Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : November | Volume : 16 | Issue : 11 | Page : NC16 - NC20 Full Version

Utility of Abraham Lens in YAG Laser Capsulotomy: A Prospective Study


Published: November 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/57190.17166
Matuli Das, Saswati Sen, Tej Mehar Singh Chugh, Pallavi Priyadarshini Sahu, Ridhima Pokharna

1. Associate Professor, Department of Ophthalmology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India. 2. Assistant Professor, Department of Ophthalmology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India. 3. Postgraduate Student, Department of Ophthalmology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India. 4. Senior Resident, Department of Ophthalmology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India. 5. Postgraduate Student, Department of Ophthalmology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India.

Correspondence Address :
Dr. Saswati Sen,
B3-105, Shreekhetra Residency, Patrapada, Bhubaneswar, Odisha, India.
E-mail: swie2185@gmail.com

Abstract

Introduction: Neodymium-doped Yttrium Aluminum Garnet (Nd:YAG) laser capsulotomy remains the safest treatment for Posterior Capsular Opacification (PCO). The use of capsulotomy lens has some benefits to offer especially when learning the procedure and in uncooperative patients. With changing curriculum in medical teaching which focusses more on practical aspects it will serve as an asset for the trainees. Even if not used routinely, its importance cannot be altogether undermined.

Aim: To assess the utility of Abraham capsulotomy lens in YAG laser capsulotomy procedure and compare it with capsulotomy performed without lens.

Materials and Methods: This was a prospective, longitudinal study conducted in the Department of Ophthalmology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India, from June 2020 to February 2021. A total of 79 patients who developed PCO after more than six months of cataract surgery and had decrease in visual acuity on Snellen’s chart by two or more lines from baseline were included. Visual acuity, Intraocular Pressure (IOP) measurement, fundoscopy, Ocular Coherence Tomography (OCT) was done for Central Macular Thickness (CMT) in all patients at presentation, one and three months following YAG capsulotomy. Nd-YAG laser capsulotomy was then done with and without the use of Abraham capsulotomy lens in two groups. Parameters such as visual acuity change, IOP, CMT, energy used in capsulotomy, type of PCO were then compared between the two groups. Independent t-test, repeated Analysis of Variance (ANOVA) and Spearman’s correlation tests were used to analyse the data.

Results: Of the 79 patients, 40 underwent capsulotomy without the Abraham lens (Group 1) and 39 with Abraham lens (Group 2). Females were more than males in both the groups. The improvement in visual acuity was statistically significant in both groups. There was statistically significant difference in CMT in both groups at each visit. The average energy used for dealing with fibrous type of calcification was significantly more than that used in elsching pearls (13.96 mj). Complications like Intraocular Lens (IOL) pitting, raised IOP, cystoid macular oedema, uveitis and retinal detachment were encountered which were managed by appropriate medical and surgical therapy.

Conclusion: Use of capsulotomy lens decreases the amount of energy needed for capsulotomy and helps to stabilise the eye and to focus better especially for ophthalmologists in their initial training days.

Keywords

Academic training, Cataract, Complications, Neodymium-doped yttrium aluminum garnet laser, Visual acuity

Cataract surgery has evolved from intracapsular cataract extraction to phacoemulsification and a more advanced procedure femtosecond laser surgery (1). In the modern, approach IOL is implanted in the capsular bag after extraction of all lens fibres. Patients undergoing these procedures have high expectations of good visual outcome. In uneventful cataract surgery, results are mostly satisfying for both the patient and the treating physician. But with the intact lens capsule, the residual lens fibres that remain behind still have the potential to cause PCO. PCO is the most common delayed complication after cataract surgery (2). The use of Nd-YAG laser for the treatment of PCO has been described since 1980’s (3),(4). It is a very safe and effective method of restoring vision with minimal complications. The process can be carried out with the help of a capsulotomy lens called Abraham lens or without it. Visual compromise due to PCO can be easily taken care of, by a simple procedure which can be easily learnt by residents as well. While training the residents one should take proper care so that complications can be avoided. The study aimed to gauge the utility of Abraham lens as well the complications, if any, between the two alternatives used for capsulotomy (with lens and without lens). The outcome parameters were changes in ocular parameters visual acuity, IOP, CMT with relation to the energy used during capsulotomy or IOL used during surgery.

Material and Methods

This was a prospective, longitudinal study carried out in the Department of Ophthalmology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India from June 2020 to February 2021. Institutional Ethical Clearance (IEC) was obtained (KIIT/KIMS/IEC/154/2019) and the study complied by the principles of Declaration of Helsinki. Patients recruited in the study had developed PCO after cataract surgery. Purposive sampling was done to recruit patients. Informed consent was obtained from all the participants.

Inclusion criteria: All patients who developed PCO after more than six months of cataract surgery and had decrease in visual acuity on Snellen’s chart by two or more lines from baseline (visual acuity one month postcataract surgery) were included in the study.

Exclusion criteria: Patients who did not give consent, having significant pre-existing corneal or retinal diseases, which hampered visual acuity were excluded from the study.

Study Procedure

Comprehensive ophthalmological examination was carried out for all patients which included visual acuity, IOP measurement, fundoscopy, OCT for CMT in all patients at presentation. Nd-YAG laser capsulotomy was then done by one opthomologist for all study subjects after dilatation with topical eye drop containing 0.5% tropicamide and 0.5% phenylephrine hydrochloride. Pattern of capsulotomy was either circular or cruciate. When circular capsulotomy was done, it was central and about three millimetres in size.

The patients were divided into two groups. Forty patients underwent capsulotomy without the use of Abraham lens (Group 1) and 39 with the use of Abraham lens (Group 2). The lens used in the study was manufactured by Ocular R. It has a black outline with an image magnification of 1.8x, a laser spot of 0.56x, contact diameter of 15.5 mm, and lens height of 16.5 mm. It has a 10 mm diameter with +66D magnifying button which enhances visualisation of the posterior capsule. Both circular and cruciate pattern capsulotomy was done in both groups and allocation of patients to groups was done randomly. Single pulse mode Nd-Yag laser was used for capsulotomy.

Total energy used was calculated by multiplying the energy (in milijoules) used in each shot with the total number of shots used. All patients were prescribed topical Non Steroidal AntiInflammatory Drugs (NSAIDs) for 15 days postcapsulotomy. The patients were again followed-up at one month and three months and comprehensive ophthalmological examination was carried out for all.

Statistical analysis

Data was coded and recorded in the MS Excel spreadsheet program. Statistical Package for the Social Sciences (SPSS) version 23.0 (IBM Corp.) was used for data analysis. Descriptive statistics were elaborated in the form of means/standard deviations and medians/IQRs for continuous variables, and frequencies and percentages for categorical variables. Data were presented graphically wherever appropriate for data visualisation using histograms/column charts for continuous data. For comparing continuous data, Independent t-test to check for the significance between the two methods was used. The p-value <0.05 was considered to be statistically significant. Spearman’s correlation test was used to find correlation between energy used in capsulotomy with the type of capsulotomy done and the type of IOL use.

Results

A total of 79 patients were included in the study; 40 patients underwent capsulotomy without lens (group 1) and 39 with the Abharam lens (group 2). The mean age group of patients in the former group was 66.6 years and the latter was 54.8 years. The numbers of female patients were more in both the groups as compared to males. The patients of group 1 presented much later (after three years postcataract surgery) as compared to the other group (one and a half years postcataract surgery). The mean visual acuity (in log mar) at baseline was better in patients, who presented at an early date postsurgery 0.66±0.540 in group 1 and 0.68±0.552 in group 2. The nature of PCO was fibrotic in majority of cases in both the groups. The mean CMT of both groups had statistically significant difference at baseline visit/first visit. The baseline demographic and ocular parameters are described in (Table/Fig 1).

The pattern of capsulotomy done was circular in 50 patients and cruciate in 29 patients. The Best Corrected Visual Acuity (BCVA) improved significantly in both the groups at one month and three months follow-up. The improvement was statistically significant both with respect to time and when compared between patients over time in each group. This implied that visual acuity improved irrespective of the use of lens and was better in the group where lens was not used. Similarly, IOP and CMT also had significant difference between two groups at baseline and at three months follow-up [Table/Fig-(2),(3).

The IOP was raised after capsulotomy in four patients, where it was done without lens and in just one patient postcapsulotomy, where it was done with lens, but analysis of all patients irrespective of lens use at baseline, one and three months showed no significant change in IOP. Similarly, CMT measured at baseline and at one and three months respectively did not show any change, though one case in each group was reported to have macular oedema.

The mean energy used in doing capsulotomy with the capsulotomy lens was 23.01 milijoules but decreased to almost half i.e 11.8 milijoules, when Abraham lens was used. Both circular and cruciate pattern of capsulotomy was done in patients of both groups. Correlation of the energy used during capsulotomy with and without lens was done with the type of IOL implanted (hydrophobic or hydrophilic) and with the pattern of capsulotomy. There was statistically significant association between the amount of energy used with the pattern of capsulotomy done lens (correlation coefficient -0.095, p-value=0.046). It meant that the pattern of capsulotomy done did have a bearing on the total amount of energy used. On correlating the parameters at individual group level, negative correlation was found between the pattern of capsulotomy done and the energy used in both the groups (Group 1=-0.245, Group 2=-0.417). This implied that cruciate pattern required less energy than the circular pattern. The values were statistically significant in the group where lens was used. There was no significant correlation between the amount of energy used and the type of IOL implanted, either at group level or during comparison irrespective of lens use. The values are elaborated in (Table/Fig 4).

The PCO were of two types-fibrotic and Elschnig’s pearls. While assessing the effect of the type of IOL on the type of PCO formed, it was found that there was no significant association between the two (Table/Fig 5).

On the other hand, energy used in dealing with fibrotic PCO’s was significantly more than that needed to tackle the Elschnig’s pearls. The mean energy used in PCO’s which was fibrotic in nature was 19.94 milijoules and in Elschnig’s pearls was 13.96 milijoules irrespective of the use of lens. On comparing the energy used to do capsulotomy in both types of PCO with or without Abraham lens, there was statistically significant probability values for both groups (Table/Fig 6).

In the present study, patients presented with few complications which were medically managed and final visual acuity was not significantly affected. (Table/Fig 7) shows complications associated with the capsulotomy procedure in the present study. IOL pitting was seen in maximum six cases, five cases of raised IOP, two cases of uveitis, and cystoid macular oedema, and one case of retinal detachment was seen. All complications were seen in the group 1, except one case each of increased IOP and retinal detachment in the group 2. It was found that uveitis occurred in cases, where maximum energy was used followed by secondary rise in intraocular pressure, IOL pitting, and macular oedema.

Discussion

Posterior Capsular Opacification (PCO) is an opaque membrane which develops due to the proliferation of the retained lens epithelial cells following cataract surgery. It can develop after a period of few months to few years postcataract surgery (5),(6). Nd-YAG laser capsulotomy is a safe procedure that successfully restores vision without many complications (7). It requires adequate precision and accurate focus to breach the posterior capsule so that vision is improved without giving rise to complications. Abraham lens is a contact lens, that helps to focus better on the posterior capsule and keeps the eye steady during the procedure.

The present study shows mean age group of the patients at presentation to be between 50-70 years. This was expected as most cataract surgeries are performed in these age groups (8),(9). Number of female patients were more in both the groups. This late presentation of female sex might imply the variable need of visual clarity with regard to occupation or as per different vocational requirements of men and women. The mean time interval between surgery and presentation for capsulotomy ranged from 1.5 years to 3.3 years. The interval was shorter in the group of patients where lens was used. This was in accordance with the mean visual acuity at presentation, which was better in patients who presented late. The time of presentation postsurgery was similar to several other studies where development of PCO was started as early as three months and was high during the five years postoperative period (5),(10).

The development of PCO is also said to be linked with factors like the type of surgery and type of IOL used and the ocular parameters get influenced by the type of PCO that develops, the pattern of capsulotomy that is used and the amount of energy used to breach the posterior capsule. Primarily, equatorial epithelial cells are responsible for the formation of the pearls while anterior epithelial cells are responsible for fibrous PCO formation. Sometimes equatorial cells also can contribute to the formation of fibrous PCO, especially in cases where cataract surgery has been delayed for several years (11). With regards to the type of PCO encountered in present study, fibrotic PCOs were more in number than the Elschnig’s pearls, in both the groups.

Similar causes may have been associated in patients of the present study too, but there was not enough preoperative information on cataract status of all the patients. Different studies have shown either fibrotic or Elschnig’s pearls to be the predominant type but no specific factor has been described for such finding (12),(13),(14),(15). Other baseline parameters like IOP, CMT were within the normal range in all patients, before the procedure implying no bias, due to any other ocular pathology affecting the parameters postcapsulotomy.

The severity of visual symptoms do not always correlate with the degree of PCO. But there was significant improvement in the mean visual acuity postcapsulotomy. This finding has been consistent across several studies corroborating with findings of the present study (9),(16). Just like the present study, several other studies have reported this improvement in visual acuity irrespective of the shape of capsulotomy or energy used in doing capsulotomy (17),(18). Some patients complain of floaters postcapsulotomy where the detached posterior capsule flap floats in the vitreous. In the present study, there were no such encounters because the capsulotomy opening was central and about three millimetres in size. Most importantly, though the use of lens did improve the accuracy of the shots, especially while doing circinate pattern, it did not have any significant contribution in the improvement in visual acuity.

Mainly two types of capsulotomy techniques were used in the present study- circular and cruciate. Circular technique means to make a central hole in the posterior capsule and cruciate pattern involves making a cross pattern with the laser which then allows the resultant capsule to retract. Studies have reported that, energy required to make a circular opening was higher than cruciate but it does not affect the resultant visual acuity or IOP and CMT significantly. It was similar to findings of the present study (19),(20). Studies which did report changes in visual acuity or complications may be due to the significantly higher energy levels in doing circular capsulotomy (21). As far as the type of IOL used is concerned, studies have shown that incidence of PCO with hydrophobic IOLs is lesser as in comparison with hyphophilic ones (5),(22),(23),(24). But Borkenstein AF and Borkenstein EM did find that hydrophobic IOLs, which underwent more damage and fraying than hydrophilic ones (25). But none of these factors were significantly altered, by the use of capsulotomy lens.

As discussed earlier, the present study had more fibrous types of PCO’s than pearls. The energy used to cut the fibrous PCO’s was more than that used for pearls in present study in both the groups. The usage of lens decreased the amount of energy used to cut the PCO. This was in accordance with another study (15). The most important aspect was the occurrence of complications postcapsulotomy which are mostly because of high levels of energy used or as a result of faulty technique. Increased IOP, uveitis, vitritis, cystoid macular oedema, corneal injury, IOL dislocation, and even retinal detachment have been reported, as complications associated with YAG capsulotomy (26),(27),(28). Baring two, all of the complications in the present study occurred, when capsulotomy was done without capsulotomy lens. IOL pitting was the most common complication followed by raised IOP. This may be due to incorrect focusing, patient non compliance and release of pigments, and subsequent inflammation during the procedure. The increase in IOP was transient and was medically managed. Development of CME is linked to energy levels, used in the procedure causing vitreous damage and/or traction (29),(30). But in a study by Steinert RF et al., the energy levels as risk factor for CME development have been excluded (31).

Similarly in the present study though energy used was low in these cases, some patients were diabetic as well, which could have contributed to the development of CME. The energy used was maximum in the patients with uveitis followed by raised IOP, which is self-explanatory. One case of retinal detachment was reported where capsulotomy was done with lens. This may have been caused because of an inadvertent peripheral retinal break induced by capsulotomy or vitreous displacement causing traction postcapsulotomy. Incidence of retinal detachment is low after capsulotomy and pre-existing high myopia could be a contributory factor in this particular case (31),(32). What is relevant to the present study was that, the use of capsulotomy lens prevented mainly the IOL pitting.

All the studies done with related to the formation of PCO and the effects of capsulotomy have findings which largely corroborate with the findings of the present study. A larger sample size would have helped to get a more elaborate picture. Moreover all the cases in the present study were done by a single experienced consultant which masked the importance of using a capsulotomy lens in beginners. Not many studies have evaluated the parameters giving importance to the use of capsulotomy lens.

Dickerson DE et al., had elaborated the pros and cons of using a lens during capsulotomy but they had used an iridotomy lens as against capsulotomy lens used in the present study (33). The study was in agreement with other observation that lens does help in accurate focusing of the laser and stabilisation of the eye. This indeed helps in minimalising a lot of complications. A lot of new and progressive changes are being incorporated in the teaching curriculum, both at undergraduate and postgraduate level. Competency-based models for teaching focus more on the practical aspects. Hence, one must need to adopt techniques, which ensure proper training of students without compromising patient safety and vision at the same time. Use of capsulotomy lens is like revisiting the old lanes of ophthalmic practices, but with a renewed purpose of better training.

Limitation(s)

The present study was limited by factors such as small sample size and a shorter follow-up period. Longterm follow-up with a larger group, may shed some light on the effect of Yag capsulotomy over CMT and IOP in the long run. Considering recent educational curriculum changes putting more emphasis on practical and hands on knowledge, it can give safer avenues for resident training programmes.

Conclusion

With advancement in surgical techniques and growing expectation of patients several measures are being routinely taken to prevent the formation of PCO like better hydrodisection, through cortical wash, use of good quality IOL and ensuring good contact of IOL surface with the posterior capsule. But for cases where PCO does develop, YAG capsulotomy remains the best option. As per present study findings, it can be summarised that the use of lens mainly helps decrease the amount of energy used to cut the PCO. It also helps the ophthalmologists in the early training period, for better focusing and stabilisation of eye. It can also be used by all in patients where compliance is an issue. The use of capsulotomy does help in better training and control over the procedure. Hence, its importance can’t be ignored altogether and it can be a useful tool, during the early training period.

Acknowledgement

The authors would like to thank Mrs. Subhadra Priyadarshini, Research Associate, (Biostatistics), R&D Department, KIMS Bhubaneswar for helping in the statistical analysis.

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DOI and Others

DOI: 10.7860/JCDR/2022/57190.17166

Date of Submission: Apr 19, 2022
Date of Peer Review: Jul 21, 2022
Date of Acceptance: Sep 23, 2022
Date of Publishing: Nov 01, 2022

Author declaration:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 22, 2022
• Manual Googling: Sep 19, 2022
• iThenticate Software: Sep 23, 2022 (5%)

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