Vishal Katiyar

Topical Anesthesia in High Volume Cataract Surgery: Pain Evaluation andFeasibility Study

Context: This study was undertaken to evaluate the use of topical anesthesia for Manual small incision cataract surgery in high volume cataract surgery setup. Aims: The primary aim was to evaluate the pain experience of the patients undergoing Manual Small Incision Cataract Surgery (MSICS) under topical anesthesia using 2% lignocaine jelly in high volume cataract surgery setup. Secondary aims were to study any relation between the pain experience and education status, gender and age of the patients. Settings and Design: The study was an Interventional case series conducted at a tertiary care eye hospital. Methods and Material: Patients screened at the peripheral field camps were transported to base hospital and underwent MSICS under topical anesthesia using lignocaine 2% jelly and intracameral 0.5% lignocaine solution. Demographic data and pain experience of the patients during the surgery was recorded and analyzed. Statistical analysis: Statistical analysis was done using MedCalc® version 12.2.1.0 software for Windows 7. Descriptive analysis, Mann-Whitney test, Kruskal-Wallis test, and Spearman’s rho coefficient were used to analyze the data. Results: The study included 270 patients, with average age 62.7 years. Average pain score was 1.6 units (SD ± 0.72, scale 1-5) with ~85% patients reporting comfortable experience. Pain perception had no relation to gender, education status or age. Conclusions: Manual Small Incision Cataract Surgery under topical anesthesia using lignocaine 2% jelly and intracameral lignocaine, in high volume cataract surgeries safe and comfortable to majority of patients and is unaffected by gender, age or educational status of the patients.

Query to the author of retinoblastoma: Achieving new standards with methods of chemotherapy

Dear Sir, We have read the symposium article titled “Retinoblastoma: Achieving new standards with methods of chemotherapy” by Kaliki and Shields [1] with great interest and appreciate their effort to summate the present status of chemotherapy for retinoblastoma. We noticed that the Fig. 2 depicted in the article on page number 105 of the journal, claims that the systemic chemotherapy reduces the size of orbital retinoblastoma as per the attached legend “Treatment of the orbital retinoblastoma with intravenous chemotherapy (a) Orbital retinoblastoma of the left eye confirmed on (b) computed tomography scan of the orbit. (c and d) Nine cycles of high-dose chemotherapy resulted in phthisis bulbi facilitating enucleation. No residual tumor was noted on histopathology. The patient subsequently underwent left orbit external beam radiotherapy and further three cycles of high-dose chemotherapy.” The figure depicts the change in retinoblastoma tumor of single patient over a period of time after systemic chemotherapy. However, it is obvious that the images depicted are of two separate patients and the one labeled (a) with advanced tumor is of a patient with older age, darker iris, and a mole on the left slope of the nasal bridge. The image (c) of Fig. 2 is a different patient with lighter iris and no mole at the mentioned site. We would like to thank the authors for explaining the anomaly. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Modified adjustable suture hang-back recession: Description of technique and comparison with conventional adjustable hang-back recession

Purpose: This study aims to describe and compare modified hang-back recession with the conventional hang-back recession in large angle comitant exotropia (XT). Methods: A prospective, interventional, double-blinded, randomized study on adult patients (>18 years) undergoing single eye recession-resection for large angle (>30 prism diopters) constant comitant XT was conducted between January 2011 and December 2015. Patients in Group A underwent modified hang-back lateral rectus recession with adjustable knot while in Group B underwent conventional hang-back recession with an adjustable knot. Outcome parameters studied were readjustment rate, change in deviation at 6 weeks, complications and need for resurgery at 6 months. Results: The groups were comparable in terms of age and preoperative deviation. The patients with the modified hang back (Group A) fared significantly better (P < 0.05) than those with conventional hang back (Group B) in terms of lesser need for adjustment, greater correction in deviation at 6 weeks and lesser need for resurgery at 6 months. Conclusion: This modification offers several advantages, significantly reduces resurgery requirement and has no added complications.

Retinitis pigmentosa and congenital ocular toxoplasmosis: a rare coexistent case presentation

Retinitis pigmentosa (RP) is the term used for a group of disorders that are characterized by inherited, progressive dysfunction, cell loss, and eventual atrophy of retinal tissue. Ocular toxoplasmosis can cause blindness secondary to the retinitis present in the posterior pole of the eye or vitreoretinal complications in the acute or recurrent form of the disease. A 30-year-old male patient presented with the complaint of diminution of vision of both eyes since birth, especially at night. The best corrected visual acuity was hand movement perception in the right eye and finger counting close to face in the left eye with projection of rays full in all quadrants (both eyes). Fundus photograph and optical coherence tomography macula confirmed fundal changes characteristic of RP and large, punched out, healed macular scar, preliminarily appearing as a congenital toxoplasmosis scar. A thorough literature search revealed only one such previously reported case report.

Pars plana vitrectomy for dislocated crystalline/artificial intraocular lens: Factors predicting the visual outcome

Aims: This study aims to study the factors predicting the visual outcome of pars plana vitrectomy (PPV) done for dislocated crystalline or artificial intraocular lens (IOL). Settings and Design: This was a retrospective observational study. Subjects and Methods: The records of patients who underwent PPV with lens retrieval and IOL exchange or repositioning for traumatic or iatrogenic dislocation of crystalline or artificial IOL were reviewed. Pre- and post-operative visual acuity and complications were recorded. Six-month patient follow-up data were reviewed. Statistical Analysis Used: Chi-square test. Results: Final best-corrected visual acuity (BCVA) 6/60 or better was found in the majority of patients who underwent PPV within 1 year of dislocation, but for patients who were delayed for over a year, the final BCVA was <6/60 (P = 0.001). Significant correlations were found between delayed PPV and postoperative retinal detachment (RD) (P = 0.001); between PPV for dislocated nuclear fragment(s) due to complicated cataract surgery and preoperative uveitis (P = 0.007) as well as postoperative cystoid macular edema (CME) (P = 0.001); between preoperative corneal edema and postoperative corneal decompensation (P = 0.03). Finally, the final BCVA <6/60 had significant correlations with preoperative corneal edema (P = 0.001) and uveitis (P = 0.039) and with postoperative corneal decompensation (P = 0.013), CME (P = 0.001), and RD (P = 0.001). Conclusions: In cases of dislocated lens, factors such as delayed intervention, dislocated nuclear fragment(s), preoperative uveitis, and corneal edema were related to increased postoperative sight-threatening complications resulting in poorer visual outcome.

Magnetic resonance imaging (MRI) in Duane retraction syndrome

Purpose: To study the magnetic resonance imaging (MRI) findings in Duane retraction syndrome (DRS). Materials and Methods: In this case–control study, 16 consecutive cases of Duane syndrome underwent MRI of the brain and orbit, after informed consent. MRI (fast imaging enhancing state acquisition) was done with special focus on pontomedullary junction to look for the status of abducens nerve and associated abnormalities along with quasi-coronal sections of orbit to estimate thickness and cross sectional area of horizontal extra-ocular muscles (EOMs). Thickness and cross-sectional area of EOMs were compared to the contralateral side and to age-matched controls. Results: Of 16 cases, 14 had DRS Type I, and 2 had DRS Type II. MRI revealed absent abducens nerve on the ipsilesional side in 12 out of 14 in DRS I, whereas two DRS II patients revealed intact abducens nerve on the affected side. Thickness and cross-sectional area of the horizontal recti was statistically comparable to the contralateral side and age-matched controls. Conclusions: All the DRS patients in study had structurally normal horizontal recti muscles, whereas 12 out of 14 of DRS-I patients had an absent abducens nerve on MRI.

Ocular trauma in Indian pediatric population

Background: Trauma to the eye and ensuing visual disability is an important cause of preventable mono-ocular blindness in the pediatric age group in India. Policy decisions are helpful in preventing this kind of trauma and improving the required trauma management services warrant an accurate estimate of various aspects of ocular trauma and its outcome in Indian population. Aims: To understand the patterns of ocular trauma in Indian pediatric population and its short-term visual outcome. Settings and Design: A tertiary center based, retrospective, observational study. Materials and Methods: Data collection from January 2010 to June 2013 including demographic profile, place of injury, distance from tertiary center, type of health care facility first sought, time delay in first treatment, medico-legal status, pattern of ocular injury on Birmingham Eye Trauma Terminology System (classification), trauma elsewhere in the body, treatment given by us, and best corrected visual acuity (BCVA) at the time of presentation and 3 months. Statistical Analysis: Multinomial logistic regression analysis to identify factors independently affecting BCVA posttreatment which included age, time of the first contact, and time delay in treatment, pretreatment BCVA. Results and Conclusions: Mean age of injury was 7.6 ± 3.3 years with 151 (79.1%) males and 40 (20.9%) females. Seventy-eight percent of patients were from rural areas and 43% first sought treatment at some other government health facility. Majority of children 83/191 (43.5%) sustained injuries at agricultural fields. Best visual acuity was observed in cases of closed globe injuries which was better than 6/18 in 81.8% (18/22) cases.

Endogenous endophthalmitis following prolong use of methotrexate

A 46 yr old male presented to us with a 2 day history of pain, redness and discharge in left eye. The patient was on oral Methotrexate (12.5 mg) weekly with folic acid supplement for the last 1 year for recurrent Uveitis (LE). There was a history of three previous episodes of acute anterior uveitis in left eye 2 years back for which he was prescribed oral steroids. The uveitis attack use to flare up on tapering the steroids. In the hope to reduce the recurrences and to prevent long-term complications, the patient was shifted to oral methotrexate (12.5 mg) weekly with folic acid supplementation. On the basis of clinical examination and B- scan a presumptive diagnosis of endogenous endophthalmitis was made. Vitreous tap revealed a straw colored sample and the culture subsequently grew methicillin sensitive Staphylococcus epidermidis. Intravitreal injection of (Piperacillin+Tazobactum) 225 microgram in 0.1 ml was administered. In addition, intravenous (piperacillin+tazobactum) 4.5 gram BD was given for 3 days. Post intra vitreal injection the symtoms and signs resolved remarkably. Methotrexate has not been previously implicated with endogenous endophthalmitis. Besides, Endogenous endophthalmitis is an ongoing diagnostic and therapeutic dilemma for ophthalmologists as it is relatively rare and often presents like uveitis. It requires a high index of suspicion for prompt diagnosis and treatment. The treatment of EE is still controversial due to a lack of clinical trials. Future large group studies need to be done for validation of the above therapeutic regime.

Macular spectral domain optical coherence tomography data in Indian subjects with cataract

Introduction: The objective of this study is to provide baseline optical coherence tomography (OCT) macular parameters data in Indian subjects with cataract and to compare these parameters with the published normative data on Indian population to understand the effect of cataract on macular thickness using cirrus spectral domain OCT. Material and Methods: This was a prospective, observational, cross-sectional analysis of 108 eyes of 108 cataract cases of north Indian origin. Results: It was observed that age of the patients and the best corrected visual acuity (BCVA) are not found to be the independent factor predicting the change in the mean values of different OCT parameters of macular thickness studied (linear regression analysis β = −2.197 to 0.34, P = 0.902–0.073). Comparison of mean values of different OCT parameters of macular thickness of studied patients with the normative population data from Indian population showed statistical difference in the values with noncataractous population having higher values for most of the studied parameters (t-test; t = 93.6–9.2, P = 0.007–0.043). Conclusion: Though the mean macular thickness of a cataract patient is lesser than that of population, age of the cataract patient does not independently predict the variation in baseline macular thickness. The BCVA achieved after an uneventful cataract surgery is found to be independent of baseline macular thickness of the patient. Moreover the presence of cataract or its grade is not associated with baseline macular thickness of the patient.

Chronic alcoholism and central serous chorioretinopathy

A 36-year-old alcoholic male suffered from central serous chorioretinopathy (CSCR). Morning serum cortisol was 293.3 ng/ml (normal range: 50-250 ng/ml), which was elevated. After 1-week of treatment with mineralo-corticoid antagonist eplerenone at 25 mg/day, patients witnessed visual acuity in the left eye increased to 6/12, which corroborated with optical coherence tomography showing substantial decrease of sub-retinal fluid. It is first documented case of CSCR associated with chronic use of alcohol that exhibited response to mineralo-corticoid antagonist eplerenone. In this study, though the exact role of alcohol intake in the pathogenesis could not be established, a disturbed the hypothalamic-pituitary-adrenal axis as a connecting link between the two conditions are observed. This will pave the way for larger, controlled studies directed to establish an association between alcohol intake and CSCR.