Is balanced salt solution really superior to ringer lactate for phacoemulsi ﬁ cation?

1. It does not seem reasonable to attribute a cause-effect relationship following only 1 day of use of the xylometazoline nasal drop in an adult with a mature system to deal with a drug. The authors also did not mention why the xylometazoline nasal drop was started on the fi rst postoperative day when it is customary to start it 7 days before operation and continue for another 7 days aft er operation. 2. CSCR was not known to occur aft er millions of routine DCR operations that took place in this world where similar stress and drugs were operant. 3. Resolving of the CSCR aft er 1 month cannot be att ributed to the cessation of the drug as CSCR can naturally resolve aft er 1 month.[3]


Is balanced salt solution really superior to ringer lactate for phacoemulsifi cation?
Dear Editor, The article by Vasavada et al. on the comparison of the use of Ringer's lactate (RL) and a balanced salt solution (BSS) on the postoperative outcomes of phacoemulsifi cation, by a randomized control trial, has added in vivo evidence about the superiority of BSS plus. [1] But except for the first postoperative day, there was no significant difference between the use of two fluids for phacoemulsifi cation. It would have been bett er if the authors had also showed the visual acuity results on the fi rst postoperative day. We presume that there were no intraoperative complications. A diff erence of 25 m of corneal swelling might have been "statistically" signifi cant, but was it "clinically" signifi cant in terms of suboptimal visual acuity? A one-week follow-up would also have helped. An Indian-made RL costs about Rs. 25 only (Ͻ $0.5) compared to Rs. 2800 ($62) for BSS plus. If we were to calculate a cost-benefi t ratio, would a single-line visual acuity diff erence on the fi rst postoperative day justify such an increased cost for most patients? Even Indian-made BSS are more than four times as costly as the RL. Also, the aqueous turnover time in the anterior chamber is less than 24 h. Hence the irrigating solution would not make any diff erence beyond the fi rst few days.
BSS plus defi nitely would have incrementally helped in complicated cataracts, very hard cataracts, patients with poor endothelial cell counts, very old patients, and also where such high-viscosity devices were not available. The authors need to be congratulated for such less endothelial cell loss, [1] compared to other studies. [2,3] This might be due to the operating surgeon's vast experience, selection of cataracts, and use of high-viscosity agents such as Provisc™ and Viscoat™.
In a country like ours, operating surgeons need to choose their consumables rationally, not just the best available, but rather optimally available. [4] It can be tailored for each cataract surgery. Ruit et al. had found no signifi cant diff erence in corneal thickness and visual acuity, even on the fi rst postoperative day, when comparing manual small incision cataract surgery and phacoemulcifi cation. [3] A BSS is bett er, but it can only be called "statistically," not "clinically" superior to the RL, unless we have evidence to the contrary.

Ocular toxicity of Calotropismissing links
Dear Editor, We read with great interest the article titled "Ocular toxicity by latex of Calotropis procera (Sodom apple)" by Basak et al. [1] Use of Calotropis for worshipping Lord Shiva is fairly common in our region (Eastern Madhya Pradesh) and also in the adjoining areas of Utt ar Pradesh. As a result, we too get to see many cases of Calotropis-induced ocular infl ammation and this had prompted us to conduct a study on the same (presented as Poster no. 049 entitled "Spectrum Of Ocular Manifestations Of Calotropis Induced Chemical Injury" in the 67 th All India Ophthalmology Conference, 5-8 February, 2009, Jaipur).
We studied 47 patients reporting to the Ophthalmology Department between June 2005 and May 2008, all with a positive history of contact with Calotropis latex. In our study, females were more affected (70%) as against male preponderance seen in the study of Basak et al. [1] A probable explanation for this could be that females are more involved in worshipping rites. Slit lamp examination showed dermatitis in 63%, conjunctivitis in 55%, keratitis with Descemet's folds in 36% and keratouveitis in 9% of the cases. Secondary glaucoma was not seen in any patient.
All patients were treated with topical antibiotics, steroids, cycloplegics and lubricants. Most patients showed a dramatic response in terms of symptomatic comfort and best-corrected visual acuity.
During the course of our study, we performed an exhaustive search of the published literature for related studies. Besides foreign case reports, we also came across three similar studies/ case reports from India [2][3][4] and one from Saudi Arabia, [5] which are mentioned in the references below.
Unfortunately, there is no mention of these case reports/ studies in the article by Basak et al. [1] To conclude, Calotropis-induced ocular infl ammation is not of infrequent occurrence in the Indian scenario and may be associated with keratouveitis. Thus, it becomes imperative for ophthalmologists to entertain a high index of suspicion for Calotropis toxicity and elicit a relevant history of contact in patients with such clinical presentation.