Publications by authors named "Rengappa Ramakrishnan"

52 Publications

Spontaneous resolution of Descemet's membrane detachment following bleb needling in a patient with iridocorneal endothelial syndrome: A case report.

Indian J Ophthalmol 2022 Jul;70(7):2639-2641

Department of Glaucoma, Aravind Eye Hospital, Post Graduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India.

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http://dx.doi.org/10.4103/ijo.IJO_3203_21DOI Listing
July 2022

Clinical profile and long term outcomes of eyes with choroidal detachment following trabeculectomy.

Indian J Ophthalmol 2022 05;70(5):1635-1641

Department of Biostatistics, Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India.

Purpose: To assess the long-term outcomes of choroidal detachments (CDs) in eyes following trabeculectomy.

Methods: Retrospective comparative case series. Data of patients with CDs following trabeculectomy (5-year period) with or without cataract surgery with a minimum of 3 months of follow-up were included.

Results: In total, 45 patients with CDs following trabeculectomy were included. The mean age was 63.27 ± 8.68 years, (M:F = 2:1); 29 of 45 eyes (64.4%) had a baseline IOP of >24 mm Hg. Patients had a median follow-up of 22.2 (IQR: 16.2-30.5) months. Further, 10 of 45 eyes (22.2%) had CDs following suture lysis. The median onset of choroidal detachment from the time of surgery was 16.0 (IQR: 11-36) days. The mean BCVA improved from 0.62 ± 0.28 to 0.24 ± 0.27 (P < 0.001) and mean IOP increased from 4.07 ± 2.66 to 11.20 ± 5.31 (P < 0.001) at last visit. The cumulative success rates were 76.4% (95% CI: 48.4-90.5) in POAG eyes and 79.3% (95% CI: 62.8-89.1) in PACG eyes (P = 0.547). Medical management was the mainstay in all patients. Four of 45 (8.88%) patients underwent subsequent choroidal drainage.

Conclusion: Choroidal detachment following modern-day trabeculectomy has favorable long-term visual acuity and IOP outcomes. There was no difference in the long-term surgical success of trabeculectomy with choroidal detachments in primary angle-closure and open-angle glaucoma eyes. Long-term follow-up is essential to prevent chronic hypotony and trabeculectomy failure.
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http://dx.doi.org/10.4103/ijo.IJO_2876_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9332943PMC
May 2022

Outcomes and favourable prognostic factors in patients of phacomorphic and phacolytic glaucoma managed by manual small-incision cataract surgery: A retrospective study.

Indian J Ophthalmol 2022 Apr;70(4):1216-1221

Glaucoma Services, Aravind Eye Hospital and PG Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India.

Purpose: To evaluate the outcomes and identify favorable prognostic factors in patients of phacomorphic (PMG) and phacolytic glaucoma (PLG) managed by manual small-incision cataract surgery (MSICS).

Methods: The medical records of patients with PMG/PLG who had undergone MSICS in a tertiary eye hospital between September 2014 and August 2018 were retrospectively reviewed. Regression analyses were conducted to identify the predictors associated with intraoperative or postoperative complications and a favorable final outcome at 1 month, namely, a best-corrected visual acuity (BCV) of 6/18 or better and an intraocular pressure (IOP) of <21 mm Hg. P < 0.05 was considered statistically significant.

Results: The records of 209 patients with PMG and 279 patients with PLG were eligible for the review. The mean preoperative IOP for PMG and PLG were 43.15 ± 12.9 and 40.05 ± 12.0 mm Hg, respectively (P = 0.006). A younger age (<60 years) was associated with a lower risk of severe postoperative inflammation in both PMG and PLG [OR = 0.45 (0.21-0.99); P = 0.047 and OR = 0.44 (0.23-0.83); P = 0.011, respectively]. There was no significant difference in the final mean logMAR BCV (P = 0.21) and IOP (P = 0.36) in the two groups. The likelihood of a final IOP of <21 mm Hg was significant for symptoms less than a week [OR = 3.52 (1.2-10.2); P = 0.02] in PMG and for absence of vitreous disturbance [OR = 35.0 (3.8-325.7); P = 0.002] in PLG. A BCV of 6/18 or better was strongly associated with symptoms for less than a week [OR = 1.58 (1.0-2.4); P = 0.043] and absence of vitreous disturbance [OR = 23.53 (5.1-108.0); P < 0.001].

Conclusion: Early diagnosis and management can translate to good outcomes in PMG and PLG.
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http://dx.doi.org/10.4103/ijo.IJO_2371_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9240532PMC
April 2022

Anisometropia and refractive status in children with congenital nasolacrimal duct obstruction-a prospective observational study.

J AAPOS 2022 04 18;26(2):76.e1-76.e4. Epub 2022 Mar 18.

Department of Glaucoma, Aravind Eye Hospital and Postgraduate Institute, Tirunelveli, Tamil Nadu, India.

Purpose: To assess the refractive status and anisometropia in children with unilateral and bilateral congenital nasolacrimal duct obstruction (CNLDO).

Methods: Consecutive children newly diagnosed with CNLDO were prospectively enrolled from November 2017 to May 2019. A complete ophthalmic evaluation including cycloplegic refraction was performed followed by appropriate intervention. Patients were followed for 6 months, and cycloplegic refraction was performed at each visit. The final refractive error was defined as the refractive error obtained from the most recent visit. Amblyogenic risk factors were assessed based on 2013 referral criteria of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS).

Results: A total of 308 patients with CNLDO were enrolled: 205 (67%) unilateral cases and 103 (33%) bilateral cases. In unilateral cases, the affected eye and unaffected fellow eye showed statistically significant difference in terms of sphere (P < 0.001), cylinder (P = 0.019), and spherical equivalent (P < 0.001); there was no interocular difference in bilateral cases (P > 0.05). Anisometropia was more prevalent in unilateral cases than in bilateral cases (11.2% vs 1.9%; P = 0.005). Based on the 2013 AAPOS referral criteria, 3.9% of the unilateral and 3.9% of bilateral cases exhibited amblyogenic risk factors. Later age of presentation was associated with higher rate of anisometropia (53.8% in the age group >48 months).

Conclusions: In our study cohort, unilateral CNLDO was associated with a higher prevalence of anisometropia compared with bilateral CNLDO. The affected eye in unilateral CNLDO had higher prevalence of refractive error.
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http://dx.doi.org/10.1016/j.jaapos.2021.11.015DOI Listing
April 2022

Transconjunctival flap sutures: A novel technique to combat hypotony.

Indian J Ophthalmol 2022 Mar;70(3):1073

Glaucoma Services, Aravind Eye Hospital and Post-Graduate Institute, Tirunelveli, Tamil Nadu, India.

Background: Hypotony secondary to overfiltration is a recognized complication following trabeculectomy. Persistent hypotony requires intervention .

Purpose: We describe a modified version of placing conjunctival compression sutures directly over the scleral flap.

Synopsis: A 70-year-old male patient diagnosed with primary open angle glaucoma in both eyes underwent combined surgery in the right eye. On the tenth post-operative day, the patient presented with severe hypotony with 360ª choroidal detachment. He was treated with corticosteroids and cycloplegics but developed hypotony maculopathy on the subsequent follow-up. Hence, he was further managed surgically by trans-conjunctival flap sutures to which he responded favorably with resolution of choroidal detachment and improvement in intraocular pressure and visual acuity.

Highlights: Transconjunctival suturing of the scleral flap is an effective and minimally invasive treatment to prevent visual loss from hypotony maculopathy for an overfiltering bleb following trabeculectomy.

Online Video Link: https://youtu.be/BJtUZcyQZ-w.
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http://dx.doi.org/10.4103/ijo.IJO_427_22DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9114532PMC
March 2022

Early outcomes of 21-gauge needle-guided tube sulcus placement of a non-valved implant in pseudophakic eyes.

Indian J Ophthalmol 2022 Mar;70(3):1051-1053

Department of Glaucoma, Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India.

We report the early outcomes and describe an ab interno 21-G needle technique of sulcus placement of the Aurolab aqueous drainage implant (AADI) tube in nine pseudophakic eyes. IOP reduced from a preoperative mean (SD) of 28.33 (9.80) to 11.56 (2.65) mm Hg and the mean (SD) number of preoperative medications reduced from 3.0 (0.7) to 0.4 (0.9) at 3 months. There were no intraoperative complications noted. This technique of sulcus placement of the AADI tube is a precise technique of tube insertion. It may be an alternative to existing ab externo procedures of tube sulcus placement, limiting multiple blind entries.
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http://dx.doi.org/10.4103/ijo.IJO_2303_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9114598PMC
March 2022

Pars plana Aurolab aqueous drainage implantation for refractory glaucoma: Outcome of a new modified technique.

Indian J Ophthalmol 2022 Mar;70(3):839-845

Glaucoma Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India.

Purpose: To report the outcomes of pars plana insertion of Aurolab aqueous drainage implant (AADI) in adults with refractory glaucoma by the novel technique of making scleral tunnel instead of patch graft to cover the tube to prevent its migration.

Methods: A retrospective study was done between April 2016 and April 2018 on patients with ≥12 months of follow-up. The main outcome measure was a surgical failure at 12 months. The failure was defined as intraocular pressure (IOP) >18 mmHg or IOP ≤5 mmHg on two consecutive follow-up visits after 3 months, reoperation for glaucoma, loss of light perception vision, or implant explantation. Alternate definitions of failure including IOP >21 and IOP >15 mmHg were also considered.

Results: : The study included 32 eyes of 32 patients. The mean age was 46.2 ± 17.5 years. The most common etiology is traumatic glaucoma (12 eyes, 37.5%). The mean preoperative IOP and anti-glaucoma medications were 43.3 ± 10.3 and 3.4 ± 0.5 mmHg, respectively; both the parameters at the final follow-up were reduced to 15.2 ± 8.1 and 1.6 ± 0.5 mmHg. The Kaplan-Meier survival estimates demonstrated that the cumulative probability of failure was 15.6% (95% CI; 6.8-33.5%) at 3 months, 18.7% (95% CI; 8.9-37.0%) at 6 months, and 25.0% (95% CI; 13.4-43.8%) at 12 months.

Conclusion: Pars plana AADI implantation with a newer modification technique is a useful procedure in reducing IOP and the number of anti-glaucoma medications in the eyes with refractory glaucoma. The visual acuity may be stabilized with the concurrent treatment of posterior segment pathology.
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http://dx.doi.org/10.4103/ijo.IJO_1791_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9114538PMC
March 2022

Winning the battle of refractory hypotony.

Indian J Ophthalmol 2022 Feb;70(2):710

Glaucoma Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India.

Background: Trabeculectomy, a mainstay in the management of glaucoma is associated with various complications, the most dreaded being hypotony.

Purpose: We present a challenging case of late-onset refractory hypotony following trabeculectomy.

Synopsis: : A 64-year-old male patient diagnosed with primary open angle glaucoma in the right eye underwent combined surgery. Three weeks later, he presented with hypotony which responded well with medical management and then he was lost to follow-up. Two years later, he presented with severe hypotony with shallow choroidal detachment in the right eye, which failed to respond to medical management. Compression sutures were placed over the bleb which also failed to work. Subsequently bleb repair was done with corneal patch graft, which helped resolve the bleb leak, with an improvement in visual acuity and intraocular pressure.

Highlights: This video highlights the importance of prompt and timely intervention of an overfiltering bleb in preventing irreversible visual loss.

Video Link: https://youtu.be/8DrxzqQ4qP4.
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http://dx.doi.org/10.4103/ijo.IJO_154_22DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9023988PMC
February 2022

Aurolab aqueous drainage implant in the vitreous cavity: Our modifications over the conventional technique of glaucoma implant surgery.

Indian J Ophthalmol 2021 07;69(7):1950-1952

Department of Retina & Vitreous, Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India.

Glaucoma drainage devices (GDDs) are used for managing refractory glaucoma due to failed trabeculectomy, neovascular glaucoma, traumatic glaucoma, and secondary glaucoma post keratoplasty. Aurolab aqueous drainage implant (AADI) is a nonvalved drainage implant conventionally implanted with the tube placed in the anterior chamber. Studies about the outcome of the various aqueous drainage devices implanted in the anterior chamber have reported complications such as tube extrusion, migration, blockage, erosion, and corneal decompensation. We propose modifying the conventional GDD implantation technique by placing the tube in the vitreous cavity, thereby negating the risk of anterior segment complications in patients with refractory glaucoma whose anterior segment is already compromised. Another novel approach implemented in this technique was making a scleral tunnel instead of using a scleral or corneal patch graft to cover the tube to prevent its migration. This article describes the surgical steps of this technique and its advantages, along with a surgical video.
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http://dx.doi.org/10.4103/ijo.IJO_3348_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8374777PMC
July 2021

Surgically induced astigmatism following single site and twin site phacotrabeculectomy augmented with mitomycin C.

Eye (Lond) 2022 05 11;36(5):1100-1105. Epub 2021 Jun 11.

Glaucoma Clinic, Aravind Eye Hospital, Tirunelveli, India.

Purpose: To determine difference in surgically induced astigmatism (SIA), post-operative intraocular pressure (IOP) and axial length (AL) between single site and twin-site phacotrabeculectomy augmented with Mitomycin C (MMC).

Design: Prospective interventional randomised controlled study.

Methods: In a prospective interventional comparative study, eligible patients were scheduled for phacotrabeculectomy. They were randomised to either group A: single site or group B: twin-site phacotrabeculectomy with MMC 0.2 mg/mL. Axial length was measured by using Zeiss IOL master I, pre-operatively and at 1, 3, 6 and 12 months post-operatively. Corneal topography was performed using Bausch and Lomb Orbscan I pre-operatively and at 3, 6 and 12 months post-operatively to analyse surgically induced astigmatism. Vector analysis was used to analyse the surgically induced astigmatism.

Results: One hundred and eight eyes of which 55 patients in group A, and 53 patients in group B were enroled for vector analysis. The mean preoperative astigmatic vector power was +0.89 ± 0.4 D and +0.97 ± 0.5 D in group A and B respectively. The mean post-operative astigmatic vector power was +0.78 ± 0.4 D in group A and +0.96 ± 0.5 D in group B at the end of 12 months. Corneal topography showed post-operative superior flattening (51.8% at 3 months and 55.4% at 12 months) in group A (P = 0.072) compared to superior steepening (59.6% at 3 months and 61.5% at 12 months) in group B (P = 0.977).

Conclusions: The two commonly used techniques of combined cataract and glaucoma surgery proved to be efficacious without significant difference in surgical induced astigmatism.
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http://dx.doi.org/10.1038/s41433-021-01601-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9046193PMC
May 2022

Novel device to contain aerosols during phacoemulsification.

Indian J Ophthalmol 2021 Jun;69(6):1605-1608

Department of Glaucoma, Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India.

We herein describe a novel device to contain droplets and aerosols during phacoemulsification. We modified the silicon phaco test chamber into an aerosol containment chamber (ACC) by shortening the chamber and making a pear-shaped opening at one aspect of its tip. The ACC was fitted over phaco tip such that 4-5 mm of phaco tip and sleeve was exposed. When the phaco tip and irrigation port are inside the anterior chamber during phacoemulsification, the portion of the modified chamber remains around the clear corneal tunnel in an enclosing manner that contains aerosols and droplets.
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http://dx.doi.org/10.4103/ijo.IJO_3478_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8302302PMC
June 2021

Agreement of findings of glaucoma screening between trained vision center technicians and glaucoma specialists at a tertiary hospital in South India.

Indian J Ophthalmol 2021 04;69(4):871-875

Department of Paediatric Services and General Ophthalmology, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India.

Purpose: To study the agreement of findings of glaucoma screening between trained vision center (VC) technicians and glaucoma specialists in patients referred from VC to the glaucoma services of a tertiary eye care hospital in south India.

Methods: This was a retrospective study comparing the findings of the VC technicians and the specialists of the glaucoma services in the base hospital, in patients referred from 13 VCs between January and June 2019. Medical records of 277 referred patients (out of 533 referrals) who attended the glaucoma clinic were analyzed.

Results: Of the 277 patients, 111 (40%) were confirmed having glaucoma, 133 (48%) were suspects, 29 (10.4%) were normal, and four (1.4%) had other pathology. The mean age of the patients was 59.7 ± 13 years and 60.6% were females. There was no statistically significant difference between the mean intraocular pressure (IOP) measured (17 ± 7.2 mmHg at the VC and 18 ± 8.7 mmHg at the clinic, p = 0.16) and the cup-to-disc ratio (CDR) (0.7 ± 0.13 at the VC and 0.6 ± 0.18 at the clinic, p = 0.57). Bland-Altman plots with 95% limits of agreement supported that mean differences were close to zero, and the intraclass correlation coefficient at 95% CI showed good consistency between the measurement of IOP (0.78 [0.74 to 0.81]) and CDR (0.90 [0.88 to 0.92]) at the base hospital and vision center.

Conclusion: There is good agreement between the findings of VC technicians and glaucoma specialists. VC technicians can help in detecting glaucoma in the community.
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http://dx.doi.org/10.4103/ijo.IJO_1390_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8012921PMC
April 2021

Response to comments on: Intraoperative injection versus sponge-applied Mitomycin C during trabeculectomy: One-year study.

Indian J Ophthalmol 2021 01;69(1):179-180

Department of Glaucoma, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Tirunelveli, S.N. High Road, Tirunelveli Junction, Tamil Nadu, India.

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http://dx.doi.org/10.4103/ijo.IJO_2044_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7926165PMC
January 2021

Reply to comments on: Intraoperative injection versus sponge-Applied mitomycin C during trabeculectomy: One - year study.

Indian J Ophthalmol 2021 01;69(1):177-178

Department of Glaucoma, Aravind Eye Hospital and Post GraduateInstitute of Ophthalmology, Tirunelveli, S.N. High Road, TirunelveliJunction, Tamil Nadu, India.

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http://dx.doi.org/10.4103/ijo.IJO_1880_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7926093PMC
January 2021

Safety and efficacy of toric implantable collamer lens V4c model - A retrospective South Indian study.

Indian J Ophthalmol 2020 Dec;68(12):3006-3011

Statistics, Aravind Eye Hospitals and Post Graduate Institute, Tirunelveli, Tamil Nadu, India.

Purpose: : The aim of this study was to evaluate the safety, efficacy, and complications of V4c Toric implantable collamer Lens (TICL) implantation for myopic astigmatism in the south Indian population.

Methods: In this retrospective observational case series, a total of 109 eyes of 67 patients who underwent V4c TICL implantation (ICL, V4C Staar Surgical, Nidau, Switzerland) between January 2012 and August 2019 were studied with a minimum follow-up period of 6 months (mean 24 months). The main outcome measures were objective and subjective refraction, uncorrected distance visual acuity, corrected distance visual acuity (CDVA), safety, predictability, adverse events, and postoperative complications.

Results: At 6 months, mean manifest refractive spherical equivalent (SE) decreased from -10.90 ± 3.7D preoperatively to -0.02 ± 0.13D postoperatively (P < 0.001) and mean cylinder decreased from -2.3 ± 1.3 D preoperatively to -0.04 ± 0.2 D postoperatively (P < 0.001). Postoperatively, SE within ± 0.5 D and ± 1.0 D of attempted correction were achieved in 96.3 (105 eyes) and 100% (109 eyes), respectively. Manifest refractive cylinder within ± 0.5 D and ± 1.0 D of attempted correction were achieved in 97.2 (106 eyes) and 100% (109 eyes), respectively. Sixty-two percent (68 eyes) showed no change in CDVA postoperatively, and no eye had lost lines of CDVA. The safety index was 1.12, and the efficacy index was 1.10. Complications were seen in two eyes (1.8%) due to high postoperative vault requiring secondary surgical interventions.

Conclusion: V4c TICL is a highly effective, safe, and predictable option in treating myopic astigmatism with excellent improvement in vision and spectacle independence.
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http://dx.doi.org/10.4103/ijo.IJO_1492_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856968PMC
December 2020

An Infectious Cause of Congenital Pupillary-Iris-Lens Membrane With Secondary Angle Closure Glaucoma in an Infant.

J Glaucoma 2021 05;30(5):e271-e273

Departments of Glaucoma.

Purpose: The aim of the study was to report an infectious cause of congenital pupillary-iris-lens membrane with secondary angle closure glaucoma in an infant.

Design: This was a case report.

Methods: Institutional review board exemption for this report was obtained from the Institutional Ethics Committee, Aravind Eye Hospital, Tirunelveli. Informed consent was obtained.A 3-month-old female infant presented to us with congenital pupillary-iris-lens membrane, iris bombe and raised intraocular pressure in the left eye. She underwent trabeculotomy and trabeculectomy along with membranectomy for the same. An aqueous tap performed a month later was suggestive of coexisting Toxoplasma gondii infection detected by polymerase chain reaction.

Result: The study provides a description of the course of management of angle closure glaucoma secondary to congenital pupillary-iris-lens membrane with an associated infection. Intraocular pressure reduced from 40 to 20 mm Hg in the left eye.

Conclusion: This condition is a rare entity of unknown etiology with an increased risk of glaucoma and visual loss. A multidisciplinary approach is needed for the management of these eyes. Infectious associations with these membranes should be ruled out by an aqueous tap with polymerase chain reaction and a close postoperative follow-up is mandatory.
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http://dx.doi.org/10.1097/IJG.0000000000001726DOI Listing
May 2021

The Aravind Pseudoexfoliation Study: 5-Year Postoperative Results. The Effect of Intraocular Lens Choice and Capsular Tension Rings.

Am J Ophthalmol 2020 11 2;219:253-260. Epub 2020 Jul 2.

Wilmer Eye Institute and Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland, USA; Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA. Electronic address:

Purpose: We compared rates of intraocular lens (IOL) decentration, neodymium-doped yttrium aluminum garnet capsulotomy for posterior capsule opacification (PCO), and visual acuity (VA) in eyes with and without pseudoexfoliation (PEX) 5 years after undergoing cataract surgery.

Design: Prospective comparative interventional study.

Methods: This multicenter study population included 1 eye of both 930 cataract patients with and 470 cataract patients without uncomplicated PEX (no small pupils or phacodonesis) all undergoing phacoemulsification by experienced Aravind Eye Care System surgeons. Eyes were randomized to either 1- or 3-piece intraocular lenses (IOLs). PEX eyes were also randomized to either receive or not receive a capsule tension ring. The main outcome measures included IOL decentration and PCO. Secondary outcomes included postoperative best-corrected VA.

Results: Follow-up was 86.2% in the PEX group and 86.7% in the control group at 5 years. The PEX group was older (P < .001) and had more men (P = .01). IOL decentration at 5 years was equally prevalent in PEX and control eyes (1.0% vs 1.1%, respectively, P = .8). Neodymium-doped yttrium aluminum garnet posterior capsulotomy rates for PCO were similar in the PEX group when compared with control subejcts (5.3% compared with 3.2%, respectively, P = .07). Best corrected VA was better at baseline and years 2 and 3 in the control group (P = .0001, P = .0005, and P = .02); however, there was no difference in BCVA at years 1, 4, and 5 between the PEX and control groups (P = .09, P = .29, and P = .5).

Conclusion: In a large-scale, long-term, prospective comparative study of cataract surgery in eyes with uncomplicated PEX, the risks of IOL decentration and PCO were low and comparable to that in control subjects. When approaching cataract surgery in eyes with relatively uncomplicated PEX, neither IOL choice (1- vs 3-piece acrylic IOL) nor the presence/absence of a capsule tension ring affects outcomes at 5 years.
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http://dx.doi.org/10.1016/j.ajo.2020.06.031DOI Listing
November 2020

Intraoperative injection versus sponge-applied mitomycin C during trabeculectomy: One-year study.

Indian J Ophthalmol 2020 04;68(4):615-619

Department of Glaucoma, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India.

Purpose: To determine the safety and efficacy of mitomycin C (MMC) injection versus sponge during trabeculectomy.

Methods: It is a prospective analysis of patients who underwent trabeculectomy with MMC and followed up for 1 year, divided into two groups, namely, group 1- injection (n = 21), group 2-> sponge (n = 21). The same concentration of MMC was used for both groups. Inclusion criteria were trabeculectomies with MMC for intraocular pressure (IOP) control in eyes with glaucoma (primary + secondary) with a follow-up of 1 year.

Results: Mean preoperative IOP in group 1 was 29.00 ± 11.92 mmHg and group 2 was 25.87 ± 11.09 mmHg, which reduced to 12.19 ± 4.03 and 15.56 ± 10.72 mmHg at final visit with P value of 0.0002 and 0.001, respectively. Mean preoperative number of antiglaucoma medications was 2.4 ± 0.87 in group 1 and 2.3 ± 0.96 in group 2, which reduced to 0.38 ± 0.5 and 0.91 ± 0.85 with P value of 0.001 and 0.0003, respectively. The complete success rate was 52.4% in the injection group and 26.1% in the sponge group at end of 1 year. Overall, success rate (complete + qualified) was 90.5% and 87% in group 1 and group 2 at final visit. All major complications were encountered in sponge group. 1 (11.1%) patient developed choroidal detachment and one had malignant glaucoma which got resolved by medical management. 33.3% cases had encapsulated bleb which received bleb needling. 44.4% cases underwent Argon laser suture lysis postoperatively.

Conclusion: The MMC injection may be as safe and as effective as conventional sponge application with comparable estimated complete treatment success.
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http://dx.doi.org/10.4103/ijo.IJO_963_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7210852PMC
April 2020

Diabetes mellitus in the Tamil Nadu State-Noncommunicable diseases nurse model in diabetic retinopathy screening.

Indian J Ophthalmol 2020 02;68(Suppl 1):S78-S82

Project Division at Lions Aravind Institute of Community Ophthalmology, Madurai, Tamil Nadu, India.

Tamil Nadu is one of the states in India, where the diabetic retinopathy (DR) project was implemented in the Tirunelveli District. Aravind Eye Hospital, Tirunelveli was the mentoring institution and ophthalmology department of Tirunelveli Medical College and Hospital (TVMCH) was the implementing partner. The objective of the project was to develop a district level model for building capacity at the government health system for effective screening, diagnosis and management (primary to tertiary) of diabetic retinopathy. The DR screening, counseling, referral and follow-up tasks were included in the scope of Non- Communicable Disease (NCD) nurses at the respective Community Health Centres and Primary Health Centres using the tele-medicine platform. During the project period (December 2016 to June 2019), 8,574 people with diabetes were registered at the 18 CHCs/PHCs. 6,462 (75.4% of those registered) were screened by NCD staff. The government has agreed to scale up services in 3 more districts.
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http://dx.doi.org/10.4103/ijo.IJO_1987_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7001166PMC
February 2020

Response to comments on: Midterm outcome of mitomycin C augmented trabeculectomy in open angle glaucoma versus angle-closure glaucoma.

Indian J Ophthalmol 2020 01;68(1):268-269

Department of Glaucoma, Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India.

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http://dx.doi.org/10.4103/ijo.IJO_1532_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6951133PMC
January 2020

Clinical outcome of a nonvalved Aurolab aqueous drainage implant in posterior segment versus anterior chamber.

Indian J Ophthalmol 2019 08;67(8):1303-1308

Department of Glaucoma, Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India.

Purpose: To evaluate the outcome of a nonvalved Aurolab aqueous drainage implant (AADI) in the management of refractory glaucoma.

Methods: Retrospective case series of patients with refractory glaucoma underwent AADI implantation in posterior segment (PS group) or anterior chamber (AC group) with minimum follow-up of 1 year. Primary outcome criterion was success, defined as intraocular pressure (IOP) <18 or >6 mm Hg or IOP reduced to <20% from baseline, for two consecutive visits after 3 months. Failure was defined as inability to meet IOP criteria, any additional glaucoma surgery, loss of light perception, and implant explantation. Secondary outcome criteria compared groups based on mean IOP, mean glaucoma medication use, best-corrected visual acuity, and complications at each postoperative visit.

Results: In the AC and PS group of 64 patients, 32 tubes each were placed. Preoperative mean IOP was 37.41 ± 8.6 and 43.38 ± 10.3 mm Hg in AC and PS, respectively. Postoperatively IOP reduced to 14.22 ± 4.9 and 15.21 ± 8.1 mm Hg in AC and PS groups, respectively (P < 0.001). Preoperative mean antiglaucoma medication changed from 2.56 ± 0.9 and 3.44 ± 0.5 to 1.03 ± 0.9 and 1.67 ± 0.5 in AC and PS, respectively, postoperatively (P < 0.001). No significant change in VA was noted in either group. At 12 months, success rate was 84% in AC group and 72% in PS group, with PS group having 2.63 times higher hazard (risk) of failure than AC group.

Conclusion: AADI implantation in PS or AC is a safe and effective method for IOP control in refractory glaucoma with its low cost being of significance in developing countries.
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http://dx.doi.org/10.4103/ijo.IJO_1341_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6677071PMC
August 2019

Midterm outcome of mitomycin C augmented trabeculectomy in open angle glaucoma versus angle closure glaucoma.

Indian J Ophthalmol 2019 07;67(7):1080-1084

Department of Glaucoma, Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India.

Purpose: The purpose of this study is to evaluate the efficacy and safety of Trabeculectomy with Mitomycin C in Open angle glaucoma versus Angle closure glaucoma.

Methods: The medical records of patients who underwent Trabeculectomy with Mitomycin C were reviewed and followed for three years, divided into two groups: group 1: Open Angle Glaucoma (n = 41) and group 2: Angle Closure Glaucoma (n = 67). Success criterion was measured as Intraocular Pressure ≤21 mmHg with (qualified) or without (complete) use of Antiglaucoma medications.

Results: A total number of 108 eyes of 137 patients were undertaken. Mean preoperative Intraocular pressure in group 1 was 31.4 ± 10.5 mmHg and in group 2 was 33.1 ± 9.4, which reduced to 10.5 ± 3.4, 10.5 ± 2.6, 11.6 ± 3.6, 11.0 ± 2.7, 11.0 ± 2.7 in group 1 and 10.9 ± 2.8, 12.0 ± 3.8, 12.8 ± 4.9, 12.4 ± 3.9, 12.4 ± 3.7 in group 2 with P value = 0.566, 0.032, 0.168, 0.049, 0.049 at three, six months, one, two, three years, respectively, with P < 0.001 at each visit. The number of Antiglaucoma medications was reduced from 0.75 ± 0.89 to 0.43 ± 0.55 at 3 yrs (P = 0.002). At 36 months follow-up, overall, 50.0% and 48.2% of eyes achieved complete and qualified success, respectively. Sub-group analysis showed that the success rate was higher in group 1 (68.3%) compared to group 2 (55.2%). Overall, complications such as hypotony (1.8%), choroidal detachment (2.8%), encapsulated bleb (2.8%), and bleb leakage (1.8%) were encountered.

Conclusion: Primary Trabeculectomy with Mitomycin C is a safe and effective means of controlling Intraocular Pressure in both groups with good success and low rates of sight-threatening complications.
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http://dx.doi.org/10.4103/ijo.IJO_1328_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6611248PMC
July 2019

Monotherapy of topical tacrolimus 0.03% in the treatment of vernal keratoconjunctivitis in the pediatric population.

J AAPOS 2019 02 19;23(1):36.e1-36.e5. Epub 2019 Jan 19.

Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India.

Purpose: To report the results of treating children with vernal keratoconjunctivitis (VKC) using a monotherapy of topical tacrolimus 0.03%.

Methods: This was a prospective, nonrandomized observational study of children newly diagnosed with VKC. The severity of the disease was graded on a 4-point scale of symptoms and signs. Patients were treated with tacrolimus 0.03% ointment and were followed for 8 months according to a schedule based on the severity of the disease. The primary measure of treatment efficacy was the change in the score of objective signs. The incidence and severity of adverse events, if any, were recorded.

Results: A total of 45 children aged 5-15 years were enrolled. The mean composite symptom score was 6.84 ± 2.26 at baseline and 0.71 ± 1.62 at 8 months, a statistically significant reduction (P < 0.001). The mean composite sign score was 9.6 ± 3.14 at baseline and 1.16 ± 1.28 at 8 months, also a statistically significant reduction (P < 0.001). Four patients had to be started on steroids within the first month of treatment and were considered treatment failures. Thus, 89% of patients showed significant improvement. No participant experienced adverse effects, although some reported a transient stinging sensation.

Conclusions: In our study cohort topical tacrolimus ointment 0.03% as a monotherapy for VKC was successful in the majority of subjects, and there was no adverse effect.
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http://dx.doi.org/10.1016/j.jaapos.2018.09.010DOI Listing
February 2019

The Aravind Pseudoexfoliation Study: Surgical and First-Year Postoperative Results in Eyes without Phacodonesis and Nonmiotic Pupils.

Ophthalmology 2019 03 17;126(3):362-371. Epub 2018 Oct 17.

Glaucoma Services, Wilmer Eye Institute, Baltimore, Maryland; Department of Ophthalmology, University of Michigan, Ann Arbor, Michigan.

Purpose: To compare intraoperative complication rates, 1-year visual outcomes, and postoperative complication rates over the first postoperative year in eyes with and without pseudoexfoliation undergoing cataract surgery.

Design: Prospective, comparative, interventional study.

Participants: Nine hundred thirty eyes with cataract and uncomplicated pseudoexfoliation (without phacodonesis, clinically shallow anterior chambers, or pupil size <4 mm) and 476 controls with cataract but without pseudoexfoliation recruited from 4 centers of the Aravind Eye Care System in Southern India. The 2 groups were randomized separately to receive either a single-piece acrylic intraocular lens (IOL; SA60AT; Alcon Laboratories, Fort Worth, TX) or a 3-piece acrylic IOL (MA60AS; Alcon Laboratories). The pseudoexfoliation group also was randomized to receive or not receive a capsular tension ring.

Methods: All eyes underwent phacoemulsification with IOL implantation and were followed up at 1 day, 1 month, 3 months, and 1 year after surgery.

Main Outcome Measures: Association of pseudoexfoliation status with intraoperative complication rates, 1-year best-corrected visual acuity, and any other complications.

Results: Mean ages were 63.0±6.9 years and 57.9±7.3 years in the pseudoexfoliation and control groups, respectively (P < 0.001). Pseudoexfoliation patients were more likely to be men (P = 0.014), to have a nuclear opalescence grade of more than 4 (P = 0.001), and to have a pupil size of less than 6 mm (P < 0.001) when compared with controls. Intraoperative complication rates were 2.9% and 1.9% in the pseudoexfoliation and control groups, respectively (P = 0.29). One-year postoperative best-corrected visual acuity was comparable (P = 0.09). Complication rates at 1 year were 2.7% and 2.5% in the pseudoexfoliation and control groups, respectively (P = 0.82). Average endothelial cell loss was 14.7% in the pseudoexfoliation group and 12.7% in the control group at 1 year (P = 0.066) when adjusting for age and nuclear opacity.

Conclusions: Pseudoexfoliation eyes without shallow anterior chamber, small pupils, or apparent zonulopathy may represent eyes with lower risks of complications. Despite smaller pupils and denser cataracts, pseudoexfoliation eyes without clinically apparent preoperative zonulopathy were not at a higher risk of intraoperative or postoperative complications or worse visual outcomes after cataract surgery.
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http://dx.doi.org/10.1016/j.ophtha.2018.10.027DOI Listing
March 2019

Optic nerve aplasia: A case series.

Indian J Ophthalmol 2018 05;66(5):717-719

Chief Medical Officer, Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India.

Optic nerve aplasia (ONA) is a congenital optic nerve anomaly characterized by the absence of optic nerve head, retinal blood vessels, retinal ganglion cells, and optic nerve fibers in a malformed eye. Clinically, the condition presents with the absence of perception of light, afferent pupillary defect and a fundus appearance of absent optic nerve head, and retinal vessels with associated ocular and nonocular abnormalities. Systemic anomalies have been reported with bilateral ONA, whereas unilateral ONA is seen in otherwise healthy individuals. We report three cases of ONA with varied clinical presentations.
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http://dx.doi.org/10.4103/ijo.IJO_1108_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5939177PMC
May 2018

Risk factors for retinopathy of prematurity in a district in South India: A prospective cohort study.

Oman J Ophthalmol 2018 Jan-Apr;11(1):33-37

Retina Department, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India.

Purpose: The purpose of this study was to determine the incidence, severity, and associated risk factors of retinopathy of prematurity (ROP) in a district in South India.

Methods: This was a prospective, observational, cohort study involving babies at risk of ROP conducted in five Neonatal Intensive Care Units in a district in Tamil Nadu, South India. All babies with gestational age at birth of ≤36 weeks and a birth weight (BW) of ≤1900 g with a follow-up period of at least 6 months were enrolled for the study. Neonatal and maternal risk factors were assessed and univariate and multivariate logistic regression analysis performed to examine the predictors of ROP.

Results: A total of 325 infants were screened. ROP was identified in 210 eyes of 106 (32.6%) babies with severe ROP (stage ≥3 ROP) occurring in 14 (13.2%) babies. Low BW (LBW) was the only significant risk factor for ROP on multivariate logistic regression analysis. The mean BW was 1285 and 1452 g for babies with and without ROP, respectively. Treatment was indicated in 22 eyes of 14 (13.2%) infants.

Conclusions: The incidence of ROP was fairly high and strongly associated with LBW. A relatively low incidence of severe ROP was, however, observed. More effort is, therefore, required towards the prevention of preterm births while the present gains in neonatal care should be sustained to reduce the incidence of ROP and thus childhood blindness in the country.
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http://dx.doi.org/10.4103/ojo.OJO_97_2016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5848345PMC
March 2018

Optic disk contractility in morning glory disk anomaly.

J AAPOS 2018 04 1;22(2):154-156. Epub 2018 Feb 1.

Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India.

Morning glory disk anomaly is a nonhereditary, congenital optic disk dysplasia characterized by conical excavation of the posterior fundus with a central glial tuft and radial retinal vessels. We report the case of a 4-year-old girl who presented with esotropia, enophthalmos, no light perception, and afferent pupillary defect in her left eye; fundus examination revealed morning glory disk anomaly. Ultrasound B-scan showed axial length increasing in the left eye on consensual light exposure. Magnetic resonance imaging/angiogram of the brain and orbits were within normal limits except for globe elongation posteriorly in the left eye. On examination under anesthesia with video indirect ophthalmoscopy, the left optic disk showed contraction and expansion when stimulated by strong light to the fellow eye and no spontaneous contraction on direct light stimulation. Morning glory disk contractility with increasing axial length on consensual light exposure in a child has not been reported previously.
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http://dx.doi.org/10.1016/j.jaapos.2017.10.017DOI Listing
April 2018

Unilateral optic nerve aplasia documented with optical coherence tomography-case report and literature review.

J AAPOS 2018 04 7;22(2):152-154. Epub 2018 Mar 7.

Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India.

Optic nerve aplasia is a rare nonhereditary developmental anomaly characterized by congenital absence of the optic nerve, retinal blood vessels, retinal ganglion cells, and optic nerve fibers in a unilaterally malformed eye of an otherwise healthy individual. We report the case of a 6-year-old girl with unilateral optic nerve aplasia documented by optical coherence tomography (OCT). She had no systemic or central nervous system anomalies. Her right eye had no light perception, total afferent pupillary defect, microcornea, variable strabismus, and enophthalmos. The fundus examination showed complete absence of the optic nerve and central retinal vessels characteristic of optic nerve aplasia in the right eye. Computerized tomography and magnetic resonance imaging showed unilateral absence of the optic nerve. Spectral domain OCT showed absence of normal foveal contour, severe atrophy of the retinal layers, extremely thin choroid, and absence of the optic nerve head.
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http://dx.doi.org/10.1016/j.jaapos.2017.09.011DOI Listing
April 2018

Reply to Pediatric optic neuritis: Points to ponder.

Indian J Ophthalmol 2017 11;65(11):1267-1268

Department of Neurophthalmology, Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India.

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http://dx.doi.org/10.4103/ijo.IJO_721_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5700620PMC
November 2017

Glaucoma following childhood cataract surgery: the South India experience.

Int Ophthalmol 2018 Dec 16;38(6):2321-2325. Epub 2017 Oct 16.

Aravind Eye Hospital, Tirunelveli, India.

Purpose: To determine the characteristics and risk factors for the development of glaucoma after cataract surgery in children seen at a major referral tertiary eye centre in South India.

Methods: This is a retrospective review of the medical records of consecutive patients seen at the glaucoma/paediatric eye clinic of the centre, with a diagnosis of glaucoma secondary to aphakia/pseudophakia over a 5-year period.

Results: There were 21 eyes of 14 children that developed glaucoma and 23 eyes of 12 children were selected as control. The mean age (standard deviation SD) at the time of cataract surgery for the glaucoma group was 7.4 (± 10.1) months and 39.13 (± 41.2) months for the control. The mean follow-up (SD) period was 114.29 (± 61.9) months and 97.61 (± 43.5) months for the glaucoma and control, respectively. The mean duration from cataract surgery to onset of glaucoma was 81.19 (± 52.4) months (median 66 months, range 21-172 months). Multivariate analysis detected age at surgery younger than 12 months (OR 10.45, 95%CI 1.76-62.03, p = 0.010) and ocular anomalies mainly microcornea (OR 7.11, 95%CI 1.14-44.46, p = 0.036) as risk factors for development of glaucoma after paediatric cataract surgery.

Conclusion: Glaucoma can develop several years after childhood cataract surgery. Surgery in the first year of life and microcornea are risk factors for the development of glaucoma post-surgery. Signs of glaucoma should specifically be looked for during follow-up visits.
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http://dx.doi.org/10.1007/s10792-017-0728-7DOI Listing
December 2018
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