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  Most popular articles (Since June 06, 2017)

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Update on optical biometry and intraocular lens power calculation
Nazneen Nazm, Arup Chakrabarti
July-September 2017, 55(3):196-210
Intraocular lens (IOL) power calculation is the single most important determinant of functionally improved result of a technically precise cataract surgery. We have discussed recent advances in the field of optical biometry and IOL power calculation formulae as a means to achieve better postoperative visual outcome. The use of automated optical biometry device, the current 'gold standard' of IOL power calculation, dates back to 1999. We have highlighted the evolution of newer optical biometry devices and the technology they are based on, and their advantages and limitations. We have done technical comparison of contemporary biometers and have included contextual current review of literature. We have described newer generation IOL power formulae, IOL power calculation in high to extreme myopia, toric calculators and intraoperative aberrometry, and concluded our discussion with a note on future prospects of IOL power calculation.
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Operation theaters and sterilization requirements — Design consideration and standards for infection control
T Nirmal Fredrick, Murugesan Kumaran
April-June 2018, 56(2):84-90
An operation theater (OT) complex is the “heart” of any hospital. An operating theater, operating room (OR), surgery suite, or a surgery center is a room within a hospital where surgical and other operations are carried out. The patient is the center point of a functioning OT complex. He/she is in isolation for varying times, away from his near and dear ones and is physically sick. Efforts should be directed to maintain vital functions, prevent infections/promote healing with safety, comfort, and economy. A “civil-mechanical-electrical-electronic-biomedical” combo effort driven and coordinated by the needs, preferences, and safety of the medical/surgical team forms the basis for starting and maintaining an OT. Hospitals should exercise great care in proper maintenance of the OR environment, heating ventilation and air-conditioning system (HVAC) system, and medical and nonmedical equipment inside the OR. Personnel involved in disinfection and sterilization process should follow aseptic protocols. Aseptic protocols mean following safe and disciplined procedures to minimize or eradicate the microbiological load in the environment and in the instrument brought into the sterile field during the surgery.
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Orbital cellulitis- A review
Raghuraj Hegde, Gangadhara Sundar
July-September 2017, 55(3):211-219
Orbital cellulitis is an infection of the orbital soft tissues posterior to the orbital septum. It has the potential to be affect sight and function of the eye and extraocular tissues. Although it is commonly seen in the pediatric age group, adult orbital cellulitis is not uncommon. Infection usually originates from sinuses but sometimes the nidus of infection is in the eyelids, from retained vegetative foreign bodies, or very rarely from distant infection spreading to the orbit spread from blood. It is characterized by pain, proptosis, chemosis, diminution of vision, fever, periorbital erythema, and limitation of ocular motility. Historically orbital cellulitis was a sight and life-threatening condition. However, with the advent of high quality imaging, antibiotics and early surgical intervention to drain the orbital abscess when indicated, the chances of visual loss have reduced significantly. The purpose of this review is to describe current investigative and management paradigms in the treatment of orbital cellulitis and current recommendation in the management of complications resulting from it.
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Newer drugs in glaucoma management
Sujatha V Kadambi, Ronnie George
April-June 2017, 55(2):134-139
Glaucoma, a chronic progressive neurodegenerative disease, has both intraocular pressure dependent and independent pathogenetic mechanisms. Medical therapy is the first line of treatment in glaucoma management. Patient adherence and persistence to pharmacotherapy is a great barrier to its success. This review highlights the recent advances in medical management and discusses newer pharmacotherapy including new molecules with novel mechanisms of action, novel target molecules/genes/tissues, and newer drug delivery systems, many of which are still in clinical trial phase.
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Accommodative spasm: Case series
Anjali Kavthekar, N Shruti, M Nivean, M Nishanth
October-December 2017, 55(4):301-303
This study highlights importance of cycloplegic refraction to detect accommodative spasm(AS) patients and role of atropinisation for its management.This retrospective case series study was done at a tertiary care eye hospital in Chennai, India. Four patients, presented with complaints of sudden onset blurring of vision and asthenopic symptoms with history of aggravation of symptoms with prolonged near work and under stressful conditions.Refraction was initially showing myopic refractive error.After cycloplegia,there was hypermetropic shift and VA was 20/20 for distance in all patients with their hyperopic correction,and N6 with upto +3.00 dioptres for near.Diagnosis of AS was made.Bifocal glasses were prescribed and atropinisation(1%) with avoidance of aggravating factors was started . Patients were tapered gradually to prevent recurrence over three months and were observed for six months in which none had reccurence.Post cycloplegia,the condition resolved and asthenopic symptoms were improved.
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Generic drugs in ophthalmic practice: Boon or bane?
Murali Ariga, M Rajalakshmi, C Praveena
July-September 2017, 55(3):220-222
Generic pharma products are inexpensive as compared to the original innovator branded drugs. True generics are not freely available in India. There have been concerns about efficacy and quality of generics that are available. This review outlines these issues and the legislation regarding the availability and use of generics in our practice.
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Juvenile X-Linked retinoschisis: Response to topical dorzolamide therapy
Krati Gupta, Dipankar Das, Harsha Bhattacharjee, Hemalata Deka, Damaris Magdalene, Saurabh Deshmukh
January-March 2018, 56(1):35-37
We report clinical course of a 22-year-old Indian male patient presenting with bilateral Juvenile X-linked retinoschisis (JXLRS) in response to topical 2% dorzolamide hydrochloride treatment. He presented with progressive diminution of vision in both eyes (OU) for the past 16 years. A “cartwheel” macular pattern was observed in his retina OU. Multimodal imaging including fundus photography, fluorescein fundus angiography, optical coherence tomography (OCT), and electroretinogram was performed. Following treatment with topical dorzolamide, there was a significant regression of the macular cyst on OCT and significant improvement in the visual acuity. This case report emphasizes on the response of macular cysts to topical dorzolamide. Thus, it may be a promising treatment option in terms of visual as well as anatomical recovery in JXLRS.
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Bilateral endogenous endophthalmitis in disseminated histoplasmosis secondary to immunosuppression: A rare case report
Surpriya Hawaibam, Dipankar Das, Ronel Soibam, Harsha Bhattacharjee, Saurabh Deshmukh, Richa Shrivastava, Krati Gupta
April-June 2018, 56(2):108-110
We report the clinical course of a 47-year-old diabetic and hypertensive male who presented to us with diminution of vision in both eyes (OU) for 4 months. He was diagnosed with granulomatosis with polyangiitis and was treated with cyclophosphamide and steroids elsewhere. Before this, he was on steroids and methotrexate for probable sarcoidosis based on cavitary lesions in the lungs. During tapering of the steroids and so in relatively immunosuppressed status, he developed fever and maculopapulo-nodular skin lesions. Skin lesion biopsy confirmed Histoplasma capsulatum and he was started on systemic antifungals. Later, he developed bilateral endogenous endophthalmitis and was managed with intravitreal medications followed by vitrectomy with lensectomy OU. The patient regained vision and is maintaining the same until 1 year of follow-up. Thus, in spite of its rare occurrence, H. capsulatum should be considered as a cause of endogenous endophthalmitis in an immunosuppressed host with systemic histoplasmosis.
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Botulinum toxins and fillers for treatment of the aging face
Bhupendra C. K. Patel
April-June 2017, 55(2):113-119
We present a comprehensive review of how to best use neuro-toxins and fillers to rejuvenate the aging face. With modern neuro-toxins and fillers, it is now possible to achieve an improvement in the aging changes of young, middle-aged, and older patients. Furthermore, with the appropriate application of these materials, surgical results can be kept looking good without the need for repeated surgical intervention. As it is important to understand the relationship of the different parts of the face when assessing the aging face, we review the best practices as applied to the whole face.
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Clinical profile of nonstrabismic binocular vision anomalies in patients with asthenopia in North-East India
Damaris Magdalene, Pritam Dutta, Mitalee Choudhury, Saurabh Deshmukh, Krati Gupta
July-September 2017, 55(3):182-186
Aim: To report the clinical profile of non-strabismic binocular vision anomalies (NSBVA) in patients with asthenopia in North-East India. Materials and methods: A hospital based study was conducted on 131 patients from age group 10-40 years attending the vision therapy clinic. Patients were divided into the age groups 10-20 years, 21-30 years and 31-40 years. A detailed orthoptic evaluation was carried out including sensory and motor testing and a diagnosis was made comparing various orthoptic parameters of the particular patients. Results: Of the 131 patients, 81 were female and 50 were male. The number of patients was 62 in the 10-20 years age group, 49 in 21-30 years age group and 20 in 31-40 years age group. The prevalence of NSBVA in age group 10-20 years was 69.35%, 21-30 years was 67.35% and 31-40 years was 50.00%. It was observed that the most common NSBVA was convergence insufficiency across all age groups followed by accommodative insufficiency and convergence excess. Conclusion: Early detection of NSBVA is important because these deviations may decompensate without treatment and become strabismic resulting in loss of stereopsis and development of suppression. Early detection and treatment provides best opportunity for academic success in school going age groups.
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Optical coherence tomography angiography: A general view
Arulmozhi Varman, Ramya Muralidharan, Dinesh Balakumar
April-June 2017, 55(2):107-112
Optical coherence tomography angiography (OCTA) is a new, non-invasive imaging technique that generates angiography images in a matter of seconds. Since it detects vascular compromise even before clinical picture sets in , it is a very useful tool in the diagnosis of retinal vascular pathology.In this review we introduce the technology and compare it with the current angiographic gold standards, fluorescein angiography (FA) and indocyanine green angiography (ICGA). Finally we summarize its potential application to retinal vascular diseases..Its current limitations include a relatively small field of view, inability to show leakage & motion artefacts.Published studies hint at OCTA's potential efficacy in the evaluation of common ophthalmologic diseases such as age related macular degeneration (AMD), diabetic retinopathy, artery and vein occlusions, and glaucoma.
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Quality healthcare and clinical processes: An amalgamation needed to achieve clinical excellence
Suneeta Dubey, Deepika Verma, AK Arora
July-September 2017, 55(3):187-191
Quality improvement is an essential component of 21st-century medicine. Dr. Shroff's Charity Eye Hospital is National Accreditation Board for Hospitals and Healthcare Providers-accredited organization which firmly believes in amalgamating quality measures with clinical processes and bringing out the most effective clinical environment for best patient care, one of the values of the organization. Clinical excellence is achieved through a stepwise approach.
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Retina spotlight: Diabetic retinopathy - Preferred practice patterns
Syed Asghar Hussain, S Natarajan, N Kasinathan, Amjad Salman, Nazimul Hussain
April-June 2017, 55(2):123-130
The management of diabetic retinopathy (DR) has always been a right combination of medical and surgical interventions, influenced by various landmark international clinical trials and treatment guidelines as proposed by various bodies such as the American Academy of Ophthalmology, the Royal College of Ophthalmologists, the International Council of Ophthalmology, and the All India Ophthalmological Society to name a few. This article aims to share the various best practices, presently being followed by senior vitreoretinal surgeons, both nationally and internationally, in managing DR, as we are experiencing a paradigm shift in the investigative modalities and treatment regimens, as compared to those which were followed, just a decade ago. A literature search was conducted using the various keywords, for the years 1980–2017 that included pertinent information from the review of more than 3537 citations collectively, using PubMed, Medline, and Hinari databases, which included comprehensive and systematic literature review and meta-analysis reports. Articles were included, only if they contributed new information about the treatment of DR, techniques in widespread clinical use and excluded those related to techniques that are considered experimental and redundant. Studies with follow-up of <18 months were excluded from this review. The relevant articles were thoroughly analyzed, with each being rated, based on the strength of the study design and weight of evidence.
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From the editor's desk
T Nirmal Fredrick
April-June 2017, 55(2):101-102
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Teleophthalmology: A successful model to tackle diabetic retinopathy
Tamilarasan Senthil, Malathi Nainappan
April-June 2017, 55(2):131-133
The aim of this study is to describe the application of teleophthalmology in screening for diabetic retinopathy in association with diabetes centers. Our model of diabetic retinopathy screening uses, technology innovation to reach out to patients who would otherwise not visit eye hospitals regularly. With more than 70 million diabetic population and only 20,000 ophthalmologists, a regular model of patients visiting eye care practitioners in person is not a feasible option in India. Technology can be used to address this gap, wherein Welcare sets up a telemedicine facility in existing diabetes centers, which includes a fundus camera, telemedicine platform and also more importantly provides a network of reporting ophthalmologists who see the images from these centers and report back within ½ h. Teleophthalmology can be a very effective model for screening of diabetic retinopathy and can help in greater detection of retinopathy and can help prevent a large number of patients from irreversible vision loss.
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Profile of brain tumors having ocular manifestations in a Tertiary Eye Care Institute: A retrospective study
Saurabh Deshmukh, Dipankar Das, Harsha Bhattacharjee, Ganesh Ch Kuri, Damaris Magdalene, Krati Gupta, Prabhjot Kaur Multani, Vivek Paulbuddhe, Shriya Dhar
April-June 2018, 56(2):71-75
Aim: To form a profile of brain tumors having ocular manifestations presenting to a tertiary eye care institute. Materials and Methods: The medical records of patients diagnosed with primary brain tumors between January 2012 and December 2017 were reviewed. Patients underwent a detailed ocular examination and neuroimaging to confirm the diagnosis. Results: Out of the 17 patients, 11 (65%) were female and 6 (35%) were male. The mean age was found to be 43.17 ± 11.04 years and the majority of the patients belonged to the age group 21—40 years (47.06%). The most common presenting symptom was found to be diminution of vision (100%), followed by headache (41.14%) and vertigo (23.52%). The most common sign was optic disc changes, namely optic atrophy (47.05%), followed by disc pallor (29.41%) and papilledema (11.76%). Meningioma (41%) was the most common tumor followed by pituitary macroadenomas (29%). At the time of presentation, two patients had the restriction of extraocular movements, seven patients had a positive relative afferent pupillary defect, and four had defective color vision. Conclusions: Ophthalmic signs and symptoms form a major part of the presentation in patients with intracranial tumors. Majority of the patients diagnosed by ophthalmologists with brain tumors presented with optic disc pallor or edema resulting in diminution of vision. By careful neuro-ophthalmic evaluation, early diagnosis of intracranial space occupying lesions can be made and prompt referral to neurosurgeon can reduce the morbidity and mortality.
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No suture no glue conjunctival autografting with pterygium surgery: A retrospective study of 35 cases
M Umamaheshwari, P Ramesh, R Vasumathi
April-June 2017, 55(2):104-106
Background: Conjunctival autografting in pterygium surgery without the use of sutures and fibrin glue is being practiced by some surgeons recently. The present study was undertaken to evaluate the outcome of the procedure. Methods: This retrospective study was conducted by reviewing the records of thirty-five consecutive cases of pterygium surgery with sutureless and glue-free conjunctival autografting done by a single surgeon from February 1, 2017, to April 30, 2017. One patient had nasal and temporal pterygium, and all other patients had primary nasal pterygium. Under peribulbar block, pterygium was excised and autologous conjunctival grafting was performed without sutures or fibrin glue. Grafts were taken from superior bulbar conjunctiva. Postoperative follow-up was done on the 1st and 7th postoperative day and then after 1 month and 2 months. Results: Patients who had graft recession, graft edema, subconjunctival hemorrhage, and dellen during immediate postoperative period eventually settled down, and the cosmetic outcome was good in all patients. Except one, in all other cases, grafts were in situ. None of them had recurrence till the last follow-up. Conclusion: Sutureless glue-free conjunctival autografting in pterygium surgery takes short surgical time, is economic, and has good cosmetic outcome.
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From the editor's desk
Nirmal T Fredrick
July-September 2017, 55(3):173-174
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Traumatic luxation of the globe: A novel simple treatment
Viji Rangarajan, Yazhini Tamilmani
April-June 2017, 55(2):145-147
Luxation of the eyeball is a rare clinical entity that may present spontaneously or more commonly following trauma, but it carries a risk of threat to permanent vision loss. Appropriate intervention should be undertaken instantly. Prompt reduction results in restoration of full anatomical, functional, and visual recovery in otherwise healthy eyes. We report a case of globe luxation following trauma by the brake handle of a two-wheeler in a 12-year-old female, who recovered completely after reposition of the globe using Desmarres Lid Retractors.
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Wavefront analysis: An additional tool for detection of keratoconus
Sujatha Mohan, Mohan Rajan, Siddhartha Singh, Atul Bhirud, Sriram Annavajjhala
July-September 2017, 55(3):177-181
Aims: The aim of this study is to analyze the role of wavefront analysis as an additional tool for the detection of keratoconus in three groups of patients (i.e., simple refractive errors, high astigmatism, and keratoconus). Design: This study was a prospective comparative study. Patients and Methods: In this prospective comparative study, a total of 115 eyes of 62 patients were examined. All the patients had a complete examination done, which included best spectacle-corrected visual acuity, slit-lamp and fundus examination, and corneal topography for diagnosis of keratoconus. Higher-order aberrations (HOAs) (coma, spherical aberration, and trefoil) were examined using Tscherning aberrometer, based on WaveLight® analyzer II. Statistical Analysis: The one-way analysis of variance test was used. Results: Spherical aberrations were reported highest in the patients with high astigmatism (mean value: 0.149), which was statistically significant when compared to simple refractive errors (P = 0.046). Trefoil aberrations were reported highest in patients with high astigmatism group (mean value: 5.579) in comparison to the other two groups (i.e., simple refractive errors and keratoconus) but were not statistically significant (P > 0.05). Coma and total aberrations were reported highest in keratoconus group (mean value: 0.314 and 2.058, respectively) in comparison to other groups (i.e., simple refractive error and high astigmatism), which was found to be highly significant (P = 0.000). Root-mean-square values of Zernike coefficient polynomials up to the third order were analyzed. Conclusions: This study highlights that assessment of HOAs using wavefront analysis can be used as an additional tool in the early diagnosis of keratoconus in addition to other standard methods.
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Scleral buckling: Principles, utility, and relevance today
VG Madanagopalan
October-December 2017, 55(4):286-292
With time, any surgical specialty or procedure invariably undergoes change. New techniques and technologies become available and the next generations of surgeons innovate to modify established methods. The surgical management of retinal detachment has come a long way from the days of Custodis and Schepens. Scleral buckling (SB), which was once the “gold standard” when reattachment of the retina was desired, no longer enjoys the coveted standing of yore. Despite being in use for more than six decades, the many “modifications” of this surgical procedure are rather superficial - although some may argue that the procedure itself is superficial - and the original surgical principles described have remained constant. In this article, we focus on the utility of buckling, the dynamic physical forces at work when a buckle attempts to reattach the retina and the role of SB in this era of microincision surgeries.
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Encysted bleb following ahmed glaucoma valve surgery: A histopathological case report
Maithri B Arunkumar, Murali Ariga, Malarchelvi Palani, Nivean Madhivanan
April-June 2017, 55(2):150-153
A 27-year-old male patient, with family history of glaucoma was diagnosed to have iridocorneal endothelial syndrome in the left eye. He was treated initially with topical medications and subsequently underwent trabeculectomy with the express implant. Postoperatively, the bleb was found to be well functioning for few months and later became flat and he was given subconjunctival (SC) 0.1 ml 5-Flourouracil (FU) injection with bleb needling. As the bleb did not form despite these measures, he underwent a second surgery with an Ahmed glaucoma valve (FP7) implantation. On review after 4 weeks, the patient had developed a large encysted bleb. Needling was done again and another dose of SC 5-FU 0.1 ml was given. The bleb became encysted again after 6 weeks, hence bleb wall excision was done, and the cyst wall was sent for histopathological analysis which revealed presence of loculated cysts and goblet cells but no inflammation. To the best of our knowledge, there have been very few histopathological case reports of encysted bleb published in peer-reviewed literature.
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Posterior iris-claw intraocular lens implantation as an effective option in aphakia
M Periyanayagi, Nithiya Selvaraj, M Sivakami
October-December 2017, 55(4):282-285
Aim: This study aims to evaluate the safety, effectiveness, and complications of posterior iris-claw intraocular lens (IOL) in aphakic patients with inadequate capsular support. Patients and Methods: This prospective interventional study was conducted in 100 eyes of 99 patients between July 2013 and June 2017. Surgical aphakia with inadequate capsular support, large zonular dialysis, subluxated lens, dislocated lens, dislocated IOL, and aphakia following congenital cataract surgery were included. Preoperative and postoperative best-corrected visual acuity (BCVA) and the occurrence of various vision-threatening complications such as iridocyclitis, decentration, vitritis, cystoid macular edema, and retinal detachment were considered during the follow-up period. Results: One hundred eyes of 99 patients who fulfilled the criteria were included. The mean follow-up period was 13.5 months (4–24 months). About 90% of patients had improvement in vision with postoperative BCVA of 6/12–6/6, 7% had visual improvement with postoperative BCVA of 6/18–6/36, and 3% had a drop in visual acuity with BCVA < 6/60. About 15% developed iridocyclitis in the immediate postoperative period and responded well to topical steroids. Nearly 2% developed vitritis during the follow-up period and 1% developed rhegmatogenous retinal detachment. None had decentration or cystoid macular edema during the follow-up period. Conclusion: Posterior iris-claw IOL implantation is a safe, effective, and timely procedure in aphakia with inadequate capsular support in the hands of a skilled experienced surgeon.
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Outcome of combined cataract extraction and trabeculectomy with mitomycin c performed by fellows
Archana Singaram, Premanand Chandran, Varsha Ramachandra, Vinoth Arunaachalam, Vishwaraj Ramaswamy, Ganesh V Raman
October-December 2017, 55(4):273-277
Aim: This study was aimed to report the outcome of combined cataract extraction and trabeculectomy with mitomycin C performed by fellows at a tertiary eye care center in South India. Materials and Methods: A retrospective review of patients who underwent combined cataract extraction, intraocular lens implantation, and trabeculectomy with mitomycin C performed by fellows between January and December 2015. Patients diagnosed with primary open-angle glaucoma, primary angle-closure glaucoma, and pseudoexfoliation glaucoma were included and those with normal tension, lens-induced, neovascular glaucoma and previous failed glaucoma-filtering surgery were excluded. Results: The study included 280 patients (282 eyes) with a mean age ± standard deviation of 67.9 ± 7.9 years. Mean intraocular pressure (IOP) reduced from a preoperative value of 21.1 ± 6.7 mmHg to 14.2 ± 3.6 and 15.3 ± 4.8 mmHg (P < 0.001) at 6 months and 1 year, respectively. Mean number of antiglaucoma medications reduced from 1.4 ± 0.7 to 0.1 ± 0.1 and 0.1 ± 0.3 (P < 0.001) at 6 months and 1 year, respectively. Mean best-corrected visual acuity improved from 6/60 to 6/12 (P < 0.001) postoperatively. Complete success was 97% at 6 months and 92% at 1 year and qualified success was 100% at 6 months and 1 year. Three patients failed during the follow-up period. The intraoperative complication rate was 7% and reoperation rate was 4.6%. Conclusion: Combined cataract extraction and trabeculectomy performed by fellows is safe and effective to restore vision and control IOP in patients with coexisting cataract and glaucoma.
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Comparison of peribulbar anesthesia with sub-tenon's in manual small incision cataract surgery
Abhinay Ashok, Srikanth Krishnagopal, Kirti Nath Jha
April-June 2018, 56(2):67-70
Aim: Comparison of peribulbar anaesthesia with sub-Tenon's anaesthesia in manual small incision cataract surgery in relation to time of onset of akinesia of extra ocular movements, pain at the time of administration, end of surgery and 1 hour after surgery and complications. Methodology: A randomized comparative study of 113 patients of which 57 patients received peribulbar anaesthesia and 56 patients received Sub-Tenon's anaesthesia. Results: The average time of onset of akinesia with sub-Tenon's anaesthesia was 2.78 ± 0.958minutes and peribulbar anaesthesia was 9.96 ± 2.141minutes. The difference was statistically significant (p = 0.00).Extraocular movements and ease of procedure between the two groups was almost the same and not statistically significant. Incidence of minor complications like chemosis and sub conjunctival haemorrhage were more in sub-Tenon's technique. Peribulbar anaesthesia ranked higher on pain score (5.12 ± 1.255) at the time of administration compared to Sub Tenon's anaesthesia (3.77 ± 1.716), the difference being statistically significant (p = 0.00). Conclusion: Sub-Tenon's anaesthesia is a safe and effective substitute for preibulbar anaesthesia in intraocular surgeries.
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