glaucoma was significantly higher and irregular compared with that in control eyes: 2.09 ± 1.40 versus 0.93 ± 0.60 diopter cylinder (P = 0.0001); the irregularity index was 2.8 (range, 1-18.1) and 2.3 (range, 0.6-2.3) at 3 mm (P = 0.0005) and 3.2 (range, 1.4-21.3) and 1.8 (range, 0.5-2.9) at 5 mm, respectively (P = 0.0003). Best-corrected visual acuity correlated significantly with cup-to-disc ratio, axial length, refractive error, astigmatism, and posterior corneal elevation. Multivariate analysis showed a significant correlation only with cup-to-disc ratio and axial length. CONCLUSIONS Childhood glaucoma causes a significant increase in posterior corneal elevation and irregular astigmatism, which contribute to visual disability in such eyes.

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 Unique Case of JOAG With Lamellar Ichthyosis With Rickets: A Case Report and Review of the Literature.

Purpose:Ichthyosis is known to have ocular associations such as blepharitis, hypertrophic conjunctivitis, corneal vascularization, ectropion, lagophthalmos, etc. However, no reports of its association with glaucoma are there, to the best of our knowledge. We report a unique case of juvenile open-angle glaucoma (JOAG) with lamellar ichthyosis. Method:A 16-year-old male child presented with a gradual, painless progressive diminution of vision in both eyes over a period of 3 years. Systemic examination revealed stunted body growth with knock-knees, suggestive of late-onset rickets. Generalized dry scaly lesions with erythema, along with hyperkeratosis of the palms and the soles, suggestive of lamellar ichthyosis were present. On ocular examination, the intraocular pressure was 36 mm Hg; optic nerve head examination revealed a horizontally oval disc with near total cupping in the right eye and total cupping in the left eye, with extensive neuroretinal rim thinning and pallor. Gonioscopy showed wide open angles with prominent iris processes. Screening of JOAG-associated genes (MYOC, NTF4, WDR36, and CYP1B1) and ichthyosis-associated gene (TGM1) was performed by the direct PCR-sequencing method. Results:A diagnosis of JOAG with advanced glaucomatous optic neuropathy with lamellar ichthyosis and rickets was made. The patient underwent right followed by left eye trabeculectomy with 0.2 mg/dL MMC (for 1 min). Postoperatively, the intraocular pressure was 8 mm Hg at 1 week, and 12 to 14 mm Hg at the 6-week, the 3-month, and the 6-month follow-up, and the visual acuity was maintained in the right eye. No mutations in MYOC, NTF4, WDR36, CYP1B1, and TGM1 were observed in the patient and his family. Conclusions:An association of glaucoma with ichthyosis should be kept in mind. Therefore, a detailed baseline ocular examination in children with ichthyosis is required, as early detection of glaucoma could prevent irreversible blindness.

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.

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

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.

Recurrent Kala Azar with Recurrent Post-Kala-Azar Anterior Uveitis in an Immuno competent Child: A Case Report

We are reporting a case of recurrent Kala azar with recurrent post-Kala-azar anterior uveitis in an 8 year old immune-competent child. Patient presented history of intermittent fever with loss of appetite and lassitude. Diagnosis of Kala azar was made on the basis of clinical examination and bone marrow microscopy. Child was treated with intravenous liposomal Amphotericin B, and was declared cured after 3 weeks. However, after one week of discharge, he presented with both eyes redness and on slit lamp examination bilateral anterior uveitis was detected. Uveitis was treated with topical steroids and cycloplegics. Relapse of Kala azar was noted 5 months after the first attack. He was treated with increased dose of intravenous liposomal Amphotericin B. After completion of treatment, bilateral anterior uveitis was noted. This was more severe than first attack, associated with fibrinous exudates in the left eye. Uveitis was successfully treated with topical steroids and cycloplegics. He presented with second relapse of Kala azar 7 months after the second attack and this time he was treated with intravenous liposomal Amphotericin B along with oral Miltefosine. On the 4th day of treatment, anterior chamber cells were noted bilaterally and this inflammation was controlled with topical steroids and cycloplegics.