Deep anterior lamellar keratoplasty outcomes in macular and granular corneal dystrophy – A comparative cross-sectional study Shreesha Kumar Kodavoor, Bijita Deb, Dandapani Ramamurthy Indian Journal of Ophthalmology 2019 67(11):1830-1833 Purpose: To compare the functional and anatomical outcomes (in terms of graft uptake and rejection/failure) of deep anterior lamellar keratoplasty (DALK) in stromal corneal dystrophy (macular and granular). Methods: Sixteen eyes with macular corneal dystrophy (MCD; group A) and 10 eyes with granular corneal dystrophy (GCD; group B) underwent successful DALK by big bubble technique or layer-by-layer dissection. Results: Both groups showed significant improvement in their best-corrected visual acuity postoperatively (postoperative P value in MCD and GCD was 0.00001 and 0.0008, respectively) with no statistically significant differences between the two groups (P = 0.77) at 1 year. Postoperative endothelial count did not drop significantly in group A (MCD, P= 0.1553). Only in seven eyes preoperative endothelial count could be obtained (due to dense stromal corneal opacity), but there was a significant endothelial count difference between preoperative and postoperative count in group B (GCD, P= 0.0405) at the end of 1 year postoperatively which could be because of age and stage of disease (advanced granular dystrophy) and also because of small sample size of GCD compared with MCD. Intergroup comparison between the two groups showed no statistically significant difference (P = 0.6353) with good postoperative outcome in both groups. Conclusion: DALK can be successfully done in both groups and results are comparable. However, long-term outcomes on a large scale need to be further evaluated.

Back to the bedside Santosh G Honavar Indian Journal of Ophthalmology 2019 67(11):1789-1791

A simple pingueculum or not? Victoria Marks, Sara E Lally, Carol L Shields Indian Journal of Ophthalmology 2019 67(11):1792-1792

Vertical rectus transposition procedures for lateral rectus palsy: A systematic review Sagnik Sen, Rebika Dhiman, Rohit Saxena, Swati Phuljhele, Pradeep Sharma Indian Journal of Ophthalmology 2019 67(11):1793-1799 Multiple transposition procedures have been described for management of lateral rectus palsy. However, relative effect and indications of each procedure are unclear. This systematic review was planned to evaluate functional and anatomical outcomes of vertical rectus transposition (VRT) surgery in patients with lateral rectus palsy. We searched databases in English language, namely, MEDLINE, PubMed Central, EMBASE, Google Scholar, Scopus, and Index Copernicus without any date restrictions in electronic searches, using the search words 'vertical rectus transposition for lateral rectus palsy,” “vertical rectus transposition for abducens palsy,” “superior rectus transposition,” “inferior rectus transposition,” and “Hummelsheim procedure.” References of the selected publications were also searched to find any relevant studies. We searched for studies that provided data on single VRT and double VRT surgeries for lateral rectus palsies. Three authors independently assessed the related studies gathered from electronic and manual searches. We found 27 studies which were relevant to the review question. As there were no randomized control trials (RCTs) available related to our study question, nonrandomized studies were used to arrive at summarization of outcomes of different transposition procedures. There is a need for prospective RCTs to investigate the different types of transposition procedures for lateral rectus palsy.

Comparison between Ozurdex and intravitreal anti-vascular endothelial growth factor treatment for retinal vein occlusion–related macular edema: A systematic review and meta-analysis of randomized controlled trials Qiuming Hu, Haoyu Li, Wenhua Xu, Yi Du, Chao Ma, Jianfeng He Indian Journal of Ophthalmology 2019 67(11):1800-1809 This systematic review aimed to evaluate the effectiveness and safety of intravitreal dexamethasone (DEX) implant and intravitreal anti-vascular endothelial growth factor (VEGF) treatments for macular edema (ME) secondary to retinal vein occlusion (RVO), central retinal vein occlusion (CRVO), and branch retinal vein occlusion (BRVO). The electronic databases comprehensively searched for the studies that compared DEX with anti-VEGF treatments in patients suffering from RVO-related ME. The effectiveness was estimated using best-corrected visual acuity (BCVA), central retinal thickness (CRT), and intraocular pressure (IOP). All data were analyzed by Review Manager (RevMan) 5.3. According to the meta-analysis from five randomized control trials, both DEX implant and anti-VEGF agent treatments were effective, but no significant differences in BCVA and CRT were observed between these two treatments. Novartis' two studies indicated that anti-VEGF agents significantly reduced the CRT compared with DEX implant at 6 months [weighted mean difference: 158.53 μm, 95% confidence interval (CI): (71.09, 245.96), P= 0.0004]. Furthermore, anti-VEGF agents showed some advantages on cataract formation [risk ratio (RR): 3.43, 95% CI: (1.35, 8.71), P= 0.009] and other adverse events [RR: 1.19, 95% CI: (1.09, 1.31), P= 0.0002] without heterogeneity (P = 0.20, I2 = 35%). Anti-VEGF agents were also effective treatments for cataract formation or less adverse events for RVO-related ME. In contrast, DEX implant had higher risk for IOP elevation and lower cataract incidence than anti-VEGF agents. Hence, complementary and alternative treatments are expected.

Development and introduction of a communication skills module for postgraduate students of ophthalmology Purvi R Bhagat, Kamini M Prajapati, Rupal B Bhatt, Vipul K Prajapati, Rohit Dureja, Gunjan P Tank Indian Journal of Ophthalmology 2019 67(11):1810-1815 Purpose: Effective communication lies at the heart of a patient--doctor relationship. Communication skills (CS) teaching and assessment is not a part of the postgraduate (PG) curriculum. Lack of effective CS in current PG students' results in patient distrust and dissatisfaction, conflicts, and compromised healthcare. The regulatory authorities of medical education have recognized the need to inculcate soft skills among medical graduates, one of which is CS. The purpose of this study was to assess the need for teaching CS to ophthalmology PG students and develop and introduce a module for the same. Methods: In this prospective, interventional study done at the ophthalmology department of a tertiary hospital, a validated 8 day CS workshop was conducted for 60 PG students through interactive lectures, observations, video sessions, and role plays. Feedbacks were obtained through narratives, validated Google survey, reflections and verbal method and analyzed. Results: In the needs assessment done on 27 departmental faculties, 20 faculties found poor communication to be a major reason for patient complaints. All faculties agreed that CS should be taught to medical students. Statistically significant improvement in CS awareness was noted among students after the workshop. Lack of CS training, work burden, and language were identified as main barriers to effective communication. All the students were satisfied with the workshop and wanted it to be conducted regularly. Conclusion: This study establishes that CS training is essential to improve patient satisfaction and patient-doctor relationships. Barriers to effective CS could be identified, for which possible solutions could be found.

Ophthalmology residency training in India: Comparing feedback about how the training equips ophthalmologists to combat retinal diseases. READS report #6 Parikshit Gogate, Partha Biswas, Taraprasad Das, Praveen Nirmalan, Sundaram Natarajan Indian Journal of Ophthalmology 2019 67(11):1816-1819 Purpose: To document whether the residency training in management of retinal diseases has improved in 2000s to meet the increasing demand of retina care in India. Methods: A survey, using a prevalidated questionnaire, was conducted by Academic and Research Committee (ARC) of the All India Ophthalmological Society (AIOS) in 2014–2016 among ophthalmologists to document teaching of retina-related clinical and surgical skills in the postgraduate residency program. Results: The 144-item questionnaire was mailed to 4512 practicing ophthalmologists with residency training in two different periods, between 1967 and 2000 (group 1; 20th-century trained) and between 2003 and 2012 (group 2; 21st-century trained). Response was received from 320 (19.1%) of group 1 ophthalmologists and 531 (18.7%) of group 2 ophthalmologists. The average age was 49.2 ± 8.7 and 32.6 ± 4 years, respectively. Group 2 residents had received superior training in indirect ophthalmoscopy, slit lamp biomicroscopy using + 78 and + 90D lens, optical coherence tomography, fundus photography, and fluorescein angiography (all P < 0.001), but there was large variation between the training institutions. The residents were not taught vitreous and retinal detachment surgeries in either period of training. Conclusion: Teaching of retina-related clinical skills have improved in Indian residency program, but there are variations across programs. This information might help redesign the ophthalmology residency programs to meet the demands of comprehensive eye care and universal health coverage of increasing retinal diseases in India.

Commentary: Improving training in retina in Indian residency programmes Atul Kumar, Divya Agarwal, Shreya Nayak Indian Journal of Ophthalmology 2019 67(11):1819-1820

Blockade of IL-27 signaling ameliorates herpes stromal keratitis with upregulated CD4+ Foxp3+ regulatory T cells influx in mice Likun Xia, Tianchang Tan, Yang Li, Qiuyue Zhong, Mei Shi Indian Journal of Ophthalmology 2019 67(11):1821-1828 Purpose: The purpose of this study was to investigate the production of IL-27 p28 and EBI3 in the ocular inflammatory sites, and the role of IL-27 signaling in a model of HSV-1 induced herpetic stromal keratitis (HSK). Methods: The BALB/c mice were injected intraperitoneally (24 h before infection) with anti-IL-27 antibody or IgG antibody as control, infected with HSV-1 via corneal scarification, and then injected intraperitoneally with anti-IL-27 antibody or IgG antibody at 1, 3, and 5 days postinfection. Slit lamp and histopathology were used to assess disease outcome. The levels of IL-27 p28 and EBI3 in corneas were determined by western blotting and immunofluorescence. Furthermore, viral titers were determined, and immune cell infiltrates were collected and analyzed by flow cytometry. Results: We found that the levels of IL-27 p28 and EBI3 in corneas were elevated significantly at the peak of HSK, and both of them were expressed simultaneously in the epithelium, stroma, and endothelium of corneas. In the group of anti-IL-27 treatment, the severity of the corneal lesion and CD4+ T cells infiltration were significantly decreased, and the percentage of CD4+ Foxp3+ Tregs was upregulated markedly in the spleen, DLNs and cornea of HSK mice compared to IgG treatment. Conclusion: These results provided evidence that IL-27 as a pathogenic pro-inflammatory cytokine controlled CD4+ Foxp3+ Tregs production in HSK, which ultimately resulted in promoting the progression of HSK and poor prognosis.

Commentary: Targeting herpetic keratitis by immunomodulation of IL-27 signaling Joveeta Joseph Indian Journal of Ophthalmology 2019 67(11):1828-1829