Comparison of corneal endothelial cell loss during manual small-incision cataract surgery using viscoelastic-assisted nucleus removal versus continuous balanced salt solution plus technique - Randomized controlled trial

Purpose

The purpose of this study was to compare and analyze the endothelial cell loss during manual small-incision cataract surgery (MSICS) using the viscoelastic-assisted nucleus removal versus basal salt solution plus technique.

Methods

This was a prospective randomized trial of 204 patients who underwent MSICS using viscoelastic-assisted nucleus removal (Group 1- OVD) versus basal salt solution plus technique (Group 2- BSS) at a tertiary eye care hospital in North India from January 2018 to 2021. Of these 204 patients, 103 (50.5%) and 101 (49.5%) were allocated to Group 1 and 2, respectively. The parameters assessed were detailed history, demographics, and anterior and posterior segment details. Visual acuity, intraocular pressure (IOP), keratometry, pachymetry, and endothelial cell density were evaluated preoperatively and postoperatively on day 1 and 30.

Results

The mean age of the patients was 64.5 ± 8.2 years (range 48-82 years). There were 129 (63.2%) males and 75 (36.8%) females. The mean LogMAR visual acuity for both groups on day 1 (Group 1- 0.3 ± 0.1, Group 2- 0.5 ± 0.2) and day 30 (Group 1- 0.1 ± 0.2, Group 2- 0.1 ± 0.1) was statistically significant (P < 0.001), and the mean IOP value showed a statistically significant value (P < 0.009) on day 1 in Group 2 (15.0 ± 2.4 mmHg) and on day 30 (P < 0.001) in both the groups (Group 1- 13.6 ± 1.8 mmHg, Group 2- 13.5 ± 2 mmHg). The horizontal and vertical k values also showed a statistically significant difference on day 1 and day 30 (P < 0.001). The mean percentage change of central corneal thickness (CCT) in Group 1 was 17.7% and in Group 2 was 17.4% on day 1, and it was 1.1% on day 30 in both the groups, which was statistically significant (P < 0.001) compared to preoperative values. The percentage change in endothelial cell density on day 1 was 9% in Group 1 and 4.6% in Group 2, which was statistically significant (P < 0.001). On day 30, it was 9.7% and 4.8%, respectively, which was statistically significant (P < 0.001).

Conclusion

Our study highlights statistically significant endothelial cell loss with viscoelastic-assisted nuclear delivery compared to BSS-assisted nuclear delivery during MSICS in a short follow-up of 1 month. The CCT values showed a slight increase, and the keratometry and IOP were unaffected compared to the preoperative parameters in both the groups.

Frankincense oil-loaded nanoemulsion formulation of paclitaxel and erucin: A synergistic combination for ameliorating drug resistance in breast cancer: In vitro and in vivo study

Nanoformulation-based combinational drug delivery systems are well known to overcome drug resistance in cancer management. Among them, nanoemulsions are well-known and thermodynamically stable drug delivery systems suitable for carrying hydrophobic drugs and phytoconstituents to tackle drug-resistant cancers. In the present study, we have investigated the effect of paclitaxel in combination with erucin (natural isothiocyanate isolated from the seeds of Eruca sativa) loaded in the frankincense oil-based nanoemulsion formulation. The choice of frankincense oil for the current study was based on reported research investigations stating its magnificient therapeutic potential against breast cancer. Optimized nanoemulsion of paclitaxel (PTX) and erucin (ER) combination (EPNE) provided sustained release and exhibited enhanced cytotoxicity towards human epithelial breast cancer cells (T-47D) as compared to individual ER and PTX. EPNE was further assessed for its antitumor activity in the 7,12-dimethylbenz(a)anthracene (DMBA)-induced breast cancer mice model. EPNE significantly decreased the levels of hepatic and renal parameters along with oxidative stress in breast cancer mice. Furthermore, EPNE also showed decreased levels of inflammatory cytokines TNF-α, IL-6. Histopathological examinations revealed restoration of the tumorous breast to normal tissues in EPNE-treated breast cancer mice. Therefore, EPNE can act as a viable lead and therapeutic option for drug-resistant breast cancer.

In situ Hydrogels for Effective Treatment of Cancer: Strategies and Polymers Used

Cancer is a worldwide health ailment with no known boundaries in terms of mortality and occurrence rates, thus is one of the biggest threats to humankind. Hence, there is an absolute need to develop novel therapeutics to bridge the infirmities associated with chemotherapy and conventional surgical methodologies including impairment of normal tissue, compromised drug efficiency and an escalation in side effects. In lieu of this, there's been a surge in curiosity towards development of injectable hydrogels for cancer therapy because local administration of the active pharmaceutical agent offers encouraging advantages such as providing higher effective dose at target site, prolonged retention time of drug, ease of administration, mitigation of dose in vivo ,improved patient compliance. Furthermore, due to its biocompatible nature such systems can significantly reduce the side effects that occur on long-term exposure to chemotherapy. The present review details the most recent advancements in in-situ gel forming polymers (natural and synthetic), polymeric cross-linking methodologies and in-situ gelling mechanisms, focusing on their clinical benefits in cancer therapy.

Pythium insidiosum Keratitis: Past, Present, and Future

Pythium insidiosum (PI) is an oomycete, a protist belonging to the clade Stramenopila. PI causes vision-threatening keratitis closely mimicking fungal keratitis (FK), hence it is also labeled as "parafungus". PI keratitis was initially confined to Thailand, USA, China, and Australia, but with growing clinical awareness and improvement in diagnostic modalities, the last decade saw a massive upsurge in numbers with the majority of reports coming from India. In the early 1990s, pythiosis was classified as vascular, cutaneous, gastrointestinal, systemic, and ocular. Clinically, morphologically, and microbiologically, PI keratitis closely resembles severe FK and requires a high index of clinical suspicion for diagnosis. The clinical features such as reticular dot infiltrate, tentacular projections, peripheral thinning with guttering, and rapid limbal spread distinguish it from other microorganisms. Routine smearing with Gram and KOH stain reveals perpendicular septate/aseptate hyphae, which closely mimic fungi and make the diagnosis cumbersome. The definitive diagnosis is the presence of dull grey/brown refractile colonies along with zoospore formation upon culture by leaf induction method. However, culture is time-consuming, and currently polymerase chain reaction (PCR) method is the gold standard. The value of other diagnostic modalities such as confocal microscopy and immunohistopathological assays is limited due to cost, non-availability, and limited diagnostic accuracy. PI keratitis is a relatively rare disease without established treatment protocols. Because of its resemblance to fungus, it was earlier treated with antifungals but with an improved understanding of its cell wall structure and absence of ergosterol, this is no longer recommended. Currently, antibacterials have shown promising results. Therapeutic keratoplasty with good margin (1 mm) is mandated for non-resolving cases and corneal perforation. In this review, we have deliberated on the evolution of PI keratitis, covered all the recently available literature, described our current understanding of the diagnosis and treatment, and the potential future diagnostic and management options for PI keratitis.

Analysis of hesitancy and motivational factors for COVID-19 vaccination among patients presenting to eye care hospitals - A multicenter questionnaire-based survey

Purpose

To analyze the hesitancy and motivational factors related to coronavirus disease 2019 (COVID-19) vaccination among patients visiting for eye care.

Methods

A telephonic survey was conducted using validated questionnaires consisting of 36 questions in five sections from July 1 to July 31, 2021. Patients visiting six tertiary centers and one secondary center of our eye hospitals were interviewed over their phones, and their responses were entered onto the Google forms. The responses were recorded as demographics, health status, awareness about vaccination, factors contributing to hesitancy or acceptance to vaccinate, and general perception about the vaccine.

Results

A total of 5033 patients were surveyed. The mean age was 49.0 ± 14.2 years. A total of 563 (11.2%) patients gave a history of symptoms or were tested positive for COVID-19; 2225 (44.2%) patients were already COVID-19 vaccinated. Around 2883 (56%) patients were aware of getting infection despite vaccination, and 4092 (81.3%) perceived vaccination should be compulsory. The main reason for vaccination hesitancy was the fear of side effects (n = 487, 17.3%). The fear of getting infected was the most common reason for vaccination (n = 911, 40.9%). Factors associated with a lower proportion of vaccinated individuals included younger age (P < 0.001), female gender (P < 0.001), lower education (P < 0.001), lower income (P < 0.001), and rural residence (P = 0.33).

Conclusion

Creating awareness about the minor side effects and reassurance can allay an individual's fears. The fear associated with the rapid spread of infection and associated mortality needs to be utilized to increase vaccination acceptance. A targeted approach toward groups with poor uptake of vaccination is necessary.

Central hypothyroidism with myxoedema: a less known but clinically challenging presentation

Myxoedema can have a variety of presentations, from mild cognitive impairment to psychosis, to overt coma. While majority of cases have primary hypothyroidism as the underlying aetiology, very few cases have central hypothyroidism. We report two patients who presented with myxoedema and were diagnosed with central hypothyroidism. A man in his 50s with a history of panhypopituitarism presented with hypotension, slurring of speech and psychosis that worsened to coma. He was initially treated as adrenal crisis, and on failing to improve he was later treated correctly as myxoedema coma. A woman in her 30s presented with bradykinesia and shock and was diagnosed with Sheehan's syndrome based on hormonal and imaging features. Both patients improved with a loading dose of oral thyroxine and intravenous steroids. Central hypothyroidism presenting with myxoedema is often complicated by coexisting pituitary hormone deficiencies. A high index of suspicion is required for better treatment outcomes.

Clinical and diagnostic color-coding in ophthalmology - An indispensable educational tool for ophthalmologists

Schematic diagrams have been important tools in Ophthalmology for ages. These are vital tools to document ocular pathologies, assist in the comparison of clinical records on follow-up visits, serve as standardized means of communication between ophthalmologists, educating trainees and postgraduates, and helping in the easy follow-up of disease course over a period. There are standardized color codes for depicting different pathologies in the anterior and posterior segments. The understanding of these guidelines allows proper documentation of findings and helps in standardizing ophthalmic care. This method of documentation is beneficial as this is a less expensive tool, provides immediate records at a glance, allows distinctive marking of clinical findings not possible to document with clinical photographs, and can help in medico-legal cases as well. This article focuses on highlighting the standard guidelines that will be useful for training ophthalmologists. This article primarily focuses on various color-codings for anterior and posterior segment schematic representations, along with a brief touch on the importance of color-coding in glaucoma and standardized eye drop (vials) color codes as per the American Academy of Ophthalmology guidelines. We believe this can be taken as a template for future reference by all trainees, postgraduates, fellows, and clinician ophthalmologists in their day-to-day clinical practice.

First case of sunflower pattern calcific deposits and posterior capsular opacification on a pseudophakos

Calcification of the intraocular lens is an uncommon phenomenon that usually follows an uncomplicated surgery. Here, the authors report the first case of a 66-year-old male patient who presented with defective vision and was diagnosed with sunflower pattern calcific deposits and Elschnig pearl pattern posterior capsular opacification in the right eye.

Mentor-mentee relationship in ophthalmology - Following the footsteps of stalwarts

Mentor- mentee relationship in any discipline is a professional and interpersonal relationship. It associates a mentor with a protégé or a mentee. Mentoring is a serious business in Ophthalmology, both academically and surgically. The mentors act as role models for future generations by acting as a friend, coach, or guide to the mentee. They do so by giving valuable advice, moral support, and inculcating skills in a mentee. It is difficult to pinpoint the precise function of the mentor-mentee relationship, but the final goal is to achieve personal and professional objectives. In the current article, the authors have shed light on the imperative aspect of one’s Ophthalmology career, i.e., the mentor-mentee relationship. This article describes various aspects of mentoring, the traits of a perfect mentor and mentee, the pre-requisites for a good mentee-mentor relationship, the hindrances and obstacles in a good relationship, and the impact of COVID-19 on the same. The potential goal of this article is to ignite the constructive spirit of the mentor-mentee relationship, encourage potential mentors to become ideal mentors, and potential mentees to gain from serious mentors

Hypercalcaemia as the initial presentation of Graves' disease

Hypercalcaemia in patients with hyperthyroidism is usually asymptomatic. It occurs due to increased bone turnover and demineralisation. There are only a few case reports where symptomatic hypercalcaemia was the presenting complaint of hyperthyroidism. An Asian man in his 40s presented to us with intractable vomiting for the last 6 months which was not controlled despite multiple antiemetic medications. On routine biochemistry performed at our institute, he was found to have hypercalcaemia and concomitant hyperthyroidism. Classical symptoms suggestive of hyperthyroidism were not present in our patient thus delaying the diagnosis. His symptoms resolved after the correction of hypercalcaemia. Hypercalcaemia did not recur after achieving an euthyroid status on treatment with carbimazole. Other common and more sinister causes for hypercalcaemia like malignancy were ruled out. This case highlights that symptomatic hypercalcaemia could be the initial presentation of hyperthyroidism and amelioration of hyperthyroidism corrects the hypercalcaemia.

The Genetics of Ethambutol-Induced Optic Neuropathy: A Narrative Review

Tuberculosis (TB) is a global health problem with the major brunt of disease occurring in developing countries. The cornerstone of treatment of TB is anti-tubercular therapy (ATT), which includes rifampicin, isoniazid, pyrazinamide and ethambutol. Because of emerging drug resistance, treatment failures, defaulters and increasing incidence of disseminated and extrapulmonary TB, the guidelines have been modified in some countries. Ethambutol is prescribed for longer times (in some cases >8 months) and hence the incidence of ethambutol-induced optic neuropathy (EtON) is expected to rise. The fundamental question which needs explanation is why only a small subset of patients on ethambutol are prone to develop loss of vision. This review focuses on available genetic studies which provide evidence that mitochondria are the likely substrates involved in the final pathway of reactive oxidative damage of the papillo-macular bundle. Genetic analysis of mitochondrial mutations encoding genes involved in oxidative phosphorylation pathways may help in isolating the subset of patients who are genetically susceptible. If the groups having high risk of developing EtON are recognised then prolonged duration of ethambutol treatment can be avoided in these susceptible individuals. A better understanding of the pathophysiology will also pave the way for the development of management strategies in this condition.

Digital Eye Strain- A Comprehensive Review

Digital eye strain (DES) is an entity encompassing visual and ocular symptoms arising due to the prolonged use of digital electronic devices. It is characterized by dry eyes, itching, foreign body sensation, watering, blurring of vision, and headache. Non-ocular symptoms associated with eye strain include stiff neck, general fatigue, headache, and backache. A variable prevalence ranging from 5 to 65% has been reported in the pre-COVID-19 era. With lockdown restrictions during the pandemic, outdoor activities were restricted for all age groups, and digital learning became the norm for almost 2 years. While the DES prevalence amongst children alone rose to 50-60%, the symptoms expanded to include recent onset esotropia and vergence abnormalities as part of the DES spectrum. New-onset myopia and increased progression of existing myopia became one of the most significant ocular health complications. Management options for DES include following correct ergonomics like reducing average daily screen time, frequent blinking, improving lighting, minimizing glare, taking regular breaks from the screen, changing focus to distance object intermittently, and following the 20-20-20 rule to reduce eye strain. Innovations in this field include high-resolution screens, inbuilt antireflective coating, matte-finished glass, edge-to-edge displays, and image smoothening graphic effects. Further explorations should focus on recommendations for digital screen optimization, novel spectacle lens technologies, and inbuilt filters to optimize visual comfort. A paradigm shift is required in our understanding of looking at DES from an etiological perspective, so that customized solutions can be explored accordingly. The aim of this review article is to understand the pathophysiology of varied manifestations, predisposing risk factors, varied management options, along with changing patterns of DES prevalence post COVID-19.

Knowledge, Attitude, and Practice Patterns Related to Digital Eye Strain Among Parents of Children Attending Online Classes in the COVID-19 Era: A Cross-sectional Study

PURPOSE

To assess the prevalence of digital eye strain among children and extrapolate the association between knowledge, attitude, and practice patterns related to device use during the coronavirus disease 2019 (COVID-19) lockdowns.

METHODS

A cross-sectional, descriptive, questionnaire-based analysis was done to assess the knowledge, attitude, and practice patterns related to digital device use among parents of children attending online classes.

RESULTS

A total of 305 responses were obtained. The most common reason for device use was online classes (288 children; 94.4%) and the most common mode was smartphone (263 children; 86.3%). The prevalence of digital eye strain was 64.6%. The mean knowledge score was 48.5 ± 5.1, the mean attitude score was 26.7 ± 4.9, and the mean practice score was 17.8 ± 3.5. The difference between knowledge, attitude, and practice scores among parents of children with and without glasses was not statistically significant (P = .580, .521, and .503, respectively). A direct correlation was found between the knowledge and practice scores (P = .002), but attitude scores did not show a significant correlation (P = .712).

CONCLUSIONS

Digital devices have been a boon to continue education during the ongoing COVID-19 pandemic. This study reveals a large knowledge gap among parents related to safe digital device use. Further, there is a need to adopt methods that would help spread awareness to the masses about the effects of excessive screen time in children in the form of digital eye strain and myopia and the corrective measures to avoid the same. [J Pediatr Ophthalmol Strabismus. 2022;59(4):224-235.].

Corneal Perforation Secondary to Rosacea Keratitis Managed with Excellent Visual Outcome

Introduction: Ocular Rosacea is a poly etiological chronic inflammatory disease with heterogeneous clinical manifestations. It is primarily a dermatologic disease, which often manifests in the eyes affecting eyelids, conjunctiva, and cornea. The leading role in the pathological process belongs to the disruption of regulatory mechanisms in the vascular, immune, and nervous systems. The varied manifestation can be erythematous pustular lesions on the face, chronic blepharitis, meibomian gland dysfunction, evaporative dry eye, peripheral corneal ulceration, corneal scarring, perforation, and neovascularization.    Case: We describe a rare case report of a 43-year-old male with progressive ocular manifestations of rosacea keratitis. Slit-lamp biomicroscopic examination revealed squamous blepharitis, telangiectatic vessels with obliterated meibomian glands, circumcorneal congestion, peripheral corneal perforation of 2x2 mm at 4 0 clock, shallow anterior chamber(AC) with positive seidel’s in the left eye. Fundoscopy showed serous choroidal detachment(CD). Snellen’s Best Corrected Visual Acuity(BCVA) was 20/240 with Intraocular pressure measured was 5 mmhg. The patient was managed with topical loteprednol, moxifloxacin, carboxymethylcellulose medications along with cyanoacrylate glue and bandage contact lens and had excellent visual acuity of 20/20 with a follow-up of 1 year. Conclusion: Ocular rosacea perforation has been reported in chronic cases and may not always require amniotic membrane transplant, patch grafting, or keratoplasty. If managed meticulously with cyanoacrylate glue and BCL can have excellent outcomes. Eye specialists should be alerted that the key to a successful outcome is excellent control of inflammatory activity and differentiating this non-infectious keratitis from other keratitis before commencing treatment.