Routine Ophthalmic Evaluation Research Articles

A STUDY OF THE POTENTIATING EFFECT OF TOPICAL PROPARACAINE 0.5% ON TROPICAMIDE 0.8% AND PHENYLEPHRENE 5% INDUCED MYDRIASIS IN A SOUTHINDIAN POPULATION

Objectives: Pupillary dilatation is an integral part of comprehensive ophthalmic examination. It is also essential for cataract surgery and outpatient laser procedures. Rapid and sustained dilatation is often required. It has been proposed that prior instillation of proparacaine 0.5% can potentiate the effect of the routinely used tropicamide 0.8% phenylephrine 5% combination mydriatic agent. However, certain studies have shown that it is not effective in dark colored iris as compared to light colored iris; hence, this study was done on a predominantly South Indian population with dark iris.
 Methods: Hundred eyes of 50 patients requiring pupillary dilatation as part of routine ophthalmic evaluation were included in the study. The patients were divided into two groups. The study group was given 0.5% proparacaine before instillation of mydriatic agent and the control group was given only tropicamide 0.8% and phenylephrine 5% eye drops. Pupillary dilatation was measured after 15 min and 30 min in both eyes. The end point was taken as 6 mm pupillary dilatation.
 Results: There was a statistically significant difference in the rate of pupillary dilatation between the control and the study group at 15 min and 30 min after instillation of eye drops.
 Conclusion: The study concluded that prior instillation produced faster dilatation even in patients with dark colored iris; hence, we suggest the use of topical anesthetic proparacaine 0.5% in situations where rapid mydriasis is required.

Assessment of Reasons for Presentation in New Primary Glaucoma Patients and Identification of Risk Factors for Late Presentation

To evaluate the reasons for seeking care among South Indian primary glaucoma patients and to determine the relationship of various patient characteristics to glaucoma severity at presentation. Cross-sectional study. One hundred sixty-one new primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG) patients seeking treatment at a tertiary eye hospital. After confirmation of diagnosis, participants' clinical information and their reported reasons for presentation were assessed. Data collected include age, gender, education, occupation, rural or urban residence, distance traveled to the hospital, method of transportation, need for an accompanying person, place of screening before referral or whether they came by themselves for testing. Advanced glaucoma was defined by a cup-to-disc ratio of 0.85 or higher in either eye. The primary outcomes were the various reasons for presentation. The secondary outcome was to determine whether a relationship existed between the patient characteristics mentioned above and presentation with advanced glaucoma. The mean age of the participants was 60.8 years. The primary reason for presentation was defective vision (55.2%) followed by routine ophthalmic evaluation (13%). Sixty-four patients (39.8%) showed advanced glaucoma in at least 1 eye at presentation. Unilateral blindness was noted in 18 patients (11.2%). The mean vertical cup-to-disc ratio was 0.66 (standard deviation [SD], ±0.16) in the better-seeing eye and 0.76 (SD, ±0.12) in the worse-seeing eye. The mean presenting intraocular pressure was 22.9 mmHg in POAG and 25.5 mmHg in PACG patients. Multivariate logistic regression analyses showed that people who are currently unemployed (P < 0.001; odds ratio [OR], 4.19; 95% confidence interval [CI], 1.95-8.99) and rural residence (P= 0.04; OR, 0.46; 95% CI, 0.21-0.99) had greater odds of demonstrating advanced glaucoma at presentation. Presentation with defective vision, older age, and education less than college graduation were associated with greater odds of showing advanced glaucoma in univariate analysis, but not in multivariate analyses. In a South Indian population, absence of work and rural residence was associated with advanced glaucoma at presentation. The population in whom these risk factors are common should be targeted for screening and outreach.

Routine slit lamp examination procedures: A risk for severe acute respiratory syndrome coronavirus 2 infection to eye care professionals.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a highly infectious coronavirus, has been rapidly spreading after its surge in China in December 2019. It is currently a global pandemic. A myriad of transmission routes have been documented, however established thus far, are respiratory droplet, contact and airborne transmissions. Susceptible persons at proximity, usually within 1-2 m, to infected persons are largely at risk of being infected. Unfortunately, health workers usually evaluate patients within this distance. Eye care professionals (ECPs) are faced with a higher risk scenario of being infected as they undertake routine clinical eye examination procedures at a close face-to-face proximity to patients, which place them at a high risk of respiratory droplets and aerosolised particles, particularly from asymptomatic and pre-symptomatic carriers. The slit lamp examination procedure is typically at a distance of between 0.25 m and 0.5 m. While undertaking certain procedures on the slit lamp, such as gonioscopy and slit lamp indirect ophthalmoscopy, the ECP holds the accessory lenses either directly on the patient's eye or at about 5-10 cm from the patient's face, respectively. The authors found it pertinent to articulate this narrative review article to guide slit lamp examination practice by ECPs during routine ophthalmic evaluation, with a view to reducing the spread of SARS-CoV-2 to ECPs. In conclusion, ECPs are at increased risk of infection due to high-risk scenarios for routine slit lamp examination procedures of the eye. Adherence to standard precautionary measures with slit lamp use is highly recommended.

Resident Perspectives

Resident Perspectives

The impact of ocular tuberculosis on vision after two months of intensive therapy

Tuberculosis is an infectious disease of global importance with major economic and social burden accounting for 25% of all avoidable deaths in developing countries. Extrapulmonary involvement may occur either in association with clinically apparent pulmonary tuberculosis or in isolation. This cross-sectional descriptive study aimed to evaluate the impact of ocular tuberculosis in visual acuity at baseline and after two months of intensive anti-tuberculous therapy. A sample of 133 pulmonary tuberculosis patients, seven disseminated tuberculosis, and three pleural tuberculosis patients was evaluated. All patients underwent routine ophthalmic evaluation, including assessment of visual acuity, biomicroscopy, applanation tonometry, indirect ophthalmoscopy, and fluorescent angiography as appropriate. None of the patients had impaired visual acuity due to tuberculosis. A rate of 4.2% (6/143) of ocular involvement was found. None of the patients with ocular involvement were HIV-infected. Of the six patients with ocular involvement, five met the diagnostic criteria for probable and one for possible ocular lesions. As for the type of ocular lesions, two patients had bilateral findings: one had sclerouveitis and the second had choroidal nodules. The other four patients presented with unilateral lesions: peripheral retinal artery occlusion in the right eye (one case), choroidal nodules in the left eye (one case), and choroidal nodules in the right eye (two cases). Patients progressed favorably after two month of intensive therapy, with no significant reduction in vision.

Correlation of ocular manifestations with the duration and activity of disease in patients with rheumatoid arthritis

Background: Rheumatoid arthritis (RA) is a chronic inflammatory arthritis which can affect extra-articular tissues including eyes. Objective: This study was aimed to evaluate the ocular manifestations, their correlation with the duration and activity of disease in patients with RA. Materials and Methods: Patients diagnosed with RA of disease onset age >20 years, irrespective of sex were selected for the study. The eye manifestations were done clinically and also with the help of slit lamp, ophthalmoscope and Schirmer’s test. The findings were statistically analysed. Result: One hundred cases of RA were selected (mean age 52.54 years). Keratoconjunctivitis sicca was the commonest finding (40%) along with few cases of keratitis (3%), scleritis (1%) and episcleritis (1%). A statistically significant negative correlation was found between the duration of disease and the Schirmer score (r=-0.785; p=0.001). Further, no statistically significant correlation between ocular manifestation and the disease severity were found. Higher ophthalmic involvement was found in seropositive patients. Conclusion: The commonest ocular manifestation found was keratoconjunctivitis sicca. The frequency and severity of involvement of eyes were found to be significantly associated with the duration of the disease. This emphasizes the need for the routine ophthalmic evaluation of RA patients on a periodic basis for the early detection as well as the prevention of ophthalmic complications and thereby modifying treatment.

Ocular disorders in stroke patients in a tertiary hospital in Nigeria.

Stroke is a medical emergency of public health importance which affects the physical, mental, and emotional well-being of its victims. Management and rehabilitation are cumbersome for patients and caregivers. Ocular involvement and visual loss could further increase the burden of care. To determine the prevalence of ocular disorders in patients with stroke in a Tertiary Hospital in Nigeria. A descriptive hospital-based study was performed on all consenting and conscious adult patients aged 18 years and above with a diagnosis of stroke made within 1-year who were admitted to the stroke ward or attended the stroke clinic of the Neurology Unit in the Department of Medicine, University of Benin Teaching Hospital, Benin City from October 2013 to December 2013. A total of 170 eyes of 85 patients were studied with a mean age of 66.08 years ± 10.99; range 43-88 years. There was a male: female ratio of 2.6:1. Ocular abnormalities were documented in 95.5% of the patients. A presenting visual acuity of ≥6/18 was found in 66.7%. Mild ptosis and exotropia were seen in 2.9% and 0.6% of the eyes respectively. Intraocular pressure was between 10-21 mmHg in 87.7% eyes while 11.8% eyes had afferent pupillary defects. Cataract was seen in 71.8% eyes and optic nerve head changes in 48.8% eyes which includes temporal disc pallor and glaucomatous optic neuropathy in 29.4% and 14.2% eyes, respectively. Abnormalities found in the retina include retinal hemorrhages in 10.6% eyes, cotton wool spots in 2.4% eyes, and hard exudates in 7.8% eyes. Retinal vascular abnormalities were documented in 32.4% eyes. Visual complaints following stroke were documented in 9.6% of the patients. Ocular abnormalities are present in patients with stroke, mostly due to predisposing risk factors for stroke, and age-related changes. Routine ophthalmic evaluation is suggested in the management of patients with cerebrovascular accident in our environment for better quality of care.

Bilateral multiple primary iridociliary cysts – A rare case report

Iridociliary cysts are often found in patients as an incidental finding during a routine ophthalmic evaluation and if asymptomatic do not require any treatment per se. However, these are often mistaken as iris melanoma and the patient is managed accordingly causing a great deal of inconvenience to the patient as well as the doctor. Case presentation A 69 year old male presented to the ophthalmic out-patients department for routine ophthalmic evaluation. On examination, he is best corrected visual acuity was 6/9, N6 in both eyes. Post-mydriasis evaluation showed a Grade II nuclear cataract in both eyes. There was a smooth, pigmented mass with a rounded surface projecting from behind the iris resembling an iris melanoma. On further evaluation, he was found to have multiple ciliary body cysts. Conclusion Ultrasound biomicroscopy is a valuable technique in diagnosing iridociliary cysts.

Have You Tested Your Goldmann Tonometer Today?

Intraocular pressure (IOP) is the only known modifiable risk factor for glaucoma. Besides being a cornerstone in glaucoma management, accurate measurement of IOP forms an important component of routine ophthalmic evaluation. Despite the innovation of various newer tonometers, Goldmann applanation tonometer is still considered the Gold standard for IOP measurement. However, there are several reported sources of error including calibration error.1 Errors in calibration of Goldmann applanation tonometer are often overlooked in clinical practice. Kumar and Jivan2 conducted a questionnaire survey of 100 ophthalmology residents from UK. 85% of respondents to their questionnaire never checked tonometers for errors.2 Wessels and Oh3 did a field survey of 94 ophthalmologists’ offices to assess the accuracy of tonometers in daily use. Less than 15% of ophthalmologists in their study knew how to perform calibration error testing.3 Given the importance of applanation tonometry in glaucoma management and the ease of calibration error testing, these figures are surprising.

Primary Bilateral Multifocal Choroiditis as an Initial Manifestation of Disseminated Cryptococcosis in a HIV-Positive Patient

Purpose: To report a rare case of primary bilateral multifocal choroditis due to disseminated cryptococcus infection in a HIV-positive patient. Methods: Retrospective report. A 30-year-old asymptomatic HIV-positive male referred to us for a routine ophthalmic evaluation had bilateral, multiple choroidal lesions. CSF confirmed cryptococcus by India ink preparation and antigen by latex agglutination. The lesions began to resolve with intravenous amphotericin B and oral fluconazole. Conclusions: Asymptomatic, primary, bilateral multifocal choroiditis due to cryptococcus is rare. A routine ophthalmic examination in HIV-positive patients can alert the treating physician to a possibility of a fatal disease.

The Male Eyebrow: A Topographic Anatomic Analysis

To study and quantify the topographic anatomy of the male eyebrow and its 3-dimensional relation, based on age and location, relative to the eye and the supraorbital rim. A prospective cohort of male patients seen for routine ophthalmic evaluation age 10 years and older had several eyebrow measurements incorporated in the examination. The presence or absence of brow ptosis was noted on the basis of observation. The location of the eyebrow relative to the center of the pupil, the lateral canthus, and the depth of the supraorbital rim was measured. The data were subjected to statistical analysis. The study included 444 eyebrows of 222 patients ranging in age from 10 to 86 years, with a mean age of 46.75 years. The incidence of brow ptosis was 7.4%. The mean distance between the lateral canthus and inferior brow (LIBD) was 11.23 mm. The mean distance between the pupil and the inferior brow and the superior brow border was 11.15 mm (PIBD) and 19.8 mm (PSBD), respectively. Statistical analysis demonstrated that the mean brow position did not vary with age. However, there was a significant negative correlation between the position of the eyebrow and the depth of the superior sulcus below the supraorbital rim (correlation coefficient, 0.431 for PIBD and depth and 0.381 for LIBD and depth, respectively). Deeper-set eyes had lower brow position. The male eyebrow sits along the supraorbital ridge and has a flat contour. In men without frank brow ptosis, the eyebrow position relative to the pupil and the lateral canthus does not significantly fall with age despite the periocular changes associated with aging. However, 3-dimensional analysis demonstrates that individuals with deep-set eyes have a lower positioned eyebrow then those with a more shallow depth below the supraorbital rim. These findings are helpful in surgical management of the eyelid-eyebrow continuum. The age-related changes in the eyebrow area should be thought of as a 3-dimensional construct with collapse of the structure and not simply descent of the eyebrow.

Changes in the ocular surface: initial observations from a pilot study of diagnostic radiology technicians (radiographers).

The purpose of this study was to evaluate the clinical and cytological changes in the ocular surface of radiology technicians (radiographers) exposed to diagnostic doses of radiation. The Schirmer, Rose Bengal staining and Tear-Break-Up-Time tear function tests were carried out following routine ophthalmic examination in 15 radiology technicians (group I) and 15 controls (group II). Impression cytology was performed by placing 5-mm-thick half-circular cellulose acetate filter paper in the upper and lower quadrants around the limbus. The cytological evaluation was made using the mapping technique. Significantly increased dry eye was detected in group I. In the impression cytology investigation, squamous metaplasia and intraepithelial lymphocytic infiltration was noted in all the group-I cases. A distinct change was observed between the regions showing squamous metaplasia and neigbouring normal epithelial cell structure. Dry eye and ocular surface cytological changes were observed in diagnostic radiology technicians. Routine ophthalmic evaluation of radiology technicians would be beneficial in detecting early cytological changes and dry eye.