Dr. Agarwal's Eye Hospital

Abstract Work-related musculoskeletal disorders (MSDs) are ubiquitous among vitreo-retina surgeons due to prolonged static posture, microscope use, and fine motor demands. With the evolution of heads-up display systems and digital visualization, ergonomic challenges and opportunities have shifted dramatically in recent years. This manuscript reviews the importance of ergonomics and posture for vitreo-retina surgeons, synthesizes contemporary findings from peer-reviewed literature, and offers actionable recommendations. A table summarizes studies on ergonomic interventions and their impact on surgeon health and performance.

ABSTRACT Introduction The management of nucleus may be challenging in both soft and hard cataracts. Hard cataracts may be difficult to fragment, and the excessive energy required to emulsify the hard nucleus can result in complications such as corneal edema, inflammation, wound burn, posterior capsular rupture, and zonular dialysis. Soft cataracts constitute the other end of the spectrum, wherein the nucleus may not provide enough hold to generate adequate vacuum and allow conventional chopping. We review the different surgical techniques for the management of hard and soft cataracts, with their advantages and limitations. Areas covered We discussed various techniques of managing hard and soft cataracts. A comprehensive Medline search was performed using ‘phacoemulsification,’ ‘hard cataract,’ ‘white cataract,’ ‘soft cataract,’ ‘mature cataract,’ and ‘hypermature senile cataract’ as keywords. Expert commentary Various techniques for handling soft and hard cataracts have been described, from simple modifications of the routine cataract surgery steps to laser-assisted cataract surgery. Adjunctive devices and femtosecond lasers are increasingly used to manage the nucleus in challenging cases. A continuous evolvement of machinery and technology will further optimize outcomes and enable safe phacoemulsification in these challenging cases.

Corneal allogeneic intrastromal ring segments (CAIRS) were recently introduced as anovel treatment modality for corneal diseases, such as keratoconus or postoperative ectasia after laser-refractive surgery. Contrary to other conventional surgical treatments for ectatic conditions, CAIRS is minimally invasive, freely adjustable in its size and length and has ashort learning curve as well as agood safety profile. This article provides step-by-step instructions for the performance and integration of the CAIRS procedure into clinical practice.

A 31-year male with headaches and auditory disturbances was referred for ophthalmologic examination with decreased vision in the right eye. The combination of multiple retinal branch artery occlusions and Gass plaques in both eyes on funduscopic examination, characteristic white matter lesions in the corpus callosum on magnetic resonance imaging, and hearing loss on audiometric tests led to a diagnosis of Susac syndrome (SuS), which is an autoimmune microangiopathy. Ultra-widefield fluorescein angiography revealed arterial wall hyperfluorescence and the involvement of the retinal veins in the left eye, a rare finding associated with this condition, highlighting that SuS affects not only arterioles but also venules. Understanding venous involvement in SuS is crucial for recognizing the disease’s complexity and providing insights into better management strategies.

A 15-year-old female presented with diminution of vision in both eyes (BE), more at night, since 1 year. There was no history of trauma, ocular treatment, or similar complaints in her family. There was history of consanguineous marriage. Her best corrected visual acuity was 6/36, N6 in the right eye (RE) and 6/18, N6 in the left eye (LE). She was unable to read any of the pseudoisochromatic Ishihara plates. Rest of the anterior segment findings and intraocular pressures in BE were within normal limits. Fundus examination revealed pale disc, arteriolar attenuation, irregular pigmentary changes at the posterior pole, minimal bony spicules, peripapillary atrophy, and tessellated fundus [Fig. 1a and b]. RE structural optical coherence tomography showed loss of foveal contour with loss of outer nuclear layer in the subfoveal and perifoveal regions. LE showed foveal thinning with loss of photoreceptor layer [Fig. 1e and f]. Fundus autofluorescence showed hypoautofluorescent nasal half of the retina with incomplete ring of hypoautofluorescence surrounded by hyperautofluorescence at the fovea in BE [Fig. 1c and d]. Full-field electroretinogram showed flat wave in BE [Fig. 2], compared to normal electroretinogram of a healthy young child [Fig. 3]. Genetic testing for the patient showed homozygous novel variant (c.1094C > A) in CERKL gene in exon 8, which has pathogenic significance, causing premature truncation of protein resulting in increased oxidative stress, thereby causing degeneration of photoreceptors. The age of presentation of retinitis pigmentosa (RP) is around third decade.[1] Patients with CERKL mutation are known to present early with increased macular involvement and have pauci-pigmented fundus.[2] As per ClinVar database (https://www.ncbi.nlm.nih.gov/clinvar/?term=CERKL[gene]), there are 236 variants of CERKL gene causing RP, which are pathogenic or likely pathogenic. The inheritance pattern and prognosis were explained to the family members of the patient. The patient was advised to undergo genetic testing, but did not undergo the same because of logistic reasons, which is a limitation of this study. To conclude, we report a case of RP with novel unreported mutations (c.1094C >A) in eastern India.[3]Figure 1: (a) Color fundus photo of RE showing arteriolar attenuation, disc pallor, and minimal bony spicules in a tessellated fundus. (b) Color fundus photo of LE showing arteriolar attenuation, disc pallor, and minimal bony spicules in a tessellated fundus. (c) Fundus autofluorescence of RE showing granular hypoautofluorescence nasal to the disc. An incomplete ring of hypoautofluorescence surrounded by hyperautofluorescence at the fovea was also seen. (d) Fundus autofluorescence of LE showing granular hypoautofluorescence nasal to the disc. An incomplete ring of hypofluorescence surrounded by hyperautofluorescence at the fovea was also seen. (e) Structural OCT of through the fovea shows loss of foveal contour with loss of outer nuclear layer in the subfoveal and perifoveal regions. (f) Structural OCT of LE through the fovea shows foveal thinning with loss of photoreceptor layer. LE = left eye, OCT = optical coherence tomography, RE = right eyeFigure 2: (a–j) Full-field electroretinogram of both eyes showing grossly attenuated waveforms of all standard International society for clinical electrophysiology of vision (ISCEV) waveformsFigure 3: (a–e) Full-field electroretinogram of a normal healthy young child according to the ISCEV standardsDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.

1Department of Vitreo Retina Aditya Birla SankaraNethralaya, 147, Mukundapur, E.M.Bypass, Kolkata-700 099, West Bengal, India. 2Department of Vitreo Retina, Agarwals Eye Hospital, Kolkata Corresponding Author: DrRupak Roy Postal Address: Aditya Birla Sankara Nethralaya, 147, Mukundapur, E.M.Bypass, Kolkata- 700 099, West Bengal, India. E-mail: [email protected] Phone number: +91 33 4401 3000 Conflicts of interests: None

We describe a new species of small-sized Calotes from mid-elevation (~1270 m asl.), swidden or shifting cultivation areas in the Subansiri river basin, Upper Subansiri District, Arunachal Pradesh, India. Mitochondrial sequence data (ND2) recovers Calotes sinyik sp. nov. as the closely related sister taxon to an unnamed species from Medog, Tibet; the two falling in a broader clade including C. paulus + C. zolaiking and species of the C. emma and C. mystaceus groups. The new species is 7.8% divergent in ND2 sequence data from the unnamed lineage from Medog and deeply divergent (≥ 21.6-28.1%) from other congeners. The new species can easily be distinguished from regional congeners by its small adult body size (maximum snout to vent length of 65 mm) and heterogenous dorsal scales, and from its closest relatives C. paulus and C. zolaiking by having 54 or 55 midbody scale rows and 42 or 43 vertebral scales. It is likely that many more allied species remain to be discovered from Northeast India, which remains poorly surveyed across taxonomic groups.

The online version contains supplementary material available at 10.1007/s12288-024-01896-7.