dos_jan_2004

DOS TIMES CONTENTS

Editor-in-chief EDITORIAL ................................... 293 REVIEW
Dr. Jeewan S. Titiyal
FOCUS w Fitting of Soft Contact Lens ...... 310
Associate Editors Jeewan S. Titiyal,
Dr. Harish Pathak w Age-related Macular Ramkishor Sah, Rajesh Sinha
Dr. Harminder K. Rai Degeneration ............................... 295
Dr. Vijay B. Wagh Rajvardhan Azad , Tara Prasad Das, MANAGEMENT PEARLS
Cyrus M. Shroff, Dinesh Talwar,
Editorial Advisers Sanjeev Nainiwal w Contact Lenses Complications
Dr. K.P.S. Malik their and Management .............. 316
CURRENT PRACTICE Jagjit S. Saini
Dr. Pradeep Sharma
Dr. Ramanjeet Sihota w Phakonit Thinoptx Rollable w Management of Convergence
IOL ................................................ 299 Insufficiency and
Dr. Ritu Arora Amar Agarwal, Athiya Agarwal, Accommodation Anomalies ..... 320
Dr. Dinesh Talwar Sunita Agarwal Sachin Kedar, Pradeep Sharma

Special Correspondents REVIEW COLUMNS
Dr. Ajay Aurora
w Problem Situations in Retinal w Letters to Editor
Dr. Rajib Mukherjee Detachment Surgery .................. 303 Practical Tips to Manage Post-
Dr. Anita Sethi Cyrus M. Shroff, Ajay Aurora Operative Endophthalmitis ..... 323
Sanjeev Naniwal, S.P. Garg, H. K. Tewari
Dr. Devender Sood APPLIANCES
Dr. Pradeep Venkatesh w Journal Abstracts ........................ 324
w Ultrasound Biomicroscopy in w DOS Quiz No. 7 .......................... 327
Coordinators Glaucoma .................................... 307
Dr. Anurag Tanuj Dada, Ramanjit Sihota, TEAR SHEET-7
Dr. Anand Harinder Singh Sethi
Dr. Madhusudan w Ocular Side Effects of Systemic
Ms. Monica Choudhry Drugs ............................................ 333
Dr. Pranav D. More Deven Tuli

Published by Keep April 3-4, 2004 Free for
Dr. Jeewan S. Titiyal
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January, 2004 291 DOS Times - Vol.9, No.7

January, 2004 292 DOS Times - Vol.9, No.7

EDITORIAL

Dear Friends, endar begins with the Kashi- submacular surgery are being tried
At the very ophthacon 2004 at Varanasi and out with variable success. In this is-
ends with are our very own Annual sue we are focussing on important
onset, I on be- DOS meet on 3rd – 4th April, 2004. clinical aspects of this disease and we
half of Delhi This issue brings out submission are fortunate to have the opinion of
Ophthalmo- guidelines for the annual conference leading vitreoretinal surgeons in our
logical Society and for the first time, we have made country.
would like to facilities for online submission of
wish all our abstracts, which I am sure will make With the end of this year oph-
members a the process much simpler. thalmic world has lost great Prof.
very happy Prem Prakash. A legend in his field,
and a prosperous new year. Age Related Macular Degenera- his sad demise has created a large
Every coming year is a new chal- tion (ARMD), the leading cause of void which can not be filled in many
lenge to all of us. We have to adapt irreversible vision loss in industria- centuries. I am thankful to Dr.
and imbibe newer techniques, keep lised countries is also showing its Pradeep Sharma who has written a
pace with newer technologies, up- face in our setup. Results of tradi- apt orbitury in respect of late
date our knowledge to the current tional treatment for wet ARMD Professer Prem Prakash.
happenings and the most tough of which includes conventional laser, Thank you,
them is to keep our patients happy micronutrients are far from satisfac-
and satisfied. tory. Alternate therapies like PDT, Dr. Jeewan S. Titiyal
The new seasons conference cal- TTT, antiangiogenesis therapy and Secretary, DOS

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FOCUS

Age-related Macular Degeneration

Age related macular degeneration (AMD) is one of the
leading causes of bilateral irreversible severe visual loss in
individuals over 50 years of age due to formation of choroidal
neovascularization (CNV) between retinal pigment epithelium
(RPE) and Bruch’s membrane or subretinal space. Laser pho-

tocoagulation is considered as the preferred treatment mo-
Dr. Rajvardhan Azad Dr. Tara Prasad Das Dr. Cyrus M. Shroff Dr. Dinesh Talwar dality for extrafoveal and juxtafoveal classic CNV. However,

because of the deleterious effects of the laser to the retina,
and also its limitations to treat only the extrafoveal and/or juxtafoveal CNV, clinicians have now shifted to various new
treatment options for subfoveal CNV lesions like photodynamic therapy(PDT), transpupillary thermotherapy(TTT), radio-
therapy, interferon alpha-2, macular rotation and submacular excision of membrane, of these the most promising are TTT
and PDT.

Dr. Sanjeev Nainiwal (SN), from the Vitreo Retinal and Medical Ophthalmology Services at Dr. Rajendra Prasad
Centre for Ophthalmic Sciences, AIIMS, New Delhi asked Dr. Rajvardhan Azad (RVA), Professor in Vitreoretinal Unit at Dr.
R P Centre for Ophthalmic Sciences; Dr. Tara Prasad Das (TPD), Consultant in Retina Unit at L V Prasad Eye Institute,
Hyderabad; Dr. Cyrus M. Shroff (CMS), Consultant in Vitreoretina at Shroff Cheritable Eye Hospital, Daryaganj, New Delhi
and Dr. Dinesh Talwar (DT) Senior Consultant Apollo Indraprastha Hospital, New Delhi & Director, Vitreo Retina & Laser
Services, Centre for Sight, New Delhi, for their views on different aspects of this vast and interesting topic. Their replies are
given in the text.

SN: What is ARMD and how do you diagnose it? (To RVA & raphy fills with dye in a lacy pattern during the very early phase of
CMS) dye transit, fluorescence brightly during peak dye transit and then
leaks into the subretinal space and around the CNVM within 1-2
RVA: l Age related macular degeneration (ARMD) is a disease minutes. The fibrous tissue within the CNVM than stains with dye
of the macular area, most often clinically apparent after 50 years with late hyperfluorescence(5-6 minutes).
of age. Early ARMD includes discrete yellow spots at the Ø OCCULT CNVM-It is a poorly defined memberane with
macula(drusen), hyperpigmentation of the RPE or sharply de- cicatrisation along with and is of two types (i) Which has less
marcated areas of RPE depigmentation. Late ARMD includes geo- precise features on the early frames with late leakage from unde-
graphic atrophy of the RPE with visible underlying choroidal ves- termined source or (ii) Fibrovascular PED which is a combination
sels, PED with or without neurosensory detachment, subretinal or of CNVM and PED. It manifests as a region of stippled or ill de-
sub-RPE neovascularization or fibroglial scar tissue, hemorrhage fined leakage in late phase into an overlying neurosensory retinal
and exudates. detachment without distinct source focus identified on early frame
of angiograms.
CMS : Age related macular degeneration is suspected when there
is a history of gradual or sudden loss of central vision in an elderly DT: The differentiation of a choroidal neovascular membrane
individual. Diagnosis is usually established by examination of the
macula by slit lamp biomicroscopy with a 90D/78D non contact (CNVM) into the classic and occult types is based on fluorescein
lens or Mainster Contact lens. Fluorescein angiography and some-
times indocyanine green angiography are required before a treat- angiography. A classic subretinal neovascular membrane (SRNVM
ment plan can be made.
or CNVM) presents a fluorescein angiographic picture character-

ized by early onset of hyperfluorsescence from the arterial phase

of the FA, during which a neovascular net may also be seen. This

SN: How do you define classic or occult CNVM? (To RVA & lesion shows progressive increase in the intensity of the

DT) hyperfluorescence in the late phase of the FA, with a bluring of the

RVA: l The lesions are defined on the basis of fluorescein an- margins of the lesion.

giography. Usually I decide on (a) Early frames i.e. early A-V phase In contrast, an occult CNVM has three common presenta-

approximately 40-50secs after tions. The first is a late leak-

dye injection (b) Midphase age from an unknown source.

frames approximately 2-3 min- In these lesions, the early

utes after and (c) Late frames phase of the FA does not show

of angiogram i.e. 5-6 minutes any well defined lesion but by

after dye injection. the mid phase of the FA, an

l Following are the FFA area of increasing

criteria of classifying CNVM: hyperfluoresence begins to get

Ø CLASSIC CNVM –It is visualized. The intensity of the

a well defined memberane hyperfluorescence and even

which on fluoroscein angiog- DRY ARMD WET ARMD the extent of the lesion in-

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creases over time upto the late phase of the FA. In order to be able eration of the underlying retinal pigment epithelium in Dry ARMD
to make a diagnosis of these lesions conclusively, it is mandatory while in Exudative ARMD, visual loss is a consequence of:
to take photographic frames during fluorescein angiography from (a) presence of exudation under the retina
the arterial phase upto at least 8 minutes after the fluorescein (b) presence of a membrane with / without development of
injection.
scar tissue causing distortion and damage of the photore-
The second presentation of an occult CNVM is that of a ceptors.
fibrovascular pigment epithelial detachment, which presents with (c) Presence of subretinal blood, which again causes direct
an irregular elevation of the RPF showing stippled damage to the photoreceptors.
hyperfluorescence within 1-2 minutes after fluorescein dye injec-
tion, with persistant staining or leakage in the late phase frames SN: What are the treatment options available for ARMD? (To
of the fluorescein angiogiam. RVA & CMS)

The third common presentation of an occult CNVM is of a RVA:l Argon/Krypton Laser photocoagulation
serous retinal pigment epithelial detachment, which presents clini- l PDT (Photodynamic therapy)
cally as a dark blister type of lesion with a ring halo around it. On l TTT(Transpupillary therapy)
fluorescein angiography, this lesion shows hyperfluorescence l Submacular surgery
which is relatively uniform and well defined and starts in the early l Macular translocation surgery
phase of the FA. The hyperfluorescence become uniform and l Trace metals and antioxidants
more intense in the late phase of the angiogram but the margins l Antiangiogenic therapy
continue to remain well defined. l Oral thalidomide and interferon alpha, gene therapy.
l Use of electronic chip implants.
SN: Why ARMD has become important in the present con-
text? (To RVA & DT) CMS: Laser photocoagulation for extrafoveal and minimally
RVA: ARMD is the most common cause of irreversible visual juxtafoveal lesions.
loss in the western world in individuals over 50 years age. 90% of
visual loss in cases of ARMD is because of wet form of the PDT and TTT for subfoveal and extremely juxtafoveal le-
disease.According to Beaver dam eye study in USA 0.1%-0.42% sions. Antiangiogenic drugs are also showing promise and these
of population between 55-64 have wet ARMD. End stage blinding may be used in conjunction with PDT/TTT.
ARMD is found in about 1.7% of all individuals aged over 50 years
and in 18% in those over 80 years. In a community based survey SN: What does your pre-laser work up include? (To RVA,
conducted by our centre , 1% of individuals above the age of 50 CMS & TPD)
years were found to have ARMD(unpublished data).
RVA: We at our centre, follow the following protocol for all our
DT: This question is extremely important for all of us. To answer patients:
it, is necessary to look at few demographic figures. According to w Best Corrected Visual acuity (Snellen and ETDRS)
the latest census figures available, 13.1% of our population, com- w IOP(Applnation)
prising 131 million people is over the age of 50 years; 2.6% of the w Amsler grid (Scotoma score)
population (i.e. 26 million people) are over the age of 70 years and w Contrast senstivity
1.3% of the population is over the age of 80 years (i.e. 13 million w Near Vision
people). If we extrapolate the figures available, it is likely that even w Reading speed
today we have 300,000 people who are blind due to Age Related w Color fundus photography
Macular Degeneration, a figure which is not different from the total w FFA
prevalence of blindness due to ARMD in UK. Since the incidence w ICG angiography (wherever required)
of both non exudative and exudative ARMD increases sharply
beyond the age of 70 years, an increase in life expectancy of our CMS: Clinical examination including Amsler grid, Fundus fluo-
population, which is likely to follow improvements in the socioeco- rescein angiography(FFA), sometimes indocyanine green angiog-
nomic status of our population in the next decade, will result in a raphy (ICG) and optical coherence tomography (OCT). The cho-
massive increase in the prevalence of this problem, as a major roidal neovascular membrane is mapped on a red-free/FFA photo
cause of blindness in the community. The problem is likely to be to help in precise treatment.
accentuated further by our success in efforts to ameliorate the
avoidable and curable causes of blindness like Vitamin A defi- TPD: My pre laser work-up includes Amsler Grid; ETDRS letter
ciency and cataract. acuity, fundus photograph, combined FFA and ICGA, and OCT.

SN: What are possible causes of visual loss in ARMD? (To SN: For TTT, how do you decide your spot size and laser
TPD & DT) power?

TPD: The likely causes of visual loss in ARMD are thinning and RVA: After measuring the Greatest linear diameter(GLD) on digital
scarring of the retina as occurs in geographic atrophy and disci- fundus camera, I consider the following
form scars. Subfoveal bleed is the cause of severe visual loss in w Add 1000 microns to GLD so that spot size should encompass
sub foveal CNV. In some cases associated cystoid macular edema the entire lesion
contributes to visual loss. w Laser spot options available on Iridex diode laser are:
0.8mm,1.2mm, 2mm, 3mm. & 5mm (new)
DT: Causes of visual loss in ARMD includes damage / degen- w Power setting of 300-550 mw are good for Indian eyes.
This is lesser compared to western eyes that have less pigmen-
tation.

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FOCUS

gives absolute value depending on the num-
ber of letters read in the chart and it is very
sensitive to subtle changes in vision.

CMS: Snellen. Plan to start using ETDRS
charts.

TPD: I use ETDRS vision chart at 4 and I
meter distance. I use the reduced Snellen
chart for near vision.

CLASSIC CNVM – Early and Late phase DT: Nidek autochart projector, which pro-
vide a modification of the Bailey-lovey charts
(on which the ETDRS charts are based).
These provide 3 or more letters per line for
assessment of the visual acuity and have line
increments similar to those of the ETDRS.

Occult CNV: Fibrovascular Pigment Epithe- Occult CNV: Late-phase Leakage of SN: According to you which type of
lial Detachment Undetermined Source patients should be treated with PDT and
why?
RVA: Patients with classic subfoveal or
juxtafoveal CNVM should be treated with PDT
as a rule. However, patients with occult
subfoveal or juxtafoveal CNVM should be
considered for PDT if cost of the procedure is
not a consideration.

A crude method to calculate laser power is to put a test CMS: Small classic, subfoveal choroidal
burn in the periphery in inferonasal quadrant, find threshold and neovascular membranes with good vision. They respond well and
reduce the power by 10%. End point should be no visible reaction PDT is the safest treatment with the least chance of vision drop
at the end of the treatment of the lesion. after treatment.

CMS: Size of spot lesion diameter at least + 500 microns. If the TPD: Classic and predominantly classic CNVs respond well to
lesion is larger than 3 mm more than one spot is used in a way that PDT. The information is based on the TAP results.
overlap is minimal. Always use test burn. If the lesion has signifi-
cant fluid I use same power which produced minimal colour change. DT: As I have mentioned previously, the ideal patient for PDT is
If the lesion has very minimal fluid or is pigmented, I reduce power one with a small (< 4 disc area) subfoveal CNVM, which is classi-
by 10%. I do not reduce power for classic choroidal neovascular cal. However I would treat all patients of subfoveal Exudative
membranes. ARMD, who can afford the treatment by PDT except patients with
large, non progressive occult CNVMs with good visual acuity (6/
TPD: Since I do not do TTT I can not answer this question. 12 or better). My criteria of affordability is as follows :
(a) Treatment being reimbursed by governmental / non gov-
DT: I do TTT in all patients who cannot afford PDT. I choose the
spot size that covers the active CNVM completely in a single sit- ernmental agency or insurance.
ting. For determination of the laser power to be used, I carry out (b) Monthly income sufficient to provide funds for an average
test spots in the inferior quadrant of the retina just posterior to the
equator, using 0.8 to 1.2 mm size spots. I determine the threshold of one treatment every four months or so.
power required for the test spot by incremental increase in the (c) Savings adequate to put aside a sum of Rs. 2.5 to 3.5 lacs,
laser power till a barely visible burn is obtained. I then calculate
the power of the actual treatment spot by using the formula : without affecting the quality of life of the individual (finan-
cially). In a patient, whose better eye has near normal vi-
(PT) Power Required For treatment = Diameter of treat- sual acuity, treatment of the worse eye with a baseline vi-
ment spot ´ Power required to create visible burn with test spot sual acuity of 3/60 or worse should only be done in excep-
tional circumstances where money is abosolutely no con-
Diameter of test spot sideration and the patient is highly motivated even after he
has been explained that the treatment would not improve
SN: Which vision assessment chart do you use and why? the quality of life significantly. Treatment of the better eye
RVA: We use both ETDRS and Snellen visual acuity charts. We with exudative ARMD is indicated even if the baseline vi-
prefer ETDRS chart because it is a universally accepted visual sual acuity is less than 3/60, provided there is minimal scar
acuity notation form.visual acuity is expressed in a standard num- tissue in the lesion.
ber, which makes it easy to do statistical calculations as com-
pared to snellen chart that is expressed in terms of fraction.It SN: What all precautions should be taken pre/post PDT?
(To RVA, TPD & DT)

RVA: l PDT procedure is relatively contraindicated in patients

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FOCUS

with severe liver disease, unstable heart disease or uncontrolled TPD: In my experience, laser photocoagulation is indicated for
hypertension.The dye should not be administered if the patient is extrafoveal CNV and selected cases of juxta foveal CNV. I prefer
allergic to porphyrin,suffers from porphyria or has received any the PDT for subfoveal and selected juxta foveal CNV.
photosensitizing drug within the last two days.
l Patients are advised not to expose any part of body to DT: laser photocoagulation is an excellent treatment for
sunlight or yellow light for atleast four days to avoid Extrafoveal CNVMs, but can be risky in juxtafoveal CNVMs (due
skinburn.Patients either go home fully covered with clothes or to the risk of the run of phenomenon – whereby a laser spot effect
may be admitted in hospital for four days.Precautions to be fol- increases during the follow up period and results in loss of visual
lowed at home are using only tubelight and preventing sunlight acuity following treatment.
exposure by putting curtains at the windows and door. PDT works best in classical subfoveal or juxtafoveal CNVMs but
is also effective in small occult lesions.
TPD: The basic precaution following PDT is to avoid direct light
to the treatment eye (preferably the face) for 5-7 days inclusive of TTT also works but is more unpredictable that PDT. For
the day of treatment. Hence we request the patients to wear long patients with classical CNVM, there is no doubt that PDT is better
sleeve dresses (or sari), socks, gloves, hat, and the dark glasses than TTT, especially in patients in whom the initial visual acuity is
for few days. I also suggest avoiding computer and TV for these very good (6/12 or better) In Occult CNVMs, the choice is less
days. A complete dark room should be avoided since this will clear. Both the treatments are effective but PDT is a safer option.
delay the drug excretion. I also request them to avoid any surgery Overall, one can expect stabilization of vision in about 50 – 60 %
in the facial region (such as ear and dental) for a week. of patients, improvement in 10 – 20 % and deterioration despite
treatment in about 20% of patients, with both PDT and TTT.
DT: We explain to all patients who are about to undergo PDT
that : At present, there is no doubt that PDT is the treatment of
(a) They are not allowed exposure to direct sunlight for 5 days choice for all patient of subfoveal CNV (where treatment is indi-
(b) They must stay indoors with curtains drawn in front of all cated) who can afford it. In patients who cannot afford PDT, TTT
is a viable alternative in most circumstances.
windows for 5 days
(c) They are not allowed to expose themselves to incandes- SN: What is your criterion for success of the procedure?
RVA: I take improvement from baseline ETDRS visual acuity or
cent bulbs for 5 days stabilization or reduction in size/intensity of hyperfluorescence in
(d) No hair dyes are permitted for 5 days the lesion on FFA as criterion of success, although some people
(e) Watching TV is permitted. consider TAP study criterion with 3 lines/15 letters of visual loss
(f) They do not need to stay in darkness. Some degree of on ETDRS chart.

fluorescent lighting is good for them and would help to in- CMS: w Stabilization of vision
activate the dye paster w Reduction in exudation
(g) On their way from the hospital to their home, the patients w Reduced fluorescein leakage
must : w Decreased thickness on OCT
i. Wear a full sleeve dress covering their arms and legs
TPD: My criteria of success is closure of the CNV complex with
completely. maintenance of central vision (Best corrected visual acuity ± 1 0
ii. Shoes and socks are needed to cover the feet, while letters in the ETDRS chat).

gloves/ socks may be used to cover the hands. DT: For conventional laser procedures, success is defined as
iii. A scarf / cap is used to cover the head and face complete destruction of the CNVM.
iv. To be on the safe side, a shawl / bed sheet is used to
For PDT, success is again defined as complete resolution
cover the body from head to toe in addition to the above of the active CNVM.
precautions.
v. Special goggles are provided to cover the eyes. For TTT however, stabilization of vision, with decrease in
(h) Patients need to avoid visits to their dentist / ophthalmolo- intensity and / or extent of the leakage may be considered to be a
gists for 5 days after the procedure and any emergency successful endpoint and no further treatment may be carried out
medical consultation must be made only after informing once this is achieved.
the treating doctor about the exposure to the photosensi-
tive dye.

SN: What is your experience with laser photocoagulation, SN: When do you decide about retreatment?
TTT & PDT? RVA: w We call the patients for followup every month and do the
prelaser workup. We decide retreatment on FFA and visual acuity
RVA: w PDT is the treatment of choice for subfoveal/ juxtafoveal usually at 3 months followup.
classic CNVM w It is considered if FFA shows evidence of leakage after
w For subfoveal occult CNVM, both PDT/TTT can be tried. 12wks of initial therapy.
w If there is loss of vision from baseline, retreatment is done.
Argon Green laser photocoagulation is the treatment of
choice for extrafoveal CNVM.

CMS: Laser – Excellent for extra-foveal lesions. CMS: Laser:- Any residual or recurrent choroidal neovascular
–Disturbing scotomas in juxta foveal lesions. membrane which is treatable with laser
TTT – About 70% stabilise vision. Very few improve vision. w TTT :- Exudation not reduced or increased. Can use OCT.
PDT – Not enough experience to comment. w Fluorescein leakage increased.

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w Increasing size of choroidal neovascular membrane. in AMD. Macular translocation probably has a role in selected
cases but complication rate in most surgeon's hands remains
TPD: Re-treatment is based on baseline VA, FAA/ICGA com- unacceptably high.
pared to the earlier visits and recent progression of the AMD. The
OCT is extremely useful to locate and quantify any associated TPD: It is so limited that I should not comment.
fluid.
DT: I do not have any personal expexence with macular rota-
DT: Retireatment following conventional laser photcoagulation tion surgery in ARMD but am not exthused by the reported results
is carried out if persistant CNVM is found on a FA done 2-3 weeks in literature so far.
following laser treatment, provided the lesion has not become
subfoveal. SN: Few last words to say?
RVA: I would like my friends to take cognizance of the following
Retreatment following PDT is carried out at 3 months if points:
evidence of peristant neovascularization is found on FA done at
that time. Retreatment in these cases is not carried out only if All patients above the age of 50 years who present to an
extensive scarring has occurred and vision has dropped mark- ophthalmologist with decrease in vision should be examined for
edly and if it is judged that no more benefit is likely from the treat- ARMD and if needed refer to a retinologist. Patients at risk i.e. who
ment. Retreatment following TTT is carried out 3 months after the have multiple drusens or RPE atrophy should be advised to have
initial treatment if FA done at that time reveals increase in size / a closer follow up and provided with Amsler grid for any metamor-
intensity of the lesion. phopsia or scotoma and immediately report to a ophthalmologist.
This becomes more significant for those patients who already
SN: Role of dietary supplements and antioxidants in pre- have wet type ARMD in one eye. The treatment of ARMD by PDT
vention or treatment of ARMD? (To RVA, CMS & TPD) or TTT should not be considered as panacea. It is not meant for
all kinds of ARMD and the success of treatment should be consid-
RVA: w AREDS STUDY-concludes that persons>55yrs with ex- ered when there is stability in the vision , which was not hitherto
tensive intermediate size drusens, at least one large drusen, non possible some 5 years ago.
central geographical atrophy in one or both eyes or advanced
ARMD or loss of vision due to ARMD in one eye should be consid- CMS: Challenging disease. The challenge is to find an effective
ered for supplementation. armamentarium of treatments which is cost effective. The treat-
w Recommends Vitamin C - 500mg ,Vitamin E - 400IU,b caro- ments of promise are PDT, TTT, Antiangiogenic factors. In the
tene - 15 mg, Zinc oxide - 80mg, Cupric oxide - 2 mg. future could be retinal cells transplants, gene therapy or such
w We usually prescribe Tab Antoxid 1 BD, Tab Zevit 1 OD refined electronic vision that it makes everything else redundant.
and Tab Evion 1 OD continous for 3 months and then alternate The other important challenge is a greater awareness among all
monthly. This includes all the nutrients in required amount as ophthalmologists so that the disease can be picked up and treated
mentioned in AREDS study. at the earliest possible stage.

CMS: There is a role in high risk cases. We prescribe especially TPD:
to those who have lost vision due to wet age related macular Ø We still do not know the exact pathophysiology of AMD.
degeneration in one eye or have large drusen in both eyes. A
positive family history also influences the decision. We like to Whenever we do not know the disease properly we have
follow the AREDS recommendation and are careful to take history many treatment options. Recent researches on the retinal
of smoking. angiogenesis and role of the vascular endothelial growth
factor (VEGF) appear very promising for future therapy.
TPD: The age related eye disease study (AREDS) has suggested Ø In India we must also do a population based epidemiology
that use of certain specific antioxidants, vitamins and minerals study to estimate the burden of AMD related blindness.
could possibly prevent or delay the progression of AMD. The Ø One must remember that despite treatment the AMD pa-
AREDS cocktail include Vitamin C and E, beta-carotene, zinc and tients are low sighted. They can be helped considerably
copper. This combination alone is not available in India; most with low vision aids and other rehabilitation services.
combinations include leutin and zeaxanthine.
DT: The varied thereapeutic approaches available in our arma-
While I use these antioxidants and mineral combinations mentarium for management of patients with ARMD provide us a
currently we need several other ancillary laboratory and clinical means to save / preserve the vision of a large proportion of pa-
studies to substantiate these recommendations. tients with ARMD.

SN: What is your experience with macular translocation Today, a combination of prophytaxis with antioxidants for
surgery in ARMD? patients at risk for development of advanced ARMD, conventional
laser photocoagulation for Extrafoveal CNVM, PDT for juxtafoveal
RVA: I have no personal experience. The role of macular trans- / subfoveal CNVM in patients who can afford it, TTT for juxtafoveal
location is still not established as long term follow-up is not avail- / subfoveal CNVMs in patients who cannot afford PDT and macu-
able and can have complications like retinal detachment, recur- lar surgery for patients for bilateral macular disciform scars offers
rent CNVM, refractive errors and inadequate displacement. Lim- the best approach for effective management of most patients with
ited macular translocation with chorioscleral outfolding has shown ARMD. These therapies and many more under development pro-
better results. vide many rays of hope to those afflicted with this previously incur-
able disorder.
CMS: Submacular excision has been universally, disappointing

January, 2004 298 DOS Times - Vol.9, No.7

CURRENT PRACTICE

On August 15th 1998 the Phakonit Thinoptx Rollable IOL
authors (Amar Agarwal)
performed the first sub 1 Amar Agarwal M.S., Athiya Agarwal M.D., Sunita Agarwal M.S.
mm cataract surgery by a
technique called PHA- which had fluid passing in- fusion line of the phaco ma- ated in one half of the
CONIT (1,2). In this the cat- side the eye. The left hand chine is introduced with foot nucleus. Similarly 3 pie-
aract was removed through was in the same position pedal on position 1. The shaped fragments are cre-
a 0.9-mm incision. The prob- where the chopper is nor- phaco probe is connected to ated in the other half of the
lem with this technique was mally held i.e.; the side port the aspiration line and the nucleus. With a short burst
to find an IOL, which would incision. The assistant injects phaco tip without an infu- of energy at pulse mode,
pass through such a small fluid (BSS) continuously at sion sleeve is introduced each pie shaped fragment is
incision. Then on October the site of the incision to cool through 0.9 mm incision. lifted and brought at the
2nd 2001 the authors did the the phaco tip. Thus the cata- Using the phacotip with level of iris where it is fur-
first case of a Phakonit Roll- ract is removed through a moderate ultrasound ther emulsified and aspi-
able IOL. The lens used was 0.9 mm opening. power, the center of the rated sequentially in pulse
a special lens from Thinoptx nucleus is directly embed- mode. Thus the whole
called the Choice 1.0 IOL. Terminology ded starting from the supe- nucleus is removed. Note in
This was the first Rollable The name Phakonit has rior edge of rhexis with the figure 7 no corneal burns are
IOL, which was implanted phaco probe directed ob- present. Cortical wash-up is
after a Phakoint procedure, been given because it shows liquely downwards towards the done with the bimanual
and as it was a rolled IOL the phaco (PHAKO) being done the vitreous. The setting at irrigation aspiration tech-
authors called it the Pha- with a needle (N) opening this stage is 50% phaco nique (Fig. 4).
konit Thinoptx Rollable IOL. via an incision (I) and with power, flow rate 24 ml/min
the phako tip (T). and 110 mm Hg vacuum. Phakonit Thinoptx
Principle When nearly half of the cen-
The problem in phacoe- Phakonit ter of nucleus is embedded, Rollabar IOL
A specially designed 0.9 the foot pedal is moved to
mulsification is that we are position 2 as it helps to hold Thinoptx the company
not able to go below incision mm keratome, an irrigating the nucleus is lifted a bit and
of 1.9 mm. The reason is be- chopper, a straight blunt rod with the irrigating chopper that manufactures these
cause of the infusion sleeves. and a 150 standard phaco tip in the left hand the nucleus
The infusion sleeve takes up without an infusion sleeve chopped. This is done with lenses has patented technol-
a lot of space. The titanium form the main pre-requisites a straight downward mo-
tip of the phaco handpiece of the surgery. Viscoelastic tion from the inner edge of ogy that allows the manu-
has a diameter of 0.9 mm. is injected with a 26G needle the rhexis to the center of the
This is surrounded by the through the presumed site nucleus and then to the left facture of lenses with plus or
infusion sleeve which allows of side port entry (Fig.1). in the form of an inverted L
fluid to pass into the eye. It This inflates the chamber shape. Once the crack is cre- minus 30 dioptres of correc-
also cools the handpiece tip and prevents its collapse ated, the nucleus is split till
so that a corneal burn does when the chamber is entered the center. The nucleus is tion on the thickness of 100
not occur (3). with the keratome. A then rotated 1800 and
straight rod is passed cracked again so that the microns. The Thinoptx tech-
The authors separated the through this site to achieve nucleus is completely split
phaco tip from the infusion akinesia and a clear corneal into two halves. nology is not limited to ma-
sleeve. In other words, the temporal valve is made with
infusion sleeve was taken 0.9-mm keratome (Fig. 2). A The nucleus is then ro- terial choice, but is achieved
out. The tip was passed in- continuous curvilinear Cap- tated 900 and embedding
side the eye and as there was sulorhexis is performed fol- done in one half of the instead of an evolutionary
no infusion sleeve present lowed by hydrodissection nucleus with the probe di-
the size of the incision was and checking the rotation of rected horizontally (Figure optic and unprecedented
0.9 mm. In the left hand and nucleus. 3). With the previously de-
irrigating chopper was held scribed technique, 3 pie nano-scale manufacturing
After enlarging the side shaped quadrants are cre-
Eye Research Centre 19, port a 20 Gauge irrigating process. The lens is made
Cathedral Road, chopper connected to the in-
Chennai-600086 (India) from off-the-shelf hydro-

philic material, which is

similar to several IOL mate-

rials already on the market.

The key to the Thinoptx lens

is the optic design and nano-

precision manufacturing.

The basic advantage of this

lens is that they are Ultra-

Thin lenses. These lenses are

called the Ultrachoice 1.0

lenses.

January, 2004 299 DOS Times - Vol.9, No.7

CURRENT PRACTICE

Fig. 1: A 26 Gauge Needle with viscoelastic mak- Fig. 2: Clear corneal incision made with the keratome lens and 300-micron for a bi-
ing an entry in the area where the side port is. This (0.9-mm). Note the left hand has a straight rod to sta- convex or plano optic, there
is for entry of the irrigating chopper. bilize the eye as the case is done without any anes- is little error in measuring
thesia. These instruments are made by katena (USA) the lens due to thickness. In
fact with the ThinLens™ one
ThinlensÔ Optics limeters. The edge for a 20- turer controls the thickness can measure lens designed
The drawing labeled diopter lens with a 0.250- of the lens or compensates to the same power without
millimeter haptic was 500- for the differences in thick- adjusting the lens bench.
ThinlensÔ Optics (Figure 5) millimeters. The edge was ness when measuring the The thinness is one of the
illustrates the optical charac- twice as thick as a standard lens. The error is not as reasons the ThinLens™ can
teristics of the ThinOptX's 6-millimeters lens. Reports much from the thickness as be manufactured in 1/8-di-
lens. The front surface is a began of patients getting the fact that most lens opter increments.
curve that approximates a glare and halos in low light benches are calibrated using
radius. The back curves is a conditions. It is doubtful the the back focal length of the Fresnel Lens
series of steps with concen- pupil was opening to some- lens. A correction factor for By definition, the
tric rings. The back surface thing greater than 5-milli- thickness is added to deter-
can be concave, convex, or meter. For light ot strike the mine the lens power. The ThinOptX™ lens is not a
plano. The combination of edge of the lens with the lens process can be very accurate Fresnel lens. The drawing
steps with the front radius in the posterior chamber, it if the differences in thick- labeled Fresnel Lens is
corrects for spherical aberra- seems the pupil would have ness of the lens are not sig- shown in Figure 7. As seen
tions. The convex and plano to be greater than 5-millime- nificant or the lens bench is from the drawing (Figure 5),
back designs can be used for ters. calibrated between each lens the lens has multiple focal
positive power lenses. The power. The bench should be points. This makes this style
concave or meniscus back Other Aberrations calibrated even with the lens Diffractive.
surface is used for negative Thickness causes a form same lens power if the lens
powered lenses. In the thickness changes signifi- The normal lines on the
drawing labeled Refractive of aberration due to light cantly. back surface of the Fresnel
Lens lines intersecting the rays traveling longer in the Lens of not originate from
lens represent parallel light. thicker portion of the lens. The ThinLens™ is so thin the same point; therefore,
The light is bent at the inter- The error is additive to that the error goes away. the back surface of the lens
section of the lens surface in spherical aberrations, but is With a central axis thickness functions as a series of
accordance with Snell's Law. small if the lens manufac- of 50-micron for a meniscus prisms. By selecting the
When light strikes the lens angle the incoming light
surface, the light is bent to- rays make with the normal
ward the central axis. All the line of each prism, one can
parallel light rays entering choose the focal pattern of
the back of the lens come to the resulting light. One such
focus at approximately the application is the headlamp
same point, therefore the of an automobile. The sec-
lens is a Refractive Lens. ond surface of the Thin-
Lens™ is designed to assist
the front surface in focusing
the light at a single point,

Glare Fig. 3: Phakonit continued. The nuclear pieces are Fig. 4: Bimanual irrigation aspiration
In the late 1970's lens chopped into smaller pie shaped fragments

companies made a lens with
an optic that was 5 by 6-mil-

January, 2004 300 DOS Times - Vol.9, No.7

CURRENT PRACTICE

with the Bimanual rolling. This can be im-
irrigation aspiration proved by having an instru-
probes. The tips of ment that would roll the
the footplates are lens.
extremely thin
which allow the Now the second problem
lens to be posi- which we noticed in the lens
tioned with the was the size of the lens. The
footplates rolled to length was all right by the
fit the eye. breadth of the lens was too
big to go through. Perhaps
Fig. 5: Thin lens Optics Fig.6: Rollable Lens insertion with forceps with an instrument which
rolls the lens it would be bet-
Fig. 7: Lens in the capsular bag Summary ter but with the present sys-
tems it was too large. If we
which by definition is a Re- First of all, we have look at a nonfoldable Phaco
fractive lens. IOL the optic is just 5 mm. If
to remove the cata- we look at the Accommodat-
Lens Insertion Technique ing IOL, model AT-45, the
The lens is taken out form ract through a sub 1 optic size is 4.5 mm. Stuart
Cumming made this lens so
the bottle. The lens is then mm incision. This is that it accommodates and
held with a forceps. The lens this can be possible only
is then placed in a bowl of possible with the with a smaller optic lens.
BSS solution that is approxi- These patients do not have
mately body temperature. Phakonit technol- a glare problem. Keeping
This makes the lens pliable. this in mind, we cut the lens
Once the lens is pliable it is ogy as cataracts can vertically on either side. This
taken with the gloved hand way the lens became smaller
holding it between the in- be removed and easily maneuverable.
deed finger and the thumb. The optic size reduced.
The lens is then rolled in a through that inci- When we rolled this lens
rubbing motion. It is prefer- and implanted it we could
able to do this in the bowl of sion. This was done achieve what we wanted.
BSS so that the lens remains
rolled well. It is better to do Fig. 8: Bimanual remoral of vicso- by us on August Now the problem we
this without gloves as the elastic, the IOL in the bag, full opened. 15th 1998. Now were worried about the pa-
rolling is much better. coming to the issue

The lens is then inserted then move the lens into the of the lens. When
through the incision care-
fully (Figure 6). The tip of the capsular bag (Figure 7). The we saw the lens we realized
haptic should haves a
pointed shape, which will teardrop on the haptic there were certain problems
allow the lens to penetrate
the corneal wound. One can should point in a clockwise in it. The lens had to be

direction. The smooth optic rolled properly. When we

lenticular surface will be fac- rolled the lens with the

ing posteriorly. The natural gloves the rolling was not

warmth of the eye causes the good, so we decided to roll

lens to open gradually. Vis- it without gloves under the

coelastic is then removed BSS. This gave us excellent

Phaconit Thinoptx Rollable IOL

PRE-OP POST-OP
DAY 30

Fig. 9: Phakonit: No induced astigmation

January, 2004 301 DOS Times - Vol.9, No.7

CURRENT PRACTICE

tient having a glare and him to shift into a smaller should be without a car- Reference
whether the cut edges of the incision. When we saw the tridge as the lens should
lens will produce any prob- patient there was no astig- be the cartridge also. 1. Sunita Agarwal, Athiya
lems to the patient. When matism. In phaco with fold- 4. Alternatively, we should Agarwal, Mahipal S Sachdev,
we saw the patient the next able IOL we do get a bit of give the surgeon a pre- Keiki R Mehta, I Howard Fine,
day we noticed the patient astigmatism. Topography rolled lens. Amar Agarwal: Phacoemulsifi-
had no glare and the lens re- was also done but we need cation, Laser Cataract Surgery &
acted very well in the eye. to do more cases to docu- Now, coming to the future - Foldable IOL's Second edition
This convinced us that the ment topographic changes 1. The lens should be an ac- Jaypee Brothers; 2000, Delhi, In-
solution was to have a in Phakonit compared to commodating type or mul- dia.
smaller optic size lens with Phako (Figure 9). tifocal type IOL
the same length to solve this 2. This way we have not 2. Benjamin F Boyd, Sunita
problem. If you will see the Now coming to the future only minimized astigma- Agarwal, Athiya Agarwal, Amar
photos you will notice the modifications of the lens tism but also will solve the Agarwal: Lasik and Beyond
optic size being smaller and which are required. problem of Presbyopia. Lasik; Highlights of Ophthalmol-
the cut edges of the lens. 1. We need to have a lens ogy; 2000, Panama.

Then we checked the the same length as what 3. Laura J Ronge: Clinical
patient's topography and is already present but the Update; Five Ways to avoid
astigmatism. There is no width being smaller. Phaco Burns; February 1999
point in having a lens go 2. We need to have an in-
through a 1 mm incision and strument that will roll the Where is my copy of
then still have problems of lens DOS Times?
astigmatism. Phakonit is a 3. We need to have an injec-
tougher surgery to perform tor that will insert the Dear DOS members, anyone who could not receive
than Phaco so the point is the lens. At present we are DOS Times from the month of January, 2004 onwards.
surgeon should be con- using a forceps which is
vinced that it make sense for not the right way as it can Please Contact: MR. SUPROTIK BANERJI
tear the lens. This injector M/s. Syntho Pharmaceuticals Pvt. Ltd.

31/16, 2nd Floor, Old Rajinder Nagar, New Delhi-60
E-mail: [email protected]

Programme for DOS Monthly Clinical Meeting for January 2004

Venue: Lecture Threatre Complex, Behind New OPD Block, Safdarjung Hospital, (MVMC), New Delhi
Date & Time : 31st January, 2004 (Saturday) at 2.30 P.M.

Case Presentation 10 Mins.
1. Case-I ....................................................................................................... Dr. Munish 10 Mins.
2. Case-II...................................................................................................... Dr. Seema Bajaj

Clinical Talk 20 Mins.
l Recent advances on role of Antioxidants in Ophthalmology ......... Dr. B.P. Guliani

Mini Symposium: Astigmatism
Chairman : Dr. K.P.S. Malik,

Co-Chairman : Dr. A.K. Grover

1. Knowing Asigmatism and its Relationship with 10 Mins.
intraocular Surgery................................................................................ Dr. Ruchi Goel 10 Mins.
10 Mins.
2. Plan to correct pre-op Astigmatism during Surgery ........................ Dr. A.K. Grover

3. Correction methods for surgically induced Astigmatism ............... Dr. K.P.S. Malik
Panel Discussions : 15 min.

January, 2004 302 DOS Times - Vol.9, No.7

REVIEW

Problem Situations in Retinal and attention needs to be
given to all cases, particu-

Detachment Surgery larly those that have AC IOL
and aphakes with poor en-
dothelial cell count due to

Cyrus M. Shroff1 MD, Ajay Aurora2 MS various reasons. Corneal
drying may be prevented by

frequent instillation of saline

or by placing methylcellu-

Rhegmatogenous retinal foration; optic nerve damage Rectus muscle rupture is lose on the cornea. If epithe-

detachment is the common- and brain stem anesthesia. a rare complication and may lial haze does develop the

est surgical problem encoun- All these are uncommon to happen in reoperations and surgery can be completed

tered by a Vitreoretinal sur- rare. Of these the important patients who are frail and with a good view after de-

geon. Last two decades have ones include Retrobulbar old. The muscle may rupture briding the corneal epithe-

witnessed, advances in hemorrhage and globe per- from its tendon attachment lium with cotton tipped ap-

Vitreoretinal surgical tech- foration.Retrobulbarhemor- to the sclera or from its belly. plicator, blunt side of a

niques that have enabled rhage, if severe, can lead to It needs to be immediately 15#blade or a hockey knife.

anatomical success rates to closure of central retinal ar- sutured with 6/0 vicryl. Following epithelial debri-

climb to 90% and better even tery. Hence, if one has de- Vortex vein damage usu- dement the cornea needs to

in situations like multiple, cided to postpone surgery, ally occurs in reoperations be frequently wetted to pre-

large and posterior breaks. an ophthalmoscopic exami- and if muscle hook is taken vent drying.

Thecornerstoneofretinalde- nation is mandatory. If CRA beyond the equator. If it oc- Pupillary constriction may

tachment surgery however is occluded a paracentesis curs, it is necessary to cau- occur due to: prolonged sur-

remains closure of all retinal will help. Globe perforation terize the vortex vein imme- gery, associated hypotony,

breaks, which may be is rare (0.1%). The likely can- diately. This may rarely lead intraocular gas injected in an

achieved by scleral buckling didates include myopic pa- to intraocular hemorrhage. aphakic eye or when com-

or internal tamponade with tients and injection by indi- bined with vitreous surgery.

or without vitrectomy. The viduals not conversant with 3. Problems due to Pupillary constriction can be

aim of this article is to high- ocular anatomy. Manage- Visualisation prevented by frequent instil-

light various problems one ment is based on the compli- Visualisation may be im- lation of long lasting cy-

may encounter while per- cations and may require paired due to problems at cloplegic agents like

forming a scleral buckling vitrectomy. various steps of surgery. cyclopentolate or homatro-

procedure, the practical These may include corneal pine before surgery. A

ways to overcome them as 2. Problems during expo- opacification, pupillary con- phenylepherine-induced di-

well as other problematic sure & localization striction, hyphema and mul- latation may be misleading.

situations that may be asso- Include scleral rupture or tiple bubbles after intraocu- Hypotony can be prevented

ciated with retinal detach- perforation, rectus muscle lar gas injection. by intraocular injection of

ment e.g, myopia and hazy rupture and vortex vein Cornea may become hazy saline and having the buckle

media. damage. during surgery due to epi- in place before SRF drainage.

Scleral rupture most often thelial edema that develops Pupillary constriction that

Problems during Scleral occurs in re-operations and due to poor handling, pro- develops during surgery

Buckling procedure usually happens below the longed surgery or raised in- may be circumvented by:

1. Problems associated rectus muscles. It may be traocular pressure. The lat- 1 Intacameral injection

with anesthesia avoided by using a blunt ter may result from traction of preservative free adrena-

These include compres- hook and dissecting under sutures and /or scleral de- line diluted to 1:10,000 con-

sion of globe by mask that good visibility. In the event pression. Prevention is best centration.

may result in central retinal of its occurrence, it is impor-

arterial occlusion; retro bul- tant to remove all traction The cornerstone of retinal detachment

bar hemorrhage; Globe per- from the globe and suture the surgery however remains closure of all
ruptured sclera. Following retinal breaks, which may be achieved
1. Shroff Eye Centre, this it is necessary to exam- by scleral buckling or internal tampon-
A-9, Kailash Colony, ine the retina and treat ac-
New Delhi cording to the complications ade with or without vitrectomy
that may have developed.
2. Shroff Charity Eye Hospital,
Darya Ganj, New Delhi-2

January, 2004 303 DOS Times - Vol.9, No.7

REVIEW

2. Use of iris hooks gical steps treated as the excessive vi- can lead to intraocular haem-
3. Use of torpedo suture These include problems able pigment cells that are re- orrhage, retinal incarcera-
(with 10/0 prolene) in aph- leased may lead to pre-reti- tion, retinal break, drainage
akic eyes related to retinopexy, pas- nal membrane formation of liquid vitreous and incar-
4. Anteriorvitrectomyin sage of scleral sutures, drain- and recurrent retinal detach- ceration/prolapse of vitre-
case the pupil is bound by a age of subretinal fluid, place- ment. Removal of the cryo ous. Following are various
membrane ment of buckle and intraocu- probe before the ice ball has problem situations one may
5. Excising portions of lar gas injection. completely thawed can re- get in:
iris sphincter with vitreous sult in retinal hemorrhage,
cutter Problems related to choroidal hemorrhage and 1. Perforation occurs
Hyphema is a rare occur- retinopexy (Cryotherapy, rarely scleral rupture, par- with anterior bite with un-
rence in a standard buckling diathermy or laser photoco- ticularly in myopes with thin derlying retina being de-
procedure. However it may agulation; Cryotherapy be- sclera: tached: suture is temporarily
occur in eyes with rubeosis ing the commonest mode of left in place and retina exam-
iridis, previous uveitis and retinopexy) may be due to: Problems related to ined with indirect.
an iris fixated or AC IOL. In scleral suture placement are a) If suture material is not
these cases it invariably re- 1. Inadequate or exces- extremely important. They
sults from associated hy- sive treatment include problems related to visible and there is no as-
potony. Hence all steps that scleral bite of insufficient sociated retinal damage,
prevent hypotony are likely 2. Faulty location of depth or an excessively deep suture is left in place and
to prevent its development. treatment bite. Many of these compli- posterior bite completed.
In case it occurs, pupil may cations may be prevented by b) If suture material is vis-
be cleared of blood by a bi- 3. Retinal Pigment Epi- using magnification (e.g., use ible, there is no associated
manual AC wash, mechani- thelial cell dispersion of operating microscope) to retinal damage and there
cal egress by methylcellulose is adequate retinal sepa-
or Healon, or a closed ante- 4 Retinal or choroidal ration, the suture is re-
rior vitrectomy. hemorrhage moved and fresh one
Fish egg phenomenon placed.
due to intravitreal gas injec- 5. Scleral damage or rup- 2. Perforation occurs
tion can obstruct the view ture with anterior bite with un-
hence gas should only be derlying retina being at-
injected once all major steps Hypotony can be prevented by intraocu- tached. Suture is left in place,
of buckling procedure have lar injection of saline and having the Indirect done to assess the
been completed. It may be buckle in place before SRF drainage damage. If there is hemor-
prevented by: rhage local pressure is given
1. Using a dry syringe 6. Damage to vortex pass the scleral sutures. till the hemorrhage stops, if
and needle veins An insufficiently deep there is a retinal break cryo
2. Rapid injection of gas is applied and the break sup-
bubble 7. Elevated IOP scleral suture may cut ported if possible. The suture
3. Positioning the needle Most of these complica- through during surgery or should be cut flush with the
tip in the center of the ex- tions can be prevented or re- later when it may be respon- sclera and left in place and
panding gas bubble duced in severity by follow- sible for buckle extrusion another bite taken more an-
In case it occurs, the ing the correct method. It is that may result in an un- teriorly.
bubbles may be coalesced by mandatory to correctly place sightly bulge, recurrent in- 3. Perforation occurs
striking an aphakic globe by the tip of the cryo probe fections and extraocular with posterior bite over de-
flicking motion of cotton against the scleral surface at muscle imbalance and even tached retina and indirect
tipped applicator, injecting the area of the break. Misin- persistent or recurrent reti- reveals no retinal damage
additional amount of gas terpreting the shaft as the nal detachment. then another bite is taken
and rarely by removing the probe tip results in posterior 2mm posterior and a wider
previously injected gas and cryo resulting in treatment of A deep scleral bite could buckle placed.
injecting a fresh gas bubble unintended areas. Retrea- result in scleral perforation. 4. Perforation occurs
by a bimanual technique. tment can be avoided by per- This happens in upto 5% of with posterior bite over at-
forming cryo in a planned se- all scleral buckles and usu- tached retina and indirect
4. Problems related to Sur- quential manner around the ally occurs in myopes and in reveals retinal damage then
break. Doing cryo around the areas where the sclera is thin. the suture material is cut
break and avoiding the base When retina underlying the flush with the sclera, cryo-
of the break itself can reduce perforation is detached it
RPE cell dispersion. Large leads to inadvertent SRF
breaks and multiple breaks drainage and or pigment re-
are better lasered than cryo lease; if it occurs at an area
where retina is attached it

January, 2004 304 DOS Times - Vol.9, No.7

REVIEW

therapy done and another choroidal effusion. If retinal with compromised ocular age.
bite is taken 2mm posterior breaks are flat, BSS /Ringer blood flow and those with
and a wider buckle placed. lactate may be injected reduced aqueous facility. Complications of Vitreous
through the pars plana and IOP particularly rises in Injection
Problems related to if the breaks are elevated gas cases where the SRF is not
is injected. drained. In cases with re- Intravitreal injection of
subretinal fluid drainage cently operated cataract the fluid or gas through pars
Problems related to Scleral wound needs to be rein- plana is required in various
This step is the most dan- Buckle Placement forced by additional sutures. situations and may result in
gerous step of buckling sur- Raised IOP may compromise complications. The injection
gery since it is a blind step. May be associated with retinal perfusion by blocking may happen in the subretinal
Despite all precautions fol- buckle size and location. A the central retinal artery. This or supraciliary space, may
lowing complications may proper scleral buckle should complication may be cause damage to the crystal-
occur: support both the anterior avoided by keeping a care- line lens, may elevate IOP or
and posterior margin of the ful watch on the optic nerve may reduce visibility by fish
1) Intraocular hemor- break. If this is not possible head before the buckle su- egg phenomenon. It is usu-
rhage: Usually minimal and with the widest buckle a ra- tures are made final and per- ally done with a 30gauge
stops with pressure at the site dial plomb may be placed or manent. needle through the pars
of drainage. One should at- Vitrectomy with internal plana. The needle tip should
tempt to prevent the hemor- tamponade may be neces- Vortex Vein Damage: be seen through the pupil
rhage from passing below sary. Most retinal breaks lie ante- with bevel facing the sur-
the macula by appropriate rior to the extrascleral por- geon. When injecting gas one
positioning of the head. If it Radial retinal folds: tion of the Vortex vein. If a should attempt to inject
still happens one can leave Scleral buckles that signifi- buckle is wide or the Vortex within the bubble. In a
some SRF behind to allow cantly reduce the circumfer- vein has an abnormal loca- phakic eye the direction of
positioning after the surgery. ence of the globe lead to pro- tion and the buckle needs to the needle tip should be to-
Despite these efforts if hem- duction of radial retinal be placed over a vortex vein wards the optic nerve while
orrhage accumulates below folds. If one of these folds in an aphakic eye it can be
the macula one could use gas more parallel to the iris
(e.g., SF6) to displace the SRF drainage the most dangerous plane.
blood or Vitrectomy may be step of buckling surgery since it is a
required. Retinal Detachment asso-
blind step ciated with Myopia
2) Retinal Incarceration:
Occurs in 2-3% cases. Devel- communicates with the reti- the scleral bite may be taken Following problems may
ops immediately after drain- nal break (fish mouth phe- on either side of the be encountered in managing
age starts and is recognized nomenon) it can lead to pas- intrascleral portion of the retinal detachments in myo-
by sudden stoppage of the sage of SRF posteriorly, lead- vortex vein; the bite may also pic eyes:
drainage. All traction should ing to recurrent retinal de- pass under the extrascleral
be released at this stage and tachment or persistence of portion of the vortex vein. A 1. Greater chances of
retina examined. It appears detachment. Increasing the portion of the scleral buckle perforation while giving a
as localised depression of height of the buckle will in- may also be cut at its poste- block (both peribulbar and
retina with radial folds. It crease the problem. Hence rior border over the area of retrobulbar block) in myopes
may be avoided by prepar- scleral buckle height may be vortex vein to prevent com- who have equatorial or pos-
ing small opening in the reduced and/or radial pression of the Vortex vein. terior staphyloma. Authors
choroid, and draining at a plomb added or an At times compression of prefer to give general anes-
dependent position. If there intravitreal injection of gas Vortex vein is unavoidable thesia to patients whose axial
is only retinal incarceration made. and this does not seem to length is greater than
with no retinal break, it is cause any untoward effects 28mm.If general anesthesia
only supported with a Increased intraocular because of the collateral cir- is contraindicated, subcon-
buckle; if there is associated pressure: Scleral buckling culation. If a vortex vein gets junctival infiltration may be
retinal break cryotherapy or reduces intraocular volume accidentally damaged the done followed by direct in-
laser with indirect ophthal- and also leads to forward extrascleral stump can be jection into the muscle cone
moscope is additionally movement of lens iris dia- compressed and cauterized. with a cannula under direct
done. phragm leading to raised However great care should visualization.
IOP. This is particularly im- be taken to avoid such dam-
3) Hypotony: is associ- portant in elderly patients 2. Small peripheral bre-
ated with increased risk of aks or central breaks may be
intraoperative hyphema and

January, 2004 305 DOS Times - Vol.9, No.7

REVIEW

missed when the retina in steroids preoperatively. A Monthly Meetings Calendar
these areas is attached or has scleral buckling procedure For The Year 2003-2004
a shallow detachment and may be attempted if the vis-
retina thin with poor contrast ibility becomes reasonable 27th July, 2003 (Sunday)
otherwise Vitrectomy is a Army Hospital
3. Cryoprophylaxis cau- better option. It is important
ses excessive RPE dispersion to use atropine eye drops 30th August, 2003 (Saturday)
that may be a contributory preoperatively and keep the Sir Ganga Ram Hospital
factor for failure of detach- pupil well dilated.
ment and excessive cryo may 27th September, 2003 (Saturday)
lead to Suprachoroidal hem- Posterior capsular opaci- Hindu Rao Hospital
orrhage. fication can be treated with
liberal Yag capulotomy 19 October, 2003 (Sunday)
4. Thin myopic globes without destabilizing the DOS Midterm Conference
may give way on application IOL followed by buckling
of excessive pressure and ex- procedure if the visibility 1st November, 2003 (Saturday)
plant sutures may be diffi- permits. Alternatively one R.P. Centre for Ophthalmic Sciences
cult to take. can do a membranectomy
with a cutter and then treat 29th November, 2003 (Saturday)
5. While taking explant the case with buckle or Dr. Shroff’s Charity Eye Hospital
sutures if one encounters Vitrectomy on its merits.
thin areas, interrupted su- 27th December, 2003 (Saturday)
tures that go superficial to The problem of a Venu Eye Hospital & Research Centre
the sclera at that site may be nondilating pupil may be
taken. overcome by use of iris 31st January, 2004 (Saturday)
hooks, sphincterotomy and Safdarjung Hospital
Hazy Media associated by the use of small pupil in-
direct for buckling proce- 28th February, 2004 (Saturday)
with Retinal Detachment dure. M.A.M.C. (GNEC)

Good visibility is essential If the visibility is poor due 27th March, 2004 (Saturday)
for successful surgical result to an associated vitreous Mohan Eye Institute
in a case of retinal detach- hemorrhage that does not
ment. Various situations that permit adequate visuali- 3-4th April, 2004 (Saturday & Sunday)
may lead to hazy media sation for buckling proce- Annual DOS Conference
other than corneal pathology dure vitreous surgery is nec-
and early cataractous lens essary. Attention DOS Members
include:
Complications of retinal The Hi-tech DOS Library has started functioning on
1. Uveitis with vitreous reattachment surgery are Ground Floor, Dr. R.P. Centre, Delhi Ophthalmic Sci-
haze best prevented by anticipa- ences, AIIMS, New Delhi-110029 rom 12.00 Noon to
tion. It’s important to be vigi- 9.00 P.M. on week days and 10.00 A.M. - 1.00 P.M. on
2. Posterior capsular lant and be an “online” Saturday, Sunday. The Library will remain closed on
opacification thinking surgeon. If a com- Gazetted Holidays. Members are requested to utilise
plication occurs on the table the facilities available i.e. Computer, Video Viewing,
3. Eyes with non-dilat- or the retina does not behave Latest Books and Journals. We are planning to sub-
ing small pupil as expected one should be scribe two journals. Member can give suggestion in this
prepared to change the plan regard.
4. Associated vitreous including performing Vitre-
hemorrhage ous surgery. Dr. Lalit Verma

Cases of uveitis with reti- Library Officer, DOS
nal detachment have a
greater chance of developing
proliferative Vitreoretino-
pathy. These cases need to
be put on local and systemic

OBITUARY

Prof. Prem Prakash, who left for heavenly
abode at New Delhi. We pray for the peace

of the departed soul.

January, 2004 306 DOS Times - Vol.9, No.7

APPLIANCES

Ultrasound Biomicros- Ultrasound Biomicroscopy in
copy (UBM) is a high reso- Glaucoma
lution ultrasound technique
developed by Pavlin, Sherar Tanuj Dada MD, Ramanjit Sihota MD, FRCS, Harinder Singh Sethi MD
and Foster in Toronto in the
late 1980's. UBM is a high- also associated with a measure the angle recess ripheral iris and the trabecu-
frequency ultrasound tech- smaller angular field. precisely. This is a very ob- lar meshwork. In addition,
nology that allows imaging jective method which is not imaging of the anterior seg-
of structural details of the Technique possible with gonioscopy. It ment structures is possible
anterior ocular segment at The examination is done helps to determine the exact even in eyes with corneal
near microscopic resolution degree of angle closure and edema or corneal opacifica-
in living patients. It provides with the patient in the su- assess whether a patient is tion that precludes gonio-
exceptionally detailed two- pine position, after local an- predisposed to angle clo- scopic assessment.
dimensional gray-scale im- aesthetic has been applied to sure.
ages of the various anterior the eye. A sufficient palpe- In open-angle glaucoma,
segment structures. bral fissure must be present 2. Determining the mecha- UBM can be used to mea-
to accommodate an eye cup nism of primary glaucoma sure the anterior chamber
Principle which is used to create a angle in degrees, to assess
· UBM uses a scan trans- small water bath. Normally Ultrasound biomicros- the configuration of the pe-
ducer having a much higher ripheral iris, and to evaluate
frequency. The transducer UBM is a high-frequency ultrasound the iris insertion in relation
frequency of conventional technology that allows imaging of to the trabecular meshwork.
diagnostic ultrasound in- structural details of the anterior ocular One can see if there is an
struments is in the range of segment at near microscopic resolution anterior insertion of the iris.
7.5 to 10 MHz. In contrast, In eyes with a narrow angle,
the transducer frequency of in living patients. UBM shows the extent of
the UBM instrument is ap- angle closure, reveals the
proximately 50 MHz. 1% or 2% methylcellulose copy is usually able to deter- depth of the anterior and
· UBM provides much solution is used. The eye cup mine the mechanism of el- posterior chambers, and
higher image resolution (ap- does cause some discomfort, evated intraocular pressure identifies pathologic pro-
proximately 25-50 um of lat- limiting the utility of this (angle closure versus open cesses pushing the lens and
eral and axial resolution) technique in children and angle) by showing the rela- iris forward
than does conventional B- some adults. Scanning is tionship between the pe-
scan ocular ultrasonogra- performed with the sus-
phy. The improved imaged pended arm of the instru-
resolution is attributable to ment held above the eye cup
the higher transducer fre- and with the ultrasound
quency of the UBM. transducer oscillating
· UBM is not able to image within the methylcellulose
as deeply into the eye as is solution Software within the
conventional B-scan. This is instrument is designed to
because improved image stop the instrument if it
resolution comes at the ex- comes too close to the cor-
pense of reduced depth of nea, thus preventing corneal
penetration of the ultrasonic damage.
beam (limited to approxi-
mately 5 mm for a 50-MHz Clinical Uses in Glaucoma Quantification of the angle
UBM instrument). The lim- 1. Quantification of the An-
ited depth of penetration is terior chamber angle

Dr. Rajendra Prasad Centre for With the UBM one can
Ophthalmic Sciences, draw calipers and directly
New Delhi

January, 2004 307 DOS Times - Vol.9, No.7

APPLIANCES

Subacute ACG (Pupillary Block) UBM of a case with Pigmentary Glaucoma AC IOL haptic induced Pseudophakic Glau-
coma

YAG Iridotomy Patent fistula of a Trabeculectomy Ciliochoroidal effusion

Cyclodialysis Angle Closure caused by Ciliary body tumour

3. Determining the mecha- Ultrasound biomicroscopy is usually ness or full thickness and
nism of secondary glaucoma able to determine the mechanism of whether the plane of curva-
ture of the peripheral iris has
In the pigment dispersion elevated intraocular pressure changed compared with the
syndrome there is a classical pretreatment findings.
picture on the UBM which synechiae, UBM can reveal pushing the lens and iris
typically reveals posterior the extent of iridocorneal ad- anteriorly, and multiple 5. Determining functional
bowing of the peripheral hesion even if the cornea is neuroepithelial cysts of the status of a filtering surgery
iris. In plateau iris syndrome hazy or opaque. The UBM iridociliary sulcus.
UBM usually reveals abnor- has been able to differenti- After trabeculectomy
mally steep anterior angula- ate between primary angle 4. Determining patency of UBM can show whether the
tion of the peripheral iris, in- closure and secondary angle laser iridotomy sclerostomy aperture is
sertion of the iris from the closure due to processes patent or blocked internally,
anterior ciliary body, and such as lens swelling and After Nd-YAG laser whether the peripheral iri-
retroiridic projection of the dislocation, massive hemor- iridotomy for angle closure, dectomy is open or blocked,
ciliary processes. In eyes rhagic retinal detachment UBM can show whether the and whether the filtering
with peripheral anterior iridotomy is partial thick- bleb is flat, shallow, or deep.

January, 2004 308 DOS Times - Vol.9, No.7

APPLIANCES

mine the lens thickness due
to the reduced depth of pen-
etration.

Post Traumatic Cyst causing angle closure Ciliary Body Blood Flow 10. Study of ciliary body
blood flow

With the new UBM ma-
chines one can study the
blood flow in the cilary body
and see the effect of various
medications / surgery on
the ciliary circulation.

After tube shunt surgery, possibly obscured by extent of ciliary body tumors References:
UBM can show the position hyphema, including angle and often reveals the route
of the tip of the tube and recession, iridodialysis and of access of the tumor to the 1. Pavlin CJ, Sherar BA, Foster
whether its orifice is open or cyclodialysis, and to illus- surface by way of a scleral FS. Subsurface Ultrasound
plugged. trate the presence and extent emissary canal. Microscopic Imaging of the
of blood clots. Angle reces- 9. Biometry of the Anterior Intact Eye. Ophthalmology
6. Evaluation of post opera- sion is characterized on Segment 1990; 97: 244-250.
tive complications after UBM by posterior displace-
trabeculectomy ment of the point of attach- With the UBM one can 2. Pavlin CJ, Harasiewicz K,
ment of the iris to the sclera. determine the corneal thick- Sherar BA, Foster FS. Clinical
After any type of glau- In the acute stage, the post- ness, anterior chamber Use of Ultrasound Biomicros-
coma filtering surgery, UBM traumatic recess is usually depth, posterior chamber copy. Ophthalmology 1991;
can be used to detect and filled with blood. depth, IOL thickness, scleral 98: 287-295.
evaluate the extent of post- thickness. One cannot deter-
operative complications 8. Evaluation of cysts and 3. Pavlin CJ. Interpreting Tech-
such as ciliochoroidal effu- tumours causing angle clo- nology. Practical Application
sion and cyclodialysis. In sure of Ultrasound Biomicroscopy.
ciliochoroidal effusion UBM Can J Ophthalmol 1995; 30:
shows the ciliary body to be Cysts and solid tumors of 225-229.
edematous and separated the anterior segment can be
from the sclera by a sono- imaged in great detail with In Glaucoma
lucent collection of supracili- UBM. This technology can
ary fluid. Many cilio- be used to determine the in- Perimetry: Basics, single field and
choroidal effusions that are ternal character of a lesion followup. Interpretation, analysis and
too limited in extent to be (solid or cystic), to ascertain application in day to day clinical situations
detectable by indirect oph- whether the lesion involves
thalmoscopy and slit lamp the anterior ciliary body or .
biomicroscopy can be im- is restricted to the iris, and
aged by UBM. In cyclodialy- to measure the full extent of Newer imaging techniques : basics and
sis UBM shows a well-de- the lesion. UBM can reveal interpretation : Utility in diagnosis and
fined separation between whether the lesion involves followup
the uveal tissue and the only partial thickness or full
sclera in the region of the thickness of the stroma and Groups of Ten Each
scleral spur. can thereby aid in surgical On Sunday :
planning.
7. Post Traumatic Glau- February 8, 2004
coma It allows measurement of
the lesion's thickness and Contact:
After blunt ocular determination of the pres- Dr. Devindra Sood
trauma, UBM can be used to ence or absence or intraocu- Glaucoma Imaging Centre
evaluate iris-angle abnor- lar invasion It also confirms P-13, South Extension Part II
malities associated with and the presence, character, and New Delhi 110049
Tel: (011) 26257803 : 26252000

January, 2004 309 DOS Times - Vol.9, No.7

REVIEW

Contact lens is the best Fitting of Soft Contact Lens
method of correction of re-
fractive errors as it provides Jeewan S. Titiyal MD, Ramkishor Sah B.Sc.(H) Ophth., Rajesh Sinha MD
clear and sharp vision with
minimal distortion in the the lens. power to correct near vision. drug delivery.
form of size and shape of the 2. Disposable soft contact The distant vision lens is In the present chapter, we
image. Contact lens practice lens: These are daily, weekly usually worn in your domi-
in India is increasing every and monthly disposable nant eye. will be discussing about the
day despite the popularity lenses. fitting philosophy of routine
of refractive surgery like 3. Extended wear soft con- 4. Color soft contact lens: soft contact lens for optical
LASIK. Every ophthalmic tact lens: These are worn Today’s color lenses look use only.
practitioner needs to be overnight for upto one great on light and dark eyes,
aware about fitting and week. whether you need vision The Basic guidelines for
management of contact correction or not. Make a
lenses. Soft contact lens be- B. According to use dramatic or subtle change. fitting soft contact lens
came popular in late 1970, 1. Soft toric contact lens: Ø The soft lenses are usu-
since then there has been 5. UV- blocking soft con-
many fold advancement in It corrects the astigmatic er- tact lens: Block the uv-rays, ally fitted larger than the
the technology of design and rors of the eye. In recent time a contact lens that screen out diameter of the cornea
understanding of fitting phi- astigmatism is no longer the sun’s harmful rays may and the diameter ranges
losophies. barrier to successful contact guard against cataract and from 13.00 to 15.00mm
lens wears. macular degeneration. (commonly 13.50 –
The soft contact lens has 14.50mm).
the advantage of greater 2. Bifocal soft contact 6. Special effect of soft Ø A smaller eye requires
comfort and shorter adapta- lens: Hate the idea of read- contact lens: There is not just smaller diameter and
tion period. It is larger than ing glasses or bifocal eye- for Halloween any more, consequently steeper
the hard lens and covers the glasses? There are contact Just for Fun, try being a Cat, base curve.
entire cornea and extends to lenses that correct both dis- Alien or Zombie. Ø There should be a 3-point
the sclera. The soft contact tance and near vision. touch fitting i.e. one at the
lens is usually hydrophilic 7. Therapeutic soft con- corneal apex and two at
and is made of Hydroxy 3. Monovision soft con- tact lens: These lenses are periphery.
Ethyl Meth Acrylate tact lens: With a mono vi- most commonly used to re- Ø There should be an ad-
(HEMA) and its co-poly- sion, You wear one contact lieve pain, promote healing, equate movement of 0.2 –
mers. There is a considerable lens with one power to cor- provide mechanical protec- 1.0 mm of the contact lens
variation in the oxygen per- rect distance vision and tion and support during with each blink. While
meability of the lenses; the other contact lens with one healing. Sometimes they can many texts and fitting
higher the hydration of the also be used as a means of guides still refer to an
lens, the greater the oxygen optimally fitting soft lens
permeability. Patients should have realistic expecta- as being 1.0mm, the ac-
tions from contact lens. There is false tual post blink movement
Varieties of soft contact belief in many individuals that contact usually measures 0.2mm
lenses lens wear arrests or eliminates the re- to 0.4 mm.
A. According to wearing Ø Soft contact lenses are
schedule fractive error generally fitted flatter

1. Daily wear soft contact Table 1: Indications of contact lens
lens: These contact lenses
are worn during working Visual Cosmetic Medical Occupational Special Indication
hours and removed before
bedtime. They typically last - Anisometropic - To avoid - Therapeutic - Professional - Aniridia
6 months to 1 year depend-
ing upon the maintenance of (Refractive) spectacles - Bandage sport

Dr. R. P. Centre for Ophthalmic - High Myopia - Prosthetic - Corneal - Swimming - Albinism
Sciences, AIIMS, - Irregular - Nystagmus
Ansari Nagar, New Delhi. lenses protection - Cricket
cornea
- Aphakia - To facilitate - Film stars
- Keratoconus
corneal - Armed forces

healing

January, 2004 310 DOS Times - Vol.9, No.7

REVIEW

Table 2: Contraindications of contact lens

Visual Cosmetic Medical Systemic conditions On Drugs Like Occupational Others

- If needed - Where - Chronic allergies - Diabetes - Topical drugs - Exposure to - Noncompliant
only for dust, fumes patients
near vision spectacles (Conjunctivitis) - Thyroid eye disease (Antiglaucoma & chemical
- Unmotivated
- Prism hide facial - Recurrent corneal - Pregnancy & Steroids) patients
required
(> 3 PD) disfigure- erosions/ Keratitis - Allergic disorder - Diuretics

ment - Intolerance & Tremor - Beta-blockers

- Ptosis / Blepheritis - Mental illness - Antihistamines

- Dysfunction of - Contraceptive pills

meibomian gland

- Dry eye

- Poor hygiene

Primary Gaze (Optimal Fit) In Gaze (Optimal Fit) Up Gaze (Sagging) Loose Fit is one who fulfills the follow-
ing criteria:
Flat Fit (Prominant Edge) Push up Test belief in many individu- i. Refractive error >+
als that contact lens wear
than “K” by about 2.00 – Ø The lower the water con- arrests or eliminates the 0.50DS, including Aph-
3.00D (approximately 0.4 tent of the lens, the lesser refractive error. akia.
to 0.8 mm), depending the build up of precipi- ii. Low astigmatism < + 0.75
upon the diameter of the tates and protein depos- Fitting Procedures DC
lens. its. The higher the water Step 1. Patient’s selection iii.Regular cornea (no any
Ø If the ratio of spherical : content, the more the lens scarring or/ distortion of
cylindrical power > 4 : 1, deposits. The patient selection is corneal mires)
it is appropriate to fit rou- based on general health, A. Indications: There are
tine spherical soft contact Ø The thinner the lens, the ocular health, occupation, many patients for whom
lens. If the ratio is less, greater the oxygen trans- motivation, expectation of contact lenses are not merely
toric contact lens is indi- mission to the cornea. the patient and personal a matter of cosmetic choice,
cated. ocular hygiene of the pa- but the best means of pro-
Ø Power is finalized by Ø Visual acuity should be tient. viding a satisfactory visual
over-refraction. better or as good as with correction (Table 1).
Ø The lower the water con- spectacles. The patient with the best B. Contraindications: There
tent of the lens, the more prognosis for successful fitting are great many factors,
durable the lens. The Ø High plus & high minus which may be considered as
higher the water content, lenses are fitted 0.5 mm contraindications (Table 2).
the more fragile the lens. larger than low powers.
Step 2. Pre-fitting Examina-
Ø Patients should have re- tion
alistic expectations from
contact lens. There is false This includes measure-
ment of uncorrected and
best corrected visual acuity,

Table 3: Radius Conversion Table (Diopter to mm)

(Lens power: Steeper side - Add Minus & Flatter side - Add Plus):

37.25 = 9.06 40.50 = 8.33 45.00 = 7.50 49.00 = 6.89
37.50 = 9.00 41.00 = 8.23 45.50 = 7.42 49.50 = 6.82
37.75 = 8.94 41.50 = 8.13 46.00 = 7.34 50.00 = 6.75
38.00 = 8.88 42.50 = 7.94 46.50 = 7.26 50.50 = 6.68
38.50 = 8.77 43.00 = 7.85 47.00 = 7.18 51.00 = 6.62
39.00 = 8.65 43.50 = 7.76 47.50 = 7.11 51.50 = 6.55
39.50 = 8.54 44.00 = 7.67 48.00 = 7.03 52.00 = 6.49
40.00 = 8.44 44.50 = 7.58 48.50 = 6.96 53.00 = 6.37

January, 2004 311 DOS Times - Vol.9, No.7

REVIEW

cycloplegics refrac- Table 4: Use the vertex conversion table "Average 12mm vertex teria shown at time
tion, keratometry, distance" For Minus Powers read Left to Right & Plus Powers read Right to Left: of determination of
videokeratography lens thickness (Table
and a detailed slit - 3.25 = + 3.00 - 7.00 = + 6.50 - 11.00 = + 9.62 - 16.25 = + 13.50 5).
lamp biomicroscopy - 3.50 = + 3.25 - 7.50 = + 6.87 - 11.50 = + 10.00 - 16.75 = + 13.75 5. Trial lens: If us-
- 3.75 = + 3.37 - 8.00 = + 7.37 - 12.00 = + 10.37 - 17.00 = + 14.00

to rule out presence of - 4.00 = + 3.75 - 8.50 = + 7.75 - 12.50 = + 10.75 - 18.00 = + 14.50 ing a trial set, select
any structural and - 4.50 = + 4.12 - 8.75 = + 8.00 - 13.00 = + 11.25 - 18.50 = + 15.00 a suitable trial lens
functional lid abnor- - 5.00 = + 4.75 - 9.00 = + 8.25 - 13.50 = + 11.50 - 19.00 = + 15.50 with a base curve of
mality, tear film status - 5.50 = + 5.12 - 9.50 = + 8.62 - 14.00 = + 12.00 - 19.50 = + 15.75 0.4 to 0.6mm (2.00 to
by schirmer and - 6.00 = + 5.62 - 9.75 = + 8.75 - 15.00 = + 12.75 - 20.00 = + 16.00 3.00D) flatter than
- 6.50 = + 6.00 - 10.00= + 9.00 - 15.50 = + 13.00

break-up time, con- the flattest “K” in the

junctival status especially add ½ of cylinder (-0.50D) to –6.50DS at spectacle plane smaller diameter

tarsal conjunctiva, corneal the sphere, so that power is (12mm) becomes – 6.00DS at lenses (12 to 13mm) and

surface, thickness and en- -6.50DS. Compensate the the corneal plane. The thick 0.6 to 1mm (3.00 to 5.00D)

dothelial status, horizontal vertex distance by Vertex soft contact lens always flatter in the large diameter

visible iris diameter, ante- Conversion (Table 4); so that compensates for a cylindri- lenses (14 to 15mm).

cal power of – 0.50 to -

Table 5: Different Power, Lens series & thickness of Lenses 0.75DC. Step 4. Lens placement on

Power range Lens series Rationales 3. Horizontal visible iris di- the eyes:

- 0.50 to - 2.00Ds U or B Better handling ameter (HVID): Measure the Place an appropriate trial
- 2.25 to - 5.50Ds U or O HVID in millimeters by cali- contact lens and wait for 15-
Balance between pers. The initial lens diam- 20 minutes for an equilibra-
physiology eter to be selected should be tion. The equilibration time

- 5.50 to - 9.00Ds O or U Optimum oxygen 0.2 to 0.5mm larger than the may depend on water con-

transmissibility HVID. tent of the lens. High water

- 9.50 to -20.00Ds HO Optimum oxygen a. If the HVID < 11.50mm - content lenses take longer to
transmissibility Lens diameter = 13.50mm settle because the volume of
The Central thickness: water is greater necessitat-
B - Series = 0.12mm U – Series = 0.07mm b. If the HVID > 11.50mm – ing a longer equilibration
HO Series = 0.035mm Optima (38) = 0.06mm. Lens diameter = 14.50mm time.

4. Select lens thickness:
These are the following cri-

rior chamber & lens status Soft Contact Lens : Reference Guide, Daily Wear / Disposable Soft Contact Lenses
pupillary size (Optic zone =
pupil size + 2.0 mm) and Manufacturer Lens type Diameter Base-curve Range of power (Diopter)
shape by transparent scale
or pupillometer. (mm) (mm)

Step3. Basic Fitting Method Bausch & Lomb B3 13.5 +6.00 to –20.00,
1. Keratometry: Record the (Spin Cast) +11.00 to +12.00DS
“K” readings and convert to B4 14.5 8.4, 8.7 +6.00 to –9.00DS
millimeters. (Table 3) CIBA Vision U3 13.5 +6.00 to –9.00DS
2. Spherical power: To de- U4 14.5 +6.00 to –9.00DS
termine the required spheri- Johnson & HO3 & HO4 13.5 & 14.5 -8.00 to –20.00DS
cal power, change the pre- Johnson Optima (38) 14.00 -0.50 to –12.00 (till –5.00 in 0.25
scription to minus cylinder (Acuvue) steps & -15.00 to –12.00 steps)
form and use the spherical PURECON
equivalent of the cylinder if Ciba Soft 13.8 8.3, 8.6, 8.9 Plane to + 6.00DS
the cylinder is greater than Std. 13.8 8.3, 8.6, 8.9 +6.00 to –10.00DS
0.50D. Add this to the Ciba Soft
sphere to determine the ini-
tial lens power. For example, Disposal 8.4, 8.8, 9.3 -0.50 to –9.00DS &
if the spectacal prescription
is - 6.00DS/ - 1.00DC X 900, & 9.1 +0.50 to –6.00DS

Universal 13.8 8.4 Plano to + 25.00Ds
13.8 8.1
P1 13.8 8.7
P2

January, 2004 312 DOS Times - Vol.9, No.7

REVIEW

Table 6: Characteristics of the soft contact lens fit Step 6. Over-refraction
Perform an Over-refrac-
Characters Well / Proper fit Loose / Flat Tight / Steep
tion on a properly fitted lens.
Visual Acuity - Good - Clear between - Blurred between blink Refraction is done through
- Remain stable each blink - Clear after blink the trial lens and power is fi-
- Poor & unstable vision nalized as detailed earlier.
with blink - Variable
- Blurred after blink - Complete Step 7. Lens dispensing
Corneal coverage - Complete - Well Centered about The trial lens and refrac-
Centration - Well Centered - May be Decentred
- Usually Up & Out limbus tion gives the base-curve,
Lens Movement about the limbus - Poor - Less than 0.1mm power, over-all diameter,
with each blink - Within 0.20 to - Excess (>2.00mm) - No/ little movement optic zone, peripheral curve
radius, width and thickness.
1.00mm on blinking in
primary gaze Step 8. Follow up care
Push up test - Moves radially - Excess a. Visual acuity (VA)
- Returns quickly - Doesn’t return - Moves slowly
- Return sluggish with contact lens is recorded
Comfort - Good in all gaze radially at each follow-up visit.
- Good for a short
Retinoscopic - Sharp before & - Poor; foreign body period b. If the vision is less
reflex after blink sensation than previously recorded
- Shows irregular VA, then refraction should
Keratometer mires - Undistorted & - Clear centrally reflex be done through the lens
General stable with peripheral (over-refraction).
distortion - Distorted & irregular
- No bulbar c. Recheck the lens fit.
conjunctival - Clear initially; blur - Irritation of limbal or d. Examination of the
compression after blink conjunctival vessels eye and contact lens.
e. Orthoptic check-up
- Buckling of lens - Scleral indentation should be performed in all
edge often seen after lens the myopes as there is an
removal imbalance of convergence
- Lens falling out of and accommodation when
the eye - More negative power one switches over from
required than actual spectacles to contact lens.
power due to f. Indirect ophthalmos-
formation of plus copy should be performed
liquid lens in patients with high myo-
pia as they are predisposed
Step 5. Evaluation of the Ø Use a lower water content gaze (Upto 1.5mm accept- to retinal problems.
lens fit material able) / Lateral gaze (Upto
1.5mm) Suggested Reading:
Evaluate the fit of the lens Ø Use a different lens thick-
according to the normal lens ness 2. Edge examination in 1. Contact Lenses: Anthony J.
fit criteria. upgaze. Phillips, Janet Stone. A text
Steep fit book for practitioner and Stu-
According to the first fit Ø Select a flatter base curve 3. Push up test dent (Third Edition)
theory Ø Select a smaller total di- The lens is displaced tem-
porally with finger so that it 2. Harold A Stein, Bernard J.
Fit smallest and thinnest ameter is only one third on cornea Slatt, Raymond M. Stein: Fit-
lens which will provide: Ø Use a higher water con- and two thirds on sclera and ting guide for Rigid and Soft
- Full corneal coverage/ its return is observed. Easy Contact Lenses.
tent material displacement and easy re-
Centration/Adequate Ø Use a different lens thick- turn to the cornea indicates 3. Andrew Gasson, Judith Mor-
movement/Comfort an ideal fit. ris: Contact Lens mannual. A
(Table 6) ness 4. Lens edge lift Practical Fitting Guide.
Corrective measures for im- The additional criteria Displace the lens by
proper fit for best fit assessment: An pushing the lower edge up- 4. Edward S. Bannet, Vanita
Flat fit ideally fitted lens should be ward with the help of the Allee Henery: Clinical
Ø Select a steeper base well centered, comfortable lower lid and observe the Mannual of Contact Lenses
curve and must provide crisp vi- edge lift at 6 o’clock. This is (Third Edition).
Ø Select a large total diam- sion, proper corneal cover- a guide about the fit.
eter age and adequate oxygen
supply to the cornea.
1. Movement with up

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MANAGEMENT PEARLS

Contact Lenses Complications of infection.
and their Management 2. Infectious Complica-

Jagjit S. Saini MD, FIACLE tions: There is a spectrum of
inflammatory adverse reac-
Trouble free contact lens open, and from the tarsal con-hydrogels lenses have tions from contact lens wear.
wearing patients are the conjunctiva when the eye is oxygen transmissibility Many of these inflammatory
keys to increasing popular- closed. There are significant above 100 and could be em- episodes cause similar
ity of contact lens practice variations in demand for ployed on extended wear symptoms of pain, redness,
base. There are however, no oxygen among individuals. basis in selected patients. photophobia, puffiness of
trouble free contact lenses or A partial pressure of 75 mm Patients who wear lenses lids and discharge at lid
patients. A smarter physi- Hg for oxygen is considered not providing enough oxy- margins. Differentiating
cian adopts strategies to ad- adequate for healthy cornea. gen to the cornea risk devel- early microbial keratitis
vice his patients on how to Numerous factors affect sus- oping hypoxia. Common from sterile marginal infil-
halt contact lens complica- ceptibility of cornea for hy- complications related to hy- trates, an immunologic re-
tions before they start. There poxic damage, which in- poxia include epithelial and sponse, represents one of the
are a number of ways to clas- clude previous ocular surgi- stromal edema, increased greatest diagnostic dilem-
sify contact lens related cal procedures. Eyes with bacterial adherence to epi- mas, and errors in treatment
complications. Generally, previous surgery such as thelial cells, decreased epi- and management can lead to
significant ocular complica- aphakia or refractive proce- thelial cell regeneration, potentially sight-threaten-
tions can be segregated into dures demonstrate poorer compromised epithelial ing consequences. There is
hypoxic, infectious, me- physiological reserves to re- junction integrity, micro- clear information now that
chanical, immunological or spond to additional meta- cysts and vacuoles, endothe- contact lenses worn on ex-
osmotic changes induced in bolic insults of contact lens lial polymegathism and bleb tended wear basis have a
the eye from contact lens wear and need special con- formation and corneal vas- higher incidence of contact
wear. While there is overlap siderations. The type of lens cularization. Hypoxia re- related infectious episodes.
among the various catego- material, lens thickness and lated problems would occur Although several factors
ries, the primary inciting fac- lens design significantly in- more often in eyes with may contribute, hypoxia,
tor should be identified in fluences availability of oxy- higher oxygen demand or poor contact lens hygiene,
order to most appropriately gen to cornea. Complica- low abilities to physiologi- and diseased state of the cor-
treat the condition. This ar- tions can result if contact cally compensate for meta- nea are prominent.
ticle will focus on describing lenses result in inadequate bolic insult. Acute hypoxia
the contemporary views on corneal oxygenation given from over wear of contact Infectious keratitis (IK) is
common contact lens related the patient’s physiological lens is a frequent problem characterized by excavation
complications and how to demands and desired wear- that may manifest in mild of epithelium and cornea
avoid and handle them in ing schedule. Critical oxy- asthenopia symptoms to stroma with infiltration and
usual clinical practice. gen levels necessary to avoid acute pain and redness in necrosis. There is often ac-
corneal edema in normal the eye. companying anterior cham-
1. Hypoxic Complica- eyes under daily wear open ber reaction and decreased
tions: Contact lens wear re- eye contact lens use needs Fortunately, most of these vision. While all types of
duces the amount of oxygen oxygen transmissibility in acute complications can be keratitis can present in con-
to the cornea, especially un- excess of 24.1 x 10-9 Barrer/ managed rather easily by tact lens wearers, two main
der closed eye conditions. cm. Under closed eye ex- changing lens materials. types of ulcerative keratitis
The oxygen required by the tended wear contact lens are more frequently ob-
cornea for essential metabo- use, lenses need to have It is important for the served in contact lens users.
lism is obtained by diffusion higher than 87 x 10-9 Barrer/ practitioner to obtain from These are bacterial keratitis
from the air when the eye is cm oxygen transmissibility. the manufacturer informa- and Acanthamoeba keratitis.
Several current daily wear tion of the oxygen transmis- Both can have significant
Professor of Ophthalmology, contact lens materials and sibility of the contact lens to visual morbidity. Although
Post Graduate Institute of Medical designs exceed the required make informed decision. other types of keratitis (vi-
Education and Research, oxygen transmissibility. Sili- Neglecting hypoxia related ral, herpetic fungal, para-
Chandigarh, India. problems predisposes eye to sitic, etc.) can occur with
more serious complications contact lens wear, the fre-
quency with which these
types occur is generally not
different between contact

January, 2004 316 DOS Times - Vol.9, No.7

MANAGEMENT PEARLS

lens wearers and non-con- Ulcers must have smear and accumulation of debris un- more common in atopic in-
tact lens wearers. While in- basic culture tests per- der the lens or preservatives dividuals. This condition
fectious corneal ulcer, is an formed. Appropriate fre- such as thimerosal in contact also appears to peak with
infrequent event, sources for quent topical antibiotics lens care solutions. Toxic ef- the height of the allergy sea-
microbial contamination put (author’s choice fluoroquin- fects on cornea from contact son. GPC is thought to be an
all contact lens wearers at olones) generally suffice. It lens care products such as immunologically mediated
risk. Common sources of is however, very essential to benzalkonium chloride, condition. Trauma is also a
contamination include the monitor and document heal- alkyl triethanol ammonium factor in the pathophysiol-
environment, the wearer’s ing and follow usual proto- chloride, chlorhexidine glu- ogy of GPC. Neutrophil
hands, the eye and ocular col to investigate in depth if conate and disodium chemotactic factor has been
adnexa, a contaminated lens healing does not progress. edetate are known. found in high concentrations
or lens case and contami- in the tears of GPC patients.
nated solutions. Eyes manifesting CLPU Superior limbic kerato- As the antigen-coated con-
or CLARE also need cessa- conjunctivitis is character- tact lens traumatizes the tar-
Contact lens induced pe- tion of lens wear and docu- ized by symptoms of red- sal conjunctiva, the ocular
ripheral ulcers (CLPU) mentation of cornea infil- ness, irritation and tearing of immune system releases in-
(Fig.1)are characterized by trates. Most ophthalmolo- sudden onset in patients flammatory mediators,
focal excavation of epithe- gists will administer pro- who have worn lenses for which leads to the attraction
lium only. Although there phylactic antibiotics as well some time. The superior part of inflammatory cells such
are infiltrates in the superfi- although in compliant pa- of the cornea demonstrates as neutrophils, basophils,
cial stroma, there is no de- tients non-steroidal anti-in- superficial vascularisation eosinophils and mast cells.
monstrable necrosis or exca- flammatory drops and and epithelium haze. There These cells react with immu-
vation extending to stroma. monitoring may be enough. is congestion of neighboring noglobulins to cause the re-
It is believed that toxins re- It is not useful to rush to ad- bulbar conjunctiva. lease of vasoactive amines
leased from gram positive minister antibiotics in non- that are responsible for the
organisms such as staph ulcerative cornea lesions. Giant Papillary Conjunc- signs and symptoms of GPC.
aureus colonizing on the Every patient however, tivitis may occur with any While the introduction of
lens itself may be causing needs to be told clearly the type of contact lens, ocular frequent replacement con-
CLPU. need for close monitoring prostheses, sutures, sclera tact lenses has helped to
and the dangers of neglect. buckles or adhesives. The manage patient with GPC,
Contact lens induced Patients adjudged to be lax symptoms include de- this condition still occur
acute red eye (CLARE) (Fig. are not fit for using contact creased lens tolerance, in- with frequent replacement
2) manifests with focal or lenses. Usually, lenses in creased lens movement, in- lenses. The majority of pa-
diffuse peripheral cornea in- such patients have features creased mucus, blurred vi- tients who develop GPC are
filtrates without disruption of spoilage. It is important sion and ocular itching. Ex- on a four-week or greater
of cornea epithelium. The that patients understand amination of the superior lens replacement schedule.
laboratory evidence sug- that contact lens care solu- tarsal conjunctiva will reveal
gests that endotoxins re- tions do not sterilize but re- tarsal injection, visible loss As with non-contact lens
leased from gram negative sult in limited disinfection. of the vascular pattern and wearers, avoidance of the al-
organisms on the contact When contact lens related papules greater than 0.3 mm lergen is the first defense. In
lens are responsible for infectious episode has oc- (Fig. 3). In the more severe some atopic patients, dis-
CLARE. The symptoms in curred, it is prudent to dis- cases, the bulbar conjunctiva continuance of lens wear or
CLARE are milder. card the spoiled lens, change may be involved and there reduction of wearing time
lens case, and the bottle of may be a superficial punc- during the allergy season
Any inflammatory epi- care solution. Stringy pa- tate keratopathy. In addi- may be warranted.
sode involving cornea is sus- tients who may want to use tion, apical staining of the
pected to harbor infectious the lens a little longer must papules with fluorescein The availability of fre-
organisms on the cornea and be warned to report any red- may be noted. Almost all pa- quent replacement lenses
contact lens. Contact lens ness immediately. tients report significant coat- has expanded the options
wear is discontinued for as ing of the contact lens. The for these patients. Switching
long inflammation persists. 3. Allergic and toxicity incidence of GPC is higher a patient to a more frequent
Biomicroscopic evaluation Complications: Although with soft lenses than with replacement schedule, in-
will usually demonstrate contact lens materials are rigid lenses. The symptoms cluding daily disposable
characteristic features. It is biologically inert, an inflam- of GPC appear to be more contact lenses, may improve
important that such lesions matory response may be severe with soft lenses than comfort. A more frequent re-
are carefully recorded for provoked in the cornea from with rigid lenses. GPC is placement schedule leads to
size, depth, and location.

January, 2004 317 DOS Times - Vol.9, No.7

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Fig. 1: Contact Lens Peripheral Fig. 2: Contact lens acute red eye which is readily evident the tonicity of the tear film,
Ulcer (CLARE) with corneal topography. such as that which occurs
All contact lenses, soft in- following epiphora (hypoto-
Fig. 3: Giant papillary conjunctivi- Fig. 4: Deposits on a soft contact cluded, commonly produce nicity) or in dry eyes (hyper-
tis lens lens mild corneal warpage, tonicity). Both hypotonic
which may only be evident and hypertonic situations
reduced lens coating and a minimum of four weeks, or with corneal topography. can alter the fit of a soft con-
decreased antigen load. until the tarsal inflammation No treatment is required for tact lens, usually creating a
Medical management, with resolves. The papillary reac- mild warpage unless it is tight lens situation, leading
antihistamines, mast cell sta- tion will not abate during significant enough to pro- to a continuing cycle of fur-
bilizers, or combination this period. These patients duce spectacle blur or result ther compromise. A change
products may also be effec- should be switched into a in unstable vision following in tear pH and relative de-
tive, though steroids should disposable lens fitting re- contact lens removal. In pa- hydration results in tight
be avoided for contact lens gime and followed every tients interested in refractive lens syndrome because of
wearers. The use of mast-cell two to three months. If GPC surgery, it is imperative that altered lens structure and
stabilizers or a combination recurs, contact lens wear lens wear discontinued un- lens fit. Acute pain, redness,
mast-cell stabilizer/ antihis- should be discontinued un- til corneal warpage is re- and blurred vision typically
tamine may enable patients til the signs of inflammation solved and serial topogra- occur 48-72 hours after re-
with ocular allergies to wear have resolved. The patient phy is stable in order to re- moval of lens. Remedies in-
their contact lenses during should be prescribed a mast- duce the risk of corneal ecta- clude refitting the lens as
the allergy season. The se- cell stabilizer or a mast-cell sia following refractive sur- necessary and treating the
verity of signs and symp- stabilizer/antihistamine gery. underlying cause of the os-
toms is a reasonable bench- combination product for one motic complication (pre-
mark in the choice of treat- to three months. The drug Superior epithelial arcu- scribing lubricants, inserting
ment for contact lens related can then be slowly tapered ate line (SEAL) manifests as punctal plugs, etc.).
GPC. Patients with mild depending on the clinical re- arc like grayish white epi-
signs and symptoms, should sponse. Rarely, patients may thelial lesion with heaped What to do When Compli-
discontinue lens wear for agree to accept rigid gas per- edges in the periphery of cations Occur:
one to two weeks. Consider meable lens instead of the superior cornea close to lim-
changing the lens replace- offending soft contact lens. bus. SEAL is believed to re- Familiarity with symp-
ment cycle for these patients sult from mechanical dam- toms and treatment of con-
to about four-weeks, and 4. Mechanical Compli- age to cornea. tact lens complications helps
monitor the patient every cations: Mechanical compli- in providing efficient care to
three months. Moderate lev- cations can range from sub- Physical deposits fre- the patient. It is important to
els of GPC will call for a two- clinical to visually signifi- quently are observed on follow a consistent policy on
to four-week discontinuance cant. All lenses can produce contact lenses (Fig. 4). These work up of these patients.
of lens wear, to allow any effects ranging from micro- deposits predispose the eye
apical staining or superficial trauma to full-thickness to several complications that a. A thorough interview
punctate keratitis to resolve. abrasions, which put the include infections and me- is required in every patient.
These patients will benefit contact lens wearer at a chanical irritation. Rarely, It is not enough to advice
from a disposable contact greater risk for infectious foreign bodies may be based on symptoms elicited
lens. For severe cases, dis- corneal ulcers. Other types trapped under the lens and through a friend or interme-
continue lens wear for a of mechanical complications cause mechanical damage to diary. The chief complaint
include corneal warpage, cornea. Although deposits elicited will direct further in-
on the lens and foreign bod- quiry. Always ask open-
ies embedded in the lens ended questions to allow pa-
may be reduced after soak- tients to describe their
ing in contact lens care solu- symptoms. Patients com-
tion and mechanical rub- plaining of pain or decrease
bing, they never really dis- in vision need to be evalu-
appear. It is prudent to ad- ated urgently. The usual
vice change of lens when de- questions on the duration
posits are visible on the lens. and chronology of com-
plaints are elicited. In addi-
5. Osmotic Complica- tion, contact lens history
tions: Osmotic complica- must be determined to assist
tions result from changes in

January, 2004 318 DOS Times - Vol.9, No.7

MANAGEMENT PEARLS

in the diagnosis. Determine tered if there is evidence of periodic intervals even water to wet lens. It is also
what kind of contact lens the symptoms from use of a par- when they do not have important to present symp-
patient wears and how they ticular solution. Hydrogen symptoms. The first follow toms associated with adap-
are being worn. What is the peroxide based solutions are up visit should be scheduled tation to contact lens wear to
usual wearing time each a good alternative in sensi- after a week and thereafter allay unfounded fears and
day? How old are the tive patients. More chronic at 2 weeks, one month, and insignificant complaints. Pa-
lenses? Moreover, if the complications such as pap- every six months. Intervals tients must be encouraged to
lenses are still in the eye illary conjunctivitis or between follow up visits seek advice from trained
with symptoms. Informa- vascularisation will need a could vary depending upon practitioners rather than
tion on cleaning and disin- reduction in wearing time contact lens history. Regular friends or relatives who may
fection is also necessary. and even cessation of lens appointments enable you to not have appropriate infor-
Find out what solutions are wear. verify patients’ compliance, mation.
being used at the present. answer their questions, and
Preventing Contact-Lens maintain their ocular health In conclusion, while we
b. Record the informa- Complications before they better overall. During each are fortunate today to have
tion on an examination or start visit, ask patients how many technology that provides for
follow-up sheet. This be- lenses they have left and healthy contact lens wear in
comes important when the Creating loyal contact how often they replace our patients, complications
same patient returns for a lens patients is through them. If their answers differ can and do occur. Three cri-
follow-up. teaching them to be smarter significantly from your ex- teria are important to pro-
and safer contact lens wear- pectation be prepared to viding superior care to our
c. Evaluation and man- ers. Some of the steps that probe further and ask why. patients:
agement begins with evalu- help are introduced below: Your patient may be stretch- a. Making sensible selec-
ation of the contact lens and ing out the replacement
eye on removal of contact a. Screening for safer cycle. If so, you’ll need again tions in lenses and pro-
lens. In choosing appropri- contact lens patients: Per- to stress the importance of spective patients when
ate management option, it is form a thorough pre-fit sticking to the prescribed in- prescribing
necessary to differentiate screening to choose safer terval. b. Being suspicious of early
those ocular changes that contact lens patients. It is im- signs of ocular compro-
can be considered physi- portant that patient’s expec- c. Care regimen. It is im- mise
ologically acceptable from tations and motivation are portant that patient receives c. Appropriately educating
those which are pathologi- understood and if required and understands correctly patients how to avoid po-
cal. Any infiltrate on the cor- patient is appropriately the contact lens application tential risks.
nea is clearly serious counseled. Ocular health and removal procedure and
whereas mild edema may be history including prior dis- care regime. It is important Further Reading
physiologically acceptable. eases and surgery on the to deliver to the patient writ- The IACLE Contact lens course
Specific management op- eye, medications currently ten care instructions also. At
tions are detailed in the sec- instilled in the eye, allergies every follow-up visit, prac- modules. International asso-
tion describing complica- and nature of occupation titioner and wearer should ciation of contact lens educa-
tions above. Generally con- must be elicited pointedly. go over the specific lens-care tors (Publisher), Sydney, Aus-
tact lens management op- Some patients may be better regimens. Verifying that pa- tralia.
tions include replacement off with spectacles than con- tients follow a proper lens- Donshik P, Porazinski A. Giant
with a new lens of same or tact lenses and should be care regimen can help enor- Papillary Conjunctivitis in
another material and design, discouraged at the begin- mously. Frequent-Replacement Con-
alter care regime and wear- ning itself. For patients al- tact Lens Wearers: A Retro-
ing mode. A common un- ready wearing contact d. Dos and don’ts: The spective Study. Tr Am Ophth
derlying problem of contact lenses information on type patient should be educated Soc 1999; 97:205-220.
lens wear is build up of vis- of lens worn, wear time and in the various dos and Pamela Capaldi and Barr J (Eds).
ible or in-visible deposits in subjective assessment of don’ts. This helps provide Seven steps to better patient
the soft contact lens matrix. comfort will provide direc- clearer instructions. Hand care- an educational resource
Advice to use frequent dis- tion to the change in contact washing, cleaning the lens for contact lens assistant. Con-
posable lenses, is therefore is lens material, design and case and lens inspection tact lens spectrum Supple-
a common practice in pa- wear. should all be emphasized to ment November 1994.
tients when lens spoilage is the patient as well as never Saini JS, Rajwanshi A and Dhar S.
frequently suspected. Lens b. Regular return visits: re-using lens care solution Clinicopathological correla-
care regimen should be al- Every contact lens wearing and never using saline or tion of hard contact lens re-
patient needs evaluations at lated changes in tarsal con-
junctiva by impression cytol-
ogy. Acta OphthalmoI.
1990;68:65-70.

January, 2004 319 DOS Times - Vol.9, No.7

MANAGEMENT PEARLS

Management on Convergence Insufficiency and
Accommodation Anomalies

Sachin Kedar MD, Pradeep Sharma MD

The symptom complex of adult who is either in the se- Diagnosis near point of accommodation
asthenopia and ocular dis- nior school or in the college 1. Remote Near Point of (NPA)
comfort makes up for a large and is prone to developing 5. Variable amount of exopho-
part of the ophthalmo- complaints when nearing Convergence (NPC): is one of ria at near fixation. However,
logist’s practice. Conver- the examination period due the most consistent findings. patients may also exhibit ortho-
gence insufficiency probably to the stress of studying for phoria and esophoria
remains the most common extended periods of time. Normal NPC:
cause of muscular astheno- There is also a growing seg- Ahildren : 6-10 cm Management
pia. The recognition and ap- ment of population that Adults : 5-8 cm 1. Optimal refractive
propriate treatment of this spends a considerable amo-
condition requires a good unt of time at the computer w Traditionally the NPC correction: In those cases
understanding of the inter- terminals and present with has been measured by which have an identifiable
play of the factors affecting a symptom complex often slowly moving a target cause of the convergence in-
the near vision complex i.e. labeled as the VDU (Visual level with the nasion to- sufficiency, such as high un-
accommodation, conver- Display Unit) syndrome. wards the eyes until the corrected refractive errors,
gence and miosis. To the Convergence insufficiency patient perceives diplo- these have to be optimally
uninitiated and the ignorant, also plays a significant part pia or the examiner notes corrected. Low myopia (< -
it can be a harrowing expe- in this group. The symptoms a break in fusion and de- 1D) is often secondary to the
rience to obtain patient sat- are aggravated by ill health, viation of the eyes. Instru- convergence insufficiency,
isfaction. poor sleeping habits and ments like the RAF scale which leads to a stimulation
anxiety. use this principle of the accommodation in an
Not much can be said be- effort to increase the accom-
yond the clinical description There are numerous w Other modifications in- modative convergence. In
of the condition given by other situations where con- clude documentation of such cases, tackling the con-
von Graefe in 1855 vergence insufficiency is the recession of the NPC vergence insufficiency by
“………such patients com- prone to develop. Patients on repetitive measure- methods enumerated below
plain of eyestrain and a sen- with higher grades of ments by 4-8 cm. Normal would be sufficient.
sation of tension in and ametropia also develop con- persons show a recession
about the globes….after vergence insufficiency. With of approximately 1 cm 2. Orthoptic treatment
brief periods of reading, the refractive errors more than forms the mainstay of the
letters start to blur and run +5 to +6D, the patient does w A significantly different treatment of convergence in-
together….. crossed diplo- not accommodate and with break point and recovery sufficiency. The goal of the
pia occurs with near work errors of -6D or more, they point is also seen treatment is to increase the
and often one eye is closed do not have the necessity to fusional range at near fixa-
or covered while reading to do so. The third clinical sce- w Inability to sustain con- tion. Extensive office based
obtain relief from visual fa- nario is of the presbyope vergence at near (10 cm) and home based treatment
tigue…” The profile of the who starts to wear the near for at least 60 seconds is strategies are followed by
patient presenting with this correction for the first time. also abnormal. This re- different authors. Optomet-
condition is as varied as the In all these situations there sults in asthenopia de- ric vision therapy usually in-
presentation itself. Typi- is a lack of accommodation spite normal fusional corporates the prescription
cally, the subject is a young and hence an absence or re- convergence values. of specific treatments in or-
duction of the accommoda- der to:
Dr. Rajendra Prasad Centre for tive convergence. This re- 2. Reduced Fusional conver- w Normalize the near-point
Ophthalmic Sciences, sults in a relative divergence gence at near fixation
New Delhi that puts a strain on the fu- of convergence
sional convergence. Normal fusional range: w Normalize fusional ver-
35-40 pd BO at near fixation
3. Reduced AC/A ratio gence ranges and facility
w Eliminate suppression
Normal AC/A ratio by
the gradient method: 3-5
pd/D
4. A normal age appropriate

January, 2004 320 DOS Times - Vol.9, No.7

MANAGEMENT PEARLS

w Normalize associated de- such that the circles can be therapy. 1. Significant difference
ficiencies in ocular motor superimposed and the pa- Convergence insuffi- in the refractive error with
control and accommoda- per slid on a scale. The circle and without cycloplegia
tion on one side has a cross on the ciency complicated by re-
top and the other side at the stricted fusional ranges need 2. Miosis
w Normalize accommoda- bottom. The patient has to an additional 12 hours of of- 3. Convergence anoma-
tive/convergence rela- fuse the two circles such that fice therapy and those with lies usually variable (excess)
tionship both the crosses are visible an accommodative element
Near point of conver- on the circle. The fusion is need up to an additional 8 Management
then maintained for about hours of office therapy. 1. Identify and treat the
gence exercises: An accom- 50 seconds as close to the
modative target, such as the nose as possible and re- 3. Surgery: The decision organic cause: spasm due to
point of a pencil (i.e., pencil peated 4-5 times in succes- to proceed with surgery irritation of the parasympa-
push-ups), is placed remote sion 4-5 times a day. A pro- should be made with cau- thetic system or oculomotor
to the patient’s near point of gressive decrease of the dis- tion and only after all ortho- nerve.
convergence and gradually tance between the paper and ptic efforts have failed. Bilat-
brought toward the tip of the eyes indicates improve- eral medial rectus resections Ciliary spasm
the nose with the patient ment. are usually the most effec- - drug induced e.g., phy-
converging to avoid diplo- tive operation for this con- sostigmine, pilocarpine,
pia. Just before there is a Other forms of conver- dition preferably as an ad- morphine, digitalis
break in fusion, the patient gence training: Base-out justable procedure. How- - lesions of brain stem and
holds fixation on the target prism reading and stereo- ever, the patient should be oculomotor nerve trunk
for 50 seconds and then re- gram cards may be used to warned about the possibil- Inflammation
laxes for 10 seconds. This so- improve fusional conver- ity of uncrossed diplopia at - Anterior uveitis
called “sustained push-up” gence. New, affordable com- distance fixation after sur- - Trigeminal neuralgia
is repeated 5 times in succes- puterized fusional vergence gery. This typically resolves - Others e.g., diphthe-
sion, 2-4 times a day, until training programs (eg, Com- within 1-3 months postop- ria, tooth extraction
the patient is able to hold puter Orthoptics) are avail- eratively. The exophoria at 2. Reassurance is suffi-
sustained fixation to about able. These self-paced pro- near usually recurs after sev- cient in most of the cases
10 cm from the eyes. The grams can be used on a per- eral years, although most along with advise regarding
patient has to be taught to sonal computer at the patients remain asymptom- ocular hygiene and proper
appreciate physiological patient’s home. atic for unknown reasons. reading habits
diplopia. Often if the target 3. In cases of large re-
is brought close enough, the Base-in prisms for near Accommodation Spasm fractive errors, the error is
patient may experience de- only: These prisms can be Definition: brought by corrected. Initially, the hy-
viation of one eye and the ground into a separate pair permetropia is slightly un-
purpose of the exercise may of reading glasses, or Fresnel the spasm of the near com- der corrected and then
be lost. The exercises can be membrane prisms can be fit- plex leading to convergence, gradually increased.
tapered and then used on an ted over the reading seg- pseudo myopia and miosis. 4. Marked spasms need
as-needed basis when the ment of the patient’s bifo- to be treated by using
patient notices a recurrence cals. Symptoms cycloplegics such as atro-
of symptoms. One of the • Blurred often fluctuating pine for several weeks.
drawbacks of the home ex- Duration of Treatment 5. The negative relative
ercises is that the patients Treatment duration will vision depending on convergence, which devel-
consider it too simplistic and patient’s refractive status ops once the spasm is cor-
often lose interest in them depend upon the particular • Macropsia rected, may be overcome by
and discontinue them. A patient’s condition and asso- • Asthenopia during close orthoptic exercises. Orthop-
course of the office-based ciated circumstances. The work tics form the mainstay of
exercises on the synopto- most commonly encoun- • Pain (eyebrows/ head- treatment in cases of conver-
phore often helps. tered convergence insuffi- ache) gence insufficiency with low
ciency usually requires 24 to • Poor concentration myopia
A Simple Home Ortho- 32 hours of office therapy. Typically, the patient is a
ptic Trainer (SHOT) de- Uncomplicated conver- youngster, under stress, the Accommodational Inertia
signed at the R P Center may gence insufficiency charac- symptoms developing after Def: condition where a
be used. This method uti- terized by only a remote prolonged and intense peri-
lizes a dark circle painted on near point of convergence: ods of near work. difficulty in changing the ac-
either side of a folded paper up to 12 hours of office commodative state from ine
Signs distance of fixation to an-

January, 2004 321 DOS Times - Vol.9, No.7

MANAGEMENT PEARLS

other, manifested by an in- group (>30 years) but some- paralysis due to any cause- present orthoptic exer-
ability to change focus times even in adolescence. drugs, trauma, third nerve cises started.
quickly. Accommodation range is be- palsy. w Convex lens with base in
low normal for the age. prisms prescribed for
Etiology: Unilateral- Clinical features: near
Adie’s syndrome Management: correct re- Myope patient is gener- w Miotics
fractive errors, improve the
Bilateral- anisometro- fusion range and conver- ally asymptomatic; the hy- Suggested Reading
pia, poor general health, fa- gence through exercises to permetrope is unable to fo-
tigue alleviate the asthenopia. cus at any distance. 1. von Noorden GK :Binocular
vision and ocular motility. 5th
Clinical features: com- Accommodational Paraly- The emmetrope has de- ed. St. Louis: Mosby, 1996:468-
plaints of intermittent blur- sis creased vision for near only. 476
ring of vision, with a delay
in the ability to change focus Def: Complete inability to Management: 2. Sharma P: Strabismus simpli-
for a particular distance es- accommodate w Rule out an associated fied. 2001: 100 -109
pecially from distance to
near; seen in the middle age Etiology: Ciliary muscle convergence paralysis- if 3. Rowe F: Clinical Orthoptics.
Blackwell Science: Oxford,
1997:155-64

New DOS Members

M-1755 M-1751 T-1044 R-1761
Modi Vandna Misra Astha Tandon Charu Ruby
167-A, Model Town Extension 122, Faizabad Road B-138, Preet Vihar B-146, Jain Nursing Home
Ludhiana Near Indira Bridge Delhi-110092 Kankarbagh Colony
Lucknow Patna-20
B-1744 S-1743
Bhati Jai Singh D-1752 Shah Snehal A-1763
4/322, Malviya Nagar DE Supriya 15, Shanti Nagar Society Agrawal Preeti Wadhwa
Jaipur-302017 Room No.3, Birla Hostel Nanakumbhanath Road HI-12, Sector-D, L.D.A. Colony
Sitapur Eye Hospital Nadiad(Kheda)-387001 Kanpur Road, Lucknow-226012
K-1745 Sitapur-261001 T-1762
Kaur Sukhmandeep M-1742 Titiksha
31, Krishna Square-II S-1753 Mishra (Major) Avinash C/O Dr. P.N. Agrawal
Amritsar Sharma Ashit C/O Lt. Col. M. Tripathi 15/74-75, Civil Lines
Room No.8, Doctor’s Hostel 1152, Block-C Kanpur
D-1746 S.N. Medical College Indira Nagar
Dua Nitin Agra Lucknow S-1760
KD-24/8, Kavi Nagar Singh Om Prakash
Ghaziabad-201002 M-1754 Kumar S-1741 81, Balaji Colony
Maurya Dharmendra Sagarika Samne Ghat
L-1747 Room No.56, 1635, Sector-13, HUDA P.O. Bhagawanpur
Lakhmani Deepak P.G. Hostel Hisar Varanasi-221005
DK House S.N. Medical College
C-2031, Indira Nagar Agra-282002 L-1740 G-1759
Lucknow-226016 Lal Mohan Gupta Arvind
A-1045 1628/13, Urban Estate 25, Ram Nagar
S-1749 Arora Tarun Kurukshetra-136118 Near Bhai Kanhiya Sahib Chowk
Shrivastava Leena A-3/69, Janak Puri, First Floor Yamuna Nagar
Mpa-57, Mhaveer Nagar-II New Delhi C-1764
Kota Chakravarti Arindam A-1050
D-1739 C/O R.N. Chakravarti Anand Raj
V-1748 Dudani Ajay Indur Flat No.112, Badrinath Apartment, B-2/42-B,
Verma Neeraj 7, Rajsarovar Niketan Sector-4, Lawrence Road
S/O Arjun Singh Kanoujia 315-A, Linking Road Plot No.18, Dwarka New Delhi-110035
Patel Nagar Chouraha Above Punjab Sind Bank, Khar(W) New Delhi-110045
Jain Colony, Fatehpur Mumbai-400052 P-1773
J-1047 Prasad Rahul
C-1750 P-1043 Jakhodia Ekta C/O Dr. Ram Kumar Prasad
Chouhan Anil Kumar Parul C/O Dr. Dhruv Jain Prasad Nivas, Bariatu
R. No.82, Resident Doctor’s Hostel E-7, Rashmi Appartments 1, Babar Road Behind Sirdi Sai Hospital
S.M.S. Med. College & Hospital Harsh Vihar, Pitampura New Delhi-110001 Ranchi-834009
Jaipur Delhi-110034

January, 2004 322 DOS Times - Vol.9, No.7

LETTERS TO EDITOR

Letters to Editor

Practical Tips to Manage Post-operative Endophthalmitis

Dear Editor, atre under proper aseptic precau- in 2 separate glass tuberculin syringes.
Endophthalmitis is defined as an tions. It is usually performed under Disposable tuberculin syringes should
topical anaesthesia; however, in un- be avoided. This is so because it is pos-
inflammation of inner coats of the cooperative patients, peribulbar or sible to inject the antibiotic slowly drop
eye associated with exudates in the retrobulbar anesthesia could be ad- by drop with a glass tuberculin syringe
vitreous, which may be infectious or ministered. by rotating the plunger while pushing
non infectious in origin. Although it forward. This motion is not possible
the incidence of intraocular infec- The most common site for admin- with a disposable syringe. Thus, a jet
tions after cataract surgery has istering intravitreal injection is of fluid is more likely to be injected
sharply declined over the past 3-4 inferotemporally 3.0 mm from the with a disposable syringe.
decades since the advent of aseptic limbus in aphakic and 3.5 mm in
techniques and the use of prophylac- pseudophakic eyes. Initially around As per EVS, systemic antibiotics
tic antibiotics, endophthalmitis still 0.5 cc vitreous should be aspirated have no added role in patients being
remains one of the most dreaded with a 21-gauge needle for making treated by intravitreal injections or
complications that an ophthalmic smears as well as for culture sensi- vitrectomy. However as a rule we do
surgeon has to face. tivity; then antibiotics are injected administer systemic Ciprofloxacin
sequentially into the vitreous cavity 200mg. IV or 750mg. oral twice a day
The mainstay of treatment for with a 26 gauge needle. In case of dry to patients of endophthalmitis. The ra-
post-operative endophthalmitis is tap, anterior chamber paracentesis tionale for this decision is that systemic
intravitreal injection of antibiotics. could be done for the same and even Ciprofloxacin does have a significant
Usually a combination of two anti- more importantly, for bringing down penetration into the vitreous cavity as
biotics is chosen which are selected the IOP prior to the intravitreal in- opposed to the systemically adminis-
based on their activity against coagu- jection. tered drugs tested during the EVS in
lase-negative staphylococci (the most most of their patients.
common cause of endophthalmitis), It is not necessary to use 2 differ-
and gram negative bacilli. The most ent needles for injecting the 2 antibi- Sanjeev Naniwal MD, DNB,
commonly used and effective com- otics though different syringes are S.P. Garg MD, H. K. Tewari, MD
bination for this purpose at present mandatory. The needle should be R.P. Centre for Ophthalmic Sciences,
is Vancomycin (1 mg / 0.1 ml) and kept facing towards the centre of the
ceftazidime (2.25 mg / 0.1 ml). globe. The bevel of the needle should AIIMS, New Delhi,
be dented upwards towards the cor-
Intravitreal injection of antibiotics nea. The antibiotics should be taken
should be given in the operation the-

Dear Dr. Titiyal, Keep April 3-4, 2004 Free
We are very pleased to see our for

published review article on OVD in ANNUAL
the the DOS times. I also enjoyed
some of the previous issues of the CONFERENCE
DOS times. Congratuations to you
and your team for disseminating rel- Delhi Ophthalmological Society
evant knowledge among the oph-
thalmic community.

Dr. Suresh K. Pandey,
John A Mohan Eye Centre,

5th Floor, Department of
Ophthalmology & Visual Sciences

University of Utah,
50 North Medical Drive,
Salt Lake City, Utah- USA

January, 2004 323 DOS Times - Vol.9, No.7

JOURNAL ABSTRACTS

Umbilical cord serum therapy leads to subacute PACG, acute PACG and chronic PACG patients
was 2294 +/- 305 cells/mm2, 2388 +/- 226 cells/mm2 and
faster healing of the persistent corneal 2108 +/- 203 cells/mm2, respectively (NS). The acute PACG
patients had significantly lower endothelial cell counts (P <
epithelial defects. 0.001) as compared to the other three groups. Eyes in which
the acute attack of angle closure persisted for less than 72 h
Vajpayee RB, Mukerji N, Tandon R, Sharma N, Pandey RM, had a mean endothelial cell count of 2016 +/- 306 cells/mm2,
Biswas NR, Malhotra N, Melki SA. as compared to 759 +/- 94.4 cells/mm2 in eyes with an at-
tack lasting for 72 h or more (P < 0.001). The endothelial count
Br J Ophthalmol. 2003 Nov; 87(11): 1312-6 was also significantly lower in eyes with chronic PACG as
compared to control eyes (P < 0.001). There was increased
Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, pleomorphism and polymegathism of the corneal endothe-
New Delhi. lial cells seen in eyes with resolved acute and chronic PACG.
The mean central corneal thickness was 531.4 +/- 25.3 micro
Authors evaluated umbilical cord serum therapy as a m in eyes with subacute PACG, 567.9 +/- 37.3 micro m in eyes
means of promoting the healing of persistent corneal epithe- with acute PACG, 526.4 +/- 31.9 micro m in eyes with chronic
lial defects. The study design was a prospective randomised PACG and 525 +/- 12.6 micro m in control eyes. The acute
controlled clinical trial. 60 eyes of 59 patients were divided PACG eyes had a significantly higher corneal thickness (P
into two groups, 31 in the cord serum group and 29 in the < 0.001) when compared to all the other groups. They con-
autologous serum control group. Epithelial defects measur- clude there is a significant decrease in the corneal endothe-
ing at least 2 mm in linear dimension resistant to conventional lial cell density in eyes that have had an acute attack of angle
medical management were included. Serial measurements closure glaucoma and in eyes with chronic PACG. The en-
of the size of the epithelial defects-namely, two maximum dothelial cell population in eyes with sub-acute PACG and
linear dimensions perpendicular to each other, and the area in the fellow eyes of all subtypes of PACG is not significantly
and perimeter was done at start of therapy and follow up days different from the normal population.
3, 7, 14, 21. The data were analysed by the non-parametric
Wilcoxon rank sum test using STATA 7.0. RESULTS: The Most ocular injuries in children are prevent-
median percentage decrease in the size of the epithelial defect able and occur from unsupervised games
was significantly greater in the cord serum group at days 7, like bow and arrow and firecracker, which
14 and 21 (p<0.05) when measured in terms of the area and can lead to significant visual loss.
perimeter. A greater number of patients showed complete
re-epithelialisation with umbilical cord serum (n = 18) than Saxena R, Sinha R, Purohit A, Dada T, Vajpayee RB,
with autologous serum (n = 11) (Pearson chi = 0.19). None
of the patients reported any side effects or discomfort with Azad RV. Indian J Pediatr. 2002 Oct;69(10):863-7.
either treatment. They conclude umbilical cord serum leads
to faster healing of the persistent corneal epithelial defects Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS,
refractory to all medical management compared to autolo-
gous serum. New Delhi, India.

Acute attack of angle closure glaucoma is The study was aimed to identify the causes, demographic
associated with significant decrease in the and clinical profile and evaluate final visual outcome of
corneal endothelial cell density pediatric ocular injuries. 204 children aged fourteen years or
less presenting to the emergency services of a tertiary care
Sihota R, Lakshmaiah NC, Titiyal JS, Dada T, Agarwal HC. centre with ocular injury were included. Demographic data,
nature and cause of injury, duration between injury and
Clin Experiment Ophthalmol. 2003 Dec;31(6):492-5. presentation to an ophthalmologist and the diagnosis were
recorded. Evaluation of visual acuity, anterior segment and
Rajendra Prasad Centre for Ophthalmic Sciences, AII MS, fundus were done. All patients were appropriately managed
New Delhi. and followed up on days 1, 7, 1 month, 3 and 6 months
Majority of injuries occurred in children of 5 years and older
Authors studied the corneal endothelium and pachy- (87.7%). There were 133 (65.1%) boys and 71 (34.9%) girls.
metry in eyes with different subtypes of primary angle clo- 49 (24%) cases presented within 6 hours of injury while 70
sure glaucoma (PACG), as compared to controls. A cross-sec- (34.3%) presented after more than 24 hours after trauma.
tional study was conducted on 30 consecutive patients in each Most common cause of injury was bow and arrow (15.2%)
subtype of PACG, subacute, acute and chronic, and 30 age followed by household appliances (14.3%). Closed globe
and refraction matched controls. The parameters recorded injuries accounted for 42.2% injuries, open globe for 53.9%
included gonioscopy, optic disc evaluation, applanation and 3.9% were chemical injuries. Best corrected visual acu-
tonometry, specular microscopy and central ultrasonic ity of 6/12 or better was achieved in 79 eyes (91.86%) in closed
pachymetry. The mean endothelial cell counts in the four globe group. However, only 17 eyes (15.45%) in open globe
groups were as follows: subacute PACG 2396 +/- 271 cells/ group could achieve this.
mm2, acute PACG 1597 +/- 653 cells/mm2, chronic PACG
2229 +/- 655 cells/mm2 and controls 2461 +/- 321 cells/
mm2. The mean endothelial cell count in the fellow eyes of

January, 2004 324 DOS Times - Vol.9, No.7

ABSTRACT FORM

Annual Conference of

DELHI OPHTHALMOLOGICAL SOCIETY

3th & 4th APRIL, 2004

* ABSTRACT SUBMISSION FORM

To be sent to: Dr. Jeewan S. Titiyal, Organizing Secretary, # 476, 4th floor,
Dr. R. P. Centre for Ophthalmic Sciences, AIIMS, Ansari Nagar, New Delhi 110 029 (INDIA)
Deadline for submission of abstracts: 1st February, 2004
Deadline for submission of complete text: 15th March, 2004

TITLE FP Poster Video
AUTHORS
INSTITUTION
TYPE OF PRESENTATION

INSTRUCTIONS TO AUTHORS: Abstracts should be submitted in English for publication in the Abstract Please Indicate: FP FP
Book. They should be typed in single spacing to fit the frame for camera ready copy. Each abstract Session - I Session - II
should be completed in only one frame. Place unusual abbreviations in parentheses after the full word,
the first time it appears. The text should not contain erasures or visible marks. Write the title in Capitals, Presenters Surname:____________________ Name____________________________
the name of the Authors and the Institution in small letters.
Format of Abstracts must be structured under following headings – Objective, Materials & Methods, Signature :_________________________________________________
Results and Conclusion. Abstract not to exceed 250 words. (Fax must be followed by submission
of hard copy of abstract by post). Postal Address:_______________________________________________________

Tel: ______________________________ Email:____________________________

Abstract received on:____________________________________________________

Please Note:
w All Abstracts should compulsarily be accompanied by full text along with the illustrations and

photographs. An MS Word file of the same is also required on a 31/2 floppy disk.
w Session - I: Dr. A.C. Agarwal Trophy Session.
w Session - II: Winner of Best Paper in this session will be awarded "Certificate of Merit".
w ONLINE SUBMISSION: (Submission can also be made online through the DOS website:

www.dosonline.org
w Video in (CD, VHS) should be submitted along with abstracts.
w Best Poster and Best Video presentation will be awarded trophy and prize money.

January, 2004 325 DOS Times - Vol.9, No.7

CONFERENCE REGISTRATION

Annual Conference of
Delhi Ophthalmological Society

Date: April 3 & 4, 2004 New Delhi

A Preview of
Ophthalmic Panorama 2004
• Plenary Session • Spot Light
• Question Time • Ophthalmic Debates

• Wet Labs • Symposia
• Video Assisted Skill Transfer Courses

• Instruction Course
• And Many More

"

REGISTRATION FORM FOR DOS ANNUAL CONFERENCE (2004)

Name _________________________________ Spouse Name ____________________________

Status: Delegate / Spouse / Resident ______ Member/Non Member Membership No. _______
Address for _____________________________ Registration fee enclosed Rs. _______________
Correspondence _________________________ (in words) _______________________________
by Cash/Draft/Cheque No. _________________ dated______drawn on _____________________
______________________________________ (Name of bank) in favour of Delhi Ophthalmologi-
cal Society (Outstation delegates to pay by DD only)

REGISTRATION FEES

Till 10.3.2004 From 11.3.2004 Spot

to 24.3.2004 Rs. 1,200.00
Rs. 1,000.00
DOS Member Rs. 700.00 Rs. 1,000.00 Rs. 2,500.00
DOS Member Spouse Rs. 1,500.00
DOS Non-member Rs. 600.00 Rs. 800.00 Rs. 700.00
DOS Non-member Spouse
Resident* Rs. 1,200.00 Rs. 1,700.00
* Proof of Residency Required
Rs. 900.00 Rs. 1,100.00

Rs. 400.00 Rs. 550.00

Mail Registration form with Demand Draft/Cheque to: Dr. Jeewan S. Titiyal, Organizing Secretary,
Room No.476, Dr. R.P. Centre for Ophthalmic Sciences, A.I.I.M.S., New Delhi-110029.

January, 2004 326 DOS Times - Vol.9, No.7

DOS QUIZ NO. 7

DOS QUIZ NO. 7

1. Dose of Melhylyprednisolone in traumatic optic neuropalty ............................................................................................
2. Tight lens syndrome is common in which type of lens .......................................................................................................
3. Which anliglaucoma drugs are contra indicated in inflammatory glaucoma .................................................................
4. Most common cause of pupil involving 3rd N palsy is ........................................................................................................
5. Most common Orbital mass lesion in adult ..........................................................................................................................
6. Most common location for Retinoschisis ...............................................................................................................................
7. Most common symptomatic choroidal metastasis ...............................................................................................................
8. Most common cause of 4th nerve palsy in children ..............................................................................................................
9. Most common cause of chronic canaliculitis is ....................................................................................................................
10. Most common corneal stromal dsytrophy to recur in graft is ............................................................................................

Rules:
l Please send your entries to the DOS office latest by 25th December, 2003.
l Prize Rs. 500/- Courtesy: Syntho Pharmaceuticals
l Quiz Trophy will be given to the member who answers maximum number of quizes in a year during the

Annual GBM of DOS.

Answers for the DOS Quiz No. 5

1. Osler’s sign is seen in Alkaptonuria
2. Site of lesions in one and half syndrome PPRF and ipsilataral MLF
3. “Double floor” sign in x-ray skull is found in Pitutary Adenoma
4. “Salmon Patch Haemorrhage” is seen in Sickle Cell Anemia
5. Vogts triad is commonly seen in Acute Angle Closure Glaucoma
6. Most common type of paranasal mucocele Frontal Mucocele
7. pH of Tear film is 7.4
8. Visual field is largest for which colour Blue
9. Best Diagnostic test for “Best Disease” is EOG
10. Corneal ulcer with “cracked wind shield” appearance is caused by Nocardia/Mycobacterium Fortitutum

Winner of DOS Quiz No. 5: Dr. Deepika Seth (Congratulation)

January, 2004 327 DOS Times - Vol.9, No.7

Goodbye Professor Prem Prakash

As the year came to an end a grand era also came to an end, as we laid down the mortal remains of a legend:
Professor Prem Prakash. He was PP for most of us. He was the father figure in Strabismus in India. He was a man
of convictions and courage. He lived his life on his principles. Even God could not deny him his right to leave this
world, in saddle.

He belonged to Solan, Himachal Pradesh and was born on the 8th of August 1936. He had done his MBBS from
Medical College Amritsar (1959) and M.S. in Ophthalmology from Dr. Rajendra Prasad Centre for Ophthalmic Sci-
ences, AIIMS in 1962. He acquired his strabismus training under Prof Cuppers (Professor of Pleoptics) at Giesen,
Prof. Prem Prakash West Germany (1968-69) and got his FDAAD where he also acquired a working knowledge of German.

Not many know that he was a fine cataract surgeon especially for the Smith-Indian tumbling technique for
Intracapsular cataract extraction (ICCE). It was he who was asked to demonstrate this Indian contribution in ophthalmology to the world, to
the august delegates of International Congress of Ophthalmology, Delhi, 1962, where he showed his “Lever-ledge-tumble” principle.

He had his share of struggles in the early part of his life as he served in various capacities as Eye and ENT specialist in Himachal
Pradesh; Registrar at Dr. Shroff’s Charity Eye Hospital, Daryaganj and Ophthalmic Surgeon under the National Society of Prevention of
Blindness-India, before joining his ophthalmic alma-mater at AIIMS as lecturer in 1966. He rose to become a Professor(1985) and Chief of
RPC (1993) before his retirement in August 1996.

Retirement for him however just meant Re-tyre-ment like changing tyres of your car and he was on drive again. He had an active
practice in strabismus, as he worked at MM Eye Tech Institute, Centre for Sight and a clinic in Vikaspuri. After the loss of his life partner, Prem
Kumari, he seemed to have lost the lust for life, but his “work-worship” continued unabated till the last, practising his principle of “Na dainyam
na cha palaayanam” (Neither be meek nor seek escapism).

He was an ardent student of philosopy and was fond of Aurobindo’s works. It was a pleasure to discuss with him on any topic. He was
also an excellent orator and could keep the audience spell-bound in a scientific talk without the props of slides even in today’s era.

His name became synonymous with Strabismus in India. He was the Founder President of the Strabismological Society of India, which
he caringly nurtured. He was also the President of Delhi Ophthalmological Society. He was awarded the P Siva Reddy Oration of All India
Ophthalmological Society. He also edited the Eastern Archives of Ophthalmology, Indian Journal of Orthoptics and Pleoptics and Strabiscope
and was on the Editorial Board of the Indian Journal of Strabismology and Pediatric Ophthalmology.

He is survived by his two sons, a grandson, and thousands of Strabismus fans. His legacy will live on by the examples he set forth by his
practice. He was a legend in Strabismus and his name shall always be imprinted in the hearts of all of us. A small poetic tribute shall
summarise our feelings for him.

At home you may have been Papa – Pradeep Sharma
But were PP for us few.
And all who delved in squint
Saw a father figure in you.

With you in lead we toiled
With you at head we grew.
But a body without a head
So we shall miss you.

With all the cherished thoughts
There is a “pleoptic” hope
To prolong your after-image
Wish there was an “alternascope”.

But, the circle of life rolls
And physically we shall part
We assure you, Sir, forever
You shall have a place in our heart.

As you embark on your final journey
To a future of golden hue
We bid you a tearful farewell
Auf wiedersehen, Adieu!
Good bye dear Professor
A Goodbye to you!

January, 2004 328 DOS Times - Vol.9, No.7

DELHI OPHTHALMOLOGICAL SOCIETY Stamp Size
2 Colour
(LIFE MEMBERSHIP FORM)
Photograph

Name (In Block Letters) _________________________________________________________________________
S/D/W/o _____________________________________________________________ Date of Birth _____________
Qualifications _________________________________________________________ Registration No. __________
Sub Speciality (if any) ___________________________________________________________________________
ADDRESS

Clinic/Hospital/Practice ______________________________________________________________________
_______________________________________________________________ Phone _________________
Residence ________________________________________________________________________________
_______________________________________________________________ Phone _________________
Correspondence ___________________________________________________________________________
_______________________________________________________________ Phone _________________
Email ___________________________________________________________ Fax No. ________________
Proposed by
Dr. _______________________________ Member Ship No. ______________ Signature _________________
Seconded by
Dr. ________________________________ Membership No. ______________ Signature _________________

[Must submit a photocopy of the MBBS/MD/DO Certificate for our records.]

I agree to become a life member of the Delhi Ophthalmological Society and shall abide by the Rules and Regula-
tions of the Society.
(Please Note : Life membership fee Rs. 3100/- payable by DD for outstation members. Local Cheques acceptable,
payable to Delhi Ophthalmological Society)
Please find enclosed Rs.____________in words ______________________________________________________ by
Cheque/DD No.______________________ Dated____________ Drawn on_____________________________________

Three specimen signatures for I.D. Card. Signature of Applicant
with Date

FOR OFFICIAL USE ONLY

Dr._______________________________________________________________has been admitted as Life Member of
the Delhi Ophthalmological Society by the General Body in their meeting held on________________________________
His/her membership No. is _______________. Fee received by Cheque/DD No._______________ dated__________
drawn on __________________________________________________________________.

(Secretary DOS)

January, 2004 329 DOS Times - Vol.9, No.7

INSTRUCTIONS

1. The Society reserves all rights to accepts or reject the application.
2. No reasons shall be given for any application rejected by the Society.
3. No application for membership will be accepted unless it is complete in all respects and accompanied by a Demand Draft of Rs. 3100/- in

favour of “Delhi Ophthalmological Society” payable at New Delhi.
4. Every new member is entitled to received Society’s Bulletin (DOS Times) and Annual proceedings of the Society free.
5. Every new member will initially be admitted provisionally and shall be deemed to have become a full member only after formal ratification

by the General Body and issue of Ratification order by the Society. Only then he or she will be eligible to vote, or apply for any Fellowship
propose or contest for any election of the Society.
6. Application for the membership along with the Bank Draft for the membership fee should be addressed to Dr. Jeewan S. Titiyal, Secretary,
Delhi Ophthalmological Society, R.No. 476, 4th Floor, Dr. R.P. Centre for Ophthalmic Sciences, AIIMS, Ansari Nagar, New Delhi – 110029.
7. Licence Size Coloured Photograph is to be pasted on the form in the space provided and two Stamp/ Licences Size Coloured photographs
are required to be sent along with this form for issue of Laminated Photo Identity Card (to be issued only after the Membership ratification).

Attention DOS Members

Applications are invited for DOS Fellowship for Partial Financial
Assistance to Attend International Conference(s). The last date for
receiving application is 31st January 2004.

For Details Please See Page No. 332.

DOS Election WANTED

Applications are invited from Delhi 1. Ophthalmologist with Excellent Operating
Members of Delhi Ophthalmological Society Skills. (Small Incision Cataract Surgery)
for the post of : Vice President (1 Post)
2. Ophthalmologist to Work in OPD and Camps.
The eligibility criteria for different post
prescribed in DOS Constitution (1998) will Salary Negotiable!!
be followed. Application should be submitted
on a plain paper duly proposed and seconded Following Training Programmes are Offered in
by a member of DOS (not in arrears). Appli-
cation should reach Secretary Office latest by MAHATHMA EYE HOSPITAL
10th February 2004 (2 p.m.). Last date of
withdrawal is 10th March, 2004 (5 p.m.) 1. Fellowship in IOL and PHACO-1 Year.
Election will be held during the Annual DOS 2. Short term Fellowship in General Ophthalmology 3 Months.
Conference on 3rd April, 2004. 3. One Month Phaco Training Programme.
4. Two Month SICS Training Programme
Secretary, DOS 5. One Month SICS Training Programme
6. 15 Days SICS Training Programme

Apply with resumes

For further details contact

Mahathma Eye Hospital

35, 11th Cross,Thillai Nagar, Main Road,
Trichy - 620 018 w E-Mail : [email protected]

( : 2741198, 2740494

January, 2004 330 DOS Times - Vol.9, No.7

DCRS

DOS Credit Rating System (DCRS)

The rate of technological and academic obsolescence tution was the cultivation and promotion of the Science
in Ophthalmology has reached astronomical levels in of Ophthalmology in Delhi.
recent times. What was advanced yesterday may already
be obsolete today. The rapid strides in skills and knowl- In a bid to strengthen our efforts in this direction and
edge have created a need for an extremely intensive fulfil the vision of our society’s founders, DOS announces
Continuing Medical Education programme. the DOS Credit Rating System (DCRS), the details of
which are given below. Our Primary objective is to pro-
DOS has always been in the forefront of efforts to mote value-based knowledge and skills in Ophthalmol-
ensure that its members remain abreast with the latest ogy for our members and give recognition and credit for
developments in Ophthalmology. Among the impor- efforts made by individual members to achieve stand-
tant objectives formulated by the founders of our consti- ards of academic excellence in Ophthalmic Practice.

DOS announces a new era in Continuing Medical Education

DOS CREDIT RATING SYSTEM (DCRS)

(A new chapter in CME)

Credits

1) Attending Monthly Clinical Meeting* † (For full attendence) 10

2) Making Case Presentation at Monthly Meeting** 15

3) Delivering a Clinical Talk at Monthly Meeting** 15

4) Free Paper Presentation at Annual Conference (To Presenter)** 15

5) Speaker/Instructor** in : Monthly Symposium 15

: Mid Term Symposium 15

: Annual Conference 15

6) Registered Delegate at Mid Term DOS Conference 20

7) Registered Delegate at Annual DOS Conference 30

8) Full Article publication in Delhi Journal of Ophthalmology/DOS Times 15

9) Letter to Editor/Correspondence in DOS Times 10

——————————————————————————————————————————————

If any of the presentations is given an Award – Institutional assessment for best performance will
Additional 20 bonus Credits. be based on the total score of members who attend
divided by number of members who attended. In-
Member who have earned 100 Credits, are enti- stitutional assessment regarding decision to retain
tled to: the institute for the next year will be based on total
score by all delegates who attend the meeting di-
a) Certificate of Academic Excellence in Ophthal- vided by average attendence of all 8 meetings.
mic Practice.
Please note that the Institutions’ grading in-
b) 50% exemption of Registration fee at next An- creases if the attendance at its meeting is higher (i.e.
nual DOS Conference. more than the average attendence of the eight
monthly meetings).
c) DOS Travel fellowship for attending confer- ——————————————————————
ence. A member to be eligible for the fellowship * Based on Signature in DCAC
needs to score 100 DCRS points. ** Subject to Submission of Full Text to Secretary, DOS
† Credits will be reduced in case attendence is only for
If any member earns 200 Credits, he/she shall, in part of the meeting.
addition to above, be awarded Certificate of Distin-
guished Resource-Teacher of the Society.

January, 2004 331 DOS Times - Vol.9, No.7

DOS FELLOWSHIP

Delhi Ophthalmological Society Fellowship for Partial
Financial Assistance to Attend Conferences

Conferences Points Awarded
International: Two fellowships per year (two fellowships can
be awarded at a time if committee feels that papers are very 1) Age of the Applicant Points
good)
· Maximum of Rs. 25,000/- per fellowship will be sanctioned a) £ 35 years 10

National: Three fellowships per year (only for AIOS) b) 36 to 45 years 07
· Maximum of Rs. 5,000/- per fellowship will be sanctioned
c) 45 years plus 05
Eligibility:
· DOS Life Members (Delhi Members only) 2) Type of Presentation
· 75 or More DCRS Points
· Accepted paper for oral presentation, poster, video or in- a) Instructor/ Co-instructor of Course 12

struction course. b) Free Paper (Oral) / Video 07

Time since last DOS Fellowship: c) Poster 05
Preference will be given to member who has not attended
3) Institutional Affiliation
conference in last three years. However if no applicant is found
suitable the fellowship money will be passed on to next year. a) Academic Institution 15
Members who has availed DOS fellowship once will not be
eligible for next fellowship for a minimum period of three b) Private Practitioner 20
years.
4) DCRS Rating in the immediate previous year
Authorship
The fellowship will be given only to presenting author. Pre- a) 75-150 05

senting author has to obtain certificate from all other co-au- b) > 150 08
thors that they are not attending the said conference or not
applying for grant for the same conference. (Preference will c) < 75 not eligible for fellowship
be given to author where other authors are not attending the
same conference). If there is repeatability of same author group Documents
in that case preference will be given to new author or new
group of authors. Preference will also be given to presenter · Proof for age. Date of Birth Certificate
who is attending the conference for the first time.
· Original / attested copy of letter of acceptance of paper for
Quality of Paper
The applicant has to submit abstract along with full text to oral presentation / video / poster or instruction course.

the DOS Fellowship Committee. The committee will review · Details of announcement of the conference
the paper for its scientific and academic standard. The paper
should be certified by the head of the department / institu- · Details of both International & National Conferences at-
tion, that the work has been carried out in the institution. In
case of individual practitioner he or she should mention the tended in previous three years.
place of study and give undertaking that work is genuine. The
fellowship committee while scrutinizing the paper may seek · Copy of letter from other national or international agency
further clarification from the applicant before satisfying itself
about the quality and authenticity of the paper. Only Single / agencies committing to bear partial cost of conference if
best paper has to be submitted by the applicant for review (6
copies). Quality of the paper will carry 50% weightage while any.
deciding the final points.
· At least one original document should be provided, that is
Poster and Video
The applicant will need to submit poster and video for re- ticket, boarding pass or registration certificate along with

view. attendance certificate of the conference.

Credit to DOS · Fellowship Money will be reimbursed only after submis-
The presenter will acknowledge DOS partial financial as-
sion of all the required documents and verified by the com-
sistance in the abstract book / proceedings.
The author will present his or her paper in the immediate mittee.

next DOS conference and it will be published in DJO/DOS · Undertaking from the applicant stating that above given
Times.
information’s are true.

· If found guilty the candidate is liable to be barred for fu-

ture fellowships.

Dr. J C Das (President DOS), Dr. Gurbax Singh (Vice Presi-

dent DOS), Dr. Kamlesh (Editor) Dr. Lalit Verma (Library Officer),

Dr. Sudipto Pakrasi (Member) and Dr. Jeewan S. Titiyal (Secretary

DOS) will be the members of DOS Fellowship for Partial Fi-

nancial Assistance to Attend Conferences Committee.

Application should reach Secretary’s office addresses to

President DOS before 31st July and 31st January for interna-

tional conference and before 30th September for national con-

ference. The committee will meet thrice in a year in the month

of August, October and February with in 2 weeks of last date

of receipt of applications. The committee will reply within four

week of last date of submission in yes/no to the applicant. No

fellowship will be given retrospectively, that means prior sanc-

tion of executive will be necessary.

Dr. Jeewan S. Titiyal, Secretary

Delhi Ophthalmological Society

R.No. 476, 4th Floor,

Dr. R.P. Centre for Ophthalmic Sciences

AIIMS, Ansari Nagar, New Delhi – 110029

January, 2004 332 DOS Times - Vol.9, No.7

TEAR SHEET NO. 7

Ocular Side Effects of Systemic Drugs

DRUG POSSIBLE SIDE EFFECTS DRUG POSSIBLE SIDE EFFECTS
Retinopathy of prematurity. Female sex hormones
Respiratory drugs Retinal artery occlusion, retinal vein
Oxygen Tamoxifen occlusion, papilledema. ocular pal-
sies with diplopia. nystagmus, optic
Cardiovascular system drugs neuropathy.

Digitalis Disturbances of color vision, scoto- Crystalline retinal deposits.
mas, photopsia.
Antibiotics
Quinidine Optic neuritis (rare). Chloramphenicol Optic neuritis and atrophy.
Streptomycin Optic neuritis.
Thiazides (Diuretics) Xanthopsia (yellow vision), myopia. Tetracycline Pseudotumor cerebri, transient myo-
pia.
Carbonic anhydrase Ocular hypotony, transient Antimalarial agents
Chloroquine, etc Macular changes, central scotomas.
inhibitors (acetazolamide) myopia. pigmentary degeneration of the
Amebicides retina, chloroquine keratopathy, ocu-
Amiodarone Corneal deposits. Optic neuropathy, lodochlorhydroxyquin lar palsies, ptosis. ERG depression
thyroid ophthalmopathy.
Optic atrophy.
Oxyprenolol Photophobia, ocular irritation.

Gastrointestinal drugs Risk of angle-closure glaucoma due
Anticholinergic agents to mydriasis. Blurring of vision due
to cycloplegia (occasional).
Chemotherapeutlc agents

Central nervous system drugs Sulfonamides Steven Johnson syndrome.

Barbiturates Extra ocular muscle palsies with
diplopia, nystagmus, ptosis, cortical
blindness Ethambutol Optic neuritis and atrophy.
Isoniazid Optic neuritis and atrophy.

Chloral hydrate Diplopia, ptosis, miosis.

Phenothiazines Deposits of pigment in conjunctiva, Heavy metals
cornea. lens and retina. Oculogyric Gold salts
crises Deposits in the cornea and conjunc-
Lead compounds tiva.
Amphetamines Widening of palpebral fissure. Dila- Optic atrophy, papilledema. ocular
tion of pupil. paralysis of ciliary Chelating agents palsies.
muscle with loss of accommodation. Penicillamine
Ocular pemphigoid, optic neuritis,
Monoamine oxidase Nystagmus, extraocular muscle ocular myasthenia.
inhibitors palsies, optic atrophy
Tricyclic agents Dilation of pupil (risk of angle-closure Oral hypoglycemic agents
glaucoma), cycloplegia.
Phenytoin Nystagmus, diplopia, ptosis. slight Chlorpropamide Transient change in refractive error.
blurring of vision (rare). Vitamins diplopia, Stevens-Johnson Syn-
Neostigmine Nystagmus, miosis. drome.
Morphine Miosis.
Haloperidol Capsular cataract. Vitamin A Papilledema, retinal hemorrhages.
Lithium carbonate Exophthalmos, oculogyric crises, loss of eyebrows and eyelashes,
nystagmus. nystagmus. diplopia, blurring of vi-
Diazepam Nystagmus. sion.

Hormonal agents Cataract (posterior subcapsular), Vitamin D Band-shaped keratopathy.
Corticosteroids local immunologic suppression,
causing susceptibility to viral (her- Antirheumatic agents Nystagmus; retinal hemorrhages,
pes simplex), bacterial. and fungal Salicylates cortical blindness (rare).
infections; steroid-induced glau-
coma. Indomethacin Corneal deposits.
Phenylbutazone
Retinal hemorrhages.

– Deven Tuli, MD

Dr. R.P. Centre, AIIMS, New Delhi-110029

January, 2004 333 DOS Times - Vol.9, No.7