Ravilla D. Ravindran

Incidence of post-cataract endophthalmitis at Aravind Eye Hospital Outcomes of more than 42 000 consecutive cases using standardized sterilization and prophylaxis protocols

PURPOSE: To report the incidence of postoperative endophthalmitis at a high‐volume eye hospital in southern India using a modified cost‐effective sterilization protocol. SETTING: Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, India. METHODS: In this retrospective observational series at a single eye hospital, records of patients who had cataract surgery using a modified sterilization protocol from January 2007 through August 2008 and developed postoperative endophthalmitis within the first 3 postoperative months were drawn from a computerized database. The patients socioeconomic status, the surgeons experience, and the type of cataract procedure performed were analyzed as possible risk factors using the chi‐square test/Fischer exact test. RESULTS: During the study period, 42 426 cataract surgeries were performed. From these, 38 cases of presumed postoperative endophthalmitis were identified (incidence 0.09%). Thirty‐five of the 38 cases were in the manual large‐ and small‐incision extracapsular cataract extraction (ECCE) group, which had a statistically higher rate than the phacoemulsification group (P = .016). There was no statistical difference in the endophthalmitis rates between private patients and charity patients for either surgical method (manual ECCE or phacoemulsification). CONCLUSIONS: The modified sterilization and asepsis protocol adopted to facilitate high‐volume cataract surgery in a clinical setting appeared to be safe and effective in preventing postsurgical endophthalmitis. Despite a 3:1 ratio of manual ECCE to phacoemulsification and the elimination of certain traditional sterilization practices, the rate of endophthalmitis in this generally underserved patient population with multiple risk factors for infection was comparable to that reported in other modern settings.

Phacoemulsification versus manual small-incision cataract surgery for white cataract

PURPOSE: To compare the safety and efficacy of phacoemulsification and manual small‐incision cataract surgery (SICS) to treat white cataracts in southern India. SETTING: Aravind Eye Hospital, Pondicherry, India. DESIGN: Randomized prospective study. METHODS: Consecutive patients with white cataract were randomly assigned to have phacoemulsification or manual SICS by 1 of 3 surgeons experienced in both techniques. Surgical complications, operative time, uncorrected (UDVA) and corrected (CDVA) distance visual acuities, and surgically induced astigmatism were compared. RESULTS: On the first postoperative day, the UDVA was comparable in the 2 groups (P = .805) and the manual SICS group had less corneal edema (10.2%) than the phacoemulsification group (18.7%) (P = .047). At 6 weeks, the UDVA was 20/60 or better in 99 patients (87.6%) in the phacoemulsification group and 96 patients (82.0%) in the manual SICS group (P = .10) and the CDVA was 20/60 or better in 112 (99.0%) and 115 (98.2%), respectively (P = .59). The mean time was statistically significantly shorter in the manual SICS group (8.8 minutes ± 3.4 [SD]) than in the phacoemulsification group (12.2 ± 4.6 minutes) (P<.001). Posterior capsule rupture occurred in 3 eyes (2.2%) in the phacoemulsification group and 2 eyes (1.4%) in the manual SICS group (P = .681). CONCLUSIONS: Both techniques achieved excellent visual outcomes with low complication rates. Because manual SICS is significantly faster, less expensive, and less technology‐dependent than phacoemulsification, it may be a more appropriate technique in eyes with mature cataract in the developing world. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Prevalence of Early and Late Age-Related Macular Degeneration in India: The INDEYE Study

PURPOSE To estimate the prevalence of early and late age-related macular degeneration (AMD) in India. METHODS Of 7518 people aged 60 years and older identified from randomly sampled villages in North and South India, 5853 (78%) attended an eye examination including fundus photography. Fundus images were graded according to the Wisconsin Age-Related Maculopathy Grading System. RESULTS Fundus images were ungradable in 1587 people, mainly because of cataract. People 80 years of age and older were less likely to attend the eye examination and more likely to have ungradable images. For ages 60 to 79 years, the percent prevalence (95% confidence interval [CI]) were late AMD 1.2 (0.8-1.5); and early AMD: grade 1 (soft distinct drusen or pigmentary irregularities), 39.3 (37.2-41.5); grade 2 (soft distinct drusen with pigmentary irregularities or soft indistinct or reticular drusen), 6.7 (5.8-7.6); and grade 3 (soft indistinct or reticular drusen with pigmentary irregularities), 0.2 (0.1-0.4). For ages 80 and older, the respective percent prevalence was: late AMD, 2.5 (0.4-4.7); and early AMD: grade 1, 43.1(35.7-50.6); grade 2, 8.1 (4.3-12.0); and grade 3, 0.5 (0-1.5). CONCLUSIONS The prevalence of early AMD (grades 1 and 2) is similar to that observed in Western populations, but grade 3 appears to be lower. The prevalence of late AMD is comparable to that in Western populations in the age group 60 to 79 years. It is likely that the prevalence in the 80 and older age group is underestimated.

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.

Prevalence of Cataract in an Older Population in India: The India Study of Age-related Eye Disease

Purpose To describe the prevalence of cataract in older people in 2 areas of north and south India. Design Population-based, cross-sectional study. Participants Randomly sampled villages were enumerated to identify people aged ≥60 years. Of 7518 enumerated people, 78% participated in a hospital-based ophthalmic examination. Methods The examination included visual acuity measurement, dilatation, and anterior and posterior segment examination. Digital images of the lens were taken and graded by type and severity of opacity using the Lens Opacity Classification System III (LOCS III). Main Outcome Measures Age- and gender-standardized prevalence of cataract and 95% confidence intervals (CIs). We defined type of cataract based on the LOCS III grade in the worse eye of: ≥4 for nuclear cataract, ≥3 for cortical cataract, and ≥2 for posterior subcapsular cataract (PSC). Any unoperated cataract was based on these criteria or ungradable dense opacities. Any cataract was defined as any unoperated or operated cataract. Results The prevalence of unoperated cataract in people aged ≥60 was 58% in north India (95% CI, 56–60) and 53% (95% CI, 51–55) in south India (P = 0.01). Nuclear cataract was the most common type: 48% (95% CI, 46–50) in north India and 38% (95% CI, 37–40) in south India (P<0.0001); corresponding figures for PSC were 21% (95% CI, 20–23) and 17% (95% CI, 16–19; P = 0.003), respectively, and for cortical cataract 7.6% (95% CI, 7–9) and 10.2% (95% CI, 9–11; P<0.004). Bilateral aphakia/pseudophakia was slightly higher in the south (15.5%) than in the north (13.2%; P<0.03). The prevalence of any cataracts was similar in north (73.8%) and south India (71.8%). The prevalence of unoperated cataract increased with age and was higher in women than men (odds ratio [OR], 1.8). Aphakia/pseudophakia was also more common in women, either unilateral (OR, 1.2; P<0.02) or bilateral (OR, 1.3; P<0.002). Conclusions We found high rates of unoperated cataract in older people in north and south India. Posterior subcapsular cataract was more common than in western studies. Women had higher rates of cataract, which was not explained by differential access to surgery. Financial Disclosure(s) The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Inverse Association of Vitamin C with Cataract in Older People in India

Objective To examine the association between vitamin C and cataract in the Indian setting. Design Population-based cross-sectional analytic study. Participants A total of 5638 people aged ≥60 years. Methods Enumeration of randomly sampled villages in 2 areas of north and south India to identify people aged ≥60 years. Participants were interviewed for socioeconomic and lifestyle factors (tobacco, alcohol, household cooking fuel, work, and diet); attended a clinical examination, including lens photography; and provided a blood sample for antioxidant analysis. Plasma vitamin C was measured using an enzyme-based assay in plasma stabilized with metaphosphoric acid, and other antioxidants were measured by reverse-phase high-pressure liquid chromatography. Main Outcome Measures Cataract and type of cataract were graded from digital lens images using the Lens Opacity Classification System III (LOCS III), and cataract was classified from the grade in the worse eye of ≥4 for nuclear cataract, ≥3 for cortical cataract, and ≥2 for posterior subcapsular cataract (PSC). Any cataract was defined as any unoperated or operated cataract. Results Of 7518 enumerated people, 5638 (75%) provided data on vitamin C, antioxidants, and potential confounders. Vitamin C was inversely associated with cataract (adjusted odds ratio [OR] for highest to lowest quartile = 0.61; 95% confidence interval (CI), 0.51–0.74; P=1.1×10−6). Inclusion of other antioxidants in the model (lutein, zeaxanthin, retinol, β-carotene, and α-tocopherol) made only a small attenuation to the result (OR 0.68; 95% CI, 0.57–0.82; P < 0.0001). Similar results were seen with vitamin C by type of cataract: nuclear cataract (adjusted OR 0.66; CI, 0.54–0.80; P < 0.0001), cortical cataract (adjusted OR 0.70; CI, 0.54–0.90; P < 0.002), and PSC (adjusted OR 0.58; CI, 0.45–0.74; P < 0.00003). Lutein, zeaxanthin, and retinol were significantly inversely associated with cataract, but the associations were weaker and not consistently observed by type of cataract. Inverse associations were also observed for dietary vitamin C and cataract. Conclusions We found a strong association with vitamin C and cataract in a vitamin C–depleted population. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

EPHA2 Polymorphisms and Age-Related Cataract in India

Objective We investigated whether previously reported single nucleotide polymorphisms (SNPs) of EPHA2 in European studies are associated with cataract in India. Methods We carried out a population-based genetic association study. We enumerated randomly sampled villages in two areas of north and south India to identify people aged 40 and over. Participants attended a clinical examination including lens photography and provided a blood sample for genotyping. Lens images were graded by the Lens Opacification Classification System (LOCS III). Cataract was defined as a LOCS III grade of nuclear ≥4, cortical ≥3, posterior sub-capsular (PSC) ≥2, or dense opacities or aphakia/pseudophakia in either eye. We genotyped SNPs rs3754334, rs7543472 and rs11260867 on genomic DNA extracted from peripheral blood leukocytes using TaqMan assays in an ABI 7900 real-time PCR. We used logistic regression with robust standard errors to examine the association between cataract and the EPHA2 SNPs, adjusting for age, sex and location. Results 7418 participants had data on at least one of the SNPs investigated. Genotype frequencies of controls were in Hardy-Weinberg Equilibrium (p>0.05). There was no association of rs3754334 with cataract or type of cataract. Minor allele homozygous genotypes of rs7543472 and rs11260867 compared to the major homozygote genotype were associated with cortical cataract, Odds ratio (OR) = 1.8, 95% Confidence Interval (CI) (1.1, 3.1) p = 0.03 and 2.9 (1.2, 7.1) p = 0.01 respectively, and with PSC cataract, OR = 1.5 (1.1, 2.2) p = 0.02 and 1.8 (0.9, 3.6) p = 0.07 respectively. There was no consistent association of SNPs with nuclear cataract or a combined variable of any type of cataract including operated cataract. Conclusions Our results in the Indian population agree with previous studies of the association of EPHA2 variants with cortical cataracts. We report new findings for the association with PSC which is particularly prevalent in Indians.

Safety and efficacy of manual small incision cataract surgery for brunescent and black cataracts

AimsTo evaluate the safety, visual outcome and complications of manual small incision cataract surgery (MSICS) in the treatment of patients with brunescent and black cataract (BBC).MethodsIn a non-randomised interventional case series, 102 consecutive patients with BBC underwent cataract extraction by MSICS, with staining of the anterior capsule by trypan blue.ResultsOf the 102 eyes with BBC, MSICS was performed through superior scleral tunnel (SST) in 31 eyes (30.4%) and through temporal scleral tunnel (TST) in 71 eyes (69.6%). The main intraoperative complication was posterior capsule rupture in two patients (2.0%). Postoperatively, 20 eyes (19.6%) developed corneal oedema. Mild iritis was seen in six eyes (5.9%) and moderate iritis with fibrin membrane formation occurred in three eyes (2.9%). On the 40th postoperative day, 80 patients (78.4%) achieved uncorrected visual acuity of 6/18 or better, and 99 (97.1%) had best-corrected visual acuity of 6/18 or better. Patients in the SST group had significantly higher postoperative astigmatism compared to those in the TST group (−1.08 D vs −0.72 D, P=0.017).ConclusionMSICS with trypan blue staining of the anterior capsule is a safe and effective method of cataract extraction for patients with BBC.

Risk factors for intraocular penetration of caterpillar hair in Ophthalmia Nodosa: A retrospective analysis

We report risk factors associated with intraocular penetration of caterpillar hair seen at our institute from January 2005 to December 2007. Records of all patients with caterpillar hair induced ophthalmitis (CHIO) were retrospectively reviewed for clinical characteristics, anatomic location of lodgment of the caterpillar hair, treatment methods, and outcomes. Out of a total of 544 cases of CHIO, 19 eyes (seven in the anterior chamber and 12 in the posterior segment) experienced intraocular penetration (3.5%). The presence of deep intracorneal hair (80 cases, 14.7%) was found to be the only risk factor for intraocular penetration (P < 0.001). The removal of intracorneal hair was possible in only 29 out of 80 eyes (36%) and this was associated with a significantly reduced risk of intraocular penetration (P = 0.022). Patients with retained intracorneal hairs should be counseled regarding risk of intraocular penetration and closely followed up for at least six months.

Prevalence and Risk Factors for Vitamin C Deficiency in North and South India: A Two Centre Population Based Study in People Aged 60 Years and Over

Background Studies from the UK and North America have reported vitamin C deficiency in around 1 in 5 men and 1 in 9 women in low income groups. There are few data on vitamin C deficiency in resource poor countries. Objectives To investigate the prevalence of vitamin C deficiency in India. Design We carried out a population-based cross-sectional survey in two areas of north and south India. Randomly sampled clusters were enumerated to identify people aged 60 and over. Participants (75% response rate) were interviewed for tobacco, alcohol, cooking fuel use, 24 hour diet recall and underwent anthropometry and blood collection. Vitamin C was measured using an enzyme-based assay in plasma stabilized with metaphosphoric acid. We categorised vitamin C status as deficient (<11 µmol/L), sub-optimal (11–28 µmol/L) and adequate (>28 µmol/L). We investigated factors associated with vitamin C deficiency using multivariable Poisson regression. Results The age, sex and season standardized prevalence of vitamin C deficiency was 73.9% (95% confidence Interval, CI 70.4,77.5) in 2668 people in north India and 45.7% (95% CI 42.5,48.9) in 2970 from south India. Only 10.8% in the north and 25.9% in the south met the criteria for adequate levels. Vitamin C deficiency varied by season, and was more prevalent in men, with increasing age, users of tobacco and biomass fuels, in those with anthropometric indicators of poor nutrition and with lower intakes of dietary vitamin C. Conclusions In poor communities, such as in our study, consideration needs to be given to measures to improve the consumption of vitamin C rich foods and to discourage the use of tobacco.