Health, from which the clinical data was derived). The funding body had no role in the conception... more Health, from which the clinical data was derived). The funding body had no role in the conception or design of the study. HUMAN SUBJECTS: Human subjects were included in this study. The human ethics committees at the University of New South Wales approved the study. All research adhered to the tenets of the Declaration of Helsinki. All participants provided informed consent. No animal subjects were included in this study.
Anterior megalophthalmos is an inherited condition characterised by enlargement of the anterior s... more Anterior megalophthalmos is an inherited condition characterised by enlargement of the anterior segment with associated glaucoma and vitreoretinopathy. These associations make surgical management very challenging. A 12-year-old boy, diagnosed and operated elsewhere for congenital glaucoma in both eyes, presented with raised intraocular pressure. Investigations revealed enlarged corneal diameter, increased anterior chamber depth with thick, clear cornea and no Haab striae while fundus evaluation revealed posteriorly dislocated cataractous lens with total rhegmatogenous retinal detachment in both eyes. The surgical challenges in management are highlighted in this case where appropriate investigations can aid in the selection of appropriate surgeries with good visual outcome.
To evaluate the intraocular pressure (IOP) control following combined routes of adjuvant bevacizu... more To evaluate the intraocular pressure (IOP) control following combined routes of adjuvant bevacizumab with trabeculectomy in refractory neovascular glaucoma. From June 2011 to December 2011, 5 consecutive cases of neovascular glaucoma with persistent raised IOP on maximal medical treatment underwent adjuvant bevacizumab by combined routes (subconjunctival (SC) and/or intracameral (IC), intravitreal (IV) injections) before pan-retinal photocoagulation (PRP). Needs for repeat procedures or medications for IOP control over the postoperative period were assessed. The mean IOP (1 SC, 1 IC + IV, 3 SC + IC routes) reduced from 40 ± 5.5 mm Hg to 17 ± 3.7 mm Hg at a mean final follow-up of 4 ± 3.7 months (range 1-9 months), respectively (p < 0.001 for each). All eyes had transient IOP spikes 1-3 months after surgery, which normalized spontaneously after PRP, while one eye required topical medications for IOP control. Combined routes of adjuvant bevacizumab augmented trabeculectomy may help in better IOP control (IC + IV > IC + SC > SC) in refractory neovascular glaucoma but require additional procedures for sustained effect.
To evaluate the effectiveness of epiconjunctival Mitomycin-C (MMC) application in early failing f... more To evaluate the effectiveness of epiconjunctival Mitomycin-C (MMC) application in early failing filtering blebs. Interventional case series. Patients with failing blebs and raised intraocular pressure (IOP) in the early (two weeks to one month) postoperative period following glaucoma filtering surgery. A retrospective analysis of records of failed blebs was done for the period of April 2011-March 2012. Patients who were subjected to three applications of MMC (0.04%) applied over the conjunctiva directly over the bleb at baseline (visit1), one week (visit 2) and at one month (visit 3) were included. Bleb characteristics were graded in a blinded fashion by one independent ophthalmologist, while IOP during follow-up visits were analyzed. Intraocular pressure, need for additional measure, or medications and bleb characteristics as graded by Indiana classification. Ten eyes of nine patients with failing blebs received topical MMC, including included eight males and one female with a mean age of 52 ± 18 years (trabeculectomy:combined surgery = 5:5). Complete success was seen in eight of 10 eyes with a final mean IOP of 14 ± 2.9 mm Hg at three months. Excluding the two eyes that required medications, IOP reduction of 9%-42% was seen at visit 2, 16-57% IOP reduction at visit 3, and 16-56% at three months' follow-up. Of eight eyes, all eyes showed decrease in vascularity of the blebs, p < 0.001. While the height of the blebs did not show significant increase, all had increase in the avascular area of the bleb. One eye developed spontaneously resolving adenoviral conjunctivitis without any sequelae. Three applications of epiconjunctival MMC may be a safe alternative for salvaging failing blebs in the early postoperative period. This may help maximize anti-fibrotic effect of MMC while minimizing complications by limiting the area of contact.
To present a selected case series of plateau iris syndrome (PIS) that attempts to highlight the v... more To present a selected case series of plateau iris syndrome (PIS) that attempts to highlight the varied outcomes. Retrospective review of three selected cases of plateau iris. Case 1 with 23 years follow-up highlights the benign nature of the disease with no disc and field changes. Case 2 represents the progressive form of the disease. Case 3 demonstrates the better efficacy of pilocarpine in comparison to other anti-glaucoma medications in the treatment of plateau iris. The understanding of the varied clinical course of plateau iris syndrome, as demonstrated by the above cases, might aid in therapeutic decision making.
Purpose: To compare the visual field index (VFI) in primary open angle glaucoma (POAG) and primar... more Purpose: To compare the visual field index (VFI) in primary open angle glaucoma (POAG) and primary angle closure glaucoma (PACG) eyes, and to study the correlation with disc variables on optical coherence tomography (OCT) in all stages of severity. Materials and Methods: Thirty POAG and PACG underwent Humphrey visual field 24-2 along with detailed examination. They also underwent stratus OCT imaging of the optic nerve and retinal nerve fiber layer (RNFL). The correlation of VFI with RNFL thickness was compared in POAG and PACG. Results: The VFI significantly differed between POAG and PACG, with POAG eyes apparently having a better VFI at all severities of glaucoma. There were statistically significant differences in the superior max (Smax) and inferior max (Imax) in early and moderate POAG and PACG eyes. In early and moderate glaucoma, multivariate regression showed that maximum correlation of the VFI was seen with the mean deviation (b = 1.7, P < 0.001), average and superior RNFL thickness (b = 2.1, P < 0.001 and b = 1.8, P = 0.03, respectively), and age (b = 0.7, P = 0.04); while no correlation was seen with intraocular pressure (IOP), axial length, sex, or other clinical variables. VFI did not correlate well with RNFL thickness or other disc variables on OCT in severe glaucoma. Conclusion: VFI may not serve as a useful indicator of visual function in severe glaucoma. More useful indicators are required to monitor glaucoma patients with severe damage.
To the Editor: It is with great interest that I read the article by Shams and Foster1 and associa... more To the Editor: It is with great interest that I read the article by Shams and Foster1 and associates on the clinical outcomes of cataract surgery in primary angle closure (PAC) or glaucoma (PACG) eyes. There has been a long felt need for studies looking at the role of the crystalline lens in angle-closure disease with several studies reporting different outcomes.2–5 So this study assumes great importance since this tries to address the issue of cataract surgery in angle-closure disease. It was therefore very impressive that there was no significant difference in the intraocular pressure (IOP) control between eyes with prior iridectomy and those without. Contrary to expectations, a better outcome was seen in eyes with severe disease as seen in chronic angle closure, higher preoperative IOP, or those with greater extent of peripheral anterior synechiae. Yet, a detailed relook into the results raises some important questions. This was a retrospective study involving 55 eyes of 39 patients, which included 19 acute PAC and 35 PACG eyes. Yet, glaucomatous optic neuropathy was present in 36 eyes of 35 PACG eyes in the study. Was 1 eye misclassified due to cataract? The goal of surgery is to give longterm IOP control and preservation of visual function, which also improves the quality of life at a reasonable cost.6 Although there was significant IOP reduction in all eyes at 7 months, 5 had a postoperative rise in IOP. It is not clear how 2 of 5 eyes were using fewer medications after surgery despite a rise from preoperative IOP. It would have been interesting to know the amount of glaucomatous damage in these eyes that would have a bearing on the implication of this postoperative IOP rise. Among 35 eyes (probably all PACG) requiring medications preoperatively, 46% required less medications after surgery, implying that >50% required the same amount of medications postoperatively. This may not be desirable in PACG eyes with severe presentation, and the effect of longterm medications on the quality of life in these eyes would certainly be an issue. Further, the long-term implication on progression is not known from this study. Despite the inherent limitations of a retrospective design, this study tries to address an important question. With increasing participation of the patient himself in his own medical care, perhaps, further randomized trials on PAC eyes alone providing insights into the long-term effects on progression, are required before cataract surgery can be discussed as a viable option to iridectomy in angle-closure disease.
To evaluate the relationship between central corneal thickness and intraocular pressure (IOP) mea... more To evaluate the relationship between central corneal thickness and intraocular pressure (IOP) measured by iCare rebound tonometry (RBT) in normals and glaucomatous patients. Methods: Of 102 patients screened, we included 62 eyes with glaucoma and 77 normal eyes in this hospital-based cross-sectional study. IOP was measured with RBT which averages 6 readings followed by Goldmann applanation tonometry (GAT). Central corneal thickness (CCT) was obtained by ultrasound pachymetry with an average of 5 consecutive readings. Relationship between RBT and CCT was studied by regression techniques using clustered data. Results: A total of 62 eyes of 33 patients with known glaucoma and 77 eyes of 40 normal patients (male: female = 72.6%:27.4%) with a mean age of 51 ± 17.7 years were included. The mean CCT was 531 ± 32.9 mm (range, 448 to 626 mm). The median deviation of iCare RBT from GAT was 1 mm Hg (range, À 7 to 20 mm Hg), which was not statistically different between normals and glaucomatous patients. The difference in IOP obtained by the 2 measurements (RBT-GAT) was found to be significantly influenced by CCT in all eyes combined (b = 0.04, P = 0.01).and in glaucomatous eyes (b = 0.06, P = 0.01) increasing maximally by 1 mm Hg for every 10 mm increase in corneal thickness in those with glaucoma. Comparing the difference between eyes with different corneal thickness, the influence was seen maximally in glaucomatous eyes with cornea thicker than 531 mm, (b = 2.3, P = 0.03). Conclusions: Difference of IOP obtained by RBT and GAT increases with increasing CCT. Consideration of this must be kept in mind while using rebound tonometer for IOP recording in glaucomatous patients.
Aim: To evaluate the applicability and effi cacy of superÞ cial keratectomy with transplantation ... more Aim: To evaluate the applicability and effi cacy of superÞ cial keratectomy with transplantation of preserved amniotic membrane in superÞ cial corneal degenerations in a rural population of Northern India in terms of visual improvement and surface regularization. Sett ings: Peripheral referral center in rural north India. Materials and Methods: This was a prospective non-comparative interventional case series where 24 eyes of 20 farmers from peripheral rural areas (M:F = 19:1) with visually signiÞ cant superÞ cial degenerative disorders (15 eyes with climatic droplet keratopathy one of which was associated with Salzmann nodular degeneration and nine eyes with band-shaped keratopathy) were subjected to amniotic membrane transplantation (single or multiple layer) combined with superÞ cial keratectomy. Subjective and objective outcomes aft er surgery were evaluated and analyzed and statistical signiÞ cance of the outcomes in various disorders was evaluated. Results: Eighty-eight per cent (21 eyes) had symptomatic relief from distressing preoperative symptoms while postoperative visual improvement by two or more lines was achieved in 23 eyes (96%) over a mean follow-up period of 26.8 ± 10.2 months. The surface irregularity present preoperatively was relieved in 23 cases while postoperative decline of vision with visually signiÞ cant scarring was seen in one case (4%), which was labeled as failure. Conclusions: Amniotic membrane transplant with superÞ cial keratectomy helped achieve subjective comfort, visual rehabilitation and clinical regularization of the corneal surface in superÞ cial corneal degenerations during the mean followup of 26.8 ± 10.2 months in rural setups.
It is with great interest that I read the article by Good and associates1 on sustained elevation ... more It is with great interest that I read the article by Good and associates1 on sustained elevation of intraocular pressure (IOP) after anti-vascular endothelial growth factor (VEGF) injections. Though several authors have observed raised IOP after intravitreal injections,2–6 this study assumes great importance since the authors have tried to identify possible risk factors responsible for the …
To analyse the disease burden of pseudoexfoliation (PXF) disease stages from East and South India... more To analyse the disease burden of pseudoexfoliation (PXF) disease stages from East and South India. Design Prospective hospital based study of patients seen at 4 tertiary centres. Subjects, participants, and/or controls Consecutive old and new patients of pseudoexfoliation with normal intraocular pressure (IOP), raised IOP (PXF with Ocular hypertension, OHT) and irreversible disc/field changes (pseudoexfoliation glaucoma, PXG) seen from April 2016-March 2017 at a tertiary centre in Odisha, East India and 3 centres in Andhra Pradesh and Telangana, South India, recruited into the prospective study were screened for baseline characteristics. Methods The clinical and demographic details including visual acuity, laterality, intraocular pressure (IOP) with details of medical/surgical therapy at presentation were collected from the hospital database at all 4 centres.
Purpose: This study aims to evaluate efficacy and outcomes of manual small incision cataract surg... more Purpose: This study aims to evaluate efficacy and outcomes of manual small incision cataract surgery with trabeculectomy (Group 1) and phacoemulsification with trabeculectomy (Group 2) in pseudoexfoliation glaucoma (PXG). Methods: In this retrospective comparative observational case series, All patients with PXG who underwent either small incision cataract surgery or phacoemulsification with trabeculectomy from 2011-2015 were studied. Data compared included best corrected visual acuity (BCVA), intraocular pressure (IOP), total surgical time, and incidence of intra/postoperative complications. Results: A total of 82 (Group 1) and 64 (Group 2) subjects were included for the study. The baseline IOP and anti-glaucoma medications in both groups were comparable pre-operatively (group 1 = 26 ± 10.3 mmHg, group 2 = 23 ± 13.9 mmHg, P = 0.1). The IOP at final follow up between the two groups was not statistically significant (group 1 = 12 ± 3.2 mmHg, group 2 = 14 ± 1.8 mmHg, P = 0.2).The average total time of surgery (group 1 = 40 ± 21.6 min, group 2 = 34 ± 14.8 min, P = 0.4) was not statistical significant between groups. The incidence of post-operative complications were similar in both groups (P = 0.95). Conclusion: Manual small incision cataract surgery with trabeculectomy is noninferior in PXG patients with comparable surgical outcomes, when compared with phacoemulsification with trabeculectomy.
Purpose: To study the perceptions, attitude, knowledge of the disease, and impediments to seeking... more Purpose: To study the perceptions, attitude, knowledge of the disease, and impediments to seeking early eye care in caregivers of children with childhood glaucoma. Methods: The study included new and old children diagnosed with childhood glaucoma (which included congenital glaucoma and developmental glaucoma) at a tertiary hospital of east India. The caregivers were administered a video-based questionnaire through open-ended questions intended to collect demographic and other personal details such as caregiver's socioeconomic status, knowledge, attitude towards eye health, and other social barriers. The responses were analyzed using thematic analysis technique into different buckets such as social status, knowledge/attitude, and sociocultural beliefs while individual responses in each bucket were analyzed. Results: Of a total of 43 patients included, >75% of patients came from places >200 km from the eye care centre with >50% coming from >300 km. Most patients presented either <1 year (42%, n = 18) or >3 years (52%, n = 22) with only 2% (n = 3) presenting between 1–3 years of age. The mother was the first person of contact to diagnose the eye abnormality in >45% of patients. Comparing differences among children who presented within 1 year of first diagnosis and those that presented later, caregivers hailing from long-distance >200 km from an eye care center, monthly income <5000 INR, and those with social/cultural taboos (like children's eyes should not be operated) were more likely to seek delayed eye care for congenital glaucoma, P < 0.001. Conclusion: Impediments in seeking early eye care for blinding diseases in children (including distance from the nearest hospital, low socioeconomic constraints, and sociocultural beliefs/taboos) mandate serious policies towards improving education about eye disease and eye health among caregivers.
Purpose: We report a case of premature expression of pseudoexfoliation syndrome with presenile ca... more Purpose: We report a case of premature expression of pseudoexfoliation syndrome with presenile cataract in a 28-year-old lady with primary developmental glaucoma who had undergone glaucoma filtration surgery 26 years ago. Methods/Results: We report a case of a 28-year-old Indian lady with progressive diminution of vision associated with photophobia in the left eye for 5 years and loss of vision in the right eye since childhood. She underwent glaucoma filtration surgery in the left eye at the age of 2 and was on 2 topical glaucoma medications when she presented to us. Refractive error was −17.00 D with −3.50 D @ 90-degree cylinder in the left eye. The right eye was phthisical. Left eye showed superior diffuse bleb, enlarged but clear cornea with superior Haab’s striae, deep and quiet anterior chamber and patent surgical iridectomy at 1 o’clock position. There was diffuse iris atrophy with pseudoexfoliation at the pupillary ruff and over the anterior lens capsule. Lens showed grade 2 nuclear cataract. Intraocular pressure in the left eye was 23 mm Hg. Fundus examination showed 0.9 cupping with an inferior notch and diffuse pallor of the optic disc. Axial length of left eye was 31.44 mm. On the basis of these findings, she was diagnosed with primary developmental glaucoma and high myopia, status after glaucoma filtration surgery with presenile cataract and pseudoexfoliation in the left eye. The topical antiglaucoma medications were augmented. After 1 month, intraocular pressure in the left eye was reduced to 14 mm Hg. She was advised to continue topical glaucoma medications and regular follow-up. Conclusions: The present case is the first to describe the unusual presentation of pseudoexfoliation in a young individual along with presenile cataract. Simultaneous occurrence of pseudoexfoliation with cataract could be due to previous intraocular surgery, iris trauma, possible low-grade inflammation, and high myopia in a predisposed eye. The clinician should be aware that although a rare condition, pseudoexfoliation can occur in the young and may be associated with presenile cataract.
The aim of this study was to evaluate responses on multifocal electroretinogram (mfERG) with gang... more The aim of this study was to evaluate responses on multifocal electroretinogram (mfERG) with ganglion cell-inner plexiform layer (GCIPL) thickness on cirrus spectral-domain optical coherence tomography (SD-OCT) in glaucoma. All diagnosed glaucoma patients attending glaucoma services at our institute from November 2012 to April 2013 were screened for this observational hospital-based study. Controls included patients attending our outpatient services for general eye checkup. Structural parameters on SD-OCT including GCIPL and retinal nerve fiber layer (RNFL) thickness were compared with functional parameters on mfERG in early (mean deviation <-6 dB), moderate (-6 to - 12 dB), and controls. A total of 54 cases and 33 controls fulfilling inclusion criteria were recruited for the study. The average and minimum GCIPL thickness did not vary significantly between early and control eyes while moderate glaucoma eyes had marginally lower GCIPL thickness than early glaucoma eyes. The GCIPL ...
Purpose To evaluate the conjunctival signs in different forms of pseudoexfoliation (PXF) syndrome... more Purpose To evaluate the conjunctival signs in different forms of pseudoexfoliation (PXF) syndrome to identify signs predicting early forms of the disease. Methods This observational study included patients with newly diagnosed PXF screened in the outpatient department of glaucoma services. Slit lamp photographs were captured in low and high magnification after full dilatation, and details like melanotic pigmentation, vascularity and tortuosity of vessels, scarring if any, presence of pterygium and actinic changes along with basal Schirmer's test were analysed. Variables in each subtype of PXF previously described by us, namely radial pigmentary (group A), combined pigmentary and classical (group B) and classical PXF (group C), were analysed and compared to agematched controls. The differences between manifest (group B ? C) and unmanifest or early form (group A) were also compared. Results A total of 89 eyes from 55 patients (M/ F = 38:17, 21 unilateral, 34 bilateral, 48 group A, 10 group B and 31 group C) were compared with 40 controls. The Schirmer's test was statically lower in patients with manifest PXF (10 ± 1.4 mm) and unmanifest PXF (14 ± 0.6 mm), p \ 0.001. The most frequent conjunctival finding (n = 88) in this cohort was lightly pigmented melanotic pigmentation present close to limbus without evidence of any feeder vessels or actinic changes and associated with pupillary ruff atrophy in the same quadrant. Analysing different PXF forms, there was conjunctival melanosis in one or all quadrants in all forms of PXF which was more prominent in manifest PXF, present in a mean 2 ± 1.7 quadrants in unmanifest and manifest PXF, p = 0.01. Conclusion Conjunctival melanosis with associated pupillary ruff atrophy in the same quadrant may be the earliest signs of early pseudoexfoliation.
Purpose: To characterize anatomical dimensions of a disc notch using novel methods using spectral... more Purpose: To characterize anatomical dimensions of a disc notch using novel methods using spectral domain optical coherence tomography (SD-OCT). Participants: All age-and severity-matched glaucoma patients with disc notch (defined as complete loss of neural rim with no residual rim between disc and cup) seen from 2014 to 2015 who underwent enhanced depth imaging with SD-OCT (Cirrus HD-OCT version 6.5, Carl Zeiss, USA) were included for this retrospective observational study. Methods: Using known dimensions of the 200 * 200 optic disc cube (6 * 6 mm), the notch width was calculated from the margins of the notch on either side using ImageJ software. The height was calculated from the lowest margin of the cup to the lowest point of the defect on the optic disc. These were compared with the quadrant retinal nerve fiber layer (qRNFT) and sectoral retinal nerve fiber layer (sRNFLT) thickness in notch and the sector 2 clock hours adjacent to the notch region (SaRNFLT). Results: The height and width of the notch in 31 eyes of 27 patients were 2.6 ± 0.48 mm and 2.23 ± 0.31 mm. The RNFL thickness in the same sector as that of the notch was 41 ± 21.06 µm while the adjacent two sectors measured 62 ± 26.5 and 64 ± 26.5 µm on either sides of the sector of the notch. The difference between the sRNFLT and s a RNFLT ranged from −9 to 67 and −13 to 50 µm, respectively. This difference was significantly associated with height of the notch (R 2 = 20.8, p = 0.01). Conclusion: Automated analysis of a notch and RNFL thickness in that sector can help in precise glaucoma monitoring in the region of interest.
Retinal nerve fiber layer defect (RNFLD) provides an early objective evidence of structural chang... more Retinal nerve fiber layer defect (RNFLD) provides an early objective evidence of structural changes in glaucoma. RNFLD detection is currently carried out using imaging modalities like OCT and GDx which are expensive for routine practice. In this regard, we propose a novel automatic method for RNFLD detection and angular width quantification using cost effective redfree fundus images to be practically useful for computer-assisted glaucoma risk assessment. After blood vessel inpainting and CLAHE based contrast enhancement, the initial boundary pixels are identified by local minima analysis of the 1-D intensity profiles on concentric circles. The true boundary pixels are classified using random forest trained by newly proposed cumulative zero count local binary pattern (CZC-LBP) and directional differential energy (DDE) along with Shannon, Tsallis entropy and intensity features. Finally, the RNFLD angular width is obtained by random sample consensus (RANSAC) line fitting on the detected set of boundary pixels. The proposed method is found to achieve high RNFLD detection performance on a newly created dataset with sensitivity (SN) of 0.7821 at 0.2727 false positives per image (FPI) and the area under curve (AUC) value is obtained as 0.8733.
Health, from which the clinical data was derived). The funding body had no role in the conception... more Health, from which the clinical data was derived). The funding body had no role in the conception or design of the study. HUMAN SUBJECTS: Human subjects were included in this study. The human ethics committees at the University of New South Wales approved the study. All research adhered to the tenets of the Declaration of Helsinki. All participants provided informed consent. No animal subjects were included in this study.
Anterior megalophthalmos is an inherited condition characterised by enlargement of the anterior s... more Anterior megalophthalmos is an inherited condition characterised by enlargement of the anterior segment with associated glaucoma and vitreoretinopathy. These associations make surgical management very challenging. A 12-year-old boy, diagnosed and operated elsewhere for congenital glaucoma in both eyes, presented with raised intraocular pressure. Investigations revealed enlarged corneal diameter, increased anterior chamber depth with thick, clear cornea and no Haab striae while fundus evaluation revealed posteriorly dislocated cataractous lens with total rhegmatogenous retinal detachment in both eyes. The surgical challenges in management are highlighted in this case where appropriate investigations can aid in the selection of appropriate surgeries with good visual outcome.
To evaluate the intraocular pressure (IOP) control following combined routes of adjuvant bevacizu... more To evaluate the intraocular pressure (IOP) control following combined routes of adjuvant bevacizumab with trabeculectomy in refractory neovascular glaucoma. From June 2011 to December 2011, 5 consecutive cases of neovascular glaucoma with persistent raised IOP on maximal medical treatment underwent adjuvant bevacizumab by combined routes (subconjunctival (SC) and/or intracameral (IC), intravitreal (IV) injections) before pan-retinal photocoagulation (PRP). Needs for repeat procedures or medications for IOP control over the postoperative period were assessed. The mean IOP (1 SC, 1 IC + IV, 3 SC + IC routes) reduced from 40 ± 5.5 mm Hg to 17 ± 3.7 mm Hg at a mean final follow-up of 4 ± 3.7 months (range 1-9 months), respectively (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001 for each). All eyes had transient IOP spikes 1-3 months after surgery, which normalized spontaneously after PRP, while one eye required topical medications for IOP control. Combined routes of adjuvant bevacizumab augmented trabeculectomy may help in better IOP control (IC + IV &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; IC + SC &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; SC) in refractory neovascular glaucoma but require additional procedures for sustained effect.
To evaluate the effectiveness of epiconjunctival Mitomycin-C (MMC) application in early failing f... more To evaluate the effectiveness of epiconjunctival Mitomycin-C (MMC) application in early failing filtering blebs. Interventional case series. Patients with failing blebs and raised intraocular pressure (IOP) in the early (two weeks to one month) postoperative period following glaucoma filtering surgery. A retrospective analysis of records of failed blebs was done for the period of April 2011-March 2012. Patients who were subjected to three applications of MMC (0.04%) applied over the conjunctiva directly over the bleb at baseline (visit1), one week (visit 2) and at one month (visit 3) were included. Bleb characteristics were graded in a blinded fashion by one independent ophthalmologist, while IOP during follow-up visits were analyzed. Intraocular pressure, need for additional measure, or medications and bleb characteristics as graded by Indiana classification. Ten eyes of nine patients with failing blebs received topical MMC, including included eight males and one female with a mean age of 52 ± 18 years (trabeculectomy:combined surgery = 5:5). Complete success was seen in eight of 10 eyes with a final mean IOP of 14 ± 2.9 mm Hg at three months. Excluding the two eyes that required medications, IOP reduction of 9%-42% was seen at visit 2, 16-57% IOP reduction at visit 3, and 16-56% at three months&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; follow-up. Of eight eyes, all eyes showed decrease in vascularity of the blebs, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001. While the height of the blebs did not show significant increase, all had increase in the avascular area of the bleb. One eye developed spontaneously resolving adenoviral conjunctivitis without any sequelae. Three applications of epiconjunctival MMC may be a safe alternative for salvaging failing blebs in the early postoperative period. This may help maximize anti-fibrotic effect of MMC while minimizing complications by limiting the area of contact.
To present a selected case series of plateau iris syndrome (PIS) that attempts to highlight the v... more To present a selected case series of plateau iris syndrome (PIS) that attempts to highlight the varied outcomes. Retrospective review of three selected cases of plateau iris. Case 1 with 23 years follow-up highlights the benign nature of the disease with no disc and field changes. Case 2 represents the progressive form of the disease. Case 3 demonstrates the better efficacy of pilocarpine in comparison to other anti-glaucoma medications in the treatment of plateau iris. The understanding of the varied clinical course of plateau iris syndrome, as demonstrated by the above cases, might aid in therapeutic decision making.
Purpose: To compare the visual field index (VFI) in primary open angle glaucoma (POAG) and primar... more Purpose: To compare the visual field index (VFI) in primary open angle glaucoma (POAG) and primary angle closure glaucoma (PACG) eyes, and to study the correlation with disc variables on optical coherence tomography (OCT) in all stages of severity. Materials and Methods: Thirty POAG and PACG underwent Humphrey visual field 24-2 along with detailed examination. They also underwent stratus OCT imaging of the optic nerve and retinal nerve fiber layer (RNFL). The correlation of VFI with RNFL thickness was compared in POAG and PACG. Results: The VFI significantly differed between POAG and PACG, with POAG eyes apparently having a better VFI at all severities of glaucoma. There were statistically significant differences in the superior max (Smax) and inferior max (Imax) in early and moderate POAG and PACG eyes. In early and moderate glaucoma, multivariate regression showed that maximum correlation of the VFI was seen with the mean deviation (b = 1.7, P < 0.001), average and superior RNFL thickness (b = 2.1, P < 0.001 and b = 1.8, P = 0.03, respectively), and age (b = 0.7, P = 0.04); while no correlation was seen with intraocular pressure (IOP), axial length, sex, or other clinical variables. VFI did not correlate well with RNFL thickness or other disc variables on OCT in severe glaucoma. Conclusion: VFI may not serve as a useful indicator of visual function in severe glaucoma. More useful indicators are required to monitor glaucoma patients with severe damage.
To the Editor: It is with great interest that I read the article by Shams and Foster1 and associa... more To the Editor: It is with great interest that I read the article by Shams and Foster1 and associates on the clinical outcomes of cataract surgery in primary angle closure (PAC) or glaucoma (PACG) eyes. There has been a long felt need for studies looking at the role of the crystalline lens in angle-closure disease with several studies reporting different outcomes.2–5 So this study assumes great importance since this tries to address the issue of cataract surgery in angle-closure disease. It was therefore very impressive that there was no significant difference in the intraocular pressure (IOP) control between eyes with prior iridectomy and those without. Contrary to expectations, a better outcome was seen in eyes with severe disease as seen in chronic angle closure, higher preoperative IOP, or those with greater extent of peripheral anterior synechiae. Yet, a detailed relook into the results raises some important questions. This was a retrospective study involving 55 eyes of 39 patients, which included 19 acute PAC and 35 PACG eyes. Yet, glaucomatous optic neuropathy was present in 36 eyes of 35 PACG eyes in the study. Was 1 eye misclassified due to cataract? The goal of surgery is to give longterm IOP control and preservation of visual function, which also improves the quality of life at a reasonable cost.6 Although there was significant IOP reduction in all eyes at 7 months, 5 had a postoperative rise in IOP. It is not clear how 2 of 5 eyes were using fewer medications after surgery despite a rise from preoperative IOP. It would have been interesting to know the amount of glaucomatous damage in these eyes that would have a bearing on the implication of this postoperative IOP rise. Among 35 eyes (probably all PACG) requiring medications preoperatively, 46% required less medications after surgery, implying that >50% required the same amount of medications postoperatively. This may not be desirable in PACG eyes with severe presentation, and the effect of longterm medications on the quality of life in these eyes would certainly be an issue. Further, the long-term implication on progression is not known from this study. Despite the inherent limitations of a retrospective design, this study tries to address an important question. With increasing participation of the patient himself in his own medical care, perhaps, further randomized trials on PAC eyes alone providing insights into the long-term effects on progression, are required before cataract surgery can be discussed as a viable option to iridectomy in angle-closure disease.
To evaluate the relationship between central corneal thickness and intraocular pressure (IOP) mea... more To evaluate the relationship between central corneal thickness and intraocular pressure (IOP) measured by iCare rebound tonometry (RBT) in normals and glaucomatous patients. Methods: Of 102 patients screened, we included 62 eyes with glaucoma and 77 normal eyes in this hospital-based cross-sectional study. IOP was measured with RBT which averages 6 readings followed by Goldmann applanation tonometry (GAT). Central corneal thickness (CCT) was obtained by ultrasound pachymetry with an average of 5 consecutive readings. Relationship between RBT and CCT was studied by regression techniques using clustered data. Results: A total of 62 eyes of 33 patients with known glaucoma and 77 eyes of 40 normal patients (male: female = 72.6%:27.4%) with a mean age of 51 ± 17.7 years were included. The mean CCT was 531 ± 32.9 mm (range, 448 to 626 mm). The median deviation of iCare RBT from GAT was 1 mm Hg (range, À 7 to 20 mm Hg), which was not statistically different between normals and glaucomatous patients. The difference in IOP obtained by the 2 measurements (RBT-GAT) was found to be significantly influenced by CCT in all eyes combined (b = 0.04, P = 0.01).and in glaucomatous eyes (b = 0.06, P = 0.01) increasing maximally by 1 mm Hg for every 10 mm increase in corneal thickness in those with glaucoma. Comparing the difference between eyes with different corneal thickness, the influence was seen maximally in glaucomatous eyes with cornea thicker than 531 mm, (b = 2.3, P = 0.03). Conclusions: Difference of IOP obtained by RBT and GAT increases with increasing CCT. Consideration of this must be kept in mind while using rebound tonometer for IOP recording in glaucomatous patients.
Aim: To evaluate the applicability and effi cacy of superÞ cial keratectomy with transplantation ... more Aim: To evaluate the applicability and effi cacy of superÞ cial keratectomy with transplantation of preserved amniotic membrane in superÞ cial corneal degenerations in a rural population of Northern India in terms of visual improvement and surface regularization. Sett ings: Peripheral referral center in rural north India. Materials and Methods: This was a prospective non-comparative interventional case series where 24 eyes of 20 farmers from peripheral rural areas (M:F = 19:1) with visually signiÞ cant superÞ cial degenerative disorders (15 eyes with climatic droplet keratopathy one of which was associated with Salzmann nodular degeneration and nine eyes with band-shaped keratopathy) were subjected to amniotic membrane transplantation (single or multiple layer) combined with superÞ cial keratectomy. Subjective and objective outcomes aft er surgery were evaluated and analyzed and statistical signiÞ cance of the outcomes in various disorders was evaluated. Results: Eighty-eight per cent (21 eyes) had symptomatic relief from distressing preoperative symptoms while postoperative visual improvement by two or more lines was achieved in 23 eyes (96%) over a mean follow-up period of 26.8 ± 10.2 months. The surface irregularity present preoperatively was relieved in 23 cases while postoperative decline of vision with visually signiÞ cant scarring was seen in one case (4%), which was labeled as failure. Conclusions: Amniotic membrane transplant with superÞ cial keratectomy helped achieve subjective comfort, visual rehabilitation and clinical regularization of the corneal surface in superÞ cial corneal degenerations during the mean followup of 26.8 ± 10.2 months in rural setups.
It is with great interest that I read the article by Good and associates1 on sustained elevation ... more It is with great interest that I read the article by Good and associates1 on sustained elevation of intraocular pressure (IOP) after anti-vascular endothelial growth factor (VEGF) injections. Though several authors have observed raised IOP after intravitreal injections,2–6 this study assumes great importance since the authors have tried to identify possible risk factors responsible for the …
To analyse the disease burden of pseudoexfoliation (PXF) disease stages from East and South India... more To analyse the disease burden of pseudoexfoliation (PXF) disease stages from East and South India. Design Prospective hospital based study of patients seen at 4 tertiary centres. Subjects, participants, and/or controls Consecutive old and new patients of pseudoexfoliation with normal intraocular pressure (IOP), raised IOP (PXF with Ocular hypertension, OHT) and irreversible disc/field changes (pseudoexfoliation glaucoma, PXG) seen from April 2016-March 2017 at a tertiary centre in Odisha, East India and 3 centres in Andhra Pradesh and Telangana, South India, recruited into the prospective study were screened for baseline characteristics. Methods The clinical and demographic details including visual acuity, laterality, intraocular pressure (IOP) with details of medical/surgical therapy at presentation were collected from the hospital database at all 4 centres.
Purpose: This study aims to evaluate efficacy and outcomes of manual small incision cataract surg... more Purpose: This study aims to evaluate efficacy and outcomes of manual small incision cataract surgery with trabeculectomy (Group 1) and phacoemulsification with trabeculectomy (Group 2) in pseudoexfoliation glaucoma (PXG). Methods: In this retrospective comparative observational case series, All patients with PXG who underwent either small incision cataract surgery or phacoemulsification with trabeculectomy from 2011-2015 were studied. Data compared included best corrected visual acuity (BCVA), intraocular pressure (IOP), total surgical time, and incidence of intra/postoperative complications. Results: A total of 82 (Group 1) and 64 (Group 2) subjects were included for the study. The baseline IOP and anti-glaucoma medications in both groups were comparable pre-operatively (group 1 = 26 ± 10.3 mmHg, group 2 = 23 ± 13.9 mmHg, P = 0.1). The IOP at final follow up between the two groups was not statistically significant (group 1 = 12 ± 3.2 mmHg, group 2 = 14 ± 1.8 mmHg, P = 0.2).The average total time of surgery (group 1 = 40 ± 21.6 min, group 2 = 34 ± 14.8 min, P = 0.4) was not statistical significant between groups. The incidence of post-operative complications were similar in both groups (P = 0.95). Conclusion: Manual small incision cataract surgery with trabeculectomy is noninferior in PXG patients with comparable surgical outcomes, when compared with phacoemulsification with trabeculectomy.
Purpose: To study the perceptions, attitude, knowledge of the disease, and impediments to seeking... more Purpose: To study the perceptions, attitude, knowledge of the disease, and impediments to seeking early eye care in caregivers of children with childhood glaucoma. Methods: The study included new and old children diagnosed with childhood glaucoma (which included congenital glaucoma and developmental glaucoma) at a tertiary hospital of east India. The caregivers were administered a video-based questionnaire through open-ended questions intended to collect demographic and other personal details such as caregiver's socioeconomic status, knowledge, attitude towards eye health, and other social barriers. The responses were analyzed using thematic analysis technique into different buckets such as social status, knowledge/attitude, and sociocultural beliefs while individual responses in each bucket were analyzed. Results: Of a total of 43 patients included, >75% of patients came from places >200 km from the eye care centre with >50% coming from >300 km. Most patients presented either <1 year (42%, n = 18) or >3 years (52%, n = 22) with only 2% (n = 3) presenting between 1–3 years of age. The mother was the first person of contact to diagnose the eye abnormality in >45% of patients. Comparing differences among children who presented within 1 year of first diagnosis and those that presented later, caregivers hailing from long-distance >200 km from an eye care center, monthly income <5000 INR, and those with social/cultural taboos (like children's eyes should not be operated) were more likely to seek delayed eye care for congenital glaucoma, P < 0.001. Conclusion: Impediments in seeking early eye care for blinding diseases in children (including distance from the nearest hospital, low socioeconomic constraints, and sociocultural beliefs/taboos) mandate serious policies towards improving education about eye disease and eye health among caregivers.
Purpose: We report a case of premature expression of pseudoexfoliation syndrome with presenile ca... more Purpose: We report a case of premature expression of pseudoexfoliation syndrome with presenile cataract in a 28-year-old lady with primary developmental glaucoma who had undergone glaucoma filtration surgery 26 years ago. Methods/Results: We report a case of a 28-year-old Indian lady with progressive diminution of vision associated with photophobia in the left eye for 5 years and loss of vision in the right eye since childhood. She underwent glaucoma filtration surgery in the left eye at the age of 2 and was on 2 topical glaucoma medications when she presented to us. Refractive error was −17.00 D with −3.50 D @ 90-degree cylinder in the left eye. The right eye was phthisical. Left eye showed superior diffuse bleb, enlarged but clear cornea with superior Haab’s striae, deep and quiet anterior chamber and patent surgical iridectomy at 1 o’clock position. There was diffuse iris atrophy with pseudoexfoliation at the pupillary ruff and over the anterior lens capsule. Lens showed grade 2 nuclear cataract. Intraocular pressure in the left eye was 23 mm Hg. Fundus examination showed 0.9 cupping with an inferior notch and diffuse pallor of the optic disc. Axial length of left eye was 31.44 mm. On the basis of these findings, she was diagnosed with primary developmental glaucoma and high myopia, status after glaucoma filtration surgery with presenile cataract and pseudoexfoliation in the left eye. The topical antiglaucoma medications were augmented. After 1 month, intraocular pressure in the left eye was reduced to 14 mm Hg. She was advised to continue topical glaucoma medications and regular follow-up. Conclusions: The present case is the first to describe the unusual presentation of pseudoexfoliation in a young individual along with presenile cataract. Simultaneous occurrence of pseudoexfoliation with cataract could be due to previous intraocular surgery, iris trauma, possible low-grade inflammation, and high myopia in a predisposed eye. The clinician should be aware that although a rare condition, pseudoexfoliation can occur in the young and may be associated with presenile cataract.
The aim of this study was to evaluate responses on multifocal electroretinogram (mfERG) with gang... more The aim of this study was to evaluate responses on multifocal electroretinogram (mfERG) with ganglion cell-inner plexiform layer (GCIPL) thickness on cirrus spectral-domain optical coherence tomography (SD-OCT) in glaucoma. All diagnosed glaucoma patients attending glaucoma services at our institute from November 2012 to April 2013 were screened for this observational hospital-based study. Controls included patients attending our outpatient services for general eye checkup. Structural parameters on SD-OCT including GCIPL and retinal nerve fiber layer (RNFL) thickness were compared with functional parameters on mfERG in early (mean deviation <-6 dB), moderate (-6 to - 12 dB), and controls. A total of 54 cases and 33 controls fulfilling inclusion criteria were recruited for the study. The average and minimum GCIPL thickness did not vary significantly between early and control eyes while moderate glaucoma eyes had marginally lower GCIPL thickness than early glaucoma eyes. The GCIPL ...
Purpose To evaluate the conjunctival signs in different forms of pseudoexfoliation (PXF) syndrome... more Purpose To evaluate the conjunctival signs in different forms of pseudoexfoliation (PXF) syndrome to identify signs predicting early forms of the disease. Methods This observational study included patients with newly diagnosed PXF screened in the outpatient department of glaucoma services. Slit lamp photographs were captured in low and high magnification after full dilatation, and details like melanotic pigmentation, vascularity and tortuosity of vessels, scarring if any, presence of pterygium and actinic changes along with basal Schirmer's test were analysed. Variables in each subtype of PXF previously described by us, namely radial pigmentary (group A), combined pigmentary and classical (group B) and classical PXF (group C), were analysed and compared to agematched controls. The differences between manifest (group B ? C) and unmanifest or early form (group A) were also compared. Results A total of 89 eyes from 55 patients (M/ F = 38:17, 21 unilateral, 34 bilateral, 48 group A, 10 group B and 31 group C) were compared with 40 controls. The Schirmer's test was statically lower in patients with manifest PXF (10 ± 1.4 mm) and unmanifest PXF (14 ± 0.6 mm), p \ 0.001. The most frequent conjunctival finding (n = 88) in this cohort was lightly pigmented melanotic pigmentation present close to limbus without evidence of any feeder vessels or actinic changes and associated with pupillary ruff atrophy in the same quadrant. Analysing different PXF forms, there was conjunctival melanosis in one or all quadrants in all forms of PXF which was more prominent in manifest PXF, present in a mean 2 ± 1.7 quadrants in unmanifest and manifest PXF, p = 0.01. Conclusion Conjunctival melanosis with associated pupillary ruff atrophy in the same quadrant may be the earliest signs of early pseudoexfoliation.
Purpose: To characterize anatomical dimensions of a disc notch using novel methods using spectral... more Purpose: To characterize anatomical dimensions of a disc notch using novel methods using spectral domain optical coherence tomography (SD-OCT). Participants: All age-and severity-matched glaucoma patients with disc notch (defined as complete loss of neural rim with no residual rim between disc and cup) seen from 2014 to 2015 who underwent enhanced depth imaging with SD-OCT (Cirrus HD-OCT version 6.5, Carl Zeiss, USA) were included for this retrospective observational study. Methods: Using known dimensions of the 200 * 200 optic disc cube (6 * 6 mm), the notch width was calculated from the margins of the notch on either side using ImageJ software. The height was calculated from the lowest margin of the cup to the lowest point of the defect on the optic disc. These were compared with the quadrant retinal nerve fiber layer (qRNFT) and sectoral retinal nerve fiber layer (sRNFLT) thickness in notch and the sector 2 clock hours adjacent to the notch region (SaRNFLT). Results: The height and width of the notch in 31 eyes of 27 patients were 2.6 ± 0.48 mm and 2.23 ± 0.31 mm. The RNFL thickness in the same sector as that of the notch was 41 ± 21.06 µm while the adjacent two sectors measured 62 ± 26.5 and 64 ± 26.5 µm on either sides of the sector of the notch. The difference between the sRNFLT and s a RNFLT ranged from −9 to 67 and −13 to 50 µm, respectively. This difference was significantly associated with height of the notch (R 2 = 20.8, p = 0.01). Conclusion: Automated analysis of a notch and RNFL thickness in that sector can help in precise glaucoma monitoring in the region of interest.
Retinal nerve fiber layer defect (RNFLD) provides an early objective evidence of structural chang... more Retinal nerve fiber layer defect (RNFLD) provides an early objective evidence of structural changes in glaucoma. RNFLD detection is currently carried out using imaging modalities like OCT and GDx which are expensive for routine practice. In this regard, we propose a novel automatic method for RNFLD detection and angular width quantification using cost effective redfree fundus images to be practically useful for computer-assisted glaucoma risk assessment. After blood vessel inpainting and CLAHE based contrast enhancement, the initial boundary pixels are identified by local minima analysis of the 1-D intensity profiles on concentric circles. The true boundary pixels are classified using random forest trained by newly proposed cumulative zero count local binary pattern (CZC-LBP) and directional differential energy (DDE) along with Shannon, Tsallis entropy and intensity features. Finally, the RNFLD angular width is obtained by random sample consensus (RANSAC) line fitting on the detected set of boundary pixels. The proposed method is found to achieve high RNFLD detection performance on a newly created dataset with sensitivity (SN) of 0.7821 at 0.2727 false positives per image (FPI) and the area under curve (AUC) value is obtained as 0.8733.
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Papers by Aparna Rao