Madan Deshpande

Extracapsular cataract surgery compared with manual small incision cataract surgery in community eye care setting in western India: a randomised controlled trial

Aim: To study “manual small incision cataract surgery (MSICS)” for the rehabilitation of cataract visually impaired and blind patients in community based, high volume, eye hospital setting; to compare the safety and effectiveness of MSICS with conventional extracapsular cataract surgery (ECCE). Methods: In a single masked randomised controlled clinical trial, 741 patients, aged 40–90 years, with operable cataract were randomly assigned to receive either MSICS or ECCE and operated upon by one of eight participating surgeons. Intraoperative and postoperative complications were graded and scored according to the Oxford Cataract Treatment and Evaluation Team recommendations. The patients were followed up at 1 week, 6 weeks, and 1 year after surgery and their visual acuity recorded. Results: This paper reports outcomes at 1 and 6 weeks. 706 of the 741(95.3%) patients completed the 6 week follow up. 135 of 362 (37.3%) of ECCE group and 165 of 344 (47.9%) of MSICS group had uncorrected visual acuity of 6/18 or better after 6 weeks of follow up. 314 of 362 (86.7%) of ECCE group and 309 of 344 (89.8%) of MSICS group had corrected postoperative vision of 6/18 or better. Four of 362 (1.1%) of ECCE group and six of 344 (1.7%) of MSICS group had corrected postoperative visual acuity less than 6/60. There were no significant differences between the two groups for intraoperative and severe postoperative complications. Conclusion: MSICS and ECCE are both safe and effective techniques for treatment of cataract patients in community eye care settings. MSICS needs similar equipment to ECCE, but gives better uncorrected vision.

Prevalence of uncorrected refractive error and other eye problems among urban and rural school children

Background: Uncorrected refractive error is an avoidable cause of visual impairment. Aim: To compare the magnitude and determinants of uncorrected refractive error, such as age, sex, family history of refractive error and use of spectacles among school children 6-15 years old in urban and rural Maharashtra, India. Study Design: This was a review of school-based vision screening conducted in 2004-2005. Materials and Methods: Optometrists assessed visual acuity, amblyopia and strabismus in rural children. Teachers assessed visual acuity and then optometrists confirmed their findings in urban schools. Ophthalmologists screened for ocular pathology. Data of uncorrected refractive error, amblyopia, strabismus and blinding eye diseases was analyzed to compare the prevalence and risk factors among children of rural and urban areas. Results: We examined 5,021 children of 8 urban clusters and 7,401 children of 28 rural clusters. The cluster-weighted prevalence of uncorrected refractive error in urban and rural children was 5.46% (95% CI, 5.44-5.48) and 2.63% (95% CI, 2.62-2.64), respectively. The prevalence of myopia, hypermetropia and astigmatism in urban children was 3.16%, 1.06% and 0.16%, respectively. In rural children, the prevalence of myopia, hypermetropia and astigmatism was 1.45%, 0.39% and 0.21%, respectively. The prevalence of amblyopia was 0.8% in urban and 0.2% in rural children. Thirteen to 15 years old children attending urban schools were most likely to have uncorrected myopia. Conclusion: The prevalence of uncorrected refractive error, especially myopia, was higher in urban children. Causes of higher prevalence and barriers to refractive error correction services should be identified and addressed. Eye screening of school children is recommended. However, the approach used may be different for urban and rural school children.

Changing pattern of childhood blindness in Maharashtra, India

Aim: To determine the causes of severe visual impairment and blindness in children in schools for the blind in Maharashtra, India. Methods: Children aged <16 years with a visual acuity of <6/60 in the better eye, attending 35 schools for the blind were examined between 2002 and 2005, and causes were classified using the World Health Organization’s system. Results: 1985 students were examined, 1778 of whom fulfilled the eligibility criteria. The major causes of visual loss were congenital anomalies (microphthalmos or anophthalmos; 735, 41.3%), corneal conditions (mainly scarring; 395, 22.2%), cataract or aphakia (n = 107, 6%), and retinal disorders (mainly dystrophies; n = 199, 11.2%). More than one third of children (34.5%) were blind from conditions which could have been prevented or treated, 139 of whom were referred for surgery. Low vision devices improved near-acuity in 79 (4.4%) children, and 72 (4%) benefited from refraction. No variation in causes by sex or region was observed. Conclusions: Congenital anomalies accounted for 41% of blindness, which is higher than in a similar study conducted 10 years ago. Corneal scarring seems to be declining in importance, low vision and optical services need to be improved, and research is needed to determine the aetiology of congenital anomalies.

Comparison of endothelial cell loss after cataract surgery: phacoemulsification versus manual small-incision cataract surgery: six-week results of a randomized control trial.

PURPOSE: To compare endothelial cell loss in cataract surgery by phacoemulsification and by manual small‐incision cataract surgery (SICS). SETTINGS: Tertiary care ophthalmic center, India. METHODS: A complete ophthalmologic examination and endothelial specular microscopy were performed preoperatively and 1 and 6 weeks postoperatively in patients having cataract surgery. The endothelial cell count (ECC) was calculated manually and automatically using an LSM 12000 specular microscope. Patients were randomly allocated to have SICS or phacoemulsification using a random number table. Phacoemulsification was performed using the stop‐and‐chop technique and SICS, by viscoexpression. RESULTS: The study evaluated 200 patients, 100 in each group. The mean preoperative ECC by the manual counting method was 2950.7 cells/mm2 in the phacoemulsification group and 2852.5 cells/mm2 in the SICS group and by the automated counting method, 3053.7 cells/mm2 and 2975.3 cells/mm2, respectively. The difference at 6 weeks was 543.4 cells/mm2 and 505.9 cells/mm2, respectively, by the manual method (P = .44) and 474.2 cells/mm2 and 456.1 cells/mm2, respectively, by the automated method (P = .98). The corrected distance visual acuity at 6 weeks was better than 6/18 in 98.5% of eyes in the phacoemulsification group and 97.3% of eyes in the SICS group. CONCLUSION: There were no clinically or statistically significant differences in ECC loss or visual acuity between phacoemulsification and SICS, although there was a small difference in the astigmatic shift. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Comparison of subtenon anaesthesia with peribulbar anaesthesia for manual small incision cataract surgery.

PURPOSE To compare the safety and efficacy of subtenon anaesthesia with peribulbar anaesthesia in manual small incision cataract surgery using a randomised control clinical trial. METHOD One hundred and sixty-eight patients were randomised to subtenon and peribulbar groups with preset criteria after informed consent. All surgeries were performed by four surgeons. Pain during administration of anaesthesia, during surgery and 4 h after surgery was graded on a visual analogue pain scale and compared for both the techniques. Sub-conjuntival haemorrhage, chemosis, akinesia after administration of anaesthesia and positive pressure during surgery were also compared. Patients were followed up for 6 weeks postoperatively. RESULTS About 146/168 (86.9%) patients completed the six-week follow-up. Thirty-one out of 88 (35.2%) patients of peribulbar group and 62/80(77.5%) of subtenon group experienced no pain during administration of anaesthesia. There was no significant difference in pain during and 4 h after surgery. Subtenon group had slightly more sub-conjunctival haemorrhage. About 57 (64.8%) patients of the peribulbar group had absolute akinesia during surgery as compared to none (0%) in sub-tenon group. There was no difference in intraoperative and postoperative complications and final visual acuity. CONCLUSION Sub-tenon anaesthesia is safe and as effective as peribulbar anaesthesia and is more comfortable to the patient at the time of administration.

Is glaucoma blindness a disease of deprivation and ignorance? A case-control study for late presentation of glaucoma in India

Aim: The aim was to identify the presenting symptoms and social risk factors for late presentation of primary glaucoma in newly diagnosed cases. Materials and Methods: It was a case-control study in a tertiary eye care center in Maharashtra, India. Newly diagnosed patients with primary glaucoma were classified as cases (late presenters) where there was no perception of light in one eye or severe visual field loss affecting an area within 20° of fixation or a cup–disc (C:D) ratio ≥0.8 and controls (early presenters), presenting relative scotoma within 20° of fixation or a C:D ratio <0.8, but >0.5. All patients underwent a comprehensive ocular examination including gonioscopy, perimetry, and detailed family and social history. Occupation, education, and socioeconomic status were graded. SPSS version 12.0 was used, and univariate and multivariate logistic regression analysis was performed. Results: Gradual progressive painless loss of vision was the commonest symptom (175, 87.5%). Primary angle closure glaucoma was more common in females (P = 0.001) and lower socioeconomic groups (P = 0.05). Patients who were less educated were more likely to have late presentation of glaucoma (P < 0.001, odds ratio = 0.07; 95% CI, 0.02–0.25). Knowledge of family history of glaucoma (P = 0.80, odds ratio = 1.16; 95% CI, 0.36–3.71) and eye clinic attendance in past 2 years still resulted in late presentation (P = 0.45, odds ratio = 1.34, 95% CI, 0.63–2.82). Conclusion: Lack of education and awareness of glaucoma were major risk factors for late presentation.

Delayed Presentation of Cataracts in Children: Are they Worth Operating Upon?

Purpose: Childhood cataract is an important cause of avoidable blindness in children. The study aimed to investigate the outcome of surgery in cataracts with delayed presentation which had been operated upon as new pediatric ophthalmology centers were set up in India. Methods: This was a retrospective interventional case series from a community eye care center in Western India. Demographic, surgical, pre-operative and post-operative details were obtained from the patients records and entered into Microsoft excel and statistical analysis conducted using SPSS-11 software (SPSS, Chicago, IL). Vision was tested 6 weeks after surgery. The predictors of good vision (≥6/18) were identified by regression analysis. If the interval between detection of cataract in children and their presentation for surgery was more than 18 months for developmental and 6 months for congenital the cataract was defined having a delayed presentation. Results: Five hundred and twenty nine eyes of 437 children aged 2 months to 16 years were operated upon in 2004–2006. Preoperative vision was <3/60 in 405 (76.6%) eyes with cataract. Of these 529, 242 eyes were with delayed presentation of cataract (83 congenital and 149 other). 102 had up to 5 years, 91 had 6–10 years and 49 had >11 yrs delay in presentation. At 6 weeks following surgery, vision was ≥ 6/18 in 36/93 (38.7%) of eyes with delayed presenting cataracts, as compared to 94/244 (38.5%) ≥6/18 in those without. Conclusion: Surgery for cataracts with delayed presentation helps to regain functional vision, which can be used for navigation and low vision aids.

Prevalence and determinants of age-related macular degeneration in the 50 years and older population: A hospital based study in Maharashtra, India

Background: We present the magnitude and determinants of age-related macular degeneration (ARMD) among the 50 year and older population that visited our hospital. Materials and Methods: This was a cohort of eye patients with ARMD, seen from 2006 to 2009. Optometrist noted the best-corrected vision. Ophthalmologists examined eyes using a slit-lamp bio-microscope. The ARMD was confirmed by fluoresceine angiography and optical coherent tomography. The age, sex, history of smoking, sun exposure, family history of ARMD, diet, body mass index (BMI), hypertension, and diabetes were associated with ARMD. Result: Of the 19,140 persons of ≥ 50 years of age-attending eye clinic in our hospital, 302 persons had ARMD in at least one eye. The proportion of overall ARMD was 1.38% (95% CI 1.21--1.55). The proportion of age-related maculopathy (ARM) and late ARMD was 1.14% (95% CI 0.99--1.29) and 0.24% (95% CI 0.21–0.24) respectively. ARM was unilateral and bilateral in 64 (29.2%) and 155 (70.8%) persons respectively. Dry ARMD was found in 47.8%. On regression analysis, old age (OR = 1.05), male (OR = 0.54), and history of smoking (OR = 2.32) were significant risk factors of ARMD. A total of 4.2% of persons with ARMD were blind (vision <3/60). Only 43% of persons with ARMD had J6 grade of the best-corrected near vision. Conclusion: ARMD does not seem to be of public health magnitude in the study area. Early stages of ARMD were common among patients. ge, being male, and history of smoking were significant risk factors for ARMD.

Visual impairment in the hearing impaired students.

Background: Ocular problems are more common in children with hearing problems than in normal children. Neglected visual impairment could aggravate educational and social disability. Aim: To detect and treat visual impairment, if any, in hearing-impaired children. Setting and Design: Observational, clinical case series of hearing-impaired children in schools providing special education. Materials and Methods: Hearing-impaired children in selected schools underwent detailed visual acuity testing, refraction, external ocular examination and fundoscopy. Ocular motility testing was also performed. Teachers were sensitized and trained to help in the assessment of visual acuity using Snellens E charts. Refractive errors and squint were treated as per standard practice. Statistical Analysis: Excel software was used for data entry and SSPS for analysis. Results: The study involved 901 hearing-impaired students between four and 21 years of age, from 14 special education schools. A quarter of them (216/901, 24%) had ocular problems. Refractive errors were the most common morbidity 167(18.5%), but only 10 children were using appropriate spectacle correction at presentation. Fifty children had visual acuity less than 20/80 at presentation; after providing refractive correction, this number reduced to three children, all of whom were provided low-vision aids. Other common conditions included strabismus in 12 (1.3%) children, and retinal pigmentary dystrophy in five (0.6%) children. Conclusion: Ocular problems are common in hearing-impaired children. Screening for ocular problems should be made mandatory in hearing-impaired children, as they use their visual sense to compensate for the poor auditory sense.

Prevalence and Determinants of Xerophthalmia in Preschool Children in Urban Slums, Pune, India—A Preliminary Assessment

Purpose: International and national programs to control vitamin A deficiency disorders (VADD) among children in developing countries are reducing the magnitude but VADD still occurs in deprived populations. The purpose of the study was to estimate the prevalence of and identify risk factors for xerophthalmia in children aged 6–71 months living in slums in Pune, India in 2003. Methods: Children were enrolled into a cross sectional study from randomly selected Anganwadis (kindergartens) in selected slums using proportional to size sampling. Parents/caregivers were interviewed by social workers about night blindness, risk factors for VADD at individual and household levels, intake of vitamin A rich foods, and history of vitamin A supplementation. Children were examined for signs of xerophthalmia by an ophthalmologist. Risk factors for xerophthalmia were explored using univariate and multivariate regression analysis. Results: 1,589 children were examined (response rate 80.2%) 22 of whom had xerophthalmia, prevalence 1.32% (95% confidence interval [CI] 0.76–1.88%). There were no gender differences. Independent risk factors for xerophthalmia were having an illiterate mother [Odds ratio [OR]15.4 (95% CI 4.4–64.1)] and lack of a safe water supply [OR 6.11, 95% CI 2.5–5.1)]. Only 11.3 and 13.3% of children in different slums had taken vitamin A supplements. Conclusions: Xerophthalmia was at a level of public health significance in children living in slums in Pune. This study highlights the importance of female education and indicates that vitamin A supplementation and other approaches to control need to be improved in children living in deprived areas like urban slums.