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

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"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."



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Lucknow
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On Aug 2018




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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.
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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.


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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.
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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.
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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 : April | Volume : 16 | Issue : 4 | Page : NC01 - NC04 Full Version

Surgical Outcomes of Trabeculectomy Alone versus Trabeculectomy with Manual Small Incision Cataract Surgery Following Acute Angle Closure Glaucoma: A Comparative Study


Published: April 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55272.16189
Soumya Ray, Soumen Chakraborty

1. RMO Cum Clinical Tutor, Department of Ophthalmology, Bankura Sammilani Medical College, Bankura, West Bengal, India. 2. Associate Professor, Department of Ophthalmology, Bankura Sammilani Medical College, Bankura, West Bengal, India.

Correspondence Address :
Dr. Soumen Chakraborty,
D 277, Luna Street, Durgapur, West Bengal, India.
E-mail: schak277@gmail.com

Abstract

Introduction: Acute Angle Closure Glaucoma (AACG) is an ophthalmic emergency and is managed medically. Therapeutic options for the management of the post congestive phase are varied and no procedure has a documented therapeutic superiority over the other. Two established procedures were therefore chosen and compared to determine their therapeutic efficacy.

Aim: To compare the surgical results of combined manual Small Incision Cataract Surgery (SICS) and trabeculectomy with standalone trabeculectomy in patients following an attack of AACG, with a final aim to decide which would be the better therapeutic approach in such a situation.

Materials and Methods: This was a prospective observational comparative study done in Bankura Sammilani Medical College located in West Bengal, India. Sixteen patients presenting with AACG in a 19 months study period from October 2019-April 2021 and having 50% or more synechial angle closure on indentation gonioscopy were selected for this study after obtaining necessary ethical clearance. Eight of them underwent trabeculectomy alone (Group A) and the rest underwent a combined procedure of trabeculectomy and SICS (Group B). They were followed-up for a six-months period and compared on the basis of Intraocular Pressure (IOP) control, Anterior Chamber (AC) depth and the requirement for further surgery.

Results: Mean IOP following surgery at the end of six weeks in Group A was 15.98±1.56 mmHg whereas in Group B it was 12.01±1.18 mmHg. Results were compared by unpaired t-test, and the difference was statistically significant (p<0.001). Three out of eight patients (37%) in Group A developed cataract which caused a reduction in visual acuity and needed cataract surgery within the six months follow-up period but none of the patients in Group B needed any additional surgery. One patient in Group A needed additional medications due to uncontrolled IOP after surgery but no such event was noted in Group B. Seventy five percent patients in Group A had Grade 2 angles whereas 87% patients in Group B had Grade 4 angles as estimated by Van Herrick’s method.

Conclusion: Combined trabeculectomy and SICS offers a better level of postoperative IOP control than trabeculectomy alone, and perhaps offers a better therapeutic option following AACG. Also, the chances of postoperative cataract formation and associated visual debility are eliminated.

Keywords

Anterior chamber depth, Cataract extraction, Intraocular pressure

The AACG quite often presents to the ophthalmologist with a demand for urgency in attention and intervention. The management on presentation is undoubtedly medical [1,2], but contention exists regarding the subsequent course of action. Approaches have varied from medications and Peripheral Button Hole Iridectomy (PBHI) to filtration procedures. But no definitive clue exists as to which would be the best therapeutic approach for the patient on a long-term basis, because none of the procedures alone can rectify the entire spectrum of structural and functional changes that occur following an attack of acute angle closure. It was therefore felt that only a combination of procedures might give the desired therapeutic results.


The aim of this study, was to find out whether combined manual SICS and trabeculectomy could offer therapeutic benefits to these patients and, at the same time, compare its efficacy to an established surgical procedure like standalone trabeculectomy. This comparison was made on four preset parameters- visual acuity at the end of a follow-up period of six weeks, quality of IOP control, postoperative AC depth as seen by Van Herrick’s method and need for further surgery or medications.

Material and Methods

The present study was a prospective observational comparative study conducted in the Department of Opthalmology, Bankura Sammilani Medical College located in the state of West Bengal, India. The study period was approximately 19 months, extending from October 2019-April 2021. Due permission was obtained from the Institutional Ethics Committee (IEC) (Memo No Eye/278/09/2019) prior to commencement of this study. All patients diagnosed with AACG during that period were included in this study after signing the informed consent.

Initial Evaluation

A total of 16 patients were enrolled in this study. All patients on arrival underwent a comprehensive eye evaluation which included slit lamp examination, visual assessment and IOP measurement of the affected eye. The other eye was also evaluated in all the cases, but as that is not a part of this study, those findings are not mentioned here.

All patients received an initial uniform medical management which included 20% solution of intravenous mannitol 1.5 g/kg body weight, oral acetazolamide 250 mg once a day, topical timolol maleate 0.5% two times a day, topical pilocarpine 2% qd and topical dexamethasone sodium phosphate 0.1% w/v qd. On resolution of the corneal oedema, indentation gonioscopy was performed using a Sussman four mirror gonioscope. Only those patients who had synechial closure of 50% or more of the angle of the AC were selected for surgery (1).

Surgery was taken up between two to three weeks after initiation of medical therapy and ensuring that IOP had returned to a level where surgery was safe to perform.

Surgery was done on an alternate basis- meaning patients with odd serial numbers undergoing trabeculectomy and those with even serial numbers undergoing a combined procedure. The trabeculectomy group was designated as Group A and the patients undergoing combined surgery as Group B.

Surgical Technique

Trabeculectomy was performed by a fornix based flap. The sclera was dissected with a crescent knife and trabeculectomy completed with a Kelly’s punch. A PBHI was done and the sclera was apposed with releasable 10’0 monofilament nylon sutures. The conjunctiva was sutured back to the sclera in a water tight manner (2). No anti-metabolites were used peroperatively in any patient.

A more extensive procedure- combined SICS and trabeculectomy (SICS+Trab) was performed on Group B patients. Following superior limbal peritomy, an ‘M’ incision was made on the sclera. The AC was entered at the base of the ‘M’. The lens cortex and the nucleus were managed in the usual way following a 5.5 mm capsulorexhis. A 6 mm rigid Poly Methyl Meth-Acrylate (PMMA) lens was implanted in the bag. Trabeculectomy was performed using a Kelly’s punch, and a PBHI followed. The wound was closed with a single suture applied at the apex of the ‘M’. The conjunctiva was closed in the usual water tight manner (3).

Postoperative Period

All patients received topical steroids (moxifloxacin 0.5% w/v + dexamethasone sodium phosphate 0.1% w/v) two hourly and cycloplegics (homatropine 2% w/v) 12 hourly from first postoperative day. Topical steroids were tapered over a period of six weeks. Cycloplegics were omitted by the end of the second week. No anti-glaucoma medications were prescribed initially.

Visual acuity assessment and slit lamp evaluation including AC depth assessment by Van Herrick’s method (4) - was done on 1st, 7th, 21st postoperative day and at the end of six weeks. IOP was assessed by Non Contact Tonometry (NCT) during the same visits. Topical medications were stopped at the end of six weeks, refraction was performed and glasses were prescribed. Subsequently, all patients were followed-up monthly for a period of six additional months.

Statistical Analysis

Pre and postoperative IOP changes were compared by paired and unpaired t-test using the Statistical Package for the Social Sciences (SPSS) software version 22.0.

Results

In total, 16 patients were enrolled in this study. The trabeculectomy group was designated as group A and the combined surgery group as group B. The age of the patients ranged between 51-66 years with a mean of 59.3±4.38 years. Twelve patients were females, making the female:male ratio 3:1. The profiles of both the groups are shown in (Table/Fig 1),(Table/Fig 2), respectively.

Visual Recovery and Sustainability

In group A visual acuity ranged from 6/12 to 6/36, whereas in group B, visual acuity ranged from 6/6 to 6/12. The causes of reduced visual acuity in patients of group A included development of cataract in three patients (37%), persistently raised IOP in one patient (12.5%) and glaucomflecken in one patient (12.5%). The only patient whose visual acuity was reduced in group B had developed posterior capsular opacification (patient 14 of (Table/Fig 2)).

B#bQuality of IOP Control

In group A the preoperative means IOP was 50.20 mmHg and the mean postoperative IOP was 15.98 mmHg. Statistically significant association was observed.

In group B the preoperative mean IOP was 50.05 mmHg and the mean postoperative IOP was 12.01 mmHg. Statistically (p<0.001) significant association was observed (Table/Fig 3).

Both procedures therefore could be considered as viable surgical approaches for patients following AACG. However, the mean postoperative IOP in Group B was much less than in Group A (p-value <0.001) (Table/Fig 4).

It can therefore be conclusively said the IOP control following combined procedure of trabeculectomy and manual SICS is much better than trabeculectomy alone. As already stated, one patient in group A showed an increase in IOP from the third week onwards which had to be controlled by miotics. This patient with persistently raised IOP was accepted as a surgical failure. No incidences of surgical failure were reported from group B.

Postoperative AC Depth

Six out of the eight patients in group A (75%) had grade 2 angle as estimated by Van Herricks method of angle grading. In contrast, 7 patients (87%) had grade 4 angle as estimated by the same method. This in turn perhaps translated to a better extent of IOP control.

Need for Further Intervention

Three out of the eight patients (37%) in group A needed further intervention in the form of cataract surgery for the cataracts that developed within the six months follow-up period. The patient who had glaucomflecken was prescribed appropriate refractive correction. None of the patients in group B needed any surgical intervention during the six months follow-up period. The only patient with posterior capsular opacification underwent a YAG laser capsulotomy at the end of six months and made a complete visual recovery.

Discussion

One of the earliest studies suggesting the effectiveness of trabeculectomy in Primary Angle Closure Glaucoma (PACG) was reported by Salmon in 1993. In his study, retrospective analysis of 46 eyes of 39 patients showed that trabeculectomy successfully reduced the IOP to less than 21 mmHg in 30 eyes (66.7%) without any additional medications (5). Since then, trabeculectomy has perhaps remained as a yardstick of surgical management of PACG by which the efficacy of other surgical procedures are measured.

But having said that, trabeculectomy is not without its downsides. It is associated with a reasonable risk of postoperative cataractogenesis. In a study by Sihota R et al., 12 of the 64 eyes (32%) with PACG which had undergone trabeculectomy developed cataracts in contrast to 4 out of 64 eyes (15%) who had undergone trabeculectomy for Primary Open Angle Glaucoma (POAG) (6). It therefore appeared that the chances of postoperative cataract formation are more in patients with angle closure glaucoma. This adds to the burden of visual debility, for which the patient has to return to the hospital again. Secondly, a progressing cataractogenesis gradually shallows the AC, thereby contributing to the process of angle closure (3). A cataract extraction would therefore be beneficial in two ways. Firstly, it would eliminate the chance of cataractogenesis, which in turn would avoid visual debility and resultant surgery. Secondly, it would contribute to rectification of one of the basic contributors to the patho-physiologic mechanisms of PACG (3),(7),(8).

Studies have also focused on cataract extraction alone as a therapeutic approach in closed angle situations (9),(10). Lowe RF et al., had shown that eyes with angle closure have a thicker lens with a steeper anterior curvature and are positioned more anteriorly than controls (11),(12),(13). Theoretically therefore, lens extraction should reverse the anatomical attributes to angle closure. Ultrasound Biomicroscopic (UBM) studies by Park SW et al., has shown that cataract extraction alone increases the AC angle depth from 208 to 468 microns (14). Based on these optimistic evidences, Wishart PK and Atkinson PL were among the first to recommend cataract extraction as a surgical modality in PACG (15). Twenty three eyes of 22 patients underwent extra capsular cataract extraction with rigid intra ocular lens implantation. Sixty five percent of the patients achieved a sustainable IOP less than 21 mmHg. Similar results with Phacoemulsification (PE) alone were also reported by Lai JS et al., and Jacob PC et al., (16),(17). However, there is no clinical trial or data which conclusively suggests that crystalline lens extraction alone is a superior therapeutic option over trabeculectomy in the management of PACG.

With multiple structural and functional mechanisms at play in the pathogenesis of PACG, many authors suggested a combination of surgical procedures in its management (3),(18). In this study, the combined surgery group showed some distinct advantages in outcomes. Firstly, the reduction of IOP from the preoperative status was much better in the combined surgery group. In this study, the postoperative mean in group A was 15.98 mmHg, whereas in group B it was 12.01 mmHg. Unpaired t-test showed a p-value <0.001, making this difference statistically significant, thereby proving the supremacy of the combined procedure as far as IOP control is concerned. A similar finding suggesting the benefits of a combined procedure in IOP reduction was intimated by Tham CC et al., where combined phaco-trabeculectomy resulted in an additional 2 mmHg reduction in mean IOP (p=0.08) (19).

Reasons for a better IOP control with a combined procedure are many. Extra capsular cataract surgery deepens the AC, relieves pupillary block and opens up appositional angle closure, thereby contributing to a better level of IOP control. In addition, it also helps in retarding the progression of further angle closure [3,7,8,10,12]. Secondly, removal of the crystalline lens eliminates chances of cataract formation, which offers a better quality of visual outcome. In this study, 37% of the patients in group A developed visually debilitating cataracts over six months follow-up period. A nearly similar incidence of cataractogenesis following trabeculectomy alone was also reported by Tham CC et al., in another study where 33% of patients developed visually debilitating cataracts within a one year follow-up period (20). This problem was not encountered in group B for obvious reasons. A simultaneous cataract extraction therefore eliminates resultant cataract related visual debility and consequent need for further surgery completely. This, in addition to beneficial effects on IOP control as already mentioned, results in amplified overall patient satisfaction.

Guidelines regarding surgical selection of patients following an attack of acute angle closure are diverse. These include presence of 50% or more angle closure on indentation gonioscopy, unsatisfactory response to medications, and presence of cupping and visual field loss and inadequate facility of outflow on tonography (1). Monitoring response to medication requires good patient compliance and is time consuming. It also runs the risk of disease progression and irreversible optic nerve damage in non responders. Tonography is a reliable indicator, but unfortunately facility for the same is not available in our institution. Authors therefore decided to follow the gonioscopic guideline to select the patients.

Limitation(s)

One limitation of this study was the small sample size. With increased health awareness and improved access to healthcare, incidence of acute congestive attacks has perhaps reduced over time. Also, all patients with AACG do not need surgical intervention– only those who conform to the above mentioned criteria need so. This explains the long study period and the relatively small number of cases.

Conclusion

The authors found both procedures to be rational, simple, cost-effective and safe surgical approaches to patients following an acute congestive attack. On comparison however it was seen that the combined procedure offered superior therapeutic benefits in terms of a better control of IOP which was statistically significant. The combined procedure- if necessary, after analysing a larger series of patients-could be accepted as a standard therapeutic approach following AACG.

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DOI and Others

DOI: 10.7860/JCDR/2022/55272.16189

Date of Submission: Jan 27, 2022
Date of Peer Review: Feb 12, 2022
Date of Acceptance: Feb 26, 2022
Date of Publishing: Apr 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: Feb 01, 2022
• Manual Googling: Feb 07, 2022
• iThenticate Software: Feb 18, 2022 (19%)

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