DOS TIMES TIM ES
Editor-in-chief Plasma Fugo Blade: Shows the cloud on the 100 micron activated tip of Fugo
Dr. Jeewan S. Titiyal blade. The yellow cover on the tip is the plasma cloud that has cutting
properties, while the red colour is that of photon cloud that doe not cut
Associate Editors
Dr. Harish Pathak
Dr. Harminder K. Rai
Dr. Vijay B. Wagh
Editorial Advisers CONTENTS
Dr. K.P.S. Malik
Dr. Pradeep Sharma EDITORIAL ..................................... 47 MANAGEMENT PEARLS
Dr. Ramanjeet Sihota
Dr. Ritu Arora CURRENT PRACTICE w Visual Rehabilitation after
Dr. Dinesh Talwar Penetrating Keratoplasty ............. 73
w Sutureless Vitrectomy ................... 48 Rajesh Sinha, Jeewan S Titiyal,
Special Correspondents S Natarajan, Aneesh Neekhra Namrata Sharma, Rasik B Vajpayee
Dr. Ajay Aurora
w Glaucoma Surgery with FUGO w Chemical Injuries:
Dr. Rajib Mukherjee Blade –A Break through in Management Guidelines .............. 76
Dr. Anita Sethi Approach and Technique ............ 51 Ritu Arora, Vandana Jain, D.K.Mehta
Daljit Singh, Kiranjit Singh,
Dr. Namrata Sharma Ravijit Singh w Management of Dislocated
Dr. Devender Sood Nuclear Fragment During
Dr. Pradeep Venkatesh w Manual SICS by Irrigating Vectis: Phacoemulsification ..................... 80
Stepwise Small Tips ..................... 55 Amit Khosla, Jasmita Popli
Coordinators Samar K. Basak
Dr. Avnish Gupta REVIEW
w Transpupillary Thermo Therapy –
Dr. Raju S. An emerging modality in treatment w Surgical Approach for
Dr. Anand Agrawal of Subfoveal and Juxtafoveal Orbitotomy ..................................... 83
Ms. Monika Choudhary Choroidal Neovascular S.M. Betharia
Membranes .................................... 59
Published by Lalit Verma, Ankur Sinha, Jayaram, w Eye Banking – The Present
Dr. Jeewan S. Titiyal H.K. Tiwari Scenario in Our Country .............. 88
R.V. Ramani
for ART OF REFRACTION
Delhi Ophthalmological Society w Proliferative Vitreoretinopathy ... 90
w Prescribing the Aging Eye Neena Kumar, Rajvardhan Azad,
Printed by – The Presbyopic Correction ........ 64 Yog Raj Sharma, Atul Kumar, Rajpal
Computype Media Monica Chaudhary
208, IJS Place, Delhi Gate Bazar, COLUMNS
New Delhi-2 Tel: 23284148, 23259312 OPHTHALMIC APPLIANCES
w Journal Abstracts .......................... 66
DOS Office w Indirect Ophthalmoscopy: w Forthcoming Events ...................... 90
Room No. 476, Dr. R.P. Centre Principles, Technique and w DOS Quiz No. 2 ............................. 95
for Ophthalmic Sciences, AIIMS, Practical Tips ................................ 70
Ansari Nagar, New Delhi-110029 Vinay Garodia TEAR SHEET-2
( : 26589549 Fax : 91-11-26588919
w RD Colour Coding Chart ........... 103
Email: [email protected] Neena Kumar
Website : www.dosonline.org
Keep October 19, 2003 Free for
MID TERM CONFERENCE
of Delhi Ophthalmological Society
August, 2003 45 DOS Times - Vol.9, No.2
August, 2003 46 DOS Times - Vol.9, No.2
EDITORIAL
Dear friends, instruments which have done away are still short of our target as far as
with the use of sutures.” Minimal procurement of corneas is con-
The advent Invasive” technique is the guru man- cerned. We receive many pledge
of 21st century has tra of the day. Earlier we had ush- cards, their number is in thousands
ushered in a tre- ered in the concept of small incision- but just a pledge for donation is not
mendous ad- no stitch cataract surgery, thanks to sufficient. In fact donation after
vancement in the Kelman’s Phacoemulsification and death is actually very less even
field of science now we have sutureless vitrecto- from those who have pledged. This
and technology at a very rapid pace. mies. The Plasma Fugo blade is a means our campaign to increase
More important has been its appli- classic example of a new technology pledging is a failure. Our focus
cation in various spheres of life and with multipurpose use as high- should be directed towards increas-
one of the most important field lighted in the article by Dr. Daljit ing the motivation of relatives and
which has seen a revolution of sort Singh. next to kin for donation. A united
has been Medicine. It would not be effort is needed by all sections of
prudent to say that along with Car- All said and done, it however re- society to help in achieving this goal.
diac medicine, Ophthalmology is mains to be seen how these ad-
one of the leading branches of clini- vancements are of help to develop- DOS website dosonline.org has
cal medicine which has undergone ing countries like ours where manual come back in a new format. Very
a sea change because of the rapid- small incision stitchless surgeries are soon every member would be able
ity at which new technology is be- more popular because of the cost to logon to the website. I look for-
ing used for diagnosis and treat- benefit as well as less surgical time ward to improve the website, spe-
ment of various ocular disorders. in dealing with high volumes of cially the discussion forum and
The specialties of Glaucoma and cataract surgery. news section along with DOS Times
Retina have seen widespread ad- archive. With the valuable feedback
vances in form of development of Corneal Blindness is a major and suggestions of our members we
sophisticated diagnostic appliances cause of concern as it forms a major can improve on the shortcomings,
(Ultrasonic Biomicroscopy, Optical chunk of treatable blindness group. if any, and thus give a new look and
Coherence Tomography etc) newer With the availability of Eye Bank- flavour to the various activities of
forms of lasers (PDT and TTT for ing services, processing and storage our esteemed organization.
ARMD) and modern microsurgical problems though taken care of, we
!!Attention DOS Members!!
The registration fees for life membership of
Delhi Ophthalmological Society
is now being increased to Rs. 3,100 from
1st August 2003
– Secretary DOS
August, 2003 47 DOS Times - Vol.9, No.2
CURRENT PRACTICE
Sutureless Vitrectomy for conjunctival peritomy there are settings where the
and no sutures are required full capabilities of 19-20
S Natarajan DO, FRVS at any conjunctival or scleral gauge instruments may not
Aneesh Neekhra MS,DNB,DOMS,FCPS opening site. The develop- be required and smaller
ment of smaller gauge instru- gauge instruments may be
Since the advent of couch- recognizing that high instru- ments may prevent the incor- more desired due to their less
ing by Sushrata, ophthalmic ment functionality may not poration of multiple func- in invasive nature.
surgical techniques are un- always be compatible with tions in their design. Also
dergoing rapid develop- small size. due to the smaller size, the Instrumentation
ments and modifications. infusion and aspiration The TSV consists of a 25-
The aim is to adopt the tech- At first, there were no suit- rates are reduced. However,
nique with best possible out- able materials to use as su- guage microcannula system
come by least possible inva- tures in the eye, so the eye had
sion of ocular anatomy. With to be bandaged and healing Fig.1: 25 gauge 'Entry Site Alingment System"
the rise in sutureless cataract was left to its own. This meant
surgeries with minimal pa- the patient was confined to Fig.2: Array of 25 Vitreo Retinal Instruments
tient morbidity post opera- bed with their head literally
tively, vitreoretinal proce- sandbagged to prevent move- Fig.3: Removal of trocar leav- Fig.4: Insertion of 25 gauge
dures also underwent lots of ment that might jeopardize ing the cannula in place as a vitrector through the cannula.
changes. the healing process. Overall channel for the introduction of The other cannula is kept
the quest for least morbidity 25 guage instruments. The in- plugged (Blue) till the introduc-
Though sophisticated in- for patient postoperatively fusion line can be seen in posi- tion of endo illuminator
struments and lasers have undergoes full circle from No tion.
been developed for suture Era in cataract surgery
vitreoretinal surgery but still to again sutureless
the patient needs to undergo vitreoretinal surgery. In the
20 gauge sclerotomies and early 1970s, Machemer1 used
post operative morbidity be- a 17-gauge 1.5mm diameter
cause of sutured wounds. multifunctional instrument
Tunnel based sclerotomy by capable of cutting and aspi-
Chen4 was suggested to cre- rating the vitreous followed
ate self sealing incisions for by a smaller vitreous cutter of
VR surgery but it requires a 20 gauge (0.9 mm) designed
conjunctival peritomy and by O'Malley and Heintz2 in
suturing and is associated 1974. The race for smaller
with complications like instruments doesn't end here.
wound leakage, extention, In 1990 De Juan and
dehiscence, hemorrhage, vit- Hickingbotham3 designed a
reous and / or retinal incar- variety of 25-guage (0.5mm
ceration, retinal tears, dialy- diameter) vitreoretinal in-
sis and difficulty in passing struments and thus the era of
instruments. Modifications sutureless vitrectomy begins.
in vitrectomy instrumenta-
tion aimed at decreasing the Transconjunctival sutu-
size of instruments must reless vitrectomy system
achieve a balance between (TSV) 25 guage developed by
ability to achieve smaller in- Fujii et al5 allows self-sealing
cision sizes versus maximiz- transconjunctival scleroto-
ing instrument functionality, mies and minimizes surgi-
cally induced trauma, im-
Aditya Jyot Eye Hospital proves operative efficiency
Aashirwad, 168-D Vikas Wadi and hastens postoperative
Dr. Ambedkar Road, Dadar T.T. recovery. The self-sealing
Mumbai - 400 014 sclerotomy obviates the need
August, 2003 48 DOS Times - Vol.9, No.2
CURRENT PRACTICE
and a wide array of vitreo- cannula consists of a small operating times were notice- tween minimum infusion
retinal instruments specifi- metallic tube 5mm long with ably greater for the 'initial rate and maximum aspira-
cally designed for this oper- an inner/outer diameter of opening' and 'final closing' tion rate is larger in the TSV
ating system. Integral to this 0.37/0.56 mm. The intraocu- steps of the surgery. The system, which allows for
vitrectomy instrument sys- lar portion of the infusion 'vitrectomy' time was an av- greater safety margin against
tem is the 25-gauge cannula is directly inserted erage of 1 min 23 sec longer hypotony during aspiration.
microcannula system. It con- into the eye through the using the 25 gauge TSV. The 25-gauge cannula
sists of a microcannula, an microcannula. A collar at the should not be used concur-
insertion trocar, an infusion extra ocular portion allows Techniques rently with standard 20
cannula, a plug forceps, and the infusion cannula to be Stretching the conjunctiva guage vitreous cutter as it
a cannula plug. The cannula held and facilitate its ma- may result in hypotony dur-
remains in place and newly nipulation. at the beginning of the pro- ing aspiration resulting form
designed smaller instru- cedure with cotton tipped functional discrepancy be-
ments can be introduced A wide array of vitreo- applicator before entering the tween infusion and aspira-
through it to perform surgery retinal microsurgical instru- pars plana ensures that at the tion rates of both systems. The
in the posterior segment. ments (Fig.2) complying end, when the trocar is re- TSV system can provide a
with the 25-gauge standards moved, the conjunctiva will better gas fill as it is a more
The microcannula con- have also been designed. help cover the hole made by closed system. The 25 g. cut-
sists of a thin- walled polya- These include a high-speed trocar. Three entries using ter can be used to sweep
mide tube 3.6 mm in length vitreous cutter, illumination trocar cannulas are made in blood off the retina.
with an inner / outer diam- probe, intraocular micro for- the inferotemporal, supero-
eter of 0.57/0.62 mm. A col- ceps, rigid retinal pick, flex- temporal and supreonasal After removal of the trocar
lar is present at the extraocu- pressure is applied to each
lar portion, which can be TSV allows self-sealing site to ensure that they are not
grasped with forceps to ma- transconjunctival sclerotomies and leaking. The conjunctiva
nipulate the microcannula. minimizes surgically induced trauma, should snap back, if the con-
A funnel - shaped entry was improves operative efficiency and junctiva begins to swell and
designed to facilitate access form a bleb, there may be a
of instruments. Once in- hastens postoperative recovery leak. Some surgeons prefer to
serted through the eye wall, take a fixation forceps and
sutures are not required to ible and extended retinal quadrants. The trocar creates manually close the wound
hold the microcannula in pick, tissue manipulator, la- 0.5mm conjunctival and and hold it for a moment un-
place. The microcannulas are ser probe, diathermy probe, scleral incisions. An infu- til the underlying vitreous
inserted through the con- aspirator and others. sion cannula is inserted into can block the wound site
junctiva into the eye by means the IT cannula and plugs form beneath the sclera.
of a trocar that, when inserted Infusion and Aspiration used to temporarily close
into the cannula, forms a con- rates other entry sites till use (Fig3, Indication
tinuous bevel with the Fig4) Many vitreoretinal proce-
microcannula, allowing ease Due to the small size the
of entry. The trocar is then infusion and aspiration The TSV requires some dures that do not involve ex-
withdrawn leaving the can- rates at various settings are modifications of technique tensive dissection, are likely
nula in place. The main pur- reduced by 6.9 and 6.6 times during vitrectomy. Maxi- to benefit from a less invasive
pose of the 25-gauge respectively when compared mum cut rates are required procedure, because much of
microcannula system is to with the 20 guage system6. to achieve optimal fragmen- the surgical trauma in those
maintain the alignment be- tation of intraocular tissue cases may be related to the
tween the conjunctival and Time Measurement and to decrease the possibil- conjunctival and scleral in-
the scleral entry site, because comparison ity of obstruction in aspira- cision procedures. The TSV
no prior conjunctival dissec- tion line, which is narrower system has been used in
tion is required for insertion In a published study done than standard 20-guage epiretinal membrane peeling,
of the trocar and cannula. by Fujii GY et al6, the mean vitrectomy systems. The vit- macular hole surgery, retinal
Therefore, the 25-gauge can- total operative time was reous cutter is used with detachment with minimal or
nula system is referred to as found to be significantly maximum aspiration rate no proliferative vitreore-
an "entry site alignment sys- greater for the 20 guage (26 (500mmHg) and concomi- tinopathy, branch retinal
tem" (EAS). (Fig.1) min 7sec) than for the 25 tant high cutting rate of vein occlusion sheathotomy,
gauge vitrectomy (17min 1500cpm. The difference be- vitreous hemorrhage,
The 25-gauge infusion 17sec). The differences in endophthalmitis. The TSV is
August, 2003 49 DOS Times - Vol.9, No.2
CURRENT PRACTICE
of potential benefit in smaller a theoretical possibility of optimal positioning at the edly clogged the cutter. Prob-
eyes of children where use of suture less sclerotomies serv- dissection point of the cross- ably, further improvement in
standard instruments may ing as a conduit for the entry ing. It was possible to peel technology will makes us
incur technical difficulties of bacteria. epiretinal membranes and able to handle complicated
related to the ocular size6. perform sheathotomy with- cases in the near future.
Surgeons may experience out prior vitrectomy in some
With the rise in health wound leaks that need to be cases. Treatment of retinal Conclusion
awareness, more and more sutured in their initial cases. detachment was successful In select cases where full
patients present early with A re-operation the next day is all cases, although none of
less complications. Such is worse than suturing at the these cases had severe pro- capabilities of conventional
cases can be better dealt with time of closure. liferative vitreoretinopathy. vitrectomy system are not re-
TSV 25 System. Newer sur- quired, the 25-gauge TSV sys-
gical indications like Results In our initial experience tem can offer better patient
vitrectomy for diabetic macu- Being a relatively new TSV was found to be suitable comfort, care and manage-
lar edema makes the scope in cases with epiretinal mem- ment by reducing operative
of this system further more. technique few studies are branes, macular hole and time effectively. With more
Glaucoma prone patients available in literature. Fujii fresh vitreous haemorrhage. advancement in technology,
undergoing vitreoretinal pro- et al described6 their initial The TSV system was used in future of sutureless 25 G
cedures may have a better experiences in a consecutive 4 cases requiring vitrectomy and thus the
mobile and healthy conjunc- series of 35 eyes. They used Vitreoretinal procedures. vitreoretinal surgery going
tiva for the future anti- the TSV in cases of retinal The four cases were for a major turning point.
glaucoma surgery. Mean- detachment, retinopathy of Epiretinal Membrane in a
while combined sutureless prematurity, Norrie disease, post laser diabetic patient, References
cataract and vitreoretinal epiretinal membrane, macu- 1. Machemer R, Buettner H,
surgery by TSV 25 G System
makes the major ophthalmic TSV system has been used in epiretinal Norton EW, PArel JM.
surgery a day care procedure membrane peeling, macular hole sur- Vitrectomy a pars plana ap-
with least possible morbid- gery, retinal detachment with minimal proach. Trans Am Acad
ity for the patients, the ulti- or no proliferative vitreoretinopathy, Ophthalmol Otolaryn gol 1971;
mate goal for any surgeon. branch retinal vein occlusion sheatho- 75:813 20.
2. O’Malley C, Heintz RM Sr.
Limitations tomy, vitreous hemorrhage, Vitrectomy with an alterna-
The TSV system should endophthalmitis tiveinstrumentssystem, Ann
Ophthalmol 1975; 7: 585-8; 591-
not be use on previously lar hole, branch retinal vein Idiopathic Macular Hole, 4.
scarred operated eyes as it is occlusion, persistent diabetic Retinal Detachment and Vit- 3. De Juan E Jr, Hickingbotham
difficult to enter the sclera macular edema and vitreous reous Hemorrhage. We D. Refinements in micro-
and the trocar may bend. In hemorrhage and retained evaluated the operative time, instruementation for vitre-
highly myopic patients with lens material post cataract wound closure, limitations ous surgery. Am J Ophthalmol
thin sclera, wound does not surgery. of the system and the out- 1990; 109: 218-20.
close in the same manner as come of surgery. The average 4. Chen JC, Sutureless pars
other patients. It is difficult No wound leakage was operating time was 30 mins plana vitrectomy through
to infuse silicone oil through seen in any case and the post- and all the wounds showed self-sealing sclerotomies.
25-gauge cannula. In retinal operative IOP was main- good closure with no wound Arch Ophthalmol 1996;
detachments with prolifera- tained. In idiopathic leaks. The epiretinal mem- 114:1273-5
tive vitreoretinopathy, be- epiretinal membrane cases, brane was successfully re- 5. A new 25- guage instrument
cause of smaller port and di- core vitrectomy and mem- moved with an increase of system for transconjunctival
ameter of 25-gauge cutter, the brane peeling was performed three lines in visual acuity. sutureless vitrectomy sur-
cutting and aspiration rates satisfactorily. Sheathotomy The macular hole showed gery: Fujii GY, De Juan E Jr,
are reduced so its efficiency at the pathologic arterio- flat edges with an open hole. Humayun Ms, Pieramici DJ,
in dense fibrous proliferation venous crossing was per- The retinal detachment un- Chang TS, Ng E, Barnes A,
may be limited. The in- formed by using a nitinol derwent resurgery for recur- Wu SL, Sommerville DN.
creased flexibility of 25 gauge pick that can be extended to rence. The vitreous hemor- Ophthalmology 2002 Oct;109
instruments may not be able adjust its curvature, which rhage was old and repeat- (10): 1807 12; discussion 1813.
to control eye positions dur- enables the surgeon to get 6. Initial experience using the
ing the surgery. There is also transconjunctival sutureless
vitrectomy system for
vitreoretinal surgery: Fujii
GY, De Juan E Jr, Humayun
MS, Chang TS, Pieramici DJ
Barnes A, Kent D. Ophthalmol-
ogy 2002Oct;109(10):1814-20.
August, 2003 50 DOS Times - Vol.9, No.2
CURRENT PRACTICE
Glaucoma Surgery with FUGO Blade
–A Break through in Approach and Technique
Daljit Singh, Kiranjit Singh, Ravijit Singh
A revolutionary new cut- is that the electromagnetic small bleeding vessels. is stony hard and the patient
ting technology is set to bring waves are brought to a sharp is in great agony. Similar
about a revolution in all focus by the electronics in the How is it used? condition is seen in many
fields of surgery. Luckily for console and in the handle, The Fugo blade is held like cases of trauma, aphakia,
us, it started with ophthal- onto the tip of the incising pseudophakia, absolute
mology, because the inven- filament. The electromag- a pen. The surgeon keeps an glaucoma and rubeosis
tor, Dr. Fugo happened to be netic oscillations are tuned eye on the 100 micron tip. He iridis. It may be a dire emer-
an ophthalmologist. He took to the tissues, so that the mo- makes up his mind in which gency in which medical
nearly 20 years to develop it. ment the activated tip direction the tip is to be treatment may take hours to
touches a tissue, the tissue moved after activation- side- take effect. We use Fugo blade
The tool molecules start resonating. ways or up and down, and to deal with emergency as
The Fugo Blade (after its At the activated tip-tissue at what angle. Planning is follows:
junction plasma energy is very important. The reason
inventor, Dr. Richard Fugo) produced that is actually vis- is that the moment the acti- a. Inject 3 ml of ligno-
is truly a novel cutting instru- ible to the naked eye. When vated tip touches the tissue, caine subconjunctival. Wait
ment, which employs looked under a high power the touched part disappears. for 15 minutes to take effect.
plasma energy for ablating microscope, the plasma en- The surgeon should hold his Massage till the conjunctival
incision paths in tissue in a ergy is visible as a 25-50 mi- breath when doing a fine and ballooning disappears.
manner similar to the Eximer cron wide pulsating yellow precise maneuver. Getting
laser and is approved for in- cloud on the activated tip. support from the forehead of b. The superior conjunc-
traocular use by the Food Around the plasma cloud, the patient helps in stability tiva is pulled down on the
and Drug Administration there is reddish much wider and better control The acti- cornea with an old fashion 3
(FDA) in the USA. The instru- photon cloud. The cutting vation switch is under the mm wide fixation forceps. It
ment consists of a console, a power resides in the plasma foot. Keep the foot away ex- has blunt teeth and does not
hand-piece and a disposable cloud. The plasma sustains cept at the actual moment of puncture the conjunctiva.
tip. Three rechargeable bat- itself by feeding on the tissue, use.
tery cells provide the energy. which is ablated in the tru- c. Clearly visualize the
One charge lasts for over an est sense. The plasma cloud Glaucoma Surgery limbus as a landmark. This
hour of cutting time. This in- oscillation instantly shatters Fugo blade has untold ap- can be facilitated if the limbal
dicates how little energy is the macromolecules of the conjunctiva is marked with
needed to energize the cut- tissue into small fragments plications, that we have ex- gentian violet. As the con-
ting tip. But the plasma en- and throw them out. The perienced in cataract, glau- junctiva is pulled down a
ergy that develops on a 100- plasma energy at the tip is at coma, extra ocular surgery, sharp blue line of the limbus
micron filament of the dis- a very high temperature. oculoplastic surgery, vitreo- is seen.
posable tip is phenomenal However, the heated field retinal surgery and sac sur-
from many points of view. It does not extend beyond 25 gery. Outside ophthalmol- d. A point is visually
is visible under high magni- microns of the plasma. The ogy it has been extensively chosen for making the track.
fication, looking like bees on Fugo Blade has an important used in ENT surgery in one The track can be made in to
a honey cone. This plasma function of non-cauterizing institution in Amritsar. In the the anaterior or the posterior
ablates in such a fashion that hemostasis in cut tissue. It following section, we shall chamber as the situation de-
it creates a smooth wall along does this in two ways- the describe our experiences in mands. A 4 mm long 100 mi-
the ablation path. The secret ablation of the vessels is the glaucoma surgery. cron Fugo blade tip is cho-
cutting path and secondly by sen.. It is placed at the se-
Dr. Daljit Singh, Director, the particle oscillation, Acute glaucoma emergency lected point and directed to-
Dr. Daljit Singh Eye Hospital, which tends to plug the When the eye is fiery red, wards the anterior chamber
Sherawala Gate, Amritsar. or the posterior chamber. An
the cornea is steamy, the pu- activated tip cuts so fast that
pil is widely dilated, the eye you have to make up your
mind, how the tip shall be
August, 2003 51 DOS Times - Vol.9, No.2
CURRENT PRACTICE
moved, once it is activated. 2. Transciliary filtration Figure 1: Shows the cloud on the 100 micron activated tip of Fugo
Move the activated tip As a new micro-surgical blade. The yellow cover on the tip is the plasma cloud that has
quickly. In a fraction of a sec- cutting properties, while the red colour is that of photon cloud
ond the tip is in the anterior procedure it is a new. Earlier that doe not cut.
chamber or the posterior in 1979 the senior author
chamber as desired. The mo- (DS) had presented “Trans- Figure 2: This patient of PKP came as a severe emergency with
ment it encounters fluid it is ciliary Filtration for Intrac- IOP near 70 mm Hg. A 100 micron track was made 1 day earlier.
inactivated automatically. table Glaucoma” in AIOS
The tip is withdrawn. Aque- and OSUK. It described mak- Figure 3: Shows a filtering bleb 3 hours after TCF operation.
ous is seen seeping through ing a filtration track through
the track just created. the pars plana of ciliary
body. The technique has
e. The conjunctiva is re- been in use in our set up till
leased. The seeping aqueous recently. We have been do-
starts making a filtration ing the new micro-surgical
bleb. No suture is required. Trans-ciliary filtration (TCF)
The emergency operation is for nearly 2 years and have
finished. performed over 350 opera-
tions. Currently, a number of
1. Doing a routine glaucoma US ophthalmologists are do-
procedure: ing glaucoma surgery proto-
col with Fugo blade.
Fugo blade takes the place
of three manual instruments, TCF makes a 150 micron
the forceps, scissors and he- (100 micron filament and 50
mostat. The following kinds micron of plasma layer) fil-
of procedures can be done: tration track between the
posterior chamber and the
a. Trabeculectomy:The subconjunctival space. We
plasma energy cuts the con- know the precise width of the
junctiva, tenon capsule, track, since that is how far
makes scleral flap easily and the plasma activity of Fugo
without bleeding. The cut blade tip extends. There are
edges of every structure are many ways to achieve. The
sharp and clean. The tissues main differences are in the
suffer minimal trauma and making of the conjunctival
the surgery time is reduced. flap and the preparation of
the scleral surface before en-
b. Non-perforating proce- tering the ciliary body.
dures: Any kind of non-per-
forating procedure can be The following is the de-
performed with ease. The tis- scription of the technique
sue ablation with plasma tip that has been followed for
proceeds at a leisurely pace more than 20 months:
without any bleeding. The
only precaution is to keep a a. About 8 mm of con-
strict visual control on the junctiva is detached and re-
ablation process, so that the tracted from the limbus, so as
anterior chamber is not to expose about 3 mm of the
opened. The seepage can be sclera in widest part.
verified by instilling a drop
of trypan blue, which will be b. The bleeding points
seen as getting washed out are closed by non-cauteriz-
by the seeping aqueous. If so ing hemostasis with Fugo
desired, the surgeon can con- blade tip at the lowest set-
vert and create one or more ting. Only the bleeding
100 micron tracks for filtra- points are touched, so that
tion. the scleral surface remains in
original condition. That is
August, 2003 52 DOS Times - Vol.9, No.2
CURRENT PRACTICE
Figure 4: Showing the filtering bleb after Trans-conjunctival TCF Figure 5: Showing the filtration area 1 year after TCF operation.
3 hours after surgery. The conjunctiva appears quite healthy.
not the case when a bipolar is replaced back to the lim- tenon capsule. Without let- left as such or a suture be
cautery is applied. bus with one or two 40 mi- ting the tissues move, Fugo applied to close it.
cron steel sutures. blade is used to make a hole
c. About 1 mm behind in the conjunctiva plus what- Trans-conjunctival TCF
the limbus, a scleral pit about 3. TCF Sans Conjunctival ever tenon capsule may be appears to have some advan-
0.6 mm wide is ablated. The Flap there, after which a pit is tages like reduced trauma to
ablation is carried to the level made in the sclera as usual, the tissues, no bleeding
of the ciliary body. This may This is our latest approach till the ciliary body is points to be tackled and prac-
be done with the standard to glaucoma filtration sur- reached. tically instant recovery. We
100 micron tip or with a flat gery. The surgery is done as have done only 8 cases with
end 0.6 mm tip. The transi- follows: c. The eye is kept stabi- this technique. They have a
tion from the sclera to the cili- lized in the same position. short follow up. If satisfac-
ary body is clearly seen as a a. The conjunctiva is The fixing hand is not tory results are obtained, it
change from white to black massaged downwards so moved. With the other hand, will be the beginning of the
appearance of the depth of that it hangs over the cornea. Fugo blade tip goes through end of the conjunctival flap
the pit. In many cases we The limbus is clearly visible the ciliary body in to the pos- era in glaucoma surgery.
have also done wider thin- through the conjunctiva. It is terior chamber. This is sig-
ning of the sclera, before mak- necessary to make sure that naled by the seepage of the A summary of results
ing a pit that reaches the cili- the location of the limbus in aqueous that is so obvious,
ary body. relation to the pulled down which may be further con- obtained in Primary
conjunctiva does not change firmed by instilling a drop of
d. The ciliary body is during surgery. To achieve trypan blue, which gets glaucoma
penetrated to reach the pos- this, the conjunctiva is washed away immediataely.
terior chamber. A 100 micron pressed against the limbus Number of cases:
tip is used for this purpose with a thin dull long and stiff d. The pressure on the
at medium setting. The mo- instrument. Currently we use limbus is released, by simply POAG : 109
ment the aqueous reservoir the back side of disposable lifting the razor blade frag-
in the posterior chamber is razor blade fragment. It keeps ment. The pulled down con- PACG : 104
reached, the fluid moves out- the limbus well defined and junctiva is allowed to retract
wards and inactivates the also stabilizes the eye. upwards. As this happens, Total : 213
Fugo blade tip. a filering bleb starts forming.
b. The conjunctiva close The hole in the conjunctiva Preoperative intraocular
e. A drop of trypan blue to the limbus at this point ap- is seen at a distance of 7 to 10
is instilled to make sure pears stretched and closely mm. away from the tans-cili- pressure:
about the drainage. applied to the sclera, of ary filtering track. It may be
course with the intervening Maximum : 70 mm
f. The conjunctival flap
Minimum : 24 mm
Average : 41.5 mm
Postoperative Complications:
Hyphema :2
Choroidal detachment : 2
Subconjunctival
hematoma : 2
August, 2003 53 DOS Times - Vol.9, No.2
CURRENT PRACTICE
Follow up : of small hyphaema and cho- chances of surgical success the revolution will not be far.
roidal detachment were self are reduced. Tissue manipu- The authors have no finan-
Maximum : 17 months limiting and recovered spon- lations, bipolar cautery and cial interest in the product.
taneously. No iridectomy is mitomycin application prob-
Minimum : 4 months done during the operation ably do much damage to the References:
thus avoiding a source of lymphatics. In doing TCF, we
Average : 5 months hyphaema. In cases of angle try to avoid these factors. 1. Singh Micro-filtration for
closure glaucoma, we have glaucoma, a new tech-
Re-operations : 26 (12%) observed immediate deepen- In short: nique. Daljit Singh. Tropi-
ing of the anterior chamber, There is a clear possibil- cal Ophthalmology. 2001;
On local as fluid starts draining from 5:7-11
the posterior chamber. Post- ity of a revolution, in glau-
medication : 22 (10.3%) operative recovery is fast and coma comparable to what 2. Transciliary Filtration
the patient is fit to be dis- happened in the field of cata- and Lymphatics of Con-
Final intraocular pressure: charged after 3 hours. There ract surgery. A revolution is junctiva- A Tale of Dis-
is no need for mitomycin ap- supposed to occur when the covery. Daljit Singh.
< 5 mm : 9 (4.2 %) plication, barring a rare case. surgeons on the front line Tropical Ophthalmology.
have either adopted the tech- 2002; 2:9-13
6-10 mm : 51 (24 %) The filtered fluid is nique or they are consider-
drained in to the lymphatics. ing it. This process takes 3. Transciliary Filtration Us-
11-15 mm : 74 (34.7 %) We mark lymphatics in ev- some time. In the present case, ing the Fugo Blade. Daljit
ery case, just before the start once the surgeons begin to Singh and Kiranjit Singh.
16-20 mm : 79 (37 %) of the operation. If lymphat- understand the versatility of Ann. Ophthalmol 2002;34
ics are poorly marked, the the new tool, the Fugo blade, (3):183-187
Comments
Trans-ciliary filtration
surgery is a viable surgical
option as we have found. By
seeking the drainage fluid
from the posterior chamber,
all the anterior chamber com-
plications whether operative
or postoperative have been
removed. The complications
Programme for DOS Monthly Clinical Meeting for August 2003
Venue: Auditorium, Sir Ganga Ram Hospital, Rajendra Nagar, New Delhi
Date & Time : 30th August, 2003 (Saturday) at 2.30 P.M.
Case Presentation
1. Congenital Anophthalmos with Ectopic Brain Tissue ................... Dr. Jasmita Popli
in the Orbit
2. Periocular Necrosis Following Local Anaesthesia for .................... Dr. Anita Sethi
for Cataract Surgery
Clinical Talk
l New Frontiers in the Management of Retinal ................................. Dr. S.N. Jha
Vascular Blocks
Mini Symposium: Rapid Fire Session
Chairmen/Moderator: Dr. A.K. Grover
What shall I do now? (Clinical Situations/Surgical Dilemmas/Operative Complications)
Moderator ..................................................................................................... Dr. A.K. Grover
Panelists ......................................................................................................... Dr. V.K. Dada,
Dr. R.L. Kaul,
Dr. Harbansh Lal, Dr. S.N. Jha
Dr. Amit Khosla
Panel Discussions : 20 min.
August, 2003 54 DOS Times - Vol.9, No.2
CURRENT PRACTICE
Manual SICS by Irrigating Vectis: Conjunctival Flap
Many a time, we do not
Stepwise Small Tips bother about this part of the
surgery. A triangular fornix-
based conjunctival flap is
Samar K. Basak, MD, DNB preferred (Fig 3). First give a
small radial cut with the scis-
sors. Do a good undermin-
ing dissection of it along with
During the last two de- from patient to patient. So for would be difficult. Tenon's capsule, and then
cades there is a tremendous all practical purpose, in cut along the limbus for 6-
leap forward in cataract sur- manual SICS, 'S' is not al- Superior Rectus Bridle Su- 8mm. The important point is
gery all over the world. In one ways Small to us. The 'S's ture to clear all the Tenon's (and
hand Phacoemulsification (Aces) for us are - Safe, Superior rectus bridle su- episcleral) attachments from
with foldable IOL has gained Sutureless, Stressless, Stable, ture is given to manoeuvre the sclera. Otherwise, first
its confidence in Western Secure and Self-sealing cata- the globe forward and down- external scleral groove inci-
world, and on the other ract surgery with a Short wards. With irrigating vectis sion may not be in perfect
hand, Manual Small Incision learning curve. Above all it technique, it is essential to depth in all length. A gentle
Cataract Surgery is definitely is Simple with Simple instru- give counterforce during the and just adequate cautery
a breakthrough in country mentation (Fig:2). Let us dis- nucleus delivery and some- (wet field cautery is always
like India. Phacoemulsi- cuss in a Small way of all the times during epinucleus de- better) is applied. Care has
fication, the term itself sug- steps which we have found livery. A specially designed to be taken not to over cau-
gests the mechanism of useful for the success of the episcleral forceps can be used terize over the scleral bed.
nucleus removal from the surgery. alternately to minimize supe- After completion of surgery
eye. But, we do not speak First of all, there are some rior rectus muscle injury. the flap is gently reapposed
about method of nucleus de- criteria for ideal case selec- and cauterized.
livery in manual SICS to our tion for the beginners:
patients. If we think criti- 1. Clear cornea with healthy
cally, the basic tangible as- endothelium.
pect in small incision cata- 2. A well dilated pupil.
ract surgery to the patient is 3. A normal anterior cham-
stitchless cataract surgery ber depth.
through a relatively a 4. Intact zonular attach-
smaller incision. ment.
In manual SICS, 'S' stands 5. Immature cortical cata-
for small, and we also talk to ract, Nuclear sclerosis
our patient about the small- Grade II and III. 6 mm 2.0 mm behind 7.5 mm 2.5 mm behind
ness of incision in cataract As the surgeon learns this Fig 1: Depending upon the nuclear size the incision can be planned.
surgery. Mature and hard technique, gradually he can
cataract is a rule in our coun- master this procedure virtu-
try, not an exception. In fact, ally in all types of cataract.
we are overburdened with
such types of cataract. So, de- Anaesthesia
pending upon the size and Peribulbar or Retrobulbar
hardness of the nucleus, we anesthesia, anything can be
design the incision length, given. The surgery can be
which may vary from 5.5 mm performed even under 'Topi-
to 7.0 mm or even 7.5 mm in cal' anaesthesia. But the im-
manual SICS (Fig 1). It varies portant point is not to give
excessive bulbar massage or
Disha Eye Hospitals & Research pressure with Super pinky. Fig 2: Simple instrumentation in Manual SICS with Irrigation
Centre, Barrackpore, That means, there should not Vectis Technique
West Bengal - 700120. be much hypotony, other-
[email protected] wise scleral tunnel making
August, 2003 55 DOS Times - Vol.9, No.2
CURRENT PRACTICE
Fig 3: a) Line of dissection b) Triangular flap Cautery and falls short on the other
side (Fig: 7). Towards the
c) After completion of surgery sides the keratome should
move centripetally. It should
cut during the entry of the
keratome and not during
exit. Care has to be taken not
to injure endothelium with
the tip of the keratome dur-
ing its manoeuvre towards
the sides.
ab c Side-port entry
Fig 4: Types of incisions: a) Straight, b) Frown and c) Chevron. It is an optional situation.
ing any step of surgery.
Incision cal obstruction of the arm by Scleral Pockets: Scleral For the beginner it helps to
In manual SICS, incision the body, if we are perfectly pockets are like pleats of our clear sub-incisional cortex.
at the centre of the superior trousers. They accommodate One has to use smaller cali-
is the main concern. The very limbus. So, we must center not only the diameter of the ber of bi-way canula through
goal of this surgery lies on the incision at 11 o'clock po- nucleus but also its thick- this port. A leaking side port
the self-sealing property of sition rather than 12 o'clock ness. They give more space is not uncommon. In case of
the incision. This incision position. That means for the for large and thick nucleus any doubt, a suture is always
has three components: right eye it is slightly supero- (Fig 5). They are not neces- preferable for the safety of the
1. External scleral incision, temporal in position and for sary in all cases especially in eye.
2. Sclero-corneal tunneling the left eye it should be softer nucleus. They may
slightly supero-nasal. cause bleeding from tunnel Capsulorhexis
and and postoperatively they Rhexis is the incision on
3. Internal incision may excite more tissue reac-
tion. the lens capsule. If the cata-
1. External Scleral Incision 2. Sclero-corneal Tunnel- ract is big, a bigger rhexis
The external incision may ing 3. Internal incision must be done. Before rhexis,
The internal incision if the whole internal incision
be Straight, Frown-shaped or Ø After making initial is made, there is free
Chevron (Fig: 4). It is usually groove, dissect little at the should be curved along the manoeuverity of the needle
given 1.5 to 2 mm behind the external scleral lip. curvature of the limbus. If it cystitome. In case of small
limbus and 5.5 to 7.5 in is straight, it has to go more rhexis, two releasing inci-
length. The highlighting Ø Split the sclera from the towards the centre of the cor- sions are to be given at 2 and
point is- the incision is to be center, as it is easier. nea to get same desired 10 o'clock position. Can-
given at right site and in ad- length of the internal inci- opener capsulotomy works
equate depth. If we plan that Ø Overlap the split area to sion (Fig: 6). That means more perfectly fine, but one has to
because of nuclear hardness create a new area. astigmatism and might be be careful during
or for some other reasons the more endothelial cell loss. hydroprocedures. Capsulo-
incision length is to be larger, Ø Wriggle the scleral split- rhexis should be the ultimate
we have to shift the incision ter forward. The dimpling-down 2.8 goal of incision on lens cap-
more posterior. mm keratome entry must be sule for all surgeons. Apart
Ø For the sides, direct the parallel to the external inci- from the placement of the lens
It is always preferable to blade centripetally. sion. If the entry is oblique, 'in-the-bag', it saves us from
shift the incision towards the internal incision runs many postoperative prob-
right side of the superior lim- Ø The cornea is more curved into the cornea on one side lems.
bus. As our pronation action than the sclera; so put the
of arm is more active than heal-down of the splitter Hydro Procedure
supination, there is mechani- as the cornea is ap- Debulk some of the vis-
proached.
coelastic substances from the
Ø Never hold the scleral lip anterior chamber to accom-
during any point of dis- modate fluid in the bag. Press
section of tunnel or dur- the nucleus to release the
August, 2003 56 DOS Times - Vol.9, No.2
CURRENT PRACTICE
Steps of Surgery in Manual SICS by Irrigating Vectis
Photo 1: Conjunctival Flap Photo 2: External incision Photo 3: Internal incision Photo 4: Scleral pocket
Photo 5: Capsulorhexis Photo 6: Hydrodissection Photo 7: Nuclear prolapse Photo 8: Nucleus delivery
Photo 9: Nucleus delivery Photo 10: Cortical cleaning Photo 11: PC IOL in-the-bag Photo 12: Wound closure
pent up fluid. See the fluid It is advisable not to struggle 1. Mechanical pull by the ir- easier. Gentle flushing of the
wave. Repeat hydro- during nuclear prolapse. rigating vectis. endothelial surface to clean
dissection procedure in 3 to Most of the time, zonular de- adherent tit-bits of cortical
4 places. Hydro-delamina- hiscence occurs during this 2. Internal hydrostatic pres- remnant with viscoelastic
tion is not at all necessary. It step. A small rhexis is the sure. sludge at this stage helps in
may create more problems to most important cause for this. good visibility. It is better not
remove epinucleus. Two relaxing incisions can 3. Posterior lip depression to chase for sub-incisional
solve the problem very easily. by the vectis. (Remember, cortex to remove all parts of
Hydroprolapsing the if we lift the anterior lip it. It is always wise to attempt
nucleus into A/C Nucleus delivery by we close the wound, but if maximum cleaning of sub-
irrigating vectis we press the posterior lip incisional cortex after place-
Drag the nucleus until the we open the wound.) ment of IOL. Fine cortical fi-
edge shows in front of the The irrigating vectis can bres are best cleaned by jet of
rhexis margin. Press down at be used directly via the 4. Scleral stretching by the fluid injected by a narrow
one end and lift the other Ringer's Lactate tubing sys- nucleus. canula.
edge. Dial in clockwise or tem or it can be fitted with a 5
anti-clockwise direction to cc syringe filled with Ringer's 5. Counter balancing force IOL Placement
prolapse the whole nucleus Lactate solution. It's a matter forwards and down- It is preferable to place the
into the anterior chamber. Si- of practice. wards by the superior rec-
multaneous irrigation is nec- tus bridle suture or epis- IOL after inflating the bag
essary at this stage. Some- In this mechanism, the cleral forceps. with viscoelastics. Only im-
times, nucleus prolapse can main forces behind nucleus portant point is to clean the
be achieved by a round hook. delivery by irrigating vectis Cortical Cleaning tunnel thoroughly before in-
are: (Fig: 8) If the hydrodissection is
perfect, cortical cleaning is
easy. From a rhexis it is
August, 2003 57 DOS Times - Vol.9, No.2
CURRENT PRACTICE
Fig 5: Scleral pockets give more space to accommodate thick
nucleus. Fig 6: Internal incision: Curved Vs. Straight
Scleral stretching
Internal M echanical direction
hydrostatic by the Vectis
pressure Posterior lip
depression
a) Parallel entry b) Oblique entry C ounter balance by
forceps/ SR suture
Fig 7: Internal incision must be parallel to the external incision.
Scleral stretching
Fig 8: Mechanism of nucleus delivery by irrigating vectis.
troducing the IOL through canula is very very important. vectis needs adequate protection to the corneal en-
the tunnel. Otherwise, some- If the scleral pockets are made, amount of viscoelastics in dothelium during the
times blood clot or lens corti- they are also to be cleaned. To many steps: nucleus delivery.
cal particles may go inside us, this is one of the major
along with the lens and causes of prolonged postop- i) During Capsulorh- Conclusion
cleaning them is difficult. erative uveitis in some cases. exis. Manual SICS has already
It also cause delayed wound
Removal of Viscoelastics healing that means, less sta- ii) During nucleus proved that it is the best alter-
from the Bag and AC bilization of astigmatism. prolapsing. native surgical approach to
instrumental phacoemu-
It is mandatory to clean all Suturing iii) During Nucleus lsification as a cost effective
viscoelastic materials from Suturing is required in rare delivery. method for the developing
the anterior chamber and countries. This technique has
from the bag. Through a large circumstances. It is given by iv) Sometimes, during all the advantages of
rhexis it is very easy to go infinity suture. For a large cortical cleaning. stitchless cataract surgery in
behind the IOL optic. Alter- incision even if the wound is terms of wider acceptance,
nately, gentle tapping with self-sealing, it is given to re- v) DuringIOLplacement. greater wound stability, ear-
the I/A canula helps to clear duce the sagging of the poste- vi) Even if the eye is soft at lier visual rehabilitation, and
most of the viscoelastics from rior flap of the tunnel and greater patient's as well as
the bag. therebytoreducetheastigma- the beginning, before surgeon's comfort. A skilled
tism. Of course, if the surgeon sclero-corneal tunnel- and experienced SICS sur-
Tunnel washing has any doubt regarding the ing, via a side-port. geon can perform high qual-
It is one of the steps we integrity of the wound, it is ity and high volume cataract
better to place an infinity su- Choice of viscoelastics is surgery at a lower cost at any
have learnt by experience. ture. also important in some cases. point of time as compared to
After completion of the sur- High-quality dispersive vis- an experienced phaco sur-
gery thorough tunnel wash- Role of Viscoelastic sub- coelastic is essential in cases geon. It is really an urgent
ing by Ringer's Lactate solu- stances in this method of suspected corneal endothe- need for our country.
tion using a hydrodissection lial problems, like corneal
Manual SICS by irrigating guttae or early Fuchs' dystro-
phy. It provides an extra coat-
ing to the corneal endothe-
lium. Thus it gives an extra
August, 2003 58 DOS Times - Vol.9, No.2
CURRENT PRACTICE
Transpupillary Thermo Therapy – An emerging
modality in treatment of Subfoveal and
Juxtafoveal Choroidal Neovascular Membranes
1Lalit Verma MD, 2Ankur Sinha (MD), 2Jayaram MD, 2H.K. Tiwari MD
Choroidal neovascular topsia. Ophthalmoscopi- Ophthalmoscopically, subretinal fluid,
membranes (CNV) are aber- cally, subretinal fluid, subretinal hemorrhage, subretinal lipid,
rant vessels that arise from subretinal hemorrhage, cystic retinal edema or thickening, or a
the choriocapillaris, pen- subretinal lipid, cystic retinal
etrate Bruch's membrane edema or thickening, or a dirty grey-green subretinal lesion gives
and proliferate between the dirty grey-green subretinal
clues to the presence of a choroidal
thickened inner aspect and lesion gives clues to the pres-
the remainder of Bruch's ence of a choroidal neovas- neovascular membrane
membrane and/or in the cular membrane. The exami-
sub-retinal pigment epithe- nation of the fellow eye of
lium and/or in the sub-reti- such patients may also help Myopic changes in the fun- ing with the above men-
nal space. in diagnosis of the cause. In dus may point towards the tioned symptoms and a
Three important causes of case of ARMD the fellow eye etiology of the CNV. Angiod subretinal hemorrhage, one
formation of CNV are Age may have drusen (hard, soft, streaks have bilateral presen- should rule out CNV second-
Related Macular Dege- confluent, calcified etc.), dis- tation. Irregular, often radial ary to ARMD.)
Pigmentary streaks/ lines Various treatment modalities
Three important causes of formation of around the disc are typical tried in CNV are
of angiod streaks. Patches of Ø Argon / Krypton laser
CNV are Age Related Macular Choroidits are seen in pa- photocoagulation
Degenerarion, Ocular Histoplasmosis tients having CNV second- Ø Trans scleral diode laser
ary to it. Ø Interferon alpha 2a
and Idiopathic choroidal neovascular
membrane ARMD is one of the major Ø Radiation therapy (Tele-
causes of CNV and 90% of therapy or Brachytherapy)
visual loss in cases of ARMD Ø Thalidomide
nerarion, Ocular Histoplas- ciform scar, pigmentary al- is because of wet form of the Ø Transpupillary Thermo
mosis and Idiopathic cho- terations, CNV etc. "Histo disesase. Therapy (TTT)
rodal neovascular mem- spots" are seen in a patient (In a patient with age Ø Photodynamic Therapy
brane. Other causes being of ocular histoplasmosis. more than 50 years present- (PDT)
Pathologic myopia, Angiod
Streaks, Multifocal Choroidi-
tis, Serpiginious Choroiditis, Graph1.MeanBest CorrectedLetter Visual Graph 2. Change in Letter Visual acuity score at 36 weeks
Choroidal ruprure (Post trau- Acuity
matic) etc. 9 9
40 8
Patients with CNV gener- 8 7
ally complain of blurring or 39 39.24 77
decrease in vision, metamor-
phopsia, micropsia, relative Letter visual acuity 38 No. of eyes 6
scotomas and rarely pho- 55
37 36.88 44
1. Vitreo-Retina Service, Apollo 37.14 37.1 33
36
2
35 35.36
1
0
Hospital & Centre for Sight, 34 < -15 >=-5 0
-5,>=-15 <=5
New Delhi >5,<=15
2. Dr. R.P. Centre for Ophthalmic >15
Sciences, AIIMS, Ansari Nagar,
New Delhi - 110029 33 < No change
0 wks
4 wks 12 wks 24 wks 36 wks D ecrease in Increase in
visual acuity visual acuity
Dur ati on
August, 2003 59 DOS Times - Vol.9, No.2
CURRENT PRACTICE
and shown variable re-
sults.
Subretial Surgery trials
concluded that there is
no reason to prefer
submacular surgery to
laser photocoagulation.
Fig 1.Colour fundus photograph and FFA of 59 year Fig 2.Colour fundus photograph and FFA of 80 Classification of CNV
old male with subfoveal CNV, upper photo and year old male with subfoveal CNV, upper photo ØTopographic classifi-
FFA is Pre –TTT, lower 3 months post TTT, note the and FFA is Pre –TTT ( letter acuity – 35), lower 3 cation
decrease in the hyperfluorescence. The pre and post months post TTT ( letter acuity – 33), note the de- l Extrafoveal
laser visual acuity was stabilized (20 letters). crease in the hyperfluorescence. l Juxtafoveal
l Subfoveal
ØAngiographic classi-
fication
l Classic
l Occult
Treatment options de-
pending upon the topo-
graphic location of the
CNV
Extrafoveal CNV- La-
ser photocoagulation
with 532 nm is still the
first line of management
in such lesions, al-
though the problems of
recurrence and persis-
tence are there.
Subfoveal CNV - Laser
Fig 4.Colour fundus photograph and FFA of 62 photocoagulation has
year old female with subfoveal CNV, upper photo been shown to be effec-
and FFA is Pre –TTT, lower 3 months post TTT, tive, but frought with
note the decrease in the size and intensity of the the problems of imme-
hyperfluorescence. The pre and post laser visual diate fall in vision.
acuity was 35 letters. Juxtafoveal CNV -- The
Fig 3. Pre TTT, 3 and 6 months post laser colour eration study group 1994) definition of such le-
fundus photograph and FFA of 67 year old female Radiotherapy did not sions is vague, adequate la-
with subfoveal CNV. Notice the partial resolution ser photocoagulation is a dif-
of the CNV. The pre and post laser visual acuity show difference between pa- ficult proposition in
was 35 letters during the course of follow up. tients and controls in visual juxtafoveal lesions, treatment
acuity at one year, hence no of juxtafoveal membrane
Ø Macular rotation surgery has shown encouraging re- benefit of the treatment (RAD with conventional laser is
Ø Subretinal surgery sults in an initial experience, study) fraught with the problem of
but needs further evaluation immediate fall of vision due
Argon and Krypton laser (RPC study 2003). Thalidomide, known to to direct effect of the laser or
photocoagulation, although prevent growth of blood ves- run off phenomenon of laser
controversial is the only Interferon alpha 2a: no sels when administered reaction. Juxtafoveal lesions
proven effective modality for benefit of the treatment was orally in rabbits, its exact role are best treated as subfoveal
delaying severe visual loss observed in a randomized is not known. lesions, (personal opinion)
(Macular Photocoagulation placebo controlled clinical however rarely laser photo-
Study Group 1982 - 1995). trial (Pharmacological Macular Rotation Sur- coagulation (532 nm) can be
therapy for macular degen- gery, various groups have
Transscleral diode laser, used different techniques
August, 2003 60 DOS Times - Vol.9, No.2
CURRENT PRACTICE
Various parameters at each follow up following TTT in subfoveal CNV action of TTT is still un-
known, various mechanisms
Parameter Prelaser 4 weeks 12 weeks 24 weeks 36 weeks thought are apoptosis, ex-
pression of heat shock pro-
Mean Letter visual acuity 35.36 39.24 37.14 37.1 36.88 teins, free radical damage etc.
Mean Scotoma Score 45.4 41.26 38.6 35.88 34.45
Mean Reading Ability 28.69 34.14 34.14 Thus the low temperature
24.67 31.74 TTT is a potential strategy for
decreasing neural damage.
Various parameters at each follow up in patients of juxtafoveal CNV subjected to TTT The aim of treatment is local-
ized and controlled heating
Follow up (weeks) of the choroidal neovascular
___________________________________________ membrane to subphoto-
coagulative temperature
Parameter Prelaser 4 12 24 36 52
Our Experience with TTT
Mean Letter ARMD 48.43 52.93 50.5 47.71 52 50 Subfoveal CNV
visual acuity Idiopathic 52.13 59.13 61.88 64.71 59 52
Mean Contrast ARMD 1.16 1.13 Forty three eyes of thirty
threshold Idiopathic 1.04 1.13 1.13 1.07 1.15 1.28 nine patients were subjected
(log units) 0.86 0.88 1.09 1.11 to TTT after an angiographic
Mean Reading ARMD 60 evidence of subfoveal chor-
Ability(seconds) Idiopathic 54.07 54.21 51.29 52.71 62 41.5 oidal neovascular membrane
68.5 secondary to ARMD. Visual
65.12 62.25 71.57 74.67 function outcome were mea-
sured before and after TTT.
Graph 3 .Mean Best Corrected Letter Visual Graph 4.Change in letter visual acuity at 12 weeks The parameters were best
Acuity corrected letter visual acuity,
AMD Idiopathic contrast threshold, reading
AMD Idi o pa th i c ability, scotoma and meta-
morphopsia score (using
Letter Visual Acuity 70 59.13 61.88 64.71 59 No. of Eyes 2 2 22 Amsler's Grid). The follow
65 2 22 up was for 4, 12, 24 and 36
weeks after the laser.
60 52.13 52 1.5
55 50 Results are summarized
1 in the graphs 1 and 2, and
50 48.43 52.93 50.5 52 1 figures 1 to 4.
45 47.71
1 In our study of subfoveal
40 CNV, the Letter acuity
0.5 stabilised or improved (move
35 00 of one line) in 71.4% at 9
months follow up (P=0.034).
30 0 0 00 0 Reading speed improved at
all follow ups till 9 months
25 which was statistically sig-
nificant (P=0. 017). Scotoma
20 -10 < = -5 0 score decreased during 9
-10 >+5,<<==+1+05 months follow up (P=0.014),
with all follow ups showing
Prelaser > >+10 statistically significant de-
4 weeks >-5,<= crease. Contrast sensitivity
12 weeks increased during 9 months
24 weeks follow up with statistically
36 weeks significant increase at 12
52 weeks weeks (P=0.042).
done with prior explanation photodynamic therapy thermotherapy (TTT) was Contd. on page 96
to the patient the risk of im- (TAP) study group in 2002 first termed by Oosterhuis et
mediate fall in vision. has shown that the stabili- al. It is a technique by which
zation of visual acuity (de- heat is delivered to the chor-
Two of the treatment mo- fined as ± 3 lines) was seen oid and retinal pigment epi-
dalities have recently in 59% of the treated eyes as thelium using a diode laser
gained importance, they are compared to 31% in the pla- at 810nm. The goal in using
TTT and PDT cebo group at 24 months fol- this technique for treatment
low up. of choroidal neovasculari-
Photodynamic Therapy - zation is to achieve occlu-
Treatment of age related Transpupillary Thermo sion of the neovasculari-
macular degeneration with Therapy -- Transpupillary zation without damage to
other cells. Heat penetration
ARMD is one of the major causes is optimized by exposure
of CNV and 90% of visual loss in time, beam diameter, and
cases of ARMD is because of wet wavelength.
form of the disesase The exact mechanism of
August, 2003 61 DOS Times - Vol.9, No.2
LIBRARY
Attention D.O.S. Members
The Hi-tech DOS Library has started functioning on Ground Floor, Dr. R.P. Centre, Delhi Ophthalmic
Sciences, AIIMS, New Delhi-110029 from 12.00 Noon to 9.00 P.M. on week days and 10.00 A.M. - 1.00
P.M. on Saturday, Sunday. The Library will remain closed on Gazetted Holidays. Members are requested
to utilise the facilities available i.e. Computer, Video Viewing, Latest Books and Journals. We are plan-
ning to subscribe two journals. Member can give suggestion in this regard.
Dr. Lalit Verma
Library Officer, D.O.S.
List of Books and Journals Available in Library
DOS Library Book List 14. Converting to Tewari
1. An Atlas of Ophthalmic Trauma Phacoemulsification (Thirgd 27. Phacodynamics Mastering the
Edition)
Editors - Thomas C Spoor Making the Transition to in-the- Tools and Techniques of
2. Manual of Fundus Fluorescein Bag Phaco Phacoemulsification Surgery
Paul S. Koch. (Second Edition)
Angiography Editors Barry S. Seibal
Editors - Amresh Chopdar 15. Mastering Phacoemulsification (A 28. Techniques of Phacoemulsification
3. Complications of Glaucoma simplified Manual of Strategies for Surgery Intraocular Lens Implanta-
Therapy the Spring, Crack and Stop and tion
Editors - Mark B. Sherwood. M.D. Chop Technique (Fourth Edition) Editors - Moshe Yalon
George L. Spaeth M.D. Editors - Paul S. Koch 29. Cataract Surgery and its Complica-
4. Corneal Topography the State of tions (Sixth Edition)
the Art 16. Ocular Infection Investigation and Editors - S. Jaffe
Editors - James P. Gills Treatment in Practice 30. A Colour Atlas of Lens Implanta-
5. Radial Keratotomy Surgical Editors - Martin Dunitz tion
Techniques Editors - Piers Percival
Editors - Donald R. Sanders M.D. 17. IOL and Phacoemulsification 31. Cataract and IOL
PHD. Secrets Editors - D. Singh R. Singh J. Worst
6. Refractive Corneal Surgery Editors - V.K. Dada R. Singh
Editors - Donald R. Sanders M.D.
PHD; Robert F. Hofmann-MD;James 18. Vitrectomy for Beginners DOS Library Journal List
J. Salz-MD Editors - Rajvardhan Azad 1. Survey of Ophthalmology
7. Second Edition-Laser Surgery Of
The Posterior Segment 19. Radial Keratotomy (Principles and Vol.44 No.3 November-December-99.
Editors - Steven M. Bloom Alexander Practice) 2. Survey of Ophthalmology
J.Brucker Editors - Keiki R. Mehta
8. Sixth Edition - Becker-Shafeer R.S. Vol.44 Supplement 1. October-99
Diagnosis and Therapy of the 20. Radial Keratotomy 3. Survey of Ophthalmology
Glaucomas Editors - Donald Sanders M.D.
Editors - H. Dundar Hoskins Jr.- Vol.44 No.2 September-October-99.
Michael Kass 21. Soft Implant Lenses in Cataract 4. Survey of Ophthalmology
9. Phacoemulsification New Technol- Surgery
ogy and Clinical Application Editors - Thomas R. Mazzocco MD. Vol.43 No.6 May-June-99
Editors - I. Howard Fine George M. Rajacich MD. 5. Survey of Ophthalmology
10. Textbook of Advanced Edward Epstein M.D.
Phacoemulsification Techniques Vol.43 No.6 May-June-99
Editors - Paul S. Koch. James-A- 22. Computerized Perimetry A. 6. Ophthalmology Clinics of North
Davison Simplified Guide
11. Ocular Differential Diagnosis (Second Edition) Editors - Mar L.F. America
Editors - Frede’rick Hampton Roy Lieberman Michael V. Drake Ocular Infections: Update on
12. Retinal Detachment A Colour Therapy
Manual of Diagnosis & Treatment 23. Fun with Phaco Editor - Terrence-P-O Brien M.D.
Editors - Jack J. Kanski Editors - V.K. Dada 7. Ophthalmology Clinics of North
13. Current Concepts in Ophthalmic America
Lasers 24. Practical Atlas of Retinal Disease Sports and Industrial Ophth
Rajvaradhan Azad, H.K. Tewari and Therapy Editor Louis D. Pizzarello MD-Mph
Editors - William R. Freeman and Michael Easterbook MD
8. Ophthalmology Clinics of North
25. Retina and Vitreous Text Book of America
Ophthalmology Ocular Oncology
Editors - Steven M. Podos and Myron Editor Joan M.O. Brien MD
Yanoff
26. A Practical Manual of Indirect
Ophthalmoscopy
Editors - Rajvardhan Azad H.K.
August, 2003 62 DOS Times - Vol.9, No.2
LIBRARY
List of Books and Journals (New Arrivals) in Library
DOS Library Books Schields, Krupin) Khosla
1. Update On General Medicine (Ameri- 17. The Glaucomas, Basic Sciences 31. Fluorescein Angiography - A Users
can Academy Ophthalmology) (Sedond Edition) - (1-714 Ritch, Manual - H.K. Tewari, Lalit Verma,
2. Fundamentals & Principles Of Oph- Schields, Krupin) Pradeep Venkatesh
18. The Glaucomas Glaucomas Therapy 32. Text Book of Ocular Therapeutics –
thalmology (American Academy (Second Edition) - 1373-1807 Ritch, Ashok Garg
Ophthalmology) Schields, Krupin)
3. Optics Refraction & Contact Lenses 19. Ophthalmic Plastic And Reconstruc- DOS Library Journals
(American Academy Ophthalmol- tive Surgery (Second Edition) - Nesi, 1. Ocular Surgery For The New Millen-
ogy) Lismanlevine
4. Ophthalmic Pathology & Intraocular 20. Practical Orthoptics In The Treat- nium (Part II - March 2000. 13:1) Oph-
Tumors (American Academy Oph- ment Of Squint (Fifth Edition) - Lyle thalmology Clinics Of North America
thalmology) And Jackson. S - Editor Gergel. Spaeth. Md)
5. Neuro Ophthalmology (American 21. Binocular Vision And Ocular 2. Information Technology In Ophthal-
Academy Ophthalmology) Montility (Fifth Edition) - Von. mology (June 2000 13:2) Ophthalmol-
6. Pediatric Ophthalmology & Strabis- Noorden ogy Clinics Of North America - Edi-
mus (American Academy Ophthal- 22. Principles And Practice Of Ophthal- tor Leonard Goldschmidt)
mology) mology (Vol - 1 Second Edition) - 3. Ocular Surgery For The New Millen-
7. Orbit Eyelids & Lacrimal System Albert, Jakobiec.Azar nium Part I (Dec 1999 12:4) Ophthal-
(American Academy Ophthalmol- 23. Principles And Practice Of Ophthal- mology Clinics Of North America -
ogy) mology (Vol - 2 Second Edition) - Georgel Spath. Md)
8. External Disease & Cornea (Ameri- Albert, Jakobiec.Azar 4. Retinal Vascular Disorders (Dec 1998
can Academy Ophthalmology) 24. Principles And Practice Of Ophthal- 11:4) (Ophthalmology Clinics Of
9. Intraocular Inflammation And Uvei- mology (Vol - 3 Second Edition) - North America (Dr. Pran N. Nagpal
tis (American Academy Ophthalmol- Albert, Jakobiec.Azar - Donated By Dr. B. Patnaik)
ogy) 25. Principles And Practice Of Ophthal- 5. Survey Of Ophthalmology (Vol 44
10. Glaucoma (American Academy Oph- mology (Vol - 4 Second Edition) - No.4 Jan-Feb 2000)
thalmology) Albert, Jakobiec.Azar 6. Survey Of Ophthalmology (Vol 44
11. Lens And Cataract (American Acad- 26. Principles And Practice Of Ophthal- No.5 March-April 2000)
emy Ophthalmology) mology (Vol - 5 Second Edition) - 7. Survey Of Ophthalmology (Vol 44
12. Retina And Vitreous (American Albert, Jakobiec.Azar No.6 May-Jul 2000)
Academy Ophthalmology) 27. Principles And Practice Of Ophthal- 8. Survey Of Ophthalmology (Vol 45
13. (1-12 Master I Ndex (American Acad- mology (Vol - 6 Second Edition) - No.1 July-August 2000)
emy Ophthalmology) Albert, Jakobiec.Azar 9. International Ophthalmology (Vol 23
14. The Cornea (Third Edition) – (Gilbert 28. Handbook Of Lasik Surgery - No.1 Pp-1-60 1999)
Smolin, Ricard) Vajpayee, T.Dada, R. Snibson 10. Retina The Journal Of Retinal And
15. Principales And Practice Of Refrac- 29. Community Ophthalmology - P.K. Vitreous Diseases (Vol 20 No.1 2000)
tive Surgery- (Elander, Rich, Robin) Khosla 11. Journal Of Cataract Refractive Sur-
16. The Glaucomas Clinical Science (Sec- 30. Community Ophthalmology - P.K. gery (Vol 26 No.8 August 2000)
ond Edition) – (715-1372 Ritch,
Methodology for Monthly Clinical Meeting:
Criteria for Selection
Formula: Institution's Marks Attendance of institution (N)
Average marks A (outside delegates) x 0.7 + ——————————————————————— x 3
maximum attendance in any monthly meeting (Nx)
Total marks by outside delegates (M) Nx = Highest attendance of all meetings
A = ———————————————————— N = Total number of delegates
n = Total number of internal delegates
Total number of outside delegates (N-n)
N = Total Attendance of an instituton
(Outside + internal delegates)
August, 2003 63 DOS Times - Vol.9, No.2
ART OF REFRACTION
Prescribing the Aging Eye commodation is 2 Diopters
– The Presbyopic Correction Keep 1/3rd in reserve for
comfort so the available ac-
Monica Chaudhary commodation is 1.33 .If the
patient desires to read
Aging eye or the PRESBY- Near vision charts are used is move the chart further and at33cms.He needs 3.0 diopt-
OPIC EYE refers to slow, nor- to detect reduction in near vi- closer reading the smallest ers .Thus the extra add re-
mal and age related irrevers- sual acuity. Patient reads the line visible. This range quired is 3 - 1.33 i. e 1.67 Di-
ible reduction in magnitude chart at 40 cms and the should coincide with the re- opters.
of accommodative ampli- smallest print read is re- quired working distance and
tude. i. e there is recession in corded. The near vision recorded as closest / Trouble shooters in pre-
near point. Comfortable near charts do not measure the clearest/farthest point in cm scribing adds
vision prevails till the near vision but the near vi- for eg. 20cm/40cm/67cm.
amount of accommodation sion adequacy. The maximum Caution – Don’t add too
employed is less than one reading efficiency is when If the patient desires near much plus it not only con-
half the total amplitude of ac- the print size is 3 times the range away reduce by 0.25 D stricts near range but also
commodation. size of the smallest print read. steps and if closer range is makes the patient accus-
A non presbyopic patient desired then increase in tomed to higher magnifica-
Presbyopia usually sets in will read 0.4 M or J1 or N6 0.25D steps. tion and will always desire
around the age of 40. The am- equivalent to 6/6 at 40 cms extra add.
plitude of accommodation distance. Presbyopic correction
drops to less than 5 by this based on Amplitude of A beginner may never be
age.The required amplitude The correction is in the accommodation sure of his working distance.
at usual working distance is form of addition over the dis-
2.5 Diopters ( 100 cm/40cm) tance correction .It is impor- To measure the amplitude In case of previous wearer
so the required amplitude tant that the addition deter- the easiest method is judge the deficit on basis of
may drop to less than half. mination is based on Age and Donder’s or Duane’s what he is using and the com-
Presbyopia can be reported the Patients unique working method. The patient reads plaint with it.
anywhere between 38 to 48 distance. the near vision chart (the
years of age depending on smallest line visible) and the A tall person habitually
the working conditions and Addition Determination chart is brought closer till the holds the book away to read
refractive error. A hyperme- can be done by following print blurs. This punctum ,so may require lesser addi-
tropic eye reports Presbyopia methods in routine proximum is converted in tion to have comfortable
earlier then myopic eye. diopters ( e g 20cm = 100/20 range further away .
Age based = 5 Diopters.)This test is pref-
The recession in near Measuring the amplitude erably done binocularly. Er- Habitual higher add us-
point is sufficient to cause of accommodation ror may arise if larger print ers may be difficult to reduce
discomfort or asthenopic is used. Near point ruler can Trial to reduce additions is
symptoms at customary near The Age also be used for measure- done gradually. Such prob-
working distance. Some on- Since amplitude of accom- ment. lem is common in our coun-
set complaints are try where over the counter
modation is age dependent Sheard’s method also glasses are frequently pur-
Blurring of vision at near the presbyopic addition can measures amplitude of ac- chased.
working distance be estimated arbitrarily based commodation. The near vi-
on patients age .The estima- sion chart is held at 40cms Patients with nuclear
Drowsiness after short tions are strictly the starting and patient reads smallest cataracts shift towards myo-
period of reading point and do not adjust for print and minus lenses are pia for distance They are
particular demands. added uniocularly till blur. used to higher plus for near
Holds book away to read This measures the Amplitude and may not accept reduced
Transient diplopia on A table by Hofstetter’s age of accommodation. additions.
near work and amplitude values is a
Accommodative spasm or good guide as starting point Based on Amplitude the Presbyopic correction in an
pseudomyopia and then modify near range ADD is calculated. Deter- uncorrected hyperopia
according to patients needs. mine NPA . Suppose it is
Dr. R.P. Centre for Ophthalmic 50cms.The Amplitude of ac- A hypermetrope are usu-
Sciences, AIIMS, Ansari Nagar, After the add is deter- ally pre presbyopes and de-
New Delhi - 110029 mined the range is tested, that velop blur and asthenopia
soon.. Vision is intermit-
tently affected as the accom-
modation reserves start to
fail. The best way to correct
August, 2003 64 DOS Times - Vol.9, No.2
ART OF REFRACTION
such patients is to refract undergoing excyclovergence. Dsph. If the best corrected are
under cycloplegia and then This is minimal for small cyl- vision < 6/6 higher addition Head should be straight
calculate the add over it inders and considerable for has to be given to let the pa-
Many times for beginners a large cylinders (> 2D). The so- tient read newsprint. This ahead for distance viewing
distance correction used lution is to assess and find a will reduce his working dis- While climbing stairs
mainly for near work is best repositioned cylinder axis at tance.
prescribed .As the patient the true reading position bin- warn to look through dis-
adapts looking through the ocularly and advice separate An binocular aphake can tance segment
distance vision for distance glasses for reading. be advised to slide away his
will also adjust. If the patient distance glasses, so that ef- Keep reading material
is asymptomatic there is no Presbyopia and fective power can be in- close to body
need of prescription. Anisometropia creased and reading made
possible for short times and For reading rotate eyes
Myopes and presbyopia We do binocular near cor- frequent change to reading and not head.
Low Myopes may be fussy rection in routine but there is glasses avoided.
no reason to believe that the Read at the working dis-
over wearing Bifocals. Some accommodation demand for Bifocals are now available tance calculated. go closer for
may never accept reading near for 2 eyes will be same for aphakes in plastic and higher adds.
additions and prefer reading for near. The myopic eye fully aspheric design which can
without glasses at the focal corrected for distance accom- solve problem of carrying 2 Trifocals have an interme-
point. If satisfied and asymp- modates less than a hyper- glasses. Such bifocals are es- diate add for the intermedi-
tomatic agree to reading metropic eye. So there may be sential for children who are ate distance and the interme-
without glasses. High My- number of situations when wearing aphakic glasses diate add is automatically
opes (>-8) may have subnor- unequal additions has to be above the age of 3 years. calculated as half of the read-
mal visual acuity due to given to avoid, unpleasant ing addition.
pathological damage to situations where patient re- Recommend proper or
retina, a higher plus addi- turns with complaint of one strong lighting to elderly to Trifocals are outdated
tion may be given to increase eye clear at close and other compensate for the lost con- nowadays as Progressives
magnification. This may eye clear away. trast sensitivity. have taken over.
limit working distance
which has to be explained. If one eye has low vision Types of lenses used for cor- Multifocals progressives
and there is no binocularity rection of presbyopes or PAL have continuous
Astigmatic Presbyope correct the better eye and give power change from distance
Accurate spherical and cy- balance add in the weaker Separate reading glasses to near add .They are avail-
eye. Bifocals able in various designs –
lindrical power has to be de- Trifocals Hard and Soft. The design is
termined Any change in Addition in aphakes and Multifocals or progressi- shown in the diagram. These
spherical component effects pseudophakes The accom- ves lenses are best for patients
determination of add. Some modative function is zero Bifocals we all know of who need all range of near
astigmatic patients may not and the expected addition is are of various types both working distances like the
be comfortable with bifocals 3.0 Diopters for reading at available in glass and plas- computer professionals.
because the axis of bifocals is 33cms.If the vision is 6/6 and tic. The original round seg- Progressives are difficult to
not same for near due to eyes reading is desired at 50 cms ment Kryptok is relatively in- adapt initially but provide
the addition has to +2.0 visible. The D type of bifocal near vision quite near the nor-
has an advantage of less im- mal non – presbyopic patient.
!!Attention DOS Members!! age jump so better accepted.
The straight top executive Another option for
The last date of acceptance of application has advantage of large near presbyopes is Contact lens.
for “DOS Fellowship for Partial segment ,less image jump but Most of our patients who
looses its popularity due to started wearing lenses 15
Assistance to Attend Conference” has poor cosmesis. Patients with years back are now shifting
been extended to 20th August, 2003 lesser adds (,1.0D) may not to presbyopic age and are not
instead of 31st July, 2003. The new be comfortable with bifocals. willing to accept glasses. For
application format is being published in Most bifocals styles available such patients Monovision
have add segments upto 3.5 concept of contact lens fitting
this issue (see page 92) Diopters. is used that is to correct one
Some practical instruc- eye for distance and other
tions for bifocal adaptation eye for reading. Also bifocal
Contact lenses are getting
popular and freely available
to patients who want to wear
contact lens at presbyopic
age.
August, 2003 65 DOS Times - Vol.9, No.2
JOURNAL ABSTRACTS
Intraoperative arcuate transverse macular degeneration
keratotomy with phacoemulsification
effectively decreases pre-existing Thach AB, Sipperley JO, Dugel PU, Sneed SR, Park
astigmatism DW, Cornelius J.
Retinal Consultants of Arizona, Phoenix 85064, USA.
Titiyal JS, Baidya KP, Sinha R, Ray M, Sharma N,
Vajpayee RB, Dada VK. Authors described the outcome of patients with occult chor-
Rajendra Prasad Centre for Ophthalmic Sciences, All India oidal neovascularization in age-related macular degenera-
Institute of Ophthalmic Sciences, New Delhi, India. tion treated with transpupillary thermotherapy. In a pro-
[email protected] spective, nonrandomized, nonmasked case series.
The authors evaluated the efficacy of paired intraoperative All patients with age-related macular degeneration with
arcuate transverse keratotomy at a 7-mm-diameter zone along a predominantly occult choroidal neovascular membrane
with a 3.5-mm clear corneal phaco tunnel in the steeper axis and an initial visual acuity of 20/400 or better were offered
to correct pre-existing astigmatism. treatment using transpupillary thermotherapy. The treat-
ment consisted of using a diode laser, a spot size of about
This prospective randomized case-control study was con- 3000 to 6000 micro m delivered over 60 seconds, and a power
ducted on 34 eyes of 28 patients with immature senile cata- of 600 to 1000 mW.Main Outcome Measures: A stable, im-
ract. They were divided into two groups; in one group (17 proved, or worsened visual acuity and the need for addi-
eyes) intraoperative arcuate keratotomy was coupled with tional treatment.
phacoemulsification in the steeper meridian (arcuate kera-
totomy group; mean preoperative astigmatism 2.28 +/- 0.89 Results showed in all sixty-nine patients were treated.
D) and the other group (17 eyes) phacoemulsification was All patients have been followed up for at least 6 months. At
performed in the steeper meridian without arcuate kerato- the 6-, 9-, and 12-month follow-up visits, 71% of patients
tomy (control group; mean preoperative astigmatism 2.04 have stable or improved visual acuity and 29% have lost 2 or
+/- 0.50 D). The patients were examined at 1 day, and 1, 4, more lines of visual acuity on the Snellen letter chart.
and 8 weeks postoperatively. Correction of keratometric astig-
matism, surgically induced refractive changes, magnitude Large-spot size transpupillary thermotherapy is effective
and axis of cylinder, spherical equivalent refraction, with in stabilizing the visual acuity in those patients who have
and against the wound change, and coupling ratio were occult choroidal neovascularization due to age-related macu-
evaluated. RESULTS: Mean reduction in keratometric astig- lar degeneration.
matism in the keratotomy group was 1.26 +/- 0.54 D (P =
.0067) and in the control group was 0.48 +/- 0.60 D (P = vvv
.0423). The difference in reduction of keratometric astigma-
tism between the two groups was statistically significant (P Optical coherence tomography allows
= .0296). Surgically induced refractive change at 8 weeks diagnosis of subtle vitreomacular
follow-up was 2.15 +/- 1.13 D in the keratotomy group and traction and provided precise
1.50 +/- 1.32 D in the control group (P = .046). Coupling ratio preoperative and postoperative
was -1.10 +/- 0.43 in the keratotomy group at 8 weeks after assessments of macular thickness
surgery while the control group was -0.82 +/- 0.38.
Massin P, Duguid G, Erginay A, Haouchine B,
The conclusion was combination of intraoperative arcu- Gaudric A.
ate keratotomy with steep axis phacoemulsification incision Department of Ophthalmology, Hopital Lariboisiere, Assis-
is more effective than steep axis phacoemulsification inci- tance Publique-Hopitaux de Paris, Universite Paris 7, Paris,
sion alone in reducing pre-existing astigmatism. France. [email protected]
vvv The authors report the use of optical coherence tomography
(OCT) for evaluation of diffuse diabetic macular edema
Large-spot size transpupillary (DME) before and after vitrectomy. DESIGN: Interventional
thermotherapy is effective in case series.
stabilizing the visual acuity in those
patients who have occult choroidal A retrospective study was made of 15 consecutive eyes of
neovascularization due to age-related 13 patients that had vitrectomy for diffuse DME and OCT
preoperatively and postoperatively. In seven eyes of six pa-
tients (group 1), vitrectomy was performed because of
vitreomacular traction observed on biomicroscopy or OCT.
In the other eight eyes of seven patients (group 2), vitrectomy
was performed for DME not responsive to laser photocoagu-
August, 2003 66 DOS Times - Vol.9, No.2
JOURNAL ABSTRACTS
lation, with no vitreomacular traction on biomicroscopy or versity Medical Center, Durham, North Carolina, USA.
OCT.
Authors compared anatomic and functional outcomes of
In results mean +/- standard deviation (SD) follow-up macular hole surgery with either silicone oil or C(3)F(8) gas
after vitrectomy was 18 +/- 10 months (range, 6 to 33 months). tamponade. In a retrospective comparative interventional
In group 1, mean +/- SD retinal thickness decreased signifi- study.
cantly from 661 +/- 181 microm preoperatively to 210 +/- 32
microm at the end of follow-up (P =.018). Median best-cor- Fifty-four eyes of 51 patients underwent pars plana
rected visual acuity (BCVA) improved from 20/100 before vitrectomy for macular holes. Thirty-one eyes were treated
surgery (range, 20/250 to 20/50) to 20/80 at the end of fol- with silicone oil tamponade, and 23 eyes were treated with
low-up (range, 20/250 to 20/25; P =.046). In one eye in group C(3)F(8) tamponade.
1, vitreomacular traction was only observed on OCT and not
on biomicroscopy. In group 2, mean +/- SD retinal thickness Demographics, preoperative and postoperative charac-
decreased from 522 +/- 103 microm preoperatively to 428 teristics, and complications were analyzed.
+/- 121 microm at the end of follow-up (P =.2). Median BCVA
was 20/100 before vitrectomy (range, 20/320 to 20/63) and Main outcome measures were preoperative and postop-
20/200 at the end of follow-up (range, 20/250 to 20/63; P erative visual acuity, initial hole closure, number of persis-
=.78). tent or recurrent holes, number of reoperations, and final
hole closure.
In conclusion vitrectomy was beneficial in eyes with dif-
fuse DME combined with vitreomacular traction but not in Results showed the silicone oil and gas tamponade
eyes without traction. Optical coherence tomography al- groups were demographically similar. The rate of hole clo-
lowed diagnosis of subtle vitreomacular traction and pro- sure after one operation with oil tamponade was signifi-
vided precise preoperative and postoperative assessments cantly lower than that with gas tamponade (65% vs. 91%; P
of macular thickness. = 0.022). The percentage of patients undergoing a second
operation was significantly higher in the oil group (35% vs.
vvv 4%; P = 0.006). However, with reoperations, the final rate of
hole closure was similar between the oil and gas groups
C(3)F(8) gas is more effective tampon- (90% vs. 96%; P = 0.628). The final median visual acuity for
ade than silicone oil with respect to the gas group was significantly better than for the oil group
achieving initial closure of macular (20/50 vs. 20/70; P = 0.047).
holes. Final visual acuity is better for
gas-operated eyes than for silicone- In conclusion C(3)F(8) gas proved to be a more effective
operated eyes tamponade than silicone oil with respect to achieving initial
closure of macular holes. Eyes receiving an oil tamponade
Lai JC, Stinnett SS, McCuen BW. required significantly more reoperations to achieve a simi-
Department of Ophthalmology, Duke Eye Center, Duke Uni- lar rate of hole closure compared with eyes undergoing a
gas tamponade. Final visual acuity was better for gas-oper-
ated eyes than for silicone-operated eyes.
vvv
High Lights for September Issue of DOS Times
Ø Management of Fungal & Acanthamoeba Keratitis : Dr. M. Srinivasan
Ø Management of Non-healing Corneal Ulcer : Dr. R.N. Bhatnagar
Ø Lamellar Keratoplasty: Current Prespective : Dr. J.S. Titiyal
Ø Difficulties and Complications of SICS : Dr. K.P.S. Malik
Ø Botulinum Toxin A Injection for Blepherospasm : Dr. Madhu Karna
Ø Retinoblastoma : Dr. Anita Sethi
Ø Surgical Management of Pediatric Cataract : Dr. Abhay Vasavada
August, 2003 67 DOS Times - Vol.9, No.2
DCRS
DOS Credit Rating System (DCRS)
The rate of technological and academic obsolescence stitution was the cultivation and promotion of the Sci-
in Ophthalmology has reached astronomical levels in ence of Ophthalmology in Delhi.
recent times. What was advanced yesterday may al-
ready be obsolete today. The rapid strides in skills and In a bid to strengthen our efforts in this direction and
knowledge have created a need for an extremely inten- fulfil the vision of our society’s founders, DOS announces
sive Continuing Medical Education programme. the DOS Credit Rating System (DCRS), the details of
which are given below. Our Primary objective is to
DOS has always been in the forefront of efforts to promote value-based knowledge and skills in Ophthal-
ensure that its members remain abreast with the latest mology for our members and give recognition and credit
developments in Ophthalmology. Among the impor- for efforts made by individual members to achieve stand-
tant objectives formulated by the founders of our con- ards of academic excellence in Ophthalmic Practice.
DOS announces a new era in Continuing Medical Education
DOS CREDIT RATING SYSTEM (DCRS)
(A new chapter in CME)
Credits
1) Attending Monthly Clinical Meeting* † (For full attendence) 10
2) Making Case Presentation at Monthly Meeting** 15
3) Delivering a Clinical Talk at Monthly Meeting** 15
4) Free Paper Presentation at Annual Conference (To Presenter)** 15
5) Speaker/Instructor** in : Monthly Symposium 15
: Mid Term Symposium 15
: Annual Conference 15
6) Registered Delegate at Mid Term DOS Conference 20
7) Registered Delegate at Annual DOS Conference 30
8) Full Article publication in Delhi Journal of Ophthalmology (Visiscan) 15
9) Letter to Editor/Correspondence/Published Article in DOS Times 10
——————————————————————————————————————————————
If any of the presentations is given an Award – Institutional assessment for best performance
Additional 20 bonus Credits. will be based on the total score of members who
attend divided by number of members who at-
Member who have earned 100 Credits, are enti- tended. Institutional assessment regarding deci-
tled to: sion to retain the institute for the next year will be
based on total score by all delegates who attend
a) Certificate of Academic Excellence in Ophthal- the meeting divided by average attendence of all
mic Practice. 8 meetings.
b) 50% exemption of Registration fee at next An- Please note that the Institutions’ grading in-
nual DOS Conference. creases if the attendance at its meeting is higher
(i.e. more than the average attendence of the eight
c) Certificate of Academic Excellence in Ophthal- monthly meetings).
mic Practice (3 years in row) will entitle the mem- ——————————————————————
ber to a proposed academic grant of Rs.5,000/- only * Based on Signature in DCAC
to enable him/her to attend any international con- ** Subject to Submission of Full Text to Secretary, DOS
ference outside India to present his/her own ac- † Credits will be reduced in case attendence is only for
cepted presentation (proof required). part of the meeting.
If any member earns 200 Credits, he/she shall,
in addition to above, be awarded Certificate of Dis-
tinguished Resource-Teacher of the Society.
August, 2003 68 DOS Times - Vol.9, No.2
DOS FELLOWSHIP
Delhi Ophthalmological Society Fellowship for
Partial Financial Assistance to Attend Conferences
The DOS Travel Fellowship will be called
DOS Fellowship for Partial Financial Assistance to Attend Conferences
Conferences b) 36 to 45 years 07
International: two fellowships per year c) 45 years plus 05
l Maximum of Rs. 25,000/-will be sanctioned 2) Type of Presentation
National: three fellowships per year (only for AIOS) a) Instructor/ Co-instructor of Course 10
l Maximum of Rs. 5,000 will be sanctioned b) Free Paper (Oral) 08
Eligibility c) Poster 05
l DOS Life Members (Delhi Members only) 3) Institutional Affiliation
l Accepted paper for presentation / poster / instruc- a) Academic Institution 15
tion course b) Private Practitioner 20
Time since last DOS Fellowship 4) DCRS Rating in the immediate previous year
Preference will be given to member who has not at- a) 50-100 05
tended conference in last three years. However if no ap- b) > 100 10
plicant is found suitable the fellowship money will be c) < 50 not eligible
passed on to next year. Members who has availed DOS Documents
fellowship once will not be eligible for next fellowship for l Proof for age. Date of Birth Certificate
a minimum period of three years. l Letter of acceptance of paper for presentation / poster
Authorship or instruction course
The fellowship will be given only to presenting au- l Details of announcement of the conference
thor. Presenting author has to obtain certificate from all l Details of conference attendant in previous three
other co-authors that they are not attending the said con- years.
ference or not applying for grant for the same conference. l Copy of letter from other national or international
(Preference will be given to author where other authors agency / agencies committing to bear partial cost of
are not attending the same conference). If there is repeat- conference if any.
ability of same author group in that case preference will l At least one original document should be provided,
be given to new author or new group of authors. Prefer- that is ticket, boarding pass or registration certificate
ence will also be given to presenter who is attending the along with attendance certificate of the conference.
conference for the first time. l Fellowship Money will be reimbursed only after sub-
Quality of Paper mission of all the required documents.
The applicant has to submit abstract along with full Dr. J C Das (President DOS), Dr. Gurbax Singh (Vice
text to the DOS Fellowship Committee. The committee will President DOS), Dr. Kamlesh (Editor) Dr. Lalit Verma (Li-
review the paper for its scientific and academic standard. brary Officer), Dr. Sudipto Pakrasi (Member) and Dr. Jeewan
The paper should be certified by the head of the depart- S. Titiyal (Secretary DOS) will be the members of DOS Fel-
ment / institution, that the work has been carried out in lowship for Partial Financial Assistance to Attend Con-
the institution. In case of individual practitioner he or she ferences Committee.
should mention the place of study and give undertaking Application should be addressed to President, DOS.
that work is genuine. The fellowship committee while Application should reach secretary’s office before 31st July
scrutinizing the paper may seek further clarification from and 31st January for international conference and before
the applicant before satisfying itself about the quality and 30th September for national conference. The committee
authenticity of the paper. will meet thrice in a year in the month of August, October
Credit to DOS and February with in 2 weeks of last date of receipt of
The presenter will acknowledge DOS partial finan- applications. The committee will reply within four week
cial assistance in the abstract book / proceedings. of last date of submission in yes/no to the applicant. No
The author will present his or her paper in the imme- fellowship will be given retrospectively, that means prior
diate next DOS conference and it will be published in sanction of executive will be necessary.
DJO. Dr. Jeewan S. Titiyal, Secretary DOS,
Points awarded Delhi Ophthalmological Society, R.No. 476, 4th Floor,
1) Age of the Applicant Points Dr. R.P. Centre for Ophthalmic Sciences AIIMS, Ansari
a) < 35 years 10 Nagar, New Delhi – 110029
August, 2003 69 DOS Times - Vol.9, No.2
APPLIANCES
Indirect Ophthalmoscopy: and during buckling sur-
gery, without compromising
Principles, Technique and on the sterility of the operat-
ing field.
The disadvantages are the
Practical Tips need for dilatation (which
anyway is necessary for any
procedure that involves a
Vinay Garodia MD, DNB, FRCS thorough evaluation of
retina), the technique is rela-
Ever since its introduction observer’s eyepiece (Fig. 1). the relative position of a pa- tively more difficult to learn
by Schepens in 1940s, Bin- The image is inverted and thology in relation to the and master, inexperienced
ocular Indirect Ophthalmos- reversed right for left. By the other structures in the retina. examiners may find the in-
copy has been an indispens- use of prisms, the viewing With this procedure, espe- verted and reversed image
able part of ocular examina- system reduces the effective cially if employed with difficult to interpret.
tion, especially for patients interpupillary distance (IPD) scleral depression, one can
with retinal diseases. to fit the patient’s pupil, and view upto the extreme pe- Technique for Indirect
Though it is relatively more thus aids in obtaining a ste- riphery of retina and can even Ophthalmoscopy
difficult to learn than direct reoscopic view. The ad- evaluate the pars plana. Before performing Indirect
ophthalmoscopy, once mas- vanced indirect ophthalmo- There is less distortion of Ophthalmoscopy, the pupil
tered, it is a very convenient scopes come with the ‘small image of the fundus in reti- must be adequately dilated.
tool for rapidly and easily pupil option’, wherein the nal periphery than in other The patient must be ex-
evaluating a large area of movable prism system can techniques. The bright light plained about the procedure
retina. Indirect Ophthalmos- and should be briefly
copy gives the advantage of Indirect Ophthalmoscopy is the easiest warned about the bright
brighter illumination, bigger and fastest method of evaluating the light that he/she will have
field of view, stereoscopic whole of retina to look into. Before doing
image, and the ability to scan scleral depression, the pa-
the whole retina upto and reduce the effective IPD, for source ensures better visual- tient must be assured that it
even beyond the ora serrata. examining the eyes with ization through the hazy is a harmless and painless
Before going on to the details smaller pupil. However, media. The stereoscopic view procedure, and is requested
of performing the procedure, when effective IPD is re- adds a third dimension to to keep his/her eyes relaxed.
the optical principle behind duced, stereopsis is also de- observation and is useful in For the procedure, an indi-
this technique (Fig. 1) must creased. There are also op- evaluating elevated lesions rect ophthalmoscope, a con-
be understood. The indirect tions for incorporating filters like retinal detachment, densing lens, a scleral de-
ophthalmoscope consists of to the light source or to the macular or disc edema, etc. pressor and a chart to map
a bright light source, which viewing system. This is use- Moreover, it has an advan- the fundus drawings are re-
directs the defocused light ful during performing Fluo- tage of being used during reti- quired. The condensing
beam towards the patient’s rescein angioscopy (blue fil- nal procedures like cryopexy lenses are available in differ-
eye. This light enters the ter over light source and yel-
patient’s eye through the di- low filters over the oculars),
lated pupil and gets reflected or the use of red free filters to
from the retina or the struc- enhance contrast of vascular
tures in its path. The emerg- structures.
ing reflected beam gets fo- Indirect Ophthalmoscopy
cused by a hand held con- is the easiest and fastest
densing lens to form a real method of evaluating the
and inverted image between whole of retina. It has the
the condensing lens and the advantages of a large field of
view, especially helpful in
Visitech Eye Hospital evaluating larger structures Fig. 1: Optical principle of Indirect Ophthalmoscopy. Note the
Advanced Centre for Vitreo Retina like retinal detachment or relative positions of Binocular Indirect Ophthalmoscope (BIO),
and Lasers, 55, Mall Road, tumour and for providing a real image (inverted), condensing lens and patient’s pupil.
Delhi - 110009. bird’s eye view to evaluate
August, 2003 70 DOS Times - Vol.9, No.2
APPLIANCES
ent powers (+14, +20 and adequately, so that the hori- After the indirect ophthal- the learning stages, and one
+28 or +30 Diopters). The zontal band need not be moscope has been adjusted needs to practice it. The little
lenses with lesser power (+14 tightened too much, which properly, the examination finger resting on the patient’s
D) have a better magnifica- can otherwise make the pro- begins. The examiner stands cheek acts as a pivot for move-
tion (3.5X) but with a smaller cedure very uncomfortable on the opposite side of the ments of the lens. It is impor-
field of view (25o), and re- and tiring for the examiner. direction to be examined. tant not to get too close to the
quire a better pupillary dila- Once the headband is se- The condensing lens is held patient, as it makes the job
tation. The lenses with cured, the viewing portion is between the thumb and the more difficult. Once a clear
higher power (+28 or +30 D) adjusted for height and first two fingers. The ring view is obtained, the exam-
have a lesser magnification should fall in the line of sight and little fingers are placed iner swivels about the point
(1.5X) but with a bigger field of the examiner. The oculars on patient’s cheek to stabilise in the patient’s pupil, keep-
(55o) and can view the fun- are kept as close to the the hand. It is better to prac- ing the examiner’s headset,
dus through relatively examiner’s eye or spectacles tice using the non-dominant condensing lens, and the
smaller pupil. An intermedi- as possible. Next the IPD is hand to hold the lens, leav- patient’s pupil in an align-
ate power lens of + 20 D is a adjusted so that both the eyes ing the dominant hand free ment.
good compromise to obtain get a symmetrical view of the for holding the active instru-
an adequate magnification light spot falling on the back ment like scleral depressor or The examiner must con-
(2.5X) and field (35o), and is of the extended hand of the cryopexy probe. The patient stantly remember that the
most commonly used. examiner. The view through is asked to look in the supe- image is inverted and re-
each of the eyes should be rior direction and the binocu- versed, so as to maintain the
The patient may be exam- similar in height and lateral lar indirect ophthalmoscope alignment of his/her move-
ined in either sitting or su- ments. After finishing evalu-
pine position. The supine the technique is relatively more difficult ating the superior retina, the
position is easier for the ex- to learn and master, inexperienced ex- patient is asked to move his/
aminer as well as the patient. aminers may find the inverted and re- her eyes in the other direc-
A motorized chair, which tions, while the examiner
can be reclined back com- versed image difficult to interpret stands in the opposite direc-
pletely, is adequate. There tion of eye’s position. The
must be adequate room for extent. The lighting system is is directed towards the patient’s face has to be
the examiner to move all adjusted such that the illu- patient’s pupil at a distance moved slightly to overcome
around the patient’s head to minated light patch occupies of approximately one arm’s the obstacles like nose and
evaluate different quadrants upper two-thirds of the field length. A reddish orange re- forehead of the patient. To
of the retina. Before starting of vision. The illumination flex is seen. The condensing overcome the physical ob-
the examination, the exam- intensity is controlled by the lens is inserted into the illu- stacle of nose, it is useful to
iner must be familiar with all rheostat in the power supply, minated path of the ophthal- turn the patient’s face
the controls of the instru- and should be kept at the moscope approximately 1.5 slightly towards the exam-
ment. Individual machines minimum necessary for the inches away from the iner (away from the direction
differ from each other in de- examination. In case of un- patient’s eye. A small image of eye movement) when
sign, but generally speaking cooperative patients, it is bet- of the retina appears when evaluating the temporal
there are a few features that ter to start with lower level of the lens is centered properly. retina. The patient must be
are common to most of the illumination and increase it The lens is then drawn constantly reminded to keep
machines. later once the patient gets slightly away from the pa- both the eyes open. The pa-
accustomed to the bright tient to fill it with the image tient may either be instructed
The indirect ophthalmo- light. It is preferable to start of the fundus. While per- to look in the various direc-
scope can either be mounted by examining the less sensi- forming this maneuver, tions, or else, he/she may be
on a headband or on a spec- tive peripheral retina first slight lateral and vertical asked to follow the thumb of
tacle. The headband is more and the posterior pole last. adjustments in lens position his/her extended hand.
comfortable, especially Even in peripheral retina, it are done to keep the image
when used for long duration. is better to observe superior centered. Slight tilting and Scleral Depression
There are two bands, a hori- retina first, as initially the adjustment of lens is required This technique allows the
zontal one to tighten around patients have a tendency to to reduce the annoying re-
the forehead, and a vertical roll up the eyes in response flection. This step of posi- evaluation of the peripheral
band to adjust the height and to light, which aids in exam- tioning and adjusting the most parts of the retina and
to support the weight of the ining the superior retina. lens is a bit difficult during pars plana. However, the
instrument. It is essential that technique of scleral depres-
the vertical band be adjusted sion can not be applied to the
August, 2003 71 DOS Times - Vol.9, No.2
APPLIANCES
Fig. 2: The normal anatomic structures in the eye can be used as Fig. 3: A sample fundus diagram, showing the universal colour
aids to orientation and are useful in mapping the lesions relative coding system for a few common lesions and structures.
to the position of equator and prominent landmarks.
eyes with open globe inju- interest. When performed veins ampulla are seen along with the colleagues. Disk is
ries, or recently operated cata- properly, it is painless pro- the equator. The long ciliary always shown with red mar-
ract surgery. The patient is cedure and adds a lot of clini- veins may be seen at 3’O gin. Arteries are made with
assured and is asked to re- cal information, especially clock and 9’O clock posi- red lines, whereas veins are
lax his/her eyes. The scleral when looking for small reti- tions. The pathology must made of blue lines. Attached
depressor can be introduced nal dialysis or retinal breaks also be localized in relation retina is red and detached
over the lids or directly on the in the periphery. to some branching vessel and retina is coloured blue. A reti-
conjunctiva, after applying must be faithfully mapped in nal hole or tear is shown as
topical anesthesia. The ex- Interpretation and Mapping the fundus drawing, to facili- red with blue outline. Chor-
aminer stands opposite to of Findings tate locating the same later. oidal lesions are depicted
the area of interest. The pa- The fundus drawing is made brown; any vitreous opacity
tient is asked to look towards It takes some time to get on a special Amsler’s chart, is depicted with green.
the direction of the examiner used to and make sense of the which has twelve clock
and the depressor is placed inverted image in indirect hours marked and has three To conclude, regular use
on the eyelids in the oppo- ophthalmoscopy. Once the concentric circles made on it. of indirect ophthalmoscopy
site direction, in the area of examiner gains experience, The innermost circle repre- is the biggest pre-requisite to
interest. Now the patient is he/she may cognitively cor- sents to the equator, the master this extremely useful
asked to gently look away rect the image mentally and middle circle the ora-seratta, technique. Mastering this
from the examiner, towards then draw it normally. For and the outer most circle the technique is essential for
the direction of the area of the beginners though, it is mid-point of pars plana. A someone who wishes to per-
interest (the direction where simpler to draw the image as proper and detailed map- form retinal cryopexy and
the depressor has been ap- it is seen, and then turn ping of normal and abnormal retinal detachment surgery.
plied), while the depressor around the paper on which findings on this chart is a While learning this tech-
also gently moves in the di- it is drawn. This automati- good practice. There are a few nique, one must be persistent
rection of the movement of cally corrects for the image conventions to fundus chart- and should not hesitate in
eye. This ensures a gentle inversion. In case of any ing. Symbols and colour cod- consulting the more experi-
pressure on the globe, which doubt, one must not hesitate ing are used to represent the enced colleagues, whenever
is appreciated by indirect to go back and recheck the various findings, a few of a problem is faced. With regu-
ophthalmoscopy. The scleral findings. which are detailed in Figure lar practice, the steps of this
depressor can be moved 3. The advantages of the use technique become a second
slightly side to side or in It is very useful to note the of conventions include less nature to the examiner and
antero-posterior direction position of any pathology need to label with words and opens up a new vista for ex-
gently to show the area of with respect to the normal enhanced communication ploring the intricacies and
anatomical landmarks on details of posterior segment.
the retina (Fig. 2). The vortex
August, 2003 72 DOS Times - Vol.9, No.2
MANAGEMENT PEARLS
Visual Rehabilitation after Keratoplasty involve correc-
Penetrating Keratoplasty tion of residual refractive er-
ror, comfort commensurate
Rajesh Sinha MD, Jeewan S Titiyal MD, Namrata Sharma MD, with a reasonable wearing
Rasik B Vajpayee MS, FRCS (Ed.) time, and maintenance of
ocular health.
Advances in microsurgi- vision. The ametropia fol- In cases of small to mod-
cal techniques and postop- lowing PK is usually related erate amounts of ametropia Among all contact lenses,
erative care have made it pos- to factors like the configura- with less than 3 D of ani- the rigid gas permeable
sible to achieve a high rate of tion of trephine incisions, sometropia and or astigma- (RGP) lenses, owing to their
corneal graft clarity in a num- donor-recipient graft dispar- tism less than 4D, spectacle high oxygen transmissibility
ber of clinical conditions. ity, irregular and inappropri- correction is tolerated. Many and the ability to correct for
Despite all these advances, ate tightness of sutures, dif- of these patients who cannot the corneal toricity, are an
many corneal surfaces re- ferences in thickness of do- be rehabilitated with spec- obvious choice to provide vi-
main irregular and have nor and recipient wound tacle correction can be aided sual rehabilitation in an eye
high degrees of astigmatism edges creating a step, spe- by contact lens. Contact lens with corneal graft (Figure 2).
following penetrating cific situations like keratoco- fitting has been reported to
keratoplasty (PK). The visual nus or difficulty of lens be successful in as many as In the phakic or aphakic
outcome of a clear corneal power calculation in the pa- 80 to 90% of these cases. Soft graft with low toricity, daily
graft (Figure 1) is often com- tient undergoing corneal contact lenses are effective wear soft contact lenses can
promised by high degrees of be used. The use of extended
astigmatism, which may be The visual outcome of a clear corneal graft is wear soft contact lenses is
associated with large often compromised by high degrees of more problematic as most
amounts of myopia, ani- studies have shown that the
sometropia and less com- astigmatism, which may be associated with corneal graft tolerates the ex-
monly with hypermetropia. large amounts of myopia, anisometropia and tended wear contact lens
Binder in a series of patients poorly and that its use in
after corneal transplantation less commonly with hypermetropia such patients is associated
and cataract extraction re- with corneal vascularisation.
ported that only 21 of the 43 triple procedure. only for correction of post- This increases the risk of
eyes achieved refractive error Management of Ametropia keratoplasty refractive errors graft rejection and hence
within 2D of emmetropia. Re- 1. Spectacles with low astigmatism, graft failure.
fractive unpredictability af- 2. Contact Lens whereas rigid gas permeable
ter penetrating keratoplasty 3. Surgical Correction contact lenses are usually Although lenses can be
(PK) is extremely common required when astigmatism fitted when sutures are in
with most studies document- a. Selective Suture of a high degree is present. place, rigid lenses are usu-
ing a cylinder of 4 to 5 Removal ally fitted after suture re-
Dioptres (D) and significant The main aims of contact moval, 12 to 18 months post-
anisometropia. Refractive b. Arcuate Keratotomy lens fitting after penetrating operatively. Prior to lens fit-
anisometropia and high c. LASIK ting, K readings and mani-
postoperative astigmatism fest refraction should be
can compromise the stable over a period of a
patient’s return to normal couple of months.
binocular function. Ani-
sometropia may also cause Some patients might be
headache, photophobia,
tearing, diplopia and blurred
Cornea and Refrective Surgery Figure 1 Figure 2
Serivice, R.P. Centre for
Ophthalmic Sciences, AIIMS,
Ansari Nagar, New Delhi - 29
August, 2003 73 DOS Times - Vol.9, No.2
MANAGEMENT PEARLS
having a very high astigma- wound are poorly apposed. More recently, several have taken place 3 to 6
tism and an irregular corneal Further, variable healing pe- studies have reported the use months prior to the proposed
surface. These patients may riod in these cases may pro- of laser in situ keratomileusis LASIK procedure.
not gain a sharp acuity with duce fluctuations in corneal (LASIK) in eyes that have
contact lens alone. A combi- topography, refraction and undergone corneal grafting. The contraindications of
nation of spectacle correction keratometry. Procedures LASIK offers several advan- performing LASIK after PK
over contact lens might help such as radial keratotomy tages over PRK in the treat- for residual refractive er-
in these cases. performed in corneal grafts ment of myopia and astigma- rors/ anisometropia include
have shown less predictable tism. These advantages in- marked peripheral corneal
However, many patients, results and a high rate of clude rapid visual rehabili- vascularization, thin host
especially the elderly are un- complications and their use tation, decreased stromal tissue, wound ectasia, a sig-
able to tolerate, handle or scarring, less irregular astig- nificant graft override or
matism, minimal regression wound malapposition and
Contact lens fitting has been reported to and the ability to treat greater minimum central corneal
be successful in as many as 80 to 90% range of refractive disorders. thickness of less than 500µm
of these cases Further, it also preserves the and simulated keratometry
Bowman’s membrane (un- readings below 38D or
maintain contact lenses. is presently discouraged. like PRK) and the anatomi- greater than 55D. If cataract
Contact lens intolerance may Hexagonal keratotomy to cal structure of the cornea is present, phacoemulsi-
be caused by ocular, occupa- correct hypermetropia has and respects the normal cor- fication with an appropriate
tional or systemic factors. In been used post keratoplasty, neal physiology. lens implant may be a better
these cases, surgical inter- with limited success owing method of addressing ani-
vention may be required to to the high incidence of astig- LASIK should be consid- sometropia or ametropia.
achieve visual rehabilitation. matism. ered as a therapeutic option
in post-PK patients in whom All patients undergoing
Apart from the spectacles Arcuate keratotomy with the conventional optical LASIK after corneal grafting
and the contact lenses vari- placement of incisions just methods have failed. Large should be explained that the
ous maneuvers have been inside the graft-host junction refractive errors, anisometro- primary goal of LASIK after
used to correct post-kerato- has been found to be quite pia not successfully cor- PK is resolution of sufficient
plasty anisometropia and effective by many surgeons. rected with spectacles and myopia and astigmatism to
high degrees of astigmatism However, the effect of these cases of contact lens intoler- allow spectacle correction of
with a variable rate of suc- incisions may not be the ance should be considered the residual refractive error.
cess. In pseudophakic eyes, same as in other cases as in a for LASIK. LASIK has been
intraocular lens exchange corneal graft, the graft-host used more commonly to treat Modifications
can decrease anisometropia junction acts as second lim- myopia or myopic astigma- recommended in surgical
and scleral wound manipu- bus. tism and less commonly hy- technique of LASIK
lation may minimize astig-
matism. However, this sur- The advent of excimer la- The corneal flap diameter
gical intervention may ser surgery has opened new
threaten the graft and may perspectives for the treat- Arcuate keratotomy with placement of
result in endothelial decom- ment of post-keratoplasty re- incisions just inside the graft-host
pensation, rejection or other fractive errors. However, junction has been found to be quite
complications. photorefractive keratectomy effective by many surgeons
(PRK) is associated with sig-
Post-keratoplasty astig- nificant amount of stromal permetropia or hyperopic should be more than the di-
matism has been treated by haze, which is related to the astigmatism. The required ameter of the graft, which
the various forms of magnitude of the ablations, safety interval between PK usually ranges from 7.5 to
incisional refractive surgery required for these cases, and and LASIK has not been pre- 8.5mm. It is recommended
such as relaxing incisions, is coupled with the regres- cisely established. Most ad- that initiation of the flap edge
astigmatic keratotomy and sion of the obtained refrac- vocate a minimal period of 2 exactly at the graft host junc-
wedge resections. Relaxing tive effect. Excimer photo-ab- to 3 years after a successful tion should be avoided so
incisions at the graft host in- lation-induced graft rejection penetrating keratoplasty for that the flap drapes the
terface are associated with and loss of best spectacle performing LASIK. Most au- wound and better wound
increased risk of wound de- corrected visual acuity have thors advocate that suture apposition of the flap is cre-
hiscence, especially where also been reported in some removal in these eyes should ated to the recipient bed. Fur-
the posterior edges of the of these cases.
August, 2003 74 DOS Times - Vol.9, No.2
MANAGEMENT PEARLS
ther, this also possibly en- scribed for a longer than has been recommended in The risk of damage to the
sures that the contractile usual period after the pro- which excimer laser abla- corneal transplant or the
forces emanating from the cedure to minimize the risk tion is done 3 months later graft host-wound interface
graft host junction both in of graft rejection. after re-lifting the flap. The or both is the most dreaded
centripetal as well as in the lamellar cut performed, complication after LASIK.
For cases with more than leads to release of the con- Wound dehiscence after PK
tractile forces which ema- is a well-described phenom-
LASIK should be considered as a nate from the graft host enon, which can occur imme-
therapeutic option in post-PK patients junction. This is subse- diately, or years after PK. In
quently followed by the re- LASIK, intraocular pressure
in whom the conventional optical alignment of the corneal tis- is elevated to more than 65
methods have failed sue. The main change in mmHg and there is a risk of
astigmatism occurs within wound dehiscence with the
centrifugal directions 6D of astigmatism, one can 1 day after cutting the flap, possibility of extrusion of the
would be released. initially perform arcuate in- but further minor progres- intraocular contents.
cision to reduce the cylinder sion or regression of the re-
A 160µm and following a period of fractive effect may be seen To conclude, the appear-
microkeratome head should stability (3-4 months), upto 3 months postopera- ance of a clear corneal graft
be used in these cases as be- LASIK can be performed to tive day. may be very satisfying to
ing in more superficial correct the residual refrac- the surgeon. However, it
lamellar plane it fulfils the tive error. Astigmatic correction by may not be the same with
need to release the periph- augmentation with arcuate the patient. At times, it
eral traction lines. Sequential treatment has incisions in the corneal stro- may be very annoying due
been recommended in post- mal bed after the laser abla- to the amount of ametropia
Some have recom- keratoplasty astigmatism tion has also been tried. The and resulting anisometro-
mended a prolonged wait- rather than the simulta- arcuate cuts were performed pia. Many treatment mo-
ing period of 5 minutes for neous treatment. In this with a guarded diamond dalities have been de-
better adherence of the flap treatment modality, a knife set with a micrometer scribed which includes
as flap adherence takes hinged lamellar kerato- at 350µm. Two arcs of 60° to early suture adjustment, se-
longer in post-keratoplasty tomy is performed first 80° were performed in the lective suture removal, spec-
patients owing to poorer which induces a biome- axis of the steep meridian. tacle correction, contact lens,
endothelial function. chanical response of the The decision to perform ar- various incisional proce-
cornea, resulting in sub- cuate cuts is based on an as- dures and the modern day
Target refraction may be stantial change in its shape sessment of the cylindrical LASIK. In spite of the advent
emmetropia or decrease in due to the previously exist- treatment possible with the of so many advanced pro-
anisometropia with a goal ing alterations of their natu- laser (maximum of 5D) and cedures, rigid gas perme-
of complete resolution of ral biomechanical state. In constraints imposed by the able contact lens, in our
cylinder. this technique, the flap is possible induced hyper- opinion, remains the main-
raised as a first stage pro- metropia and insufficient stay of visual rehabilita-
Although graft rejection cedure. A two stage surgery optical zone size. tion in such cases.
after LASIK has not been
reported unlike PRK, topi-
cal steroids should be pre-
August, 2003 75 DOS Times - Vol.9, No.2
MANAGEMENT PEARLS
Chemical Injuries: these irrigating systems may
Management Guidelines provide continuous irriga-
tion but they fail to flush the
Ritu Arora MD., Vandana Jain MBBS. , D.K.Mehta MS, MNAMS ocular surface homoge-
neously especially the cul-
Chemical burns represent provide prognostic guide- This is particularly true for de-sacs. On one hand it is
potentially blinding ocular lines based on the corneal grade IV burns (50-100% true that composition of irri-
injuries and constitute a true appearance and extent of limbal ischemia) which are gating fluid is less important
ocular emergency. Recent limbal ischemia. This classi- equated with poor prognosis. than the speed with which it
studies put the incidence of fication has become the is initiated, on the other hand
ocular burns of the eye at benchmark since its intro- Emergency (Immediate) the argument that still re-
7.7% - 18% of all ocular trau- duction in 1965. Treatment mains is the choice of irrigat-
mas. The majority of victims ing fluid. Osmolarity of cor-
are young and exposure oc- Roper Hall classification Immediate irrigation is of neal stroma is 420 mOsm/L,
curs at home, work and in as- Grade I: There is no cor- paramount importance after so if irrigation is done with a
sociation with criminal as- the chemical and thermal hyposomolar fluid such as
saults. Alkali injuries occur neal opacity or limbal is- burns. In most cases victims water, there is additional
more frequently than acid chemia and the prognosis is are disabled by severe ble- uptake of water into cornea
injuries. Lime injuries are the excellent. pharospasm with ensuing along with diffusion of the
commonest in our setup. In- disorientation, which can be chemical into the deeper lay-
juries due to sulfuric acid Grade II: The cornea is overcome by passive open- ers of the cornea.
though less severe are also hazy with visible iris details, ing of the lids and intermit-
becoming common because there is ischemia of less than So Kuckelkom et al has
of battery use in inverters. recommended the use of irri-
Alkali injuries occur more frequently gating fluids with higher os-
Chemical injuries of the than acid injuries. Lime injuries are the molarity for initial irrigation.
eye produce extensive dam- Sterile lactated ringer and
age to the ocular surface epi- commonest balanced salt solution (BSS)
thelium, cornea, anterior seg- are believed to be more effec-
ment and limbal stem cells one-third of the limbus and tent application of topical tive than normal saline (NS).
resulting in permanent uni- the prognosis is good. anesthetic. All the aspects of A new amphoteric solution
lateral or bilateral visual im- conjunctiva and cornea diphoterine is proposed for
pairment. Damage to limbal Grade III: There is sufficient should be irrigated and the initial irrigation, it binds
stem cell result in corneal stromal haze to obscure iris patient should be asked to both alkalis and acids. 0.4%
conjunctivalisation, vascu- details, ischemia of one third look in all directions. Cotton diphoterine has a pH of 7.4
larization, chronic inflam- to one half of the limbus and tipped applicator soaked in and an osmolarity of 820
mation and recurrent or per- the prognosis is guarded. EDTA 1% can be used to fa- mosm/L.
sistent epithelial defects. Se- cilitate cleaning of cul-de-sac
vere damage to conjunctival Grade IV: The cornea is from lime particles. After a thorough irriga-
cells causes mucus defi- opaque with no view of iris tion, it is important to assess
ciency and persistent sub- or pupil, there is ischemia of The effectiveness of rins- the degree of burn with re-
conjunctival inflammation more than one-half of limbus ing therapy can be assessed spect to conjunctival necro-
resulting in severe dry eye and the prognosis is poor. by using universal indicator sis, limbal ischemia, corneal
and fibrosis of subconjuncti- paper to determine the pH of damage, intraocular pres-
val tissue. A new classification has the external eye. Irrigation sure and degree of intraocu-
been proposed by Dua et al must be continued as long as lar penetration.
Ballen first suggested a that take into account the ex- the pH value remains out-
classification, which was tent of limbal involvement in side the normal range. Medical Treatment
modified by Roper-Hall to clock hours and the percent- Treatment in acute stage
age of conjunctival involve- Several methods of facili-
Guru Nanak Eye Centre, ment. Dua et al stressed the tating irrigation have been is aimed at promoting ocu-
Maulana Azad Medical College, inadequacy of the currently suggested, including im- lar surface epithelialization,
New Delhi. followed RoperHall classifi- plantation of a T-tube and augmenting corneal repair
cation that is reflected in the use of an irrigating scleral and controlling inflamma-
inconsistencies of success lens. But it is believed that tion with the objective of pre-
rates reported in literature. venting scarring sequelae
and severe visual loss. Topi-
August, 2003 76 DOS Times - Vol.9, No.2
MANAGEMENT PEARLS
Dua’s classification expression of neutrophil col-
lagenase and epithelial
Grade Prognosis Limbal Conj. Analogue gelatinase, suppression of a1
Involvement Involvement Scale antitrypsin degradation, and
I Very good scavengingofreactiveoxygen
II Good 0 clock hours 0% 0/0% species. Tab doxicycline
III Good =3 clock hours = 30% .1-3/1-29.9% 100mg twice a day can be
IV Good -guarded >3-6 clock hours >30-50% 3.1-6/31-50% given.
V Guarded-poor >6-9 clock hours >50-75% 6.1-9/51-75%
VI Very poor >9-<12 clock hours >75-100% 9.1-11.9/75-99.9% c. Collagenase Inhibitors
Total limbus Total conj.inv. 12/100% Several collagenase in-
cal antibiotics are instilled to mal adhesion protecting thelium by intraocular injury hibitors including cysteine,
protect the eye from second- ocular surface from the results in decreased secretion acetylcysteine, sodium
ary infection along with my- windshield wiper effect of of ascorbate and a reduction ethylenediaminetetraacetic
driatic-cycloplegic agents to lids. in its concentration in the acid (EDTA), calcium ETDA,
prevent the formation of pos- But they may be poorly anterior chamber, that may penicillamine and citrate
terior synechiae and the de- tolerated by acutely chemi- lead to impaired collagen have been reported to be effi-
velopment of ciliary spasm cally injured eye. synthesis. Oral ascorbate cacious. However acetyl-
with its attendant discomfort. Various other drugs such (2g/day) and topical 10% cysteine is unstable, has low
as Fibronectin, Epidermal solution formulated in artifi- potency and has poor cor-
Modalities to promote re- neal penetration. Its effect is
epithelialization being Immediate irrigation is of paramount relatively weak compared to
a. Tear substitutes: importance after the chemical and citrate and markedly inferior
thermal burns to tetracyclines. 10% solu-
Preservative free tear sub- tions of sodium citrate made
stitutes can ameliorate per- growth factor and Retinoic cial tears are effective. up in artificial tears applied
sistent epitheliopathy, re- acid are in investigational topically reduce corneal ul-
duce the risk of recurrent ero- stages. b. Tetracycline ceration. Combined treat-
sions and accelerate visual Tetracyclines can protect ment with ascorbate and cit-
rehabilitation. 2. Support Repair and Mini- rate is superior to treatment
b. Bandage soft contact lens: mize Ulceration the cornea against proteolytic with either substance alone.
a. Ascorbate degradation after moderate to
Hydrophilic high oxygen severe ocular chemical injury. 3. Control Inflammation
permeability lenses should Ascorbate is an essential They inhibit matrix metallo- a. Corticosteroids
be preferred water-soluble vitamin that is proteinases by mechanisms
Ø Promotes epithelial mi- a cofactor in the rate-limiting independent of their antimi- Corticosteroids reduce in-
step of collagen formation. crobial properties, primarily flammatory cell infiltration
gration Damage to ciliary body epi- through restriction of the gene and stabilize neutrophilic
Ø Helps basement mem- cytoplasmic and lysosomal
membranes. Because of un-
brane regeneration
Ø Enhances epithelial stro-
August, 2003 77 DOS Times - Vol.9, No.2
MANAGEMENT PEARLS
founded fears that they may Chronic burns activity, cell migration and
delay re-epitheliazation and growth promoting activity
potentiates sterile corneal ul- Assess- Vascularization and anti-inflammatory activ-
ceration, clinicians are reluc- Conjunctivalisation ity. It acts as a basement mem-
tant in their use in acute stage. Symblepharon brane and facilitates migra-
But corticosteroids have no Corneal clarity tion of epithelial cells, rein-
adverse effect on the rate of forces adhesions of basal
epithelial wound healing. Clock hours of limbal ischemia epithelial cells, promotes epi-
The key to successful corti- thelial differentiation and
costeroids use is to maximize Symblepharon release with AMT with ALT prevents epithelial apop-
the anti-inflammatory effect with or without PK tosis. It produces growth fac-
during the window of oppor- (In 1 or 2 sittings) tors, inhibits protease activ-
tunity in the first 7-10 days, ity and acts as a bandage
later they can be tapered. Fellow eye normal Fellow eye affected contact lens. Recently vari-
able results regarding the use
In a study conducted by Limbal auto graft -limbal allograft of amniotic membrane in
Davis et al it was suggested -Cadaveric limbal allograft acute ocular burns have been
that a regime of topical ste- -Cultured limbal stem cells reported. Meller et al re-
roids combined with topical ported that AMT alone was
vitamin C does not cause ANG is suited for use in ocular surface sufficient to restore corneal
corneoscleral perforation. reconstruction. It does not express HLA- and conjunctival surface in
But further studies are A, B or DR antigens, has antimicrobial mild to moderate burns. In
needed to validate the risk properties, antifibroblastic activity, cell severe burns it restored the
benefit ratio of duration of conjunctival surface without
use of corticosteroids follow- migration and growth promoting & symblepharon and reduced
ing chemical injuries. anti-inflammatory activity limbal stromal inflammation
but did not prevent limbal
b. Progestational Steroids means of decreasing symble- cal intervention invariably stem cell deficiency that re-
Progestational steroids pharon formation is to per- becomes necessary. Early quired further limbal stem
form lysis of conjunctival ad- surgical therapy, if indicated cell transplantation. How-
have less anti-inflammatory hesions daily as they form by is directed towards removal ever Dua et al reported fail-
potency than do corticoster- an ointment coated glass rod of necrotic corneal epithe- ure of AMT to restore ocular
oids but they have only a or cotton tipped applicator. lium and conjunctiva, estab- surface or preserve the integ-
minimal effect on stromal re- lishment of limbal vascular- rity of eye in severe acute
pair and collagen synthesis. Other forms of early treat- ity and re-establishment of burns. A recent report by
Medroxy progesterone 1% ments that have fallen into limbal stem cell population. Kobayashi et al also empha-
has been experimentally disuse include aprotinin, sized that immediate amni-
shown to inhibit collagenase subconjunctival heparin, Amniotic membrane otic membrane transplanta-
and reduce ulceration after subconjunctival serum injec- transplantation tion is useful for mild to mod-
chemical injury, suppress tions, topical vasodilators erate acute chemical burns
corneal neovascularisation and glued on contact lenses. Certain properties make and preserves ocular surface
and minimally suppress amniotic membrane ideally integrity.
stromal wound repair. So af- Surgical therapy suited for use in ocular sur-
ter 10-14 days they can be Mild to moderate burns face reconstruction. It does Our experience has
substituted in place of corti- not express HLA-A, B or DR shown limited utility of am-
costeroids. Medroxyproges- show good response with antigens, has antimicrobial niotic membrane transplan-
terone though not easily medical therapy alone how- properties, antifibroblastic tation for severe chemical
available in Indian set up but ever for severe burns surgi- burns with near total limbal
can be reconstituted from in- and conjunctival ischemia.
jections. However for moderate burns
it helped in reducing the de-
Scleral lenses and symble- gree of symblepharon and
pharon rings prevent appo- creating a smooth base for
sition of tarsal and bulbar secondary intervention at a
conjunctival surfaces that are later date.
denuded of epithelium. A
simpler but still effective
August, 2003 78 DOS Times - Vol.9, No.2
MANAGEMENT PEARLS
Tenoplasty ful in the management of uni- button that is then sewn into to reestablish limbal vascu-
In severe injuries the most lateral chemical injury, it has position with 10/0 nylon larity, in conjunction with
not been extensively applied sutures on the corneal side limbal autograft.
immediate concern is the de- to the management of bilat- and 8/0 vicryl sutures on the
velopmentofanteriorsegment eral chemical injury. Recent scleral side. Systemic immu- Large diameter penetrat-
necrosis due to loss of limbal innovations that can be used nosuppression is again em- ing keratoplasty, Keratoe-
vascular blood supply. In this in such cases are limbal al- ployed to prevent allograft pithelioplasty, Keratopros-
setting prompt reestablish- lograft transplantation or the rejection. This procedure is thesis and tissue adhesives
mentoflimbalvascularitymay use of cultured limbal stem advantageous as it is avail- may be used but have failed
reduce the subsequent devel- cells. able to all patients and elimi- to produce convincing re-
opment of the disastrous con- 1. LimbalAutograft nates risk to the donor. sults.
sequences. 4. Culturedlimbalstemcells
In cases of unilateral Advances in ocular sur-
Tenoplasty is based on chemical injuries limbal In 1993 Lindberg et al were face transplantation tech-
principle of using vital con- autografting from the fellow able to propagate ocular epi- niques allow late visual re-
nective tissue within the or- eye as an early intervention thelial cell in vitro. This tis- habilitation of a scarred and
bit to re-establish limbal vas- as early as 3 weeks after in- sue culture work was the ba- vascularised ocular surface.
cularity and to facilitate re- jury offers the potential of a sis for recent autologous Limbal stem cell transplan-
epitheliazation. All the ne- phenotypically normal ocu- transplantation of cultivated tation for incomplete
crotic conjunctival and epis- lar surface. This in turn re- corneal epithelium. Full thick- transdifferentiation and per-
cleral tissue is excised fol- duces or prevents conjuncti- ness 1-2mm2 biopsies from the sistent corneal epithelial dys-
lowed by blunt separation of valisation of cornea that re- limbus of healthy eyes were function, and conjunctival
tenon’s tissue from the equa- sults in a thickened vascular- taken and cultured on acellu- and or mucosal membrane
torial region of the globe and transplantation for ocular
from the extraocular muscles. Chemical injuries of the eye produce surface mechanical dysfunc-
Tenon’s sheet is prepared extensive damage to the ocular surface tion produce satisfactory re-
with a smooth surface to al- epithelium, cornea, anterior segment and sults. Rehabilitation of the
low conjunctival epithelium limbal stem cells resulting in permanent ocular surface may be fol-
to slide on this layer. The unilateral or bilateral visual impairment lowed if necessary, by stan-
tenon’s flap is then advanced dard penetrating kerato-
to the limbus and sutured ized, irregular and unstable lar human amniotic mem- plasty if all aspects of ocular
tightly to the sclera. But teno- cornea. brane. These were then auto surface rehabilitation are
plasty is less successful in 2. Living related conjuncti- grafted onto the fellow af- complete or by large diameter
insuring appropriate and fected eyes. penetrating keratoplasty if
adequate corneal epithelial val limbal allograft successful limbal stem cell
recovery. Bilateral stem cell loss, as So in the future limbal transplantation cannot be
in cases of bilateral chemical stem cell cultures may be used achieved but other ocular sur-
Limbal stem cell transplan- injuries, living related al- as the source for all limbal face rehabilitation is com-
tation (LSCT) lograft procedures can be transplantation including plete.
done. Donor with the best autografts and allografts.
LSCT restores the normal ABO blood and HLA tissue Protocol in acute stage
corneal epithelial phenotype match is chosen. Surgical However in the acute stage
after chemical injury. Success- procedure is similar to con- of burns, role of LSCT is not Ø Immediate irrigation
ful transplantation depends junctival limbal autografting. very well established due to
upon having controlled ocu- But to reduce the risk of rejec- the associated problems of Ø Assess- limbal and con-
lar inflammation with appro- tion systemic immunosup- inflammation and ischemia junctival ischemia, IOP,
priate medical therapy and in- pression is routinely em- that impair the success of corneal clarity and in-
suring that the graft is prop- ployed. procedure. traocular penetration
erly attached to well vascular- 3. Cadaveric keratolimbal
ized conjunctiva. In Grade IV allograft Conjunctival transplanta- Ø Medical therapy-topical
injuries prior extension of an If a suitable living donor is tion antibiotics, cycloplegics,
appropriate vascular supply unavailable a cadaveric al- tear substitutes, topical
to the limbal region by teno- lograft is recommended. In Following an acute chem- steroids, ascorbate, citrate
plasty either before or at the this a circular allograft is ob- ical injury, the role of conjunc- and tetracyclines
same time as limbal stem cell tained from donor corneal tival transplantation now is
transplantation is mandatory. largely confined to advance- Ø Surgical therapy-AMT,
While LSCT is extremely use- ment with Tenon’s capsule Tenoplasty, conjunctival
transplantation and LSCT
August, 2003 79 DOS Times - Vol.9, No.2
MANAGEMENT PEARLS
Management of Dislocated tempts by phaco surgeon.
Nuclear Fragment During The worst strategy is to try to
Phacoemulsification chase a descending nucleus
with phaco tip. Downward
Amit Khosla MD, Jasmita Popli MS fluid infusion expands the
rent and the nucleus is
Posterior dislocation of Operative Factors Therefore, presence of any of pushed further away. Aspi-
nucleus is a serious compli- Ø Inexperienced surgeon the warning signs men- rating vitreous places trac-
cations of phacoemulsi- Ø Surgeon over-confidence tioned below should not be tion on the vitreous base
fication because of morbid- Ø Topical anaesthesia (in ignored. causing giant retinal tears.
ity to the patient and stress The visibility for eventual
to the surgeon. These re- uncooperative patient) Signs of Early Posterior vitrectomy which has to fol-
tained posterior nuclear frag- Ø Radial tears in capsu- Capsule Rupture/Zonular low is also reduced due to
ments greatly increase the Dehiscence corneal edema.
risk of vision threatening lorhexis Ø Sudden deepening of the
complications like corneal Ø Vigrous hydroprocedures Managing Dropping
edema, persistent uveitis, chamber, with momen- Nucleus
vitritis, refractory glaucoma, when AC is full of vis- tary expansion of the pu-
cystoid macular edema, vit- coelastic pil. A phaco surgeon can at-
reous haemorrhage, retinal Ø Inability to gauge the Ø Sudden, transitory ap- tempt extraction of a par-
tears and retinal detachment. depth during sculpting pearance of clear red re- tially descended nucleus if
However, post-operative Ø Perforating the nuclear flex peripherally. the conditions are favourable
complications are relatively plate at 6 O’clock position Ø Newly acquired difficulty like a well dilated pupil, a
lesser and visual recovery during trenching to rotate a previously mo- part of nucleus still hooked
quiet satisfactory after timely Ø Continued aspiration af- in the bag and absence of vit-
intervention by a vitreo- reous prolapse.The surgeon
retinal surgeon. Early recognition of PC rupture or must stop irrigation and
zonulodialysis is the key to avoiding avoid any anterior chamber
In this comprehensive ar- fluctuations.the possible
ticle, we discuss the pre-op- dropped nucleus techniques include:-
erative and intra-operative Ø Holding the nucleus with
risk factors for nucleus drop, ter fragment removal bile nucleus.
the early signs of posterior Higher rates of dropped Ø Excessive lateral mobil- forceps.
capsule rupture (PCR) with nucleus occurred when Ø Viscoexpression by using
nucleus still present in eye, phacoemulsification was ity/displacement of the
and management of nucleus still evolving. Incidence of nucleus. a combination of vis-
drop. posteriorly dislocated lens Ø Excessive tipping of one coelastic cannula and in-
fragment reported in the lit- pole of the nucleus. jected viscoelastic to el-
Risk Factors for Nucleus erature so far is 0.4% to 4%. Ø Partial descent of the evate the nucleus.
Drop With better understanding of nucleus into anterior vit- Ø Use of sheet glides
Pre-operative the procedure and the newer reous space. through the main wound
Ø Posterior polar cataract state of the art phaco ma- to stablise the nucleus.
Ø Hard cataract chines, the incidence of Management of Nucleus Ø “PAL” technique (poste-
Ø Total cataract nucleus drop is on the de- Drop rior assisted Levitation)in
Ø Vitrectomised eye cline. which a cyclodialysis
Ø Pseudo-exfoliation syn- Early recognition of PC As already mentioned, spatula is inserted
rupture or zonulodialysis is surgical intervention by through a pars plana stab
drome the key to avoiding dropped vitreoretinal surgeon can incision to support and
nucleus. Any further maneu- improve the visual outcome push the nucleus into AC
Vitreo-Retinal Services ver will increase the likeli- in a case of dropped nucleus from below. However,
Department of Ophthalmology hood of a dropped nucleus. considerably. Complica- there is risk of iatrogenic
Sir Ganga Ram Hospital tions in these cases often re- vitreous traction and
sult from nucleus retrieval at- chance of touching the
retina with a metal
spatula tip.
The capsulorhexis must
be broken before nucleus is
August, 2003 80 DOS Times - Vol.9, No.2
MANAGEMENT PEARLS
Table 1: Principles to minimize traction: geon observes the patient for
Ø Avoid aspirating (without cutting) any presenting gel. settling down of corneal Observation
Ø Attempts to retrieve any lens fragments that started to dis- edema and inflammation Frequent indefinite fol-
and closely follows him up
locate posteriorly should be made only with vitrectomy for emergence of complica- low-up may be sufficient at
handpiece. tions listed in Table 2. following instances when
Ø Avoid the use of lens loop, forceps, and other instruments associated with minimal in-
that have the potential to engage and pull on vitreous gel. Inflammation can be se- flammation.
Ø Perform a complete limbal vitrectomy before any lens vere, to such an extent that a
placement. sterile endophthalmitis may (a) Small cortical matter
Ø Confirm the absence of vitreous to the wound or other result. Lens debris can form (b) Small epinuclear plate
anterior structures at the time of wound closure. a pseudohypopyon in the (c) Small nuclear frag-
Ø Perform indirect ophthalmoscopy with slceral depression anterior segment. The ante- ment (<25% of lens material)
at the end of the procedure to identify any retinal tears. rior segment surgeon should However, even small frag-
put the patient on topical ments may be associated
with severe complications.
antiglaucoma medication as CME persistent uveitis, glau-
pushed into AC. Enlarge the ITY IS DEPENDENT ON well oral and intravenous coma and drop in visual acu-
section to remove the THE EXTENT OF MANIPU- hyperosmotic agents. ity are an indication for sur-
nucleus. This should be fol- LATIONS DURING INITIAL Trabeculectomy in such gery in such cases.
lowed by a thorough anterior CATARACT EXTRACTION. cases is not very effective and
vitrectomy and removal of as Though IOL placement can vitrectomy is the treatment of Timing of Surgery
much of cortex and be done at this stage it re- choice. Dropped nucleus is not an
epinucleus as possible. emergency. However, the
However, results of this pro- The worst strategy is to try to chase a best timing of vitrectomy con-
cedure are not as good as tinues to be debated. Some
those of PPV. descending nucleus with phaco tip studies have shown that bet-
ter results are obtained when
What an anterior segment duces the surgical options vitrectomy is delayed to al-
surgeon can do? available to the vitreoretinal Managing posteriorly low medical treatment of in-
It is essential for the ante- surgeon, as limbal route can- dislocated retinal nucleus flammation, IOP and corneal
rior segment surgeon to NOT not be used. In additions, fragment edema while others report no
PANIC in the face of such a bubbles form on the posterior The goal is to remove the difference in visual recovery
catastrophic complication. surface of IOL during phaco remaining nucleus, epinuc- between early and delayed
The surgeon must secure the fragmentation, reducing the leus and cortex without caus- vitrectomy. Advocates of
wound. Only dry aspiration visibility. At the end of the ing vitreoretinal traction. For early vitrectomy argue that
should be attempted. Ante- procedure, an anterior seg- better visual outcome a sec- the incidence of corneal
rior vitrectomy preferably dry ment surgeon, if equipped, ondary surgical intervention edema, chronic glaucoma
vitrectomy under viscoelas- should perform indirect by a vitreoretinal specialist and intraocular inflamma-
tic should be done with due ophthalmoloscopy with is desirable. Reported mean tion are reduced. Technically
care taken to preserve the scleral depression to localize visual acuity in nucleus drop delayed vitrectomy is easier
anterior capsulorhexis and the fragments and breaks, if patients prior to vitrectomy as posterior vitreous detach-
free the wound of vitreous. any, because these will re- is 6/60 and post-vitrectomy ment (PVD) is created and
Alternative method is to in- quire at least laser or cryo is 6/9. nucleus becomes softer. We
troduce vitrectomy cutter retinopexy.
from the side port and a slow It is essential for medicole- Table 2: Complications associated with nucleus drop along
infusion canula through an- gal purposes that the cata- with their average reported incidence
other side port. The fluid ract surgeon FULLY EX- Complication Incidence
should be directed towards PLAINS TO THE PATIENT
the anterior chamber angle. what has happened, what l Intraocular inflammation 70%
To minimize the traction on can be done and what is the l Secondary glaucoma 50%
retina follow the principles prognosis. 50%
listed in Table 1. Though vitrectomy can be l Corneal edema 1.5%
DO NOT FISH for lens done on the same day as cata- l Retinal detachment
fragments, which are not vis- ract surgery, it is reasonable l Choroidal effusions 4.5%
ible. FINAL VISUAL ACU- that the anterior segment sur- l CME 3.0%
August, 2003 81 DOS Times - Vol.9, No.2
MANAGEMENT PEARLS
believe that the surgery Ø Increased incidence of RD for phacofragmentation. ticle at the vitreous base.
should be performed within The possible techniques Continuous vacuum reduces Thus, PFCL acts as a cush-
2 weeks to expedite visual re- the chances of fragments ion, which prevents retinal
habilitation. are dropping onto retina. Frag- trauma, especially to macula
1. Soft nucleus ments on retinal surface during fragment removal by
Indications for Surgery should be carefully aspi- raising it away from retinal
1. Eyes with very small re- – only vitreous cutter rated and moved to the mid surface. It is especially help-
2. Moderate to hard nucleus vitreous cavity (at least 5 to 6 ful in associated R.D. as it
tained nuclear fragments mm from retina) to avoid ul- serves to reattach the retina.
and epinuclear fragments – Bimanual crush tech- trasonic damage to retina. Indirect ophthalmoscopy
where inflammation has nique with lighted pick, pipe with scleral depression is a
not subsided by 1 to 2 and vitreous cutter Use of PFCL must at the end of the proce-
weeks. PFCL are clear fluids with dure, wherein one must scru-
2. Nucleus fragments larger – Ultrasonic fragmenta- tinize periphery for retained
than 3mm size or more tion high specific gravity (1.76 to fragments and retinal
than 25% of lens matter. 3. Extremely hard nucleus 2.03) and low viscosity. breaks. Studies report that
3. Significant intraocular in- Their short-term exposure PFCL does not alter visual
flammation. – Limbal extraction with causes minimal toxic effect to prognosis, however, a selec-
4. Poorly controlled second- use of PFCL retina. Removal with PFCL tion bias is likely as PFCL is
ary glaucoma is not so easy and is used less used in more complicated
5. Retinal detachment. – Phacofragmentation frequently now. It can be used cases.One common compli-
6. Cystoid macular edema. – Bimanual crush tech- in very hard cataract. A thor- cation is that PFCL is re-
nique ough three port pars plana tained in the eye.
Surgical Techniques vitrectomy (PPV) with re-
The surgical procedure of Phacofragmentation moval of vitreous around Results
nucleus is essential before – 60% cases have visual
choice is three port pars An adequate initial three instilling PFCL as an unre-
plana vitrectomy.At many lieved vitreous traction may acuity of 6/12 or better.
national conferences ante- port vitrectomy completely cause peripheral retinal – Results are better in cases
rior approach has been break giving PFCL access to
discussed,but there are no releasing the fragment is es- subretinal space. PFCL is in- with least manipulations
articles on this approach in jected below the nucleus to by phaco surgeon
literature or standard text sential to avoid inadvertent elevate it on the liquid sur- Summary
books. face to mid vitreous cavity Ø Explain to the patient.
vitreous traction. where both manipulation Ø Secure wound/no vitre-
Problems of nucleus and fragmentation are safer. ous.
removal through anterior/ Phacofragmentation uses One must fill PFCL only up Ø Refer to VR surgeon
limbal approach with to equator. Not only does within two weeks.
vitrectomy phacofrag needle which is this provide a reasonable Ø Control inflammation,
Ø Incomplete vitrectomy working space, but also pre- glaucoma.
Ø Vitreous traction longer and narrower than vents trapping of lens par- Ø Good results with mini-
Ø PVD cannot be generated mal fishing.
phaco tip and does not re-
quire a sleeve. Endoillumi-
nator is used to stabilize and
feed the nuclear fragment. A
separate infusion port
should be used to maintain
globe anatomy. 5% to 20% ul-
trasonic power in pulse
mode with moderate suction
rate of !00 to150mmof Hg is
sufficient for efficient nucleus
extraction. Venturi pump is
better than peristaltic pump
DOS Credit Rating System Report Card
DCRS July 2003 Army Hospital (R&R)
Total No. of Delegates ....................................................................................................................................................................... 121
Delegates from Out side (N) .............................................................................................................................................................. 114
Delegates from Army Hospital (n) ........................................................................................................................................................ 7
Overall assessment by outside delegates (M) ............................................................................................................................ 888.5
Assessment of case presentation-I (Dr. Lt. Col.A. Banarji) by outside delegates ...................................................................... 803.5
Assessment of case presentation-II (Dr. Lt. Col. (Mrs.) Madhu Bhaduria) by outside delegates ............................................. 814.5
Assessment of clinical talk (Dr. D.P. Vats) by outside delegates ................................................................................................. 862.5
August, 2003 82 DOS Times - Vol.9, No.2
REVIEW
Surgical Approach for Orbitotomy compression of optic nerve is
also possible by this ap-
proach.
S.M. Betharia, MD Transcutaneous ap-
proaches
Careful planning of the To avoid damage to optic dial, lateral and inferior ap- This can be transeptal or
surgical approaches to or- nerve, posterior dissection proaches. ENT surgeon will
bital lesions is very impor- should not extend beyond approach the orbit from me- subperiosteal. The various
tant to achieve the best re- posterior ethmoidal artery at dial or inferior side whereas
sults. Based on the findings 35 mm. from the rim. The lat- the neurosurgeon will ap- incisions named include
of the axial and coronal CTs eral wall can be resected 20 proach it from superior side.
and MRI along with ultra- to 25 mm posteriorly at the I shall deal with the surgical Benedict incision, which is a
sonography the most precise level of the zygomatic sphe- approaches by the oph-
approach can be determined noid suture line before the thalmic surgeon, which will superior sub-brow incision,
to either biopsy, debulk or re- middle cranial fossa is en- include anterior and lateral
move a tumor. tered or the inferior orbital orbitotomy. Lynch incision on the medial
fissure is interfered with. The
Before embarking on Or- anterior third of the greater Anterior orbitotomy side (anterior ethmoidectomy
bital Surgery a thorough wing of sphenoid and the This can be by transcon-
knowledge of surgical zygoma form not only the lat- incision) & vertical lid
anatomy of the orbit is nec- eral wall of the orbit but also junctival and transcutane-
essary. Orbital surgery the medial wall of the tem- ous route. spilliting incision of Byron
should be learnt in a
stepwise manner under the Smith. Incision can be placed
guidance of a senior surgeon
otherwise the rate of compli- in the skin crease or inferior
cations is likely to be more
with sometimes-disastrous subcilliary region to hide the
results.
scar. Care should be taken to
Important points in the sur-
gical anatomy: The orbit con- avoid injury to levator when
sists of seven bones namely
frontal, sphenoid, zygomatic, going by trans-septal and
palatine, maxillary, ethmoid
and lacrimal. The roof is sub periosteal approaches.
comprised of frontal bone
and lesser wing of the sphe- The complications of ante-
noid. Fossa for the lacrimal
gland and trochlear fossa are rior orbitotomy include dam-
located there. The suture line
between the frontal bone and Before embarking on Orbital Surgery a age to levator causing ptosis
the ethmoid, lacrimal, max- thorough knowledge of surgical
illary and nasal bones marks anatomy of the orbit is necessary and damage to various
the level of cribriform plate
and is also the location of the muscles causing muscle im-
foramina for the anterior and
posterior ethmoidal arteries. balance and diplopia. Dis-
The distance between the
anterior lacrimal crest to the section in the proper tissue
optic foramen is 45 to 50 mm.
poral fossa. Posteriorly, the Transconjunctival approach planes, using blunt dissec-
Dr. R.P. Centre for Ophthalmic posterior third of the greater It allows access to lesions
Sciences, AIIMS, Ansari Nagar, wing of sphenoid forms both tors and judicious use of the
New Delhi - 110029 the lateral orbital wall and anterior to equator of the
the anterior boundary of the globe and the anterior cryoprobe go a long way in
middle cranial fossa. The intraconal space. This can be
zygomatic temporal suture combined with lateral removal of encapsulated le-
line is at the same posterior orbitotomy as well. After do-
level as the zygomatic sphe- ing 180° conjunctival peri- sions like neurilemomma,
noid suture and thus marks tomy medial rectus is iso-
the posterior limit of lateral lated with a muscle hook. 6- haemangioma, dermoid cyst
orbitotomy (20 mm). The su- 0 vicryl suture is passed just
perior incision is made at the behind insertion. The suture etc.
level of zygomatic frontal is tied and double locked.
suture. If made higher it The muscle is then Lateral orbitotomy
would risk entering the an- disinserted from the globe. The incision which is
terior cranial fossa. The infe- The globe is retracted later-
rior bone incision is made at ally. A soft malleable retrac- now a days used is Stallard
the same level as the supe- tor is placed over the medial – Wright incision which
rior limit of the zygomatic rectus to have adequate ex- gives better exposure and
arch. posure. The mass is excised more versatility. It is a lazy
in to or biopsy is done. The S-shaped incision starting
Surgical approaches muscle is reinserted and con- lateral to the supraorbital
The orbit can be ap- junctiva is reapproximated. notch just beneath the lateral
The common lesion removed half of the brow and extends
proached from superior, me- is usually haemangioma. De- infero laterally along the or-
bital rim, past the lateral can-
thal angle and ending over
the zygomatic arch medial to
the hairline. Sharp dissec-
tion is carried through or-
bicularis muscle to the peri-
August, 2003 83 DOS Times - Vol.9, No.2
REVIEW
osteum. The bleeding from quired. The inferior cut is should be avoided. Traction closed separately. Post op-
orbicularis is controlled with made at the level of the up- on the lateral rectus should eratively light pressure
cautery. per border of zygomatic arch. be avoided. The muscle and dressing is applied for 24
A higher incision reduces orbital fat should be retracted hrs. Drain is pulled on 1st
The periosteum is incised exposure and lower incision by malleable retractors to postoperative day and su-
with a scalpal blade about 2 makes removal of wall more provide good exposure. Or- tures are removed after 5 to 7
mm lateral to orbital rim and difficult and risks fracturing bital exploration is best ac- days. Systemic corticoster-
dissected from underlying into inferior orbital fissure. complished with blunt finger oids should be given intra
bone with a Freer elevator. The superior cut should be dissection, or by using small operatively and continued
Periosteum should be kept at or not more than 5 mm retractors or Freer elevator. postoperatively. Systemic
intact for later closure. Once above the frontozygomatic Slow oozing from orbit is antibiotics and anti-inflam-
the dissection is carried into suture line to prevent en- controlled by gentle pressure matory drugs and vitamin
temporalis fossa, periosteum trance into anterior cranial packs. Gentle suction can supplements are given.
and muscle will be firmly ad- fossa. The cut should be also be used. Wet field bipo-
herent to bone. Separation is angled inferiorly about 45 lar cautery is preferable us- Summary
facililated by introducing a degrees to provide stabiliza- ing long blunt tipped for- Orbital surgery needs a
gauge sponge into sub peri- tion upon replacement. The ceps.
osteal dissection plane with orbital contents and temp- careful planning and good
a periosteum elevator push- oralis muscle must be pro- If the lesion is well de- evaluation along with orbital
ing it to just behind the tected with malleable retrac- fined and well encapsulated CT and ultrasonography. If
sphenozygomatic suture. tors during bone cutting. The complete removal can be at- the lesion is anterior to equa-
This results in a clear bony bony rim may be fixed by tempted by use of cryoprobe. tor or anterior conal then an-
surface. Bleeding at this point approximating periosteum More infiltrative lesions are terior orbitotomy can be used.
from disruption of only but greater stability is more difficult to remove with- All deep seated lesions pos-
zygomatico temporal artery achieved by suture fixation out damage to orbital con- terior to equator and in the
passing through lateral or- with 3-0 nylon passed tents. During manipulation central space need lateral
bital wall is controlled by through holes predrilled in of globe or optic nerve fre- approach. Well encapsu-
pressure. The periosteum is the rim on either side of quent observation of pupil is lated lesions can be excised
firmly attached at the orbital planned cut. The metallic essential. It is wise to leave in toto whereas in infiltrative
rim and is gradually and wire should not be used if some lesion behind rather lesions or suspected
slowly dissected. Once postoperative MRI is antici- than sacrifice ocular function malingnant lesions a biopsy
within the orbital space the pated. by over aggressive extirpa- can be planned. Stallard
periorbita is easily separated tion. When lesions are better Wright incision is excellent
from bone. The dissection of After making bone inci- treated by means other than for lateral approach. Careful
the periorbita should not be sions the lateral wall is frac- surgery are encountered, a orbital dissection in proper
carried too far posteriorly. A tured outward using a biopsy should be performed tissue planes, proper expo-
small recurrent branch of rongeur. The bone fragment and sent for frozen section. sure and use of cryoprobe go
middle meningeal artery is removed completely and is After confirming the lesion a long way in removal of the
may be severed at the level of stored in a saline moistened the orbitotomy should be clo- tumor. Examination of the
sphenofrontal suture caus- sponge till it is replaced. sed without further disrup- size of pupil and fundus ex-
ing bleeding. Exposure is im- Thinner portion of the tion of orbital contents. At the amination during and after
proved by passing four 6.0 greater wing of sphenoid can completion of surgery surgery is important. Light
silk traction sutures around be removed by bone ronguer. haemostasis is achieved. A pressure dressing for one day
the wound and clamped to Adequate haemostasis must drain might be required and systemic steroids
sterile drapes. Visualization be ensured at this point be- rarely and should be placed should be given in all cases.
is improved by using operat- fore opening periorbita. The in the dependent region Complications such as pto-
ing loupes and a fiberoptic peripheral and intraconal through a separate stab sis, diplopia, diminution of
coaxial headlamp or an op- space is accessed by opening wound. Periosteral suturing vision or rarely loss of vision
erating microscope. periorbita by giving one an- should not be tight. The or- must be explained to patient
terior-posterior cut above or bital rim is replaced. The pe- before surgery and proper
Two cuts are made in the below the lateral rectus and riosteum is closed over the consent should be obtained.
lateral wall by Stryker saw. the cut is extended by per- bony rim to provide nourish- Similarly pre and post opera-
Exact placement of cuts de- pendicular incision anteri- ment and to reposition the tive photographs of the pa-
pends upon the size and po- orly to form a T shaped open- lateral canthal tendon. tient and documentation of
sition of the anticipated le- ing. Injury to lacrimal gland Muscle and skin layers are C.T. and ultrasonography are
sion and the exposure re-
August, 2003 84 DOS Times - Vol.9, No.2
REVIEW
essential. the location of the mass Where is my copy of
lesion. DOS Times?
Carry Home Message Ø A thorough knowledge of
Ø Orbital surgery can give surgical anatomy is a Dear DOS members, anyone who could
must for orbital surgeon. not receive DOS Times from the month of
very satisfactory results if Ø A special informed con-
learnt properly. sent should be obtained July, 2003 onwards.
Ø The C.T. is a better inves- before surgery.
tigation than MRI for most Ø Documentation should be Please Contact:
of the cases and should be complete.
done in all cases. Ø It is a very specialized sur- MR. SUPROTIK BANERJI
Ø Ultrasonography should gery and needs proper M/s. Syntho Pharmaceuticals Pvt. Ltd.
be done in all cases. training to obtain satisfac- 31/16, 2nd Floor, Old Rajinder Nagar, New Delhi-60
Ø Approach will be anterior tory results.
or lateral depending upon E-mail: [email protected]
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August, 2003 85 DOS Times - Vol.9, No.2
TARIFF
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August, 2003 86 DOS Times - Vol.9, No.2
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August, 2003 87 DOS Times - Vol.9, No.2
REVIEW
“An eye for an eye will Eye Banking – The Present
make the whole world go Scenario in Our Country
blind” – said Mahatma
Gandhi, in those troubled R.V. Ramani
days of our independence
struggle. In the present day’s tor can be trained to harvest nation, take efforts to harvest Though the first
context this expression of the donor material in a sci- corneal tissue and collect the eye bank in India
“an eye for an eye” could entific way. blood for serology and to en-
perhaps revolutionize the sure safe transportation of was started as
field of Eye banking. With the availability of ad- the tissues to the parent eye early as 1949 at
vanced storage media, it is bank. Chennai, till the
Though the first eye bank possible to store the cornea. Eye banks should provide a 90’s, our country
in India was started as early Thus transplantation need round the clock public re- had to depend on
as 1949 at Chennai, till the not be done any more as an sponse system over the tele-
90’s, our country had to de- emergency procedure but phone and conduct public Sri Lanka for
pend on Sri Lanka for donor can be elective. awareness programme on donor eyes.
eyes. Concerted efforts from eye donation, coordinate
all quarters during the later Advances in modern with donor families and hos- councilors.
half’s of 80’s and 90’s have medicine, such as improved pital to motivate eye dona- Eye bank association of
brought in drastic changes. surgical techniques, operat- tion, harvest corneal tissue,
Though we cannot claim ing with microscopes, im- process and evaluate col- India has clearly laid down
that we have reached a state proved sutures and ad- lected tissue, distribute tissue the code of ethics for eye
of self sufficiency in terms of vances in eye banking have in an equitable manner, en- banks and the medical stan-
the need for the cornea, there sparked a turn around in the sure safe transportation of dards have been prescribed
is definite change as far as success rate of corneal trans- tissue and carry out regular by the Government of India.
the public awareness in con- plants making it among the corneal transplantation. Eye banks are expected to
cerned. most successful organ trans- maintain stringent condi-
plants. Eye Bank training centres tions needed for processing
According to Indian should have eye bank mis- the collected tissue. These
Council of Medical Research Eye Banking system has a sions along with training for guidelines have brought
(ICMR) study on blindness, three tier approach. The dif- all levels of personnel for eye about uniformity in the ap-
about 25% of the total blind ferent constituents are eye banking and research. proach to eye banking.
in India are blind due to cor- donation centres, eye banks
neal blindness. Out of these and eye banking training Hospital cornea retrieval No religious teaching or
2.5 million blind people, centres. All of them have to programmes, of late, have leader forbids donation. The
even if or so 1 million are be integrated. They will not yielded very good results. largest fraction of eye dona-
blind by a curable corneal be effective alone. Under this programme, the tions in India (approx one
disease, we require really a eye bank has to select hospi- third) has been coming in
large number of people to Eye donation centres tals with ICU/ICCUs, solicit from Gujarati speaking Jains.
donate their eyes if we want should provide public and their involvement, give them Jain religious leaders con-
to effectively take care of these professional awareness of orientation and motivate sider eye donation as a sub-
patients eye donation, coordinate their key staff, and grief lime form of charity and
with hospitals and donor stress a powerful link be-
Of all the organ trans- families to motivate eye do- tween ‘daan’ (charity) and
plants, corneal transplanta- ‘moksha’ (salvation).
tion is unique since: It is easy Sharing the grief, few words of
to harvest from the donor, it consolation, putting forth the Islamic nations like Syria,
can be done anywhere and gratitude of the community towards Jordan, Saudi Arabia, Egypt,
does not require specialized the donor family, regular remembrance and Malaysia have accepted
facilities such as a sterile the- of the act of eye donation, all of them eye donation and allow li-
atre, the equipment needed censed eye banks to func-
is minimal and an MBBS doc- go a long way
Dr. R.V. Ramani,
Managing Trustee
Sri Kanchi Kamakoti Medical Trust,
Sankara Eye Centre, Coimbatore
August, 2003 88 DOS Times - Vol.9, No.2
REVIEW
tion. Prominent leaders have strictures for persons/insti- Monthly Meetings Calendar
issued statements towards tutions contravening condi- For The Year 2003-2004
eye donation. tions laid down therein, it
sadly does not contain any 27th July, 2003 (Sunday)
Most of the eye donations suggestions to improve eye Army Hospital
in the State of Kerala is of- banking.
fered by the Christian com- 30th August, 2003 (Saturday)
munity through active Eye Banking has to be ap- Sir Ganga Ram Hospital
Church-affiliated social proached with sustained
workers with support from commitment. It has to be de- 27th September, 2003 (Saturday)
clergy that preaches eye do- veloped as a “movement”. New Institute/Hospital
nation. The role of constant cam-
paigns to create awareness 19 October, 2003 (Sunday)
Hindu mythology is among the general public DOS Midterm Conference
strewn with episodes on eye and the youth can never be
donation. The story of the over emphasized. Publicity 2nd November, 2003 (Saturday)
legendary Kannapan who materials, audio visual pre- R.P. Centre for Ophthalmic Sciences
offered his eyes to Lord sentations and the media
Shiva, has more than in- play vital role. The myths and 29th November, 2003 (Saturday)
spired many to pledge their misconceptions about eye Dr. Shroff’s Charity Eye Hospital
eyes. donation is not only preva-
lent among the villagers, even 27th December, 2003 (Saturday)
Under the Transplanta- the urbanites and the edu- New Institute/Hospital
tion of Human Organs Act, cated lack clear knowledge
1994 (THOA),the qualifica- and perception of eye dona- 31st January, 2004 (Saturday)
tion of doctors permitted to tion. Once their misconcep- Safdarjung Hospital
perform enucleation (surgi- tions on eye donation, the
cal eye removal) has been re- process of enucleation, the 28th February, 2004 (Saturday)
duced from MS (Ophth.) to outcome and the follow up M.A.M.C. (GNEC)
MBBS. Eye donation in India are made clear to the general
is always decided by the public, nothing prevents 28th March, 2004 (Saturday)
donor’s surviving relatives them from coming forward to Mohan Eye Institute
and not by the actual donor, take up this most humanitar-
and that enucleating doctors ian act. 3-4th April, 2004 (Saturday & Sunday)
always have to legally obtain Annual DOS Conference
a written consent from the The entire process should
relatives of the deceased be- have a humanitarian touch. follow up and feedback to ably supported by committed
fore they actually remove the It should never assume a rou- the donor family, few words campaigners in different
eyes. tine mechanical approach. of appreciation and remem- parts of the country, eye
Sharing the grief, few words brance, all of them have to be banking would soon become
The THOA ’94 Act while of consolation, putting forth incorporated in the manage- a success story in every state
it defines punishment and the gratitude of the commu- ment of modern eye banking. of our country.
nity towards the donor fam-
ily, regular remembrance of Science and modern tech- Soon there will be a day,
the act of eye donation, all of nology have made vision when the common man says,
them go a long way. Prompt restoration after corneal
and immediate response to transplantation an absolute “Do not bury;
an eye call, a clean process reality. Our eye surgeons Do not burn;
of harvesting, organised and technicians are fast ac- Donate Eyes”
evaluation and utilization, quiring the skills. If this tech- – Those immortal
nological advancement is eyes.
According to Indian Council of Medical
Research (ICMR) 25% of the total blind
in India are blind due to corneal
blindness
August, 2003 89 DOS Times - Vol.9, No.2
EVENTS
Forthcoming Events – NATIONAL
—————————————————————————————————————————————————————
Event Conference Date Venue Contact Person and Address
——————————————————————————————————————————————————————
Advanced Programme on 23rd- 24th Dr. R.P. Centre Contact : Mr. Sujay Debnath,
Soft Contact Lenses Fitting Aug. 2003 for Ophthalmic M/s Bausch & Lomb Eye Care India Pvt. Ltd.
& Management Sciences, AIIMS, Ph : 011-26601160, 26601161, Mobile : 9810752026
New Delhi Email : [email protected]
National Workshop on 17th-18th Dr. R.P. Centre Contact : Prof. R.B. Vajpayee, Dr. Jeewan S. Titiyal
Phacoemulsification Sept. 2003 for Ophthalmic 492, 4th Dr. R.P. Centre for Ophthalmic Sciences,
Sciences, AIIMS, AIIMS, New Delhi - 110029, India
8th Dr. R.K. Seth Memorial 2nd New Delhi Ph : 26593192, 26588852-65, Ext. 3192, 3146
Symposium on Low Vision Oct. 2003 Park Royal International Fax : 011-26588919 Email : [email protected]
"An Overview" Nehru Place,
10th-11th New Delhi Contact: Dr. Sunita Lulla C/o. CME Dept. Venu
Ophthacon 2003 Oct. 2003 Eye Institute & Research Centre, 1/31, Sheikh
(38th U.P.State Ophthalmology LLRM Medical College, Sarai-II, New Delhi-17, Ph.: 91-11-29251155,
Conference) 19th Meerut, (U.P.) 29251156, 29251951, 29252417, Fax: 91-11-29252370,
Oct. 2003 E-mail: [email protected]
Eye Topia 2003 India Habitate Centre
Mid Term DOS 3rd-4th Lodhi Road, New Delhi Contact Person : Dr. Sandeep Mithal,
April 2004 Upgraded Department of Ophthalmology,
Annual DOS Conference India Habitate Centre LLRM Medical College, Meerut, (U.P.)
Lodhi Road, New Delhi Email : [email protected]
Phone : 91 - 121 - 2763133
Contact Person: Dr. Jeewan S. Titiyal,
Secretart (DOS) R.No. 476, 4th Floor,
Dr. R.P. Centre for Opthalmic Sciences,
New Delhi - 110 029
Ph.: 26589549, Fax : 26588919,
E-mail: [email protected]
Website: dosonlin.org
Contact Person: Dr. Jeewan S. Titiyal,
Secretart (DOS) R.No. 476, 4th Floor,
Dr. R.P. Centre for Opthalmic Sciences,
New Delhi - 110 029 Ph.: 26589549,
Fax : 26588919, E-mail: [email protected]
Website: dosonlin.org
INTERNATIONAL
Event Conference Date Venue Contact Person and Address
———————————————————————————————————————————————————
XXI Congress of thre ESCRS 6-10 Sept. MUNICH, Contact: ESCRS Temple House, Temple Road
2003 GERMANY Blackrock, Co. Dublin, Ireland
Tel: + 353 1 209 1100, Fax: + 353 1 209 1112
e-mail: [email protected]
Joint Meeting of the European 13-16 Sept. LISZT, Contact: Ferenc Kuhn
Vitreoretinal Society & Web: www.evrs.org/meetings
International Society of 2003 HUNGARY
Ocular Trauma
United Kingdom and Ireland 18-19 Sept. CHESTER, Tel: +44 164 2854 054, Fax: +44 164 2231 154
Society of Cataract and Email: [email protected]
Refractive Surgeons 2003 UK Web: www.euroasiancongress.com
Joint European Research 8-11 Oct. ALICANTE, SPAIN Contact: EVER, Fax +32 16336785
Meeting in Ophthalmology 2003 Web: www.ever.be, Email: [email protected]
August, 2003 90 DOS Times - Vol.9, No.2
REVIEW
Proliferative vitreore- Proliferative Vitreoretinopathy
tinopathy (PVR) is charac-
terised by migration, meta- Neena Kumar MD, Rajvardhan Azad MD, FRCS (Ed), Yog Raj Sharma MS,
plasia and proliferation of Atul Kumar MD, Rajpal MD
retinal pigment epithelial
cells, glial cells and mac- Ø There was no clinical cor- posterior to vitreous base. breakdown of blood ocular
rophages leading to forma- relation between the most 2. Diffuse posterior – barrier5 are the stimuli for the
tion of fibrocellular mem- severe form (grade D) and cellular activation and mi-
branes on both surfaces of visual prognosis. confluence of focal epicen- gration. The pigment epithe-
the detached retina which on ters posterior to vitreous lial cells, glial cells and
contraction causes distortion Ø There was limited quanti- base. primitive fibroblastic ele-
and elevation of the retina fication of extent of dis- 3. Subretinal proliferations – ments move both in response
that induces a secondary trac- ease. bands of moth eaten to vitreous convection cur-
tional retinal detachment1. sheets; extent quantified if rents and to physical- me-
Ø This system did not in- retina is elevated. chanical forces such as ther-
PVR is seen in 5 – 10 % of clude PVR anterior to the 4. Circumferential traction mal shock induced by
rhegmatogenous retinal de- equator. along the posterior edge of cryopexy and in response to
tachments and is the most In 1991, an updated clas- vitreous base with central chemotactic stimuli to sites
common etiology of failure of displacement of retina where they exert traction or
scleral buckling surgery. sification system was pro- and radial folds posteri- begin to proliferate.6
PVR is also a common com- posed that included addi- orly. 1. Proliferation
plication of perforating inju- tional factors such as ante- 5. Anterior traction – vitre-
ries to the posterior segment. rior tractional and prolifera- ous base displaced to pars Retinal pigment epithelial
tive components, more de- plicata, iris or pupillary (RPE) cells and intraretinal
Classification of PVR tailed descriptions of poste- glial cells are in the resting
In 1983, the Retina Soci- rior contraction types and the phase and do not actively
proliferate under normal cir-
ety proposed a classification PVR is seen in 5 – 10 % of cumstances. However, in re-
system for PVR2. This classi- rhegmatogenous retinal detachments and sponse to ischemic, thermal
fication consists of four or mechanical injury, these
grades: is the most common etiology of failure cells as well as fibroblastic
of scleral buckling surgery elements from the choroids,
A – Minimal – Vitreous sclera and other unknown
haze and pigment clumps presence of subretinal mem- margin. sources begin to proliferate.
branes3 Shortcomings of these RPE cells and glial cells un-
B – Moderate – Wrinkling classifications are that they dergo metaplastic change
of inner retinal surface, The new classification do not take into account im- and get transformed into
rolled edges of break, vascu- system consists of the follow- portant features that influ- myofibroblast. These cells
lar tortuosity ing modified PVR grades: ence the prognosis. along with fibroblasts form
1. Number, location and opaque, contractile mem-
C – Marked – Full thick- A – Pigment clumps in the size of retinal breaks branes.5,6,7,8
ness, fixed retinal vitreous cavity, vitreous haze 2. Number and type of pre-
folds vious operation 2. Extracellular matrix
B – Retinal wrinkling 3. Time course and biologi- elaboration and remodeling
C1 – One quadrant breaks with rolled edges, reti- cal activity of the prolif-
C2 – Two quadrants nal rigidity, vascular erative process. Membranes in PVR con-
C3 – Three quadrants tortuousity, and decreased tain extracellular matrix
D – Extensive – Fixed vitreous mobility Pathophysiology of PVR composed primarily of col-
Stages of development of lagen and various gly-
retinal folds in four C – Full thickness fixed PVR cosaminoglycans, in addi-
quadrants folds (subdivided into ante- 1. Cellular activation tion to cellular elements (RPE
D1 – Wide funnel rior and posterior forms) cells, glial cells, fibroblasts
D2 – Narrow funnel Exposure of large area of and macrophages).9collagen
D3 – closed funnel Extent of involvement ex- the pigment epithelium to is secreted by fibroblasts,
This classification system pressed in clock hours (sub- the vitreous cavity4 and
has following disadvan- divided into contraction
tages: types):
1. Focal posterior – single or
Dr. R.P. Centre for Ophthalmic
Sciences, AIIMS, Ansari Nagar, multiple isolated folds
New Delhi - 110029
August, 2003 91 DOS Times - Vol.9, No.2
REVIEW
Fig. 1: PVR Grade A Fig. 2: PVR Grade B [Inferior giant tear with Fig. 3: PVR Grade C [Fixed retinal fold in
rolled edges (arrow)] two quadrouts (arrow)]
RPE cells and glial cells as of frank membrane by pull- access to the vitreous cavity with respect to periretinal
procollagen which later on ing individual collagen fi- at the time of the retinal tear membranes, determines the
undergoes posttranslational bers toward themselves us- if vitreous hemorrhage oc- ease with which they can be
modification leading to col- ing alternating extension curs or after the breakdown closed at the time of surgery.
lagen fiber formation. and retraction of their lame- of the blood ocular barrier
llipodia and subsequently caused by cryotherapy, di- II. Anteroposterior location
3. Contraction piling up collagen in small athermy and laser treatment. of the transvitreal sheet
The membranes recov- bundles adjacent to them- The anteroposterior loca-
selves.11,12 4. RPE cells release TGF-
ered from the eyes with PVR b, a potent stimulator of fibro- tion of the transvitreal sheet
contain abundant cells and Factors which initiate and genesis determines the ante-
extracellular components. hasten the process of PVR roposterior location of the
Their morphology suggests Prognostic features circumferential buckle in
that these cellular mem- 1. RPE dispersion into I. Number, size and loca- cases where vitrectomy is un-
branes are capable of exert- the vitreous cavity and onto necessary. In addition, the lo-
ing traction on the retina and the inner retinal surface that tion of retinal breaks cation of the transvitreal
vitreous in a manner similar occurs at the time of retinal The size and number of sheet is often an indication
to the contraction exerted by tear formation retinal breaks potentially in- of how far anteriorly the pre-
syncytial smooth muscle el- fluence the amount of retinal membranes can be
ements.9,10 Another mecha- 2. Cryotherapy which re- retinopexy applied and dissected from the retina. The
nism for contraction of col- leases viable RPE cells into thereby influence the degree entire undissectable region
lagen is also suggested the vitreous cavity of breakdown of the blood- must be supported with a cir-
which is called hypocellular ocular barrier and in the case cumferential buckle.
gel contraction. Cells pro- 3. Specific serum compo- of cryotherapy, the number
duce contraction of collagen nents (i.e. fibronectin and of RPE cells dispersed into III.Severity of contraction
lattices and by analogy vit- platelet derived growth fac- the vitreous cavity. The loca- within the vitreous base
reous collagen in the absence tors) stimulate cellular migra- tion of retinal breaks, most Cell mediated contraction
tion and proliferation. These importantly their location
serum components may gain of the vitreous base is a uni-
versal feature of PVR. Sever-
ity of vitreous base contrac-
tion as well as extent of adja-
cent undissectable preretinal
membranes reflect a poor
prognosis for retinal reat-
tachment. It needs a high cir-
cumferential buckle and
retinectomy in severe cases.
Fig. 4: PVR Grade D1 Fig. 5: PVR Grade D2 IV.Severity of poste-
quatorial preretinal
membrane formation
The most important prog-
August, 2003 92 DOS Times - Vol.9, No.2
REVIEW
nostic feature regarding these Role of scleral buckling traocular instruments. Crys- b. Daunorubicin
membranes is the degree to procedure/ two stage talline lens even if clear is c. Retinoids
which they can be removed surgery for PVR: removed by phaco- d. Immunotoxin
at the time of vitreous sur- fragmentor in patients more e. Taxol
gery. The concept of scleral than 30 years of age and vit- f. Colchicine
V. Number of previous op- buckling alone or two stage rectomy probe in less than 30
surgery for PVR was pro- years of age. This assists in 3. Drugs that interfere with
erations posed by R.G. Michel better dissection of mem- the synthesis, secretion
The greater the number of (1984,1990),13 M. Glaser branes especially in anterior and posttranslational
previous operations per- (1990),14 Stephen Ryan PVR. Membrane dissection is modification of collagen
formed on an eye, the worse (1985).15 They observed that done using vitreoretinal pick, a. Antimetabolites
the prognosis. This may re- closing retinal breaks even in intraocular forceps and scis- b. Cis-Hydroxyproline
sult from an increase in in- what seems to be advanced sors. All traction should be c. Penicillamine
flammation and breakdown cases of PVR eliminated the relieved before fluid-air ex-
of blood-ocular barrier. need of vitreoretinal surgery change is done otherwise 4. Drugs that affect binding
VI.Severity and location of in many cases. In case existing tears will enlarge of cells to components of
subretinal membranes vitreoretinal surgery was re- and air will spread the extracellular matrix
Dense subretinal mem- quired it allowed time for subretinally. Transvitreal and collagen
branes adjacent to optic nerve maturation of membranes, drainage of subretinal fluid a. RGDS
and macula holding the which takes 6-8 weeks. After is done through preexisting b. Heparin
retina in napkin ring con- 6-8 weeks membranes can be breaks or a posterior c. Low molecular weight
figuration require more ex- removed as single sheet. Early retinotomy. After fluid-air
tensive dissection with large membranes are fragile and exchange retinal breaks are Heparin
retinotomies to allow access difficult to dissect. This prob- The efficacy of these phar-
to the subretinal space to ad-
equately relieve traction. PVR is also a common complication of macological agents however
perforating injuries to the posterior seg- has not been clearly estab-
Principles of treatment of lished. None of the drugs
PVR ment. tested to date is fully satis-
ü Close all retinal breaks factory either because the ef-
ü Counteract retinal traction ably also limits recurrence treated with photocoagula- fect on membrane formation
ü Minimize recurrence of rate. Thus there is a rationale tion. is only transient or because
for those few cases in which of toxicity.
traction it is possible to identify and Other modalities in use
ü Choose optimal timing of close the breaks and thereby are long acting tamponades References
reattach the retina and post- like inert gases (C3 F8, C2F6)
intervention pone vitreous surgery. 1 and silicone oil. Perfluo- 1. Ryan SJ. The pathophysi-
Grizzard and Hilton (1982) rocarbon liquids help in ology of proliferative
Surgical management of reported 23.4% success with membrane dissection. Reti- vitreoretinopathy and its
PVR scleral buckling in stage C3 nectomy and retinal tacks are management. Am. J.
and D1 and 0% in D2 (34.7% required in cases of Ophthalmol. 1985; 100:
The surgical management in all stages).15 Yoshida et al unrelievable traction. 188-193.
of PVR is complex and in- reported 47% reattachment
volves numerous decisions in cases of severe PVR.16 Pharmacologic agents for 2. Hilton G, The Retina Soci-
and manipulations often prevention of PVR ety Terminology Commit-
based on subjective assess- Vitreoretinal surgery for 1. Anti-inflammatory tee. The classification of
ment because no two eyes are PVR retinal detachment with
exactly same. Some of these agents: prolifrative vitreoretino-
controversies are one stage or A 3600 broad and high Corticosteroids reduce in- pathy. Ophthalmology
two stage surgery, removing buckle with or without flammatory response in the 1983; 90: 121-125.
or retaining of crystalline encirclage is used to relieve eye thereby moderating the
lens, early or delayed sur- anterior vitreous traction that breakdown of blood ocular 3. Machemer R. Aaberg
gery, silicone oil or long act- is often not completely dis- barrier. T.M., Freeman H.M. et al.
ing gases as tamponade, re- sected. Three scleral ports are An updated classification
moval or retention of silicone made for infusion, 2. Drugs that inhibit of retinal detachment with
oil and use of PVR suppress- endoillumination and in- cellular proliferations proliferative vitreoretino-
ing agents. a. 5-FU pathy. Am. J. Ophthalmol.
1991; 112: 159-165.
4. Vidaurri – Leal J. and
Glaser B. Effect of fibrin on
August, 2003 93 DOS Times - Vol.9, No.2
REVIEW
morphologic characteris- 7. Glaser B.M., Cardin A. 10. Kirmani M., Ryan S.J. In 13. Glaser B.M. Surgery for
tics of retinal pigment epi- and Biscoe B. Proliferative vitro measurement of con- proliferative vitreoretino-
thelial cells. Arch. vitreoretinopathy: the tractile force of trans- pathy. Retina. Vol. III, Sec-
Ophthalmol. 1984; 102: mechanism of develop- vitreal membranes formed ond edition: 2265, 1990.
1376-1379. ment of vitreoretinal trac- after penetrating ocular
tion. Ophthalmology 1987; injury. Arch. Ophthalmol 14. Grizzard W.S. and Hilton
5. Campochiaro P.A., Bryan 94: 327-332. 1985; 103: 107-110. G.F. Scleral buckling for
retinal detachment com-
J.A. III, Cpnway B.P. and 8. Miller B., Miller H, 11. Blumenkranz M.S., plicated by periretinal
Patterson R. and Ryan S.J. Hartzer M. Contractile proliferation. Arch.
Jaccoma E.H.: Intravitreal Retinal wound healing, mechanism in prolifera- Ophthalmol 1982; 100: 419-
cellular activity at the tive vitreoretinopathy 422.
chemotactic and mitoge- vitreoretinal interface. (PVR). Invest. Ophthalmol
Arch. Ophthalmol. 1986; Vis. Sci. 1986; 27 (suppl.) 15. Yoshida A., Ho, P.C.,
nic activity implications 104: 281-285. 188. Schepens C.L., MacMeel
J.W. and Duncon J.E. Se-
of blood retinal barrier 9. Machemer R. Massive 12. Michels R.G. Treatment of vere proliferative vitreo-
periretinal proliferation, a complicated retinal de- retinopathy and retinal
breakdown. Arch. logical approach to tachment. In retinal de- detachment:II. Surgical
therapy. Trans Am tachment. 2nd edition. results with scleral buck-
Ophthalmol 1986; 104: Ophthalmol. Soc.1977; 75: 1990. ling. Ophthalmology 1984;
556-586. 91: 1538-1543.
1685-1687.
6. Campochiaro P.A., Glaser
B.M. Mechanism in-
volved in retinal pigment
epithelial cell chemotaxis.
Arch. Ophthalmol 1986;
104; 277-280.
August, 2003 94 DOS Times - Vol.9, No.2
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