Indian Journal of Clinical and Experimental Ophthalmology

7-11

Authors: Suroma Joysmine Marndi, Ram Kumar, Ram Yash Singh Yadav.

Aim: To assess pre-existing astigmatism and to evaluate the effect of limbal relaxing incision on pre-existing astigmatism post-operatively in patients undergoing SICS cataract surgery. Materials and Methods: The study was conducted in the Department of Ophthalmology at Nehru Hospital attached to B.R.D. Medical College, Gorakhpur from period of July 2016 to June 2017. Study Design: This study is a comparative observational study. All the surgeries were performed by one surgeon. Study Group: patients meeting the inclusion criteria i.e. 1-3 D astigmatism as per keratometric readings. Results: A total of 90 patients were included in the study. Mean age 58.19 ± 7 years(range 30-70yrs). Mean pre-operative astigmatism of 1.44 ± 0.39D was found in these patients. Data analyzed demonstrated statistically significant reduction in the mean post-operative day 30 astigmatism in the LRI group to 0.54 ± 0.34 D (range: 0 to 2.5) from 1.31 ± 0.38 D (range: 1 to 3 D) preoperatively as compared to control group to 1.19 ± 0.56 D (range: 0 to 2.5) from 1.57 ± 0.37 D (range: 1 to 3 D) preoperatively, p-value 0.0001. There were no intraoperative complications or postoperative subjective complaints in our patients. Conclusion: Limbal relaxing incisions performed during SICS cataract surgery appear to be effective as well as safe procedure to reduce pre-existing corneal astigmatism.

16-20

Authors: Eknath Biroba Shelke, Harshal Namdeorao Yerkade, Mahesh Prakashrao Sonepethkar, Pradip Bhikshukrao C

Introduction: Phacoemulsification technique for cataract using either peribulbar anesthesia (PA) or topical anesthesia (TA) has evolved in last decade. Only few studies has compared between two anesthetic procedures for phacoemulsification. We compared patient and surgeon satisfaction, clinical outcome between two anesthetic procedures. Materials and Methods: The Study was conducted during February 2017 to July 2017. Patients after being randomly assigned to group PA and TA were underwent phacoemulsification. Corneal condition, postoperative complication at day 1, best corrected visual acuity at day 40 were compared. Both patients and surgeons were asked questions on degree of analgesia and level of comfort respectively. Data was analyzed using appropriate test of significance. Results: 50 patients were taken into study in each group. No significant difference was noted between two groups pre-operatively. Patients in PA group felt statistically significantly less pain compared to TA group (χ2 = 11.78, df = 2, P = 0.0027). Satisfaction of surgeons was more with PA than compared with TA. [Relative Risk=1.49, (95% CI: 1.02-2.17)]. On day 1 postoperative complications were greater in TA group (76%) than compared to PA group (64%).Complications associated with anesthetic procedure were more in PA group than compared with TA group. Conclusions: Patient’s satisfaction was statistically significantly greater in PA group compared to TA group. Surgeon’s satisfaction was also not different from patient’s satisfaction and found to be more with peribulbar block than compared to topical anesthesia. Clinical outcome remains unaffected by either of anesthetic technique.

28-31

Authors: Talluri Jeeva Ratnam, Vijetha P.

Purpose: To know whether cataract alters critical flicker fusion frequency. Design: A hospital based observational study. Materials and Methods: There were 113 patients with immature cataract fundus view are studied. Pre and post operatively critical flicker fusion frequency (CFFF) test conducted and frequency values noted. All patients were recorded of vision, relative afferent pupillary defect (RAPD), intraocular pressure and dilated fundus findings. Any abnormal fundus, glaucoma and RAPD were excluded. Results: CFFF values taken for analysis. There was no change in CFFF values post operatively. Those who had higher CFFF values remained higher postoperatively also. And similarly remained low those with lower CFFF values. There was no statistical significance (p-value=0.2182). Conclusion: Cataract did not alter the CFFF. High or low CFFF values can be concluded as dependant on optic nerve and retinal health status.

36-39

Authors: Kumaresh Chandra Sarkar, Piyali Sarkar, Jayanta Das.

Introduction: Lens Induced Glaucoma (LIG) is one of commonest cause of secondary glaucoma due to senile cataracts. The purpose of this study was to assess the outcome of LIG following cataract surgery. Objective: To determine the frequency, types, the clinical presentations, management and outcome of lens-induced glaucoma (LIG). Materials and Methods: It was a prospective observational study which was done at Calcutta National Medical College, Kolkata, from July 2012 to June 2013. Patients who attended out-patient department (OPD) of this hospital with LIG were admitted for conservative management followed by cataract surgery. Demographic data, clinical presentations, management and outcome were recorded and analysed. Results: The age of presentation of LIG was varied ranging from 31 years to 85 years. The study had female preponderance (53.7%). The major type of LIG was phacolytic glaucoma (53.8%). All the patients had pain and watering in the eyes and decreased vision during admission. Most patients (31 eyes) were presented with visual acuity of hand movements (57.4%) and intraocular pressure more than 40 mm Hg (61.1%). Most of the patients (75.9%) underwent manual small incision cataract surgery (M-SICS) with posterior chamber lens (PCIOL) implantation. Reduced Intraocular pressure (IOP) after complete follow up was 15.2 mm Hg and most of the patients (75.9%) had their post-operative best corrected visual acuity more than 6/36 after completed follow up. Conclusion: Cataract surgery was the most important effective mode of lowering IOP and visual recovery in patients with lens induced glaucoma. Public awareness and early detection by house physician is important for an early intervention which aids IOP control and visual recovery in LIG.

46-49

Authors: Sheldon Goudinho, Lisa Jerry, Jasmine Mary Jacob.

Threshold severity of diabetic macular edema (DME) at which initiation of laser treatment is justified, was defined as ‘clinically significant macular edema’ (CSME) by ETDRS (Early treatment of diabetic retinopathy study). ETDRS showed that macular photocoagulation decreased persistent macular edema and risk of moderate visual loss by 50% in CSME. Benefit of treatment generally observed in 3-4 months. Objectives: To estimate the improvement in visual acuity VA and contrast sensitivity CS at four months following macular photocoagulation, in a single arm of Type 2 diabetes patients diagnosed with CSME in a semi-urban population of South Kerala. Methodology: It was a prospective study (Descriptive). 250 eyes of Type 2 diabetics with CSME were included. Focal/grid pattern macular photocoagulation, using frequency doubled Nd: YAG laser was administered to all participants. Improvement in VA was defined as gain by one line/more and decrease by more than two lines was considered as worsening. Any drop/gain in CS was considered significant. Analysed using SPSS 16.0. Results: 148 eyes (59.2%) received focal and 102 eyes (40.8%) received grid pattern lasers. 242 eyes were included in final analysis. VA in 77 eyes (30.8%) was stable, improved by one line/more in 134 eyes (53.6%), decreased by <2 lines in 22 eyes (8.8%) and decreased by >2 lines in 9 eyes (3.6%). Paired sample t-test to compare VA and CS before and after therapy, showed significant improvement (p<0.001 and p<0.001 respectively). Conclusion: VA as well as CS showed statistically significant improvement at 4 months following focal/ grid pattern of macular photocoagulation in CSME.

56-59

Authors: M.K. Singh, V.P. Singh, P. Bhushan, R.P. Maurya, P.K. Chaturvedi.

Purpose: Aims of this study is to characterise the visual disability of patients of moderate to severe diabetic retinopathy in terms of logarithm of minimum angle of resolution (LogMAR) visual acuity and contrast sensitivity. Methods: A total of 30 eyes with moderate to severe diabetic retinopathy having low vision (WHO Criteria) with predefined inclusion and exclusion criteria were included as cases and 40 eyes with normal or near normal visual status correctable by refraction were included as control in the study. The visual acuity and contrast sensitivity were noted and analysed. Results: The best corrected visual acuity (BCVA) of all eyes in control group is less than 0.5 LogMAR units. Among cases, 29(96.7%) eyes have BCVA in the range of 0.5 to 1.0 LogMAR units and 1(3.3%) eye has BCVA in the range of 1.0 to 1.3 LogMAR units, satisfying the inclusion criteria significantly (p value < 0.001). In case group, direct correlation of association is observed between uncorrected visual acuity and best corrected visual acuity (r = 0.69), near visual acuity (r = 0.49), best corrected near visual acuity (r = 0.64) and inverse correlation of association with contrast sensitivity (r = -0.65) which are statistically significant (p value <0.05). Conclusions: In patients of diabetic retinopathy with visual impairment, irrespective of varying pathology of visual impairment, there is a negative correlation between contrast sensitivity and visual acuity in logMAR units. The logMAR visual acuity and contrast sensitivity is a better tool than vision assessment by snellen chart for evaluation, monitoring and prescription of low vision devices in subjects with visual impairment.

67-69

Authors: Subramanya Kota Giliyar, Abdul Rauf Abid, Pooja B. Wagganavar, Vinuta Mohan Kulkarni.

Aim: To assess vision in children with delayed development or cerebral palsy attending OPD at tertiary care hospital, for early assessment and accurate detection of visual disorder, which in turn helps their rehabilitation, locomotor and cognitive functions. Materials and Methods: Total of 24 (18 males and 6 females) children with delayed development and 12 (6 males and 6 females) with cerebral palsy were examined. Central steady maintenance method (CSM) was used for visual assessment as children were not co-operative for Teller’s acuity card. Thorough examination was done in children including dilated refraction & fundus examination. Clinical findings like nystagmus, squint, roving eye movements were noted and photographed. Selected children were given glasses and few were advised visual stimulation exercises. Results: Out of 36 children, about 24 were males and 12 were females. It was noted that about 16% in developmental delay children and about 17% in cerebral palsy children had abnormal birth history Among 24 children with developmental delay, 16% had squint,12.5% had horizontal nystagmus, among 12 children with cerebral palsy, 66% had fundus abnormalities, 50% had squint,16% had horizontal nystagmus, Central steady maintenance was good in 8% of developmental delayed children and 15% of cerebral palsy children. Conclusion: Above study showed that visual assessment in children with delayed development and cerebral Palsy provided relevant information for creating a rehabilitation program aimed at the individual as a whole. Visual impairment plays key role in locomotor and cognitive performance in CP and visual exploration seems to be crucial in rehabilitation of affected children, contributing to their motor improvement and to a better visual prognosis.

73-77

Authors: Subhashchandra Daga,, Prajakta Sambare, Sucheta Kulkarni, Pravin Narwadkar, Chirag Bhalerao.

Design: A prospective observational study. Setting: The study was conducted over a period of one year, from 01-07-2013 to 30-06-2014 at a hospital attached to a newly established rural medical college in India; located 45 km away from the regional eye centre. Subjects: All babies, without exclusions, were screened for retinopathy of prematurity (ROP) as per guidelines of National Neonatology Forum (NNF) of India, i.e. babies born < 34 weeks gestation and/or < 1750 g birth weight, and the babies 34-36 6/7 weeks gestation or 1750-2000 g birth weight, with risk factors for ROP. Interventions: 53 babies were screened for ROP as per NNF guidelines. Main Outcome Measures: 16 babies required laser therapy from the 53 babies that were screened over a period of one year. All weighed 1500 g or less at birth. Their GA was less than 33 weeks or less. Conclusion: BW 1500 g or less and/ or GA less than 34 weeks, appear to be appropriate ROP screening criteria. Applying NNF criteria, no ROP would have been missed. In 19 (35.8%) babies screening could have been avoided. It is desirable to determine appropriate ROP screening criteria for a particular centre; based on local evidence.

85-88

Authors: Yogish S. Kamath, Ashish Rander, Shailaja B S, Lavanya G. Rao, Sulatha V Bhandary.

Aim: To assess the changes in Intraocular pressure (IOP) after intravitreal bevacizumab therapy. Design: Prospective, Observational, Tertiary care hospital based study. Participants: 95 patients receiving intravitreal bevacizumab, for varying indications, were included. Materials and Methods: A study of the change in intraocular pressure of 95 patient eyes receiving intravitreal injection of bevacizumab for varying indications was performed at 4hours, 2 weeks and 6 weeks post injection. Results: There was a statistically significant increase in IOP 4 hours post injection [p value= .000; 95% confidence limits of -2.07 to -1.11; mean difference of -1.59]. There was no statistical significance in IOP rise at 2 weeks (p= 0.32; 95 % confidence limits of -1.13 and 0.18; mean difference of -0.47) or at 6 weeks (p= 1.00; 95% confidence limits of -0.86 to 0.44; mean difference of -0.21). The endpoint IOP in the single injection and multiple injection groups was statistically insignificant (t=-0.32, df = 92, significance value=0.749, 95% confidence interval -1.48 to 1.07). Conclusion: Although a statistically significant short-term rise in IOP was observed, this increase was clinically insignificant. The IOP reverted towards baseline values on subsequent visits at 2 weeks and 6 weeks post-injection. The number of injections did not have any effect on the IOP change. Clinical significance: Our study evaluated the effect of intravitreal injection of bevacizumab on intraocular pressure in an Indian population and found no clinically significant rise in the same.

96-99

Authors: Rajni Sethia, Aakash Patel, Harita Shah, Roshani Patel, Toral Rajput.

Introduction: The purpose of this study is to find out the association of duration of diabetes and increased HbA1c level with corneal thickness in patients of DM. Materials and Methods: After obtaining approval by ‘Sumandeep Vidyapeeth Institutional Ethical Committee’, a comprised study of 150 type-II DM patients were conducted (only left eye included). All the patients underwent complete ophthalmic examination and all study procedure was performed after obtaining informed consent from all patients and in accordance with declaration of Helsinki. Result: The mean CCT of patients with DM <7 years was 543.1 (SD - 23.51) and that of patients with duration of DM ≥ 7 years was 546.95 (SD – 25.23). The difference was statistically insignificant (p value = 0.335). The mean CCT of patients with HbA1c <7% was 545.3 (SD – 24.31) and that of patients with HbA1c ≥ 7% was 545.1 (SD – 24.63). The difference was statistically insignificant (p value = 0.96). Conclusion: In our study we conclude that corneal thickness is not affected by DM, its duration and HbA1c levels.

107-111

Authors: Archana Nikose, Aditya Rokade, Pradnya Laddha, Prateek Mohod.

Aims and objectives: To study the incidence of clinical forms of vitamin A deficiency and create awareness for importance of dietary vitamin A among parents. Materials and Methods: This cross sectional study was done in a rural based tertiary care centre which included 256 patients attending the paediatric OPD between the age group of 1 month to 10 years during July and August 2015. Questionnaires were prepared for socioeconomic status and nutritional status. An ophthalmic examination was carried out along with a trained paraopthalmic assistant in the paediatric OPD. The findings of torch light examination were confirmed on slit lamp examination. The positive findings of vitamin A deficiency were compared with the WHO classification. Statistical analysis was done by using the SPSS software V.11. Results: The total number of children examined were 256 which included 101 (39.5 %) from rural areas and 155 (60.5 %) from urban areas. Conjuctival xerosis was noted in 19 (7.4%) children out of which 9 children (3.5%) were from urban and 10 children (3.9%) from rural areas. 21 children (8%) suffered from night blindness which is another sign of Vitamin A deficiency (XN). Conclusion: Vitamin A deficiency affects most of the school going children in rural India and it occurs mainly due to dietary insufficiency hence can be prevented.

115-119

Authors: Kalpana. R., Kanmani Kothandaraman, Anuradha. P.

Introduction: Diabetes mellitus one of the major cause of avoidable blindness where patients with diabetic retinopathy are 25 times more likely to become blind than the non diabetic. Diabetic retinopathy and neuropathy being the major microvascular complications of diabetes, the aim of this study is to determine the association of retinopathy with peripheral neuropathy in diabetic patients in a tertiary care hospital. Materials and Methods: Study included diabetic patients with age more than 35years of age with a total number of 150 patients attending ophthalmology outpatient department of Saveetha medical college and Hospital. They underwent a detailed ocular examination and fundus examination to know the prevalence and severity of diabetic retinopathy. Peripheral neuropathy was assessed by doing a nerve conduction velocity of peripheral nerves in all patients. The results were evaluated to ascertain the prevalence of diabetic retinopathy and to establish an association with diabetic peripheral neuropathy. Results: Among the study population the mean age of the patients was 58+/-8.5 and males were affected more than females. The occurrence of complications increased with an increase in HbA 1c values. The prevalence of diabetic neruropathy was 72% and diabetic retinopathy was 44%. The prevalence of diabetic retinopathy in individuals with diabetic peripheral neuropathy was 51% which was 1.75 times more than without diabetic neuropathy (29%). This helps us to know the magnitude of problem of diabetic retinopathy and to timely treat it.

123-126

Authors: Sushil Ojha, Ashutosh Sayana, Neeraj Saraswat, Vaibhav Kumar Jain

Aim: The aim is to study the management of primary pterygium by surgical excision with sutureless conjunctival autograft with limbal stem cells. Materials and Methods: Patients with advanced pterygium were recruited from eye outpatient department (OPD) of rural tertiary care hospital of central India from January 2016 to October 2016. Informed written consent was taken before enrollment. The total 54 eyes (of 42 patients) were operated for pterygium with conjunctival autograft with limbal stem cells. Graft margins were buried around 0.25mm below the host conjunctiva. Results: The mean age of the patients was 48.71 ± 12.87 years. The male patient were 30 (38 eyes, 71.43%) and females were 12 (16 eyes, 28.57%). The most common age group of presentation was 40 to 60 years (28 patients, 66.67%), followed by 61 to 80 years (10 patients, 23.81 %) and lastly age less than 40 years (4patients, all female, 9.52%). At the follow up of 6 months 1 eyes showed recurrence and at 1 year 1 eyes showed recurrence. The recurrence was 3.70 percentage at 1 year of follow up. The recurrent pterygium were reoperated with pterygium excision with mitomycin C (0.02). The patients with recurrence have completed 2 months follow up without any signs of recurrence. In 28 patients (51.85%) showed improvement in visual acuity (2 or more lines) on Snellen chart. Conclusion: Management of primary pterygium by surgical excision with sutureless conjunctival autograft with limbal stem cells is a effective surgical technique in preventing recurrence of pterygium and good cosmetic appearance of eyes after pterygium surgery. The author recommends use of Mitomycin C (MMC) or 5 Fluorouracil (FU) only in selected cases pterygium like extensively infiltrating pterygium or recurrent pterygium.

131-135

Authors: Heena C. Radadia, Ashiwini A. Sapre, Priya P. Joshiyara, Dhaval M. Shah, Nittal A. Ninama.

Introduction: Study was conducted to analyse the average macular thickness globally from different age group from the healthy Indian population. Study will help to quantify any difference in thickness between gender and right and left eye too. Data can be compared with different ethnic groups. Materials and Methods: In total 147 patients have been enrolled in study attending daily ophthalmology out patient department. Age distribution of patients are 11 to 75 years. After patient fits inclusion criteria, single handed macular thickness measurement by spectral Domain OCT was carried out after consent. Measurement area is automatically identified by placing rim of 1mm, 3mm and 6mm diameter evenly around the centre of macula. Here we have encountered only central subfoveal values. Then macular thickness is calculated itself by algorithm. Protocol also displays binocular symmetry. To make sure for the accuracy of the results only the signal strength of 6 or higher and binocular symmetry more then 85% will be accepted in our study. Each patient was scanned single time with accuracy. Change in macular thickness was calculated by using paired sample t test, independent sample t test and T- test assuming equal variences. Result: Mean central subfoveal thickness for our population is 238.7278±14.2460 µ. However for different age group A,B,C and D the values for central subfoveal thickness are 241.9038±14.6972µ, 241.6428±8.2017µ, 235.5681±14.3381µ and 236.8428±18.1032µ respectively. There is weak negative corelation between left eye macular thickness and age which is statistically significant (r= -0.22)(p=0.005) (95% CI for r= -0.37 to 0.06). There is no correlation between right eye macular thickness and age (r= -0.07)(p=0.35) (95% CI for r= -0.23 to 0.08). The mean±SD values for Right and Left eye are 237.5986±13.7804 and 239.8571±14.6568µ respectively. In paired t test for right and left eye macular thickness difference is statistically significant (p=0.0043)(95% CI -3.7967 to- 0.7203). Mean values for different age group A,B,C and D for right eye are 239.1923±13.7579µ, 240.2380±7.9994µ, 233.4318±14.5496µ and 238.4857±17.2496µ respectively. While for the left eye 244.6153±15.3650µ, 243.0476±8.2549µ, 237.7045±13.9610µ and 235.2000±19.0259µ respectively. Normative values we found for male and female are 238.5735±13.4868µ and 238.9556±14.9075µ respectively. Difference in right and left macular thickness in male and female is not statistically significant as (p=0.5867,p=0.9221)(95%CI-5.6616 to 3.2148, -4.5699 to 5.0468). Mean±SD for different age group A, B, C and D for male are 242.8076±12.7059µ, 240.8157±8.0868µ, 236.6052±14.1240µ and 234.5882µ respectively. While for left eye central subfoveal thickness for different age group A,B,C and D are 241.00±16.6589µ, 242.3260±8.3214µ, 234.7800± 14.5914µ and 238.9722±19.1989µ respectively. Conclusion: Study has provided normative data of central subfoveal thickness for normal west Indian population. Normative values derived from this study can be used for different macular diseases in which macular thickness either increases or decreases. However studies from different ethnic group shows different mean values for macular thickness. This should be considered while diagnosing any macular pathology involving thickness. In our study difference between gender is not statistically significant while difference between right and left eye shows significant difference.

141-146

Authors: Rashmi Jain, Sithara Sara Oomman, Irfan Ahamed H.B., Anupama Bappal, Vidya Hegde.

Introduction: Aim of the study was to measure the visual function and quality of life amongst cataract patients attending camps. Methodology: A cross sectional study was conducted among patients attending Ophthalmology camp and having impaired vision due to cataract. This study was approved by the Institutional Ethics Committee. After obtaining informed consent, validated questionnaires developed by Aravind Eye Hospital, to measure the Visual functioning (VF) and Quality of Life (QOL) were administered to the patient. Results: A total of 324 patients (201 males and 123 females) with mean age 54.33 years (SD=8.99) were interviewed. Nearly half (46.9%) of the patients had severe or grade IV visual impairment as per WHO criteria of visual impairment. Two-thirds participants admitted that impaired vision adversely affected activities of daily living. The various sub scales studied in QOL questionnaire were: self care, mobility, social and mental problems due to impaired vision. All of these were almost equally affected due to cataract. Total VF score differs significantly (p<0.0005) for various visual impairment categories, except between category 2 and 3, where there is no significant difference (p=.695). In the QOL score there exists significant difference (p<0.0005) between group 1 with respect to other groups of visual impairment. VF & QOL score had no statistically significant association with age, gender and socioeconomic class. Conclusion: The visual function score and the quality of life score worsen as the visual acuity deteriorates due to cataract. Hence we need to strengthen our outreach programs so that we diagnose and treat cataract early leading to better quality of life.

152-156

Authors: Sandeep. K, Kunal Bhadbhade.

Register The incidence of subclinical macular edema after uneventful cataract surgery has become an issue of safety for this frequent operation. It was reported that the incidence of leakage sites was most prominent after 6 weeks. There are studies which show increased OCT–measured foveal thickness following cataract surgery due to subclinical changes of the macular blood retinal barrier (BRB) in the postoperative period. Spectral domain OCT has been used to measure macular thickness in the present study which was demonstrated to be superior to time domain OCT in the investigation of retinal response to cataract surgery. The present study is a prospective interventional study done to evaluate the incidence.