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Purpose: To evaluate the outcome of transscleral fixation of closed loop haptic acrylic posterior chamber intraocular lens (PCIOL) in aphakia in nonvitrectomized eyes. Materials and Methods: Patients with postcataract surgery aphakia, trauma with posterior capsule injury, subluxated crystalline lens, and per operative complications where sulcus implantation was not possible were included over a 1-year period. Scleral fixation of acrylic hydrophilic PCIOL was performed according to the described technique, and the patients were evaluated on the day 1, 3, 14, and at 3 and 12 months postoperatively for IOL centration, pseudophakodonesis, change in best-corrected visual acuity (BCVA), and any other complications. Results: Out of twenty-nine eyes of 24 patients, who completed the study, 25 (86.2%) eyes had improved, 2 (6.9%) eyes showed no change, and 2 (6.9%) eyes had worsening of BCVA. Three (10.3%) eyes developed postoperative complications. A significant improvement in mean BCVA (P < 0.0001) was observed after the procedure. Mean duration of follow-up was 26.2 months (range 22–35 months). Conclusion: The use of closed loop haptic acrylic IOL for scleral fixation appears to be safe and effective alternative to conventional scleral fixated polymethyl methacrylate intraocular lenses.

Context: Intracameral mydriatic solution can eliminate the disadvantages of repeated eye drop instillation regimen and provide adequate mydriasis for phacoemulsification with added advantages. Aims: Evaluating the role of intracameral irrigating solution (0.5% lignocaine + 0.001% epinephrine) in initiating and maintaining the pupillary mydriasis during phacoemulsification. Secondary aims were to observe the effect of surgical time, nucleus density and ultrasound time on mydriasis during the procedure. Settings and Design: The study is a prospective interventional case series, conducted at tertiary care institution. Materials and Methods: Thirty patients underwent phacoemulsification under topical anesthesia for visually significant cataract. Pupillary dilatation was achieved by intracameral irrigation of mydriatic solution alone. Pupillary diameter was measured serially during surgery and ultrasound time and total surgical time were noted. Statistical Analysis Used: Paired samples student- t test was done to compare means. Spearman correlation coefficient was used to study the effect of various parameters on mydriasis. Results: Thirty eyes completed the study. The pupil size increased from 2.1 mm (Range 2-3.5 mm SD ± 0.32) to 6.9 mm (Range 5-9 mm SD ± 1.02) in 30 seconds time after intracameral mydriatic solution delivery, and was 7.0 mm (Range 3.5 - 9 mm SD ± 0.20) at the end of surgery. Duration of surgery, grade of nucleus and ultrasound time had statistically insignificant effect on mydriasis. Conclusions: Intracameral solution containing 0.5% lignocaine and 0.001% epinephrine provides rapid mydriasis which is adequate for safe phacoemulsification and is unaffected by other parameters.

Aims: To evaluate a new approach for recanalization (RC) of nasolacrimal duct obstruction in the treatment of the symptomatic nasolacrimal duct obstruction (NLDO). Materials and Methods: A prospective, interventional, comparative study in 302 eyes of 209 patients of symptomatic nontraumatic NLDO. Eyes with previous failed surgery were excluded. One hundred and fifty-one eyes underwent RC with 20 G endodiathermy bipolar probe connected to a 7 W diathermy followed by bicanalicular intubation under direct visualization. One hundred and fifty-one eyes underwent standard external dacryocystorhinostomy (DCR). Follow-up was for 24 months and evaluation was done on basis of change in symptoms and lacrimal syringing. Data was analyzed by Chi-square test and unpaired t-test. P value < 0.05 was considered statistically significant. Results: Success defined as an asymptomatic patient or freely patent syringing was 92.7% (140 eyes) in RC group and 83.44% (126 eyes) in DCR group. Success was significantly more (P ≤ 0.01) in RC than DCR group. Surgical time was significantly less in RC than DCR (P ≤ 0.001). In RC group, RC could not be performed in three eyes and had to be later taken up for DCR. Intubation after RC was not achieved in four eyes; however these eyes had a patent pathway till 24 months. Twenty-two eyes had a premature extrusion of the tube; but the success rate in these (20 eyes) was comparable to the others within the group (P > 0.05). Two eyes in RC and one in DCR group had complications. Conclusions: RC with 20 G endodiathermy bipolar probe is a quick, simple, and effective alternative to standard external DCR.

The authors here describe manual small incision cataract surgery (MSICS) by using topical anesthesia with intracameral 0.5% lignocaine, which eliminates the hazards of local anesthesia, cuts down cost and time taken for the administration of local anesthesia. Aims: To evaluate the patients′ and surgeons′ experience in MSICS using topical anesthesia with intracameral lignocaine in terms of pain, surgical complications, and outcome. Settings and Design: Prospective interventional case series. Materials and Methods: Ninety-six patients of senile cataract were operated by MSICS under topical anesthesia with intracameral lignocaine using "fish hook technique." The patients and the single operating surgeon were given a questionnaire to evaluate their experience in terms of pain, surgical experience, and complications. Statistical Analysis Used: Statistical analysis software "Analyseit." Results: There were 96 patients enrolled in the study. The mean pain score was 0.7 (SD ± 0.97, range 0-5, median 0.0, and mode 0.0). Fifty-one patients (53%) had pain score of zero, that is, no pain. Ninety-one patients (~95%) had a score of less than 3, that is, mild pain to none. All the surgeries were complication-free except one and the surgeon′s experience was favorable in terms of patient′s cooperation, anterior chamber stability, difficulty, and complications. The ocular movements were not affected, and hence, the eye patch could be removed immediately following the surgery. Conclusions: MSICS can be performed under topical anesthesia with intracameral lignocaine, which makes the surgery patient friendly, without compromising the outcome.

A prospective comparative study was undertaken to compare the patients' pain experience, surgical outcome and surgeon's experience in phacoemulsification and manual small incision cataract surgery (MSICS) under topical anesthesia supplemented with intracameral lignocaine (TASIL). In Group 1 (n=88) phacoemulsification was done and in Group 2 (n=92) MSICS was done. Pain scores were marked by the patients on a Visual analog scale (VAS) after the surgery. The surgical experience was noted on a questionnaire by the operating surgeon. Descriptive analysis and one-tailed Mann-Whitney test were used to draw results. The average VAS score in Group 1 was 0.65 (SD 1.31) and in Group 2 it was 0.90 (SD 1.22). This difference in the average was not statistically significant with P=0.09. The study demonstrates that MSICS and phacoemulsification both can be done safely under TASIL with acceptable patient comfort, and the pain experienced by the patients during the procedures is comparable.

Dear Sir, We have read the symposium article titled “Retinoblastoma: Achieving new standards with methods of chemotherapy” by Kaliki and Shields [1] with great interest and appreciate their effort to summate the present status of chemotherapy for retinoblastoma. We noticed that the Fig. 2 depicted in the article on page number 105 of the journal, claims that the systemic chemotherapy reduces the size of orbital retinoblastoma as per the attached legend “Treatment of the orbital retinoblastoma with intravenous chemotherapy (a) Orbital retinoblastoma of the left eye confirmed on (b) computed tomography scan of the orbit. (c and d) Nine cycles of high-dose chemotherapy resulted in phthisis bulbi facilitating enucleation. No residual tumor was noted on histopathology. The patient subsequently underwent left orbit external beam radiotherapy and further three cycles of high-dose chemotherapy.” The figure depicts the change in retinoblastoma tumor of single patient over a period of time after systemic chemotherapy. However, it is obvious that the images depicted are of two separate patients and the one labeled (a) with advanced tumor is of a patient with older age, darker iris, and a mole on the left slope of the nasal bridge. The image (c) of Fig. 2 is a different patient with lighter iris and no mole at the mentioned site. We would like to thank the authors for explaining the anomaly. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Sir, We have read the article published in the current issue of IJO, titled “Comparison of different techniques of cataract surgery in bacterial contamination of the anterior chamber in diabetic and non-diabetic population.”[1] We have the following observations and would like to have author's comments on them. Side port in phacoemulsification surgery is understandable, but irrigation of the anterior chamber using the side port in MSICS indicates that a side port was made in MSICS patients also. However this is not mentioned in the MSICS steps. Kindly clarify, when was that made and the purpose served by the side port. Sub-conjunctival injection at the end of surgery was not given. As we see it, this is a usual practice in cataract surgery that a sub-conjunctival injection of steroid and antibiotics is given just before patching the eye in surgery under local anesthesia. Apart from a depot of antibiotic and steroid, sub-conjunctival injection helps in reposition of the conjunctival flap. Why this deviation from the routine practice? Only an antibiotic solution drop was instilled at the end of surgery. Was there any specific reason for not instilling steroid solution? As mentioned, the eye patch was opened after 6 h of surgery. Again we would consider this as a deviation from routine practice as the dressing is opened on the next day. Any advantage of not giving sub-conjunctival injection of antibiotic steroid solution and then early opening of the eye dressing to start topical medication? Kindly clarify. The eye drop regimen after opening the eye dressing was too aggressive. One hourly instillation of antibiotic steroid eye drop is not justified routinely without any evidence of excessive inflammation or infection. Kindly comment. The antibiotic steroid combination was started at one hourly frequency and later tapered to once daily. It is incorrect to taper the dose of any antibiotic. The antibiotics should be used in adequate dosage and stopped immediately, with no tapering, to prevent emergence of acquired bacterial resistance. Tapering of antibiotics is not justified at all. Author should have used separate antibiotic and steroid drops if they wanted to taper the steroid drop dosage instead of using fixed dose combination of steroid and antibiotic. It is ironical that the authors have condemned the use of antibiotics in irrigating solution for possibility of inducing resistance and at the same time indulged in tapering the dosage of antibiotic eye drop which itself is capable of inducing resistance by exposing the bacteria to sub-minimal lethal dosage.

Dear Sir, We appreciate the interest shown in our work. Our response to the queries raised follows. For probing, after entering the puncta, the probe is initially directed medially until a hard stop is encountered. The probe is then slightly withdrawn and rotated upward 90°, in the same plane, and then angled to point 15° posteriorly.[1] Once the probe enters the nasolacrimal duct, its direction automatically becomes slightly lateral (as is the direction of this pathway). Anyone with some experience navigates the pathway with ease. However, we agree that false passages and trauma may occur We do not undermine the utility of endoscopy in children where pathways are narrow and child being under general anesthesia does not respond to pain. We have demonstrated this procedure only in adults above 18 years. Creation of the false passage in adults is usually painful and with the instrument that we are using the possibility of it being created is reduced though not eliminated. Once the probe is in the inferior meatus, it is visualized with the optic fiber directly. Probably in patients that could not be intubated and those that failed, false passage creation was one of the contributory factors Regarding the comment on success rate, please note that a probing as a treatment option in adults with blocked nasolacrimal ducts is not new and has been demonstrated to cause a significant symptomatic relief.[2] We have intubated our patients after recanalization, which should logically enhance the success. Moreover, we have specified that our criteria for success were “either a satisfied patient or a patent pathway on syringing”.[3] The process does have a learning curve, but its simplicity makes it worthwhile The patient recruitment was carried out from January 2009 to December 2010, and the study was completed in December 2012.