dos_feb_2004

DOS TIMES CONTENTS

Editor-in-chief EDITORIAL .................................... 341 w Anterior and Posterior Capsule
Dr. Jeewan S. Titiyal Staining in Pediatric Cataract
MANAGEMENT PEARLS Surgery ........................................ 358
Associate Editors w Soft Toric Contact Lens Suresh K Pandey, David J Apple, Taketoshi
Dr. Harish Pathak Wakabayashi, Narumichi Yamamoto
Dr. Harminder K. Rai Fitting .......................................... 342
Dr. Vijay B. Wagh Jeewan S. Titiyal, Jaswant Arneja, w The Sociology of Strabismus .... 363
Ramkishor Sah, Rajesh Sinha Prof. Prem Prakash
Editorial Advisers w Practical Aspects of Fitting
Dr. K.P.S. Malik Soft Toric Lenses ........................ 346 ART OF REFRACTION
Rajesh Wadhwa
Dr. Pradeep Sharma w Difficult Situations of
Dr. Ramanjeet Sihota CURRENT PRACTICE Refraction .................................... 367
w Pars Planitis ................................ 349 Monica Chaudhary, Jeewan S. Titiyal
Dr. Ritu Arora
Dr. Dinesh Talwar Sanjeev Nainiwal S.P. Garg, H. K Tewari COLUMNS
w Vision 2020 : The Right to
Special Correspondents w Journal Abstracts ....................... 371
Dr. Ajay Aurora Sight ............................................. 351 w Forthcoming Events .................. 372
G. V. S. Murthy MD, Sanjeev K. Gupta, w DOS Quiz No. 8 .......................... 375
Dr. Rajib Mukherjee Praveen Vashist
Dr. Anita Sethi
REVIEW TEAR SHEET-8
Dr. Devender Sood w Chemotherapy of
Dr. Pradeep Venkatesh w Sudden Loss of Vision
Retinoblastoma .......................... 353 Revised ........................................ 379
Coordinators Sameer Bakhshi Satya Karna
Dr. Anurag
Dr. Anand Keep April 3-4, 2004 Free for
Dr. Madhusudan
Ms. Monica Choudhry ANNUAL CONFERENCE
Dr. Pranav D. More
of
Published by
Dr. Jeewan S. Titiyal Delhi Ophthalmological Society

for
Delhi Ophthalmological Society

Printed by
Computype Media
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Website : www.dosonline.org

February, 2004 339 DOS Times - Vol.9, No.8

February, 2004 340 DOS Times - Vol.9, No.8

EDITORIAL

Dear, racts as highlighted by Suresh Pandey deed a proud moment for all of us.
colleagues, et al. Infact the last 3 Presidents of AIOS
have been members of our society.
The use of The growing importance of chemo- This reflects the widespread popular-
dyes in various therapy in management of Retino- ity of our organization, its growing
surgical proce- blastoma was recently highlighted in stature and its professionalism. I am
dures has ma- the ICOO at Hyderabad and the ar- sure that in years to come DOS will
de surgeons ticle by Dr. Bakshi highlights the prac- continue to do well and maintain the
life much eas- tical aspects very well. high standards for which we are
ier especially known for.
in performing cataract surgery in In the end I would like to congratu- Thank you,
white cataracts. The use has also been late one of our senior members Dr.
extended to staining of anterior and R.B. Jain for winning the post of Vice Dr. Jeewan S. Titiyal
posterior capsule in pediatric cata- President at the recently concluded Secretary, DOS
AIOS conference at Varanasi. It is in-

Keep April 3-4, 2004 Free for

ANNUAL CONFERENCE

Delhi Ophthalmological Society

Programme for DOS Monthly Clinical Meeting for February 2004

Venue: Ground Floor, Lecture Theater, M.A.M.C., New Delhi
Date & Time : 28th February, 2004 (Saturday) at 2.30 P.M.

Case Presentation

1. Proptosis in a Child ....................................................................... Dr. Laxmi Narain 10 Mins.

Discussant: Dr. Meenakshi Thakkar

2. Proptosis in an Adult..................................................................... Dr. Swarn 10 Mins.

Discussant: Dr. Usha Yadav

Clinical Talk 20 Mins.
l Diabetic macular oedema ............................................................. Prof. D.K. Mehta

Mini Symposium: Pre-empting complications in ophthalmic surgery 10 Mins.
Chairman : Prof. D.K. Mehta 10 Mins.
10 Mins.
Co-Chairman : Prof. Kamlesh 10 Mins.
1. Cataract/Phaco............................................................................... Guest Speaker 10 Mins.
2. Retina ............................................................................................... Dr. B. Ghose 10 Mins.
3. Glaucoma ........................................................................................ Dr. J.C. Das
4. Ptosis ................................................................................................ Dr. Sushil Kumar
5. Squint ............................................................................................... Dr. P.K. Pandey
6. Cornea ............................................................................................. Dr. Ritu Arora

Panel Discussions : 10 min.

February, 2004 341 DOS Times - Vol.9, No.8

MANAGEMENT PEARLS

Soft Toric Contact Lens Fitting fit of the lens by assessing
the complete corneal cover-

age in all gaze positions,

Jeewan S. Titiyal1 MD, Jaswant Arneja2 MS, Ramkishor Sah1 B.Sc. (Hons.) Ophth. centration, adequate move-
ment (within 0.20 -
Rajesh Sinha1 MD, FRCS
0.40mm), good patient com-

fort and excellent & stable

visual acuity after each

Almost 50% of people re- like for fitting spherical 8.60mm. Now, you have blink. It is not always pos-

quiring optical correction lenses there is no need to do the spherical and cylindri- sible to show full vision to

have significant amount of spherical equivalent in toric cal power as well as the a patient, as trial lens axis

astigmatism that is 0.75 Dc fitting. base curve of the trial lens. and power might not match

or more. Correction of to that of spectacle.

astigmatism with contact Step - 2: The vertex distant Step - 4: Trial lens

lenses can be effectively compensation (VDC) Toric trial lens sets usu- Step - 6: Axis finalization

achieved by rigid gas per- The VDC of the sphere ally have six lenses with dif- If the above steps are

meable lenses and toric con- and cylinder are separately ferent cylindrical axis and fine then axis finalization is

tact lenses. In regards to done e.g. if the spectacle base curve (table - I). done. For finalization of the

soft contact lenses, toric number / refraction is - Choose a trial lens as close axis, the practitioner

lenses are required if the 6.00Ds / -2.00Dc x 1800, as possible to the spectacle should concentrate on the

astigmatism is more than change it to -5.75Ds / - cylinder axis (i.e. 1800 for laser marks on the toric

1.00Dc. Which may not get 1.75Dc x 1800. case - 1). lens. The rotation of a lens

corrected simply with The prescription of ocu- Trial lenses for case -1 with reference to laser

spherical lenses. lar refraction is converted will be - 3.00Ds/ -1.75Dc X marks can be measured by

Soft toric lenses are now into cross-cylinder form 1800 / 8.6mm. Fit this se- the following methods.

available at lower costs, and then transferred to cor- lected trial toric lens on a. The slit-beam rotation on

greater reproducibility, en- neal plan (final lens power/ patient's eye and wait for the slit lamp

hanced parameters & com- compensate effective pow- 15-20 minutes before as- b. Estimation of rotation of

fort. Because of innovations er if more than +/- 4.00D in sessing the fit. axis marks itself

and significant design any meridian) by the help of c. Graticule of the eye piece

changes, a greater percent- conversion chart. Step - 5: Fitting assess- (slit lamp protractor)

age of astigmatic patients d. With the help of trial

are treated by soft toric - 800 - 7.37 = - 7.50 frame
lenses than before. Three situations can hap-

For a successful fitting of - 6.00 - 5.62 = -5.75 pen with the toric lens ro-
soft toric contact lenses, prac- tation:

titioner needs to follow Cross – Cylinder form) (Corneal plane power) (a) No rotation or mini-

the following steps: mal rotation of 50 degrees.

Step - 3: Base-Curve ments Fig - 1 (No rotation)

Step - 1: Refraction Base-curve of toric lens is The fit of soft toric con- (b) Rotation to Left Hand

A manifest cycloplegic determined by doing tact lenses is same as that of side (with reference to the

refraction with best-cor- keratometry or video spherical soft lenses. Assess practitioner). Fig - 2 (Left

rected visual acuity, cylin- keratography. If K-reading

der in minus form e.g. - is 7.6mm (Horizontal) and [Table - I]
5.25Ds / + 2.25Dc x 900, 7.80mm (Vertical), add

this prescription should be 0.80mm (normal range = Different Power Axis Base - curve
changed to - 3.00Ds / - 0.60 - 0.80mm) to the flat- -3.00Ds/ -1.75Dc X 900 8.30mm
2.25Dc x 1800 (case-1). Un- ter meridian (or the highest

reading in mm). In the -3.00Ds/ -1.75Dc X 1800 8.30mm

1. Dr Rajendra Prasad Centre for above case 7.80mm is flat- -3.00Ds/ -1.75Dc X 900 8.60mm
Ophthalmic Sciences, AIIMS, ter (higher) than 7.60mm, -3.00Ds/ -1.75Dc X 1800 8.60mm
New Delhi hence 7.80mm + 0.80mm = -3.00Ds/ -1.75Dc X 900 8.90mm
2. Nayantara Eye Centre, New Delhi 8.60mm. The base curve of -3.00Ds/ -1.75Dc X1800 8.90mm
the trial lens will be

February, 2004 342 DOS Times - Vol.9, No.8

MANAGEMENT PEARLS

rotation or clockwise rota- Fig.1 patient to avoid lens
tion - CA) damage.
SPHERICAL TORIC w While removal the pa-
(c) Rotation to Right tient should either pinch
Hand side (with reference Fig. 2: LEFT ADD the lens from the center
to the practitioner). Fig - 3 or else rotate.
(Right rotation or Fig. 3: RIGHT SUBTRACT
Anticlockwise rotation - Handling tips:
AS) / -2.25Dc X 1700. Ø Choose trial lens axis as w Instill lubricating or

A simple formula for fi- Step - 7: Lens dispensing close as possible to the rewetting drops into the
nalization of toric axis is LA After axis finalization eye just prior to removal
- RS (Left Hand Rotation - spectacle axis. of contact lens.
ADD & Right Hand Rota- the final toric lens order is w Rotate the lens in the eye
tion - SUBTRACT) or/ CA- given to the manufacturers. Ø If the trial lens axis and slightly to either side (off
AS (Clockwise Rotation- axis) before removal of
ADD & AS (Anticlockwise Key Points: spectacle axis are differ- the lens.
Rotation - SUBSTRACT) Ø After equilibration for 15- w Rub the lens with linear
20 minutes, a trial lens ent, then don't attempt motion during cleaning
Case - 1 : shows unpredictable rota- (avoid circular motion)
Spectacle number - tion or mislocation greater over-refraction as it can
than 300, a base curve Dispensing and follow-Up
300Ds / -2.25 X 1800, the change, a larger diameter, lead to confusion. care:
trial toric contact lens cho- or a different type of toric w Instruct the patients re-
sen was (-3.00Ds / -1.75Dc lens should be considered. Ø Final lens base curve
X 1800). Ø Small degree of mislo- garding proper wear and
should be the same as care procedures.
Situation: I cation (00-50) is accepted w Schedule visits at 3 days,
If you observe no rota- by most patients espe- trial lens base curve. 10 days, 1 month, 3
cially if cylindrical months, and every 6
tion or minimal rotation of power is less or equal Ø Like a trial toric lens, fi- months.
50 after a blink. than 2.00Dc. w Have the patients wear
Ø Don't make any changes nal lens would also show their lenses at least 4
Results: There is no in trial lens axis. hours prior to visit.
change required in the axis. Ø Trial lens (Diagnostic similar rotation. w Evaluate visual acuity,
Hence the axis of the pre- lens) fitting is very reli- lens fit and complete slit
scription will remains same able and scientific meth- Ø Do best refraction and lamp examination.
as spectacle prescription ods of fitting toric lens. w Discuss and reinforce
i.e. -3.00Ds / -2.25Dc X don't assess visual acuity proper patients compli-
1800. ance.
with trial lenses, to avoid Wear modality and Re-
Situation: II placement schedule:
If you observe rotation to dissatisfaction by pa- w Recommended for daily
wear only
Left Hand side or Clock- tient. Record visual acu- w Monthly or more fre-
wise rotation by 100. quent replacement ac-
ity only after the final cording to patient re-
Results: Add 100 to the quirement.
spectacle axis (according to lens is dispensed.
rule # LA-RS). Hence the FAQs:
new prescription becomes - Care and maintenance of 1Q. Are soft toric contact
3.00Ds / -2.25Dc X 100. these lenses: lenses as comfortable as
w Similar to standard soft regular soft contact
Situation: III lenses?
If the rotation is 100 to contact lenses.
w Proper insertion & re- A. Yes! Soft toric lenses
Right Hand side or are made of exactly the
Anticlockwise. moval to be taught to the

Results: Subtract 100 to
the spectacle axis (LA-RS
rule). Hence the new pre-
scription becomes -3.00Ds

February, 2004 343 DOS Times - Vol.9, No.8

MANAGEMENT PEARLS

Available power range: SL -66 Toric (Monthly disposable) not quite as good as vision
Optima Toric (Daily wear) with glasses, but it is still
better than vision with non-

Spherical: Plano to -9.00Ds (in 0.25 steps) Spherical: Plano to -9.00Ds (till -600 in 0.25 toric soft lenses.
Cylindrical: -0.75 to -3.25Dc (in 0.50 steps) steps & -6.00 to -9.00 (in 0.50 steps)

Axis: 700, 800, 900, 1000, 1100, 1600, 1700, 1800, Cylindrical: -0.75, -1.25, -1.75, -2.25 5Q. Can I go home with my
new toric lenses today?
100, 200. Axis: 100 to 1800 (in 100 steps)
A. Possibly, but may be
Base-curve: 8.30, 8.60, 8.90 Base-curve: 8.50

not. Because they are

same comfort produc- Few examples of toric lense following: more complex than

ing gel materials as Example –1 regular lenses and

regular soft contact Spectacle Prescription : - 6.00Ds/ - 3.00Dc x 1800 8.6mm are available in so

lenses. As with regular Vertex Distance : - 5.50Ds/ - 2.50Dc x 1800 8.6mm many different

soft lenses, oxygen can Trial lens : - 3.00Ds/ - 1.25Dc x 1800 8.6mm power combinations,

pass through toric soft Rotation to R.H.S by 150 toric lenses have to

lenses, allowing the Subtract : 1800 – 150 = 1650 be custom fit to your

surface of the eye to Final lens prescription : - 5.50Ds/ -2.50Dc x 1650 8.6mm eyes. First, the right
"breathe". Example – 2 fit has to be found. In
Spectacle Prescription : - 0.00Ds/ - 2.00Dc x 1600 8.6mm many cases, new
2Q. Can someone who Vertex Distance : - 0.00Ds/ - 2.00Dc x 1800 8.6mm lenses must be or-
has astigmatism and Trial lens : - 3.00Ds/ - 0.75Dc x 1800 8.6mm dered to your precise
is nearsighted (or far- Rotation to L.H.S by 100 specifications. When
sighted) wear a toric Add : 1600 + 110 = 1700 8.6mm the lenses arrive, the
lens? : - 0.00Ds/ -1.75Dc x 1700 fit and quality of vi-
Final lens prescription sion will be checked
A. Yes. A toric con- Example – 3 : - 3.00Ds/ - 1.75Dc x 200 8.3mm on your eyes before
tact lens can correct ei- Spectacle Prescription : - 3.00Ds/ - 1.50Dc x 1800 8.3mm the lenses are dis-
ther nearsightedness Vertex Distance : - 0.00Ds/ -1.25Dc x 1800 8.3mm pensed to you. The
or farsightedness at Trial lens process can usually
the same time it cor-

rects astigmatism. No Rotation be completed in a

3Q. How do soft toric Final lens prescription : - 3.00Ds/ -1.50Dc x 200 8.3mm few days.
contact lenses differ Example – 4
from regular soft con- Spectacle Prescription : - 1.00Ds/ - 3 .00Dc x 1200 8.3mm 6Q. What about
tact lenses? Vertex Distance : - 1.00Ds/ - 2.75Dc x 900 8.3mm cost?
Trial lens : - 2.00Ds/ -0.75Dc x 1800 8.3mm
A. Regular soft con- Rotation to R.H.S by 100 A. Because toric
tact lenses have only Subtract : 1200 – 100 = 1100 contact lenses are
one curvature for cor- Final lens prescription : - 1.00Ds/ -2.75Dc x 1100 8.3mm more difficult to
recting vision. Toric make and take more
time to fit, contact

lenses have two cor- lens fitting fees tend

recting curvatures. Regular lenses is comparable to vi- are some cases in which vi- to be higher than for single

soft contact lenses freely ro- sion with eyeglasses. There sion with toric soft lenses is vision contact lenses. The

tate while being worn. Soft

toric lenses are designed to
fit on the eye like a hand in Different brands of soft toric contact lenses:

glove and therefore should Name Type Approximate price (Rs.)
not rotate.

a. Optima Toric B&L (Standard) Daily wear 3500 - 3800/ - (One pair)

4Q. How well will I see b. SL Toric - 66 B&L (Standard) Disposable 5500 - 6000/ - (12 - Pairs)
with soft toric contact Focus Toric (Ciba-Vision) Disposable 6000 - 6400/ - (12 - Pairs)
lenses? Acuvue Toric (J&J) Disposable Not available in India.
Silk Lens (Custom made) Daily Wear 2500 - 3000/- (One pair)
A. Quite well indeed. Flexon Toric Purecon (Custom made) Daily Wear 3500 - 4000/- (One pair)
Studies have found that vi-
sion with toric soft contact

February, 2004 344 DOS Times - Vol.9, No.8

MANAGEMENT PEARLS

lenses themselves also tend variety of colors. However, A. a. In toric lenses, espe- Edward S. Bennett, Paul Blaze,
to cost more than single vi- the choice of colors may be cially back surface torics Melvin R. Remba: Correction
sion lenses. more limited than with have a tendency to stick of astigmatism. 351: 409.
regular lenses. very close to the cornea on 2. Terry R. Scheid: Clinical
7Q. Are there alternatives slightest dehydration. Thus, manual of specialized contact
to soft toric contact 10Q. Why Left-hand rota- rotating the lens off-axis re- lens prescribing. Howard B:
lenses? tion / Clockwise rotation moves this strong apposi- Toric (Astigmatic) soft contact
(ADD) & Right-hand rota- tion and results in easier re- lenses. Chapter - 3.
A. Yes. Sometimes, when tion / Anti-clockwise rota- moval. 3. Anthony J. Phillips, Janet
the amount of astigmatism tion (SUBTRACT)? Why Stone: Contact lenses - A text
is small, a regular soft con- not vice-versa? b. To avoid any damage book for practitioner and Stu-
tact lens will "mask" the of laser marking of the toric dent (Third edition).
astigmatism, and a toric A. Why LARS! Visualize lenses at 6'o clock. 4. Gerald E. Lowther: Contact
lens won't be needed. the standard notation of lenses - Procedure and tech-
Greater amounts of astig- axis. If we rotate lens clock- References: niques.
matism can be corrected by wise, we have gone to lesser 5. Barry A. Maltzman: Soft toric
toric soft contact lenses, value of axis e.g. if for ex- 1. Edward S. Bennett, Vinita contact lenses for astigmatism.
eyeglasses, or rigid contact ample, the inferior lens Allee Henry: Clinical manual CLAO 1994-2003. Websits:
lenses. To great advantage mark of an axis 900, lens ap- of contact lenses (3rd edition). www.contactlensdocs. com
of toric soft lenses over rigid pears to rotate 100 to the left,
contact is comfort. then it is effectively aligned In Glaucoma
along 800. To compensate
8Q. Can I get an extended for this we should add 100 Perimetry: Basics, single field and
wear soft toric lenses? and order a lens with 1000 followup. Interpretation, analysis and
(900 + 100 = 1000) such that application in day to day clinical situations
A. Yes. Extended wear after 100 clockwise rota-
soft toric lenses are avail- tions, the lens will actually .
able. You can even get dis- reach the desired 900. The
posable extended wear soft same principles apply if ro- Newer imaging techniques : basics and
toric lenses and planned re- tation is to the right, but interpretation : Utility in diagnosis and
placement daily wears soft lens rotation must be sub- followup
toric lenses. But most prac- tracted to obtain the cor-
titioners prefer daily wear rect axis.
disposable lenses.

9Q. What about different 11Q. Why off axis removal Groups of Ten Each
On Sunday :
colors? is most essential in soft
February 8, 2004
A. Toric lenses come in a toric lenses?

OBITUARY Contact:
Dr. Devindra Sood
Dr. J.S. Saini, who left for heavenly abode at Glaucoma Imaging Centre
Chandigarh. We pray for the peace of the P-13, South Extension Part II
departed soul. New Delhi 110049
Tel: (011) 26257803 : 26252000

ATTENTION DOS MEMBERS

DOS members are requested to send us their suggestions or resolutions to be dis-
cussed in the general body meeting to be held on 6th April 2004. These will be dis-
cussed first in the executive meeting and then forwarded to General Body Meeting.

– Secretary DOS

February, 2004 345 DOS Times - Vol.9, No.8

MANAGEMENT PEARLS

Practical Aspects of Fitting Soft Toric Lenses

Rajesh Wadhwa, B.Sc.Hons

We all know that toric keratometery or topogra- surface toric lens (back sur- have used various styles in
soft lenses exist. We also phy, the refractive astigma- face toric is in close apposi- scribe marks. These could be
know that they are easy to tism is measured simply by tion with corresponding l In the form of dots or
fit. Then what are the doing refraction. corneal toricity and thus lines
“tricks” that work? This has a natural stabilizing ef- l Single or grouped.
short write-up is just to We must identify where fect without significant l At 6 o’clock
sharpen the skills that the the astigmatism is residing, elastic distortions). l At 0-180 degree merid-
readers already have. It in order to choose a correct ian:
would be realized that most toric lens design and to 2) Since the refractive
of the so-called “tricks” are know how much a toric lens indices of cornea and the These scribe marks are
only a re-look at the already will help. contact lens are not equal, visible to the naked eye and
known facts. the same curvature in the better still with a slit lamp.
A soft toric lens can be two media (cornea and con- We can assess the rotation
We can use our skills to toric on front surface or tact lens) induces different of the lens by experience or
create a successful soft toric back surface or rarely on powers. This can cause “in- by quantitative assessment.
practice. Now let’s get go- both surfaces. duced astigmatism”. The latter can be done by
ing right from the base line. u If corneal astigmatism having a graticule in the
=refractive astigmatism The latter concern about eyepiece or by reading the
First and foremost is to “induced astigmatism” has slit-beam scale of the slit
know the purpose of toric Implies total astigma- only one practical applica- lamp.
fitting. In hard lenses, the tism is corneal= prefer to tion. The cylindrical power
main purpose is to improve use back surface toric of the toric contact lens will The rotation of the lens is
physical fitting by using u Corneal astigmatism > correct approximately 10- depicted by simple conven-
toricity on the back surface. refractive astigmatism tion. This is best understood
The soft lens is made toric by the example given here:
mainly to provide good vi- The cylindrical power of the toric
sion. contact lens will correct approximately When we say, “the lens
has rotated to the right”, we
We know that astigma- 10-15% more astigmatism than what mean
tism can be on the anterior is the cylindrical power · The right is of the ob-
corneal surface or may be
resident due to deeper lay- Implies astigmatism 15% more astigmatism than server and not of the
ers of the refractive compo- partly neutralized by lens what is the cylindrical wearer
nents. When the astigma- =use front toric power. · The 6 O’clock position of
tism is not on the anterior u Corneal astigmatism < the lens has rotated to the
corneal surface, it is called refractive astigmatism The first issue of stabiliz- right i.e. an anti-clock
lenticular astigmatism ing the lens (in real words, wise movement
(even if it is not because of Implies lenticular astig- holding it in the correct axis The simple rule of LARS
the lens). matism (try to neutralize orientation) is achieved by works the best. An example
with induced astigmatism various adjustments in the explains this well:
For our purpose here, the or use bitoric) lens geometry. This may be Suppose the axis re-
“corneal astigmatism” is achieved by making the quired is 160o
“anterior corneal astigma- The selection of the lens lens prism ballast or thin If the scribe marks at 6
tism”. The total astigma- design (front or back toric) zones or any other method. O’clock rotate 100 to the
tism is the refractive astig- is usually limited to front- We are “served in the pat- right, following the LARS
matism. While the corneal surface toric since it will ter” with scribe marks that rule, we should subtract 10o
astigmatism is measured by correct most of the astig- give us indication of how from the original axis of
matisms. well the contact lens is ori- 160o. Thus we get a value of
55, Main Market, Kalkaji, ented. 150o . We shall order a new
New Delhi-19 The main concerns now contact lens with axis at
E-mail: [email protected] are Different companies 1500 . It is important to con-

1) To stabilize a front

February, 2004 346 DOS Times - Vol.9, No.8

MANAGEMENT PEARLS

0-180 degrees axis marking 6’o Clock marking with sup- lution over the worn lens 1.62D
porting 10/30 degrees mark- (most of the multipurpose Thus the correct
firm that the new lens locates ings on either side solutions available in India
exactly as much rotated as the can be used for the pur- vertexed power is: <=>-
original lens. If this is Practical tips while doing pose) 7.37/-1.62
achieved, the lens will effec- over-refraction (with first · Rotating lens === Here
tively be at the right axis trial lens inserted) we need to recalculate or World over, toric lens fit-
now. Scribe marks are not recheck compensation for ting is successful upto 83%
the axis meridian but are If we encounter: rotated trial lens in best of hands and proce-
only indicative if the axis · Plain cylinder at original If previously successful dures.
meridian is in correct align- patient returns and com-
ment. axis=Under/over cor- plains of blur: In our clinic we have
rection · The most common cause about 95% success rate be-
Steps in Fitting Torics · Cross cylinder = wrong is switched lenses (right cause we filter our patients
axis lens in left eye & vice before fitting. Following is
The steps listed here are · Every 10 degrees mislo- versa) a guide to selecting the
cation = residual cylin- · Dry lens is also common right soft toric lens patient
according to the resource der is 1/3 of lens cylin- The vertex distance calcu- (assuming that there is no
der power lation: medical condition that is
available in India. · 30 degrees mislocation One of the most practical contraindicative):
implies that residual cyl- errors is the way we calcu- · First & foremost see the
· After preliminary ex- inder is same as lens cyl- late vertex distance com-
inder power pensation of a toric lens. ratio between sphere and
amination and However, if the mislo- If we go by sphero-cylin- cylinder in the refrac-
cation is as large as 30 de- der form, usually the em- tion. Assess if the ratio of
keratometry of the eye, grees, it is advisable to pirical calculation is Sph.: Cyl is better or
choose a new lens design. wrong. A cross cylinder equal to 4:1 e.g. In case a
perform refraction form is more accurate for patient has a refraction
Practical tips during fol- vertex-distance compensa- of -6.00/-2.00, the total
· Transpose into minus low-up visit tion. We can understand power ratio of Sph:Cyl=
this with a simple example: 3:1. Being lesser than 4:1,
cylinder form A well-fitted toric soft If we take a spectacle this is a fit case for torics.
contact lens shows all the lens power as –8.00/2.00, In case the refraction is –
· Choose the trial lens sim- features of well fitted the vertxed power (for 12 6.00/-0.50, the ratio of
spherical soft contact lens mm) is as follows: Sph:Cyl is now 12:1, such
ply by using vertex dis- and also should not rotate · 8.00DS-7.37D a case is expected to do
more than 5 degrees on · 2.00 DS-2.00D well with a regular
tance correction (as de- blinking Therefore we get the cal- spherical lens. The rule is:
culated contact lens power consider the patients for
tailed later in this article). If the patient complains of as –7.37/-2.00 and this is toric fitting if cylinder
consistent blur, this is indica- wrong. power is equal to or more
·· Insert the trial lens (usu- tive of one of the following: than 20% of the total
· Dirty lens === Usually The correct calculation is power. Less than 20% cyl-
ally given free of charge (by cross cylinder method) inder is expected to per-
needs cleaning with good form well with spherical
by most manufacturers) digital rubbing only Take the net power in soft contact lens
· Dry lens === Just instill a two meridians. One merid- · Existing RGP wearers
· Do over-refraction to few drops of rewetting so- ian is having a total power with good corrected vi-
of –8.00D and other is hav- sion will usually not like
find out best vision ing a total power of – the toric soft contact
10.00D (derived as 8+2) lens.
prescription · Patients with very low or
<=>-8.00D is -7.37D zero spherical compo-
· Assess the alignment <=>-10.00D is -9.00 nent in a cylindrical re-
The cylindrical power fraction will often re-
and calculate any cor- therefore will be (9.0-7.37=) spond poorly to torics.
· Toric soft contact lens
rection required as does not work well in ir-

per LARS technique.

· Order another lens (ex-

pected to be the final

lens)

· Reassess

February, 2004 347 DOS Times - Vol.9, No.8

MANAGEMENT PEARLS

regular astigmatism cylinder at 180 degrees or a many toric brands. Toric lens fitting is a spe-
· Uniocular patients usu- +cylinder at 90 degrees) Let’s choose the right pa- cialty work and it enjoys the
astigmatism, the lens has proportionate level of grati-
ally do not enjoy toric thickest top & bottom tients, right contact lens fication and respect from
lenses due to inherent zones. This means that and then dispense well-fit- successfully fitted patients.
fluctuations in visual with every blink lids try to ted toric soft contact lenses
performance with every rotate it horizontally. This to reap the fruits.
blink (in binocular: one makes the success rate low.
eye covers up for the Attention DOS Members
other during the blink Inference is: there is
dynamics) higher success rate when The Hi-tech DOS Library has started functioning
toric lenses are fitted in on Ground Floor, Dr. R.P. Centre, Delhi Oph-
Key points: “against the rule “astigma- thalmic Sciences, AIIMS, New Delhi-110029 rom
If the axis of kerato- tism and low success is en- 12.00 Noon to 9.00 P.M. on week days and 10.00
countered in “with the rule A.M. - 1.00 P.M. on Saturday, Sunday. The Library
metric meridian is different astigmatism”. will remain closed on Gazetted Holidays. Mem-
from refracted axis: Pre- bers are requested to utilise the facilities available
scribe the refractive axis New introductions: i.e. Computer, Video Viewing, Latest Books and
Since we had a mini- Journals. We are planning to subscribe two jour-
In order to find the re- nals. Member can give suggestion in this regard.
sultant cylinder when mum cylindrical power of
over-refraction shows axis 1.00D until recent past (in Dr. Lalit Verma
different from trial lens fit- ready lens stock), practitio-
ted :Put the same combina- ners had opted out of fitting Library Officer, DOS
tion in the trial frame and 0.5D or 0.75D astigmats
read the net power from len- (e.g. –1.00/-0.75 refrac-
someter. tion). New avenues have
opened with 0.75D Cyl
We know from lens ge- power now available in
ometry that in case of
“with the rule” (i.e. minus

Shroff Hospital

February, 2004 348 DOS Times - Vol.9, No.8

CURRENT PRACTICE

Pars Planitis presence of a snowbank in Pattern 2 patients. Patients
the pars plana region infe- with Pattern 3 disease have

riorly is very characteristic. a chronic smoldering uvei-

Sanjeev Nainiwal MD, DNB, S P Garg MD, Peripheral retinal phlebitis, tis with one or more exac-
Hem K Tewari MD neovascularisation of the erbations.
vitreous base may be seen in Macular involvement is

these patients. Disc edema probably the most impor-

is common in children tant prognostic factor as far

Pars planitis is an idio- or hyperopic shift due to while CME is common in as the visual acuity is con-

pathic syndrome consisting macular edema, hypotony, adults. Vitreous hemor- cerned. Twenty percent of

of intraocular inflamma- or change in lens position), rhage and posterior vitre- the patients of intermediate

tion involving the periph- or opacities in the visual ous detachment may also be uveitis have a chance of de-

eral retina, pars plana & the axis from inflammatory associated with pars veloping multiple sclerosis

vitreous. It has been de- cells, fibrin or protein in the planitis. Complications like or optic neuritis during 5

scribed as chronic cyclitis years period.

(Fuchs, 1908), peripheral Pars planitis is usually a bilateral dis- Management
uveitis (Schepens, 1950), ease (70-80%) presenting mainly in the The management of Pars
pars planitis (Welch, 1960),
chronic cyclitis (Hogan, first three decades of life. planitis begins with a good

1961), and intermediate clinical history and proper

uveitis (IUSG, 1987). anterior chamber, keratic retinal detachment, glau- examination with the help

Pars planitis is a subtype precipitates, or secondary coma, band shaped of a slit lamp, 3-mirror fun-

of intermediate uveitis with cataract1. Photophobia and keratopathy, macular het- dus biomicroscopy and

associated vitritis and cys- increased lacrimation oc- erotopia may occur in the good indirect

toid macular edema (CME). curs when iris, cornea or course of the disease. opthalmoscopy with scleral

The reported incidence of iris-ciliary body complex is Smith et al have de- indentation.

intermediate uveitis is 4.6% involved. These patients scribed clinical course and Laboratory workup is

to 15.4% of all uveitis cases may rarely present with progression of disease in aimed to differentiate un-

in a referral hospital but it sudden loss of vision sec- three patterns2. Pattern 1 derlying systemic diseases

may be higher because of its ondary to vitreous hemor-

indolent nature. rhage due to bleeding from The most common presentation of pars

Pars planitis is usually a a vascularised ‘snow bank’. planitis is mild, painless blurring of
bilateral disease (70-80%) Significant loss of vision vision with floaters and photophobia.
presenting mainly in the may occur due to cystoid

first three decades of life. macular edema (CME) or

The exact cause of the dis- disc edema. patients (10%) have a self- & to rule out an infectious

ease is not known but may On examination, the eye limiting course with no ex- cause. These include Com-

be linked to HLA due to its is typically quiet with mild acerbations. A prolonged plete blood count (CBC),

immunological susceptibil- anterior chamber reaction. course without exacerba- ESR, Chest X-ray, Mantoux

ity. There may be few keratic tions (59%) constitute the test for tuberculosis; angio-

precipitates, peripheral an-

Clinical features terior synechiae, minimal Table 1: Four-step approach to treat pars planitis

The most common pre- flare and cells. A compli-

sentation of pars planitis is cated cataract, at the initial Step 1: Corticosteroid alone: Mainstay of treatment
mild, painless blurring of presentation, is not an un- Step 2: Cryotherapy of the vitreous base: Patients who
vision with floaters and common finding. Retrolen-
photophobia. Blurred vi- tal flare & cells are usually fails to respond to steroid therapy for 6 months.
sion may be because of re- present. Also a useful alternative in patients who show
fractive error (e.g. myopic intolerance to steroid therapy
Most of the findings are Step 3: Therapeutic pars plana vitrectomy: Patients
Dr. Rajendra Prasad Centre for in the vitreous. Vitreous with complications like vitreous hemorrhage,
Ophthalmic Sciences, cells and snowballs com- vitreous membranes etc.
All India Institute of Medical posed of intact & degener- Step 4: Immunosuppressive agents: Patients who are
Sciences, New Delhi – 110029 ated macrophages are the not responding to steroids and cryotherapy.
hallmark of the disease. The

February, 2004 349 DOS Times - Vol.9, No.8

CURRENT PRACTICE

The presence of CME is an indication for Cryotherapy is indicated in tial to ensure favorable re-
cases not responding to ste- sults. Only those cases with
treatment; the other indications for roids or immunosuppre- a history of recurrent inter-
mediate or posterior uveitis
therapy are visual acuity below 6/12 & ssives and is directly ap- treated repeatedly with oral
plied to the or peribulbar steroids
severe floaters in patients with a visual neovascularized snowbank should be considered for
this mode of treatment.
acuity of 6/12 or better. at the vitreous base. The ef- Those patients showing a
tendency towards steroid
fect lasts for 3-6 months af- induced glaucoma should
be excluded.
tensin converting enzyme may be medical or surgical. ter the initial treatment.
Local and systemic ad-
assay, serum lysozyme and Corticosteroids in the form Pars plana vitrectomy is ministration of corticoster-
oids and systemic therapy
chest radiographs to rule of topical drops, periocular indicated only in patients with immunosuppressive
agents are currently used
out sarcoidosis; VDRL, subtenon injections and sys- with vitreous membranes, for treating posterior uvei-
tis. These therapies often
FTA-ABS or monoclonal temic administration is the vitreous opacities in the vi- fail because sufficient drug
does not reach the uveal tis-
antibody – Treponema mainstay of medical treat- sual axis, retinal detach- sue due to the presence of
blood ocular barrier. Sys-
pallidum for syphilis and ment. Periocular steroids ment, nonresolving vitre- temic toxicities are dose
limiting for these medica-
Lyme ELISA & indirect im- are indicated in patients ous hemorrhage & CME not tions. Intravitreal delivery
of the corticosteroid,
munofluorescence anti- with predominantly unilat- responding to medical fluocinolone acetonide, at
an optimal rate, to main-
body (IFA) for Lyme dis- eral involvement. The ab- therapy. tain a therapeutic level in
the uvea for a long period,
ease. The other important sence of systemic complica- The currently introduced would minimize systemic
exposure to the drug and
investigation in patients thereby, reduce systemic
toxicity.
with pars planitis is fluores- Macular involvement is probably the
cein angiography for the References
presence of cystoid macular most important prognostic factor as far
1. S. P Garg, Sanjeev Nainiwal,
edema. Ancillary tests like as the visual acuity is concerned. Suma Krishnan, Hem K
ultrasound biomicroscopy Tewari. Uveitis: Current con-
cepts and management.
(UBM), optical coherence tions & easy schedule of ad- concept of intravitreal ste- Monthly Bulletin of Delhi
Ophthalmological Society
tomography (OCT) & elec- ministration are its major roid implant is a promising DOS Times, December 2002;
Vol 8 (6): 21-23.
troretinogram (ERG) may advantages. Systemic ste- surgical mode of treatment
2. Smith RE, Godfrey WA, and
sometimes be useful. roids are indicated in bilat- of pars planitis. It is specifi- Kimura SJ. Chronic cyclitis. I
Course and visual prognosis,
The presence of CME is eral disease & in patients cally indicated for recur- Trans Am Acad Ophthalmol
Otolaryngol, 1973; 77: 760-
an indication for treatment; who are intolerant to perio- rent, noninfectious poste- 768.

the other indications for cular steroids. Oral rior uveitis treated repeat- 3. Kaplan HJ. Intermediate uvei-
tis (Pars planitis, Chronic cy-
therapy are visual acuity immunosuppressives are edly with oral or peribulbar clitis)- a four-step approach to
treatment. In Saari, KM, ed:
below 6/12 & severe float- indicated in vision threat- steroids. This implant con- Uveitis update, Amsterdam,
1984, Excerpta Medica.
ers in patients with a visual ening cases with failure of tains fluocinolone

acuity of 6/12 or better. steroids. Chorambucil, cy- acetonide coated with a

Since the etioloty of pars clophosphamide & polymer of PVA & silicone.

planitis is still unknown, cyclosporine have been It is a sustained release de-

the treatment is directed not tried but their availability, livery system designed to

deliver the drug for ap-

The surgical options available for the proximately three years.
treatment of pars planitis are cryo- The dimensions of the im-
therapy, pars plana vitrectomy and plant are 2mm x 2mm x
6mm and comes in 2 dosage

lensectomy. forms: 2mg and 6mg. The
device is implanted at the

at the cause but at the effect affordability, compliance pars plana region after

i.e. the inflammation and to and safety form the major making an appropriate

restore the visual function constraint. sclerotomy and secured

of the eye. Kaplan had re- The surgical options with non-absorbable su-

ported a four-step approach available for the treatment tures.

to treat such cases3 (Table of pars planitis are cryo- For intraocular steroid

1). therapy, pars plana vitre- implants, appropriate pa-

Treatment of pars planitis ctomy and lensectomy. tient selection is very essen-

February, 2004 350 DOS Times - Vol.9, No.8

CURRENT PRACTICE

Vision 2020 : The Right to Sight Ø SEVA Foundation
Ø Swiss Red Cross
G. V. S. Murthy MD, Sanjeev K. Gupta MD, Praveen Vashist MD Ø Vision 2020 Australia
Ø Vision 2020 UK
An estimated 180 mil- non-governmental and pri- Ø American Academy of Ø World Council of Op-
lion people in the world are vate organizations that col- Ophthalmology
visually disabled. Of these, laborate with the WHO in tometry
about 45 million are blind the prevention of blindness. Ø Asian Foundation for the Vision 2020 aims at
(vision < 3/60 in the better Prevention of Blindness elimination of avoidable
eye), and almost 135 mil- The five conditions that blindness by provision of
lion have low vision. In have been identified as im- Ø The Canadian National high quality eye care ser-
general three quarters of mediate global priorities Institute for the Blind vices that are accessible and
the world’s blindness is within Vision 2020 are cata- acceptable to all popula-
avoidable (preventable or ract, trachoma, onchocer- Ø The Carter Centre tions. Each country will
curable). Cataract is the ciasis, childhood blindness, Ø Foundation Dark & decide on its priorities
main cause of blindness. and refractive errors and based on the magnitude of
Other causes include tra- low vision. Light Blind Care specific blinding conditions
choma, uncorrected refrac- Ø The Fred Hollows Foun- in that country. Thus Vi-
tive error, glaucoma, dia- These conditions have sion 2020 is applicable to all
betic retinopathy, age-re- been chosen on the basis of dation countries.
lated macular degeneration their contribution to the Ø IMPACT - EMRO
and onchocerciasis. burden of blindness and the Ø International Centre for Indian Scenario
feasibility and affordability India was the first coun-
Despite the best of ef- of interventions to control Eyecare Education
forts during the last fifty them. Ø International Federation try to launch the National
years, the burden of blind- Programme for Control of
ness in the world is increas- Under the Vision 2020 ini- of Ophthalmological So- Blindness in 1976 with the
ing because of a relative tiative, blindness will be con- cieties (IFOS) goal of reducing the
lack of access to eye care trolled through: Ø International Trachoma prevalenc of blindness. Of
services, population Ø Disease prevention and Ø Internazionale per la the total estimated 45 mil-
growth and ageing. If ad- Prevensione della Cecita lion blind persons (vision <
ditional resources are not control Ø Lighthouse International 3/60 in the better eye) in the
urgently tapped and efforts Ø Training of personnel Ø Lions Clubs Interna- world, 7 million are in In-
made to control this Ø Strengthening of existing tional Foundation dia. Due to the large popu-
scourge of mankind, the Ø Operation Eyesight Uni- lation base and increased
global burden of blindness eye care infrastructure versal life expectancy, the number
can double by the year 2020. Ø Use of appropriate and Ø Royal National Institute of blind, particularly due to
for the Blind cataract is expected to in-
Vison 2020: The Right to affordable technology crease. India is committed
Sight is the common Ø Mobilization of re- COE (20)* to reduce the burden of
agenda launched by the avoidable blindness by the
World Health Organiza- sources Training Centres (200) year 2020 by adopting
tion and a Task Force of In- The founding members of strategies advocated for Vi-
ternational Non-govern- Service Centres (2000) sion 2020: The Right to
mental organizations to Vision 2020 include: Sight. Vision 2020: The
combat this mammoth Ø World Health Organiza- Primary level Vision Right to Sight was launched
problem. It is a partnership Centres (20,000) in India at a meeting in Goa
between international, tion on October 10-13, 2001.
Ø International Agency for *COE=Centre of Excellence
Department of Community (The figures in parenthe- The Government of In-
Ophthalmology the Prevention of Blind- ses denote the number of dia constituted a ‘Working
Dr. R. P. Centre for Ophthalmic ness centers that need to be Group on Vision 2020: The
Sciences, A.I.I.M.S., New Delhi Ø Christoffel-Blindmission developed by the year Right to Sight in India’ to
(Christian Blind Mission 2020 in India) prepare the Plan of Action
International) and Strategies on “Vision
Ø Helen Keller Worldwide 2020: The Right to Sight”
Ø Sight Savers Interna- initiative for controlling
tional
Ø ORBIS International
The other supporting mem-
bers include:
Ø Al Noor Foundation

February, 2004 351 DOS Times - Vol.9, No.8

CURRENT PRACTICE

To combat these diseases, the following Human Re- thalmologists and 8 ticians, orthoptists; and,
source needs have been identified: paramedics (hospital), 2. Community based - those
covering a population of with outreach/field func-
Category Current Required by 500,000. tions, which would include
number year 2020 Ø There is a need to de- primary eye care workers
velop 20000 Vision Cen- and ophthalmic assistants.
Ophthalmic surgeons 12000 25000 tres, each with one oph-
Ophthalmic assistants (community) 6000 25000 thalmic assistant (com- The recommended ratio is
Ophthalmic Paramedic (Hospitals) 48000 munity) or equivalent, 1 community-based MLOP
Eye Care Managers 18000 covering a population of per 50,000 population. De-
Community Eye Health Specialists 200 2000 50,000. sired ratio of ophthalmolo-
20 200 Ø Eye Care Managers will gist: MLOP in hospitals is rec-
be required at Service ommended as 1:3 to 1:4.
blindness in the country. Working Plan are listed be- Centres
This group comprises of low : Ø Community Eye Health Further reading:
eminent ophthalmologists Specialists will be required
and representatives from The target diseases for Vi- at Training Centres 1. Plan of Action: VISION 2020:
the government and non- sion 2020 in India include: The following pyramid The Right to Sight. National
governmental sectors. The Ø Cataract portrays the recommended Programme for Control of
draft Plan of Action was Ø Childhood Blindness Service Delivery Model by Blindness-India, Ophthalmol-
submitted by the Working Ø Refractive Errors and the year 2020. ogy/Blindness Control Section,
Group to the Ministry of Directorate General of Health
Health and Family Welfare, Low Vision Mid-Level Ophthalmic Services, Ministry of Health
Government of India in Ø Corneal Blindness Personnel (MLOP) and Family Welfare, Govern-
August 2002. This was ap- Ø Diabetic Retinopathy ment of India, New Delhi.
proved in principle as a Ø Glaucoma MLOPs include all cat-
document for future plan- Ø Trachoma (focal) egories of professionals 2. Report of the Meeting of the
ning of National who work full time in eye Working Group on VISION
Programme for Control of The above targets are based care, except qualified doc- 2020: The Right to Sight India,
Blindness in India. on the following: tors/ophthalmologists. Pune 20-21,2003. . National
Ø Assumption that 2/3 of Broadly, two streams of Programme for Control of
The Working Group met MLOPs are envisaged: Blindness-India, Ophthalmol-
subsequently to detail out ophthalmologists are ogy/Blindness Control Section,
the strategies for combating surgically active; 1. Hospital-based- those Directorate General of Health
blindness in India. Some Ø Hospital based para- working in regular facilities Services, Ministry of Health
components of the Plan of medics estimated cur- (clinics/hospitals), which in- and Family Welfare, Govern-
Action and subsequent rec- rently at 18000; clude ophthalmic nurses, ment of India, New Delhi.
ommendations of the Ø There is a need to de- ophthalmic technicians, op-
velop 2000 Service cen- tometrists, refractionists, op- 3. Strategic Plan for Vision 2020:
ters – each with two oph- The Right to Sight. Elimination
of Avoidable Blindness in the
South-East Asia Region. World
Health Organization, Regional
Office for South-East Asia,
New Delhi. July 2000.

!!! ATTENTION DOS MEMBERS !!!

DOS Executive nominated honorable Dr. Satish Sabharwal
as Chairman of the Election Commission for the next DOS
election for the various posts to be held on April 4th, 2004.

The members of the Commission are
Dr. (Air Marshal) MS Boparai and Dr. G. Mukherjee

February, 2004 352 DOS Times - Vol.9, No.8

REVIEW

Chemotherapy of Retinoblastoma cisplatin, carboplatin and
etoposide. Carboplatin is
Sameer Bakhshi MD preferred over cisplatin be-
cause of its reduced ototox-
Introduction risk of other cancers. keratopathy; it often does icity and nephrotoxicity
Retinoblastoma origi- not spare vision. It ad- profile as compared to
Modes of therapy in retino- versely affects midface cisplatin. An increased inci-
nates from the retinal neu- growth in 90% of patients. dence of secondary primary
roepithelium that can dif- blastoma The risk of secondary non- tumors has been attributed
ferentiate into almost any ocular malignant tumors to the use of cyclophospha-
type of outer or inner reti- The aim of treatment in increases 6-fold after EBRT mide and etoposide in chil-
nal cell, including photore- especially in those with a dren with RB1 mutations.
ceptors. It is the most com- retinoblastoma is to cure the germ line mutation of RB1
mon intraocular tumor in (1-3). Patients carrying RB- Various chemotherapeu-
childhood, occurring in 1 of patient with preservation of 1 germline mutation have a tic regimens have been used
17000 to 24000 live births, 35% cumulative risk of sec- which include: vincristine,
independent of race and vision; the second aim is to ondary cancers in the radia- adriamycin and cyclophos-
sex. Approximately, 80% of tion field by the age of 30 phamide (VAC); vincris-
cases occur before 4 years of minimize the long-term ef- years, whereas those who do tine, carboplatin and
age while 40% of cases oc- not have RB-1 mutation the etoposide in various combi-
cur during infancy. The me- fects of therapy. With ad- risk is 6%. This effect may nations such as VEC, VC
dian age of diagnosis is 2 be age dependent with the and CE; VEC along with cy-
years. Bilateral retinoblas- vances in therapy, the sur- greatest risk in those retino- clophosphamide (VECP).
toma occurs earlier than blastoma patients with he- Recently, VEC is the pre-
unilateral disease. vival has risen from 30% in reditary disease treated un- ferred drug combination
der 1 year of age. The cumu- (Table 1). Carboplatin has
Retinoblastoma may oc- the 1930’s to nearly 95% in lative risk of death from sec- good penetration in eye;
cur as a hereditary or non- ondary tumors is 26% at 40 brain and bone marrow,
hereditary tumor. Tumors the 1990’s for non-meta- years of age. Plaque radio- which are two potential sites
in nonhereditary retino- therapy avoids the long- for metastatic disease in re-
blastoma (60% cases) are static retinoblastoma. How- term complicationsof EBRT, tinoblastoma. Further, the
typically solitary and uni- but this cannot be used in combination of etoposide
lateral with no family his- ever, untreated retinoblas- large tumors, tumors with and carboplatin has been
tory and no detectable chro- vitreous seeding, or tumors proven to have activity and
mosomal abnormalities. Al- toma is always fatal. The at the posterior pole. synergy in other embryonal
though <10% of cases of ret- neuroectodermal tumors in
inoblastoma have a positive major therapies that have C. Chemotherapy is one children. However, there is
family history, about 40% of of the possible treatment no randomized trial to sug-
retinoblastoma are of he- resulted in this improved modalities, which is free gest that one combination is
reditary origin caused by a from long-term effects of ra- better than the other.
germ line mutation in RB1 survival are enucleation diation. This is used in ret-
gene on chromosome 13q14; inoblastoma in three set- Drug resistance in retino-
25% cases have bilateral dis- and external beam radia- tings: intraocular RB, blastoma
ease while 15% have unilat- micrometastatic RB and
eral disease. Hereditary RB1 tion therapy (EBRT), both of overt dissemination. It has been shown that
mutations are found in all multidrug resistance is
cells thereby increasing the which are associated with Chemotherapy drugs/com- caused by the overexpre-
ssion of a membrane-asso-
Pediatric Orcology Service significant morbidity. binations used in retino- ciated energy-dependent
Dr. B.R.A. Institute Rotary drug efflux pump, the P-gly-
Cancer Hospital A. Enucleation cures lo- blastoma coprotein. The P-glycopro-
All India Institute of Medical Drugs commonly used in tein is encoded by mdr1
Sciences calized retinoblastoma but gene, and cells with
New Delhi-110029 retinoblastoma include vin- multidrug resistance often
Email: [email protected] at the cost of loss of sight. cristine, adriamycin, idaru- show amplification of this
bicin, cyclophosphamide, gene. Although, the effect of
Aside from its obvious ad-

verse physiologic and psy-

chological effects, enucle-

ation can be associated with

chronic local effects such as

discharge from the orbit,

contraction of the socket,

and extrusion of the im-

plant. Thus, there is a need

for relatively non-invasive

focal ophthalmological

therapies.

B. EBRT provides good

local control in retinoblas-

toma when used in conjunc-

tion with local non-invasive

ophthalmological thera-

pies. However, it has signifi-

cant local side effects such

as xerophthalmia, cataract,

retinopathy and

February, 2004 353 DOS Times - Vol.9, No.8

REVIEW P-glycoprotein is reversible subretinal seeds are man-
with high concentrations of aged differently using
Table1: Chemotherapy VEC Protocol cyclosporine and might chemoreduction without
even be diminished in the focal consolidation treat-
A. Drugs future by using MoAbs ments because the number
against P-glycoprotein, the of seeds is usually far beyond
Ø Vincristine 1.5 mg/m2 Day 1 (0.05 mg/kg for chil- role of cyclosporine in re- the capability of focal treat-
dren < 3 years and max dose 2 mg) versing drug resistance in ment methods and the mul-
patients with retinoblas- titude of tiny seeds typically
Ø Carboplatin 560 mg/m2 Day 1 (18.6 mg/kg for toma remains unclear in the respond with regression,
children <3 years) absence of a randomized calcification, and often com-
trial (4). plete disappearance after
Ø Etoposide 150 mg/m2 Day 1&2 (5 mg/kg for chil- several months of treat-
dren <3 years) Chemotherapy in intraocu- ment. In applying this strat-
egy in the management of
B. Cycles lar retinoblastoma (Chemo- bilateral retinoblastoma, it
seems appropriate to con-
Ø Every 3-4 weeks; reduction) serve both eyes at first. The
Ø Ensure ANC>1000 and platelets >100,000/mm3 Chemoreduction is the decision to enucleate 1 eye
can be postponed at least
C. Number of Cycles use of chemotherapy to until early response to pri-
shrink the tumor so that lo- mary chemotherapy has
Ø 2-6 cycles for chemoreduction cal treatment can be deliv- been assessed. It is then
Ø 6 cycles for chemoprevention ered to a smaller volume easier to judge which eye is
Ø 6-18 cycles for systemic disease and cause less morbidity. salvageable and which not.
This technique has been em-
Table 2: Exclusion criteria for treatment with ployed in an effort to avoid Chemotherapy is admin-
chemoreduction or at least delay EBRT and istered every 3-4 weekly for
Ø Biomicroscopic evidence of iris neovasculari- enucleation for children 2-6 cycles using a combina-
with retinoblastoma, espe- tion of 2, 3 and 4 cytostatic
zation cially those with bilateral drugs. Patient requires te-
Ø Neovascular glaucoma disease. The great advan- dious monitoring every 2-3
Ø Tumor invasion into the anterior chamber, iris, tage of chemoreduction in weekly and possibly exten-
retinoblastoma seems to be sive treatment using focal
optic nerve and/or choroid the ability to move the tu- measures, to avoid ultimate
Ø Extraocular disease as documented by clinical, mor margins away from vi- failure. Additional focal
sually vital structures, such treatment is mandatory
ultrasonographic and neuroimaging modalities as the optic disc and the fo- since histopathological
Ø If vitrectomy is performed for an eye with un- veola. evaluation still reveals vi-
able proliferating tumor
suspected retinoblastoma Management of this dis- cells after 2-6 cycles (5). At
ease involves attention to 3 any suggestion of tumor pro-
Table 3: Post-enucleation specimen (Histopathologi- anatomic sites of tumor, in- gression, the eye needs
cal criteria for chemoprevention) cluding the individual reti- enucleation or EBRT. A regi-
nal tumors, associated vit- men with fewer than 6
A. Indications for chemoprevention reous tumor termed “vitre- cycles is less effective in pre-
Ø Anterior chamber seeding ous seeds”, and associated venting enucleation or
Ø Iris infiltration, subretinal tumor or seeds. EBRT, especially in eyes
Ø Ciliary body infiltration, Retinal tumors generally re- with Reese-Ellsworth (RE)
Ø Massive choroidal infiltration, spond rapidly to chemo- stage IV and V (6). At
Ø Invasion of optic nerve lamina cribrosa reduction; residual tumors present, it is not possible to
Ø Retrolaminar optic nerve invasion can thereafter be destroyed indicate as to which drug
Ø Invasion of optic nerve transection* without vision loss by using combination is the best.
Ø Scleral infiltration, adjuvant local brachy-
Ø Extrascleral extension* therapy, photocoagulation, Efficacy of chemo-
* These require additional EBRT as this is considered as extraocu- cryocoagulation and/or la-
lar disease limited to orbit ser therapy. Eyes with addi-
tional vitreous seeds or
B. Indications for no additional chemotherapy
Ø Intraretinal extension
Ø Prelaminar optic nerve invasion

February, 2004 354 DOS Times - Vol.9, No.8

REVIEW

reduction Chemoreduction response ally lower success rates with treatment. Small re-
An early volume re- in relation to site and size 26 of 39 (67 %) and four of tinoblastoma foci
of retinoblastoma eight (50%) tumors re- (less than or equal to
duction of around 50% sponding. The dispropor- 2 mm in basal di-
after two courses of The retina may be di- tionate choroidal blood flow mension) may have
VEC can usually be ex- vided into three easily iden- supplied by the short poste- a worse response to
pected (7). The overall tifiable zones progressing rior ciliary vessels probably chemotherapy than
salvage of eyes in the from the posterior pole an- contributes to increased larger tumors. Vas-
chemoreduction stud- teriorly. Macular tumors drug delivery to the macula, cular perfusion and
ies is about 80%. EBRT were found to have the thereby suggesting that drug delivery may be
was added in an addi- highest success rates with macular tumors receive reduced in very
tional 30% of the sal- 26 of 31 tumors (84 %) re- higher concentrations of small tumors result-
vaged eyes. Thus ap- sponding (p<0.060) (10). Tu- chemotherapy and there- ing in chemoresis-
proximately 50-60% of mors in the equatorial and fore respond better to this tance and continued
affected eyes treated anterior ora zones had seri- growth.
with chemoreduction
are successfully pre- Chemoreduction in
served with avoidance retinal detachment
of EBRT or enucleation
(8). The rate of globe Retinoblastoma
preservation is best with total retinal de-
with less advanced eyes tachment tradition-
(85%), such as those in ally has been man-
RE groups I to IV aged with enucle-
whereas with more ad- ation. After 2
vanced eyes, such as months of chemore-
those in RE group V, duction in those
preservation is less suc- with retinal detach-
cessful at <50%. ment, all tumors
showed a response
In a study by CL with a mean of 33%
Shields et al (9), decrease in base and
chemoreduction using 47% decrease in
six cycles of VEC offers thickness (11). The
satisfactory retinoblas- subretinal fluid re-
toma control for RE solved completely in
groups I-IV eyes, with 41% case, leaving
treatment failure ne- flat retina; partial
cessitating additional resolution was achi-
EBRT in only 10% of eved in 18% case;
eyes and enucleation in minimal resolution
15% of eyes at 5-year of the subretinal fluid was
follow-up. Patients with RE noted in 41% cases. At a
group V eyes required EBRT mean follow-up of 10
in 47% and enucleation in months after initiation of
53% at 5 years. Thus, all lo- chemoreduction, complete
calized intraocular retino- resolution of the subretinal
blastoma have a potential fluid occurred in 76% cases
for eye preservation using and partial resolution of
chemoreduction (Figure 1). subretinal fluid occurred in
However, any evidence for 24% cases. Preliminary ob-
potential micrometastatic servations suggest that
disease or overt metastatic chemoreduction may be used
disease should be excluded in initial management of ret-
from chemoreduction inoblastoma, even for large
(Table 2).

February, 2004 355 DOS Times - Vol.9, No.8

REVIEW

tumors with total reti- Fig ure 2: Alg orith m for m anagem en t of m etastatic retinoblastom a Kaplan-Meier esti-
nal detachment. mates showed that

Recurrence of retino- M etastatic D isease 96% of patients who
received adjuvant

blastoma following therapy would re-

chemoreduction main free of metasta-

The mean interval sis at 10 years post-

from discontinuation enucleation com-

of chemoreduction to 1. Orbital and head C T scan pared with 76% of
first recurrence of reti- 2. Bone m arrow biopsy
nal tumor was 4 3. Bone scan those who did not re-
months, recurrence of 4. CSF Cytology
ceive adjuvant

therapy.

vitreous seeds was 2

months, and recur- Chemoprevention

rence of subretinal Orbital and/or preauricular nodal disease following vitrectomy
seeds was 2 months Distant m etastatic disease Retinoblastoma may

(12). Thus, monitoring present with atypical

of the eye is especially features such as vitre-

critical following Orbital Neoadjuvant CT 2-4 cycles, local RT ous hemorrhage or
chemoreduction to Exenteration CT and/or surgery signs of vitreous in-
detect recurrence. It is flammation, particu-

reassuring to know larly in older children.

that most children CT & RT Lim ited Surgery CR or PR P r o g re ss iv e Vitrectomy should be
manifest their recur- Disease avoided in these cases

rent retinal tumors until the possibility of

and subretinal seeds underlying retino-

by 3 years after treat- Adjuvant HDT with ASCT Alternate blastoma is excluded.
ment with little recur- CT&RT therapy If vitrectomy is per-

rence thereafter; ac- formed in an eye with

cordingly, follow-up unsuspected retino-

can be adjusted for this time seed recurrence are those logical to consider chemo- blastoma, enucleation com-

interval. Vitreous seed re- who, at initial examination therapy following enucle- bined with chemotherapy,

currence, however, contin- are younger, had large tu- ation to prevent metastasis radiotherapy, or both with-

ues to be a problem up to 5 mor dimensions, and had in high-risk cases; this is re- out delay is advised to pre-

years after treatment and tumor-associated subr- ferred to as chemo- vent systemic tumor dis-

potentially longer; there- etinal seeds. All children re- prevention. Various histo- semination (16).

fore, patients with vitreous ceiving a chemoreduction pathological factors have

seeds at initial examination protocol should be moni- been identified as potential Chemotherapy for ex-

might require cautious ocu- tored by a retinoblastoma risk factors for retinoblas- traocular retinoblastoma

lar examination for many specialist who is able to de- toma (Table 3); however, Metastatic retinoblas-

years following treatment. tect minute recurrences and there is some controversy as toma is seen in less than 10%

At 5 years’ follow-up, the capable of treating the re- to whether choroidal in- cases in developed nations

recurrence rates for currences. volvement alone is a signifi- whereas almost 2/3rd of

intraretinal tumors, vitre- cant risk factor for me- cases of retinoblastoma in

ous seeds and subretinal Chemotherapy for retino- tastases (13,14,15). The cur- developing countries. Che-

seeds are seen in 24%, 50% blastoma post-enucleation rent strategy is to give 6 motherapy is indicated in

and 62% of eyes respectively (Chemoprevention) cycles VEC to prevent me- all these situation and is

(12). Those at greatest risk With improved under- tastases and the rate of me- used in two fashions:

for retinal tumor recurrence standing of the risk factors tastasis is significantly re- 1. Conventional chemo-

are eyes with tumor-associ- predictive of metastasis, duced in the group receiv- therapy wherein the same

ated subretinal seeds sur- and the availability of effec- ing chemoprevention as drugs are used as is used in

rounding the base of the tu- tive chemotherapy regi- compared with the group chemoreduction or chemo-

mor. Patients at greatest risk mens for intraocular retino- that did not receive chemo- prevention, but for a longer

for vitreous or subretinal blastoma, it would seem therapy (4% vs 24%). duration of 6-18 months.

February, 2004 356 DOS Times - Vol.9, No.8

REVIEW

2. High dose chemo- results have been reported toma. copathologic features of ret-
therapy (HDT) wherein af- using HDT with ASCT. inoblastoma after primary
ter initial conventional che- Thus, HDT in these two situ- Conclusions chemoreduction. Arch Ophth-
motherapy, the patient is ations seems to be a thera- Retinoblastoma is a almol 1998;116:887-93.
consolidated with high peutic alternative with the 2. Gunduz K, Shields CL, Shields
doses of the same agents and advantage of shorter dura- chemosensitive disease but JA, et al. The outcome of
bone marrow rescued with tion of therapy (19). cannot be cured with che- chemoreduction treatment in
an autologous stem cell motherapy alone. It is a very patients with Reese-Ellsworth
transplantation (ASCT). B. Those with systemic effective mode of therapy in group V retinoblastoma. Arch
and/or CNS dissemination preserving vision and the Ophthalmol 1998;116:1613-7.
Two different subgroup (bones, bone marrow, posi- long-term complications of 3. Shields CL, Shields JA, Needle
of patients with extraocular tive CSF cytology or mass le- enucleation and EBRT, espe- M, et al. Combined chemor-
retinoblastoma with differ- sion in brain) are seldom cially in intraocular retino- eduction and adjuvant treat-
ent outcome can be distin- cured with conventional blastoma. Metastatic ret- ment for intraocular retino-
guished (Figure 2): chemotherapy. However, inoblastoma to the orbit can blastoma. Ophthalmology
HDT using carboplatin, be treated with good results 1997;104:2101-11.
A. Extraocular disease etoposide and cyclophos- with combination chemo- 4. Shields CL, Honavar SG,
limited to orbit alone (in- phamide is effective in pa- therapy, radiotherapy and Meadows AT, et al. Chemo-
vasion upto or beyond the tients with chemosensitive possibly conservative eye reduction plus focal therapy
cut end of optic nerve; retinoblastoma patients surgery as well. Distant for retinoblastoma: factors
scleral invasion upto the or- with distant metastatic dis- metastatic disease cannot be predictive of need for treat-
bital contents) or with con- ease, except those with CNS cured with conventional ment with external beam ra-
comitant lymph node inva- disease (20). Prognosis is ex- chemotherapy in majority diotherapy or enucleation. Am
sion. These patients have a tremely poor in those with of the cases, however, HDT J Ophthalmol 2002;133: 657-
5-year progression free sur- CNS disease. CNS irradia- with ASCT appears to be a 64.
vival of >80% using initial tion, as is currently em- promising therapy for such 5. Shields CL, Honavar SG,
exenteration followed by in- ployed, does not cure CNS cases. Retinoblastoma with Shields JA,et al. Factors pre-
tensive chemotherapy and disease. Role of intrathecal CNS metastases continues dictive of recurrence of reti-
radiotherapy (17). Similar therapy using methotrex- to have dismal prognosis nal tumors, vitreous seeds,
results have also been ob- ate, cytosine arabinoside despite HDT with SCT and/ and subretinal seeds follow-
tained using initial and hydrocortisone, as is or cranial radiation. ing chemoreduction for ret-
neoadjuvant chemotherapy employed in CNS leukemia, inoblastoma. Arc Ophthalmol
followed by limited surgery is debatable. Thus, more ef- Bibliography 2002;120:460-4.
(enucleation or resection of fective therapeutic strate- 6. Honavar SG, Singh AD,
residual orbital mass) and gies are required to cure 1. Bechrakis NE, Bornfeld N, Shields CL, et al. Postenuc-
adjuvant therapy and radio- CNS disease in retinoblas- Schueler A, Coupland SE, leation adjuvant therapy in
therapy (18). Comparable Henze G, Foerster MH. Clini- high-risk retinoblastoma.
Arch Ophthalmol 2002;120:
923-31.

DOS Election

Applications are invited from Delhi Members of Delhi Ophthalmologi-
cal Society for the post of : Vice President (1 Post)

The eligibility criteria for different post prescribed in DOS Constitution
(1998) will be followed. Application should be submitted on a plain paper
duly proposed and seconded by a member of DOS (not in arrears). Applica-
tion should reach Secretary Office latest by 10th February 2004 (2 p.m.).
Last date of withdrawal is 10th March, 2004 (5 p.m.) Election will be held
during the Annual DOS Conference on 3rd April, 2004.

Secretary, DOS

February, 2004 357 DOS Times - Vol.9, No.8

REVIEW

Anterior and Posterior Capsule Staining in
Pediatric Cataract Surgery: Surgical Techniques,
Guidelines and Recommendations

Suresh K Pandey MD1, David J Apple MD1,
Taketoshi Wakabayashi MD, PhD2, Narumichi Yamamoto MD, PhD2

During the past few ied 3 different types of cap- make this difficult maneu- solution is mixed together.
years there has been enor- ver safer (Figures 2).5 Pos- This can be used for mul-
mous interest in the use of sular dyes –2% fluorescein terior capsule staining also tiple cases throughout the
vital dyes to enhance visu- helps identify presence of surgical day.
alization during various sodium, 0.5% ICG and 0.1% posterior capsule tear as
steps of ophthalmic surger- shown in Figure 2C. Surgical Technique
ies. In this article, we trypan blue for anterior and A 0.5% solution of ICG
present applications of the Availability, Preparation
two most commonly used posterior capsule staining and Cost of the Dyes and 0.1% solution of trypan
dyes, trypan blue and blue is commonly used to
indocyanine green (ICG), in adult and pediatric cata- Both ICG and trypan stain anterior or posterior
for anterior and posterior blue are not approved by lens capsules. For anterior
capsulorhexis in pediatric ract surgery. These experi- United States Food and capsulorhexis, ICG or try-
cataract surgery. We have Drug Administration for pan blue may be used under
also provided guidelines mental studies demon- capsular staining. ICG dye an air bubble. The posterior
and recommendations for is available in USA, being capsule staining can be
ophthalmic surgeons, based strated that 0.5% approved for choroidal an- done by instilling 1
on the published experi- giography. However, its la- microdrop of the dye solu-
mental and clinical stud- indocyanine green and beling issues avert packag- tion into the capsular bag,
ies.1-9 ing the ICG dye in a smaller, after cortical clean up. Af-
0.1% trypan blue dyes can more cost-effective quan- ter waiting 60-90 seconds,
Use of 0.5% indocyanine tity. A 0.1% solution of the excessive dye was
green and 0.1% trypan blue be successfully used to stain trypan blue is commercially washed out from the capsu-
dye for anterior capsule available in the trade name lar bag. After filling the cap-
staining was reported by the posterior lens capsule to of VisionBlueÒ (Dutch sular bag with viscoelastics
Horiguchi and Melles.1,2 A Ophthalmic Research Com- (HealonÒ , Pfizer, New
clinical study comparing enhance visualization pany, Netherlands). The York, NY), PCCC can be ini-
both dyes was first reported 0.1% Vision BlueÒ solution tiated by using a 26-gauge
by Chang.3 Pandey and as- while learning and per- is ready for injection re- needle cystitome. The
sociates4-7 extensively stud- quiring no dilution. Prepa- PCCC can be completed us-
forming posterior ration of the ICG for cap- ing a Utrata’s forceps. Op-
1. John A. Moran Eye Center, sule staining can be accom- tic capture of a posterior
Department of Ophthalmology and capsulorhexis, a technically plished at the beginning of chamber intraocular lens
Visual Sciences, Fifth Floor, the surgical day. ICG can be (PC-IOL), as well as ante-
University of Utah, 50 North challenging procedure (Fig- prepared as described by rior vitrectomy, can also be
Medical Drive Salt Lake City, Horiguchi and associates.1 performed, if required.
Utah-84132, USA. ures 1, 2).5-7 According to In brief, one half (0.5cc) mil-
2. Department of Ophthalmology, liliters of the provided Our experimental stud-
Institute of Clinical Medicine, recently published clinical diluent are mixed with the ies revealed that posterior
University of Tsukuba, 1-1-1 dry ICG powder. Four and capsule staining using ICG
Tennoudai, Tsukuba, Ibaraki, 305- reports, ophthalmic dyes one half (4.5cc) milliliters of or trypan blue is very help-
8575, Japan. balanced salt solution are ful when performing the
are increasingly being used then added to this and the PCCC procedure in chil-
dren.5 Recent clinical re-
to facilitate anterior and

posterior capsulorhexis

during pediatric cataract

surgery.8-10 Staining of the

lens epithelial cell using

trypan blue dye, to facilitate

intraoperative removal

during pediatric cataract

surgery had also been re-

cently suggested.11

Experimental studies us-

ing 0.5% indocyanine green

and 0.1% trypan blue for

staining the posterior cap-

sule, while performing pos-

terior continuous curvilin-

ear capsulorhexis (PCCC)

in pediatric eyes, demon-

strated that dye-enhanced

visualization may help

February, 2004 358 DOS Times - Vol.9, No.8

REVIEW

Fig. 1. Gross photographs of a human eye obtained post-mortem showing posterior continuous curvilinear capsulorhexis (PCCC) after
staining of the capsular bag with indocyanine green (ICG). Cornea and iris were excised to allow better visualization.
Fig. A: Anterior (surgeon’s) view of the cleaned and stained capsular bag showing initiation of the PCCC. Note that it is easier to visualize the

stained posterior capsule flap (PCF) against transparent (non-stained) anterior hyaloid phase (AHP) of the vitreous.
Fig. B: The PCCC is in progress.
Fig. C: The PCCC is completed. Note the stained PCCC margin; PCF: posterior capsule flap.
Fig. D: The posterior capture of the intraocular lens (IOL) optic. Both intraocular lens haptics are present in the capsular bag and the IOL

optic is captured behind the posterior capsule.

Fig. 2. Dye-enhanced pediatric cataract surgery. Photographs of a pediatric eye obtained post-mortem, taken from anterior (surgeon’s view)
illustrating the use of the capsular dye to enhance visualization during various steps of the pediatric cataract surgery.
Fig. A: Posterior capsulorhexis after the staining of the capsular bag with trypan blue.
Fig. B: Posterior capsulorhexis and optic capture of a foldable IOL after the staining of the capsular bag with trypan blue.
Fig. C:Visualization of a posterior capsule tear after staining of the capsular bag with ICG (arrows).

ports from other center con- when performing PCCC.8,9 and posterior capsulorhexis both anterior and posterior
firmed the experimental in congenital cataract com- capsule was poor without
finding using these dyes to Wakabayashi and bined with anterior staining because of associ-
stain the posterior capsule vitrectomy. The visibility of ated corneal opacity in 6-
Yamamoto8 reported ICG

staining used for anterior

February, 2004 359 DOS Times - Vol.9, No.8

REVIEW

Fig. 3: (A-H). Indocyanine green (ICG) enhanced posterior continuous curvilinear capsulorhexis (PCCC) month old congenital cata-
in congenital cataract combined with anterior vitrectomy. The visibility of the posterior capsule was ract. After cataract re-
poor without staining in this 6-month-old child with nuclear cataract, because of corneal opacity. After moval, ICG staining of the
the extraction of the cataract, a PCCC was performed after ICG staining of the posterior capsule. Note capsular bag was to better
the PCCC was successfully completed because of better visualization of the stained posterior cap- visualize the posterior cap-
sule flap against the transparent anterior hyaloid face of the vitreous. sule. The PCCC was suc-
cessfully completed be-
cause of better visualization
of the stained posterior cap-
sule flap against the trans-
parent anterior hyaloid face
of the vitreous as shown in
Figure 3. Clear visual axes
have been maintained post-
operatively.

Learning, perfecting the
anterior and posterior
capsulorhexis procedure
during pediatric cataract
surgery can be difficult for
the beginning surgeon, due
to the thin and transparent
nature of the capsule. In ad-
dition, achieving a consis-
tent size of the anterior and
posterior capsule opening
for performing the IOL op-
tic capture can be challeng-
ing. A thin sclera, highly
elastic anterior and poste-
rior capsules and a positive
vitreous pressure, make
ACCC/PCCC even more
difficult than in older chil-
dren/adults.

Posterior capsule stain-
ing facilitates PCCC with or
without IOL optic capture
during cataract surgery in
infants and children (Fig-
ure 2).5 Vitreous loss can
also be identified by the for-
mation of colored localized
clumps, depending on the
type of dye used. Even
when utilizing the vitrector
to open the posterior cap-
sule, visualization of the
capsulotomy edge can be
difficult and would be en-
hanced by use of a dye. Also,
IOL insertion into a soft pe-
diatric eye after CCC and
PCCC can be very difficult.

February, 2004 360 DOS Times - Vol.9, No.8

REVIEW

Adequate visualization of ries. According to the au- terior lens capsule using sule and the absence of vit-
the remaining capsule and thor, both dyes provided trypan blue was actually reous leakage (due to high
of the capsulotomy edges is consistently excellent visu- weaker, and less force was molecular weight).5 Both of
paramount to avoid inad- alization and clinical re- required to begin the tear at these dyes provide excellent
vertent sulcus placement, sults without any adverse the capsule edge (Mana visualization of the anterior
asymmetric bag-sulcus effects. However, trypan Tehrani, MD, Personal com- capsule flap during CCC,
fixation or dislocation of the blue created a more intense munication, November without causing any toxic
IOL through the PCCC. and persistent staining and 2003). These authors per- effects to the corneal endot-
provided superior visual- formed special elasticity helium. Trypan blue has the
Safety and Efficacy ization when compared tests using fresh lens cap- advantage of being less
Several laboratory, ani- with ICG, according to this sules, which were removed, costly when compared to
first clinical study (Chang during routine cataract sur- the cost of ICG, and to the
mal and clinical studies DF, MD. Compare two gery in human eyes. One best of our knowledge, the
have evaluated capsular dyes. Eye Net 2000; 4:22). half of the excised capsule cost of a 0.5-ml ampule of
dyes and capsule staining was dyed with VisionBlueÒ VisionBlueÒ is $5.0, com-
techniques for safety and We would like to empha- the other half (non-stained) pared to the $90.00 cost of
efficacy during adult cata- size care when performing was used as a control. 1 ampule of 25 mg ICG
ract surgery. Horiguchi et anterior capsule staining in Analysis of 15 capsules sug- powder. Currently, 0.1%
al.,1 reported the technique vitrectomized patients dur- gested that the capsules trypan blue is the concen-
of staining the anterior cap- ing pediatric cataract sur- that stayed in contact with tration used by most sur-
sule using a 2% solution of gery. Inadvertent staining the trypan blue was actu- geons. Further studies may
ICG in patients with ma- of the posterior lens capsule ally weaker, in terms that be helpful to determine the
ture cataracts. They com- may occur secondary to dif- only a half of strength was least concentration of the
pared the results of fusion of dye into the vitre- necessary to tear up the trypan-blue dye (e.g.,
phacoemulsification and ous cavity, thereby obscur- capsule. The precise mecha- 0.05%, 0.025%, 0.01%, etc.)
IOL implantation in 2 ing the red reflex.12 How- nism is not clear at present, that can be used to stain the
groups of 10 eyes. In the ever, the trypan blue mol- and requires further inves- anterior lens capsule in or-
first group, the anterior ecule is large and under nor- tigations. However, this der to perform CCC during
capsule was stained with mal circumstances does not phenomenon seems to be pediatric cataract surgery.
ICG before CCC, and in the appear to cross the intact due to the presence of pre-
second, no dye was used. zonula ciliaris (cilary zonu- servative in the trypan blue Staining under the air
There was no statistically les). It is likely that an intact solution. bubble technique is safer
significant difference re- anterior hyaloid face would and therefore recom-
ported in their study be- prevent bulk flow of dye Guidelines and Recom- mended for cataract pa-
tween both groups con- into the vitreous cavity. The mendation for Surgeons tients presenting with high
cerning specular-micros- surgeon should avoid using intralenticular pressure
copy endothelial cell count- any ophthalmic dyes in pe- We would like to provide and a fragile anterior lens
ing, and laser flare-cell pho- diatric cataract surgery some recommendations capsule (e.g. pediatric trau-
tometry, thus the staining combined with implanta- and guidelines for oph- matic cataract). When in-
procedure was considered tion of hydrophilic acrylic thalmic surgeons regarding jecting under air, the dye
to be safe. lenses having a high water suitable ophthalmic dyes should be injected after the
content (>70%), as this can and the anterior and poste- paracentesis but prior to
Clinical experience with lead to permanent staining rior capsule staining tech- creating the main incision
ICG and trypan blue for an- (discoloration) of the IOL nique in pediatric cataract to help with anterior cham-
terior capsule staining in by some ophthalmic dyes.13 surgery. These are based on ber stability. Viscoelastic
mature white or brunescent This discoloration may be- our experience in postmor- solutions can be used to
cataracts was first reported come associated with a de- tem human eyes, use on pa- visco-seal the incision site in
by David Chang3 in two crease or alteration in the tients from our institution, order to avoid escape of the
consecutive, non-random- best-corrected visual acu- as well as published clinical air bubble, and to minimize
ized series of mature or ity, and eventually require reports from several other any anterior chamber fluc-
brunescents cataracts. The IOL explantation/ex- surgeons. Both ICG and tuations. Alternatively,
technique of dye injection change.13 trypan blue are currently mixing the dye with a vis-
under an air bubble was uti- preferred over fluorescein coelastic solution may also
lized. ICG dye was used in In an ongoing study, sodium dye, due to better be used for better anterior
the first series, and trypan Tehrani and associates staining of the anterior cap- capsule staining, and for
blue in the subsequent se- found that the stained an-

February, 2004 361 DOS Times - Vol.9, No.8

REVIEW

limiting the contact with tively easy to perform after recommendations. Indian J white cataracts. J Pediatr Ophth-
adjacent ocular tissues. staining of the otherwise Ophthalmol 2002;50:157-159 almol Strabismus. 2003;40: 268-271
transparent posterior cap- 8. Wakabayashi T, Yamamoto N. 11. Kiel AW, Butler T, Gregson R. A
Use of non-toxic oph- sule, as demonstrated for Posterior capsule staining and pos- novel use for trypan blue to mini-
thalmic dyes for anterior the first time, in our experi- terior continuous curvilinear mize epithelial cell proliferation
capsule staining in ad- mental study (Figures 1,2)5 capsulorhexis in congenital cata- in pediatric cataract surgery. J
vanced, white pediatric and that was confirmed by ract. J Cataract Refract Surg Pediatr Ophthalmol Strabismus.
cataracts allows perfor- clinical studies.8,9 Posterior 2002;28:2042-2044 2003; 40:96-97
mance of a safe and suc- capsule staining may be 9. Saini JS, Jain AK, Sukhija J, Gupta 12. Birchall W, Raynor MK, Turner GS.
cessful CCC.10 The dyes can specially useful for poste- P, Saroha V. Anterior and poste- Inadvertent staining of the poste-
also be helpful when train- rior capsulorhexis proce- rior capsulorhexis in pediatric cata- rior lens capsule with trypan blue
ing residents in the tech- dure being performed in ract surgery with or without trypan dye during phacoemulsification.
niques of CCC, and when younger children with poor blue dye: randomized prospective Arch Ophthalmol 119:1082-83, 2001
performing CCC in cases visualization. In addition to clinical study. J Cataract Refract 13. Werner L, Apple DJ, Crema AS, et
presenting with nebular anterior and posterior Surg 2003;29:1733-1737 al. Permanent blue discoloration
and/or macular corneal capsulorhexis, staining of 10. Guo S, Caputo A, Wagner R, of a hydrogel intraocular lens
opacity. Anterior capsule the lens epithelial cell using DeRespinis P. Enhanced visualiza- caused by intraoperative use of
staining can also be useful trypan blue dye, to facilitate tion of capsulorhexis with indocya- trypan blue. J Cataract Refract Surg
when converting from a intraoperative removal nine green staining in pediatric 28:1279-1286, 2002
can-opener technique to during pediatric cataract
CCC. Surgeons operating surgery had also been re- Monthly Meetings Calendar
only rarely on children may cently suggested.11 For The Year 2003-2004
also find anterior and pos-
terior capsule staining use- References: 27th July, 2003 (Sunday)
ful as an aid to dealing with Army Hospital
the elastic nature of the cap- 1. Horiguchi M, Miyake K, Ohta I, Ito
sule, and the increased ten- Y. Staining of the lens capsule for 30th August, 2003 (Saturday)
dency for the run-away circular continuous capsulorhexis Sir Ganga Ram Hospital
rhexis. Even when the cata- in eyes with white cataract. Arch
ract is not completely Ophthalmol 1998; 116:535-537 27th September, 2003 (Saturday)
white, the learning curve Hindu Rao Hospital
when beginning CCC in 2. Melles GRJ, Waard PWT, Pameyer
unfamiliar territory (such JH, Beekhuis WH. Trypan blue 19 October, 2003 (Sunday)
as infantile cataract cases) capsule staining in cataract sur- DOS Midterm Conference
can be shortened by en- gery. J Cataract Refract Surg 1999;
hanced visualization of the 24:7-9 1st November, 2003 (Saturday)
capsular edge. These dyes R.P. Centre for Ophthalmic Sciences
may be useful for operating 3. Chang DF. Capsule staining and
on adult and pediatric cata- mature cataracts: a comparison of 29th November, 2003 (Saturday)
ract cases with poor or no indocyanine green and trypan blue Dr. Shroff’s Charity Eye Hospital
red reflex, or when the sur- dyes. Br J Ophthalmol (video re-
geon is learning, or in de- port) July 2000. 27th December, 2003 (Saturday)
veloping-world settings Venu Eye Hospital & Research Centre
where inexpensive surgical 4. Pandey SK, Werner L, Escobar-
microscopes with imperfect Gomez M, Roig-Melo EA, Apple 31st January, 2004 (Saturday)
co-axial light may be a ne- DJ. Dye-enhanced cataract surgery. Safdarjung Hospital
cessity. Part 1: anterior capsule staining for
capsulorhexis in advanced/white 28th February, 2004 (Saturday)
In summary, capsular cataract. J Cataract Refract Surg M.A.M.C. (GNEC)
dyes can be successfully 2000; 26:1052-1059
used in pediatric cataract 27th March, 2004 (Saturday)
surgery for performing an- 5. Pandey SK, Werner L, Escobar- Mohan Eye Institute
terior and posterior capsu- Gomez M, Werner LP, Apple DJ.
lorhexis. Posterior capsulor- Dye-enhanced cataract surgery. 3-4th April, 2004 (Saturday & Sunday)
hexis, a technically chal- Part 3: Posterior capsule staining Annual DOS Conference
lenging procedure, is rela- to learn posterior continuous cur-
vilinear capsulorhexis. J Cataract
Refract Surg 2000; 26:1066-1071

6. Pandey SK, Werner L, Apple DJ,
Wilson ME. Dye-enhanced adult
and pediatric cataract surgery. In:
Buratto L, Werner L, Zanini M,
Apple DJ, eds., Phacoemulsi-
fication: Principles and Techniques.
Slack Inc., Thorofare, NJ, 2002,
Chapter 41.

7. Pandey SK, Werner L, Wilson ME,
et al. Anterior capsule staining:
Current techniques, guidelines and

February, 2004 362 DOS Times - Vol.9, No.8

REVIEW

The Sociology of Strabismus beings which need to be un-
derstood e.g.
Prof. Prem Prakash
1. Physical growth of
In the following para- eyes with (single binocular sion there are many strains eyes has been compared to
graphs the two eyes in per- vision) resulting in sepa- on binocular functions of physical growth of indi-
fect harmony in a normal rate living (unmarried eye. All these situations vidual.
adult have been compared state) or congenital squint. have been compared to ex-
to a couple who have been Or lack of these prerequi- plain the problems of Bin- 2. Development of vi-
married and have very har- sites the may lead to divorce ocular vision and squint to sion in each eye has been
monious happy marriage, or acquired squint. Even in a couple for easy under- compared to educational
there are certain prerequi- a state of married life there standing to a lay man. development of individual.
sites which must be ful- are many things which
filled. Lack of these prereq- cause strain on married life In these comparisons 3. Fusion (i.e. the capac-
uisites may not have led to and similarly in the pres- few technical terms have ity of the two eyes to per-
a harmonious marriage or ence of binocular single vi- been compared to certain ceive objects as single) has
developments in human been compared to love be-
tween a couple which en-
ables them to view the ob-
jectives of life as single.

Status of Eyes in New Born Status of New Born Children

1. Two eyes in a newly born child have very poorly de- 1. Two children, a boy and girl growing and getting edu-

veloped vision and little coordination between them- cated independently without any mutual relationship.

so to say they have quite independent existence. However they are destined to marry each other and face

However they are destined to work in coordination the world together.

to perceive outside world as a single entity.

2. Development of Eyes 2. Development of Children

i) The anatomical (physical) development continue to i) The children, with proper nourishment grow into

take place even after birth till complete maturity. physically healthy mature man and woman.

ii) The eyes gradually develop full vision with the avail- ii) With proper and adequate educational inputs, they

ability of proper and adequate inputs of visual develop into well educated individuals (Education-

stimuli after birth. vision)

iii) The two eyes start coordinating with each other per- iii) With mutual understanding and interaction they get

ceiving the two images of outside world as one i.e. into a harmonious marriage (fusion) having com-

they have developed fusion (single binocular vision). mon interest.

3. Orthophoria (no Squint) 3. Perfect Marriage
The orthophoric condition means perfectly balanced Perfectly adjusted couple with almost

and coordinated eyes, usually associated with almost: (i) equal education (vision)
i) equal vision (sensory) (ii) physical status with
ii) with normal structure and movement (motor) and (iii) mutual understanding and love without any dishar-
iii) normal fusion (bifoveal single vision) associated with
mony. This is rather uncommon.
no deviation.
The condition is rather uncommon.

4. Binocular Vision (Normal) 4. Common Perception
iv) Both the eyes having normal and equal vision with Couple, each partner having normal and equal
Education with mutual love and affection with
normal fusion faculty resulting in two separate im- Common perception of life.
ages being perceived as one.

5. Stereopsis (Depth Perception) 5. Depth of Understanding
Both the eyes having fusion (common perception) Couple having common perception of life but still

with some disparity of images in each eye giving rise to a having some different interests in life giving rise to better
sense of depth (three dimensional view). and deeper understanding of the world.

February, 2004 363 DOS Times - Vol.9, No.8

REVIEW

6. Squint (Congenital and Acquired) 6. Separate Living (Unmarried State and Divorce)
It is condition in which the visual axis of the two Pair ( a boy & girl) which does not perceive identical

eyes do not meet each other at the subject of regard i.e. the view of objection in life & A pair (destined to be married)
object in space is not perceived by two eyes as single by which has remained unable to perceive similar views of
the fusion of separate images made in each eye. life and remain un-united is comparable to congenital
squint and a couple which ceases to have similar view of
This condition when present since birth is congeni- life and get separated is a divorced couple (comparable to
tal squint or when acquired later in life is acquired squint. acquired squint).

7. Cause of Squint (Congenital) 7. Causes of Separate Living (Unmarried State)

i) Unable to attain normal structural (physical) devel- i) If either of the child is unable to attain normal struc-

opment either of the eye ball itself or its movement tural (Physical) growth.

mechanism (muscles etc) ii) Unequal education and mental development.

ii) Due to unequal development of vision in each eye. iii) Lack or development of mutual affection and love

iii) Lack of fusion (Binocular vision) (the mutual binding forces).

8. Acquired Squint 8. Separate Living (Divorce)

i) Loss or impairment of vital structural (physical) in- i) Loss or impairment of vital physical requirement of

tegrity of either eye or its movement. either partner.

ii) Loss or significant impairment of vision of either eye. ii) Loss or significant impairment of intelligence, men-

iii) Loss or significant impairment of fusion faculty. tal faculties etc. of either partner.

iii) Loss of significant impairment of mutual love or af-

fection.

9. Facultative Suppression 9. Individual Suppression
Non recognition and suppression of image from one No recognition and suppression of a partner in mar-

eye when the image from the other eye is being recognised riage by society when the other partner is being given good
by higher centre-brain. Often recognition is given alter- social recognition often recognition is given alternately
nately to each eye when they have equal vision but have each partner in different spheres of life when they have
no mutual coordination e.g. congenital alternative squint). equal accomplishment but are living separately without
any interaction.

10. Obligatory suppression (Amblyopia) 10 Suppressed Individual (Educationally)
In this one eye can’t see properly as its image is ig- The individuals personality is suppressed because of

nored or suppressed by the higher centre (brain because its inferior status due to one or other cause makes him
of its inferior status to the other eye. Even the better eye is functionally incapable even when the other partner is not
closed i.e. the competition of the two eyes is removed) the in the field.
weaker eye still cannot function properly.

11. Latent Squint (Decompensated) 11. Latent Disharmony
Well balanced eyes without any symptoms but have Well adjusted harmoniously living couple with a ten-

a tendency to deviate (separate out) being kept well coor- dency to separate out (quarrel) but are kept together with
dinated with the help of strong fusion. deep mutual love and affection without any strain in life.

12. Latent Squint (Decompensated) 12. Strained Couple
Balanced eyes but with symptoms of eye strain due The couple with a tendency to separate out which

to weak fusion or due to some anatomical abnormalities can’t be overcome by mutual love and affection causes a
with a great tendency to deviate (separate out). strain in their normal living.

13. Concomitant Manifest Squint 13. Divorced Couple
The eyes have manifest squint (often with poor vi- Couple living separately, (often one partner has poor

sion in one eye) and are without any fusion but have no accomplishment lacking mutual understanding, love and
defect in movement (physical defect). affection but having no physical handicap.

February, 2004 364 DOS Times - Vol.9, No.8

REVIEW

14. Paralytic Squint 14. Physically Handicapped Couple
The eyes having normal vision and fusion but hav- Couples with equal social status and mutual under-

ing deviation due to obstacle of movement of the eye ball. standing, love and affection but unable to live together
due to physical obstacles.

15. Accommodative Squint 15. Divorce due to overstrain
Visually defective eye using excessive accommoda- A poor couple in its zeal to improve its lot accom-

tion (extra muscle effort) to see better, resulting in squint. modates & loses its matrimonial harmony due to exces-
sive hard work resulting in divorce.

16. Accommodative Squint with Convergence Excess 16. Separation due to excessive work
Visually defective eyes which have been aided with A poor overworked couple which has been economi-

glasses and are well balanced for distance but still squint cally aided for routine harmonious day today life but sepa-
while looking for near. rated when the couple is put to more hard and exacting
tasks.

17. Convergent Squint 17. Confronting couple
When the eye deviate towards each other i.e. towards Divorced couple who happen to confront each other

the nose resulting in strong abnormal sensory adaptation/ with strong understandable mutual interaction/adapta-
relationship. tion,

18. Divergent Squint 18. Dissociated Couple
When the eyes deviate away from each other or to- Divorced couple with an effort to walk away from

wards the nose resulting in strong abnormal sensory ad- each other’s life with lesser mutual/undesirable interac-
aptation/relationship. tions.

19. Vertical Squint 19. Divorced couple who are living in different socio/

When the eyes are deviated in vertical plane with economic strata and thus happen to have minimal abnor-

minimal abnormal sensory relationship. mal mutual interaction.

20. Treatment 20. Financially Aided Couple
(Optical glasses) To give adequate financial/social support to the req-
To give adequate power of glasses to each eye ac-
uisite amount to both partners to make them of equal and
cording to its need to make excessive strain thus remov- normal socio-economic status to avoid any stress or strain
ing the tendency to squint. which may jeopardize its matrimonial harmony.

21. Optical Prisms 21. Physical Aided Couple
Provision of prism glasses to bring about passive co- A couple which is physically separated and is un-

ordination of the two eyes with out changing their respec- able with their mutual effort to come together is being
tive deviated position. physically assisted to achieve togetherness.

22. Orthoptic Exercises 22. Counsellor Advice
It is a process by which exercises are given to the eye It is a process by which a counsellor creates aware-

to create a situation resulting in stimultaneous percep- ness of co-existence in a divorced couple and helps in cre-
tion of images in two eyes and then fusing them into one ating and strengthening a feeling of mutual love and af-
resulting in a single binocular vision. fection for each other.

23. Surgical (cosmetic surgery) 23. Reunion (Apparent)
Surgical procedure by which eyes are straightened A separated couple physically made to live with each

to proper position to achieve an apparent lack of devia- other with external help (without any mutual love and
tion (without any single binocular vision). affection just for the sake of appearance.

24. Functional surgery in concomitant squint 24. Physically separated couple who have potential and

The deviated eyes which have fusional potential but affection for each other brought together by external help.

February, 2004 365 DOS Times - Vol.9, No.8

REVIEW

are unable to achieve normal position themselves are made
to do so by surgical intervention.

25. Surgery (paralytic squint) 25. Rehabilitation (Physical)
Surgery undertaken to improve the movement of one Steps under taken to bring about improvement in a

or both eyes to bring about binocular vision in a limited physical handicap of the partner one or both to bring about
field of vision (usually completed normalcy can not be a limited conjugal bliss (absolute conjugal harmony can-
achieved). not be achieved).

26. Treatment of Amblyopia 26. Social/Educational Improvement
Attempt to improve vision of a defective eye to nor- To improve the standards of the socially/education-

mal levels or to make it equal to the vision of better eye. ally weak partner to normal levels or to equal levels of
the other partner.

27. Amblyopia 27. Educational Underdevelopment
Under development of vision of one or both eyes, it Under the development of a partner or both the part-

may be due to: ners either due to non-availability of proper socio-educa-
i) Inadequate stimuli to the eye during their develop- tional faculties during their development period of life or
due to certain suppressive influence on life during that
ment period, or period. There is not only hindrance to educational devel-
ii) Certain inhibitory influence which suppress the de- opment but there is also regression of his already required
socio-educational faculties.
velopment of vision whatever has been already ac-
quired. It may be associated with or without the
presence of squint.

28. Management of Amblyopia 28. Management of Educational Handicap

1. Occlusion: Closure of better eye to give opportunity 1. Education by private coaching the individual is

to the affected eye to get visual stimulus & prevent coached alone without being exposed to competition

competition & inhibition from the normal eye. with other normal individuals.

2. Pleoptics: In case where occlusion does not succeed, 2. Intensive Coaching: Special intensive coaching by

intensive exercises are given by special instruments highly trained teachers.

to improve vision. 3. Counselling: Reconciliation is often helped by a well-

3. Binocular (Orthoptic exercises): It is a process by meaning counsellor to achieve common objectives

which exercises are given to the eye to create a situ- of life.

ation resulting in simultaneous perception of images

in two eyes and then using them into one resulting

in a single binocular vision.

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Congratulations!

Ø Dr. R.B. Jain, for being elected as vice president AIOS in the Varanasi
AIOS conference Jan.,2004

Ø Dr. Raj Anand, for completeing ICO International Fellowship in Oph-
thalmic Plastic and Reconstructive surgery at University of Hospitals and
Clinics (UIHC), IA, USA.

February, 2004 366 DOS Times - Vol.9, No.8

ART OF REFRACTION

Difficult Situations of Refraction the retinoscopy over the old
glasses if present. If avail-
Monica Chaudhary B.Sc.(Hons.), Jeewan S. Titiyal MD able Halberg clips may be
used for over refraction. The
retinoscopy over the glasses
derives the deficiency in

Despite our best retinos- Eg : 1 yr child EG: Current spectacle Prescription is – 13 DS / -1.0 DC at 180
copy we still come across Refraction under Atro- Retinoscopy over this glass is -2.0
difficult situations .We may
do a perfect retinoscopy but pine 1% ointment -1.0
at times are unable to de-
cide on prescriptions. +3.5 Add both -13 -2 = -15

We want to discuss some +4.0 -12 _ 1.0 = -13.0
special cases of refraction
which we have come across Refractive error = So the final correction required is -15 DS / -2.0 DC at 180
over the years. Most of them
are the situations which our 1. Subtract 1D for dis-
students usually have
doubts and want help. tance (if done at 1M) = + 2.5

1. An infant / Toddler DS/ +0.5DC at 90. should be towards the reti- the correction required. The
l Always refract under main purpose of doing this
2. Subtract 1 d for Atro- noscope to evaluate the eliminates the under or
a strong cycloplegic Prefer- overcorrection due to the
ably Atropine 1%ointment pine effect = + 1.5 DS foveal reflex variation in the Back Ver-
tex Power of the finally
l They are normally / +0.50 DC at 90 l Oblique fixation will made glasses over the trial
hyperopic so a retinoscopy frame used.
of error of up to 4 diopters 3. No need to prescribe give rise to false recording
is normal so does not need Over refraction will
prescription this error if the child has no of astigmatism. eliminate your complaint
from the patient that the
l Prescribe an infant or pathology like squint l Avoid using words vision with glasses is not as
toddler only if the Hypero- good as what was during
pia is more than 3.5 diopt- 4. In case of Eso devia- like “it will not hurt”, be- the subjective assessment.
ers or Myopia is greater
than 1.5 diopters or if the tion Prescribe = + 2.5DS/ cause every time the child 3. An aphake
astigmatism is more than 2 l Begin with kerato-
diopters +0.50 DC at 90 (full correc- has gone for vaccination he
metry as this gives you the
l Neglect small cylin- tion as with cycloplegic). may have heard such words clue or the corneal cylinder
drical errors in prescription value and its axis. The inter-
if needed 5. The small cylindrical l GA should be re- nal or the lenticular astig-
matism is absent so the
l If squint is present, error could be ignored in served to last to an impos- most of the times the K cyl-
Its important to correlate inder matches the accep-
the prescription with the the prescription so a spheri- sible child. Repeated at- tance, unless there is a reti-
type of the squint present i.e nal cylinder.
in Convergent squint sub- cal equivalent may be good tempts should be made be
tract for the working dis- l Back vertex power or
tance and prescribe the full enough at this age rescheduling appointments the position of the high plus
correction as under the cy- lens held while doing retin-
cloplegic. at times. oscopy is important. Using
a trial frame is most appro-
Dr. R. P. Centre for Ophthalmic Uncooperative Child l Besides the side ef- priate.
Sciences, A.I.I.M.S., l Being stern never
New Delhi fects of GA, the retinoscopy l Near Addition is a
works must in the aphakic pre-
l Try being out of your under GA may not pick up

white coat the fixation or the fovea re-
l An infant is usually
flex, leading to false read-
uncooperative when he is
hungry or sleepy. Avoid ings.
such times while doing re-
tinoscopy l Sedation like

l Be very fast Phenargan syrups in my
l Small toys, old pens
may make the child friendly experience, make the child
l Let the child be on
parents lap to make him more irritable.
feel secure
l Fixation of the child 2. A high Myope / or a high
Hyperope

l Retinoscopic reflex
may be difficult to visualize
or interpret

l It is best to perform

February, 2004 367 DOS Times - Vol.9, No.8

ART OF REFRACTION

RE LE RE LE
Eg: + 13 +1.25 Eg : _ 1.0 +1.0

+ 15.0 + 1.25 _6.5 -5.0

Working distance = 1 m Refractive error = -2.0 DS/ -5.5 DC at 100

Refractive error: RE : +12 DS / + 2.0 DC at 90 = 6/6 = / -6.0 DC at 80

Add + 2.75DS for near In case the patient has problems adjusting to

LE: Plane = 6/6 Prescribe (spherical equivalent)

RE : - 2.75 DS / -4.0 DC at 100

Contact Lens is given in RE LE : - 1.0 DS / -4.0 DC at 80
So Gls prescribed over would be
RE: Plain = 6/6 Eg : +10.0 -3.5
-6.0
Add + 2.50 (check with contact lens) +12.0
LE: Plain = 6/6
Bifocal RE only

scription. Ø Uniocular aphake Aphakic acceptance = + 8.0 DS / + 1.0 DC at 60 = 6/ 12
a) This patient will need Phakic acceptance = _ 6.0 DS / -2.0 DC at 15 = 6/ 18
Ø An Aphakic Infant or
Child; contact lenses to elimi- needed .Bifocals or now while subjectively assessing
a) The retinoscopy values nate anisometropa. Progressives are a good op- cylinder value and axis
b) Glasses have to be given tion .
are mostly around +20 over the Aphakic contact 6. Irregular astigmatism
and the refractive error lens eye for near prefer- 5. High Astigmatism l Commonly seen in
decreases with age , so re- ably in bifocal form l It is generally recom-
check the change every 2 Keratoconus, corneal scars,
to 3 months 4. A Pseudophake mended to prescribe full some cataracts.
b) Prescribe as early as pos- l Prescription may cylinder to get best visual
sible – the next day of the acuity l The retinoscopic
surgery, to prevent am- fluctuate initially (more if findings are very approxi-
blyopia Phaco surgery is not done) l If the patient fails to mate
c) Correct the child’s re- adapt after several weeks of
fractive error for near l Keratometry is useful wear, modifications such as l Depend on subjective
that is prescribe the dis- to know cylinder amount reducing the cylindrical refraction techniques
tance correction + the and axis. powers maintaining the
near add as the infant same axis and merging as l Visual acuity achie-
needs vision upto 1 l Anisometropia is spherical equivalent may ved may never be 100%
meter distance .Bifocals most disturbing in prescrib- be tried. with spectacles.
are added only at 1.5 to ing so judgment in binocu-
2years age (when the lar balancing is important. l Don’t manipulate the l Pinhole vision is al-
child starts walking) Anisomeropia theoretically old wearers axis too much, ways better and contact
d) Visual acuity (objective should not be more than 2.5 unless indicated by retinos- lenses are advisable to get
methods) and Binocular to 3.0 diopters. Though the copy. There will be lot of good vision in such cases
tests should be done at subjective response is the adaptation problems in
all follow up visits to rule best to check for diplopia or slight axis change. Explain l Antiglare glasses
out amblyopia and sqint. suppression while in the beforehand. may help in eliminating
c) Contact lenses are advis- trial frame. Some patients glare complaints
able in all aphakics still are very sensitive to small l Cylinder powers
there are times during degrees of aniesokonia and higher than 4 D with bifo- Scissors Reflex
the day when the child some may accept large dif- cals may have adaptation l Usually seen in cata-
needs glasses. ferences. Anyway the sur- problems.
geons keeps this in mind al- racts and irregular
ways before surgery. l Autorefractors are a astimatism
good help for axis accuracy
l Near addition usu- l End point, may be dif-
ally between +2. to + 3.Ds is l There is no replace- ficult to achieve
ment of a cross cylinder
l The end point may be
when the reflex breaks from
the centre and not from pe-

February, 2004 368 DOS Times - Vol.9, No.8

ART OF REFRACTION

riphery RE: 6/24 LE: 6/18p l Don’t’ use occuluder
l Authorefractors help Dry ref: -1.50 -1.0 while taking acceptance,
cover the other eye with a
in this case -1.0 -2.0 high plus lins to reduce the
l Dry Refraction is bet- amplitude of nystagmus.
Variable and unstable retinoscopy
ter than wet in such cases l Record binocular vi-
to avoid peripheral distor- Dry Acceptance RE: -1.75 DS=6/6 sion also.
tion sand aberrations as
much as possible Le: -1.50 DS=6/6 13. Patients with Low vi-
sion
7. Nuclear Sclerosis Repeat refraction under HA2%
l One is very likely to l Depend on your reti-
+ 1.25 +1.25 noscopy to prescribe
see rapidly increasing myo-
pia at times uniocularly +1.5 +1.25 l Neglect small cylin-
ders in prescriptions they
l Surgeon may have to Va under HA may not contribute much in
decide surgery in case of vision
marked anosometropia R E 6/6p LE: 6/6
l Use ETDRS charts for
l The refraction may Acceptance RE: -0.25 DC at 180=6/6 acuity recording and accep-
show two reflexes, one cen- tance rather than Counting
tral through the nuleus LE: Plain =6/6 Fingers.
much higher minus and
other peripheral, and much This clearly explains psedomyopia. l Check binocular ac-
more plus. Concentrate on ceptance of glasses and let
the central glow. l Record vision under correct his near visual acu- your patients decide.
cyclplegia along with ac- ity
l Subjective tech- ceptance. 14. Complicated Pseudo-
niques are the best in such 11. Low refractive errors. phakia
cases to prescribe. l Compare this with
PMT findings. If accommo- l Low errors can be l Are patients with
l Patients may be get- dation in excessive the pa- tiled lens, up drown pupil
ting used to higher near ad- tient may have tendency to grouped into those which or dislocated IOL.
ditions due to their increas- accept more minus. Relax
ing minus for distance, so the eye by fogging and pre- reduce the visual acuity ti l In case of tilted lens –
sometimes higher additions scribe on basis off there may be large astigma-
may be required to satisfy cyclopegic findings. 6/12 or better. The indi- tism not matching the cor-
the patient. neal cylinder. Do retinos-
l Visual Acuity will im- vidual will not be dissatis- copy and take subjective
9. Pseudomyopia or Ac- prove after accommodative acceptance. Keeps the cyl-
commodative spasm spasm is over. fied so such because of vi- inder prescription to a low
balancing with the other
l This may be com- l Visual hygiene and sion but will have astenopia eye
monly seen in young adults exercises should be ex-
and children who do lot of plained to relax accommo- or intermittent blurring l In case of up drawn
near work like reading and dation. pupil. The visual axis and
studying complaints. the refraction axis may not
10. Early Presbyope match. Take subjective and
l The Patient usually l Is said to be one who l Do cycloplegic re- prescribe.
complaints of blurred dis-
tance vision of recent onset, has near vision inadeq- fraction (preferably l In case of disclocated
without any pathology. uance before the age of 40 IOL – treat it like subluxated
tropicamide) lens and record both phakic
l On Dry retinoscopy l Such patients are and aphakic acceptance.
the judgement can be made hypermetropes or have plus l Correct the small er-
by variable retinosocpy val- cylindrical errors for dis- 15. Post Yag Capsulo-
ues. The shift will be more tance due to which their rors to relieve patient of as- totomy
towards minus and vision near vision gets affected.
and refraction findings may thenopia. l Most of the times the
not correlate. l Do best distance re- glow is faint and objective
fraction and prescribe the l Decision is done only readings are not there.
l Repeat Cylcloplegic plus for distance. This will
refraction in such cases. if the penitent is symptom- l Try previous accep-

atic.

12. Nystagmus
l Cycloplegic refrac-

tion is must to have fairly
accurate retinoscopic find-
ings.

l Patients may have
subnormal vision so objec-
tive findings are important.

February, 2004 369 DOS Times - Vol.9, No.8

ART OF REFRACTION

tance – prior to YAG and it etc tion as much as possible l The patients usually
works in most cases. l Refract under dila- l Subjective Tech- need glasses in between CL
wear so little overcorrec-
l Else do Keratometry tion both through Aphakic niques are important as tion will help them over-
and knowing the cylinder and Phakic poritions. there is likely to be some come spectacle blur phe-
on this basis refine the amount of irregular astig- nomenon.
spherical correction subjec- l Take acceptance both matism with disturbing ab-
tively. aphakic or phakic with best erration due to different Summary
corrected visual acuity both zones of ablation As a practioner, we are
16. Case of ambnlyopia in wet and Dry state.
9. Post contact lens wear still coming across cases
l Prescribe the l Retinoscopy is likely l Acceptance will which even years of expe-
to give high cylinders and rience may not help. Each
ambloyopic eye according difficult to judge due to par- show higher minus if taken patient teaches us and its
tial areas of glow. soon after removal of con- ongoing. The findings
to the retinoscopy tact lenses. above are just my experi-
l Prescribe whichever ences, however I may have
l Depend on the objec- is best accepted, Phakic or l This variation is missed on some. I hope
aphakic much higher in PMMA these tips may be a help to
tive findings l Vision may be subnormal wearers. Refraction may all and I welcome your sug-
also take weeks to be stable. gestions and advices.
l Advice occlusion
8. Post refractive surgery l However, refracting
along with glasses. l Do Dry refraction after 24 hours of removal of
lenses is fairly good enough.
17. Subluxated lens trying to relax accommoda-
l Such is commonly

seen in Ectopia lentis,
Homocystinuria , trauma

New DOS Members

B-1056 B-1777 A-1057 S-1786
Behera Geeta Babber Meenu Acharya Manisha C. Sood Rimi
10/68, Ladies Hostel Eye Department J-303, Siddh Apartments 78, Vinoba Basti
A.I.I.M.S. Rajindra Hospital 107, Indraprastha Extension Sri Ganga Nagar
Ansari Nagar Patiala Patparganj, Delhi
New Delhi-110029 S-1787
K-1778 G-1767 Sonker U.K.
G-1055 Kandara Usha Gupta Monika 84/341, Katra Mahboolganj
Goenka (Major) Ranjit House No.1520, Street No.15, Guru Room No.8, Lucknow
5/111, Cariappa Vihar, Delhi Cantt. Nanak Nagar P.G. Girl’s Hostel
New Delhi-110010 Near Gurubax Colony M.L.B. Medical College K-1788
Patiala Jhansi-284128 Kalra Rohit
P-1784 Sitapur Eye Hospital
Paul Gautam M-1779 G-1768 Sitapur
Qtr. No.15, Registrar Flat Manoher Jaishri Murli Gupta Neeraj Kumar
Silchar Med. College Qtr. Complex “Murli Manoher Niket” Room No.117 S-1789
Silchar Medical College Bhinasar C.V. Raman Hostel Sharma Anand
Dt. Cachar Bikaner M.L.B. Medical College A-16, Indrapuri
Jhansi Agra-282005
C-1772 B-1780
Chandra Vikas Buntolia Ramesh Chand M-1769 P-1790
D-117, Ramesh Vihar Manjeet Singh House Maurya Vijay Kumar Purohit Jayprakash A.
Aligarh Near Samrat Cinema Hig-6/346, Phase-III, “Hasu-Smruti”
Sikar Jhunsi Avas Vikas Colony, Jhansi 9, Gopal Nagar
M-1774 Rajkot-360002
Malhi Ravinder Kaur J-1781 C-1771
H.No.73, E-Block Jain Vikas Chandra Silni M-1791
Bhai Randhir Singh Nagar 52, Block-E 163/9a, Saket Nagar Maheshwari Alok
(B.R.S. Nagar), Ludhiana Sri Ganga Nagar Bhopal 3/95, Kamal Kunj
Vikas Nagar
P-1776 S-1782 A-1785 Lucknow
Prasher Pawan Sharma Anil Ahuja Renu
Room No.17, F-153, Jan Path Ahuja Hospital C-1800
Doctor’s Hostel, Rajindra Hospital Shyam Nagar, Ajmer Road D-Com-19/Ii, Trans Yamuna Chauhan Sunil
Patiala Jaipur Agra 35, Panchwati
Alwar

February, 2004 370 DOS Times - Vol.9, No.8

JOURNAL ABSTRACTS

Early intervention at a prethreshold stage after surgery, examination findings at the time of onset of
symptoms and referral, laboratory workup, treatment,
of ROP decreases the incidence of an un- and outcome. The cataract surgeons involved were con-
tacted to determine their cataract practice and to deter-
favorable outcome. mine any possible breach in the sterile technique. The
median interval to onset of symptoms after cataract sur-
Azad RV, Sethi A, Kumar H.J. gery was 5.0 days (mean, 5.8 days; range, 3-9 days). The
Pediatr Ophthalmol Strabismus. 2003 Nov-Dec;40(6):330-4. initial diagnoses at the time of onset of symptoms were
Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New keratitis (n = 3), scleritis (n = 1), and excessive anterior
chamber reaction (n = 3). The last 4 patients were treated
Delhi. with topical and/or systemic corticosteroid therapy be-
fore referral. All cases subsequently developed deep
The purpose was to evaluate the success of and timing keratitis. Specimens for microbiology workup were ob-
for intervention in retinopathy of prematurity (ROP). tained by scrapings (n = 6), corneoscleral biopsy (n = 4),
Eighty-two eyes of 50 children with stage 3 ROP were di- and anterior chamber paracentesis (n = 4). Organisms
vided into two groups based on severity. Cryotherapy or identified were Aspergillus flavus (n = 2), Aspergillus
laser therapy was performed soon after the detection of terreus (n = 2), Aspergillus spp. (n = 2), and Candida
threshold stage in the first group of 40 eyes and at a albicans (n = 1). The infection resolved with medical
prethreshold stage in the second group of 42 eyes. The therapy in 2 cases; the final visual acuity was 20/125 in
patients were observed from 4 months to 2 years and re- one case and 20/20 in the other case. The infection pro-
gression or progression was noted. Unfavorable outcomes gressed to endophthalmitis in 5 eyes, resulting in complete
including macular and disc drag and the progression of loss of vision. The source of infection could not be identi-
ROP to stages 4 and 5 were correlated with birth weight, fied in any case. Fungal infection of self-sealing tunnel
gestational age, age at threshold, and age at intervention. incision for cataract surgery is a diagnostic and therapeu-
Study results show regression of ROP occurred in 75 tic challenge carries a very poor outcome.
(91.46%) of the eyes. An overall unfavorable outcome oc-
curred in 14 (17.07%) of the eyes, 11 of which reached Screening for diabetic retinopathy by
threshold during the critical period of 37 to 39 non-ophthalmologists: an effective pub-
postconceptional weeks of age. Of the cases (n = 14) with lic health tool.
an unfavorable outcome, 9 eyes (22.5%) were in the group
treated in the threshold stage (n = 40) and 5 eyes (11.9%) Verma L, Prakash G, Tewari HK, Gupta SK, Murthy GV, Sharma N.
were in the group treated at a prethreshold stage (n = 42).
The mean birth weight, gestational age, age at threshold, Acta Ophthalmol Scand. 2003 Aug;81(4):373-7.
and age at intervention in the favorable and unfavorable
outcome groups were 953.2 +/- 2.19 g and 1,059.57 +/- Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India In-
2.62 g, 28.63 +/- 2.03 weeks and 28.36 +/- 1.98 weeks, stitute of Medical Sciences, New Delhi 110 029, India.
38.04 +/- 2.13 weeks and 37.71 +/- 1.13 weeks, and 38.32
+/- 2.34 weeks and 38.25 +/- 1.05 weeks, respectively. Au- The purpose of the study was to investigate and report
thors conclude that early intervention at a prethreshold the reliability of detection and grading of diabetic retin-
stage of ROP or at a younger postconceptional age (ie, opathy by direct ophthalmoscopy through a dilated pupil
younger than 37 weeks) may decrease the incidence of an by general physicians (non-ophthalmologists) and optom-
unfavorable outcome. etrists who have undergone a short period of training.
Authors included a total of 400 eyes of 200 diabetes pa-
Fungal infection of sutureless self-seal- tients examined by two non-ophthalmologists. Their ob-
ing incision for cataract surgery is a diag- servations were compared with an ophthalmologist’s di-
nostic and therapeutic challenge. agnoses for the same patients. The diagnoses made by the
general physician (kappa = 0.8381, SE = 0.041) and the
Garg P, Mahesh S, Bansal AK, Gopinathan U, Rao GN. optometrist (kappa = 0.7186, SE = 0.051) showed good rates
Ophthalmology. 2003 Nov;110(11):2173-7. of agreement with the ophthalmologist’s diagnoses. The
provision of appropriate screening protocols and follow-
Cornea Service, L. V. Prasad Eye Institute, Hyderabad, India. up parameters can enable primary care physicians and
support personnel to reliably screen individuals for retin-
Authors report the clinical picture and outcome of fun- opathy in diabetes. This will reduce the workload of ter-
gal infection of self-sealing wounds in cataract surgery. tiary hospitals, and provide optimal services to the huge
In a retrospective noncomparative case series study 7 con- majority of the Indian population that has limited access
secutive patients who underwent cataract surgery in dif- to eye care services.
ferent locations in India and developed microbiologically
proven fungal infection of the surgical wound were in-
cluded. All were managed at a tertiary eye care center in
India between May 2001 and April 2002. The data re-
viewed included patient age, gender, onset of symptoms

February, 2004 371 DOS Times - Vol.9, No.8

EVENTS

Forthcoming Events – NATIONAL

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

Event Conference Date Venue Contact Person and Address

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

Eye Scope 2004 14th-15th Bombay City Institute Secretary: Dr. Mihir Kothari,

Feb. 04 & Research Centre City Eye Institute & Research Centre,

Mumbai 5, Babulnath Nagar, Mumbai-400007

Ph.: (022) 2367-1011, 23619234,

Fax: 2363-7293

E-mail: [email protected]

Website: www.eyecareforall.com

12th Annual Meeting Vitreo 20-22nd Corbett Claridges Contact Person: Mr. Shobhit Chawla,
Retinal Society of India Feb. 2004 Hideaway, Ramnagar Organising Secretary, Prakash Netra Kendra,
Uttaranchal NH 2, Vipul Khand-4, Gomtinagar,
Lucknow (U.P.)

Annual DOS 3rd-4th India Habitate Centre Contact Person: Dr. Jeewan S. Titiyal,
Conference April 2004 Lodhi Road, New Delhi Secretariat (DOS) R.No. 476, 4th Floor,
Dr. R.P. Centre for Ophthalmic Sciences,
National Workshop on New Delhi - 110 029 Ph.: 26589549,
Phacoemulsification Fax : 26588919, E-mail: [email protected]
Website: http://www.dosonline.org

21st-22nd R.P. Centre for Contact Person: Dr. Jeewan S. Titiyal,
April, 2004 Ophthalmic Sciences R.P. Centre, Ophthalmic Sciences, AIIMS,
Ansari Nagar, New Delhi - 110 029
AIIMS, Ansari Nagar, E-mail: [email protected]
New Delhi

INTERNATIONAL

Event Conference Date Venue Contact Person and Address

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

International Symposium on 11-14 MONTE CARLO Contact: Iliana Eliar, Assistant Project Manager,
Ocular Pharmacology Kenes International Global Congress Organizers
Mar. 2004 & Association Management Services
E-mail: <[email protected]>

ASCRS Annual Symposium 1-5 SAN DIEGO, CA USA Contact: ASCRS Tel.: 1703-591-2220
May 2004 Fax: 1703 591 0614, Web: www.ascrs.org

XXII Congress of the ESCRS 18-22 PARIS, FRANCE Temple House, Temple Road, Blackrock,
Co Dublin, Ireland
Sept. 2004 Tel.: 3531-209-1100 Fax: 3531-209-1112
E-mail: [email protected]

American Academy of 23-26 NEW ORLEANS, American Academy of Ophthalmology,
Ophthalmolgy Oct. 2004 LA, USA New Orleans, LA, USA Tel.: 1415-561-8500 Ext. 304
Fax: 1415-561-8583, Web: www.aao.org

February, 2004 372 DOS Times - Vol.9, No.8

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: 20th 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 should be Session - I Session - II
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, the name of the Presenters Surname:____________________ Name____________________________
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 (8 minutes) in CD, VHS should be submitted along with abstracts.
w Best Poster and Best Video presentation will be awarded trophy and prize money.

February, 2004 373 DOS Times - Vol.9, No.8

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
• Instruction Course
• And Many More

Entry to the trade & scientific sessions will be

strickly allowed only for registered delegates

"

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 Ophthalmological
______________________________________
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 Rs. 850.00
Resident* - Member Rs. 1,200.00 Rs. 1,700.00
-Non-Member Rs. 900.00 Rs. 1,100.00
* Proof of Residency Required
Rs. 400.00 Rs. 550.00

Rs. 500.00 Rs. 650.00

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.

February, 2004 374 DOS Times - Vol.9, No.8

DOS QUIZ NO. 8

DOS QUIZ NO. 8

1. The most important determinant in selecting a procedure for ptosis surgery .............................................................
2. Inheritance of Keratoglobus is ...............................................................................................................................................
3. Who invented slit lamp biomicroscope ...............................................................................................................................
4. Economic blindness is defined when vision drops below .................................................................................................
5. Wave length of double frequency Nd: yag laser is .............................................................................................................
6. Antibiotic of choice in angular conjuctivitis is ...................................................................................................................
7. Latent hyper metropia amounts for .....................................................................................................................................
8. Ophthalmic nodosa is caused by ...........................................................................................................................................
9. Most effective treatment for rosacia keratitis is .................................................................................................................
10. Systemic anomaly associated with blepharo phimosis syndrome ..................................................................................

Rules:
l Please send your entries to the DOS office latest by 25th February, 2004.
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. 6

1. Most common lesion involving anterior segment of eye in AIDS Kaposi Sarcoma
2. Most common symptomatic metastatic uveal tumors Breast Carcinoma
3. Dilator pupillae orginates from which embryonal layer Neuroectoderm
4. Most common cause of bull’s eye maculopathy Cone Dystrophy
5. Cherry red spot disappears after injury by 4-6 Weeks
6. Economic blindness is called when snellen acuity falls below 6/60
7. Epithelium of canaliculus is lined by Stratified Squamous Epithelium
8. Which laser is used in IOL master Diode-780 mm
9. Magnification caused by direct ophthalmoscope 15 times
10. Most common systemic disease associated with necrotizing scleritis Rheumatoid Arthritis
Winner of DOS Quiz No. 6: Dr. Ajay Sapra (Congratulation)
DOS Times - Vol.9, No.8
February, 2004 375

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 Regulations
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)

February, 2004 376 DOS Times - Vol.9, No.8

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).

Nominations for
DR. P.K. JAIN ORATION & DR. S.N. MITTER ORATION

Nominations are invited for a distinguished Ophthalmologist of long standing and who is a
voting member of the Delhi Ophthalmological Society, for the above mentioned Orations of
DOS.

Selection Procedure
Nomination can be sent by:
1. Any of the Past Awardees
2. Any of the Past Presidents
3. At least 5 members of the Executive Committee
4. At least 15 members of the Delhi Members of DOS.

The nomination must include an introductory paragraph justifying the Nomination, a Biodata
of the Nominee, a statement to the effect that the Nominee would accept the Award if awarded
and would deliver an Oration of his choice at the Annual Conference of the DOS and would
intimate the Society the Topic at least 4 weeks before the Conference and a typed script 15 days
before. The Awardee would need to give the copyright of the text of his talk to the Society.

Selection Process
The selection will be made by a Selection Committee consisting of the President, Secretary and
3 senior, distinguished members from 3 different sub-specialties of Ophthalmology. The
Executive Committee would take the final decision on the basis of the recommendations of the
Selection Committee. The nominations must be received in DOS Secretariat not later than 5.00
p.m. on February 24th, 2004.

Advance copy of the nominations may be sent by fax/email. The hard copy must however be received in the DOS
Secretariat by the last date for receiving the nominations.

February, 2004 377 DOS Times - Vol.9, No.8

DCRS

DOS Credit Rating System (DCRS)

The rate of technological and academic obsolescence in was the cultivation and promotion of the Science of Oph-
Ophthalmology has reached astronomical levels in recent thalmology in Delhi.
times. What was advanced yesterday may already be ob-
solete today. The rapid strides in skills and knowledge have In a bid to strengthen our efforts in this direction and
created a need for an extremely intensive Continuing fulfil the vision of our society’s founders, DOS announces
Medical Education programme. the DOS Credit Rating System (DCRS), the details of which
are given below. Our Primary objective is to promote value-
DOS has always been in the forefront of efforts to en- basedknowledgeandskillsinOphthalmologyforourmem-
sure that its members remain abreast with the latest de- bers and give recognition and credit for efforts made by
velopments in Ophthalmology. Among the important individual members to achieve standards of academic ex-
objectives formulated by the founders of our constitution cellence 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 – Ad- Institutional assessment for best performance will
ditional 20 bonus Credits. be based on the total score of members who attend
divided by number of members who attended. Insti-
Member who have earned 100 Credits, are entitled tutional assessment regarding decision to retain the
to: institute for the next year will be based on total score
by all delegates who attend the meeting divided by
a) Certificate of Academic Excellence in Ophthal- average attendence of all 8 meetings.
mic Practice.
Please note that the Institutions’ grading increases
b) 50% exemption of Registration fee at next An- if the attendance at its meeting is higher (i.e. more
nual DOS Conference. than the average attendence of the eight monthly
meetings).
c) DOS Travel fellowship for attending conference. ——————————————————————
A member to be eligible for the fellowship needs to * Based on Signature in DCAC
score 100 DCRS points. ** Subject to Submission of Full Text to Secretary, DOS
† Credits will be reduced in case attendence is only
If any member earns 200 Credits, he/she shall, in for part of the meeting.
addition to above, be awarded Certificate of Distin-
guished Resource-Teacher of the Society.

February, 2004 378 DOS Times - Vol.9, No.8

TEAR SHEET NO. 8

Sudden Loss of Vision Revisited

Transient Persistent
(Vision returns to normal within 24 hours)
Painless (Fundus examination)
Few Seconds:
Amaurosis fugax (unilateral) Unilateral
Retinal artery occlusion
Local Retinal vein occlusion
Impending central retinal vein occlusion Ischemic optic neuropathy
Ischemic optic neuropathy Vitreous hemorrhage
Carotid occlusive disease Retinal detachment
Intermittent angle closure glaucoma
Papilledema Bilateral
Optic disc drusen Methyl alcohol poisoning
Orbital tumor (gaze evoked) Quinine poisoning

Systemic (Bilateral) Painful
Vertebrobasilar insufficiency (bilateral) Acute angle closure glaucoma
Fainting with vasomotor collapse) Corneal hydrops (keratoconus)
Heart failure Optic neuritis (pain with eye movements)
Hypotension (fatigue, hunger, vitamin deficiency) Penetrating or blunt injury
Hypertension
Sudden change in blood pressure Hyphaema
Central nervous system lesions Traumatic optic neuropathy
Choroidal tear
5-60 minutes: Ruptured globe
Migraine (with or without a subsequent headache)
Cardiac arrhythmia/thromboembolism Following surgery
Ocular ischemic syndrome Endophthalmitis
Giant cell arteritis Optic nerve injury during orbital surgery

Functional visual loss

February, 2004 – Satya Karna, DO DNB

Karna Eye Clinic, Lajpat Nagar, New Delhi

379 DOS Times - Vol.9, No.8