Devesh Varma - Academia.edu (original) (raw)

Papers by Devesh Varma

Research paper thumbnail of Cataract surgery in pseudoexfoliation syndrome

Current Opinion in Ophthalmology, 2010

Pseudoexfoliation (PXF) syndrome is characterized by the deposition of distinctive fibrillar mate... more Pseudoexfoliation (PXF) syndrome is characterized by the deposition of distinctive fibrillar material in the anterior segment of the eye. It is an age-related process that is associated with open and narrow angle glaucomas and the formation of cataracts. Not only is PXF associated with the formation of dense nuclear cataracts, it is also well known that those presenting with PXF are at a higher risk of developing complications during, and even after, cataract surgery. Complications associated with cataract surgery in PXF can occur from poor pupillary dilation, zonular weakness leading to intraoperative or postoperative lens dislocation and vitreous loss, postoperative intraocular pressure (IOP) spikes potentiating glaucomatous damage, capsular phimosis, prolonged inflammation, and postoperative corneal decompensation. The surgeon should be prepared to encounter the various potential intraoperative and postoperative complications in eyes with pseudoexfoliation syndrome during cataract surgery. In this way, the surgeon can plan his/her surgical technique to help avoid surprises during cataract surgery and be prepared to manage the potential postoperative complications that can occur in pseudoexfoliation eyes.

Research paper thumbnail of Structural and functional changes to the retina and optic nerve following panretinal photocoagulation over a 2-year time period

Research paper thumbnail of Seasonal variation in the incidence of malignant glaucoma after cataract surgery

Journal of Ophthalmic and Vision Research, 2019

Purpose: To investigate a potential link between the incidence of malignant glaucoma after catara... more Purpose: To investigate a potential link between the incidence of malignant glaucoma after cataract surgery and seasonal variations in daylight. Methods: In total, 18,374 uncomplicated cataract surgeries were performed between June 2008 and June 2013 at an ambulatory surgery center in Toronto. Toronto's average monthly daylight over that time period-in hours per day for each month-was determined. The number of malignant glaucoma cases that developed after cataract surgery performed in months with above average daylight was compared to the number of cases that developed after cataract surgery performed in months with below average daylight. Fisher's exact test was used to analyze the relationship between the development of malignant glaucoma and variation in daylight during the month of cataract surgery. Results: Malignant glaucoma developed in 16 eyes. Thirteen cases of malignant glaucoma developed in months with above average daylight and three cases developed in months with below average daylight (P = 0.01). Eyes that developed malignant glaucoma in months with more daylight were slightly longer (21.95 ± 1.23 mm) than those that developed malignant glaucoma in months with less daylight (21.55 ± 0.88 mm). Conclusion: Light-induced choroidal expansion may play a major role in the development of malignant glaucoma following cataract surgery.

Research paper thumbnail of Effectiveness of a 3D-printed mask fitter in an Ophthalmology setting during COVID-19

Canadian Journal of Ophthalmology, 2021

Objective: To assess the effectiveness of a 3D-printed custom mask fitter in lieu of N95 respirat... more Objective: To assess the effectiveness of a 3D-printed custom mask fitter in lieu of N95 respirators among ophthalmologists and other eye care professionals who may not be prioritized to receive N95 respirators amidst the coronavirus disease 2019 pandemic. Methods: This was a proof-of-concept study from a tertiary eye care center in Oakville, Canada. All participants underwent the N95 Qualitative Fit Test with a custom mask fitter secured over an American Society for Testing and Materials Level 3 face mask. Participants answered a 10-point Likert scale questionnaire on comfort, ease of use, and feasibility of the custom mask fitter, as well as comfort of a regular face mask. Results: Twenty participants were recruited. Of the 20 recruited, 18 (90%) successfully passed the fit test. The median scores for comfort, ease of use, and everyday feasibility for the custom mask fitter were 3.5, 4.5, and 3, respectively, whereas the median score for comfort of a regular face mask was 8.5. Conclusion: A reusable, low-cost, 3D-printed custom mask fitter is a potential effective alternative to an N95 respirator among eye care professionals but may require improvement in its design and comfort. This is especially relevant in the context of a limited supply of N95 respirators amidst a global pandemic. Objectif: Évaluer l'efficacité d'un ajusteur de masque personnalisé imprimé en 3D en remplacement des masques respirateurs N95 à l'intention des ophtalmologistes et autres professionnels de la vision qui n'ont peut-être pas la priorité en matière d'accès aux masques respirateurs N95 dans le contexte de la pandémie de maladie à coronavirus 2019. Méthodes: Il s'agissait d'une étude de validation du concept réalisée dans un centre de soins oculaires tertiaires situé à Oakville, en Ontario, au Canada. On a fait passer à tous les participants un essai d'ajustement qualitatif pour un masque respirateur N95 (N95 Qualitative Fit Test) lors du port d'un masque chirurgical de niveau 3 selon l'American Society for Testing and Materials avec un ajusteur de masque personnalisé. Les participants ont répondu à un questionnaire Likert (10 questions) pour évaluer le confort, la facilité d'utilisation et la valeur pratique de l'ajusteur de masque personnalisé, de même que le confort d'un masque chirurgical ordinaire. Résultats: Des 20 sujets qui ont pris part à l'étude, 18 (90 %) ont réussi le test d'ajustement. Les scores médians pour le confort, la facilité d'utilisation et la valeur pratique au quotidien de l'ajusteur de masque personnalisé s'élevaient à 3,5, à 4,5 et à 3, respectivement, tandis que le score médian pour le confort d'un masque chirurgical ordinaire se chiffrait à 8,5. Conclusion: Si un ajusteur de masque personnalisé imprimé en 3D réutilisable et peu coûteux peut constituer une solution de remplacement efficace au masque respirateur N95 chez les professionnels de la vision, son design et son confort auraient besoin d'être améliorés. Voilà qui est particulièrement pertinent dans le contexte d'un approvisionnement limité en masques respirateurs N95 pendant une pandémie planétaire.

Research paper thumbnail of Cataract Surgery in the Nanophthalmic Patient

Research paper thumbnail of Faculty of 1000 evaluation for Anterior chamber flare after femtosecond laser-assisted cataract surgery

F1000 - Post-publication peer review of the biomedical literature, 2013

Research paper thumbnail of Oblique illumination and trypan blue to enhance visualization through corneal scars in cataract surgery

Canadian Journal of Ophthalmology / Journal Canadien d'Ophtalmologie, 2011

Research paper thumbnail of Malignant Glaucoma After Routine Cataract Surgery

Research paper thumbnail of Phacodonesis and a Subluxated Crystalline Lens

bmctoday.net

The combination of advanced glaucoma and phacodonesis with lens subluxation suggests pseudoexfoli... more The combination of advanced glaucoma and phacodonesis with lens subluxation suggests pseudoexfoliation (PXF) syndrome, which needs to be ruled out. Another potential cause is high myopia, in which significant phacodonesis is not uncommon. Cataract extraction is certainly indicated, not only to remove the opaque media but also because of the patient's glaucoma. Anterior displacement of the unstable lens may play a role in the high IOP, and removal of the crystalline lens is often associated with decreased pressure. Intracapsular cataract extraction and the implantation of either an ACIOL (angle or iris supported) or a suturefixated PCIOL are valid options. My preference, however, would be to preserve the posterior capsule by fixating the lens capsule to the scleral wall. The Cionni Rings for Sclera Fixation and the Ahmed Capsular Tension Segments (CTS) (both from Morcher GmbH, Stuttgart, Germany; distributed in the United States by FCI Ophthalmics, Marshfield Hills, MA) were shown to be highly effective for fixation of the capsular bag to the scleral wall. I have developed with Hanita Lenses (Kibbutz Hanita, Israel) an alternative device, the AssiAnchor (not available in the United States), which clips to the anterior capsule Nonocular adverse events reported at a rate of 1-4% were fever, increased cough, infection, otitis media, pharyngitis, rash, and rhinitis.

Research paper thumbnail of Urgent Virtual Eye Assessments During the COVID-19 Pandemic

Clinical Ophthalmology

We aimed to evaluate the effectiveness and safety of a virtual eye assessment triage system imple... more We aimed to evaluate the effectiveness and safety of a virtual eye assessment triage system implemented in response to COVID-19. Patients and Methods: We conducted a retrospective cross-sectional study using a consecutive sample of all virtual assessments conducted from March 24 to June 7, 2020 at a single ophthalmology center in Toronto, ON, Canada. Visual acuity and smartphone photographs were uploaded to an electronic assessment website. All patients were virtually triaged to an email or phone consult. Patient outcomes and satisfaction were assessed with a quality assurance survey. Primary outcome measures were the incidence of unplanned additional in-person visits and changes in treatment. Results: We performed 1535 virtual assessments. Of the triage pathways, 15% received an email consult only and 85% received a phone consult. Subsequently, 15% required an in-person assessment, 3% were referred elsewhere, and 0.1% were sent to the emergency. Presentations were most commonly cornea (52%) and retina (25%). They were non-urgent in 68% of cases and no pharmacologic treatment was required for 49%. Of 397 patients that responded out of 653 patients surveyed, 4% had an unplanned additional visit to the emergency, after which two patients underwent urgent retinal surgery and one patient underwent urgent glaucoma surgery. Two patients (0.5%) had a minor change in treatment. Conclusion: As routine regular in-person visits were not possible during the COVID-19 lockdown, virtual eye assessments provided an opportunity to triage patients. Virtual assessments have the potential to reduce in-person visits, but caution must be exercised to not miss vision-threatening conditions.

Research paper thumbnail of Laser PI: How to Keep the Lawyers at Bay

Research paper thumbnail of Driving digital transformation of comprehensive primary health services at scale in India: an enterprise architecture framework

BMJ Global Health

In its commitment towards Sustainable Development Goals, India envisages comprehensive primary he... more In its commitment towards Sustainable Development Goals, India envisages comprehensive primary health services as a key pillar in achieving universal health coverage. Embedded in siloed vertical programmes, their lack of interoperability and standardisation limits sustainability and hence their benefits have not been realised yet. We propose an enterprise architecture framework that overcomes these challenges and outline a robust futuristic digital health infrastructure for delivery of efficient and effective comprehensive primary healthcare. Core principles of an enterprise platform architecture covering four platform levers to facilitate seamless service delivery, monitor programmatic performance and facilitate research in the context of primary healthcare are listed. A federated architecture supports the custom needs of states and health programmes through standardisation and decentralisation techniques. Interoperability design principles enable integration between disparate info...

Research paper thumbnail of Multi-country clinical outcomes of a new nondiffractive presbyopia-correcting intraocular lens

Journal of Cataract and Refractive Surgery

Purpose To evaluate the effectiveness and safety of a novel presbyopia-correcting intraocular len... more Purpose To evaluate the effectiveness and safety of a novel presbyopia-correcting intraocular lens (IOL) with a nondiffractive design, DFT015, compared with an aspheric monofocal IOL, SN60WF. Setting Nineteen investigational sites in four countries: Australia, Canada, Spain, and the United Kingdom. Design Prospective, randomized, parallel-group, controlled, assessor- and patient-masked clinical study. Methods Participants aged >=22 years with bilateral cataracts were randomized to DFT015 or SN60WF in a 5:4 ratio and masked until final postoperative follow-up at Month 6. The primary effectiveness objective was superiority of DFT015 over SN60WF in mean monocular photopic distance-corrected intermediate visual acuity (DCIVA) at Month 3. Secondary effectiveness objectives included noninferiority of DFT015 to SN60WF in mean monocular photopic best-corrected distance visual acuity (BCDVA), and superiority in mean monocular photopic distance-corrected near visual acuity (DCNVA) at Month 3. Visual disturbances were assessed at Month 6. Results Two-hundred-and-eighty-two patients were randomized to DFT015 (n = 159) or SN60WF (n = 123). All effectiveness objectives were achieved at Month 3 in first eyes. For monocular photopic results in first eyes, DFT015 demonstrated superior mean DCIVA (LS Means of -0.139 logMAR in favor of DFT015, P < .001), noninferior mean BCDVA (97.5% upper confidence limit [UCL] of the difference was <0.1 logMAR) and superior mean DCNVA (95% UCL of the difference was <0.0 logMAR) compared with SN60WF at Month 6. DFT015 exhibited a similar visual disturbance profile to that of SN60WF. Conclusions DFT015 provides superior intermediate and near vision, and a similar visual disturbance profile, compared with an aspheric monofocal IOL.

Research paper thumbnail of Clear lens extraction in eyes with primary angle closure and primary angle-closure glaucoma

Research paper thumbnail of Development and Reliability of an Appropriateness and Prioritization Instrument for Eye Care Practice: A Modified Delphi Process

Research paper thumbnail of Retrospective analysis on the visual outcomes and photic phenomena following bilateral extended depth of focus intraocular lens implants

Canadian Journal of Ophthalmology

OBJECTIVE To evaluate binocular visual outcomes and presence of photic phenomena in patients with... more OBJECTIVE To evaluate binocular visual outcomes and presence of photic phenomena in patients with bilateral extended depth of focus (EDF) intraocular lens (IOL) implants. DESIGN Retrospective consecutive case series. PARTICIPANTS Patients above the age of 18 years without prior ocular pathology or surgery with bilateral EDF IOL implants (ZXR00; Johnson & Johnson Vision) between January 2015 and December 2017 in Canadian ophthalmology centres. METHODS Patient charts were retrospectively evaluated for binocular uncorrected distance visual acuity (UCDVA), binocular corrected distance visual acuity (CDVA), binocular uncorrected near visual acuity (UCNVA), photic phenomena (glare, halos, or dysphotopsia), complications, or reoperations. Subgroup analysis investigated the effect of monovision on the above outcomes. RESULTS In total, 87 individuals with bilateral EDF IOL implants were included in the analysis. Median logMAR pre-operative CDVA was 0.18 (0.1-0.3). The median logMAR postoperative bilateral UCDVA was 0.14 (0.00-0.18), median CDVA was 0.00 (0.00-0.10), and median UCNVA was 0.10 (0.10-0.20). Overall, 16 (18.4%) cases self-reported the presence of photic phenomena, the most common of which were halos (13.8%). Subgroup analysis determined that there was no significant difference in visual outcomes or presence of photic phenomena when stratifying patients based on the degree of postoperative monovision (p = 0.31-0.57). CONCLUSIONS Overall, the Tecnis Symfony EDF IOL provided a reasonable range of binocular distance and near vision. Approximately 12.6% of patients self-reported any postoperative photic phenomena; however, all cases were subjectively considered mild and tolerable. Monovision had no effect on visual outcomes or the presence of photic phenomena.

Research paper thumbnail of Visual function, digital behavior and the vision performance index

Clinical Ophthalmology

Historically, visual acuity has been the benchmark for visual function. It is used to measure the... more Historically, visual acuity has been the benchmark for visual function. It is used to measure therapeutic outcomes for vision-related services, products and interventions. Quantitative measurement of suboptimal visual acuity can potentially be corrected optically with proper refraction in some cases, but in many cases of reduced vision there is something else more serious that can potentially impact other aspects of visual function such as contrast sensitivity, color discrimination, peripheral field of view and higher-order visual processing. The measurement of visual acuity typically requires stimuli subject to some degree of standardization or calibration and has thus often been limited to clinical settings. However, we are spending increasing amounts of time interacting with devices that present high-resolution, full color images and video (hereafter, digital media) and can record our responses. Most of these devices can be used to measure visual acuity and other aspects of visual function, not just with targeted testing experiences but from typical device interactions. There is growing evidence that prolonged exposure to digital media can lead to various vision-related issues (eg, computer vision syndrome, dry eye, etc.). Our regular, daily interactions (digital behavior) can also be used to assess our visual function, passively and continuously. This allows us to expand vision health assessment beyond the clinic, to collect vision-related data in the whole range of settings for typical digital behavior from practically any population(s) of interest and to further explore just how our increasingly virtual interactions are affecting our vision. We present a tool that can be easily integrated into digital media to provide insights into our digital behavior.

Research paper thumbnail of Re: Srinivasan et al.: Comparison of new visual disturbances after superior versus nasal/temporal laser peripheral iridotomy: a prospective randomized trial (Ophthalmology. 2018;125:345-351)

Research paper thumbnail of Proportion of undetected narrow angles or angle closure in cataract surgery referrals

Canadian journal of ophthalmology. Journal canadien d'ophtalmologie, 2017

To determine the proportion of patients referred for cataract surgery consultation who had undete... more To determine the proportion of patients referred for cataract surgery consultation who had undetected narrow angles (primary angle closure suspect [PACS], primary angle closure [PAC], or primary angle closure glaucoma [PACG]). Retrospective chart review. Phakic patients referred by eye care providers (optometrists and ophthalmologists) to a tertiary centre for cataract management between July 1, 2010 and June 30, 2012 were identified and reviewed. Demographic, referral, and specialist assessment information, as well as biometric data, including anterior segment optical coherence tomography, were collected. Patients with undetected narrow angles were identified. Univariate tests and multivariable analyses were performed to determine risk factors for narrow angles or angle closure. A total of 1229 patients were included. The mean patient age was 67.8 ± 13.0 years, 53.9% of patients were female, and 26.8% were Asian or South Asian. Of the sample population, 139 (11.3%) patients had PAC...

Research paper thumbnail of Undetected angle closure in patients with a diagnosis of open-angle glaucoma

Canadian journal of ophthalmology. Journal canadien d'ophtalmologie, 2017

The aim of this study was to identify the proportion of patients referred to a tertiary glaucoma ... more The aim of this study was to identify the proportion of patients referred to a tertiary glaucoma centre with a diagnosis of open-angle glaucoma (OAG) who were found to have angle closure glaucoma. Retrospective chart review. Consecutive new patients referred for glaucoma management to a tertiary centre between July 2010 and December 2011 were reviewed. Patients whose referrals for glaucoma assessment specified angle status as "open" were included. The data collected included glaucoma specialist's angle assessment, diagnosis, and glaucoma severity. The status of those with 180 degrees or more Shaffer angle grading of 0 was classified as "closed." From 1234 glaucoma referrals, 179 cases were specified to have a diagnosis of OAG or when angles were known to be open. Of these, 16 (8.9%) were found on examination by the glaucoma specialist to have angle closure. Pseudoexfoliation was present in 4 of 16 patients (25%) in the missed angle-closure glaucoma (ACG) grou...

Research paper thumbnail of Cataract surgery in pseudoexfoliation syndrome

Current Opinion in Ophthalmology, 2010

Pseudoexfoliation (PXF) syndrome is characterized by the deposition of distinctive fibrillar mate... more Pseudoexfoliation (PXF) syndrome is characterized by the deposition of distinctive fibrillar material in the anterior segment of the eye. It is an age-related process that is associated with open and narrow angle glaucomas and the formation of cataracts. Not only is PXF associated with the formation of dense nuclear cataracts, it is also well known that those presenting with PXF are at a higher risk of developing complications during, and even after, cataract surgery. Complications associated with cataract surgery in PXF can occur from poor pupillary dilation, zonular weakness leading to intraoperative or postoperative lens dislocation and vitreous loss, postoperative intraocular pressure (IOP) spikes potentiating glaucomatous damage, capsular phimosis, prolonged inflammation, and postoperative corneal decompensation. The surgeon should be prepared to encounter the various potential intraoperative and postoperative complications in eyes with pseudoexfoliation syndrome during cataract surgery. In this way, the surgeon can plan his/her surgical technique to help avoid surprises during cataract surgery and be prepared to manage the potential postoperative complications that can occur in pseudoexfoliation eyes.

Research paper thumbnail of Structural and functional changes to the retina and optic nerve following panretinal photocoagulation over a 2-year time period

Research paper thumbnail of Seasonal variation in the incidence of malignant glaucoma after cataract surgery

Journal of Ophthalmic and Vision Research, 2019

Purpose: To investigate a potential link between the incidence of malignant glaucoma after catara... more Purpose: To investigate a potential link between the incidence of malignant glaucoma after cataract surgery and seasonal variations in daylight. Methods: In total, 18,374 uncomplicated cataract surgeries were performed between June 2008 and June 2013 at an ambulatory surgery center in Toronto. Toronto's average monthly daylight over that time period-in hours per day for each month-was determined. The number of malignant glaucoma cases that developed after cataract surgery performed in months with above average daylight was compared to the number of cases that developed after cataract surgery performed in months with below average daylight. Fisher's exact test was used to analyze the relationship between the development of malignant glaucoma and variation in daylight during the month of cataract surgery. Results: Malignant glaucoma developed in 16 eyes. Thirteen cases of malignant glaucoma developed in months with above average daylight and three cases developed in months with below average daylight (P = 0.01). Eyes that developed malignant glaucoma in months with more daylight were slightly longer (21.95 ± 1.23 mm) than those that developed malignant glaucoma in months with less daylight (21.55 ± 0.88 mm). Conclusion: Light-induced choroidal expansion may play a major role in the development of malignant glaucoma following cataract surgery.

Research paper thumbnail of Effectiveness of a 3D-printed mask fitter in an Ophthalmology setting during COVID-19

Canadian Journal of Ophthalmology, 2021

Objective: To assess the effectiveness of a 3D-printed custom mask fitter in lieu of N95 respirat... more Objective: To assess the effectiveness of a 3D-printed custom mask fitter in lieu of N95 respirators among ophthalmologists and other eye care professionals who may not be prioritized to receive N95 respirators amidst the coronavirus disease 2019 pandemic. Methods: This was a proof-of-concept study from a tertiary eye care center in Oakville, Canada. All participants underwent the N95 Qualitative Fit Test with a custom mask fitter secured over an American Society for Testing and Materials Level 3 face mask. Participants answered a 10-point Likert scale questionnaire on comfort, ease of use, and feasibility of the custom mask fitter, as well as comfort of a regular face mask. Results: Twenty participants were recruited. Of the 20 recruited, 18 (90%) successfully passed the fit test. The median scores for comfort, ease of use, and everyday feasibility for the custom mask fitter were 3.5, 4.5, and 3, respectively, whereas the median score for comfort of a regular face mask was 8.5. Conclusion: A reusable, low-cost, 3D-printed custom mask fitter is a potential effective alternative to an N95 respirator among eye care professionals but may require improvement in its design and comfort. This is especially relevant in the context of a limited supply of N95 respirators amidst a global pandemic. Objectif: Évaluer l'efficacité d'un ajusteur de masque personnalisé imprimé en 3D en remplacement des masques respirateurs N95 à l'intention des ophtalmologistes et autres professionnels de la vision qui n'ont peut-être pas la priorité en matière d'accès aux masques respirateurs N95 dans le contexte de la pandémie de maladie à coronavirus 2019. Méthodes: Il s'agissait d'une étude de validation du concept réalisée dans un centre de soins oculaires tertiaires situé à Oakville, en Ontario, au Canada. On a fait passer à tous les participants un essai d'ajustement qualitatif pour un masque respirateur N95 (N95 Qualitative Fit Test) lors du port d'un masque chirurgical de niveau 3 selon l'American Society for Testing and Materials avec un ajusteur de masque personnalisé. Les participants ont répondu à un questionnaire Likert (10 questions) pour évaluer le confort, la facilité d'utilisation et la valeur pratique de l'ajusteur de masque personnalisé, de même que le confort d'un masque chirurgical ordinaire. Résultats: Des 20 sujets qui ont pris part à l'étude, 18 (90 %) ont réussi le test d'ajustement. Les scores médians pour le confort, la facilité d'utilisation et la valeur pratique au quotidien de l'ajusteur de masque personnalisé s'élevaient à 3,5, à 4,5 et à 3, respectivement, tandis que le score médian pour le confort d'un masque chirurgical ordinaire se chiffrait à 8,5. Conclusion: Si un ajusteur de masque personnalisé imprimé en 3D réutilisable et peu coûteux peut constituer une solution de remplacement efficace au masque respirateur N95 chez les professionnels de la vision, son design et son confort auraient besoin d'être améliorés. Voilà qui est particulièrement pertinent dans le contexte d'un approvisionnement limité en masques respirateurs N95 pendant une pandémie planétaire.

Research paper thumbnail of Cataract Surgery in the Nanophthalmic Patient

Research paper thumbnail of Faculty of 1000 evaluation for Anterior chamber flare after femtosecond laser-assisted cataract surgery

F1000 - Post-publication peer review of the biomedical literature, 2013

Research paper thumbnail of Oblique illumination and trypan blue to enhance visualization through corneal scars in cataract surgery

Canadian Journal of Ophthalmology / Journal Canadien d'Ophtalmologie, 2011

Research paper thumbnail of Malignant Glaucoma After Routine Cataract Surgery

Research paper thumbnail of Phacodonesis and a Subluxated Crystalline Lens

bmctoday.net

The combination of advanced glaucoma and phacodonesis with lens subluxation suggests pseudoexfoli... more The combination of advanced glaucoma and phacodonesis with lens subluxation suggests pseudoexfoliation (PXF) syndrome, which needs to be ruled out. Another potential cause is high myopia, in which significant phacodonesis is not uncommon. Cataract extraction is certainly indicated, not only to remove the opaque media but also because of the patient's glaucoma. Anterior displacement of the unstable lens may play a role in the high IOP, and removal of the crystalline lens is often associated with decreased pressure. Intracapsular cataract extraction and the implantation of either an ACIOL (angle or iris supported) or a suturefixated PCIOL are valid options. My preference, however, would be to preserve the posterior capsule by fixating the lens capsule to the scleral wall. The Cionni Rings for Sclera Fixation and the Ahmed Capsular Tension Segments (CTS) (both from Morcher GmbH, Stuttgart, Germany; distributed in the United States by FCI Ophthalmics, Marshfield Hills, MA) were shown to be highly effective for fixation of the capsular bag to the scleral wall. I have developed with Hanita Lenses (Kibbutz Hanita, Israel) an alternative device, the AssiAnchor (not available in the United States), which clips to the anterior capsule Nonocular adverse events reported at a rate of 1-4% were fever, increased cough, infection, otitis media, pharyngitis, rash, and rhinitis.

Research paper thumbnail of Urgent Virtual Eye Assessments During the COVID-19 Pandemic

Clinical Ophthalmology

We aimed to evaluate the effectiveness and safety of a virtual eye assessment triage system imple... more We aimed to evaluate the effectiveness and safety of a virtual eye assessment triage system implemented in response to COVID-19. Patients and Methods: We conducted a retrospective cross-sectional study using a consecutive sample of all virtual assessments conducted from March 24 to June 7, 2020 at a single ophthalmology center in Toronto, ON, Canada. Visual acuity and smartphone photographs were uploaded to an electronic assessment website. All patients were virtually triaged to an email or phone consult. Patient outcomes and satisfaction were assessed with a quality assurance survey. Primary outcome measures were the incidence of unplanned additional in-person visits and changes in treatment. Results: We performed 1535 virtual assessments. Of the triage pathways, 15% received an email consult only and 85% received a phone consult. Subsequently, 15% required an in-person assessment, 3% were referred elsewhere, and 0.1% were sent to the emergency. Presentations were most commonly cornea (52%) and retina (25%). They were non-urgent in 68% of cases and no pharmacologic treatment was required for 49%. Of 397 patients that responded out of 653 patients surveyed, 4% had an unplanned additional visit to the emergency, after which two patients underwent urgent retinal surgery and one patient underwent urgent glaucoma surgery. Two patients (0.5%) had a minor change in treatment. Conclusion: As routine regular in-person visits were not possible during the COVID-19 lockdown, virtual eye assessments provided an opportunity to triage patients. Virtual assessments have the potential to reduce in-person visits, but caution must be exercised to not miss vision-threatening conditions.

Research paper thumbnail of Laser PI: How to Keep the Lawyers at Bay

Research paper thumbnail of Driving digital transformation of comprehensive primary health services at scale in India: an enterprise architecture framework

BMJ Global Health

In its commitment towards Sustainable Development Goals, India envisages comprehensive primary he... more In its commitment towards Sustainable Development Goals, India envisages comprehensive primary health services as a key pillar in achieving universal health coverage. Embedded in siloed vertical programmes, their lack of interoperability and standardisation limits sustainability and hence their benefits have not been realised yet. We propose an enterprise architecture framework that overcomes these challenges and outline a robust futuristic digital health infrastructure for delivery of efficient and effective comprehensive primary healthcare. Core principles of an enterprise platform architecture covering four platform levers to facilitate seamless service delivery, monitor programmatic performance and facilitate research in the context of primary healthcare are listed. A federated architecture supports the custom needs of states and health programmes through standardisation and decentralisation techniques. Interoperability design principles enable integration between disparate info...

Research paper thumbnail of Multi-country clinical outcomes of a new nondiffractive presbyopia-correcting intraocular lens

Journal of Cataract and Refractive Surgery

Purpose To evaluate the effectiveness and safety of a novel presbyopia-correcting intraocular len... more Purpose To evaluate the effectiveness and safety of a novel presbyopia-correcting intraocular lens (IOL) with a nondiffractive design, DFT015, compared with an aspheric monofocal IOL, SN60WF. Setting Nineteen investigational sites in four countries: Australia, Canada, Spain, and the United Kingdom. Design Prospective, randomized, parallel-group, controlled, assessor- and patient-masked clinical study. Methods Participants aged >=22 years with bilateral cataracts were randomized to DFT015 or SN60WF in a 5:4 ratio and masked until final postoperative follow-up at Month 6. The primary effectiveness objective was superiority of DFT015 over SN60WF in mean monocular photopic distance-corrected intermediate visual acuity (DCIVA) at Month 3. Secondary effectiveness objectives included noninferiority of DFT015 to SN60WF in mean monocular photopic best-corrected distance visual acuity (BCDVA), and superiority in mean monocular photopic distance-corrected near visual acuity (DCNVA) at Month 3. Visual disturbances were assessed at Month 6. Results Two-hundred-and-eighty-two patients were randomized to DFT015 (n = 159) or SN60WF (n = 123). All effectiveness objectives were achieved at Month 3 in first eyes. For monocular photopic results in first eyes, DFT015 demonstrated superior mean DCIVA (LS Means of -0.139 logMAR in favor of DFT015, P < .001), noninferior mean BCDVA (97.5% upper confidence limit [UCL] of the difference was <0.1 logMAR) and superior mean DCNVA (95% UCL of the difference was <0.0 logMAR) compared with SN60WF at Month 6. DFT015 exhibited a similar visual disturbance profile to that of SN60WF. Conclusions DFT015 provides superior intermediate and near vision, and a similar visual disturbance profile, compared with an aspheric monofocal IOL.

Research paper thumbnail of Clear lens extraction in eyes with primary angle closure and primary angle-closure glaucoma

Research paper thumbnail of Development and Reliability of an Appropriateness and Prioritization Instrument for Eye Care Practice: A Modified Delphi Process

Research paper thumbnail of Retrospective analysis on the visual outcomes and photic phenomena following bilateral extended depth of focus intraocular lens implants

Canadian Journal of Ophthalmology

OBJECTIVE To evaluate binocular visual outcomes and presence of photic phenomena in patients with... more OBJECTIVE To evaluate binocular visual outcomes and presence of photic phenomena in patients with bilateral extended depth of focus (EDF) intraocular lens (IOL) implants. DESIGN Retrospective consecutive case series. PARTICIPANTS Patients above the age of 18 years without prior ocular pathology or surgery with bilateral EDF IOL implants (ZXR00; Johnson & Johnson Vision) between January 2015 and December 2017 in Canadian ophthalmology centres. METHODS Patient charts were retrospectively evaluated for binocular uncorrected distance visual acuity (UCDVA), binocular corrected distance visual acuity (CDVA), binocular uncorrected near visual acuity (UCNVA), photic phenomena (glare, halos, or dysphotopsia), complications, or reoperations. Subgroup analysis investigated the effect of monovision on the above outcomes. RESULTS In total, 87 individuals with bilateral EDF IOL implants were included in the analysis. Median logMAR pre-operative CDVA was 0.18 (0.1-0.3). The median logMAR postoperative bilateral UCDVA was 0.14 (0.00-0.18), median CDVA was 0.00 (0.00-0.10), and median UCNVA was 0.10 (0.10-0.20). Overall, 16 (18.4%) cases self-reported the presence of photic phenomena, the most common of which were halos (13.8%). Subgroup analysis determined that there was no significant difference in visual outcomes or presence of photic phenomena when stratifying patients based on the degree of postoperative monovision (p = 0.31-0.57). CONCLUSIONS Overall, the Tecnis Symfony EDF IOL provided a reasonable range of binocular distance and near vision. Approximately 12.6% of patients self-reported any postoperative photic phenomena; however, all cases were subjectively considered mild and tolerable. Monovision had no effect on visual outcomes or the presence of photic phenomena.

Research paper thumbnail of Visual function, digital behavior and the vision performance index

Clinical Ophthalmology

Historically, visual acuity has been the benchmark for visual function. It is used to measure the... more Historically, visual acuity has been the benchmark for visual function. It is used to measure therapeutic outcomes for vision-related services, products and interventions. Quantitative measurement of suboptimal visual acuity can potentially be corrected optically with proper refraction in some cases, but in many cases of reduced vision there is something else more serious that can potentially impact other aspects of visual function such as contrast sensitivity, color discrimination, peripheral field of view and higher-order visual processing. The measurement of visual acuity typically requires stimuli subject to some degree of standardization or calibration and has thus often been limited to clinical settings. However, we are spending increasing amounts of time interacting with devices that present high-resolution, full color images and video (hereafter, digital media) and can record our responses. Most of these devices can be used to measure visual acuity and other aspects of visual function, not just with targeted testing experiences but from typical device interactions. There is growing evidence that prolonged exposure to digital media can lead to various vision-related issues (eg, computer vision syndrome, dry eye, etc.). Our regular, daily interactions (digital behavior) can also be used to assess our visual function, passively and continuously. This allows us to expand vision health assessment beyond the clinic, to collect vision-related data in the whole range of settings for typical digital behavior from practically any population(s) of interest and to further explore just how our increasingly virtual interactions are affecting our vision. We present a tool that can be easily integrated into digital media to provide insights into our digital behavior.

Research paper thumbnail of Re: Srinivasan et al.: Comparison of new visual disturbances after superior versus nasal/temporal laser peripheral iridotomy: a prospective randomized trial (Ophthalmology. 2018;125:345-351)

Research paper thumbnail of Proportion of undetected narrow angles or angle closure in cataract surgery referrals

Canadian journal of ophthalmology. Journal canadien d'ophtalmologie, 2017

To determine the proportion of patients referred for cataract surgery consultation who had undete... more To determine the proportion of patients referred for cataract surgery consultation who had undetected narrow angles (primary angle closure suspect [PACS], primary angle closure [PAC], or primary angle closure glaucoma [PACG]). Retrospective chart review. Phakic patients referred by eye care providers (optometrists and ophthalmologists) to a tertiary centre for cataract management between July 1, 2010 and June 30, 2012 were identified and reviewed. Demographic, referral, and specialist assessment information, as well as biometric data, including anterior segment optical coherence tomography, were collected. Patients with undetected narrow angles were identified. Univariate tests and multivariable analyses were performed to determine risk factors for narrow angles or angle closure. A total of 1229 patients were included. The mean patient age was 67.8 ± 13.0 years, 53.9% of patients were female, and 26.8% were Asian or South Asian. Of the sample population, 139 (11.3%) patients had PAC...

Research paper thumbnail of Undetected angle closure in patients with a diagnosis of open-angle glaucoma

Canadian journal of ophthalmology. Journal canadien d'ophtalmologie, 2017

The aim of this study was to identify the proportion of patients referred to a tertiary glaucoma ... more The aim of this study was to identify the proportion of patients referred to a tertiary glaucoma centre with a diagnosis of open-angle glaucoma (OAG) who were found to have angle closure glaucoma. Retrospective chart review. Consecutive new patients referred for glaucoma management to a tertiary centre between July 2010 and December 2011 were reviewed. Patients whose referrals for glaucoma assessment specified angle status as "open" were included. The data collected included glaucoma specialist's angle assessment, diagnosis, and glaucoma severity. The status of those with 180 degrees or more Shaffer angle grading of 0 was classified as "closed." From 1234 glaucoma referrals, 179 cases were specified to have a diagnosis of OAG or when angles were known to be open. Of these, 16 (8.9%) were found on examination by the glaucoma specialist to have angle closure. Pseudoexfoliation was present in 4 of 16 patients (25%) in the missed angle-closure glaucoma (ACG) grou...