Contact lens rehabilitation following repaired corneal perforations

BACKGROUND: Visual outcome following repair of post-traumatic corneal perforation may not be optimal due to presence of irregular keratometric astigmatism. We performed a study to evaluate and compare rigid gas permeable contact lens and spectacles in visual rehabilitation following perforating corneal injuries. METHOD: Eyes that had undergone repair for corneal perforating injuries with or without lens aspiration were fitted rigid gas permeable contact lenses. The fitting pattern and the improvement in visual acuity by contact lens over spectacle correction were noted. RESULTS: Forty eyes of 40 patients that had undergone surgical repair of posttraumatic corneal perforations were fitted rigid gas permeable contact lenses for visual rehabilitation. Twenty-four eyes (60%) required aphakic contact lenses. The best corrected visual acuity (BCVA) of ≥ 6/18 in the snellen's acuity chart was seen in 10 (25%) eyes with spectacle correction and 37 (92.5%) eyes with the use of contact lens (p < 0.001). The best-corrected visual acuity with spectacles was 0.20 ± 0.13 while the same with contact lens was 0.58 ± 0.26. All the patients showed an improvement of ≥ 2 lines over spectacles in the snellen's acuity chart with contact lens. CONCLUSION: Rigid gas permeable contact lenses are better means of rehabilitation in eyes that have an irregular cornea due to scars caused by perforating corneal injuries

Knowledge synthesis of benefits and adverse effects of measles vaccination: the Lasbela balance sheet

<p>Abstract</p> <p>Background</p> <p>In preparation for a cluster-randomized controlled trial of a community intervention to increase the demand for measles vaccination in Lasbela district of Pakistan, a balance sheet summarized published evidence on benefits and possible adverse effects of measles vaccination.</p> <p>Methods</p> <p>The balance sheet listed: 1) major health conditions associated with measles; 2) the risk among the unvaccinated who contract measles; 3) the risk among the vaccinated; 4) the risk difference between vaccinated and unvaccinated; and 5) the likely net gain from vaccination for each condition.</p> <p>Results</p> <p>Two models revealed very different projections of net gain from measles vaccine. A Lasbela-specific combination of low period prevalence of measles among the unvaccinated, medium vaccination coverage and low vaccine efficacy rate, as revealed by the baseline survey, resulted in less-than-expected gains attributable to vaccination. Modelled on estimates where the vaccine had greater efficacy, the gains from vaccination would be more substantial.</p> <p>Conclusion</p> <p>Specific local conditions probably explain the low rates among the unvaccinated while the high vaccine failure rate is likely due to weaknesses in the vaccination delivery system. Community perception of these realities may have had some role in household decisions about whether to vaccinate, although the major discouraging factor was inadequate access. The balance sheet may be useful as a communication tool in other circumstances, applied to up-to-date local evidence.</p

Comparative evaluation of femtosecond laser-assisted cataract surgery and conventional phacoemulsification in white cataract

Jeewan S Titiyal, Manpreet Kaur, Archita Singh, Tarun Arora, Namrata Sharma Cornea, Cataract &amp; Refractive Surgery Services, Dr Rajendra Prasad&nbsp;Centre for Ophthalmic Sciences, All&nbsp;India Institute of Medical&nbsp;Sciences, New Delhi, India Purpose: To compare femtosecond laser-assisted capsulotomy with conventional manual capsulorhexis in cases of white cataract.Patients and methods: The prospective comparative study enrolled 80 eyes (80 patients) with white cataract that underwent either femtosecond laser-assisted cataract surgery (Group I, n=40) or conventional manual phacoemulsification (Group II, n=40) at a tertiary care ophthalmic institution. The groups were divided based on the patient&rsquo;s choice and affordability of the procedure. Capsulotomy/capsulorhexis was evaluated in terms of size, circularity index (4&Pi; [area/perimeter2]), intraocular lens coverage, and continuity. Each group was further subdivided based on the release of white milky fluid on initiation of the capsulotomy/capsulorhexis, and the &ldquo;fluid&rdquo; cases were compared with the &ldquo;no-fluid&rdquo; cases. The primary outcome measure was capsulotomy/capsulorhexis characteristics in the two groups. The secondary outcome measures were intraoperative phacoemulsification parameters, intraoperative complications, and postoperative visual acuity.Results: The size of the capsulotomy/capsulorhexis was 4.9&plusmn;0.1 mm in Group I and 5.3&plusmn;0.4 mm in Group II (P&lt;0.001). Mean circularity index was 0.996&plusmn;0.003 and 0.909&plusmn;0.047 in Groups I and II, respectively (P&lt;0.001). In Group I, free-floating circular capsulotomies were obtained in 52.5% (21/40) eyes; 37.5% (15/40) eyes had microadhesions; and 10% (4/40) eyes had incomplete capsulotomy in 1&ndash;2 clock hours. The incidence of residual adhesions was more in cases with release of white milky fluid (P=0.003). In Group II, a multistep capsulorhexis was performed in 70% (28/40) of the eyes. There was no difference in terms of visual outcomes and intraoperative complications.Conclusion: Femtosecond laser-assisted cataract surgery has the advantage of creating a circular and optimally sized capsulotomy in cases of white cataract. The release of white milky fluid during femtosecond laser delivery is the most important factor affecting the creation of a free-floating capsulotomy. Keywords: femtosecond laser-assisted cataract surgery, white cataract, conventional phacoemulsification, capsulorhexi

Comparison of visual performance and after cataract formation between two monofocal aspheric intraocular lenses following phacoemulsification for senile cataract: A randomized controlled study

PURPOSE: Monofocal aspheric intraocular lenses (IOLs) provide better visual outcome compared to other available IOLs following cataract surgery. However, the imported IOLs are expensive and are not affordable by all subset of patients in low- to middle-income countries like India. The aim of this study is to compare the safety and efficacy of a relatively low cost indigenous IOL (Acriol EC) with an imported aspheric IOL (AcrySof IQ). METHODS: A randomized controlled trial was conducted at a tertiary care centre. Two hundred and five eyes of 137 patients >45 years of age with uncomplicated age-related cataract were recruited. All cases underwent standard phacoemulsification and randomly assigned to one of the IOL implantations (Group I: AcrySof IOL; Group II: Acriol EC IOL). Primary outcome measure was best-corrected visual acuity (BCVA). Secondary outcomes included visual function (VF) score, spherical equivalent, contrast sensitivity, optical aberrations, and posterior capsular opacification. Independent t-test to compare two means; Mann-Whitney test; Pearson's Chi-square test, and McNemar's test were used for analyzing the nonparametric data such as incidence of posterior capsule opacification. RESULTS: There was no significant difference in the mean postoperative BCVA at 1, 3, 6, and 12 months in either group (P > 0.05). The contrast sensitivity, wavefront aberrations, VF score, and posterior capsular opacification were comparable between the groups except for higher-order aberrations and spherical aberration, which were higher in Group II. CONCLUSIONS: Acriol EC IOL provides visual outcomes comparable to other commonly used aspheric IOLs with comparable safety and efficacy at an affordable cost

Comparative evaluation of toric intraocular lens alignment and visual quality with image-guided surgery and conventional three-step manual marking

Jeewan S Titiyal, Manpreet Kaur, Cijin P Jose, Ruchita Falera, Ashutosh Kinkar, Lalit MS Bageshwar Cornea, Cataract and Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India Purpose: To compare toric intraocular lens (IOL) alignment assisted by image-guided surgery or manual marking methods and its impact on visual quality. Patients and methods: This prospective comparative study enrolled 80 eyes with cataract and astigmatism &ge;1.5 D to undergo phacoemulsification with toric IOL alignment by manual marking method using bubble marker (group I, n=40) or Callisto eye and Z align (group II, n=40). Postoperatively, accuracy of alignment and visual quality was assessed with a ray tracing aberrometer. Primary outcome measure was deviation from the target axis of implantation. Secondary outcome measures were visual quality and acuity. Follow-up was performed on postoperative days (PODs) 1 and 30. Results: Deviation from the target axis of implantation was significantly less in group II on PODs 1 and 30 (group I: 5.5&deg;&plusmn;3.3&deg;, group II: 3.6&deg;&plusmn;2.6&deg;; p=0.005). Postoperative refractive cylinder was -0.89&plusmn;0.35 D in group I and -0.64&plusmn;0.36 D in group II (p=0.003). Visual acuity was comparable between both the groups. Visual quality measured in terms of Strehl ratio (p&lt;0.05) and modulation transfer function (MTF) (p&lt;0.05) was significantly better in the image-guided surgery group. Significant negative correlation was observed between deviation from target axis and visual quality parameters (Strehl ratio and MTF) (p&lt;0.05). Conclusion: Image-guided surgery allows precise alignment of toric IOL without need for reference marking. It is associated with superior visual quality which correlates with the precision of IOL alignment. Keywords: toric IOL alignment, image-guided surgery, manual marking toric IOL, Callisto eye and Z align toric IOL, visual quality toric IOL, visual quality image-guided surger

Small incision lenticule extraction (SMILE) techniques: patient selection and perspectives

Jeewan S Titiyal, Manpreet Kaur, Farin Shaikh, Meghal Gagrani, Anand Singh Brar, Anubha Rathi Cornea, Cataract and Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India Abstract: Refractive lenticule extraction is becoming the procedure of choice for the management of myopia and myopic astigmatism owing to its precision, biomechanical stability, and better ocular surface. It has similar safety, efficacy, and predictability as femtosecond laser-assisted in situ keratomileusis (FS-LASIK) and is associated with better patient satisfaction. The conventional technique of small incision lenticule extraction (SMILE) involves docking, femtosecond laser application, lenticule dissection from the surrounding stroma, and extraction. It has a steep learning curve compared to conventional flap-based corneal ablative procedures, and the surgical technique may be challenging especially for a novice surgeon. As SMILE is gaining worldwide acceptance among refractive surgeons, different modifications of the surgical technique have been described to ease the process of lenticule extraction and minimize complications. Good patient selection is essential to ensure optimal patient satisfaction, and novice surgeons should avoid cases with low myopia (thin refractive lenticules), difficult orbital anatomy, high astigmatism, or uncooperative, anxious patients to minimize complications. A comprehensive MEDLINE search was performed using &ldquo;small incision lenticule extraction,&rdquo; &ldquo;SMILE,&rdquo; and &ldquo;refractive lenticule extraction&rdquo; as keywords, and we herein review the patient selection for SMILE and various surgical techniques of SMILE with their pros and cons. With increasing surgeon experience, a standard technique is expected to evolve that may be performed in all types of cases with optimal outcomes and minimal adverse effects. Keywords: refractive lenticule extraction, femtosecond-laser assisted lenticule extraction, SMILE techniques, refractive surger

Twelve-Months Follow-Up Postmarket Study of a Hydrophobic Intraocular Lens Using a Preloaded Automated Injector in an Indian Population

Jeewan S Titiyal,1 Samar K Basak,2 Naren Shetty,3 Umang Mathur,4 Prema Padmanabhan,5 Sri Ganesh,6 Arindam Dey,7 Dandapani Ramamurthy8 1Department of Cornea and Refractive Surgery, All India Institute of Medical Sciences, New Delhi, India; 2Department of Cornea and Cataract Services, Disha Eye Hospitals, Kolkata, India; 3Department of Cataract and Refractive Services, Narayana Nethralaya, Bengaluru, India; 4Department of Ophthalmology, Dr. Shroff’s Charity Eye Hospital, New Delhi, India; 5Department of Ophthalmology, Sankara Nethralaya, Chennai, India; 6Department of Phaco and Refractive Surgery, Nethradhama Superspeciality Eye Hospital, Bengaluru, India; 7Alcon Laboratories (India) Private Ltd, Bengaluru, India; 8Department of Cornea, Cataract and Refractive Services, The Eye Foundation, Coimbatore, IndiaCorrespondence: Jeewan S Titiyal, Department of Cornea and Refractive Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India, Email [email protected]: To assess real-world clinical outcomes and safety of the Clareon® intraocular lens (IOL) and AutonoMe® automated preloaded delivery system in an Indian population.Patients and methods: This was a prospective, single-arm, multicenter, 12-month clinical study in patients aged ≥ 20 years with unilateral or bilateral cataracts. Surgery was performed by phacoemulsification followed by implantation of the Clareon monofocal IOL (CNA0T0). Monocular best-corrected distance visual acuity (BCDVA) and uncorrected distance visual acuity (UCDVA) were assessed at 1 week and 1, 6, and 12 months after implantation. Posterior capsular opacification (PCO), surface haze, and glistenings were evaluated at all visits. Surgeons’ satisfaction with automated injector system was also evaluated using a questionnaire. Safety was assessed by monitoring adverse events (AEs).Results: A total of 151 eyes received the CNA0T0 IOL. Mean ± SD monocular BCDVA improved from 0.53± 0.44 logMAR preoperatively to 0.00± 0.08 logMAR at week 1 and − 0.03± 0.08 logMAR at 12 months after implantation. At 12 months, 137/137 (100%) of eyes achieved BCDVA of 0.3 logMAR or better. Mean ± SD monocular UCDVA was 0.78± 0.40 logMAR preoperatively, 0.11± 0.15 logMAR at week 1, and 0.08± 0.13 logMAR at 12 months after implantation. At 12 months, 132/137 (96%) eyes achieved UCDVA of 0.3 logMAR or better. Serious intraoperative AEs were posterior capsule rupture (n=1) and ciliary zonular dehiscence (n=1). Surgeons reported that the automated preloaded device was more intuitive compared with other push- or screw-style preloaded injector systems. None of the eyes in this study presented surface haze; all were graded as 0 glistenings at all visits. No clinically significant PCO or neodymium-doped yttrium aluminum garnet (Nd:YAG) capsulotomies were reported.Conclusion: The hydrophobic IOL preloaded in an automated injector system provided good visual and refractive outcomes, as well as no surface haze and grade 0 glistenings. None of the patients required Nd:YAG capsulotomy.Keywords: glistenings, posterior capsular opacification, visual acuit

Comparison of Safety and Efficacy of Intrastromal Injections of Voriconazole, Amphotericin B and Natamycin in Cases of Recalcitrant Fungal Keratitis: A Randomized Controlled Trial

Gunjan Saluja,1 Namrata Sharma,1 Rinky Agarwal,1 H P Sharma,2 Deepali Singhal,1 Prafulla Kumar Maharana,1 Rajesh Sinha,1 Tushar Agarwal,1 T Velpandian,2 Jeewan S Titiyal,1 Gita Satpathy3 1Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India; 2Ocular Pharmacology and Pharmacy Division, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India; 3Department of Ocular Microbiology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, IndiaCorrespondence: Namrata SharmaDepartment of Ophthalmology, Cornea, Cataract and Refractive Surgery Services, 4th Floor Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar East, New Delhi, Tel +91-11-26593144Fax +91-11-26588919Email [email protected]: To compare the safety and efficacy of intrastromal voriconazole (IS-VCZ), amphotericin B (IS-AMB) and natamycin (IS-NTM) as an adjunct to topical natamycin (NTM) in cases of recalcitrant fungal keratitis.Design: Prospective randomized trial.Setting: Tertiary eye centre.Participants: Sixty eyes of 60 patients with microbiologically proven recalcitrant fungal keratitis (ulcer size &gt; 2 mm, depth &gt; 50% of stroma, and not responding to topical NTM therapy for two weeks) were recruited.Methods: patients were randomized into three groups of 20 eyes, each receiving ISVCZ 50ug/0.1 mL, ISAMB, 5ug/0.1 mL and ISNTM 10ug/0.1 mL (prepared aseptically in ocular pharmacology). The patients in all three groups continued topical NTM 5% every four hours until the ulcer healed. Primary outcome measure was time taken till complete clinical resolution of infection, and secondary outcome measure was best corrected visual acuity (BCVA) at six months.Results: All three groups had comparable baseline parameters. The mean duration of healing was significantly better (p=0.02) in the ISNTM group (34&plusmn; 5.2 days) as compared to the ISVCZ group (36.1&plusmn; 4.8 days) and the ISAMB group (39.2&plusmn; 7.2 days). About 95%, 90% and 95% patients healed successfully in the ISVCZ, ISAMB and ISNTM groups, respectively. In terms of healing, deep vascularization was significantly greater in the ISAMB group (55%, p=0.02) when compared to the ISVCZ and ISNTM groups (31% and 26%, respectively). There were fewer repeat injections in the ISNTM group (7/20 vs 8/20 and 9/20 in the ISVCZ and ISNTM groups, respectively).Conclusion: Intrastromal injections are a safe and effective adjunct to conventional therapy in the management of recalcitrant fungal keratitis. ISNTM had a similar visual outcome with faster healing while ISAMB had a higher rate of deep vascularization after healing.Keywords: intrastromal injections, recalcitrant fungal keratiti