PURPOSE:To determine the surgical outcomes of bleb needling and the risk factors of failure of needling after failed filtration surgeries in patients with pediatric glaucoma.METHODS:The medical records of patients who underwent needling with 5-fluorouracil following filtering surgeries (trabeculectomy, combined trabeculectomy, and trabeculotomy) between January 2012 and December 2016 were retrospectively reviewed. At the 1-year follow-up visit, complete success and qualified success were defined as an intraocular pressure (IOP) of less than 18 mm Hg with and without antiglaucoma medication, respectively.RESULTS:Forty-five eyes that underwent needling and fulfilled the study criteria were included in the analysis. The mean age at needling was 9.6 years. The mean time interval between filtration surgery and the first needling procedure was 57.3 days. Thirty-eight of 45 eyes (84.4%) had undergone needling within 3 months after the primary surgery. Cumulative success was achieved in 35 eyes (77.7%) after needling (complete success in 22 eyes and qualified success in 13 eyes). Mean follow-up after needling was 18.9 months. The mean IOP before and after needling was 31.7 ± 9.45 and 16.6 ± 5.68 mm Hg, respectively (P < .00001). Steroid-induced glaucoma (P = .01), high IOP prior to the first filtration surgery (P = .01), and an inability to achieve low IOP (< 9 mm Hg, P = .04) immediately after needling were significant risk factors associated with failure.CONCLUSIONS:Bleb needling is an efficient method for lowering IOP after a failed trabeculectomy or combined trabeculectomy and trabeculotomy in the pediatric population. [J Pediatr Ophthalmol Strabismus. 2021;58(2):118-125.].

We present a rare case of phacomatosis pigmentovascularis in a 6-year-old child. The child had one functioning eye with severe glaucoma at presentation. We managed the case with primary Ahmed glaucoma valve implantation followed by two needling attempts. After 3 years of follow-up, the intraocular pressure was well maintained with the addition of two antiglaucoma medications.

ObjectivesIn this study, we sought to evaluate the extent of further visual field that could be assessed when using stimulus size V in standard automated perimetry compared with size III in advanced stage glaucoma and whether cut-off values could be determined for when to switch from size III to size V.DesignProspective cross-sectional study.SettingSingle-centre outpatient eye clinic in India (New Delhi).ParticipantsAdvanced stage glaucoma defined as stages 3–4.InterventionCentral static perimetry with Octopus 900 G programme (size III stimulus dynamic strategy) and low vision central programme (size V stimulus dynamic strategy).Primary and secondary outcome measuresVisual field assessment for right and left eyes with both sizes III and V were undertaken within one clinic visit.ResultsWe recruited 126 patients (170 eyes). Mean patient age at assessment was 55.86 years (SD 15.15). Means (SD) for size III versus size V, respectively, were 6.94 dB (5.58) and 12.98 dB (7.77) for mean sensitivity, 20.02 dB (5.67) and 19.22 dB (7.74) for mean deviation, 5.89 dB (2.29) and 7.69 dB (2.78) for standard loss variance and 3.32 min (1.07) and 6.40 min (1.43) for test duration. All except mean deviation were significantly different between size III and V tests.ConclusionUseful visual field information was obtained with size V stimuli which allowed continued monitoring of these patients that was not possible with size III. Increased test duration, standard loss variance and mean sensitivity were found with size V, as expected, given that more visual responses were obtained with the increased target size. A switch from size III to V may be considered when mean sensitivity reaches 10 dB and/or mean deviation reaches 18 dB.

To study the impact of prophylactic intracameral (IC) moxifloxacin on the incidence, clinical profile and outcomes in eyes developing post-cataract surgery endophthalmitis (PCE). This was a single-centre, retrospective, comparative, observational study in which all eyes with PCE between June 2013 and May 2014 without IC moxifloxacin prophylaxis (group A) and June 2015–May 2016 with IC moxifloxacin prophylaxis (group B) were analysed. A total of 101,815 cataract surgeries were performed in group A and 112,967 in group B. PCE was diagnosed in 179 eyes (0.18%) in group A and 92 eyes (0.08%) in group B (p < 0.001). Greater reduction in risk of PCE was seen in subsidised patients compared to private. The presenting and final visual acuity was significantly better in group B (p < 0.05). Prophylactic IC moxifloxacin reduced the incidence of PCE with maximum benefit being observed for the subsidised patients and also helped achieve a significantly better visual acuity following the resolution of endophthalmitis.

PURPOSE:This study assesses the practice patterns of diagnosing ophthalmologists, as reported by glaucoma patients attending specialty glaucoma clinics in urban and rural areas of North India, for a second opinion.METHODS:Prospective cross-sectional study using a structured interview-based survey was conducted from 1 November 2011 to 31 October 2012 on patients attending two specialty glaucoma care facilities in North India. Both clinics were in North India; however, one was rural (Kaithal) and one was urban (Delhi). Patients were asked through descriptions of machines and processes, regarding practice patterns of their glaucoma diagnosing ophthalmologists. The interview was conducted by ophthalmic assistants in tune with the vernacular of the region, in a language understood by the interviewee.RESULTS:A total of 1506 patients consented to participate in the survey. The majority of patients reported undergoing tests for intraocular pressure measurement; however, 56-60% of these tests were carried out by the non-contact tonometer. More than 90% of patients reported no knowledge regarding the type and severity of the glaucoma they suffered from, and even less reported undergoing gonioscopy (3.6% Karnal and 16% Delhi). 84-86% patients who underwent perimetry reported undergoing at least some digital imaging of the optic disc.CONCLUSIONS:Better counselling of, and communication with, the patient would help increase their awareness regarding their condition and the care required. This has the potential to enable better compliance with and adherence to treatment. Standardized training of ophthalmologists to improve clinical diagnosis of glaucoma would also go a long way.

Purpose The presence of central visual field loss does not infer the extent of peripheral visual field loss. In advanced stage glaucoma, we evaluated whether automated kinetic perimetry provided additional visual field information to that of central static perimetry. Materials and Methods We undertook a prospective cross-sectional study of advanced-stage glaucoma defined as stages 3-4. Visual field assessment for right and left eyes was undertaken within one clinic visit using the Octopus 900 G programme and kinetic strategy. Results We recruited 126 patients (170 eyes). Mean patient age at assessment was 55.86 years (SD 15.15). Mean kinetic reaction time was 1503.96 ms (SD 801.68). Kinetic I4e was plotted in 71% of eyes with an unadjusted area of 2513.68 degrees(2)(SD 2397.91) and mean isopter radius of 23.16 degrees (SD 13.07). Kinetic I2e was plotted in 53.5% of eyes with an unadjusted area of 627.07 degrees(2)(SD 1291.94) and mean isopter radius of 7.47 degrees (SD 10.59). Increased reaction time was associated with a poorer visual field (p= .001). Mean sensitivity, mean deviation and standard loss variance values on static perimetry were higher in patients who had a defined kinetic field boundary than in patients with no kinetic response to I4e stimulus (p= .0001). However, this corresponded to only small-to-medium correlation between static fields and existent kinetic fields: the presence of poor static fields did not always infer a poor kinetic visual field as poor static fields could also have good kinetic visual fields. Conclusions Although we confirmed a lack of agreement and only a small to medium correlation between the extents of central versus peripheral visual field loss, automated kinetic perimetry did provide additional peripheral (outside the static 30-degree central field) visual field information which was clinically useful in the presence of non-informative severely defected central visual fields.

PURPOSE To assess efficacy of intravenous (IV) ketorolac for postoperative pain control after external dacryocystorhinostomy. METHOD Fifty-five patients from January to April 2019 were randomized, to a double-blind prospective interventional study. Intervention arm received IV ketorolac (60 mg/2 ml) immediately post-op, control received IV saline bolus. Pain assessment was done with numerical rating scale pre- and postinjection (day 0) and on day 1. Requirement for analgesics and antiemetics was recorded. RESULTS Total 55 patients (11 men and 44 women) with mean age 49.93 ± 16.29 years were included in the study. Twenty-four (43.6%) patients received IV ketorolac and 31 (56.4%) received placebo. Mann-Whitney U test showed mean rank score for pain scale was significantly lower in intervention arm versus control arm, assessed postinjection (16.69 vs. 36.76 respectively, p = .000) and at day 1 (21.08 vs. 33.35 respectively, p = .003). CONCLUSION IV ketorolac significantly lowers self-reported pain score following external dacryocystorhinostomy with reduced requirement of analgesic and antiemetic medications.

Purpose: To determine the rate of anatomical closure and visual outcome following vitreous surgery for idiopathic macular hole (IMH) using Optical Coherence Tomography (OCT). Methods: Interventional case series. 23 eyes with idiopathic macular hole having a preoperative OCT macular hole diameter ranging from 280 to 1051 microns underwent vitrectomy with internal limiting membrane peeling and perfluoropropane gas injection. Outcome measures: Primary outcome: Anatomical closure of macular hole demonstrated by OCT. Secondary outcome measures: Visual acuity and complications. Results: Type I closure was seen in 14 eyes and type II closure was seen in 7 eyes. Anatomical closure was not achieved in 2 eyes with macular hole diameter of greater than 400 microns. Conclusion: OCT measurements are useful to predict the anatomical and visual outcomes following surgery for idiopathic macular hole.

India is often highlighted for its disproportionate spending on health care.[1] Overall, India lacks adequate health care infrastructure and facilities.[2] Even today, access to health care facilities are urban-centric, while a majority of our population lives in rural areas. Discrepancy in resource distribution deprives the rural population leaving their health care needs unattended.[3] There have been efforts to overcome these and ensure that those living in relatively inaccessible areas should be able to receive timely care. But evidence shows that access to health care remains the lowest in the most vulnerable, rural population. It has been noted that there is not much variance amongst rural and urban populations when it comes to minor illnesses, but for major illnesses, rural regions remain suboptimally cared for due to non-availability of treatment and diagnostic facilities in the vicinity.[4] The problem of this rural urban disparity is the same in ophthalmology where majority of the eye care providers are situated in urban or semi-urban areas. Rural areas are served by Non-Government Organisations (NGOs), a majority of whom are also situated in urban and semi-urban areas. These non-rural-based eye care organisations serve the rural population through outreach camps and primary eye care centres. Such an effort can handle diseases like cataract and refractive errors. Emerging diseases like diabetic retinopathy, age related macular diseases (ARMD) and glaucoma are on a steep rise in India largely due to the ageing population, changing lifestyle and enhanced life expectancy.[5] To deal with these, where expert long-term follow-up care is required, relying on outreach programmes for will be ineffective and impractical. This emerging scenario emphasises the need for models established in the rural areas, providing high volume and high quality comprehensive eye care services. Sadguru Netra Chikitsalaya (SNC), A Unique Rural-based Eye Care Provider In 1950, Gurudev (Param Pujya Ranchhoddasji Maharaj, respectably called as Gurudev) spearheaded the movement of voluntary eye care services by organizing a free eye camp at Chitrakoot. In spite of difficulties and absence of basic facilities, 950 cataract surgeries were done through the camp. Following this, similar eye care activities were undertaken across the length and breadth of India. These efforts gradually converged into forming an institution and in the year 1968 - Sadguru Netra Chikitsalaya (SNC) was established under, Shri Sadguru Seva Sangh Trust.[6] Over the years, SNC has grown from strength to strength. Today, it is recognised worldwide as the largest rural eye care provider and also for its high volume and high quality of comprehensive eye care services. Services are supported by a team of more than 100 full time ophthalmologists who perform more than 132000 ophthalmic surgeries annually at Chitrakoot.[6] Key features at SNC include: 1. Serving more than a million patients every year, 2. Performing more than 100000 cataracts surgeries annually, 3. Performing more than 25000 specialty procedures annually, 4. 25 modular operation theatres, 5. 3500 rural outreach eye screening camps annually, 6. 53 vision/primary eye care centers, 7. 2.5 million surgeries since inception, and 8. Assured standardized quality care, across all the strata of society. Establishing Eye Care in Rural Areas - Challenges SNC faced several challenges on its way to become the largest eye care provider in India. Initially, majority of the work was carried out in the winter months through volunteers and devotees of Gurudev. Temporary structures were erected to operate patients and provide care during this short period every year. Efforts were then made to regularize work throughout the year - a challenge by itself, with minimal patient inflow during the rest of the year and non-availability of full time skilled workers. Financial viability was another concern as all the services were provided free of cost. With limited support from donors, scaling up with infrastructural backup and meeting requirements of people to work for the organization was a real challenge. The region lacked even basic educational facilities. To attract and retain skilled manpower including ophthalmologists, managers, Information and Technology, and paramedical staff to such a remote and backward place was extremely difficult. Reduced connectivity and poor supply chain for sustaining and further scaling up of eye care activities was difficult. Regularization of eye care activities through the years with lack of management systems and absence of technical knowhow also stood out as barriers. Focus on quality assurance, and monitoring was minimal in those days. In spite of all these challenges, eventually the plan to create a high-volume high-quality rural eye care set up was successfully implemented in one of the most remote and backward areas of India. This article describes how "Rural based model of Chitrakoot" was established as a state of the art, high-volume eye care provider along with maintaining equal focus on higher levels of quality assurance. High-Volume Eye Care - Major Drivers Access to care in rural areas, depends on various factors. The major factors which helped SNC improve its patient base over the years are - Patients centric care Ears to the ground: In rural India, people take opinions at face value and the 'word-of-mouth' effect influences the service sector. Positioning makes you unique and patients become your true ambassadors spreading information about your services. Focusing care around the patient and ensuring their satisfaction increases the reach of your services. In the case of SNC, hospital data shows that patients travelled large distances to avail trustworthy services. [Fig. 1].Figure 1: Patients and distance travelled for eye careCommunity engagement Unlike urban and corporates setups, rural positioning is not feasible without ensuring community buy in and participation. People in the community need a sense of ownership in the process and the problems. Success can be attained when one involves the community at every stage. A wider reach can be attained through effective community participation. With community engagement and involvement, today we conduct the largest number of outreach camps and have the largest primary eye care network spread across Madhya Pradesh and Uttar Pradesh. Several focused efforts including sponsors day, vision center foundation day etc., are organized to ensure active participation of the stakeholders. Outreach and vision center network of SNC are depicted in Fig. 2.Figure 2: SNC outreach networkCreating access to care There have been several additional challenges in creating access for the rural population including transportation, lack of health seeking behavior and lack of awareness. One needs to device models and mechanisms to ensure people have access to care at various possible points. Apart from direct walk-in patients, we have regular outreach programs which reach out to the rural population on a continual basis. In order to bring patients from remote and rural areas of Madhya Pradesh and Uttar Pradesh, transportation facility is provided to and from the base hospital. Specialized screening camps as for Diabetic Retinopathy are also conducted on a regular basis. Ensuring affordability To ensure that all the segments of the population avail the services, we need to device a sustainable mechanism of financing eye care services. SNC adopted a model similar to that of the Indian Railways wherein the decision on payment for a service is in the hands of patients. But we added free service as our organizational policy 'no one should be denied treatment due to their inability to pay'. This is being followed in our models. SNC is one of the few tertiary care institutes which also provides specialty services to camp patients completely free of cost. Today people from all segments of society access care [Fig. 3] establishing SNC as a large charity with an equally competent sustainable eye care model.Figure 3: Affordability chart of SNCPartnership and collaborations To work in underserved areas and provide care in a sustainable manner, one needs to collaborate and partner with both health and non-health sector groups and voluntary organizations. This will be helpful in gaining more community trust, sharing financial burden, and training and skill development. Presently, SNC partners with several INGOS, NGOs, and governments at local and state level through which several programs are undertaken. This provides a base for increased utilization of eye care facilities at SNC. High Quality Eye Care - Major Drivers In the eye care field there is a notion that quality and quantity don't go hand in hand, but to a large extent, we at SNC have been able to achieve both. Being located in a rural area, there are certain limitations of working, but in spite of all these, we work towards achieving quality outcomes in a high volume situation. There are certain aspects of functioning which help us to deliver high quality eye care services to the rural masses and the same are as follows: Organizational culture and values While working in a rural set up one often makes compromises in service delivery parameters. At SNC, right from the top management, everyone is committed to provide the best possible care to the patients, which in itself represents culture for the success of the organization. All employees at SNC work towards the vision of "Sight for the Blind". Every single day, one can see the same dedication and commitment to work. This is reflected in the fact that a large proportion of the work force has been associated with the organization for over two decades and a few of them have been involved right from its inception. The devotion of senior workers acts as a source of inspiration for the junior staff, which makes the continuity of quality eye care a reality. The involvement of volunteers and the local community gives a further impetus. To top it all, the most important aspect of eye care delivery at SNC involves utilization of the same resources for all patients irrespective of their ability to pay. Infrastructure and facilities The key to delivering high volume quality eye care is lies in providing cutting-edge infrastructure and facilities. There are 25 modular operating theatres at SNC. They are shared across paying and non-paying patients, delivering similar quality outcomes across all categories. The organization keeps itself up-to-date with the latest ophthalmic equipment and gives regular training to its personnel on using it. Exclusively, several wards have been dedicated to cataract alone with a bed capacity of 250 in each. All specialty services (retina, glaucoma, cornea, oculoplasty and pediatric ophthalmology) are available under the same roof with the most advanced diagnostics and treatment facilities. System and protocols A standard of care has been developed to manage high volume service delivery without compromising on the quality. This standardized care is delivered across all strata of patients - non–paying, subsidized and paying. Surgical steps practiced by all the surgeons are similar in order to minimize the surgical time. Surgical SOPs at SNC are evidence-based, with separate instrument sets for every surgery, single use sterile gloves for every case, use of good quality disposables and intraocular implants, changing gowns between cases and separate septic theatre for infected cases, etc. Regular surveillance of the operating theatre is carried out by taking weekly swabs from critical areas, fortnightly air cultures and water cultures every month. Every new batch of consumables for intraocular use is cultured prior to use. The single most important aspect of OT protocols involves a separate sterile and dirty corridor and a conduit for the low of material without the possibility of being mixed. This system helps the team to manage the increased volume without any compromise in quality. Human resources training and academic orientations Recruitment of well trained and qualified staff for effective eye care delivery is important. All the faculty are well-versed and proficient in current clinical and surgical procedures. Regular training of junior doctors is undertaken through a state of the art wet lab and structured fellowship programs. Emphasis is on absorbing faculty from the training doctors pool in order to deliver standardized and quality eye care. Weekly CMEs, journal clubs and classes are held to keep everyone updated with the latest in eye care. In order to keep the employee motivated, they are honored for their hard work, dedication and commitment to the organization and its ethics. There is an onsite nursing college, optometry school and vision care technician program to generate trained staff for the organization. Focus on continual improvement We are an ISO: 2015 certified organization, reflecting our organization's commitment to continuous quality improvement. We are compliant with NABH standards awaiting final assessment and accreditation from the board. All quality norms are in accordance with national and international guidelines. The eye hospital has a quality wing which strives for excellence in eye care by regularly monitoring and improving SOPs. In order to keep abreast with the latest technology in eye care, the institute is not weary of adapting to new procedures and techniques and this is evident in our moving from the era of ICCE to ECCE to manual SICS and phacoemulsification. We implant IOLs Implantation for every patient and 30% of our cataract surgeries are by phacoemulsification. Results High volume provider: With effective and efficient strategies, the organization has been able to keep the steady phase of its growth in reaching the rural mass and provide eye care. Year-on- year it shows improved the volume with a precise focus on outcome and comprehensiveness in care. The volume of surgical operations increased from about 30,000 in the year 2002-03 to more than 132,000 in the year 2018-19, a phenomenal growth of almost 400%. [Fig. 4] With a focus on providing comprehensive eye care to rural masses, the organization took several steps from building infrastructure and skill development to adopting newer technology and techniques. This resulted in increasing the access of affordable subspecialty services in the region.Figure 4: Eye Surgeries at SNCQuality assured practices- complications and surgical site infections With increasing volumes, maintaining or further improving the quality of services presents a great challenge to any organization. We took several steps to reduce our infection. These include a strict sterilization protocol, adherence to standard operating protocols in the theatre, adaptation of preoperative prophylaxis for prevention of endophthalmitistis, including the peri-operative use of intracameral antibiotics. Similarly, the state of art wet lab training facility for the trainee surgeons as well as one to one training program has resulted in significant reduction in complication rates of novice surgeons. Our cumulatively infection rate over a period of 5 years is 0.04%, which is at par to the acceptable global standard of <0.07. Similarly, the complication rate reported during the last 5 years' period of time is 0.83%, which is again better than the considered benchmark of <2%. Compliance to care and cataract post-operative visual outcome In spite being located in rural area and serving a radius of 400 km, the hospital was able to ensure an adequate postoperative follow up for the cataract patients. Compliance was assured by effective counseling of patients, follow-up specific camps, follow-up at vision centres and through an active support of community level volunteers. Also, the compliance is being closely monitored and improvements are tried to be made on an ongoing basis. If we look at the cumulative post-operative visual outcome (4 weeks follow-ups) over a period of last 5 years among the reported, 92% of the patients who underwent cataract had good (≥6/18P) visual outcome (>90% WHOs bench mark) and 4.65% had borderline (<6/18P to 6/60) visual outcome (against <5%) and only 3.35% patients had poor (<6/60) visual outcome (against <5%). Way Ahead Among all the medical visits in India, more than 80% are contributed by rural population, with most of the patients travelling over 100 km to access health care facilities.[2] Changing disease priorities in ophthalmology will lead to further problems in terms of accessibility and affordability. Development of comprehensive eye care facilities in rural areas with community participation may be an optimal solution. The Chitrakoot Model remains a unique example of how a most backward rural area can become a hub for advanced eye care services and provide high volume, high quality care in an optimally cost-effective and sustainable manner. If a successful model can be established in Chitrakoot, then it should be possible to replicate it everywhere across India. We wait for such a day with deep optimism and hope. About the author Dr BK Jain BK Jain, Director and Trustee of Sadguru Netra Chikitsalaya, Shri Sadguru Seva Sangh Trust is a renowned name in the eye care domain for his contribution to the community eye care movement in rural India, specifically in the Central and Northern Indian states. He was successful in establishing a rural based state-of-the-art eye care facility Sadguru Netra Chikitsalaya, with arms of program management, training, research, advocacy and and advocacy. Under his able guidance, Sadguru Netra Chikitsalaya not only has become one of the largest rural eye care providers in the world, but also has come to be an unique example for developing rural areas through eye care programs. Dr Jain has been honored with several international and national awards for his outstanding contributions and has also been included in several committees including the advisory committee of National Program for Control of Blindness (NPCB).

Purpose: Vision loss in Sturge-Weber syndrome (SWS), a rare congenital disorder, is primarily due to glaucoma. Methods: We reviewed the data of all consecutive SWS-associated glaucoma cases in patients who had undergone combined trabeculotomy-trabeculectomy (CTT) at a tertiary glaucoma facility between January 1993 and December 2015. We analyzed the preoperative and postoperative intraocular pressure (IOP), corneal clarity, visual acuity, success rate, need for repeat surgery, and number of topical antiglaucoma medications needed at last follow-up. Results: Twenty-six eyes of 20 patients with SWS (surgical age 0.7-96 months; mean 18.64 ± 29.74 months) had undergone primary CTT. The mean preoperative IOP was 32.76 ± 7.86 mm Hg (range 22-54 mm Hg) with medication (mean 3.11 ± 1.17; range 1-5). At the last follow-up (61-288 months); mean SD 134.73 ± 67.77 months), two eyes had IOP <6 mm Hg. Twenty-four eyes analyzed had an IOP of 13.63 ± 6.11 (mean ± SD; range 9-41) mm Hg. All these had an IOP <15 mm Hg at last follow-up except one, which had an IOP of 41 mm Hg. There was a mean reduction of 54.62% ± 31.33% in IOP from baseline. The antiglaucoma medication score at last follow-up visit was 0-3. No eye achieved predefined complete success or modified complete success. A total of 41.7% (10/24) of eyes attained both qualified and modified qualified success. Eleven eyes needed repeat surgeries. No intraoperative complications were noted. Visual acuity was below 6/60 in four eyes. Conclusions: Combined trabeculotomy-trabeculectomy showed promising results as a treatment for SWS-associated glaucoma in children. Long-term visual and surgical outcomes are encouraging.

PURPOSE:The aim of the study was to assess level of glaucoma awareness amongst glaucoma patients by studying characteristics amongst urban and rural glaucoma populations in North India.METHODS:A questionnaire was designed and administered after appropriate validation amongst patients to identify determinants of glaucoma awareness. Trained personnel delivered the 11 questions to 1506 patients, aged 18 and above through random sampling. The questionnaire evaluated source of awareness, education, gender, location and age on the level of awareness of glaucoma. The outcomes were assessed based on patient's responses.RESULTS:Age and education essay a significant role in glaucoma awareness. Awareness levels increased with the level of education significantly in both rural and urban settings (P value <0.001). Patients from lower educational backgrounds were significantly more likely to share their condition with their spouse compared to those with higher education (P value <0.001). Compared to the middle aged and elderly, young adults were less aware that glaucoma could run in families (P value <0.015).CONCLUSIONS:There is a significant gap in the knowledge about glaucoma and its risks in both urban and rural set-ups in Northern India necessitating active steps to spread awareness regarding glaucoma and its relation with blindness.

PurposeAssess long-term outcome of combined trabeculotomy-trabeculectomy (CTT) in primary congenital glaucoma (PCG).MethodsData of PCG patients treated with CTT by a single surgeon between 1976 and 1993 were reviewed for reduction in intraocular pressure (IOP), visual acuities, surgical success rates, and need for repeat surgeries at last follow-up (FU). At the last FU, IOP<21 mm Hg without any topical antiglaucoma medication (TAM) was complete success and with 1-2 TAMs was qualified success. IOP reduction ≥30% without any TAM was modified complete success and with 1-2 TAMs was modified qualified success. IOP>21 mm Hg, IOP reduction <30%, or use of >2 TAM at last FU, or need for additional surgery was considered as failure.ResultsTwo hundred thirty eyes of 121 patients had been followed up for 21.5-38 years (mean 28.87±2.77 years). Eyes that were pthisical (3), had immeasurable IOP (2), or IOP<6 mm Hg (3) were excluded from the success analysis. At last FU, mean IOP reduction was 22.71±11.28 mm Hg and TAM score was 1.71 (0-4). Complete success was achieved in 14 (6.3%), modified complete success in 14 (6.3%), qualified success in 148 (66.7%), and modified qualified success in 140 (63.1%). Success probability was 95% till 25 years and 92, 90, 85, 79 and 68% at 26, 27, 28, 29, and 30 years, respectively. Severe visual impairment or functional blindness was found in only 13 (10.7%) patients.ConclusionCTT shows long-term success in PCG patients. All patients must be monitored for IOP control to avoid need for repeat surgeries.

PURPOSE To describe the safety profile and clinical response on elevated intraocular pressure (TOP) of betaxolol hydrochloride ophthalmic suspension 0.25% (betaxolol) and timolol maleate ophthalmic gel-forming solution (TGFS) (0.25% and 0.5%), in subjects under 6 years of age.METHODS Subjects were randomized to betaxolol 0.25% (twice daily) or TGFS (daily) (0.25% or 0.5%) in this double-masked study. IOPs were obtained at the same time of day (9 AM) at 2 baseline visits and weeks 2, 6, and 12. Mean change from baseline in TOP was the primary efficacy parameter.RESULTS One hundred five subjects were randomized (34 to betaxolol, 35 to TGFS 0.25%, 36 to TGFS 0.5%). Betaxolol, TGFS 0.25%, and TGFS 0.5% produced statistically significant mean reductions in TOP; mean reductions after 12 weeks of treatment were 2.3, 2.9, and 3.7 mm Hg, respectively. In subjects who were not being treated with topical IOP-lowering medication at baseline, mean TOP reductions after 12 weeks of treatment were 3.1, 4.8, and 3.8 mm Hg, respectively. In patients discontinuing 1 or more topical TOP-lowering medications at baseline, mean IOP reductions at Week 12 were 1.8, 1.8, and 3.7 mm Hg, respectively. Responder rates (>= 15% reduction from baseline) for betaxolol, TGFS 0.25%, and TGFS 0.5% were 38.2, 45.7, and 47.2%, respectively. Adverse events were predominantly, nonserious and did not interrupt patient continuation in the study.CONCLUSIONS Betaxolol ophthalmic suspension 0.25%, TGFS 0.25%, and TGFS 0.5% were well tolerated. Despite low responder rates, all 3 treatments produced statistically significant mean reductions in TOP in pediatric glaucoma subjects. (J AAPOS 2009;13:384-390)

It is estimated that by the year 2010, 60.5 million people would be burdened by glaucoma and that by 2020 there would be 79.6 million sufferers. Forty-seven per cent of the glaucomas worldwide would be in Asia with more than 75% being angle closure.1 At present twelve million Indians are affected by glaucoma accounting for 12.8% of the blindness in the country.2 Hospital-based data from India report primary open angle glaucoma (POAG) to be as common as primary angle closure glaucoma (PACG), with 45 to 55% of primary glaucomas being PACG.34 In the glaucoma clinic of an eye hospital, 45.9% of all primary adult glaucomas were of the angle closure type.4 Of these 24.8% had acute angle closure glaucoma, 31.2% had subacute and 44% had chronic glaucoma. Since then the definition of angle closure glaucoma has undergone a change. Angle closure is now described as an anatomical disorder where symptomatology does not specify the involved mechanism.5 In Asian eyes, the majority of the closures arise from a combination of a pupil block and nonpupil blocking mechanisms.6 Primary angle closure suspect (occludable angle), primary angle closure (PAC) and PACG are now distinct entities reflecting the severity of the disease.789 More than 80% of the chronic angle closures have no significant symptoms.4 Three landmark studies conducted in India, the Vellore eye survey reported a prevalence of 4.32% for PACG. Occludable angles accounted for 10.3% in the population.10 The Andhra Pradesh eye disease survey reported a prevalence of 0.71% for PACG and occludable angles accounted for 1.41% of the study population.11 The Aravind comprehensive eye survey reported a prevalence of 0.5% for PACG (95% CI 0.3 - 0.7).3 Despite near similar study populations, a meaningful comparison is difficult because of the differences in patient selection, methodology and definitions used. Screening for angle closure glaucoma appears tempting to minimize the loss of vision, but it is still not a viable option. In fact glaucoma does not fulfill all the criteria laid down by the World Health Organization to justify a population-based screening. Also, available resources (trained ophthalmologists, instrumentation and time) and the economics of glaucoma detection and treatment are not uniform. Every step in glaucoma management - investigation / treatment could further burden these scarce resources, which if judiciously used could actually benefit more people.11 Case detection in the clinic is perhaps the best approach as of now. Improved detection with simple tests (flashlight test and von Herrick's test) and confirmation on gonioscopy play a key role in diagnosis. It is heartening to note three articles on various aspects of angle closure in this issue of the Indian Journal of Ophthalmology. Two of these detail case detection in the clinic. The study by Al-Mubrad et al. looks at a rapid, noninvasive method for screening in the clinic while Kaushik et al. emphasize gonioscopy as a cost-effective tool for identifying signs of angle closure. Drugs prescribed for diverse conditions can aggravate closure; particularly in those with narrow angles and or a previously undiagnosed angle closure.12 In our concern for primary angle closure we often tend to neglect secondary angle closure. Desai et al. emphasize the effect of one such drug. In conclusion, in India asymptomatic chronic angle closure glaucoma mimicking POAG is common. Gonioscopy is the confirmatory test and must become a part of the routine workup for our glaucoma patients and suspects. Provocative testing may play a supportive role in asymptomatic occludable angles. The definitive treatment for angle closure is a laser iridotomy. The efficacy of the iridotomy is dependant on the underlying mechanism causing closure and also the stage of the disease.13 Following the iridotomy, angle closure is treated medically or surgically in the same manner as open angle glaucoma. Treatment of the fellow eye with a laser iridotomy is mandatory.

Glaucoma is a leading cause of blindness. Delay in diagnosis of open angle glaucoma (OAG) results from lack of symptoms. In angle closure glaucoma (ACG) there is often neglect of symptoms. Creating awareness about the disease and screening the high risk groups would reduce the burden of irreversible blindness due to glaucoma. Adequate therapy in the form of drops, lasers and surgery is available. Close interaction with the physician is important as many topical antiglaucoma medications have adverse systemic side-effects and many drugs used for systemic diseases raise the intra-ocular pressure (IOP). All drugs currently available for glaucoma lower IOP but new drugs for neuroprotection may change the future management strategies. While drugs and surgery are the mainstay for OAG, laser iridotomy is the definitive treatment for ACG.

Aim: To study the medication costs of various topical glaucoma medications using data collected from real world use by patients.Methods: Patients with primary open angle glaucoma treated at glaucoma clinics in 5 hospitals (1 rural and 4 urban) in northern India from 1 January to 30 June 2008 were enrolled. The number of days each bottle of medication lasted was recorded, and the mean cost per day was computed from the maximum retail price and mean number of days each medication lasted.Results: 790 of 801 eligible patients completed the study. The mean number of days that a bottle of medication lasted was found to be highest for Xalatan® and Xalacom® at 35.23 days and 35.00 days, respectively. The brand name prostaglandin analogues all lasted for a mean of more than 30 days: Xalatan, 35.23 days (SD, 4.14 days); Lumigan®, 31.37 days (SD, 5.31 days); and Travatan®, 34.84 days (SD, 6.51 days), while the generic eye drops lasted for about 21 days: latanoprost, 20.69 days (SD, 3.69 days) and bimatoprost, 21.39 days (SD, 4.34 days). The cost of the generic medication was less than the brand name medication in all groups (for example, bimatoprost, Indian rupees 9.76 versus Indian rupees 12.33) except for brimonidine/timolol (Indian rupees 8.73 versus Indian rupees 8.66). Further analysis in 2009 showed that, for latanoprost, brimonidine and brimonidine/timolol, the difference between the brand name and generic medications decreased in 2009 over 2008 (in the latanoprost group, the cost difference over the year reduced from Indian rupees 592 in 2008 to Indian rupees 523 in 2009); the cost difference for bimatoprost increased from 2008 to 2009.Conclusion: When both cost and number of days a bottle lasts were considered over the long term, use of generic medications might not minimise the cost of glaucoma medical management by much when compared with the brand name medication.