Publications by authors named "Viney Gupta"

149 Publications

Hyperproliferative embryotoxon simulating double cornea.

BMJ Case Rep 2021 Dec 22;14(12). Epub 2021 Dec 22.

Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, Delhi, India

Posterior embryotoxon, an anteriorly displaced Schwalbe's line, is the most common feature of Axenfeld Rieger syndrome. We report a case of Axenfeld anomaly with unusual corneal manifestation, that is, a fairly symmetric, hyperproliferated posterior embryotoxon mimicking double cornea as well as a double pupil.
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http://dx.doi.org/10.1136/bcr-2021-246960DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8704954PMC
December 2021

Validating the use of U-tool as a novel method for measuring the corneal diameter in infants screened for congenital glaucoma.

Indian J Ophthalmol 2022 Jan;70(1):143-146

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Purpose: The Castroviejo caliper is routinely used for measuring the corneal diameter in patients with primary congenital glaucoma, but needs an examination under anesthesia (EUA) or sedation. A simple U-shaped tool was devised to aid in the estimation of the corneal diameters of patients in settings where an ophthalmic caliper is not available or EUA is not feasible.

Methods: Infants presenting to the congenital glaucoma clinic posted for EUA were recruited. The demographic details of the patients such as age, sex, and diagnosis were noted. A simple U-shaped tool was devised using three Schirmer strips or a printable ruler. Before the patient underwent a EUA, the corneal diameters were measured using the U-tool. During EUA, corneal diameters were measured using the Castroviejo caliper.

Results: The mean age of infants was 6.7 ± 3.39 months (R = 1-12). The mean corneal diameter measured using the U-tool was 13.29 ± 1.33 mm and with Castroviejo caliper was 13.18 ± 1.39 mm. The difference between the corneal diameters measured using the two techniques was -0.114 mm with the Bland-Altman plot 95% Limits of agreement (LoA) from -0.965 to 0.737 mm. Corneal diameters measured with both instruments had a good correlation (Pearson's correlation coefficient = 0.95, P < 0.001).

Conclusion: U-tool can be used for screening congenital glaucoma by first-contact physicians or optometrists. It can also be used by ophthalmologists when EUA is delayed.
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http://dx.doi.org/10.4103/ijo.IJO_930_21DOI Listing
January 2022

Goniotomy on Goat's Eye (GOGE) Model: To Improve Angle-based Surgery Skills of the Residents.

Curr Eye Res 2021 Dec 20:1-4. Epub 2021 Dec 20.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Purpose: To describe a realistic goat's eye model to aid in surgical training of ophthalmology residents for improvising skills in intraoperative gonioscopy and incisional goniotomy surgery.

Methods: This study provides a descriptive report explaining the step-by-step methodology for setting up a goat's eye model to train the ophthalmology residents in both intra-operative gonioscopy and incisional goniotomy. The goat's eyeball was prepared and mounted within the socket of a mannequin head. The mannequin head was tilted and microscope angulation was adjusted to allow adequate visualization of angle structures. Following intra-operative visualisation of angle structures through a Swan Jacob lens, incisional goniotomy was performed using a microvitreo-retinal blade on approximately 120° nasal angle. The model was found to produce reproducible results when tested on 22 trained residents.

Conclusion: The Goniotomy on Goat's Eye (GOGE) model can provide a realistic and a relatively inexpensive tool for resident surgeons to develop bimanual coordination and enhance their surgical skills to perform effective intraoperative gonioscopy and incisional goniotomy surgery.
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http://dx.doi.org/10.1080/02713683.2021.2018468DOI Listing
December 2021

Artificial intelligence integrated smartphone fundus camera for screening the glaucomatous optic disc.

Indian J Ophthalmol 2021 Dec;69(12):3787-3789

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/ijo.IJO_1831_21DOI Listing
December 2021

A genomewide association study on individuals with occludable angles identifies potential risk loci for intraocular pressure.

J Genet 2021 ;100

National Institute of Biomedical Genomics, P.O.: N.S.S, Kalyani 741 251, India

Glaucoma is a heterogeneous group of optic neuropathies and is one of the leading causes of irreversible blindness worldwide. Primary angle closure glaucoma (PACG) is a major subtype, prevalent mostly in east and south Asia, where occludable anterior chamber angle is considered as a primary risk factor, which in turn could be responsible for high intraocular pressure (IOP) and subsequent neurodegeneration of retinal ganglion cells. Clinically, IOP is considered as a major risk factor for glaucoma and viewed as an important endophenotype to promote the disease severity. To investigate the comprehensive genomic insights, we conducted a genomewide association study (GWAS) on IOP in individuals with occludable angle (<15 degrees), thus anatomically predisposed to PACG. After performing GWAS on IOP, we identified 25 genomewide suggestive significant loci (<1e, = 240) of which, six were in complete linkage disequilibrium with the genic region. We successfully replicated the most significant discovery, SNPs of (rs2065712) in a separate cohort of 89 individuals ( =1.16e). We identified multiple SNPs in to be associated with IOP. Also, we obtained genes harbouring significantly associated SNPs, included in relevant biological pathways that could potentially be involved in IOP variation and glaucomatous neurodegeneration.
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January 2021

Exome sequencing identifies procollagen-lysine 2-oxoglutarate 5-dioxygenase 2 mutations in primary congenital and juvenile glaucoma.

Indian J Ophthalmol 2021 Oct;69(10):2710-2716

Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India.

Purpose: To report the association of procollagen-lysine 2-oxoglutarate 5-dioxygenase 2 (PLOD2) mutations with bilateral primary congenital glaucoma (PCG) in monozygotic twins and with nondominant juvenile-onset primary open-angle glaucoma (JOAG).

Methods: We utilized family-based whole-exome sequencing to detect disease-causing mutations in a pair of monozygotic twins with de-novo PCG and compared its existence in 50 nonfamilial cases of JOAG and 30 healthy controls. To validate the identified mutations, direct Sanger sequencing was performed. For further evaluation of gene expression in the ocular tissues, we performed whole-mount in situ hybridization in zebrafish embryos.

Results: We identified a novel missense mutation (c.1925A>G, p.Tyr642Cys) in the PLOD2 gene in the monozygotic twin pair with PCG and another missense mutation (c.1880G>A, p.Arg627Gln) in one JOAG patient. Both mutations identified were heterozygous. Neither the parents of the twins nor the parents of the JOAG patient harbored the mutation and it was probably a de-novo change. The zebrafish in situ hybridization revealed expression of the PLOD2 gene during embryogenesis of the eye.

Conclusion: We observed an association of PLOD2 mutations with PCG and with nonfamilial JOAG. This new gene needs to be further investigated for its role in pathways associated with glaucoma pathogenesis.
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http://dx.doi.org/10.4103/ijo.IJO_1750_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8597539PMC
October 2021

Juvenile-onset Open-angle Glaucoma - A Clinical and Genetic Update.

Surv Ophthalmol 2021 Sep 15. Epub 2021 Sep 15.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. Electronic address:

Juvenile-onset open-angle glaucoma (JOAG) is a subset of primary open-angle glaucoma that is diagnosed before 40 years of age. The disease may be familial or non-familial, with proportions varying among different populations. Myocilin mutations are the most commonly associated. JOAG is characterized by high intraocular pressures (IOP), with many patients needing surgery. The mean age at diagnosis is in the 3 decade, with a male preponderance. Myopia is a common association. The pathophysiology underlying the disease is immaturity of the conventional outflow pathways, which may or may not be observed on gonioscopy and anterior segment optical coherence tomography. The unique optic nerve head features include large discs with deep, steep cupping associated with high IOP-induced damage. Progression rates among JOAG patients are comparable to adult primary glaucomas, but as the disease affects younger patients, the projected disability from this disease is higher. Early diagnosis, prompt management, and life-long monitoring play an important role in preventing disease progression. Gene-based therapies currently under investigation offer future hope.
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http://dx.doi.org/10.1016/j.survophthal.2021.09.001DOI Listing
September 2021

In Vivo Imaging of the Schlemm's Canal and the Response to Selective Laser Trabeculoplasty.

Am J Ophthalmol 2021 Jul 18;234:126-137. Epub 2021 Jul 18.

From the Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.. Electronic address:

Objective: To evaluate the presence of angle dysgenesis on ASOCT (anterior segment optical coherence tomography) (ADoA) as a predictive factor in determining outcomes of selective laser trabeculoplasty (SLT).

Design: A prospective clinical cohort study.

Subjects: Patients with juvenile-onset open-angle glaucoma (JOAG) without angle dysgenesis on gonioscopy.

Method: JOAG patients with uncontrolled intraocular pressure (IOP), who were to undergo SLT, were evaluated for the presence or absence of ADoA, which was defined as the absence of Schlemm's canal (SC) and/or presence of a hyperreflective membrane (HM) over the trabecular meshwork, as identified on ASOCT before the SLT procedure. Furthermore, the number of ASOCT B-scans in which SC was identified as present, were then quantified. Success of SLT was defined as a reduction of IOP by 20% or more from pre-laser value at 6-month follow-up without any further IOP-lowering medication or surgery. Only 1 repeat SLT was admissible for defining SLT success over the 6-month period. A successful reduction in IOP at 6-month follow-up was correlated with the extent of ADoA.

Results: In comparison to pre-SLT IOP, 57.1% eyes (20/35) showed more than 20% reduction in IOP at 6 months with a mean reduction of 7.6 ± 1.8 mm Hg (29.6%). When all 3 observers agreed, SC was identified in 90% eyes (18/20) with success vs 26.6% eyes (4/15) with failure (P < .001). All eyes (5/5) with presence of HM showed failure (P < .001). All eyes (19/19) in which SC was present in >50% ASOCT B scans (>25/50 scans/eye) showed success (P < .001). On a bias-reduced regression analysis, the identification of SC on any 2 consecutive scans increased the chances of success at 6 months by 8.3 times, whereas the identification of SC in >50% of ASOCT scans was associated with a 21.4 times greater chance of success.

Conclusions: The presence of SC on ASOCT is a strong predictor for successful IOP reduction after SLT in JOAG eyes.
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http://dx.doi.org/10.1016/j.ajo.2021.07.002DOI Listing
July 2021

Need of additional iridotomies despite lens extraction in spherophakes.

BMJ Case Rep 2021 Apr 19;14(4). Epub 2021 Apr 19.

Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India.

Spherophakes are known to have irregular anterior chamber (AC) depths due to their poorly supported zonules. This irregularity leads to an unstable AC, often resulting in angle closure glaucoma from anterior subluxation of globular lenses. A peripheral iridotomy may be helpful to encourage aqueous drainage in initial stages, however, is not often required once lens is extracted. But, we have observed persistent instability of AC in spherophakic eyes despite lens extraction, leading to frequent iridocorneal contact locally over some quadrants. The presumed aetiology in such scenarios could be constant anteroposterior instability of IOL-bag complex due to generalised zonulopathy and hence localised iris bombe in areas with previous iridocorneal contact. Timely identification and performing additional iridotomies during surgery at such sectors even after lens extraction facilitated symmetric deepening of the AC. Hence, we recommend use of additional iridotomies at areas with persistent iridocorneal contact even after lens extraction.
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http://dx.doi.org/10.1136/bcr-2021-242838DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8057550PMC
April 2021

Myopia and glaucoma progression among patients with juvenile onset open angle glaucoma: A retrospective follow up study.

Ophthalmic Physiol Opt 2021 05 7;41(3):475-485. Epub 2021 Apr 7.

Glaucoma Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Objective: To identify the risk factors for glaucoma progression, especially the association with myopia, among treated juvenile open angle glaucoma (JOAG) patients.

Methods: Glaucomatous progression was analysed in the eyes of JOAG patients with at least 5-years of follow up in this retrospective study. Baseline variables such as age, inheritance pattern, baseline intraocular pressure (IOP), baseline central corneal thickness, visual acuity, baseline refractive error, spherical equivalent (SE) and duration of follow-up were noted. Stereoparametric global trend analysis and Moorfields Regression Analysis on confocal scanning laser ophthalmoscopy were used to detect progression. Variables associated with glaucoma progression, with respect to progressors (PG) and non-progressors (NPG) were analysed. Since both eyes of a patient were taken for analysis, a generalised estimating equation method was used to correct the bias.

Results: Among 74 eyes (37 subjects), glaucoma progression was noted in 11 eyes (14.9%) of 8 patients, with a median time to progression of 7.4 years (range 5-15.5 years). For myopes (SE ≤ -1.00 D), glaucoma progression was 18 times more likely than mild and no myopes (>-1DS) (p = 0.03, 95% CI: 1.14, 217.44). The prevalence of myopia in the JOAG, PG and NPG cohorts was 70.3%, 87.5%, and 65.5%, respectively. Myopia progression was noted at follow up in 70% patients. One-unit increase in baseline vertical cup disc ratio, 1 mmHg increase in IOP fluctuations and 1 dB year depression of visual field were associated with 0.44, 0.06 and 0.07 D year increases in the rate of myopia progression, respectively.

Conclusions: JOAG progressors had a greater baseline myopic refraction and a faster myopia development over time. The development of myopia in JOAG eyes could be an indicator of glaucoma progression, and hence progressing myopic (≤-1 D) JOAG patients should be followed up more rigorously.
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http://dx.doi.org/10.1111/opo.12805DOI Listing
May 2021

Trabeculectomy: is releasable suture trabeculectomy a cause of better bleb?

Rom J Ophthalmol 2021 Jan-Mar;65(1):54-58

Dr. Rajendra Prasad Center for Ophthalmic Sciences, AIIMS New Delhi, India.

To compare the outcome of fixed suture trabeculectomy with releasable suture trabeculectomy in terms of IOP control, bleb morphology, complications and need of antiglaucoma medication post-surgery. This study enlisted 200 cases of open angle glaucoma, whose IOP was uncontrolled despite maximal medication. Trabeculectomy was performed using releasable suture in one group of 100 patients and fixed suture in another group of 100 with mitomycin 0.02% in both groups. The study was randomized, the method being the simple randomization. Fornix based trabeculectomy was done in both groups. Two 10-0 nylon releasable sutures were used at two corners of the rectangular flap and one fixed 10-0 vicryl suture was used in the center of the flap. Two mattress sutures (conjunctiva cornea) were also used. Essentially, all the sutures were removed postoperatively over a period of 2-4 weeks depending upon the level of IOP. Mitomycin c 0.02% was used in both groups. The mean preoperative intraocular pressure was 33 ± 12 mmHg in the single suture group and 39 ± 13 mmHg in the releasable suture group (p). We observed a highly significant reduction of intraocular pressure at all times in both groups compared with the preoperative intraocular pressure (P, 0.0001). There was an obvious difference between the bleb morphology between conventional trabeculectomy and releasable suture trabeculectomy. Blebs in releasable suture trabeculectomy were more diffuse, low lying and presented a more ideal vascularity. Releasable suture trabeculectomy is a far much better technique than conventional trabeculectomy. Results are very good in terms of IOP control, post-operative complications, and bleb morphology. They may possibly have a role in wound modulation thereby achieving an ideal bleb, though more large sample studies need to be done.
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http://dx.doi.org/10.22336/rjo.2021.10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7995504PMC
September 2021

Aniridia with Persistent Pupillary Membrane.

Ophthalmol Glaucoma 2021 Mar-Apr;4(2):208

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1016/j.ogla.2020.12.004DOI Listing
October 2021

Functional evaluation of the macular area in early glaucoma using microperimetry.

Indian J Ophthalmol 2021 04;69(4):876-881

Glaucoma Research Facility and Clinical Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Purpose: To evaluate the central visual field by microperimetry (MP), in early glaucoma.

Methods: Consecutive perimetrically experienced patients with a single nasal step or arcuate scotoma and 14 control eyes underwent MP. Retinal sensitivity on MP was mapped for frequency and depth of loss in the central 10° around fixation.

Results: Twenty-one eyes had a single nasal step and 19 eyes with single arcuate scotoma on standard automated perimetry (SAP), with central 10° being normal on 30-2 and 10-2 perimetry. The average mean sensitivity on MP, in glaucomatous and control eyes was 11.8 ± 3.9 dB and 16.6 ± 1.2 dB, respectively, P = 0.0004. The average mean defect on MP-1, in glaucomatous and control eyes was -6.5 ± 2.0 dB and -3.0 ± 1.2 Db, respectively, P = 0.05. The corresponding retinal hemisphere showed significant defects in MP. In eyes with single nasal steps, an absolute scotoma was seen in 14-28% of eyes 8-10° off fixation, moderate to mild defects were seen in 10-52% eyes, and 10% eyes showed involvement up to 4° from the fixation. Eyes with arcuate scotoma had an absolute scotoma on MP in 95% of eyes, 6-10° from fixation, with extension up to 2° from fixation in 21%. In glaucomatous eyes, the normal hemisphere on SAP showed a mild defect on MP in 43%. Control eyes did not show any defect in SAP or MP.

Conclusion: A significant loss of central retinal sensitivity is recorded on MP in early glaucomatous neuropathy as compared to SAP. Paramacular absolute defects were seen at 6-10° from fixation.
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http://dx.doi.org/10.4103/ijo.IJO_1199_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8012941PMC
April 2021

Comparative Evaluation of Rebound and Perkins Tonometers in Pediatric Glaucoma With Varied Corneal Characteristics.

J Glaucoma 2021 04;30(4):312-316

Dr Rajendra Prasad Centre for Ophthalmic Sciences.

Precis: Icare tonometer overestimated intraocular pressure (IOP) as compared with Perkins and this variation was higher in IOP>19 mm Hg and corneal opacity in patients with pediatric glaucoma.

Purpose: To compare the IOP measured by Icare ic200 with Perkins tonometer in pediatric glaucoma with different corneal characteristics.

Methods: Patients of pediatric glaucoma posted for routine examination under anesthesia, age below 12 years were enrolled. All patients underwent IOP measurement with Perkins and Icare ic200 tonometer by the same observer. Basic demographic data and other relevant clinical data were recorded. Central corneal thickness (CCT), horizontal corneal diameter, and corneal characteristics such as cornea clarity was recorded.

Results: A total of 194 eyes of 105 patients were analyzed. The difference between Perkins and Icare IOP was -0.816 mm Hg with the Bland-Altman plot 95% limits of agreement (LoA) from -11.194 to 9.562 mm Hg and 5.1% (10) values lying outside LoA. At IOP <19 mm Hg, the difference was -0.65 mm Hg and IOP ≥19 mm Hg, the difference was higher, -1.12 mm Hg. In the clear cornea group (123 eyes), the difference in IOP by 2 tonometers was -0.776 mm Hg with the Bland-Altman plot 95% LoA between -10.679 and 9.128 mm Hg. In hazy corneas (36 eyes), the difference in IOP was 0.531 mm Hg. The Bland-Altman plot showed 95% LoA between -6.242 and 7.303 mm Hg. In the scarred cornea group (35 eyes), the difference in IOP between the 2 was -2.343 mm Hg and the Bland-Altman plot showed wide 95% LoA from -16.302 to 11.616 mm Hg.

Conclusion: Icare tonometer overestimated IOP as compared with Perkins and this variation was higher in eyes with IOP≥19 mm Hg, CCT >615 μm, and scarred corneas. A moderate correlation between IOP and CCT for both tonometers was noted.
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http://dx.doi.org/10.1097/IJG.0000000000001765DOI Listing
April 2021

Single-port transconjunctival vitrectomy for malignant glaucoma.

J Cataract Refract Surg 2021 Nov;47(11):e14-e18

From the Dr. Rajendra Prasad Center for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India (S. Gupta, Lakra, Beniwal, Chawla, V. Gupta); Iclinix Advanced Eye Care, New Delhi, India (Gogia).

The management of malignant glaucoma involves either anterior vitrectomy with zonulectomy and iridectomy or 3-port core pars plana vitrectomy (PPV) by retinal surgeons. The proposed modification can be performed with reasonable success rates. In this technique, synechiolysis and anterior chamber irrigation were performed through a limbal incision, and a single-port 23- or 25-gauge vitrector was introduced through PPV superotemporally to perform anterior vitrectomy and central posterior capsulotomy in pseudophakic eyes. The same procedure can be performed after cataract surgery in phakic eyes. Vitrectomy is continued until anterior chamber deepens, ensuring a conduit between anterior and posterior chambers through the posterior capsulotomy alone, bypassing the need for a posterior iridectomy/zonulectomy. In a series on 9 eyes, all achieved optimization of anterior chamber depth with intraocular pressure normalization in 8 of 9 eyes, without showing any signs of recurrence at a mean follow-up of 8.6 months.
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http://dx.doi.org/10.1097/j.jcrs.0000000000000519DOI Listing
November 2021

Safety and efficacy of incisional goniotomy as an adjunct with phacoemulsification in primary angle-closure glaucoma.

J Cataract Refract Surg 2021 04;47(4):504-511

From the Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Purpose: To evaluate the intraocular pressure (IOP)-lowering efficacy and safety of incisional goniotomy as an adjunct to phacoemulsification in primary angle-closure glaucoma (PACG) patients.

Methods: Consecutive patients with PACG (high or borderline IOP) deemed fit for phacoemulsification were enrolled. After phacoemulsification, incisional goniotomy was performed with or without goniosynechialysis. Patient demographic profile, clinical data, and adverse events, if any, were analyzed during at least a 6-month follow-up period. Success was defined as IOP of 18 mm Hg or lesser with or without medications.

Setting: Tertiary care Ophthalmic hospital.

Design: Prospective interventional case series.

Results: Of 46 eyes (38 patients) included, 69.6% eyes were classified as having advanced glaucoma. The mean treated IOP decreased by 7.3 ± 1.0 (SE) mm Hg (95% CI, 5.2-9.3) from 21.4 ± 6.6 to 14.2 ± 3.7 mm Hg at a mean duration of 11.7 ± 5.5 months (6-22 months) postoperatively (P < .001, paired t test). There was 66.6% reduction in median number of hypotensive medications (P < .001, Wilcoxon signed-rank test). Observed complications included hyphema (13 eyes [28%]), IOP spike (3 eyes [6.5%]), and cyclodialysis (1 eye [2.17%]). High treated IOP and number of medications were significantly associated with failure in univariate analysis (P < .05, Fisher exact test). The cumulative survival probability for qualified success at 22 months was 87.8% ± 0.07 (95% CI, 0.65-0.96).

Conclusions: Incisional goniotomy as an adjunct with phacoemulsification resulted in a significant and sustained reduction in IOP along with decrease in number of glaucoma medications in chronic PACG eyes, irrespective of the disease stage.
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http://dx.doi.org/10.1097/j.jcrs.0000000000000481DOI Listing
April 2021

Correlation of histopathology of trabecular meshwork with clinical features in primary congenital glaucoma.

Br J Ophthalmol 2022 Jan 16;106(1):60-64. Epub 2020 Oct 16.

Glaucoma research facility and services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Purpose: To correlate histopathological changes of trabecular meshwork (TM) with clinical features in primary congenital glaucoma (PCG).

Methods: This was a prospective interventional study including 66 eyes of 39 PCG children aged ≤12 months at diagnosis. Corneal clarity, corneal diameter (CD), intraocular pressure (IOP) and cup disc ratio (C:D ratio) were assessed at baseline and at 1-year follow-up. The trabecular meshwork (TM) specimens obtained during primary combined trabeculectomy and trabeculotomy augmented with Mitomycin-C were evaluated on light microscopy to look for eosinophilic membrane (EM), status of trabecular beams and trabecular endothelial cells (TEC), presence of intervening spaces, TM thickness and TEC count which were then correlated with clinical features.

Results: At 1-year follow-up, IOP reduced from 27.96±10.2 to 11.88±5.63 mm Hg, p<0.001, C:D ratio decreased from 0.65±0.34 to 0.49±0.06, p=0.036, and the bleb had a significant tendency to change from well formed (59-46) to flat type (3-6) or thin, cystic type (4-14) (p=0.014). Presence of EM on the cameral surface was associated with a lower baseline IOP. Fused trabecular beams were associated with higher baseline IOP. The TM was significantly thicker in eyes with IOP >20 mm Hg at presentation (1.86±0.7 mm vs 1.3±0.47 mm, p=0.0356). Eyes with IOP ≤14 mm Hg at final follow-up had lower TEC count than eyes with IOP >14 mm Hg (0.92±0.45 cells/mm vs 1.00±0.74 cells/mm, p=0.0028).

Conclusion: A light microscopic analysis of surgical specimens may guide prognosis of PCG. However, larger studies are required to validate these results.
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http://dx.doi.org/10.1136/bjophthalmol-2020-316346DOI Listing
January 2022

The Descemet Membrane in Primary Congenital Glaucoma.

Cornea 2021 Feb;40(2):172-178

Glaucoma Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Purpose: To evaluate Descemet membrane (DM) morphology in eyes with primary congenital glaucoma (PCG) in vivo using high-definition anterior segment optical coherence tomography (ASOCT) and on histopathology.

Methods: Corneal scans of patients with PCG (22 eyes of 15 patients) were evaluated for DM morphology and anterior chamber angle using ASOCT. The DM thickness in PCG eyes was compared with fellow eyes (8 eyes) of unilateral patients with PCG and healthy controls (12 eyes) on ASOCT. The DM morphology was also compared on the histopathology of corneal tissues (9) obtained from PCG eyes after keratoplasty and enucleated eyes of retinoblastoma (6 controls) on light microscopy with immunostaining for collagen IV.

Results: On ASOCT, all affected eyes showed the presence of either a thickened DM complex or a hyper-reflective double layer representing the thickened DM and pre-Descemet layer (PDL), unlike a single membrane in the controls and fellow eyes. On ASOCT, among patients with PCG, the DM showed significant thickening (32.0 ± 11.2 μm) versus fellow eyes (14.4 ± 3.3 μm) and controls (11.5 ± 1 μm) (P < 0.001; analysis of variance). The thickened DM complex continued peripherally into the trabecular meshwork as an abnormal membrane in 16/22 affected eyes. On histopathology, thickening of DM was also more among PCG eyes (median: 67.9 μm range: 27.2-214.9) versus controls (median: 27.7 μm, range: 22.1-36.1; P = 0.005) as also of PDL (median: 14 μm, range: 5.9-30.5) of PCG versus (median 3.5, range: 1.3-6.7 μm) in controls; P = 0.014.

Conclusions: Thickening of DM and PDL occurs in eyes with PCG and is seen to have a peripheral extension upto the angle recess.
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http://dx.doi.org/10.1097/ICO.0000000000002472DOI Listing
February 2021

Differences in outflow channels between two eyes of unilateral primary congenital glaucoma.

Acta Ophthalmol 2021 Mar 23;99(2):187-194. Epub 2020 Jul 23.

Department of Anatomy and Electron Microscopy Facility, All India Institute of Medical Sciences, New Delhi, India.

Purpose: Primary congenital glaucoma (PCG) occurs in only one eye in some patients. We aimed to characterize anatomical features of the angle and Schlemm's canal (SC) in vivo among fellow eyes of patients with unilateral primary congenital glaucoma.

Methods: Both eyes of 33 children with unilateral PCG and 30 healthy, age-matched children, old enough to co-operate were analysed using high-resolution anterior segment spectral domain (SD) OCT. Subgroup analysis was done for the presence/absence of angle dysgenesis as defined by the presence of abnormal tissue/hyper-reflective membrane within angle recess and/or the absence of SC. Other anatomical landmarks differentiating the fellow eyes from eyes with glaucoma were also evaluated and compared with healthy subjects.

Results: The presence of abnormal tissue at the angle and/or a hyper-reflective membranous structure covering the meshwork was seen in all affected PCG eyes (100%) and in 21 (63%) unaffected fellow eyes; p = 0.001. The SC could be seen in 8 (24%) affected in comparison with 29 (88%) fellow unaffected eyes; p = 0.001. The ASOCT scans of 54 (90%) healthy eyes and 3 (9%) fellow PCG eyes revealed a direct communication of anterior portion of the SC with the anterior chamber. Among the fellow eyes, a communication of the supraciliary space with anterior chamber could be discerned in 26 eyes (79%).

Conclusions: Despite angle dysgenesis, outflow channels such as the uveoscleral or a direct communication of SC with the anterior chamber play a role in preventing the development of glaucoma in fellow eyes of unilateral PCG.
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http://dx.doi.org/10.1111/aos.14540DOI Listing
March 2021

Quantification of Iridotrabecular Contact in Primary Angle-Closure Disease.

J Glaucoma 2020 08;29(8):681-688

Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Precis: Iridotrabecular contact (ITC), a measure of angle closure, can be quantified along with other angle parameters on anterior segment optical coherence tomography (ASOCT). Hence, angle changes and angle closure mechanisms can be detected predicting the efficacy of iridotomy.

Purpose: To assess 360-degree ITC and ocular parameter changes, after laser peripheral iridotomy (LPI), in primary angle-closure disease (PACD) subgroups.

Methodology: This was a prospective observational study including 90 subjects, 30 each of primary angle-closure suspect (PACS), primary angle closure (PAC), and primary angle-closure glaucoma (PACG). Anterior segment OCT parameters were measured before and 3 weeks after LPI ITC: central anterior chamber depth, lens vault, angle-opening distance, angle recess area, trabecular iris space area, trabecular iris angle at 500 and 750 μm from scleral spur.

Results: ITC was highest in PACG, 81.43%±22.39%, followed by PAC, 28.53%±21.30%, and PACS, 10.76%± 8.54% (P=0.011). There was a significant decrease in ITC in all 3 groups after iridotomy (P<0.001), with a residual ITC of 68.56%±26.44% in PACG, 18.23%±15.98% in PAC, and 5.13%±5.11% in PACS. A significant positive correlation was seen between the extent of ITC, baseline intraocular pressure, and visual field index. ITC was highest in eyes with exaggerated lens vault (77.3%±32.03%), as compared with eyes having a plateau iris configuration or relative pupillary block configuration (P<0.001).

Conclusions: Iridotomy at any stage of PACD shows a significant decrease in ITC, with areas of residual ITC. Even in PACG, the iridotomy is effective in exposing parts of the trabecular meshwork that had contact earlier. Greater baseline ITC and postlaser ITC are a biomarker for higher intraocular pressure and greater visual field damage, which need lifelong review and appropriate management.
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http://dx.doi.org/10.1097/IJG.0000000000001572DOI Listing
August 2020

Case Report: Cyclodialysis Cleft in a Case of Open-globe Injury and Role of Swept-source Anterior Segment Optical Coherence Tomography in Diagnosis.

Optom Vis Sci 2020 06;97(6):395-399

Glaucoma Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Significance: Cyclodialysis clefts can potentially develop secondary to open globe injury. The swept-source anterior segment optical coherence tomography (SS-AS-OCT) may be a valuable diagnostic tool for the identification and estimation of the circumferential extent of cyclodialysis clefts. It could be considered an alternative when ultrasound biomicroscopy cannot be performed successfully.

Purpose: The purpose of this study was to report a case of open-globe injury associated with cyclodialysis cleft and the utility of SS-AS-OCT in its diagnosis.

Case Report: A 12-year-old boy presented to the clinic because of penetrating ocular trauma to his left eye with a projectile stone. He was diagnosed with limbal perforation with uveal tissue prolapse and cataract. He underwent limbal repair with cataract extraction and posterior chamber intraocular lens implantation. However, even at the 6 weeks' post-operative period, he did not gain vision and had persistent hypotony with hypotonic maculopathy. Gonioscopy showed a 2-clock-hour superonasal cyclodialysis cleft. However, on SS-AS-OCT, it was discovered that the cleft extended along 5 clock hours, involving both superonasal and inferonasal quadrants. Recognizing the large extent of the cleft, endocyclopexy by modified sewing-machine technique was planned and performed. An IOP spike and improvement in vision were noted on the next post-operative day. The SS-AS-OCT confirmed cleft closure.

Conclusions: Although rare, cyclodialysis can occur in cases of open globe injury. The SS-AS-OCT is a useful diagnostic tool to study the circumferential extent of cyclodialysis and may unravel detachments hidden behind intact anterior ciliary body face.
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http://dx.doi.org/10.1097/OPX.0000000000001518DOI Listing
June 2020

Trabeculectomy on Animal Eye Model for Resident Surgical Skill Training: The Need of the Hour.

Curr Eye Res 2021 01 16;46(1):78-82. Epub 2020 Jun 16.

Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences , New Delhi, India.

: To describe a goats' eye training model for teaching of trabeculectomy and releasable suture techniques for Ophthalmology residents. : A descriptive report explaining the methodology for setting up a goats' eye wet-lab model for teaching trabeculectomy for Ophthalmology residents. It details the approaches to eyeball preparation, steps of surgery, application and release of two representative types of 'releasable sutures' in a step-by-step manner. : A systematic approach using goats' eye model to teach trabeculectomy and releasable suture techniques can enhance residents' understanding, confidence and expertise to operate upon human eyes.
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http://dx.doi.org/10.1080/02713683.2020.1776880DOI Listing
January 2021

Trabeculectomy in an unsuspected extramedullary iris-ciliary body plasmacytoma.

Eur J Ophthalmol 2021 Sep 21;31(5):NP5-NP8. Epub 2020 Apr 21.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Extramedullary plasmacytoma of the iris and ciliary body is extremely rare. We present a case which was misdiagnosed as granulomatous uveitis with neovascular glaucoma, and underwent a trabeculectomy with mitomycin-c along with iris biopsy. The post-operative period showed early bleb failure and catastrophic growth of the suspected mass. Histopathological examination revealed a diagnosis iris plasmacytoma. Subsequent ultrasound biomicroscopy showed involvement of the iris and ciliary body. A prompt systemic workup was done, and an associated systemic plasma cell dyscrasia was ruled out. The affected eye was enucleated, and the patient remains disease free at the end of 3-year follow-up.
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http://dx.doi.org/10.1177/1120672120920225DOI Listing
September 2021

The mutational spectrum of Myocilin gene among familial versus sporadic cases of Juvenile onset open angle glaucoma.

Eye (Lond) 2021 02 16;35(2):400-408. Epub 2020 Apr 16.

Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India.

Purpose: Juvenile onset primary open angle glaucoma (JOAG) is a rare disorder associated with high IOP and progressive optic neuropathy in patients diagnosed before the age of 40 years. While in some populations it has primarily an autosomal dominant pattern of inheritance, in others it occurs in a primarily sporadic form. The main aim of the study was to assess the relative prevalence of Myocilin (MYOC) mutations in familial versus sporadic cases of JOAG.

Methods: We screened 92 unrelated (sporadic) JOAG patients, and 22 affected families (70 affected members and 36 unaffected) for variations in the MYOC gene. We also analyzed the clinical features associated with these variations.

Results: Three coding sequence variants were identified as mutations causing JOAG. Four families segregated distinct mutations at Gly367Arg, and two families at Gln337Arg, while only two sporadic JOAG cases harbored MYOC mutations (Gly367Arg and Gln48His). The frequency of MYOC mutations in familial cases (27%) was significantly higher than in sporadic JOAG cases (2%); p = 0.001. A 90% penetrance for the Gly367Arg variant was seen by the age of 40 years in our patients. Characteristic allele signatures, indicative of specific founder effects, were not observed for the Gly367Arg mutation that was looked for in 12 patients among 2 geographically close families, which harbored this mutation.

Conclusion: Our data demonstrated that genetic screening for MYOC mutations should be focused toward cases with familial rather than sporadically occurring JOAG.
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http://dx.doi.org/10.1038/s41433-020-0850-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8027054PMC
February 2021

Long-term functional outcomes of different subtypes of primary congenital glaucoma.

Br J Ophthalmol 2020 09 23;104(9):1288-1292. Epub 2019 Dec 23.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All india Institute of Medical Sciences, New Delhi, India

Aim: To analyse long-term visual outcomes across different subtypes of primary congenital glaucoma (PCG).

Methods: Patients with PCG with a minimum of 5-year follow-up post surgery were included in the study. Snellen visual acuity recordings taken at their last follow-up were analysed. We evaluated the results using Kaplan-Meier curves to predict the probability of maintaining good vision (as defined by a visual acuity of 6/18 or better) in our patients after 30-year follow-up. The results were also analysed to determine whether there were any differences in the long-term visual acuities with time between the neonatal and infantile PCG. We also analysed the reasons for poor visual outcomes.

Results: We assessed a cohort of 140 patients with PCG (235 eyes) with an average follow-up of 127±62.8 months (range 60-400 months). Overall, the proportion of eyes with good visual acuity was 89 (37.9%), those with fair visual acuity between 6/60 and 6/18 was 41 (17.4%), and those with poor visual acuity (≤6/60) was 105 (44.7%). We found a significant difference (p=0.047) between neonatal and infantile patients with PCG whereby the neonatal cohort fared worse off in terms of visual morbidity. On Kaplan-Meier analysis, the cumulative probability of survival of a visual acuity of 6/18 or better was more among the infantile PCG in comparison to the neonatal PCG (p=0.039) eyes, and more among the bilateral than the unilateral affected eyes (p=0.029). Amblyopia was the most important cause for poor visual acuity as shown on a Cox proportional-hazards regression model.

Conclusions: Long-term visual outcomes of infantile are better than neonatal PCG. Eyes with unilateral have worse visual outcomes compared with those with bilateral PCG because of the development of dense amblyopia.
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http://dx.doi.org/10.1136/bjophthalmol-2019-315131DOI Listing
September 2020

The immortal Ologen: persisting 10 years after trabeculectomy.

Can J Ophthalmol 2019 12 30;54(6):e305-e308. Epub 2019 Apr 30.

All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1016/j.jcjo.2019.03.004DOI Listing
December 2019

Is this iris or an implant?

Clin Exp Optom 2020 11 19;103(6):920. Epub 2019 Nov 19.

Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1111/cxo.13014DOI Listing
November 2020

Classifying juvenile onset primary open angle glaucoma using cluster analysis.

Br J Ophthalmol 2020 06 28;104(6):827-835. Epub 2019 Sep 28.

Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, Delhi, India

Aim: To classify unrelated patients with juvenile onset primary open angle glaucoma (JOAG) into clinically useful phenotypes using cluster analysis.

Methods: Out of the 527 unrelated patients with JOAG, the study included 414 patients who had all the phenotypic characteristics required for the study. A cluster analysis was performed to classify the patients based on their iris and angle morphology, age of onset, highest untreated intraocular pressure (IOP), worst mean deviation and greatest vertical cup disc ratio of the worst eye. The iris features were broadly classified into three groups: those with normal iris crypts (NIC), those with prominent iris crypts (PIC) and those with absence of iris crypts. The gonio photographs were graded as normal appearing angle or those with angle dysgenesis in the form of a featureless angle, one with a high iris insertion and an angle with prominent iris processes. Using a hierarchical clustering model and a two-way cluster analysis, the distribution of clusters of JOAG was analysed to obtain a classification of JOAG subtypes.

Results: The four major clusters identified were: Cluster 1 with NIC and normal angles had the lowest untreated IOP and higher age of onset among all clusters. Cluster 2 with NIC and featureless angle was found to be associated with earliest age of onset. Cluster 3 had NIC and either a high iris insertion or prominent iris processes. Cluster 4 was a heterogeneous cluster with maximum number of patients in a group comprising of those with PIC and high iris insertion.

Conclusions: Cluster analysis extracted four subgroups of the JOAG phenotype that have clinical and prognostic significance and can potentially be helpful while evaluating these patients in the clinics.
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http://dx.doi.org/10.1136/bjophthalmol-2019-314660DOI Listing
June 2020

Choroidal Vascular Pattern in Cases of Sturge-Weber Syndrome.

Ophthalmol Retina 2019 12 22;3(12):1091-1097. Epub 2019 Jul 22.

Vitreo-retina, Trauma and Uvea Services, Dr. Rajendra Prasad Center for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

Purpose: To study the choroidal vascular pattern in patients with Sturge-Weber syndrome (SWS) using swept-source OCT (SS-OCT).

Design: Prospective comparative observational study.

Participants: All patients with SWS with no history of prior treatment for posterior segment pathology were included.

Methods: Both eyes of all patients were studied using fundus imaging, SS-OCT, fundus fluorescein angiography (FFA), and indocyanine green angiography (ICG) by 2 independent observers.

Main Outcome Measures: The FFA and ICG were screened for any vascular abnormalities. The SS-OCT was evaluated for choroidal changes.

Results: A total of 34 eyes of 17 patients with diagnosed SWS in the age group 9 to 26 years were studied. The FFA and ICG in 7 and 11 patients, respectively, showed some vascular abnormalities. SS-OCT was performed in all patients. The diffuse choroidal hemangioma (DCH) was characterized by loss of the choroidal vascular pattern, increase in the choroidal thickness and loss of visualization of the sclerochoroidal interface. Based on the FFA, ICG, and SS-OCT imaging, there were 3 patients with no DCH, 5 with bilateral DCH, and the remaining 9 patients had unilateral DCH. The detection rate was 50% clinically: 52.94% with FFA, 82.35% with ICG, and 86.36% with SS-OCT. There was substantial agreement between the 2 observers for all 3 investigations.

Conclusion: SS-OCT is a reliable noninvasive imaging modality for early diagnosis and follow-up of DCH over time.
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http://dx.doi.org/10.1016/j.oret.2019.07.009DOI Listing
December 2019

'Ɛ' sign: a clinical clue to the diagnosis of microspherophakia.

Eye (Lond) 2020 03 7;34(3):597-599. Epub 2019 Aug 7.

Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India, 110029.

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http://dx.doi.org/10.1038/s41433-019-0544-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042234PMC
March 2020
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