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1.  Prevalence and Risk Factors for Vitamin C Deficiency in North and South India: A Two Centre Population Based Study in People Aged 60 Years and Over 
PLoS ONE  2011;6(12):e28588.
Background
Studies from the UK and North America have reported vitamin C deficiency in around 1 in 5 men and 1 in 9 women in low income groups. There are few data on vitamin C deficiency in resource poor countries.
Objectives
To investigate the prevalence of vitamin C deficiency in India.
Design
We carried out a population-based cross-sectional survey in two areas of north and south India. Randomly sampled clusters were enumerated to identify people aged 60 and over. Participants (75% response rate) were interviewed for tobacco, alcohol, cooking fuel use, 24 hour diet recall and underwent anthropometry and blood collection. Vitamin C was measured using an enzyme-based assay in plasma stabilized with metaphosphoric acid. We categorised vitamin C status as deficient (<11 µmol/L), sub-optimal (11–28 µmol/L) and adequate (>28 µmol/L). We investigated factors associated with vitamin C deficiency using multivariable Poisson regression.
Results
The age, sex and season standardized prevalence of vitamin C deficiency was 73.9% (95% confidence Interval, CI 70.4,77.5) in 2668 people in north India and 45.7% (95% CI 42.5,48.9) in 2970 from south India. Only 10.8% in the north and 25.9% in the south met the criteria for adequate levels. Vitamin C deficiency varied by season, and was more prevalent in men, with increasing age, users of tobacco and biomass fuels, in those with anthropometric indicators of poor nutrition and with lower intakes of dietary vitamin C.
Conclusions
In poor communities, such as in our study, consideration needs to be given to measures to improve the consumption of vitamin C rich foods and to discourage the use of tobacco.
doi:10.1371/journal.pone.0028588
PMCID: PMC3232233  PMID: 22163038
2.  Inverse Association of Vitamin C with Cataract in Older People in India 
Ophthalmology  2011;118(10):1958-1965.e2.
Objective
To examine the association between vitamin C and cataract in the Indian setting.
Design
Population-based cross-sectional analytic study.
Participants
A total of 5638 people aged ≥60 years.
Methods
Enumeration of randomly sampled villages in 2 areas of north and south India to identify people aged ≥60 years. Participants were interviewed for socioeconomic and lifestyle factors (tobacco, alcohol, household cooking fuel, work, and diet); attended a clinical examination, including lens photography; and provided a blood sample for antioxidant analysis. Plasma vitamin C was measured using an enzyme-based assay in plasma stabilized with metaphosphoric acid, and other antioxidants were measured by reverse-phase high-pressure liquid chromatography.
Main Outcome Measures
Cataract and type of cataract were graded from digital lens images using the Lens Opacity Classification System III (LOCS III), and cataract was classified from the grade in the worse eye of ≥4 for nuclear cataract, ≥3 for cortical cataract, and ≥2 for posterior subcapsular cataract (PSC). Any cataract was defined as any unoperated or operated cataract.
Results
Of 7518 enumerated people, 5638 (75%) provided data on vitamin C, antioxidants, and potential confounders. Vitamin C was inversely associated with cataract (adjusted odds ratio [OR] for highest to lowest quartile = 0.61; 95% confidence interval (CI), 0.51–0.74; P=1.1×10−6). Inclusion of other antioxidants in the model (lutein, zeaxanthin, retinol, β-carotene, and α-tocopherol) made only a small attenuation to the result (OR 0.68; 95% CI, 0.57–0.82; P < 0.0001). Similar results were seen with vitamin C by type of cataract: nuclear cataract (adjusted OR 0.66; CI, 0.54–0.80; P < 0.0001), cortical cataract (adjusted OR 0.70; CI, 0.54–0.90; P < 0.002), and PSC (adjusted OR 0.58; CI, 0.45–0.74; P < 0.00003). Lutein, zeaxanthin, and retinol were significantly inversely associated with cataract, but the associations were weaker and not consistently observed by type of cataract. Inverse associations were also observed for dietary vitamin C and cataract.
Conclusions
We found a strong association with vitamin C and cataract in a vitamin C–depleted population.
Financial Disclosure(s)
The author(s) have no proprietary or commercial interest in any materials discussed in this article.
doi:10.1016/j.ophtha.2011.03.016
PMCID: PMC3185206  PMID: 21705085
3.  Prevalence of Cataract in an Older Population in India 
Ophthalmology  2011;118(2-19):272-278.e2.
Purpose
To describe the prevalence of cataract in older people in 2 areas of north and south India.
Design
Population-based, cross-sectional study.
Participants
Randomly sampled villages were enumerated to identify people aged ≥60 years. Of 7518 enumerated people, 78% participated in a hospital-based ophthalmic examination.
Methods
The examination included visual acuity measurement, dilatation, and anterior and posterior segment examination. Digital images of the lens were taken and graded by type and severity of opacity using the Lens Opacity Classification System III (LOCS III).
Main Outcome Measures
Age- and gender-standardized prevalence of cataract and 95% confidence intervals (CIs). We defined type of cataract based on the LOCS III grade in the worse eye of: ≥4 for nuclear cataract, ≥3 for cortical cataract, and ≥2 for posterior subcapsular cataract (PSC). Any unoperated cataract was based on these criteria or ungradable dense opacities. Any cataract was defined as any unoperated or operated cataract.
Results
The prevalence of unoperated cataract in people aged ≥60 was 58% in north India (95% CI, 56–60) and 53% (95% CI, 51–55) in south India (P = 0.01). Nuclear cataract was the most common type: 48% (95% CI, 46–50) in north India and 38% (95% CI, 37–40) in south India (P<0.0001); corresponding figures for PSC were 21% (95% CI, 20–23) and 17% (95% CI, 16–19; P = 0.003), respectively, and for cortical cataract 7.6% (95% CI, 7–9) and 10.2% (95% CI, 9–11; P<0.004). Bilateral aphakia/pseudophakia was slightly higher in the south (15.5%) than in the north (13.2%; P<0.03). The prevalence of any cataracts was similar in north (73.8%) and south India (71.8%). The prevalence of unoperated cataract increased with age and was higher in women than men (odds ratio [OR], 1.8). Aphakia/pseudophakia was also more common in women, either unilateral (OR, 1.2; P<0.02) or bilateral (OR, 1.3; P<0.002).
Conclusions
We found high rates of unoperated cataract in older people in north and south India. Posterior subcapsular cataract was more common than in western studies. Women had higher rates of cataract, which was not explained by differential access to surgery.
Financial Disclosure(s)
The authors have no proprietary or commercial interest in any of the materials discussed in this article.
doi:10.1016/j.ophtha.2010.05.020
PMCID: PMC3146699  PMID: 20801514
5.  Polymorphisms in ARMS2/HTRA1 and Complement Genes and Age-Related Macular Degeneration in India: Findings from the INDEYE Study 
Purpose.
Association between genetic variants in complement factor H (CFH), factor B (CFB), component 2 (C2), and in the ARMS2/HTRA1 region with age-related macular degeneration (AMD) comes mainly from studies of European ancestry and case-control studies of late-stage disease. We investigated associations of both early and late AMD with these variants in a population-based study of people aged 60 years and older in India.
Methods.
Fundus images were graded using the Wisconsin Age-Related Maculopathy Grading System and participants assigned to one of four mutually exclusive stages based on the worse affected eye (0 = no AMD, 1–3 = early AMD, 4 = late AMD). Multinomial logistic regression was used to derive risk ratios (RR) accounting for sampling method and adjusting for age, sex, and study center.
Results.
Of 3569 participants, 53.2% had no signs of AMD, 45.6% had features of early AMD, and 1.2% had late AMD. CFH (rs1061170), C2 (rs547154), or CFB (rs438999) was not associated with early or late AMD. In the ARMS2 locus, rs10490924 was associated with both early (adjusted RR 1.22, 95% confidence interval [CI]: 1.13–1.33, P < 0.0001) and late AMD (adjusted RR 1.81, 95% CI: 1.15–2.86; P = 0.01); rs2672598 was associated only with early AMD (adjusted RR 1.12, 95% CI: 1.02–1.23; P = 0.02); rs10490923 was not associated with early or late AMD.
Conclusions.
Two variants in ARMS2/HTRA1 were associated with increased risk of early AMD, and for one of these, the increased risk was also evident for late AMD. The study provides new insights into the role of these variants in early stages of AMD in India.
We report results from a genetic association study of early AMD in an Indian population. Two variants in the ARMS/HTRA1 region were associated with early AMD but variants in C2, CFH, and CFB were not.
doi:10.1167/iovs.12-10073
PMCID: PMC3490538  PMID: 23060141
6.  EPHA2 Polymorphisms and Age-Related Cataract in India 
PLoS ONE  2012;7(3):e33001.
Objective
We investigated whether previously reported single nucleotide polymorphisms (SNPs) of EPHA2 in European studies are associated with cataract in India.
Methods
We carried out a population-based genetic association study. We enumerated randomly sampled villages in two areas of north and south India to identify people aged 40 and over. Participants attended a clinical examination including lens photography and provided a blood sample for genotyping. Lens images were graded by the Lens Opacification Classification System (LOCS III). Cataract was defined as a LOCS III grade of nuclear ≥4, cortical ≥3, posterior sub-capsular (PSC) ≥2, or dense opacities or aphakia/pseudophakia in either eye. We genotyped SNPs rs3754334, rs7543472 and rs11260867 on genomic DNA extracted from peripheral blood leukocytes using TaqMan assays in an ABI 7900 real-time PCR. We used logistic regression with robust standard errors to examine the association between cataract and the EPHA2 SNPs, adjusting for age, sex and location.
Results
7418 participants had data on at least one of the SNPs investigated. Genotype frequencies of controls were in Hardy-Weinberg Equilibrium (p>0.05). There was no association of rs3754334 with cataract or type of cataract. Minor allele homozygous genotypes of rs7543472 and rs11260867 compared to the major homozygote genotype were associated with cortical cataract, Odds ratio (OR) = 1.8, 95% Confidence Interval (CI) (1.1, 3.1) p = 0.03 and 2.9 (1.2, 7.1) p = 0.01 respectively, and with PSC cataract, OR = 1.5 (1.1, 2.2) p = 0.02 and 1.8 (0.9, 3.6) p = 0.07 respectively. There was no consistent association of SNPs with nuclear cataract or a combined variable of any type of cataract including operated cataract.
Conclusions
Our results in the Indian population agree with previous studies of the association of EPHA2 variants with cortical cataracts. We report new findings for the association with PSC which is particularly prevalent in Indians.
doi:10.1371/journal.pone.0033001
PMCID: PMC3297613  PMID: 22412971
7.  Bilateral Simultaneous Disc Edema and Cataract Associated with Albright Hereditary Osteodystrophy 
A 16-year-old female presented with poor vision in both eyes. On clinical examination, she had bilateral cataracts and optic disc edema bilaterally on ultrasound examination. Extensive intracranial calcification was evident on computerized tomography. Physical examination revealed short stature, rounded chubby face, dental abnormalities, brachydactyly, and obesity. Laboratory evidence of hypocalcemia, hyperphosphatemia, elevated parathyroid hormone level (indicative of pseudohypoparathyroidism) along with the constellation of phenotypical characteristics lead to a diagnosis of Albright's hereditary osteodystrophy. This case is being presented to increase awareness regarding presence of coexisting and previously undiagnosed hypocalcemic syndromes in pediatric cataracts. The role of an ophthalmologist may be pivotal in diagnosing such an entity as documented in the present case.
doi:10.4103/0974-9233.92136
PMCID: PMC3277018  PMID: 22346135
Albright's Hereditary Osteodystrophy; Cataract; Disc Edema; Hypocalcemia
8.  Comparative study on the incidence and outcomes of pigmented versus non pigmented keratomycosis 
Indian Journal of Ophthalmology  2011;59(4):291-296.
Purpose:
To determine the incidence, outcomes and establish factors determining visual prognosis of keratomycosis due to pigmented fungi in comparison with nonpigmented fungi.
Materials and Methods:
All culture-proven cases of fungal keratitis from January 2006 to August 2008 were drawn from a computerized database and cases with adequate documentation were analyzed for predisposing factors, clinical characteristics, microbiology and treatment methods. Outcomes of keratitis due to pigmented and nonpigmented fungi were compared using t-test and χ2 test.
Results:
Of 373 cases of keratomycosis during the study period, pigmented fungi were etiological agents in 117 eyes (31.3%) and nonpigmented fungi in 256 eyes (68.7%). Eyes with nonpigmented keratitis had significantly larger ulcers (14.96 mm2 ) and poorer vision (1.42 logMAR) at presentation compared to those with keratomycosis due to pigmented fungi (P=0.01). The characteristic macroscopic pigmentation was seen in only 14.5% in the pigmented keratitis group. Both groups responded favorably to medical therapy (78.1% vs. 69.1%) with scar formation (P=0.32) and showed a significant improvement in mean visual acuity compared with that at presentation (P<0.01). Visual improvement in terms of line gainers and losers in the subgroup of eyes that experienced healing was also similar. Location of the ulcer was the only factor that had significant predictive value for visual outcome (P=0.021).
Conclusion:
Incidence of keratomycosis due to pigmented fungi may be increasing as compared to previous data. These eyes have similar response to medical therapy and similar visual outcome compared to nonpigmented keratitis. Central ulcers have a poor visual outcome.
doi:10.4103/0301-4738.81997
PMCID: PMC3129754  PMID: 21666314
Keratitis; keratomycosis; nonpigmented fungi; outcomes; pigmented fungi
9.  Risk factors for intraocular penetration of caterpillar hair in Ophthalmia Nodosa: A retrospective analysis 
Indian Journal of Ophthalmology  2010;58(6):540-543.
We report risk factors associated with intraocular penetration of caterpillar hair seen at our institute from January 2005 to December 2007. Records of all patients with caterpillar hair induced ophthalmitis (CHIO) were retrospectively reviewed for clinical characteristics, anatomic location of lodgment of the caterpillar hair, treatment methods, and outcomes. Out of a total of 544 cases of CHIO, 19 eyes (seven in the anterior chamber and 12 in the posterior segment) experienced intraocular penetration (3.5%). The presence of deep intracorneal hair (80 cases, 14.7%) was found to be the only risk factor for intraocular penetration (P < 0.001). The removal of intracorneal hair was possible in only 29 out of 80 eyes (36%) and this was associated with a significantly reduced risk of intraocular penetration (P = 0.022). Patients with retained intracorneal hairs should be counseled regarding risk of intraocular penetration and closely followed up for at least six months.
doi:10.4103/0301-4738.71711
PMCID: PMC2993991  PMID: 20952845
Caterpillar hair; intraocular penetration; ophthalmitis
10.  Prevalence of Early and Late Age-Related Macular Degeneration in India: The INDEYE Study 
This large, two-center, population-based study provides estimates of the prevalence of age-related macular degeneration in India.
Purpose.
To estimate the prevalence of early and late age-related macular degeneration (AMD) in India.
Methods.
Of 7518 people aged 60 years and older identified from randomly sampled villages in North and South India, 5853 (78%) attended an eye examination including fundus photography. Fundus images were graded according to the Wisconsin Age-Related Maculopathy Grading System.
Results.
Fundus images were ungradable in 1587 people, mainly because of cataract. People 80 years of age and older were less likely to attend the eye examination and more likely to have ungradable images. For ages 60 to 79 years, the percent prevalence (95% confidence interval [CI]) were late AMD 1.2 (0.8–1.5); and early AMD: grade 1 (soft distinct drusen or pigmentary irregularities), 39.3 (37.2–41.5); grade 2 (soft distinct drusen with pigmentary irregularities or soft indistinct or reticular drusen), 6.7 (5.8–7.6); and grade 3 (soft indistinct or reticular drusen with pigmentary irregularities), 0.2 (0.1–0.4). For ages 80 and older, the respective percent prevalence was: late AMD, 2.5 (0.4–4.7); and early AMD: grade 1, 43.1(35.7–50.6); grade 2, 8.1 (4.3–12.0); and grade 3, 0.5 (0–1.5).
Conclusions.
The prevalence of early AMD (grades 1 and 2) is similar to that observed in Western populations, but grade 3 appears to be lower. The prevalence of late AMD is comparable to that in Western populations in the age group 60 to 79 years. It is likely that the prevalence in the 80 and older age group is underestimated.
doi:10.1167/iovs.09-4114
PMCID: PMC2868454  PMID: 19696177
11.  Safety and efficacy of manual small incision cataract surgery for phacolytic glaucoma 
Aims
To evaluate the safety, visual outcome and complications of manual small incision cataract surgery (MSICS) in the treatment of patients with phacolytic glaucoma.
Methods
In a nonrandomised interventional case series, 33 consecutive patients with phacolytic glaucoma underwent cataract extraction by MSICS, with staining of the anterior capsule by trypan blue.
Results
The mean preoperative intraocular pressure (IOP) was 46.2 mmHg. No significant intraoperative complications such as posterior capsule rupture or expulsive hemorrhage occurred. In 31 patients (93.9%), an intraocular lens (IOL) was implanted in the posterior chamber. In two of 33 patients (6.1%), the posterior capsule was removed and the patient was left aphakic because of severe pre‐existing zonulysis. The postoperative best‐corrected visual acuity was 20/60 or better in 29 cases (87.9%) and 20/40 or better in 26 patients (78.8%). The IOP was 22 mmHg or less in all 33 cases without the use of anti‐glaucoma medications and the mean IOP was 15.1 mmHg (range, 7–22, SD ± 3.9). Postoperative corneal edema occurred in 11 cases (33.3%) and anterior chamber inflammation was present in nine cases (27.3%). Both conditions resolved with standard medical therapy.
Conclusion
Manual small incision cataract surgery with trypan blue staining of the anterior capsule is a safe and effective method of cataract extraction for patients with phacolytic glaucoma.
doi:10.1136/bjo.2006.105874
PMCID: PMC1857686  PMID: 17322465
12.  Capsulotomy and hydroprocedures for nucleus prolapse in manual small incision cataract surgery 
Manual small incision cataract surgery (MSICS) involves the manual removal of nucleus through a scleral tunnel. To achieve 100% success every time, one has to do a good capsulotomy and should master the technique to prolapse the nucleus into anterior chamber. During conversion from extracapsular cataract surgery to MSICS, one can perform a can-opener capsulotomy and prolapse the nucleus. However, it is safer and better to perform a capsulorrhexis and hydroprolapse the nucleus, as it makes the rest of the steps of MSICS comfortable. Use of trypan blue in white and brown cataracts makes the capsulorrhexis and prolapse simple and safe. Extra caution should be taken in cases with hypermature cataracts with weak zonules and subluxated cataracts.
PMCID: PMC2661528  PMID: 19075402
Capsulorrhexis; can-opener capsulotomy; hydrodissection; hydroprolapse; manual small incision cataract surgery; trypan blue

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