dos_Sep_2015

Editor-in-chief Editorial Capsule 47 End Stage Stevens Johnson
3 The Vision of Sight Syndrome: Can We Do
M. Vanathi Something???

Section Editors Guest Editorial Diagnostics Discussion
Cataract & Refractive Retina & Uvea 5 Eye Banking in India 51 Idiopathic Polypoidal

Umang Mathur Pradeep Venketesh Special Message Choroidal Vasculopathy
Saurabh Sawhney Manisha Aggarwal 7 Spotlight on Current Status of
Eye Banking and Corneal Clinical Spotlight Retina
Sanjiv Mohan Shahana Majumdhar Transplantation in India 53 Intraoperative Surgical
S. Khokhar Rohan Chawla Microscope with

Cornea & Oular Surface Ravi Bypareddy Featuring Sections Integrated OCT (iOCT) and
Uma Sridhar Ophthalmoplasty & Heads-Up Display (Hud)
Deepa Gupta Ocular Oncology Cornea
9 Pintucci’s Keratoprosthesis Practice Requisites
Umang Mathur Neelam Pushker 57 Multifocal ERG
Ramendra Bakshi Maya Hada 15 Deep Anterior Lamellar 61 Interpretation of Pentacam
Manisha Acharya Sangeeta Abrol Keratoplasty in Full Thickness Maps
Corneal Pathologies
Glaucoma Rachna Meel
Dewang Angmo Squint & Ocular Oncology 67 Analysing Change in
19 Intra-arterial Chemotherapy for Keratoconus with the Help
Reena Sharma Neuro-ophthalmology Retinoblastoma of Topographic Indices
Sunita Dubey Swati Phuljhale
Viney Gupta Zia Chaudhuri Oculoplasty Community Ophthalmology
Kanak Tyagi Suma Ganesh 23 Cyanoacrylate Adhesive as 71 Corneal Blindness: Current
Sclerosant in Arterio-Venous Scenario in India
Delhi Advisory Board
Y.R. Sharma Mahipal Sachdev Malformation of the Eyelid Miscellaneous
Atul Kumar Radhika Tandon
P.V. Chadha Jolly Rohtagi Retina 75 Nano-Medicine in Ocular
Noshir M. Shroff J.C. Das 25 Corticosteroid use in the Drug Delivery
Rajendra Khanna B.P. Gulliani
Vimla Menon Ritu Arora Management of Diabetic Macular DOS TIMES Quiz
H.K. Yaduvanshi Kamlesh 77 QUIZ - Episode 2
Anita Panda G.K. Das Edema
Pradeep Sharma B. Ghosh
Ramanjit Sihota Tanuj Dada Snapshot DOS Crossword
Harish Gandhi Abhishek Dagar 31 Ocular Involvement in a Case of 79 DOS CROSSWORD-
Anup Goswami Sarita Beri Amniotic Band Syndrome Episode 2
35 A Rare Case of Pyogenic
Rajpal P.K. Sahu
Mandeep Bajaj Kamlesh Granuloma Quick Picks

B. Ghosh Taru Dewan Innovations 81 Visual Acuity Charts
Rajiv Garg H.S. Sethi
National Advisory Board 37 Stab Incision Glaucoma Surgery News Watch
R.D. Ravindran Barun Nayak 82 Obituary &
Debashish Bhattacharya Venketesh Prajna (SIGS)

Revathi S. Natarajan Monthly Meeting Korner ‡„‡”•Š‹’ ‡‡ϐ‹–
Yogesh Shah Amod Gupta 41 Ocular Surface Squamous 83 DOS Announcement
Arup Charaborti Jagat Ram Neoplasia Masquerading as 87 DOS Clinical Monthly Meet
Anita Raghavan Amar Agarwal Scleritis 88 DOS Travel Fellowship
Chandna Chakraborti Mangat Ram Dogra 45 Bilateral Simultaneous CXL+ 89 DOS Membership Form
Sushmita Shah D. Ramamurthy Intacs for Progressive 91 Forthcoming Events
Sushmita Kaushik T.P. Lahane Keratoconus 95 DOS TIMES Authors
Pravin Vadavalli Samar Basak
Somshiela Murthy Cyrus Mehta Guidelines

Sri Ganesh Mahesh Shanmugam www. dos-times.org 1
M.S. Ravindra J. Biswas

Rohit Shetty Srinivas Rao
Mallika Goyal Nikhil Gokale
Partha Biswas Santosh Honavar
Nirmal Frederick Arulmozhi Varman
Abhay Vasavada Mohan Rajan
Mukesh Taneja Rakhi Kusumesh
Shalini Mohan Gopal S. Pillai
Ragini Parekh Subendu Boral

Tejas Shah Gunjan Prakash
Sujith Vengayil Pravin More

M. Kumaran Sajjad Ahmed Shiekh
Punith Kumar Santhan Gopal
Elankumaran

DOS Correspondents
Anita Ganger Manzoorul Mehdi
Rebika Dhiman Shikha Yadav
Manish Mahabir Manu Saini
Shiva Gantyala Meenakshi Wadwani

Sridevi Medha Sharma
Saranya

DOS TIMES
Editorial Assistance & Layout: SUNIL KUMAR

Printer: New Pusphak Printers
Cover Design: Aman Dua

DOS Times will hitherto be published once every two months
by Dr. M. Vanathi, on behalf of Delhi Ophthalmological Society,
DOS Secretariat, Dr. R.P. Centre, AIIMS, New Delhi. All solicited &
unsolicited manuscripts submitted to DOS TIMES are subject to
editorial review before acceptance. DOS TIMES is not responsible for
the statements made by the contributors. All advertising material is
expected to conform to ethical standards and acceptance does not
imply endorsement by DOS TIMES.

ISSN 0972-0723

DOS EXECUTIVE MEMBERS

Executive Committee:

ˆϐ‹…‡ ‡ƒ”‡”•

Dr. Cyrus M. Shroff Dr. Rishi Mohan Dr. M. Vanathi
President Vice President General Secretary

Dr. Arun Baweja Dr. Vipul Nayar Dr. Ruchi Goel Dr. Devn Tuli
Joint Secretary Treasurer Editor ‹„”ƒ”› ˆϐ‹…‡”
DOS Representative to AIOS
Executive Members

Dr. Jatinder Singh Bhalla Dr. Bhuvan Chanana Dr. Anshul Goyal Dr. Avnindra Gupta Dr. Ajay Aurora

Dr. Rajat Jain Dr. Deepankur Mahajan Dr. J. K.S. Parihar Dr. Manavdeep Singh Dr. Namrata Sharma

šǦ ˆϐ‹…‹‘ ‡„‡”•

Dr. Rajendra Khanna Dr. Rajesh Sinha Dr. Sanjeev Gupta
Ex-President Ex-Secretary Ex-Treasurer

DOS HALL OF FAME Tejpal Saini B. Pattnaik DOS General Secretaries
DOS PRESIDENTS Satish Sabharwal Satinder Sabharwal
A.K. Grover Hari Mohan Arun Sangal
S.N. Mitter A.C. Chadha N.C. Singhal J.C. Das R.S. Garkal R.V. Azad
H.S. Trehan M.S. Boparai Madan Mohan Gurbax Singh S.R.K. Malik B. Ghosh
Tej Pal Saini N.N. Sood Pratap Narain Noshir M. Shroff Madan Mohan Mahipal Sachdev
L.P. Agarwal P.K. Jain (Brig.) R.C. Sharma Mahipal S. Sachdev J.C. Bhutani Atul Kumar
D.C. Bhutani L.D. Sota Lalit Verma S.C. Sabharwal Lalit Verma
R.C. Aggarwal L.D. Sota B.N. Khanna S. Bharti A.C. Chadha Dinesh Talwar
S.K. Angra R.N. Sabharwal Sharad Lakhotia Pratap Narain Harsh Kumar
S.N. Kaul D.K. Mehta P.V. Chadha S.K. Angra J S. Titiyal
S.N. Kaul Y. Dayal N.L. Bajaj B.P. Guliani G. Mukherjee Harbansh Lal
H.S. Trehan K.P.S. Malik Mathew M. Krishna Harbansh Lal H.K. Tewari Namrata Sharma
Hari Mohan R.B. Jain J S. Titiyal Amit Khosla
R.S. Garkal G. Mukherjee Prem Prakash Rajendra Khanna R. Kalsi Rohit Saxena
J.C. Bhutani R.V. Azad D.K. Sen Cyrus Shroff D.K. Mehta Rajesh Sinha
S.R.K. Malik P.C. Bhatia M. Vanathi
P.K. Khosla K.P.S. Malik
K. Lall

A.K. Gupta

Sincere thanks to all DOS OFFICE STAFF : ˆϐ‹…‡ ‡…”‡–ƒ”›ǣ Parveen Kumar Š DOS Accountant: Sandeep Kumar Š DOS TIMES Assistant: Sunil Kumar
DJO Assistant: Varun Kumar Š Library Attendant: Niyaj Ahmad Š ˆϐ‹…‡ ––‡†ƒ–ǣ Harshpal

2 DOS TIMES - SEPTEMBER-OCTOBER 2015

EDITORIAL CAPSULE

HE ISION OF IGHT

The best and most beautiful things in the world cannot be seen or
even touched –

They must be felt with the heart
Ȇ ‡Ž‡ ‡ŽŽ‡”

Dear Members

As we move on, the second issue of DOS TIMES comes out in the midst of Dr. M.Vanathi
the Eye Donation Fortnight Celebrations. Eye Donation is an act of supreme
kindness to the society. It will indeed be the height of humane behavior to be
able to donate one’s eyes. Any act that contributes towards increasing the eye
donation awareness and in enabling more procurement of donor eyes will go
a long way in tackling our problem of corneal blindness. This issue’s guest
editorial on the Eye Banking Scenario in India aptly describes the current
scenario of Eye banking in India. The special message on eye donation on eye
donation also elucidates the need for community participation in enhancing
eye donation. The act of donation encompasses so many issues that it needs
to be felt deep in the heart to be able to execute it.

I wish to thank all DOS members for the sincere appreciation received on the bold new outlook of DOS TIMES
2015. This edition has a wonderful assembly of articles of varied interest to a wide variety of audience. In the
clinical spotlight section, there is a comprehensive coverage of intraoperative OCT imaging in retinal surgeries.
Retina section features updates on the technique of intra-arterial chemotherapy in retinoblastoma, and the use
‘ˆ •–‡”‘‹†• ‹ †‹ƒ„‡–‹… ƒ…—Žƒ” ‡†‡ƒ ™Š‹…Š ƒ”‡ …—””‡– –‘’‹…• ‘ˆ ‹–‡”‡•– ‹ –Š‡ ϐ‹‡Ž† ‘ˆ ‘’Š–ŠƒŽ‹… ’”ƒ…–‹…‡Ǥ Š‡
cornea section highlights the intricacies involved in Pintucci’s keratoprosthesis. The article on corneal blindness
covers the community ophthalmology concepts. Innovations section covers a topic of growing popularity – micro
incision stab surgery in glaucoma which is well written up as well. This edition’s monthly meeting korner has
some exciting cases that have been well documented. The regular features of quiz and crossword, snapshot and
quick picks are all in the array. Browse in to read more. Our website, www.dosonline.org also has a new outlook
with a ready assembly of academic material.

In the perspective of Helen Keller, the only thing worse than being blind is having sight but no vision. Alone
we can achieve so little. Together we can do so much. I seek your ardent support in all our academic activities
–‘ ƒ‡ ‡˜‡”› ‹‹–‹ƒ–‹˜‡ ƒ •—……‡••Ǥ – ™ƒ• ‹†‡‡† ˜‡”› Š‡ƒ”–‡‹‰ –‘ •‡‡ –Š‡ Š‹‰Š‡•– ‡˜‡” ƒ––‡†ƒ…‡ ‹ –Š‡ ϐ‹”•–
DOS monthly clinical meet this July. I humbly request all DOS members, to extend their active participation to all
activities of DOS. Let us work in unison to see DOS rise further in the country’s world of academics to achieve the
vision of sight.

Dr. M.Vanathi MD
Additional Prof. of Ophthalmology
Cornea, Cataract & Refractive Services
Dr R P Centre for Ophthalmic Sciences
All India Institute of Medical Sciences
New Delhi 110029, India
[email protected]

www. dos-times.org 3

GUEST EDITORIAL

Corneal blindness is estimated to be the second most prevalent cause of unilateral blindness in

India, but the epidemiological data is limited. Previous, southern India based study showed corneal

blindness will continue to increase with a prevalence rate from 0.66% (2001) to 0.84% (2020), and

largely from unilateral cases1. Moreover, about 80% of overall blindness in India is found in those

ƒ‰‡† ͷͲ ›‡ƒ”• ‘” ‘”‡ǡ ™Š‡”‡ƒ• …‘”‡ƒŽ „Ž‹†‡•• ‡ˆˆ‡…–• ƒ •‹‰‹ϐ‹…ƒ–Ž› ›‘—‰‡” ’‘’—Žƒ–‹‘ –Šƒ

other forms of blindness2.

While prevention is the most desirable way to control corneal blindness, but once the cornea

lost its transparency, keratoplasty will remain the primary sight restoring procedure. Again, not all

cornea blindness is amenable to vision restoration with keratoplasty. Only 40% of bilateral corneal

blindness is estimated to be treatable with keratoplasty in one Indian study3. Operating in high-

risk eyes in developing world settings often leads to a high rate of repeat keratoplasty4. India is the

only country with largest number of treatable corneal blindness and for this we need quality eye Dr. Samar Basak
banking.

›‡ ƒ‹‰ ‹ †‹ƒ …ƒ „‡ –”ƒ…‡† „ƒ… –‘ ͳͻͶͷ ™Š‡ –Š‡ ϐ‹”•– ›‡ ƒ ™ƒ• ‡•–ƒ„Ž‹•Š‡† ‹ ‡‰‹‘ƒŽ •–‹–—–‡ ‘ˆ ’Š–ŠƒŽ‘Ž‘‰›ǡ

Madras (Chennai). Over the decades there has been a slow, yet steady growth in all aspects of eye banking. The growth picked up

pace during the last 25 years as efforts in various parts of the country were coordinated under a single umbrella organization –

Eye Bank Association of India (EBAI) and outcome of strong Public Private Partnership – NPCB from Public Sector and EBAI from

Private/NGO sector.

There were four Editorials and Guest Editorials in Indian Journal of Ophthalmology in the year 1989, 1996, 1997 and 20045-8.

There is also a special article on Eye Banking in India in 20129. These articles tell the success stories of Indian eye banking from

–‹‡ –‘ –‹‡Ǥ Š‡ ϐ‹”•– ‡†‹–‘”‹ƒŽ ™”‹––‡ „› ”‘ˆ ƒŽ‡˜‡” ‹ ͳͻͺͻ ƒˆ–‡” ˆ‘”ƒ–‹‘ ‘ˆ Ǥ Dz Š‡”‡ ƒ”‡ ‘˜‡” ͳʹͲ ‡›‡ „ƒ• ˆ‘”ƒŽŽ›

established in different parts of the country. Most of them are only on paper, only about 20 are collecting 50 or more donor eyes in

a year. And not more than 2000 corneal grafts are being done in the whole country in a year, a drop in an ocean effort.”

In India in 1995 against 11,878 donor eyes collected, only 4,431 penetrating keratoplasties were performed7. After 20 years,

†‹ƒ ›‡ ƒ‹‰ Šƒ• ‰”‘™ •‹‰‹ϐ‹…ƒ–Ž› ™‹–Š ƒ …‘ŽŽ‡…–‹‘ ‘ˆ ͷͲ͸ͲͲ …‘”‡ƒ• ƒ† —–‹Ž‹œƒ–‹‘ ‘ˆ ʹͶǡ͵ͲͲ …‘”‡ƒ• ȋͶͺΨȌ ‹ –Š‡ ›‡ƒ”

2014-15 (EBAI data).

CURRENT STATUS OF INDIAN EYE BANKING
Ȉ —ŽŽ› —…–‹‘‹‰ ›‡ ƒ ƒ† ›‡ ‘ƒ–‹‘ ‡–”‡ Ȃ ͹͸Ͳ Ȉ ͳͺ ›‡ ƒ• …‘ŽŽ‡…– ‘”‡ –Šƒ ͳͲͲͲ ‘”‡ƒ•Ȁ›‡ƒ”
Ȉ Ž› Ͷ͵ ›‡ ƒ•Ȁ • …‘ŽŽ‡…– ‘”‡ –Šƒ ͳͲͲ …‘”‡ƒ•Ȁ›‡ƒ” Ȉ Ž› Ͷ ›‡ ƒ• —–‹Ž‹œ‡ ‘”‡ –Šƒ ͳͲͲͲ …‘”‡ƒ•Ȁ›‡ƒ”
Ȉ ͵͸ ›‡ ƒ• —–‹Ž‹œ‡ ‘”‡ –Šƒ ͳͲͲ …‘”‡ƒ•Ȁ›‡ƒ”
Ȉ Š‡ ‡–‹”‡ …‘ŽŽ‡…–‹‘ …‘‡• ˆ”‘ Œ—•– ƒ„‘—– ʹ͸Ψ ‘ˆ –Š‡ ”‡‰‹•–‡”‡† ‘”‰ƒ‹œƒ–‹‘• ƒ† ʹΨ ‘ˆ –Š‡ ”‡‰‹•–‡”‡† ‘”‰ƒ‹œƒ–‹‘•

account for more than 50% of the collection. That means we are still 25 years back as Dr. Kalever stated in 1989.
This lack of cornea collection is not due to a lack of eye banks, but the lack of professional eye banks that can effectively
perform the four key eye bank functions: approach and consent, recovery, processing, and distribution. During a joint workshop
conducted by EBAI and NPCB in July 2004 a road map for Indian Eye Banking was presented which consisted of a three tier
•–”—…–—”‡ …‘•‹•–‹‰ ‘ˆ –”ƒ‹‹‰ …‡–”‡•ǡ ‡›‡ „ƒ• ƒ† ‡›‡ †‘ƒ–‹‘ …‡–”‡•Ǥ – ™ƒ• ’”‘’‘•‡† –Šƒ– ˆ—ŽŽǦϐŽ‡†‰‡† ‡›‡ „ƒ• „‡
restricted to 50 and the rest of the organizations be called as eye donation centres. The government accepted the proposed plan as
ƒ ‡ˆˆ‡…–‹˜‡ ƒ† ˆ‡ƒ•‹„Ž‡ ™ƒ› –‘ •–”‡‰–Š‡ ‡›‡ „ƒ‹‰Ǥ ʹͷ Ž‘…ƒ–‹‘• ƒŽŽ ‘˜‡” –Š‡ …‘—–”› Šƒ˜‡ ƒŽ”‡ƒ†› „‡‡ ‹†‡–‹ϐ‹‡†Ǥ
There are at least 15 successful Eye Bank models in India, largely because of they are more of professional Eye banks
following new operating model (mostly supported by SightLife, USA). Two key factors are: professional eye bank managers and
the development of Hospital Cornea Retrieval Programs (HCRP), where trained eye donation counselors are posted in large
hospitals to approach potential donor families to gain consent.
Š‹• ‹• ‹ …‘–”ƒ•– –‘ –Š‡ –›’‹…ƒŽ †‹ƒ ‡›‡ „ƒ ‘’‡”ƒ–‹‘ǡ ™Š‹…Š —•‡• ƒ Dz˜‘Ž—–ƒ”›dz ‡›‡ †‘ƒ–‹‘ ’”‘‰”ƒ ™‹–Š ƒ ˆ‘…—•
on public awareness and responding to family requests to do eye collection. The voluntary donation program is operationally
‹‡ˆϐ‹…‹‡–ǡ ™‹–Š —…Š Ž‘™‡” –‹••—‡ —–‹Ž‹œƒ–‹‘Ǥ Š‡ ‘˜‡”ƒŽŽ †‹ƒ ‡›‡ „ƒ —–‹Ž‹œƒ–‹‘ ‘ˆ –‹••—‡ǡ –Š”‘—‰Š ’”‹ƒ”‹Ž› ˜‘Ž—–ƒ”›
collection, is 38%; whereas utilization of corneas within a HCRP model (12 sample eye banks) is 72%, based primarily on
improved donor selection.

TARGET
In India, a 2004 national plan was developed by the NPCB, EBAI and NGOs to treat corneal blindness, with a target of 100,000

transplants annually by the year 2020. If we target overall utilization of 50%, we need 200,000 corneas for achieving this target.
This is highly possible by extended and targeted HCRP program across the country. To be honest, this is less than 1% of all
annual deaths in India (currently we are procuring corneas from less than 0.5% of total death). A close partnership between the
professional eye banks and the participating large Government hospitals is a critical element to the success of this approach.

˜‡ ™‹–Š ƒ ‡ˆˆ‡…–‹˜‡ ‡›‡ „ƒ‹‰ǡ ϐ‹†‹‰ ‡‘—‰Š ˆƒ‹Ž› ‡„‡”• ™‹ŽŽ‹‰ –‘ †‘ƒ–‡ –Š‡‹” †‡ƒ” ‘‡ǯ• …‘”‡ƒ• …ƒ „‡ •–‹ŽŽ
†‹ˆϐ‹…—Ž–Ǥ —„Ž‹… ƒ™ƒ”‡‡•• ’”‘‰”ƒ‡• ’Žƒ› ƒ ‹’‘”–ƒ– ”‘Ž‡ ƒ† ‹– •Š‘—Ž† ‰‘ ‘Ǥ ’Šƒ•‹•‡ –Šƒ– …‘”‡ƒ• …ƒ „‡ †‘ƒ–‡† „›
ƒ›‘‡ǡ ™Šƒ–‡˜‡” –Š‡‹” ƒ‰‡ǡ ‰‡†‡”ǡ ”‡Ž‹‰‹‘Ǣ ƒ† –Šƒ– ‡‹–Š‡” ‡—…Ž‡ƒ–‹‘ ‘” ‹ •‹–— •…Ž‡”‘Ǧ…‘”‡ƒŽ ‡š…‹•‹‘ …ƒ—•‡• †‹•ϐ‹‰—”‡‡–
of the face or any delays in funeral arrangements. Family pledging is also more important as consent of next of kin is usually
needed before eyes or corneas can be removed.

LEGISLATION IN EYE BANKING
Favourable ‘presumed consent’ law is in practice in some countries, like, the United States and Ethiopia. Under this law,

www. dos-times.org 5

GUEST EDITORIAL

every person who dies while in hospital or elsewhere is presumed to be an eye donor unless this is actively rejected by their next
of kin. In India, now we have ‘required request’ law for eye donation since 2013. This law requires hospital authorities to identify
potential cornea donors and obtain consent from bereaved family members. It has been started in only few states, not in majority
of the states.

We have also recent amendments to Transplantation of Human Organs Act (1994) passed in the Parliament. Under the new
”—Ž‡ ‹– Šƒ• „‡‡ …ƒŽŽ‡† ƒ• Dz ”ƒ•’Žƒ–ƒ–‹‘ ‘ˆ —ƒ ”‰ƒ ƒ† ‹••—‡• …– ȋʹͲͳͶȌǤ †‡” –Š‹• ”—Ž‡ǡ ƒ’ƒ”– ˆ”‘ ‡‰‹•–‡”‡† ‡†‹…ƒŽ
Practitioners, a Trained technician is also allowed to enucleate the whole globe or excise the in situ Sclero-corneal button. They can
be Nurses, Paramedical Ophthalmic Assistant, Optometrist, Refractionist, Paramedical workers or Medical Technicians, provided
the person is duly trained to enucleate/excise eyeball/cornea from registered, authorised and functional eye bank or Government
‡†‹…ƒŽ …‘ŽŽ‡‰‡ ƒ† —•– Šƒ˜‡ –Š‡ –”ƒ‹‹‰ …‡”–‹ϐ‹…ƒ–‡11.

MEDICAL STANDARDS OF INDIAN EYE BANKING
In 2007, with the help of ORBIS an International meeting of Eye Banking experts from all over the country was organized to

†‡„ƒ–‡ ƒ† ϐ‹ƒŽ‹•‡ ƒ‡†‡–• –‘ ‡†‹…ƒŽ –ƒ†ƒ”†• †‹ƒ ›‡ ƒ‹‰Ǥ ƒ–‡” ‘ ‹ ʹͲͳ͵ǡ ™‹–Š –Š‡ Š‡Ž’ ‘ˆ ǡ ǡ ƒ†
SightLife, Eye Banking experts again have upgraded the medical standards standard as per current need.

ACCREDITATION
Eye Banking Accreditation program on a pilot basis involving seven eye banks was implemented in 2011-12, with the support

of international NGOs - Orbis International, SightLife and Sight Savers. The process and procedures were developed with the help
‘ˆ ‹‰Š– ‹ˆ‡ –‡ƒǤ Š‡ ƒ••‡••‘”• ™‡”‡ ƒŽ•‘ –”ƒ‹‡† „› ‹‰Š– ‹ˆ‡ –‡ƒǤ Š‡ ϐ‹†‹‰• ‘ˆ –Š‡ ’”‘Œ‡…– ™‡”‡ •—„‹––‡† –‘ ƒ† Ǥ

It has been proposed that Accreditation of the Indian Eye Banks are essential as per the NABH/NABL standard, Through
Accreditation EBAI would be in a position to enforce uniform medical standards across the country. Adherence to medical standards
also means that only the eye banks which can mobilize necessary resources to maintain round the clock services would be able
to continue. It would help in checking proliferation of sub-standard eye banks or donation centres, and to support growth of only
state-of-the-art eye banks. Accredited eye banks would be in a position to distribute surplus corneas across the country via cornea
†‹•–”‹„—–‹‘ •›•–‡ ƒ† ”ƒ‹•‡ ‡…‡••ƒ”› ”‡•‘—”…‡•Ǥ Š‡ ‘’‡”ƒ–‹‰ •—”‰‡‘ ‹• ƒŽ•‘ …‘ϐ‹†‡– ‘ˆ —•‹‰ –Š‡ –‹••—‡ ˆ”‘ ƒ ƒ……”‡†‹–‡†
eye bank.

CORNEA STORAGE MEDIA
Currently, majority of the eye banks are using MK medium for short term (72-48 hours) or Cornisol/Optisol GS medium

for intermediate term (fupto 14 days). SightLife partner eye banks are also using Optisol GS medium (getting from SightLife at a
subsidised price). Cornisol (a product of AuroLab) is as per with Optisol GS medium and it is available at a very good price. Sadly,
many eye banks are still following the old moist chamber method where cornea remains viable for 24 hours. This may be one of the
reasons for underutilization in some eye banks.

CME ON EYE BANKING
It is good that continuing medical education are going nicely every year under the aegis of EBAI. This is a platform where all

level of eye bank workers starting from eye donation counselor, technician, eye bank manager, medical director or board members
can exchange their knowledge and interact with best-performing eye bank people. Wet lab, instrument handing, didactic lectures,
interactive sessions all are important for quality eye banking.

EYE BANKING IN INDIA – TASK AHEAD
Ȉ ‘ ‡•–ƒ„Ž‹•Š ƒ ‡ˆϐ‹…‹‡– –Š”‡‡ –‹‡” …‘—‹–› ‡›‡ „ƒ‹‰ •›•–‡ –Šƒ– ™‘—Ž† †‡Ž‹˜‡” ”‡“—‹”‡† “—ƒ–‹–› ƒ† “—ƒŽ‹–› ‘ˆ …‘”‡ƒ

to the community
Ȉ ‘”‡ƒ †‹•–”‹„—–‹‘ •›•–‡ ‹• ƒŽ”‡ƒ†› ‹ ’Žƒ…‡ Ȃ „—–ǡ ‹– Šƒ• –‘ ‰‘ ƒ…”‘•• –Š‡ …‘—–”› ™‹–Š –Š‡ Š‡Ž’ ‘ˆ
‘˜‡”‡– ƒ†
•Ǥ
Ȉ ‘ ˆ‘”—Ž‹œ‡ ƒ–‹‘ƒŽ ‡”ƒ–‘’Žƒ•–› ”‡‰‹•–”› •›•–‡ǡ ƒ† ‡–™‘”‹‰ ™‹–Š –Š‡ ‡›‡ „ƒ• ƒ† …‘”‡ƒŽ •—”‰‡‘ ƒ–‹‘™‹†‡Ǥ
Ȉ ƒ•• ‡†—…ƒ–‹‘ ƒ„‘—– ‡›‡ „ƒ‹‰ ˜‹ƒ •‘…‹ƒŽ ‡†‹ƒ ‡–™‘”•ǡ ’Ž‡†‰‹‰ ƒ† ‡†‹ƒ •—’’‘”–Ǥ
Ȉ ”ƒ‹‹‰ ‹• –‘ „‡ …‘–‹—‡† ƒ††”‡••‹‰ –Š‡ “—ƒŽ‹–› ‹••—‡• ‘ …‘”‡ƒ ”‡–”‹‡˜ƒŽǡ ‡˜ƒŽ—ƒ–‹‘ǡ •–‘”ƒ‰‡ ƒ† †‹•–”‹„—–‹‘ –‘ –Š‡ …‘”‡ƒŽ

surgeons.
Ȉ ’‰”ƒ†‡ •‹ŽŽ• ‘ˆ ’Š–ŠƒŽ‘Ž‘‰‹•–• ‹ …‘”‡ƒŽ •—”‰‡”› •‘ –Šƒ– …‘”‡ƒ• ƒ”‡ ‘’–‹ƒŽŽ› —–‹Ž‹œ‡†Ǥ – ’”‡•‡– ™‡ ƒ”‡ Šƒ˜‹‰ ͵ͲͲǦ͵ͷͲ

corneal surgeons who are regularly doing keratoplasty.
If we go by our goal in 2020, we need at least 1000 corneal surgeons and each one of them are performing 100 keratoplasty per
year. But at present, we are producing only 55 corneal surgeons per year through fellowship/residency program.
Cornea Society of India and SightLife, are in the process of immediate training program of different wet lab and skill transfer
courses from time to time to train lamellar corneal surgery so that utilization may be more.
Lastly, educate common man to show how we could prevent and reduce the incidence of corneal blindness.

Dr. Samar K Basak MD, DNB, FRCS
President, Eye Bank Association of India &
Director Disha Eye Hospitals,
Barrackpore, Kolkata, India

REFERENCES 5. Kalevar V. Eye banking in India. Indian J Ophthalmol 1989;37:110-1.
6. Rao GN. What is eye banking? Indian J Ophthalmol 1996;44:1-2
1. Dandona R, Dandona L. Corneal blindness in a southern Indian population: Need for health 7. Saini J S. Realistic targets and strategies in eye banking. Indian J Ophthalmol 1997;45:141-2.
promotion strategies. Br J Ophthalmol. 2003;87:133–41. 8. Rao GN. Eye banking - Are we really up to it in India? Indian J Ophthalmol 2004;52:183
9. Oliva MS, Schottman,T and Gulati M. Turning the tide of corneal blindness. Indian J
2. Resnikoff S, Pascolini D, Etya’ale D, et al. Global data on visual impairment in the year 2002.
Bull World Health Organ. 2002;82:844–51. Ophthalmol. 2012; 60:423-7.
10. Ganesh G. personal communication, Data from Eye Bank Association of India, on 30th July,
3. Sinha R, Sharman, Vajpayee RB. Corneal blindness - present status. Cataract Refract Surg
Today. 2005:59–61. 2015.
11. The Gazette of India. Part II Section 3: No. 161, New Delhi, 27th March, 2014, pp. 39-40.
4. Garg P, Krishna PV, Stratis AK, Gopinathan U. The value of corneal transplantation in reducing
blindness. Eye (Lond) 2005;19:1106–14.

6 DOS TIMES - SEPTEMBER-OCTOBER 2015

SPECIAL MESSAGE

Dear Friends,

It is an exciting time for corneal surgeons. New gadgets, innovative surgical techniques some of
which have been true game changers, better understanding of the etiopathogenesis of various
corneal diseases, newer medications and drug delivery systems and the increasing availability
of quality eye banking services have all led to a ‘feel good effect’ and infused fresh energy and
‡–Š—•‹ƒ• ‹ –Š‘•‡ ‡‰ƒ‰‡† ‹ –Š‡ ϐ‹‡Ž†Ǥ

The cornea is a colourless transparent tissue that serves as a window and looking glass, forms Prof. Radhika Tandon
ƒ ‹’‘”–ƒ– ”‡ˆ”ƒ…–‹˜‡ ˆ—…–‹‘ƒŽ —‹– ƒŽ‘‰ ™‹–Š –Š‡ ’”‡Ǧ…‘”‡ƒŽ –‡ƒ” ϐ‹Ž ƒ† ‹ …‘Œ—…–‹‘
with the crystalline lens helps to form a focused clear image of the outside world on the retina.
–• ˆ—…–‹‘ ‹• Šƒ’‡”‡† †—‡ –‘ †ƒƒ‰‡ –‘ –Š‡ ‘…—Žƒ” •—”ˆƒ…‡ǡ –‡ƒ” ϐ‹Žǡ ‡’‹–Š‡Ž‹—ǡ •–”‘ƒ ‘”
endothelium and if damage is deemed irreversible, replacement by a healthy cornea from a
donor is currently the acceptable mode of therapy.

Younger readers may be surprised to learn that at the turn of the last century corneal
transplantation involved taking tissue directly from the eye of a living donor where the surgeon was required to personally
‡šƒ‹‡ –Š‡ †‘‘” …‘”‡ƒ –‘ …‘ϐ‹” –”ƒ•’ƒ”‡…› ƒ† ƒ„•‡…‡ ‘ˆ ‘–Š‡” ’ƒ–Š‘Ž‘‰›Ǥ – ™ƒ• ‘Ž› ‹ –Š‡ ‹† ͳͻ͵Ͳ• –Šƒ– –Š‡
suitability of postmortem tissue was proven, eye banking actually started, and as a natural consequence to these developments
more donor tissue became available. Even then, the surgeons still played a major role in the eye banking process: the sole
responsibility of the eye bank primarily being the collection of donor tissue. The surgeon would inspect the tissue to determine
suitability and the cornea would usually be transplanted in the same hospital.

With the advent of corneal preservation medium in the 1970s the scenario changed with eye banks playing a more pro-active
and participatory role in the process, developing a closer relationship with the surgeon.

By the end of the 20th century there was a remarkable advancement in attitudes and practices shifting from a mere reliance
on trust to a higher degree of control of each step involved in safe transplantation of donor tissue.

The beginning of the 21st century saw this concept implemented more stringently with the introduction of quality management
systems and quality control measures and the development of guidelines enforced by government regulations in keeping with
legislative reforms.

‘™ Šƒ• †‹ƒ ‡’– ’ƒ…‡ ™‹–Š –Š‡ —ˆ—”Ž‹‰ ‘ˆ –Š‡ ‡–ƒ’Š‘”‹…ƒŽ ϐŽƒ‰ ‘ˆ ‹–‡”ƒ–‹‘ƒŽ •–ƒ†ƒ”†•ǫ ” ƒƒ” ƒ•ƒǡ ”‡•‹†‡–
has succinctly described in a nutshell in this issue of DOS Times the key features highlighting the national Status. Legislative
reforms, increasing implementation of successful hospital cornea retrieval programmes, greater public awareness, increased
consciousness in the eye banking and corneal transplantation community to focus more on transplants and ensure adequate
supply of transplantable corneas rather than set targets mainly for donation and eye collection, availability of better storage
media, facilities for providing pre-cut tissue, infusion of a ‘cool factor’ by greater participation and collective understanding
have all helped to make eye bank management and operations fruitful and worthy of active involvement.

Wishing all the members of DOS and readers of DOS Times a very happy festive season with an appeal to support the
movement for uniform standards and encourage quality assurance measures in all day-to-day work extending to the clinic,
OT, eye bank and beyond to the community.

With best wishes,

Prof. Radhika Tandon MD, DNB, FRCOphth, FRCSEd, MNASI
Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences,
New Delhi, India.
&
Vice President
Eye Bank Association of India

www. dos-times.org 7

CORNEA

PINTUCCI’S KERATOPROSTHESIS

Quresh B. Maskati

Dr. Quresh B. Maskati MS PINTUCCI BIO-INTEGRATED KERATOPROSTHESIS
Maskati Eye Clinic, Mumbai, India (PBIKP)

Keratoplasty or corneal transplant is accepted The original design was a 3.5 mm diameter cylinder
as one of the most successful of all transplants of PMMA with a 0.6mm thick, soft Dacron mesh embedded
done in the body1,2 with a fairly low rejection ‹ –Š‡ …‡–”‡ͺ Ž‹‡ ƒ ϐŽƒ”‡† ƒ ƒ †ƒ…‡”ǯ• •‹”–Ǥ Š‹• ™ƒ•
rate. However, this is only in cases where
immunological isolation of the cornea is Figure 1(a): showing harvesting free buccal mucosa graft from lower
preserved. Even today, in the 21st century, there lip, Figure 1(b): harvested graft - inner surface (that covers the host
are cases in which keratoplasty is doomed to failure. For very cornea) Figure 1(c): harvested graft, outer surface.
severe ocular surface disorders with bilateral loss of vision,
such as severe Stevens’ Johnson Syndrome with keratinisation, www. dos-times.org 9
•‡˜‡”‡ …Š‡‹…ƒŽ „—”•ǡ ‘…—Žƒ” ’‡’Š‹‰—• ™‹–Š •‹‰‹ϐ‹…ƒ– †”›
eye, disorganised anterior segments due to trauma, any cause of
„‹Žƒ–‡”ƒŽ –‘–ƒŽ •–‡ …‡ŽŽ Ž‘•• ‘” †‡ϐ‹…‹‡…›ǡ •‡˜‡”‡Ž› ˜ƒ•…—Žƒ”‹•‡†
recipient eyes etc, keratoplasty will not work and should
not be attempted3. The world over, the search for the perfect
Keratoprosthesis (KP) is a continuous process for such cases4.
There are several dozens of KP invented over the years5-7. Only
a handful however are currently in use and have stood the test
of time. The Daljit Singh champagne cork KP also known as the
Worst-Singh KP8 has perhaps the largest number implanted
till date (over 5000- personal communication). The others are
–Š‡ ‘†‹ϐ‹‡† •–‡‘Ǧ †‘–‘ ‡”ƒ–‘’”‘•–Š‡•‹• ȋ Ȍ ƒ†
the Pintucci Bio-Integrated Keratoprosthesis (PBIKP). The
Dohlman or Boston Keratoprosthesis is useful in less severe
eye conditions such as vascularised corneal opacities, repeated
failed grafts, chemical burns and Stevens’ Johnson Syndrome
without Keratinisation, For the Dohlman Keratoprosthesis
(DKP), some degree of tear secretion and a normal blink
mechanism are essential for long term success9,10. For any KP,
it is essential to have accurate light perception and to rule out
pre-existing end stage glaucoma or a retinal detachment. The
PBIKP and the DKP are the two which the author has personal
experience. This article highlights the author’s experience with
PBIKP.

The dacron mesh of PBIKP is porous
and allows connective tissue and blood
vessels to grown three-dimensionally
into its pores in the 2 months that it is
kept under the orbicularis oculi. This
helps in the bio-integration of the
keratoprosthesis

CORNEA

Žƒ–‡” ‘†‹ϐ‹‡† „› ”Ǥ –‡ˆƒ‘ 6b) and the Dacron mesh,
Pintucci into a 4mm diameter (now fully covered with
PMMA cylinder. After his connective tissue and blood
untimely demise a few years vessels on both surfaces and
ago, the author has further around the edge) inspected.
‘†‹ϐ‹‡† –Š‡ †‡•‹‰ –‘ ‹…Ž—†‡ The Dacron mesh that was
a front plate and a back plate of soft and pliable at insertion is
PMMA with the Dacron mesh ‘™ ˆƒ‹”Ž› ϐ‹”ǡ „—– •–‹ŽŽ ƒŽŽ‘™•
now 0.5mm thick sandwiched passage of vicryl sutures fairly
in between, with dimensions easily. The eye is then opened,
as shown in the diagram. a speculum inserted and the
„—……ƒŽ —…‘•ƒŽ ϐŽƒ’ ‹• ”‡ϐŽ‡…–‡†
SURGICAL TECHNIQUE Figure 2: Showing commencement of surgery in a case of chemical back to be hinged in the upper
burns with extensive symblepharon temporal quadrant (Figure
The surgical technique 7a). Using the central corneal
is very similar to that devised suture as a centration point, a
by the late Dr. Stefano Pintucci 4mm trephine is used to make
of Rome, Italy. It consists of 2 a circular groove in the cornea
stages.

(a) (b)

Figure 3(a): Showing the peritomy and host cornea with the central corneal marker stitch after clearing all adhesions Figure 3(b): The buccal mucosal
graft sutured over cornea and into fornices - end of stage 1.

Stage One the surrounding conjunctiva (Figure 3b). (a)
Some anchoring sutures are taken to
The lower lip is everted, held in a the recti muscles as well. A conformer is (b)
special clamp (Figure 1a) and a large free placed in the eye and left in place for 15
graft (Figure 1b & Figure 1c) harvested days. Figure 4(a): Depicting the diagramatic
from the mucosal side. Gauze soaked in representation. (Figure 4(b): Clinical photograph
hydrogen peroxide is used to seal bleeders The Pintucci Bio-Integrated Kerato of Pintucci Keratoprosthesis (PBIKP).
on the raw donor surface and a tincture Prosthesis (PBIKP) (Figure 4 a&b) is
benzoin dressing is applied on the bare removed from its sterile packaging,
area. No sutures are taken. This graft washed with saline and placed upside
contains mucosa as well as sub-mucosal down under the Orbicularis Oculi muscle
connective tissue. The graft is then placed after making a linear incision through
‘ ƒ ϐŽƒ– •—”ˆƒ…‡ ƒ† ˜‹•‹„Ž‡ ϐ‹„”‡• ‘ˆ –Š‡ skin and Orbicularis below the lower lid
Orbicularis oris muscle are trimmed off. (Figure 5a). This PBIKP is then left in place
The eye (Figure 2) is opened, symblephara for 2 months or more. The orbicularis
are released and a speculum inserted. muscle is sutured with absorbable suture
The corneal epithelium is scraped off as and the skin with non-absorbable sutures
well as any conjunctival overgrowths on (Figure 5b) which are removed after
to the cornea. 360 degrees Peritomy is seven to ten days.
done. A single 10/0 nylon stitch is taken
in the centre of the cornea, half thickness Stage Two
depth, (Figure 3a) to serve as a marker
for the centre of the cornea in the second Two months later, the PBIKP is
stage. The buccal mucosal free graft is removed after making an incision similar
placed over the cornea and sutured with to the earlier one under the lower lid
interrupted polyglycolic acid sutures to (Figure 6a). The PMMA cylinder is
cleaned of all connective tissue (Figure

10 DOS TIMES - SEPTEMBER-OCTOBER 2015

CORNEA
(a) (b)

Figure 5(a): Showing PBIKP insertion. Figure 5(b): Showing incision skin and orbicularis and closure of lid incision after PBIKP insertion.

(a) (b)

Figure 6(a): Showing commencement of Stage 2 of the surgery, 2 months later. Figure 6(b): Bio-integrated PBIKP removed from lower lid and PBIKP
after cleaning the PMMA surfaces.

(a) (b)

Figure 7(a): 5JQYKPI TGƀGEVKPI VJG ITCHVGF DWEECN OWEQUC Figure 7(b): Central corneal trephination with skin biopsy trephine.

(Figure 7b). 3 radial cuts are made on the 1mm within the limbus (Figure 8a). keratoplasty, with a full thickness knife
cornea at 12, 4 and 8 o’clock positions The central 4mm button is then excised entry, followed by excision with corneal
extending from the circular groove to (Figure 8b) as done in penetrating extension scissors. The iris is held with

www. dos-times.org 11

CORNEA

•—–—”‹‰Ǥ Š‡ „—……ƒŽ —…‘•ƒŽ ϐŽƒ’ǡ ™Š‹…Š
(a) (a) Šƒ† „‡‡ ”‡ϐŽ‡…–‡† ‡ƒ”Ž‹‡”ǡ ‹• ‘™ „”‘—‰Š–

back and sutured to its original position
(Figure 10a), after carefully noting the
position of the projecting upper half of
the PMMA cylinder. The same trephine
is used to carefully trephine the central
4mm of the buccal mucosa (Figure 10b).
This allows the PMMA cylinder to project
approximately 0.5mm above the buccal
mucosa. The eye is then patched for 24 to
48 hours.

(b) (b) POST-OPERATIVE TREATMENT

Figure 8: Showing diagrammatic representation Figure 9(a): Showing extraction of crystalline Routine post-operative care after
QH TCFKCN EWVU KP EQTPGC CHVGT TGƀGEVKQP QH lens using cryoprobe. Figure 9(b): Excision of stage 1 includes oral Fluoroquinolone
mucosa (a). Excision of the corneal button (b). all iris tissue. ƒ–‹„‹‘–‹…• ˆ‘” ϐ‹˜‡ †ƒ›•Ǣ ‘”ƒŽ ƒ–‹Ǧ
‹ϐŽƒƒ–‘”› –ƒ„Ž‡–• „Ǥ‹Ǥ†Ǥ ˆ‘” ϐ‹˜‡ †ƒ›•
strong-toothed forceps (Figure 9b), after inserted through the central 4mm corneal and oral betamethasone 0.5mg tablets
”‡ϐŽ‡…–‹‰ –Š‡ ͵ …‘”‡ƒŽ ϐŽƒ’•Ǥ —Ž–‹’Ž‡ opening. The lower half of the Poly Methyl „Ǥ‹Ǥ†Ǥ ˆ‘” ϐ‹˜‡ †ƒ›•Ǥ ŽŽ ’ƒ–‹‡–• ƒ”‡ ‰‹˜‡
cuts are made from the pupil to the iris Meth Acrylate (PMMA) cylinder projects a liquid diet through a drinking straw for
root and the iris is removed segment into the vitreous cavity. The vascularised, –Š‡ ϐ‹”•– –Š”‡‡ †ƒ›• ˆ‘ŽŽ‘™‡† „› ƒ •‘ˆ–ǡ
by cut segment. The crystalline lens if colonised, bio-integrated Dacron mesh bland diet for another four days. The raw
present is extracted intra-capsularly with will now sit on top of the patient’s cornea. surface on the lower lip heals in a week
Cryoprobe (Figure 9a). If there is an Intra- This mesh is sutured to the cornea with to ten days.
Ocular Lens (IOL) in place, it is removed. 6/0 or7/0 vicryl sutures. The PMMA front
Single port central vitrectomy is done. and back plates are no hindrance for the On removal of the eye patch, the
patients are instructed to put antibiotic
The 3 corneal radial incisions are drops and steroid drops q.i.d. for 2
sealed with 8/0 vicryl. The PBIKP is then months.

After stage 2, they are asked to
continue antibiotic drops and steroid
drops q.i.d for one month and reduced to
b.i.d. in the next month. The steroid drops
are stopped after 2 months. Antibiotic
drops either b.i.d. or once a day are
continued for life. All patients are advised
to use lubricating drops as frequently
as necessary. Patients are told to clean
their PMMA cylinders using cotton buds
moistened with lubricating drops daily to
prevent discharge accumulating on them
and reducing their vision.

(a) (b)

Figure 10(a): Showing PBIKP placed in corneal trephined opening. Figure 10(b): Buccal mucosa resutured over PBIKP.
12 DOS TIMES - SEPTEMBER-OCTOBER 2015

CORNEA

‡Ž‡‡–• …‘’Ž‡–‡Ž› ϐ‹ŽŽ ‡ƒ…Š ’‘”‡ ˆ”‘ 2. Kenyon KR, Wagoner MD, Shore JW.
both the anterior and posterior surfaces
(a) as well as from the edges. When this Ocular Surface Transplantation, In :
PBIKP is implanted within the eye,
(b) –Š‡ ƒ…”‘ ‡•Šǡ ‘™ ϐ‹” –Š‘—‰Š ‘Cornea’, Krachmer, Mannis: Holland,
still pliable, allows blood vessels and
Figure 11(a): Showing clinical picture of eye connective tissue from the ocular surface Mosby; 1997. p. 1887-901.
with PBIKP 2 years after surgery with visual and the buccal mucosa to grow into the
acuity of 6/18. Figure 11(b): 5 years post- mesh and integrate with the blood vessels 3. Geerling G, Liu C, Collin J, Dart J. Cost
operative clinical photograph with visual and connective tissue already there. This
acuity of 6/18. allows true bio-integration. As each pore and gains of complex Procedures to
‹• ϐ‹ŽŽ‡† ™‹–Š Ž‹˜‹‰ –‹••—‡ǡ –Š‡ …Šƒ…‡• ‘ˆ
Reason for Success microbes being able to get into the eye rehabilitate end stage Ocular Surface
The Dacron Mesh, which is 0.5mm through the mesh are remote. This ‘living
shield’ also acts as a barrier for epithelial Disease.BJO 2002;86:1220-1.
thick is porous and allows connective migration from the surface, preventing the
tissue and blood vessels to grown possibility of retro-prosthetic epithelial 4. Liu C. Tighe B. Striving for the perfect
three-dimensionally into its pores in membranes and therefore extrusion of
the 2 months that it is kept under the the PBIKP (Figure 11a & Figure 11b). KP, editorial. BJO 1998;82:3-4.
orbicularis oculi. These mesodermal
The incidence of glaucoma post- 5. Dohlman CH. Keratoprosthesis, In :
operatively is relatively low (less than
10% in the author’s series of 85 cases ‘Cornea’, Krachmer, Mannis: Holland,
since 1997 with the original Pintucci
design and 4 cases with the indigenously Mosby; 1997. p. 1855-62.
ƒ†‡ ‘†‹ϐ‹‡† Ǥ Š‹• ‹• ’”‘„ƒ„Ž›
due to the fact that when the iris is 6. Cardona H. Keratoprosthesis. Am J
excised, the ciliary body is also pulled
upon causing several cyclodialysis clefts, Ophthal 1962;54:284.
thus causing diminished production of
aqueous humour12-14. 7. Strampelli B. Osteo-odonto-

REFERENCES Keratoprosthesis. Ann Ottalmol Clin

1. Gloor P. Complicated Penetrating Ocul 1963;89:1029-39.
Keratoplasty. In : ‘Cornea’, Krachmer,
Mannis: Holland, Mosby; 1997. p. 1731- 8. Singh D, Bansel DC, Singh A.
811.
Keratoprosthesis: A clinical study.

Indian J Ophthalmol 1973;21:112-6.

9. Dohlman CH, Terada H.

Keratoprosthesis in Pemphigoid and

Stevens-Johnson syndrome. Adv Exp

Med Biol 1998;438:1021-5.

10. Yaghouti F, Nouri M, Abad JC,

Power WJ, Doane MG, Dohlman

CH. Keratoprosthesis: Preoperative

prognostic categories.Cornea

2001;20:19-23.

11. Pintucci S, Pintucci F. The Dacron Felt

colonisable KP. Refract Corn Surg

1993;9:196-7.

12. Pintucci S, Pintucci F, Caiazza S,

Cecconi M. The Dacron felt colonisable

Keratoprosthesis after 15 years. Eur J

Ophthalmol 1996;6:125-30.

13. Pintucci S, Pintucci F. New Dacron

Colonisable KP. BJO 1995;79:825-9.

14. Maskati QB, Maskati BT. Asian

experience with the Pintucci

keratoprosthesis. Indian J Ophthalmol

2006;54:89-94.

Financial Interest: Š‡ ƒ—–Š‘” †‘‡• ‘– Šƒ˜‡ ƒ› ϔ‹ƒ…‹ƒŽ ‹–‡”‡•– ‹ ƒ› ’”‘…‡†—”‡Ȁ’”‘†—…– ‡–‹‘‡† ‹ –Š‹• ƒ—•…”‹’–Ǥ

www. dos-times.org 13

CORNEA

DEEP ANTERIOR LAMELLAR KERATOPLASTY IN
FULL THICKNESS CORNEAL PATHOLOGIES

Manotosh Ray

Š‡ –‡” Dz†‡‡’ Žƒ‡ŽŽƒ” ‡”ƒ–‘’Žƒ•–›dz ™ƒ• …‘‹‡† „› †—ƒ”†‘

Arenas Archilla in mid 80’s when he used intrastromal air to

facilitate dissection and exposure of Descemet’s membrane4.

Dr. Manotosh Ray MD, FRCS In 2002, Anwar et al described the big-bubble technique, the

Consultant, Cornea & External Eye Diseases ϐ‹”•– ’”‘…‡†—”‡ –‘ ƒ…Š‹‡˜‡ ƒ “—‹… ƒ† ”‡’‡ƒ–ƒ„Ž‡ „ƒ”‹‰ ‘ˆ

National University Hospital, Singapore Descemet membrane in anterior lamellar keratoplasty5. This is

D the most accepted and commonly practiced technique of DALK worldwide now.
eep anterior lamellar keratoplasty (DALK) is a

novel surgical technique designed to remove INDICATIONS

(rtrt‘tisapcasifb–AdkTvsonnueiŠhDeiutpoaneeeermlsprvctlm‡etarncaregMrdklPeuhtoe ia-hdefrnseogeKotcoonl)tifeiDhn†hvnrtntooevtrurcyuieoe‡iiAcimsfagrcatvgococfifsrroϐskyolsLnoekaha‹cnnaaoetmyanKcrttonlolrtasdftliant‹uiteryuefmolbhsc–oihcldinsvmc‹csuotmnayauesnt˜i,oohessoe,.snrrsrl‡sotin,riealorgnedn rncopvnntlalefhDeeaodImdeoyeigucei–enetretananntynArii”cr.nsayahinesslbi‡nedegdhgmpLeslee’almTbedƒia1eoenteKlaal.earkhmmod–stipartrtibhrpsstenhneiehqateylafaneerouoaahedrdcortuestiat‡gsdgsitcnasnoeshtorlimennhrwthlitorttcmalcrotoycuagohioeo–eennhoateeialoil fmtpiseepoltnsotib.nrfeelevaorhnkfd,‘aghngtlaen.dcenecsgriertnihˆiietlhiueecaeocdi haeernhaoeaaattlntfamatawlIssylodgƒeieesssrlhrtlliv,,.ti smvncecooeemtaaoptuplaraiilniwchcDobPfrmlononullolamnyatloomdndmuryeceaKuseeo,egtfnarrta,aotpuymcehaDueiprnndfcntlleisieorelo(rttcilostsoewmeesrhsPteorwtdhwerciiojemrKiaaooeeeonvttbm.i)vfhanchmDnllot,ecoInittiaaeaogpnMihamnenwtp,odrgtssatgpaendhe’whlmDstaeetattln.oetsiaelhnhAorhcIsntdDhnttelmudihoteLoiolgoeeeaoehoKprefrdismrvtipnomocnchcgoolplgpeeesatoovoeeinbeiiuamadllrrorllenrnciorgvnntsnolaueaeuvtisearfwentynanimgtersaaoa’lfhndgaeelsss,lli..oeomreetncrmesamocccleshoiwpebitwtspptmbsatnzehhuunasrelaoroiceadcieterrectttincahprihgghifesatopkDcgPbdqnheienouCehanrcaihlrioratlnseiotaKAuqeoaviysrniensaalmfsuoefghdoesellluL.sutnedie-rgemnkoeeikso.wdcWnKlefcsecoloaeooopl,TredhlofraafnrnaselohinaDuosnnttmcxtiesktei(livdfaethchddmsqidtqeAautaetatiheueriousiniiellisofaofeli,rnLccinuurfenprtetn(psevgvtoaelnkkFdssaKh,smtliclppctoitiiaetDtunngccheetalaiDhsnavouaAosoencoinsieeeAulrsetrcunLltytdaiietnpenoLklossdKyaaldpdgeeKnan1cnyoa6ssshirscll.boe)ctbefsoai,hsoouaTosnelsrsenfvnorroendsicecTsaDviiwllemcaltnmncfDoi)ttooecneoehbroA.daarri.tctrnrAaicgdDtpeirooalliLaevWanshsaalitdenLcrAmmszsaKuilelelcDpnoitoieKaiieegirLyPtszaeanzaaevetaccneiidoeKeKllheeollpcreroelcilaodastcfdaldin.dbrpriucluosdyesiotaloqysoaalnWscypriidnafrdtPspuooicnrtvoumoirnnesdsthKnaooiannkiDkroblrfustdesoloernlense,oithbeAu.tiratndheloatprtwesopiagholaLhwygasletaveabhimgealpiHhiKi,tclaltnnicliplyoloemieadthbyeiosenpukn,dhcaorurlieetsawllmoencsodoflalsotkk,tnnsoyirv,esntcoitepceedoetdepcfpr-hethosevapuorrodisamidoeesrlecnmeaacemlmhstrcsteirtrorhattsfrafiozttcchfalfeoeeoo,uopauu-ilhntoeaomoosetLdcsnccirnrrDlrdtairhrorrldt.gooAtoiqigwsmmialnniwAt.vhnTiumnnvoiuSafttneeefcieLuoeehebhmeuuuIoertIiaaaalirKKnnndddhllyyeeecssssr.llllll.

HISTORY TECHNIQUE

DALK has really come long way over the years2. Lamellar Deep anterior lamellar keratoplasty in patients with a full
keratoplasty was performed in the starting years of corneal thickness corneal pathology is technically a very challenging
transplant surgery, but lost favor to PK as it was technically •—”‰‹…ƒŽ ‘’–‹‘Ǥ ‘™‡˜‡”ǡ ™‹–Š ‘†‹ϐ‹…ƒ–‹‘• ‹ –Š‡ •—”‰‹…ƒŽ
‘”‡ †‹ˆϐ‹…—Ž– ƒ† ˜‹•—ƒŽ ‘—–…‘‡• ™‡”‡ —•ƒ–‹•ˆƒ…–‘”›Ǥ
‘•‡ technique and surgical expertise, this can still be achieved.
Barraquer and colleagues developed new techniques of lamellar
keratoplasty, dissecting the corneal stroma down to two-thirds Although recent techniques of DALK have been developed
of its thickness in both the donor and the recipient tissue in to remove the corneal stroma with ease and success, the basic
1950s3. However, the technique lost favor due to poor visual technique of layer-by-layer manual dissection is still useful in
outcomes pertaining to interface scarring and irregular surface. some cases such as pre-existing corneal perforation and strong
adhesion between stroma to DM as in deep stromal scarring.

www. dos-times.org 15

CORNEA

DISCUSSION

Various surgical techniques have

been developed to perform the corneal

stromal lamellar dissection. Adequate

removal of all or almost all of the corneal

stroma is deemed as necessary criteria for

a successful DALK. This can be achieved

by a layer-by- layer dissection, injection of

air, saline, or viscoelastic into the stromal

layers. The DALK bed is usually prepared

by performing a partial anterior stromal

trephination set at 7-8.5mm. Sugita and

Kondo10 describe a hydrodelamination

technique into the deep stromal to swell

–Š‡ •–”‘ƒŽ …‘ŽŽƒ‰‡ ϐ‹„”‡• –‘ ƒ‹† ‹ ˆ—”–Š‡”

delamination. Anwar achieved DM baring

by injecting air into the stromal bed to

produce a ‘big bubble’ to separate the DM

from the residual corneal stromal11. The

Figure 1: Corneal perforation with iris prolapse in chronic blepharokeratitis technique described here is traditional

layer by layer manual dissection that

Host corneal trephination cannot be done The graft should not be sutured is carried as deep as possible until the
in the presence of a corneal perforation. too tightly to the host as this could lead appearance of the smooth and glossy DM.
Lamellar dissection can be initiated to tissue distortion and gaping of the This makes the surgery technically more
manually with a diamond blade after recipient DM at the site of perforation, challenging. With an increase in residual
marking the desired recipient size. increasing the likelihood of post- stromal led thickness, there is also an
Pre-Descematic DALK can be done by operative double anterior chamber. increase in the likelihood of poorer visual
performing manual layer by layer deep Double continuous running suture outcome with irregularities and scarring
dissection using a lamellar crescent creates a more even distribution of at the interface. Good visual outcome can
blade, assisted by intra-operative tension compared to interrupted be achieved when DM is exposed at least
pachymetry. A marginal dissector is often sutures, reducing graft deformation and at the central visual axis (Figure 2).
helpful in carrying out delicate dissection. separation from recipient DM. Full air
Dissection may not be able to be fully DM- ϐ‹ŽŽ‡† ƒ‹” –ƒ’‘ƒ†‡ ‘ˆ ƒ– Ž‡ƒ•– ͺ ‹—–‡• This high incidence of DM perforation
baring in these cases since the Anwar Big should be performed prior to concluding is not unexpected given the nature of the
Bubble technique cannot be used and the the surgery7. Approximately half of the air cases that are selected. Though a double
†‹••‡…–‹‘ ’Žƒ‡ ƒ› „‡ †‹ˆϐ‹…—Ž– –‘ ƒ…Š‹‡˜‡ should be removed at the end of surgery. anterior chamber may be seen in the
in the presence of a deep scar. Lamellar The pupil should be dilated with topical initial post-operative phase, all eventually
dissection can continue at the unaffected mydriatics to prevent pupillary block resolves with no need for surgical
parts of the cornea and it is advisable glaucoma. Post-operatively, the patient intervention. Double anterior chamber
to work around the area of pathology. has to be instructed to maintain a ‘face up’ can potentially lead to graft oedema with
Dissection over the microperforation site posture without the use of any pillows. subsequent primary graft failure. Hence,
should be left to the end as this frequently if persistent after a few days, a secondary
In spite of being effective, this procedure with injection of intracameral
air may be necessary to drain the collected
leads to anterior chamber instability and procedure is technically challenging, aqueous humour from the interface.

collapse. Management of DM perforation time consuming, leaves a relatively ‘†‹ϐ‹…ƒ–‹‘• ‘ˆ •—”‰‹…ƒŽ –‡…Š‹“—‡ǡ ƒ•

depends on the location and size of the rough surface and has high rate of DM described earlier, is necessary to deal

perforation as well as the stage at which perforation, which is inevitable in some with these cases and the surgeon has to

it occurs. Adequate management may cases8. Comparable visual outcome can be competent in dealing with the high

avoid conversion to a PK. In the event be achieved in a pre-descematic and true risk of DM perforations. In the event of

of a DM perforation, the AC needs to be DM exposing DALK9. DM perforation, small amount of residual

quickly reformed and stabilized. This can

be achieved using intracameral injection

of air on a 30G needle, allowing the

surgeon to continue with the lamellar

dissection. This can be repeated as air is

often lost during the dissection, leading to

anterior chamber collapse. Alternatively,

a cohesive ophthalmic viscoelastic device

(OVD) may be injected to support the

anterior chamber. However, there is a risk

of entrapment of OVD between the DM

and the graft, which could lead to delayed Figure 2(a): Post-operative clinical picture of DALK at 1 week Figure 2(b): Post-operative clinical

absorption. picture of DALK at 4 months

16 DOS TIMES - SEPTEMBER-OCTOBER 2015

CORNEA

stromal may be left behind. Good visual posterior lamellar keratoplasty can still membrane in anterior lamellar
outcome can still be achieved if the be performed. keratoplasty. J Cataract Refract Surg.
pathological area is mostly excised and 2002;28:398-403.
the central visual axis is relatively clear CONCLUSION 6. Yahalom C, Mechoulam H, Solomon
and almost down to the DM. A, Raiskup FD, Peer J, Frucht-Pery J.
The surgical technique of DALK in Forty years of changing indications
Early post-operative DALK full thickness corneal pathologies and in penetrating keratoplasty in Israel.
complications include double anterior managing its complications involves Cornea. 2005;24:256–8.
chamber, pupillary block and persistent a steep learning curve. Although the 7. Luengo-Gimeno F, Tan DT, Mehta JS:
epithelial defects. Late complications decision to perform a DALK in the presence Evolution of deep anterior lamellar
include interface haze or irregularities, of a full thickness corneal pathology may keratoplasty (DALK). The ocular
infection or graft rejection. Some patients be controversial, a good visual outcome surface 2011;9:98-110.
may develop temporary rise of intra- can still be achieved in selected cases. 8. Tsubota K, Kaido M, Moden Y, Satake
ocular pressure. These were attributed to The technique largely eliminates the risk Y, Bissen-Miyajima H, Shimazaki J.
steroid response. With titration of their of endothelial rejection. Furthermore, by A new surgical technique for deep
steroid medications and use of short- avoiding entry into the anterior chamber, lamellar keratoplasty with single
term anti-glaucoma medications, most ‹– •‹‰‹ϐ‹…ƒ–Ž› ”‡†—…‡• –Š‡ ”‹• ‘ˆ running suture adjustment. Am J
of them could be resolved. The risk of intraocular complications as seen in full Ophthalmol. 1998;126:1-8.
post-PK glaucoma ranges from 10-53%12. thickness corneal graft. 9. Sarnicola V, Toro P, Gentile D,
DALK on the other hand is associated Hannush SB: Descemetic DALK and
with a lower risk of glaucoma due to the REFERENCES predescemetic DALK: outcomes in
decrease in the potency, frequency and 236 cases of keratoconus. Cornea
duration of steroid use post-operatively. 1. Watson SL, Ramsay A, Dart JK, 2010, 29:53-59.
Musa et al found a transient rise in IOP Bunce C, Craig E. Comparison of 10. Sugita J, Kondo J: Deep lamellar
due to steroid use in about 20.3% of deep lamellar keratoplasty and keratoplasty with complete removal
cases13. penetrating keratoplasty in patients of pathological stroma for vision
with keratoconus. Ophthalmology. improvement. The British journal of
In the presence of a full thickness 2004;111:1676–82. ophthalmology 1997;81:184-88.
corneal pathology, dissection down 11. Anwar M, Teichmann KD: Deep
–‘ ƒ› „‡ †‹ˆϐ‹…—Ž– ƒ† ‹–‡”ˆƒ…‡ 2. Luengo-Gimeno F, Tan DT, Mehta JS: lamellar keratoplasty: surgical
irregularities can affect visual outcome. Evolution of deep anterior lamellar techniques for anterior lamellar
In the presence of a full thickness corneal keratoplasty (DALK). The ocular keratoplasty with and without baring
pathology, corneal endothelium health surface 2011,9:98-110. of Descemet’s membrane. Cornea
may be compromised. However, in view 2002, 21:374-383.
‘ˆ –Š‡ „‡‡ϐ‹–• ‘ˆ ƒ ‘˜‡” ƒ ǡ ƒ 3. Barraquer JI: Lamellar keratoplasty. 12. Greenlee E, Kwon Y: Graft failure:
lamellar graft in eyes with relatively (Special techniques). Annals of III. Glaucoma escalation after
Š‡ƒŽ–Š› ‡†‘–Š‡Ž‹— …‘—Ž† †‡ϐ‹‹–‡Ž› ophthalmology 1972,4:437-469. penetrating keratoplasty. Int
be a better option. In the event of long- Ophthalmol 2008;28:191-207.
term endothelial failure, a secondary 4. Archila EA. Deep lamellar ͳ͵Ǥ —•ƒ ǡ ƒ–‹Ž ǡ ƒϐ‹“ ǡ
ƒŽŽ‘™ƒ›
keratoplasty dissection of host tissue P, Ball J, Morrell A: Long-term
with intrastromal air injection. risk of intraocular pressure
Cornea. 1984;5:217-218. elevation and glaucoma escalation
after deep anterior lamellar
5. Anwar M, Teichmann KD. Big- keratoplasty. Clinical & Experimental
bubble technique to bare Descemet’s Ophthalmology 2012;40:780-785.

Financial Interest: Š‡ ƒ—–Š‘” †‘‡• ‘– Šƒ˜‡ ƒ› ϔ‹ƒ…‹ƒŽ ‹–‡”‡•– ‹ ƒ› ’”‘…‡†—”‡Ȁ’”‘†—…– ‡–‹‘‡† ‹ –Š‹• ƒ—•…”‹’–Ǥ








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www. dos-times.org 17

OCULAR ONCOLOGY

INTRA-ARTERIAL CHEMOTHERAPY FOR
RETINOBLASTOMA

Mahesh Shanmugam, Rajesh Ramanjulu, Jayant Kadaskar

Intraarterial chemotherapy is the technique of supraselective ophthalmic artery
chemosurgery involving direct cannulation of ophthalmic artery and injecting the
chemotherapeutic agent in the proximal portal of ophthalmic artery. This can offer

excellent tumor control with minimum ophthalmic risk

Retinoblastoma is most common primary Shields et al independently studied IAC and found excellent
intraocular malignancy in childhood1,2. In past tumor control with minimum ophthalmic risk13. Various studies
few decades, treatment of retinoblastoma has have showed IAC can be used as primary or secondary treatment
evolved dramatically with emphasis on less modality in eyes with recurrent or residual retinoblastoma14-20.
invasiveness and morbid modality. Classical
treatment options available are enucleation, CHEMOTHERAPEUTIC AGENTS USED FOR IAC
systemic chemotherapy, external beam radiotherapy, and
focal therapies like thermotherapy, laser photocoagulation, Melphalan is the primary chemotherapeutic agent used in
cryotherapy, plaque radiotherapy3-8. With the higher dosage ‰‹˜‡ ‹–• ‡ˆϐ‹…ƒ…› ƒ† ‹–• •Š‘”– ŠƒŽˆǦŽ‹ˆ‡ ȋͳǤͷ Š‘—”•Ȍǡ ƒ‹‰
of chemotherapeutic agents and stem cell rescue treatment, it an ideal candidate for local injection15 (Table 1). Melphalan
clinicians aim at globe salvage even in advance stages of the can be used as monotherapy or in combination with Topotecan
tumor. As the intravenous therapy has its own limitations in cases of extensive retinoblastoma with extensive vitreous
with systemic complications and inability to regress large seeds. Carboplatin is reserved for bilateral cases to reduce
retinoblastoma and vitreous seeds, newer approaches to the cumulative dose of Melphalan, or for cases which are
treat eye with such lesions is a constant need. This led to the refractory to Melphalan or its combination with Topotecan21.
introduction of intrarterial route of chemotherapy (IAC) and The indications22 for IAC are given in (Table 2).
has assumed major role in management of retinoblastoma
owing to its colossal success. IAC is targeted therapy of TECHNIQUE
delivering chemotherapeutic agent directly in ophthalmic
artery and thereby maximizing its ocular therapeutic effect with The procedure is performed under general anesthesia
minimization of the systemic absorption and complications under sterile conditions. Anticoagulation with intravenous
(Figure 1-3). infusion of heparin is delivered to target the clotting time
of 2 to 3 times of baseline. Through trans femoral approach
HISTORY ipsilateral internal carotid artery is catheterized. Visualization

In 1958, Reese used trimethyl melamine intra arterially, Table 1: Drugs used in IAC
delivering drug by direct puncture in internal carotid artery.
It was then termed as intra-arterial chemotherapy (IAC)9. Drug Class Dose
Subsequently in 1986, Japanese physicians, led by Kaneko Melphalan
and Mori, began catheterizing the internal carotid artery from Topotecan Alkylating agent 2.5/5/7.5 mg
femoral access. They occluded the internal carotid artery with Carboplatin
tiny balloon above the exit of the ophthalmic artery, before Topoisomerase inhibitor 0.3-0.6 mg
injecting the chemotherapeutic drug into the (temporarily)
occluded internal carotid artery. This prevented the drugs from Alkylating agent 25-50 mg
entering into the central nervous system and also achieving
high therapeutic concentration in the eye. They called this Table 2: Indications for IAC
ƒ’’”‘ƒ…Š Dz•‡Ž‡…–‹˜‡ ‘’Š–ŠƒŽ‹… ƒ”–‡”› …Š‡‘–Š‡”ƒ’›dz10. Non germline mutations
Age greater than 4 months
Š‹• –‡…Š‹“—‡ Šƒ• „‡‡ Žƒ–‡” ”‡ϐ‹‡† „› „”ƒ•‘ Unilateral retinoblastoma
as supraselective ophthalmic artery chemosurgery involving Recurrent retinoblastoma following previous intravenous
direct cannulation of ophthalmic artery and injecting drug in chemotherapy and plaque therapy
proximal portal of ophthalmic artery. With this technique he Recurrent sub retinal seeds involving two or more quadrants
has successfully treated children with retinoblastoma both of Recurrent vitreous seeds
advanced forms and with initial presentation11,12.

www. dos-times.org 19

OCULAR ONCOLOGY

Figure 1: CT scans showing the catherization and the injection Melphalan passing through the concentration as achieved by intravenous
ophthalmic artery. chemotherapy.

of arterial anatomy is done with serial and in tumors after chemoreduction. Various studies (Table 3) have shown
angiography runs. Ostium of ophthalmic Enucleation is reserved for eyes in ‡ˆϐ‹…ƒ…› ‘ˆ ™Š‡ —•‡† ƒ• ’”‹ƒ”› ‘”
ƒ”–‡”› ‹• ‹†‡–‹ϐ‹‡† ƒ† •—’”ƒ•‡Ž‡…–‹˜‡Ž› advanced retinoblastomas, but is not secondary treatment. Gobin et al studied
catherized. A supraselective injection applicable as the primary treatment 95 eyes with supraselective IAC, 82%
through microcatheter is performed to modality in children with bilateral globe salvage when used as primary
…Š‡… ’‘•‹–‹‘‹‰ ƒ† ”‡ϐŽ—š ‹ˆ ƒ› „‡ˆ‘”‡ tumors as it leads to permanent loss treatment and 58% globe salvage when
chemotherapy agents are injected12,21. of vision. External-beam radiotherapy used as secondary treatment15. Shields
is considered a last-resort option et al. reported their experience in
Alternatively chemotherapy delivery because of its devastating local and 70 consecutive patients treated with
through a catheter placed in internal systemic consequences, including supraselective IAC, with 72% globe
carotid artery at take-off of ophthalmic cataract formation, ocular dryness, facial salvage when used as primary treatment
artery with balloon occlusion of distal dysmorphism, and secondary cancers23. and 62% globe salvage when used as
ϐŽ‘™ …ƒ ƒŽ•‘ „‡ ’‡”ˆ‘”‡†10. Intravenous chemotherapy, which forms secondary treatment17.
the primary modality of treatment in
ADVANTAGES OF INTRA-ARTERIAL more than 80% of children is particularly Suzuki et al reported globe salvage
CHEMOTHERAPY futile in saving eyes with advance disease. in 100% group A, 88% group B, 65%
group C, 45% group D, and 30% group
Focal therapies have limited role IAC delivers drugs directly to the E eyes. Visual acuity of 20/40 or better
in treatment of advanced or extensive tumor bed with minimal systemic was achieved in 51% eyes. Shields et al
retinoblastoma, and thereby are reserved toxicity. Also achieves nearly 10 times the reported globe salvage was achieved in
for smaller or less extensive disease 100% group B, 100% group C, 94% group
D, and 36% group E eyes (Table 4)14,17.
Table 3: Globe salvage with IAC
In advanced disease particularly
Globe salvage Primary Treatment Secondary Treatment Group E, results of IAC are relatively
poor, and should be used with caution
Gobin et al ( n=95 eyes) 82% 58% since higher prevalence of High risk RB
necessitating enucleation and systemic
Shields et al (n=70 eyes) 72% 62% chemotherapy24,25.

Table 4: Success of IAC in various groups of Retinoblastoma In cases of RD associated with
retinoblastoma, IAC have better
Retinoblastoma Suzuki et al (n=408) Shields et al (n=70) prognosis. Shields et al have reported in a
study of 15 patients with RB-induced RD,
Group A 100% -- resolution of RD was noted in 43% cases
with complete RD and 100% cases with
Group B 88% 100% partial RD26.

Group C 65% 100% Major advantages of IAC are globe
salvage, minimal systemic side effects,
Group D 45% 94% resolution of retinal detachment and
maximal control of intraocular tumor.
Group E 30% 36%
COMPLICATIONS OF IAC

Though impressive tumor response
and high rate of globe salvage have been
reported with IAC, it is not short of
complications. Complications of IAC27-
32 (Table 5) can be secondary to drug
toxicity or mechanical damage due to
technique itself.

Complication of IAC can be ocular
and systemic.

Vitreo-retina & Ocular Oncology Services, Sankara Eye Hospital, Bangalore, Karnataka, India

Dr. Mahesh Shanmugam MS Dr. Rajesh Ramanjulu MD Dr. Jayant Kadaskar DNB

20 DOS TIMES - SEPTEMBER-OCTOBER 2015

OCULAR ONCOLOGY

Table 5: Local complications / Figure 2: Pre and post IAC treatment fundus images. This child had a recurrence in the region of
ocular complications chorio-retinal atrophy and was not amenable for any local or systemic therapy. IAC was planned
and delivered. The tumor regression can be well noted.
Cranial nerve palsy
Periorbital edema
Madorosis
Vitreous hemorrhage

Retinal detachment
Retinal ischemia
Retinal pigment epithelium changes
Chorioretinal atrophy
Ophthalmic artery occlusion

Meun et al studied 15 eyes treated Figure 3: Loss of vision and excessive RPE atrophy following IAC possibly secondary to ophthalmic
with IAC, with mean follow up of 8.7 artery occlusion.
months, with tumor control in 80% eyes.
They have reported ocular side effects Table 6: Systemic Complications LIMITATIONS OF IAC
that included third nerve palsy (40%),
orbital edema (20%), permanent retinal Hematoma at groin site Compared to intravenous
detachment (7%), vitreous hemorrhage chemotherapy (chemoreduction) IAC
(27%) and retinal pigment epithelium Transient pancytopenia from bone has got better success rate for advanced
changes (47%). marrow suppression tumors (Table 7).

Eagle et al reported in retrospective Carotid vascular spasm Vitreous and subretinal seeds
analysis of eight eyes treated with IAC Stroke recurrence has been reported with IAC. In
subsequently requiring enucleation, a series, 9% of tumors had recurrence of
found histopathologic evidence of Focal perfusion defects on Magnetic subretinal seeding and 11% had vitreous
ischemic atrophy involving outer Resonance Imaging seeding. This constituted the major cause
retina and choroid in four eyes, while of enucleation29.
intravascular birefringent foreign
ƒ–‡”‹ƒŽ ™ƒ• ‘„•‡”˜‡† ‹ ϐ‹˜‡ …ƒ•‡• Table 7: Summarising the differences between IVC and IAC
with occluded vessels stimulating
‰”ƒ—Ž‘ƒ–‘—• ‹ϐŽƒƒ–‘”› ”‡•’‘•‡33. Intrarterial chemotherapy Intravenous chemotherapy
—‹‡” ‡– ƒŽ ƒŽ•‘ ”‡’‘”–‡† •‹‹Žƒ” ϐ‹†‹‰•
of choroidal occlusive vasculopathy local complications Systemic complications
leading to chorioretinal atrophy in 2 of Potential for loss of vision No risk for loss of vision
13 eyes studied with additional arterial Prevents new tumor in treated eye Prevents new tumor in both the eyes
emboli in one eye34. ‘ „‡‡ϐ‹– ‹ ‹‡ƒŽ‘„Žƒ•–‘ƒ Reduces risk of Pinealoblastoma
Second malignant neoplasm Second malignant neoplasm
Steine et al reported that IAC
triggers vascular toxicity through
endothelial cell damage. They have
attributed these changes in retinal and
choroidal vasculature to pH of drug,
mechanical damage and particulate size
of chemotherapeutic drug35.

Systemic complication (Table 6)
from IAC though rare, is noted and
includes hematoma at groin site. This
may be related to the technique itself.
Others include transient pancytopenia
due to bone marrow suppression,
anemia and neutropenia rarely requiring
intervention. Secondary complications
related to brain hypoperfusion have been
rarely reported, due to carotid vascular
spasm and has led to stroke or focal
neurological defects. Magnetic resonance
imaging in these cases has displayed focal
perfusion defects.

www. dos-times.org 21

OCULAR ONCOLOGY

IAC offers no protection 12. Abramson DH, et al. A phase I/II study of external beam irradiation in children
direct intraarterial (ophthalmic artery) with retinoblastoma. Ophthalmology
against systemic metastatic disease, chemotherapy with melphalan for 1996;103: 263-68.
intraocular retinoblastoma initial results. 24. Wilson MW, Qaddoumi I, Billups C,
pinealoblastoma and secondary Ophthalmology 2008;115:1398–1404. Haik BG, Rodriguez-Galindo C. A
clinicopathological correlation of 67
malignant neoplasm. Since it’s targeted 13. Shields CL, Bianciotto CG, Jabbour P, eyes primarily enucleated for advanced
ƒƒ•—„”ƒƒ‹ƒ ǡ ƒŽŽ› ǡ
”‹ˆϐ‹ intraocular retinoblastoma. Br J
dose have minimal systemic absorption, GC, et al. Intra-arterial chemotherapy Ophthalmol. 2011;95:553–8.
for retinoblastoma: Report No 1, control 25. Kaliki S, Shields CL, Rojanaporn D, Al-
so is its inability to control extraocular of retinal tumors, subretinal seeds, Dahmash S, McLaughlin JP, Shields
and vitreous seeds. Arch Ophthalmol. JA, et al. High-risk retinoblastoma
tumor cells. 2011;129:1399–406 „ƒ•‡† ‘ ‹–‡”ƒ–‹‘ƒŽ …Žƒ••‹ϐ‹…ƒ–‹‘
of retinoblastoma: Analysis of 519
CONCLUSION 14. Suzuki S, Yamane T, Mohri M, Kaneko A. enucleated eyes. Ophthalmology.
Selective ophthalmic arterial injection 2013;120:997–1003.
IAC has evolved as a technique to therapy for intraocular retinoblastoma: 26. Shields CL, Kaliki S, Shah SU,
The long-term prognosis. Ophthalmology. Bianciotto CG, Jabbour P, Shields JA.
treat and salvage eyes with group C and 2011;118:2081–7. Effect of intraarterial chemotherapy
on retinoblastoma-induced retinal
D retinoblastoma with higher cure rate. 15. Gobin YP, Dunkel IJ, Marr BP, Brodie detachment. Retina.2012;32:799–804.
SE, Abramson DH. Intra-arterial 27. Muen WJ, Kingston JE, Robertson F, Brew
This is balanced to a minor degree by the chemotherapy for the management of ǡ ƒ‰‘‘ ǡ ‡††› Ǥ ˆϐ‹…ƒ…› ƒ†
retinoblastoma: Four-year experience. complications of super-selective intra-
ocular and systemic side effects. Arch Ophthalmol. 2011;129:732–7. ophthalmic artery melphalan for the
treatment of refractory retinoblastoma.
REFERENCES 16. Peterson EC, Elhammady MS, Quintero- Ophthalmology. 2012;119:611–6.
Wolfe S, Murray TG, Aziz-Sultan MA. 28. Vajzovic LM, Murray TG, Aziz-Sultan
1. Shields CL, Kaliki S, Rojanaporn D, Selective ophthalmic artery infusion of ǡ …Š‡ϐŽ‡” ǡ ‘Žˆ‡ ǡ ‡•• ǡ
et al. Intravenous and intra-arterial chemotherapy for advanced intraocular et al. Supraselective intra-arterial
chemotherapy for retinoblastoma: What retinoblastoma: Initial experience with chemotherapy: Evaluation of treatment-
have we learned? Curr Opin Ophthalmol 17 tumors. J Neurosurg. 2011;114:1603– related complications in advanced
2012;23:202–09. 8. retinoblastoma. Clin Ophthalmol.
2011;5:171–6.
2. The Committee for the National Registry 17. Shields CL, Manjandavida FP, Pieretti 29. Shields CL, Bianciotto CG, Jabbour
of Retinoblastoma. Survival rate and risk G, Arepalli SA, Jabbour P, Shields ǡ
”‹ˆϐ‹
ǡ ƒƒ•—„”ƒƒ‹ƒ ǡ
factors for patients with retinoblastoma JA. Intra-arterial chemotherapy for Rosenwasser R, et al. Intra-arterial
in Japan. Jpn J Ophthalmol 1992;36:121– retinoblastoma: Use as primary chemotherapy for retinoblastoma:
31. or secondary therapy in 70 eyes. Report No 2, treatment complications.
Ophthalmology. 2014;121:1453–60. Arch Ophthalmol. 2011;129:1407–15.
3. Schiedler V, Dubovy SR, Murray TG. 30. Venturi C, Bracco S, Cerase A, Cioni S,
Snare technique for enucleation of eyes 18. Munier FL, Beck-Popovic M, Balmer Galluzzi P, Gennari P, et al. Superselective
with advanced retinoblastoma. Arch A, Gaillard MC, Bovey E, Binaghi S. ophthalmic artery infusion of melphalan
Ophthalmol. 2007;125:680–3. Occurrence of sectoral choroidal occlusive for intraocular retinoblastoma:
vasculopathy and retinal arteriolar Preliminary results from 140 treatments.
4. Chan MP, Hungerford JL, Kingston embolization after superselective Acta Ophthalmol. 2013;91:335–42.
JE, Plowman PN. Salvage external ophthalmic artery chemotherapy for 31. Bianciotto C, Shields CL, Iturralde JC,
beam radiotherapy after failed advanced intraocular retinoblastoma. Sarici A, Jabbour P, Shields JA. Fluorescein
primary chemotherapy for bilateral Retina. 2011;31:566–73. ƒ‰‹‘‰”ƒ’Š‹… ϐ‹†‹‰• ƒˆ–‡” ‹–”ƒǦƒ”–‡”‹ƒŽ
retinoblastoma: rate of eye and chemotherapy for retinoblastoma.
vision preservation. Br J Ophthalmol. 19. Shields CL, Kaliki S, Al-Dahmash S, Ophthalmology. 2012;119:843–9.
2009;93:891–4. ‘Œƒƒ’‘” ǡ ‡ƒŠ‡› ǡ
”‹ˆϐ‹
ǡ ‡– ƒŽǤ 32. Francis JH, Abramson DH, Gobin YP,
Management of advanced retinoblastoma Marr BP, Dunkel IJ, Riedel ER, et al.
5. Augsburger JJ, Faulkner CB. Indirect with intravenous chemotherapy Electroretinogram monitoring of dose-
ophthalmoscope argon laser treatment then intra-arterial chemotherapy as dependent toxicity after ophthalmic
of retinoblastoma. Ophthalmic Surg. alternative to enucleation. Retina. artery chemosurgery in retinoblastoma
1992;23:591–3. 2013;33:2103–9. eyes: Six year review. PLoS One.
2014;9:e84247.
6. Shields JA, Shields CL. Treatment of 20. Francis JH, Gobin YP, Dunkel IJ, 33. Eagle Jr RC, et al. Histopathologic
retinoblastoma with cryotherapy. Marr BP, Brodie SE, Jonna G, et observations after intraarterial
Trans Pa Acad Ophthalmol Otolaryngol. al. Carboplatin +/-topotecan chemotherapy for retinoblastoma. Arch
1990;42:977–80. ophthalmic artery chemosurgery for Ophthalmol 2011;129:1416–21.
intraocular retinoblastoma. PLoS One. 34. Munier FL, et al. Occurrence of sectoral
7. Shields CL, Shields JA, Cater J, 2013;8:e72441. choroidal occlusive vasculopathy and
Othmane I, Singh AD, Micaily B. Plaque retinal arteriolar embolization after
radiotherapy for retinoblastoma: long- 21. Shields CL, Bianciotto CG, Jabbour P, superselective ophthalmic artery
term tumor control and treatment ƒƒ•—„”ƒƒ‹ƒ ǡ ƒŽŽ› ǡ
”‹ˆϐ‹ chemotherapy foradvanced intraocular
complications in 208 tumors. GC, et al: Intra-arterial chemotherapy retinoblastoma. Retina 2011;31: 566–73.
Ophthalmology.2001;108:2116–21. for retinoblastoma: report No. 1, control 35. Steinle JJ, et al. Intra-ophthalmic artery
of retinal tumors, subretinal seeds, chemotherapy triggers vascular toxicity
8. Chan HS, Gallie BL, Munier FL, and vitreous seeds. Arch Ophthalmol –Š”‘—‰Š ‡†‘–Š‡Ž‹ƒŽ …‡ŽŽ ‹ϐŽƒƒ–‹‘
Beck Popovic M. Chemotherapy for 2011;129:1399– 1406. and leukostasis. Invest Ophthalmol Vis
retinoblastoma. Ophthalmol Clin North
Am. 2005;18:55–63. 22. Shields CL, Lally SE, Leahey AM, Jabbour Sci 2012; 53:2439–45.
PM, Caywood EH, Schwendeman R,
9. Reese AB, Hyman GA, Tapley ND, Forrest Shields JA. Targeted retinoblastoma
AW. The treatment of retinoblastoma by management: when to use intravenous,
x-ray and triethylene melamine. AMA intra-arterial, periocular, and intravitreal
Arch Ophthalmol. 1958;60:897–906. chemotherapy. Curr Opin Ophthalmol.
2014;25:374-85.
10. Yamane T, Kaneko A, Mohri M. The
technique of ophthalmic arterial infusion 23. Imhof SM, Mourits MP, Hofman P,
therapy for patients with intraocular Zonneveld FW, Schip- per J, Moll AC, et al:
retinoblastoma. Int J Clin Oncol. —ƒ–‹ϐ‹…ƒ–‹‘ ‘ˆ ‘”„‹–ƒŽ ƒ† ‹†Ǧˆƒ…‹ƒŽ
2004;9:69–73. growth retardation after megavoltage

11. Abramson DH. Super selective ophthalmic
artery delivery of chemotherapy
for intraocular retinoblastoma:
ǮǮ Š‡‘•—”‰‡”›ǡǯǯ –Š‡ ϐ‹”•– –ƒŽŽƒ”† Ž‡…–—”‡Ǥ
Br J Ophthalmol 2010;94:396–99.

Financial Interest: Š‡ ƒ—–Š‘”• †‘ ‘– Šƒ˜‡ ƒ› ϔ‹ƒ…‹ƒŽ ‹–‡”‡•– ‹ ƒ› ’”‘…‡†—”‡Ȁ’”‘†—…– ‡–‹‘‡† ‹ –Š‹• ƒ—•…”‹’–Ǥ

22 DOS TIMES - SEPTEMBER-OCTOBER 2015

OCULOPLASTY

CYANOACRYLATE ADHESIVE AS SCLEROSANT IN ARTERIO-
VENOUS MALFORMATION OF THE EYELID

Raj Anand

Dr. Raj Anand MS to the anterior lamina of the lid. Underlying tarsal plate and
Consultant, Oculoplasty Services conjunctival tissues were unremarkable. Examination of the
Eye 7 Chaudhary Eye Centre, eye was within normal limits except for this lesion.
New Delhi, India
Based on this examination he was diagnosed to have a
This article highlights the use of liquid •—’‡”ϐ‹…‹ƒŽ ”–‡”‹‘Ǧ ‡‘—• ƒŽˆ‘”ƒ–‹‘ ȋ Ȍ ‘ˆ –Š‡ —’’‡”
cyanoacrylic adhesive (which is familiar to us eyelid right eye. He was advised excision biopsy of the lesion
as tissue adhesive for corneal perforations) for
management of arterio- venous malformations. Figure 1: Showing upper lid arterio-venous malformation (AVM)
The technique of injection, advantages and scope
of use of this adhesive is discussed Figure 2: Showing increase in the size of lesion in two weeks’ time
Arterio-venous malformation (AVM) is a rather uncommon under local anaesthesia. When he presented to us 2 weeks later
vascular malformation of the eyelids1. AVM consist of an artery for surgery the lesion had grown bigger to 5x4x4 mm in size
and a vein without a interposed capillary bed system- instead (Figure 2).
there is a tangled mass of abnormal vessels – called the ‘Nidus’-
communicating the artery and vein. Currently complete SURGICAL TECHNIQUE
surgical removal of the AVM including the Nidus remains the ‘…ƒŽ ‹ϐ‹Ž–”ƒ–‹‘ ™‹–Š ʹΨ š›Ž‘…‹ƒ‡ ™‹–Š ƒ†”‡ƒŽ‹ ȋͳ
most successful treatment modality2,3. Complete removal of the
Ž‡•‹‘ ’‘•‡• –Š”‡‡ …ŠƒŽŽ‡‰‡•Ǧ ϐ‹”•–ǡ ‘™‹‰ –‘ ˜ƒ•…—Žƒ” ƒ–—”‡ in 1,00,000) was done surrounding the area of AVM. 0.2cc
this lesion tends to bleed a lot, second lesion collapses as soon Cyanoacrylate glue was loaded in a 1 cc syringe with 26 G
as incision is made in the lesion and third there may not be
distinct margin between pathological and normal tissue. Owing
–‘ –Š‡•‡ ˆƒ…–‘”• …‘’Ž‡–‡ ”‡‘˜ƒŽ ‘ˆ –Š‡ Ž‡•‹‘ ‹• †‹ˆϐ‹…—Ž–Ǥ •‡
of cyanoacrylate glue (used as a sclerosant)- that we routinely
use to seal corneal perforations- may help all three issues and
allow complete successful removal of the lesion.

A case of AVM of the upper eyelid highlights this
unique role of cyanoacrylate glue in treating arterio-venous
malformation. A thirteen year old child presented with a
reddish, soft compressible lesion in the right upper lid that
was noticed 6 months back as a small pin pint lesion and has
been steadily increasing in size since then (Figure 1). The lesion
was soft in consistency, non-tender and there was no history of
bleed from the lesion. It was measuring 3x3x2 mm in size. On
closure examination dilated feeder and draining vessels were
‘–‡† —†‡” –Š‡ •‹Ǥ Š‡ Ž‡•‹‘ ™ƒ• ™‡ŽŽ †‡ϐ‹‡† ƒ† …‘ϐ‹‡†

Arterio-venous malformation (AVM)
is a rather uncommon vascular
malformation of the eyelids. AVM

consist of an artery and a vein without
a interposed capillary bed system-
instead there is a tangled mass of

abnormal vessels – called the ‘Nidus’-
communicating the artery and vein

www. dos-times.org 23

OCULOPLASTY

Figure 3: Showing raw area after excision of the AVM Figure 4: Showing lesion healed with secondary intension

Figure 5: Showing upper lid AVM (Image Courtesy Dr. Raman Mittal) Figure 6: Showing post excision (Image Courtesy Dr. Raman Mittal)

needle and the glue was injected management is a combined

directly in the lesion in a single approach of pre-operative

gentle push. The lesion soon selective angiography with

‰‘– •‘Ž‹†‹ϐ‹‡† ™‹–Š‹ …‘—’Ž‡ ‘ˆ embolization followed by

seconds and the margins of lesion resection of Nidus4-6. failure

became very well delineated to remove nidus completely

from the normal tissue. Infact results in recurrence of the

the size of area demarcated AVM. As the lesion was quite

after glue injection was slightly •—’‡”ϐ‹…‹ƒŽ ƒ† –Š‡”‡ ™ƒ• ‘

larger than the area of clinically apparent deeper connection,

visible. The lesion lesion was angiography was not

held with a tooth forcep and warranted in our case however

pulled away from posterior in case of bigger lesions like

lamina to create a plane between shown in Figures (5-7) it may

lesion and normal tissue. The be a good idea to know the

lesion was excised along this feeder and draining vessels.

plane with minimal bleeding. Figure 7: Showing Large AVM of the eyelid (image courtesy CT or MR angiography may
The raw area underneath the Dr. Sima Das) help delineate the feeder and
lesion looked bigger than the draining vessels and thereby

clinically apparent lesion (Figure DISCUSSION avoiding the lesions with
3) thereby emphasizing the role of glue intracranial extensions.
in complete excision of the lesion. The AVM has tendency to grow in size as
raw area being small was left to heal by they recruit more feeder blood vessels This agent’s low viscosity, rapid
secondary intention (Figure 4). with time and it may also become painful polymerization, and minimal tissue
due to thrombosis or haemorrhage. It was toxicity, as well as the ability to make the
The child was followed subsequently evident in our case too, who was seen 2 agent radiopaque without impairing its
on day 1,7 and 30. The wound healed very ™‡‡• ƒˆ–‡” –Š‡ ϐ‹”•– ˜‹•‹– ™‹–Š •‹‰‹ϐ‹…ƒ– occlusive properties, have made acrylic
well with minimal scarring. increase in size. The best method of adhesives our agent of choice in treating
–Š‡•‡ †‹ˆϐ‹…—Ž– Ž‡•‹‘•7.

REFERENCES 5. Goldberg RA, Garcia GH, Duckwiler GR. Combined
embolization and surgical treatment of arterio venous
1. Wright JE Orbital vascular anomalies. Trans Am Acad malformation of oorbit. Am J Ophthalmol 1993;116:17-25.
Ophthalmol Otolaryngo 1974; l78:606–16.
6. Hayes BH, Shore JW, Westfall CT et al. Management of orbital
2. Flanagan JC Vascular problems of the orbit. Ophthalmology and periorbital arterio venous malformation. Ophthalmic
1979; 86:896–913. surg 1995; 26:145-52.

͵Ǥ —•‹ ǡ
”ƒ‡ˆ‡ ǡ ‘…Š
”–‡”‹‘˜‡‘—• ϐ‹•–—Žƒ ’”‡•‡–‹‰ ƒ• ƒ 7. Rosen RJ, Contractor S. The use of cyanoacrylate adhesives in
tumor of the upper eyelid. Ophthalmic Surg 1994; 25:471-73. the management of congenital vascular malformations. Semin
Intervent Radiol. 2004;21:59-66.
4. Rootman J, Kao SC, Graeb DA. Multidisciplinary approaches
to complicated vascular lesions of the orbit. Ophthalmology
1992;99: 1440-6.

Financial Interest: Š‡ ƒ—–Š‘” †‘‡• ‘– Šƒ˜‡ ƒ› ϔ‹ƒ…‹ƒŽ ‹–‡”‡•– ‹ ƒ› ’”‘…‡†—”‡Ȁ’”‘†—…– ‡–‹‘‡† ‹ –Š‹• ƒ—•…”‹’–Ǥ

24 DOS TIMES - SEPTEMBER-OCTOBER 2015

RETINA

CORTICOSTEROID USE IN THE MANAGEMENT OF
DIABETIC MACULAR EDEMA

Kanhaiya Mittal, Shreyas Temkar, Rohan Chawla, Koushik Tripathy, Yog Raj Sharma,
Pradeep Venkatesh, Raj Pal Vohra

‘”–‹…‘•–‡”‘‹†• Šƒ˜‡ ƒ–‹Ǧ‹ϐŽƒƒ–‘”›ǡ ƒ–‹ƒ‰‹‘‰‡‹…ǡ ƒ† ƒ–‹’‡”‡ƒ„‹Ž‹–›

properties. Because of their multi-factorial pharmacologic effect, corticosteroids are

currently the optimal therapeutic option when resolution of macular edema cannot

be achieved with anti-VEGF treatment

Diabetic macular edema (DME) is the commonest strengthening tight junctions to limit permeability and leakage
cause of visual loss in patients with non that causes macular edema. They also increase the production of
proliferative diabetic retinopathy and a common annexin-1, inhibit phospholipase A2, and inhibit transcription
cause of visual loss in proliferative diabetic of genes for cyclooxygenase which in turn reduces production
retinopathy. Approximately 29% of all patients of interleukins and prostaglandins. Because of their multi-
with diabetes of more than 20 years duration factorial pharmacologic effect, corticosteroids are currently the
are at risk of macular edema. The Wisconsin Epidemiologic optimal therapeutic option when resolution of macular edema
Study of Diabetic Retinopathy (WESDR) revealed that the 10- cannot be achieved with anti-VEGF treatment.
year rate of developing diabetic macular edema in the United
States was 20.1 percent among type I diabetics, 25.4 percent ROUTES OF DELIVERY OF STEROIDS IN THE
among type II diabetics using insulin, and 13.9 percent for type TREATMENT OF DME
II diabetics not using insulin1. According to Early Treatment
Diabetic Retinopathy Study (ETDRS), early detection and laser i. Periocular injection
–”‡ƒ–‡– ‘ˆ …Ž‹‹…ƒŽŽ› •‹‰‹ϐ‹…ƒ– †‹ƒ„‡–‹… ƒ…—Žƒ” ‡†‡ƒ ii. Intravitreal injection
(CSDME) decreases the risk of moderate visual loss by 50%2. iii. Intravitreal sustained release devices
Though laser has been the standard of care till recently, many iv. Suprachoroidal drug delivery (investigational)
new treatment modalities are available now for the management
of DME. The emergence of anti- vascular endothelial growth AGENTS USED IN THE MANAGEMENT OF DME
factor (anti-VEGF) is a milestone in the management of DME.
These agents have shown to provide visual acuity gain in The agents used in management of diabetic macular
patients with DME which is in contrast to focal/grid laser edema (Table 1) are:
photocoagulation which provide only stabilization of vision. a) Triamcinolone acetonide
Recently, expanding arrays of corticosteroid formulations and b) Dexamethasone
delivery systems have also been evaluated in clinical trials for c) Fluocinolone acetonide
the management of DME.
Triamcinolone Acetonide
PHARMACOTHERAPY WITH CORTICOSTEROIDS
Triamcinolone acetonide (TA) is a medium potency
DME has multifactorial etiology which includes increased steroid (5 times more potent than hydrocortisone). Only two
production of VEGF and release of vasoactive mediators like preservative free formulations of TA {Triesence® (Alcon, Fort
histamine, interleukins, endothelin, angiotensin II, basic Worth, TX) and Trivaris® (Allergan, Irvine, CA)} are approved
ϐ‹„”‘„Žƒ•– ‰”‘™–Š ˆƒ…–‘” ȋ„Ǧ
Ȍǡ ƒ† ’Žƒ–‡Ž‡– †‡”‹˜‡† ‰”‘™–Š by Food and Drug Administration (FDA), USA for intraocular
factor (PDGF). This causes breakdown of blood retinal barrier use. Generic preservative free formulations of triamcinolone
with increased vascular permeability and leakage leading to are available in India. Kenalog® (Bristol-Myers Squibb,
Š›’‘š‹ƒ ƒ† ‹ϐŽƒƒ–‹‘3. Princeton, NJ) on the other hand contains preservative (benzyl
alcohol) and is approved for intra-articular use in arthritis
‘”–‹…‘•–‡”‘‹†• Šƒ˜‡ ƒ–‹Ǧ‹ϐŽƒƒ–‘”›ǡ ƒ–‹ƒ‰‹‘‰‡‹…ǡ and intramuscular use for ocular conditions. The approved
and antipermeability properties. They inhibit macrophages ocular indications for intravitreal Triesence or Trivaris,
that release angiogenic growth factors and down-regulate and intramuscular Kenalog are sympathetic ophthalmia,
Intercellular Adhesion Molecule 1 (ICAM-1), which mediates –‡’‘”ƒŽ ƒ”–‡”‹–‹•ǡ —˜‡‹–‹• ƒ† ‘…—Žƒ” ‹ϐŽƒƒ–‘”› …‘†‹–‹‘•
leukocyte adhesion and transmigration. In addition, unresponsive to topical steroids. Triesence is also approved
corticosteroids alter the composition of endothelial basal for visualization of the vitreous during vitrectomy. As of
membrane by changing the local ratio of two laminin now intravitreal use of TA for DME is off label. The effect of
isoforms, suppressing basement membrane dissolution and intravitreal TA lasts till 3-4 months.

www. dos-times.org 25

RETINA

Table 1: Summary of the sustained release implants currently used in the in the ranibizumab + deferred laser
management of DME group; and 1.5 letters worse in the TA +
prompt laser group. When analysis was
Retisert Illuvien Ozurdex …‘ϐ‹‡† –‘ –Š‡ ’•‡—†‘’Šƒ‹… ‰”‘—’
of patients, TA showed similar visual
Active ingredient Fluocinolone Fluocinolone Dexamethasone acuity results to ranibizumab, indicating
Acetonide Acetonide that decreased acuity could be at least
in part attributed to cataract formation.
Company Bausch & Lomb, Alimera Sciences, Allergan, Inc, Irvine, At the two-year visit, the percentages
Rochester, NY Inc, Alpharetta, CA ‘ˆ ‡›‡• ™‹–Š …‡–”ƒŽ •—„ϐ‹‡Ž† –Š‹…‡••
Georgia ηʹͷͲ Ɋ ™‡”‡ ͷͻ ’‡”…‡– ‹ –Š‡ •Šƒ
+ prompt laser group; 43 percent in the
Type of device Implantable, non- Injectable (25g) Injectable (22g) ranibizumab + prompt laser group; 42
percent in the ranibizumab + deferred
biodegradable non- biodegradable biodegradable laser group; and 52 percent in the TA +
prompt laser group7. These results show
Total dose 0.59mg 0.19mg 0.7mg the potential of TA to serve as a less
expensive, but comparable therapy to
Delivery rate 0.3-0.4 μg/day 0.2/0.5 μg/day anti-VEGF injections.

Duration of 30 months 36/18 months 6 months The complications of intravitreal
action triamcinolone can be divided into steroid-
related and injection-related adverse
Other Silicone elastomer Silicone elastomer Poly (D,L- lactide- effects. Most common steroid-related
composition cup with polyvinyl cup with polyvinyl coglycolide) side effects include cataract formation
alcohol alcohol and an elevation in intraocular pressure
(IOP). Injection-related side effects
FDA approval Chronic non- DME Chronic non- include retinal detachment, vitreous
status infectious infectious posterior hemorrhage, bacterial endophthalmitis,
posterior uveitis uveitis, retinal vein non-infectious endophthalmitis, and
occlusion and DME pseudo-endophthalmitis caused due to
steroid particulates. Secondary ocular
Intravitreal Triamcinolone or 4 mg of intravitreal TA combined with hypertension has been reported in about
sequential grid laser about 1 month later. 40 % of the eyes injected with intravitreal
Š‡ ‡ˆϐ‹…ƒ…› ‘ˆ ‹–”ƒ˜‹–”‡ƒŽ They found that combined treatment of triamcinolone acetonide8. Few studies
triamcinolone has been evaluated in a intravitreal TA plus grid laser did not yield suggest that the risk of steroid-induced
number of studies. Tewari et al evaluated better central foveal thickness reduction ocular hypertension is not dose-
–Š‡ ‡ˆϐ‹…ƒ…› ‘ˆ ƒ •‹‰Ž‡ ‹Œ‡…–‹‘ ‘ˆ or BCVA improvement at 6 months than dependent and lower dose of TA was not
intravitreal TA in patients with macular intravitreal TA alone and grid laser markedly different from higher doses9.
edema due to diabetic retinopathy, branch ƒŽ‘‡ ™ƒ• •‹‰‹ϐ‹…ƒ–Ž› ™‘”•‡ –Šƒ –Š‡ ʹ
retinal vein occlusion and central retinal other treatment modalities6. The DRCR Triamcinolone implant
vein occlusion. In patients with DME, protocol I represented a pivotal clinical
central macular thickness decreased and trial assessing three different treatment I-vation (SurModics, Inc., Eden
˜‹•—ƒŽ ƒ…—‹–› •‹‰‹ϐ‹…ƒ–Ž› ‹’”‘˜‡† ƒ– schemes: intravitreal 0.5 mg Ranibizumab Prairie, MN) is a nonbiodegradable
1 and 3 months. However recurrence of plus prompt or deferred focal/grid laser; implant containing titanium screw coated
macular edema and fall in visual acuity or 4 mg intravitreal TA combined with ™‹–Š ͻʹͷ Ɋ‰ ‘ˆ –”‹ƒ…‹‘Ž‘‡ ƒ…‡–‘‹†‡
was noted in 41% and 53% of DME eyes focal/grid laser compared with focal/ and the nonbiodegradable polymethyl
at 6 and 9 months respectively4. Gillies grid laser alone. At the two-year visit,
et al compared 4 mg of TA with sham compared with the sham + prompt laser
injection. Mean best corrected visual group, the mean change from baseline
ƒ…—‹–› ȋ Ȍ ‹’”‘˜‡† •‹‰‹ϐ‹…ƒ–Ž› in the visual acuity letter score was 3.7
at 24 months compared with sham letters greater in the ranibizumab +
injection5. Lam et al compared grid laser prompt laser group; 5.8 letters greater
photocoagulation, 4 mg of intravitreal TA,

Vitreo-retina Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences,All India Institute of Medical Sciences, New Delhi, India

Dr. Kanhaiya Mittal MD Dr. Shreyas Temkar MD Dr. Rohan Chawla MD, FRCS Dr. Koushik Tripathy MD

Padmashree Prof. Dr.Y.R. Sharma MS Dr. Pradeep Venkatesh MD Dr. Raj Pal Vohra MD

26 DOS TIMES - SEPTEMBER-OCTOBER 2015

RETINA

methacrylate and ethylene-vinyl compared two doses of FA implant (0.2 dexamethasone implant 0.7 mg (22.2%)
acetate. It is implanted through a pars ƒ† ͲǤͷ Ɋ‰ Ȁ†ƒ›Ȍ ™‹–Š •Šƒ ‹Œ‡…–‹‘ and dexamethasone implant 0.35 mg
plana sclerotomy by a 25G needle after in patients with at least one prior laser ȋͳͺǤͶΨȌ –Šƒ •Šƒ ȋͳʹΨǢ ’ζ ͲǤͲͳͺȌǤ
conjunctival dissection, delivering the treatment. At 24 months, both doses Mean average reduction in central retinal
drug for up to two years. The usefulness of Fluocinolone showed a statistically thickness from baseline was greater with
of this device is yet to be established and •‹‰‹ϐ‹…ƒ– ‹’”‘˜‡‡– ‹ ‡ƒ dexamethasone implant 0.7 mg (-111.6
clinical trials are underway. compared to sham. Three year follow ɊȌ ƒ† †‡šƒ‡–Šƒ•‘‡ ‹’Žƒ– ͲǤ͵ͷ
up showed that both the Fluocinolone ‰ ȋǦͳͲ͹Ǥͻ ɊȌ –Šƒ •Šƒ ȋǦͶͳǤͻ ɊǢ ’δ
Periocular Triamcinolone arms continued to result in a statistically 0.001). Cataract-related adverse events
•‹‰‹ϐ‹…ƒ– „‡‡ϐ‹– …‘’ƒ”‡† ™‹–Š •Šƒ19. in phakic eyes were 67.9%, 64.1%, and
TA can be delivered to posterior The FAME study group also found that 20.4% in the 0.7 mg, 0.35 mg, and sham
segment periocularly via different ‹ ’ƒ–‹‡–• ™‹–Š …Š”‘‹… ǡ ͲǤʹ Ɋ‰Ȁ groups, respectively. Increases in IOP were
routes including subconjunctival, day implant provided substantial visual usually controlled with medication or no
anterior subtenon, posterior subtenon, „‡‡ϐ‹– ˆ‘” —’ –‘ ͵ ›‡ƒ”• ƒ† ™‘—Ž† „‡ therapy; only 2 patients (0.6%) in the 0.7
”‡–”‘„—Ž„ƒ” ƒ† ’‡”‹„—Ž„ƒ” ȋ‘”„‹–ƒŽ ϐŽ‘‘” an option for patients not responding to mg group and 1 patient (0.3%) in the 0.35
injection)3. Posterior subtenon TA (PST) other therapies20. mg group required trabeculectomy22.
can be administered by conventional
Nozik’s method using 25G10 or 26G needle, The Fluocinolone acetonide in The Ozurdex plus laser versus
ƒ† „› ʹʹ
’‘Ž›–‡–”ƒϐŽ—‘”‘‡–Š›Ž‡‡ Human Aqueous (FAMOUS) study showed laser trial (PLACID) study comparing
intravenous cannula method11. Local –Šƒ– ’ƒ–‹‡–• ”‡…‡‹˜‹‰ ͲǤͷ Ɋ‰ Ȁ†ƒ› dexamethasone 0.7mg implant plus laser
injections of TA provide good local implant group gained higher visual acuity vs laser alone showed that the percentage
concentration of the drug, with negligible Ž‡––‡”• ƒ• …‘’ƒ”‡† –‘ ͲǤʹ Ɋ‰ Ȁ†ƒ› ‰”‘—’ of patients who gained 10 letters or
systemic side effects. Various studies FA implant. But, IOP elevation was more more in BCVA was more in implant plus
Šƒ˜‡ „‡‡ †‘‡ –‘ ‡˜ƒŽ—ƒ–‡ –Š‡ ‡ˆϐ‹…ƒ…› ‹ ͲǤͷ Ɋ‰ Ȁ†ƒ› ‹’Žƒ–•21. laser group than laser alone at 1,4 and
of PST in DME. Verma et al compared grid 9 months. But this difference was not
laser photocoagulation plus posterior Raise in intraocular pressure maintained at 12 months. However
subtenon triamcinolone vs grid laser and cataract formation are the main the area under curve analysis showed
photocoagulation only and found a complications of FA implant. Pearson greater improvement in BCVA from
•‹‰‹ϐ‹…ƒ– ‹’”‘˜‡‡– ‹ ƒ† et al had found the incidence of ocular baseline to month 12. There was also
contrast sensitivity in the former group12. hypertension in patients with FA implant greater reduction in retinal thickness
Bakri and Kaiser evaluated the role of PST to be 61.4% (vs 5.8% in standard of and reduction in area of vascular leakage
in improving visual acuity in patients with care) at any time and 33.8% required in implant plus laser group through the
”‡ˆ”ƒ…–‘”› Ǥ Š‡› ˆ‘—† •‹‰‹ϐ‹…ƒ– surgery for ocular hypertension by 4 follow-up period. Increased IOP was more
improvement in visual acuity at 1 month years. Of implanted phakic eyes, 91% (vs common with combination treatment
which was maintained till 12 months13. 20% in standard of care) had cataract but no surgeries for elevated IOP were
Studies have been done to compare the extraction by 4 years18. The FAME study required23.
‡ˆϐ‹…ƒ…› ƒ† •ƒˆ‡–› ‘ˆ ˜• ‹–”ƒ˜‹–”‡ƒŽ group also found that subjects requiring
triamcinolone. These studies have shown cataract surgery were more frequent in The CHAMPLAIN study group showed
–Šƒ– Šƒ• …‘’ƒ”ƒ„Ž‡ ‡ˆϐ‹…ƒ…› –‘ –Š‡ ‹•‡”– ‰”‘—’•ǡ ƒ† –Š‡‹” ˜‹•—ƒŽ „‡‡ϐ‹– a reduction of central retinal thickness
intravitreal triamcinolone in terms of was similar to that of subjects who were ƒ† …Ž‹‹…ƒŽŽ› •‹‰‹ϐ‹…ƒ– ‹’”‘˜‡‡–
improving visual acuity and decreasing pseudophakic at baseline. Glaucoma in visual acuity after dexamethasone
central macular thickness. Also, PST being requiring incisional surgery occurred in implant injection in vitrectomised eye for
an extraocular procedure, the risk of ͵Ǥ͹Ψǡ ͹Ǥ͸Ψǡ ƒ† ͲǤͷΨ ‘ˆ ͲǤʹ Ɋ‰ Ȁ†ƒ›ǡ ͲǤͷ refractory DME. The mean change from
complications associated with intraocular Ɋ‰ Ȁ†ƒ› ƒ† •Šƒ ‰”‘—’•ǡ ”‡•’‡…–‹˜‡Ž›19. baseline central retinal thickness (403
injections like endophthalmitis is ρȌ ™ƒ• Ǧͳͷ͸ ρ ƒ– ™‡‡ ͺ ȋ δ ͲǤͲͲͳȌ
•‹‰‹ϐ‹…ƒ–Ž› ”‡†—…‡†14-17. Dexamethasone and -39 μm at week 26 (p = 0.004). The
mean increase in best-corrected visual
Fluocinolone acetonide Dexamethasone is also a high acuity from baseline (54.5 letters) was
potency steroid used for long time ͸ǤͲ Ž‡––‡”• ȋ͵Ǥͻǡ ͺǤͳ Ž‡––‡”•Ȍ ƒ– ™‡‡ ͺ ȋ’ δ
Fluocinolone acetonide (FA) is a in ophthalmic practice in various 0.001) and 3.0 letters (0.1, 6.0 letters) at
high potency steroid as compared to TA. formulations. Currently it is used in DME week 26 (p = 0.046). At week 8, 30.4% of
It is 25 times more potent than cortisol. as a sustained release implant under the ’ƒ–‹‡–• Šƒ† ‰ƒ‹‡† η ͳͲ Ž‡––‡”• ‹ „‡•–Ǧ
FA implant is available commercially as trade name of Ozurdex. corrected visual acuity24.
Retisert and Illuvien.
The Macular Edema: Assessment Ozurdex for Diabetic Macular Edema
Pearson et al compared FA of Implantable Dexamethasone in Treated with Pars Plana vitrectomy and
implant (0.59 mg) with standard of Diabetes (MEAD) study was carried Membrane Removal (OPERA Study) is an
care (additional laser or no treatment). out in patients with DME. Cases with ongoing phase IV clinical trial evaluating
‹‰‹ϐ‹…ƒ– ‹’”‘˜‡‡– ‹ ˜‹•—ƒŽ ƒ…—‹–› …‡–”ƒŽ ƒ…—Žƒ •—„ϐ‹‡Ž† –Š‹…‡•• ε͵ͲͲ the use of dexamethasone implant
and decrease in retinal thickness was μm were randomized in a 1:1:1 ratio (Ozurdex) in patients with macular
seen at 6 months, 1 year, 2 years and 3 to dexamethasone implant 0.7 mg, edema associated with an epiretinal or
years in implant group than in standard dexamethasone implant 0.35 mg or preretinal membrane requiring surgical
of care group18. sham procedure and followed for three intervention with a follow-up of 1 year.
years. The percentage of patients with The results of this study are yet to be
The Fluocinolone Acetonide for ηͳͷǦŽ‡––‡” ‹’”‘˜‡‡– ‹ ˆ”‘ published.
Diabetic Macular Edema (FAME) study baseline at study end was greater with

www. dos-times.org 27

RETINA

Figure 1: SD-OCT line and cube scan showing presence of severe cystoid centre involving DME. is preferred. With the currently available
evidence, ocular steroids as monotherapy
or in combination with other modalities
Šƒ˜‡ …‘’ƒ”ƒ„Ž‡ ‡ˆϐ‹…ƒ…› –‘ ƒ–‹

therapy. The choice of pharmacotherapy
and the route of delivery (Peri-ocular
or intravitreal injection or intravitreal
implant) in any patient of DME should
be individualized taking into account
the location of edema, chronicity of
edema, previous response to therapy,
the lens status (phakic or pseudophakic),
the presence of risk for glaucoma, the
cost of the treatment modality and the
compliance of patient. Prior to giving
PST or intraocular steroid injection,
consideration is given to factors such
as history of glaucoma, cup-disc ratio,
prior records of intraocular pressure,
any evidence of intraocular variation
with topical steroid use, family history
of glaucoma etc. which may help exclude
patients with a higher risk of developing
steroid induced glaucoma. For intravitreal
injection, we generally use 2mg dose of
triamcinolone. Considering the higher
…‘•– „—– •‹‹Žƒ” ‡ˆϐ‹…ƒ…›ǡ •‹†‡Ǧ‡ˆˆ‡…–
’”‘ϐ‹Ž‡ ƒ† ˆ”‡“—‡…› ‘ˆ ƒ†‹‹•–”ƒ–‹‘ǡ
Dexamethasone implant (Ozurdex) is
used in selected cases.

OUR APPROACH Figure 2: SD-OCT line and cube scan of same patient 1-month post intravitreal triamcinolone
2mg injection.
Fundus Fluorescein Angiography
(FFA) and Optical coherence tomography
(OCT) are the most useful ocular
investigations in a patient with DME.
Š‡ ”‘Ž‡ ‘ˆ ‹ ‹• –‘ …‘ϐ‹”
the presence of macular edema, to know
the type of macular edema, to assess
macular thickness, to know the response
to pharmacotherapy and in follow-up of
these patients. FFA helps to know the type
of leak (focal or diffuse) and to rule out
macular ischemia. Both OCT and FFA have
important role in deciding appropriate
treatment plan in patients with DME.

Our strategy in the management of
DME is as follows – for cases of centre
involving DME with diffuse leak /leak
close to the fovea, intravitreal anti-VEGF
(Bevacizumab/Ranibizumab) or PST
followed by laser is used. In general we
prefer intravitreal injection of steroid over
PST in cases where oedema is very severe.
Figure 1 is a SD-OCT line and cube scan
of a patient showing presence of cystoid
centre involving DME. Figure 2 is a SD-OCT
line and cube scan of the same patient,
1-month postintravitreal triamcinolone
2mg injection. In cases of DME where the
leak is away from macular centre without
•‹‰‹ϐ‹…ƒ– –Š‹…‡‹‰ ‘ˆ ˆ‘˜‡ƒǡ Žƒ•‡” ƒŽ‘‡

28 DOS TIMES - SEPTEMBER-OCTOBER 2015

CONCLUSION controlled, randomized clinical trial. RETINA
Ophthalmology 2006;113:1533–8.
Even though, anti-VEGF therapy is 6. Lam DSC, Chan CKM, Mohamed edema. Korean J Ophthalmol KJO
becoming the treatment of choice for S, Lai TYY, Lee VYW, Liu DTL, et 2006;20:205–9.
center-involved DME, ocular steroids al. Intravitreal triamcinolone 16. Cellini M, Pazzaglia A, Zamparini E,
including the recently approved plus sequential grid laser versus Leonetti P, Campos EC. Intravitreal vs.
sustained-release implants have added triamcinolone or laser alone for subtenon triamcinolone acetonide
greatly to the treatment options especially treating diabetic macular edema: for the treatment of diabetic cystoid
if patient are pseudophakic. They have six-month outcomes. Ophthalmology macular edema. BMC Ophthalmol
shown promise of limiting the frequency 2007;114:2162–7. 2008;8:5.
and reducing cost of intravitreal injections 7. Diabetic Retinopathy Clinical 17. Qamar RMR, Saleem MI, Saleem MF.
associated with intravitreal anti-VEGF Research Network, Elman MJ, Aiello ‘’ƒ”‹•‘ ‘ˆ –Š‡ ‡ˆϐ‹…ƒ…› „‡–™‡‡
therapy. Cataract and glaucoma appear to LP, Beck RW, Bressler NM, Bressler an intravitreal and a posterior
be the major concerns in the clinical use SB, et al. Randomized trial evaluating subtenon injection of triamcinolone
of steroids. With proper patient selection ranibizumab plus prompt or deferred acetonide for the treatment of diffuse
and monitoring, these complications can laser or triamcinolone plus prompt diabetic macular edema. Eurasian J
be effectively prevented or managed. laser for diabetic macular edema. Med 2013;45:185–90.
Research and trials in newer routes Ophthalmology 2010;117:1064–77. 18. Pearson PA, Comstock TL, Ip M,
of delivery (like suprachoroidal 8. Jonas JB, Kreissig I, Degenring R. Callanan D, Morse LS, Ashton
injections) might help to overcome these Intravitreal triamcinolone acetonide P, et al. Fluocinolone acetonide
complications without compromising the for treatment of intraocular intravitreal implant for diabetic
–Š‡”ƒ’‡—–‹… ‡ˆϐ‹…ƒ…› ƒ† ƒ› „‡‰‹ ƒ ‡™ proliferative, exudative, and macular edema: a 3-year multicenter,
horizon in the management of DME. neovascular diseases. Prog Retin Eye randomized, controlled clinical trial.
Res 2005;24:587–611. Ophthalmology 2011;118:1580–7.
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Davis MD, DeMets DL. The 2008;53:139–49. vitreous inserts for diabetic
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subtenon injection of corticosteroids –‡” „‡‡ϐ‹– ‹ ’ƒ–‹‡–• ™‹–Š
1984;91:1464–74. —•‹‰ ’‘Ž›–‡–”ƒϐŽ—‘”‘‡–Š›Ž‡‡ ȋ Ȍ chronic diabetic macular edema.
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2. Treatment techniques and clinical Ophthalmol 2002;30:55–7. ʹͳǤ ƒ’‘…Š‹ƒ”‘ ǡ ƒϐ‹œ
ǡ ŠƒŠ
12. Verma LK, Vivek MB, Kumar A, Tewari SM, Bloom S, Brown DM, Busquets
guidelines for photocoagulation HK, Venkatesh P. A prospective M, et al. Sustained ocular delivery
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Ocul Pharmacol Ther Off J Assoc Ocul Bandello F, Maturi RK, Augustin AJ,
Study Report Number 2. Early Pharmacol Ther 2004;20:277–84. et al. Three-year, randomized, sham-
13. Bakri SJ, Kaiser PK. Posterior controlled trial of dexamethasone
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14. Ozdek S, Bahçeci UA, Gürelik G, 23. Callanan DG, Gupta S, Boyer DS,
Ophthalmology 1987;94:761–74. ƒ•ƒ”‡‹•‘ºŽ— Ǥ ‘•–‡”‹‘” •—„–‡‘ Ciulla TA, Singer MA, Kuppermann
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4. Tewari HK, Sony P, Chawla R, Garg SP,

Venkatesh P. Prospective evaluation

of intravitreal triamcinolone

acetonide injection in macular

edema associated with retinal

vascular disorders. Eur J Ophthalmol

2005;15:619–26.

5. Gillies MC, Sutter FKP, Simpson JM,

Larsson J, Ali H, Zhu M. Intravitreal

triamcinolone for refractory diabetic

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of a double-masked, placebo-

Financial Interest: Š‡ ƒ—–Š‘”• †‘ ‘– Šƒ˜‡ ƒ› ϔ‹ƒ…‹ƒŽ ‹–‡”‡•– ‹ ƒ› ’”‘…‡†—”‡Ȁ’”‘†—…– ‡–‹‘‡† ‹ –Š‹• ƒ—•…”‹’–Ǥ

www. dos-times.org 29

SNAPSHOT

OCULAR INVOLVEMENT IN A CASE OF AMNIOTIC
BAND SYNDROME

Debarpita Chaudhury, Arijit Mitra
Ababy of 3 weeks age presented to us with
gross facial malformations and inability to occurred in the 36th gestational week. Birth weight was 2880
close both eyelids. On examination there was grams, head circumference was 31 centimeters and Apgar
microphthalmos, lower lid coloboma with score was 9/10. The child was unable to close her eyes and
corneal opacity in the left eye. Right eye had she had discharge from both the eyes in the post natal period.
The mother was booked and immunized and not on any

lower lid coloboma and exposure keratitis medication. VDRL was negative. Her gynaecologist however

involving the cornea. The lid colobomas were a direct result of had informed the mother during the later stages of gestation

compression from the amniotic bands. Compression from the after evaluation of her ultrasonography (USG) reports that the

amniotic bands also caused improper fusion of the embryonic baby had amniotic bands entangling her face and had informed

processes resulting in cleft lip and cleft palate. Antibiotic and the mother of probable malformations of the face before birth.

lubricant eye drops and ointment were prescribed in both On examination there was microphthalmos, lid coloboma with

eyes. On subsequent follow up the exposure keratitis in the corneal opacity in the left eye. Right eye had lid coloboma with

right eye resolved resulting in exposure keratitis and discharge
a corneal opacity. The baby was Amniotic band syndrome (ABS) is a (Figure 1). The lid coloboma was
diagnosed as a case of amniotic a direct result of compression
band syndrome (ABS) which constellation of congenital malformations from the amniotic bands.
is a sporadic set of congenital attributed to amniotic bands that entangle Since the amniotic bands had

malformations attributed to foetal parts during intrauterine life, entangled the face in the intra-
amniotic bands which entangle which results in a broad spectrum of uterine period it had caused
foetal parts during intrauterine anatomic disturbances ranging from minor compression over both the
life. ABS involving the face and eyes and the maxillary region

eyes is extremely rare with very constriction rings and lymphedema of the resulting in improper fusion of
few reported cases in literature. digits to complex, bizarre multiple congenital the embryonic processes. This
compression resulted in lower

INTRODUCTION anomalies incompatible with life lid colobomas of both eyes and a

Amniotic band syndrome cleft lip and cleft palate (Figure

(ABS) is a constellation of 2). Baby was advised antibiotic

congenital malformations attributed to amniotic bands that and lubricant eye drops and ointment in both eyes and asked

entangle foetal parts during intrauterine life, which results in a to come for follow-up. On the next follow-up visit the clinical

broad spectrum of anatomic disturbances ranging from minor

constriction rings and lymphedema of the digits to complex,

bizarre multiple congenital anomalies incompatible with life1,2.

ABS can be diagnosed prenatally by ultrasound; otherwise, the

defects are seen after birth. ABS is not very often, but should

be considered in every newborn with congenital anomalies,

specially defects of extremities and/or body walls. The incidence

of ABS is estimated in a wide range of 1:1200 – 1:15000 live

births, about 1:70 in stillborns and among abortuses as high as

178:10000.Among total of 3% major malformations in general

population, ABS is responsible for 1-2%1-5. Thus ABS is in

general a rare condition and ABS involving the eyes is extremely

rare and in this case report we present one such case with gross

facial malformation and involvement of both eyes due to intra-

uterine compression from amniotic bands.

CASE REPORT Figure 1: Showing the face of the child with ocular and facial deformity
due to ABS.The child has microphthalmos,lower lid coloboma with
A baby girl of 3 weeks of age presented to us after being corneal opacity in the left eye.Right eye has lower lid coloboma and
referred by a Paediatrician for her ocular condition. The exposure keratitis involving the cornea
mother gave a history of malformation of the baby involving
the face and both eyes being present since birth. The delivery www. dos-times.org 31

SNAPSHOT

picture had improved and the such cases have been reported

exposure keratitis had regressed in literature. Our patient had

and resulted in a corneal opacity ocular malformation, lower lid

in the right eye. An USG B-scan colobomas in both eyes and

was done which was normal microphthalmos in the left eye

in the right and showed a and a cleft lip and cleft palate

disorganized microphthalmic due to compression from the

globe in the left eye. The baby amniotic bands over the face.

was referred to a paediatric Since there is such a wide

plastic surgeon for opinion who spectrum of possible anomalies

advised facial reconstructive and many combinations of their

surgery. simultaneous appearance, there

are no two identical cases of

DISCUSSION ABS1.

The etiopathogenesis ABS can be diagnosed

of ABS is still unknown, but prenatally by ultrasonography,

there are two main theories. which can sometimes show

Š‡ ™‹†‡Ž› ƒ……‡’–‡† Dz‡š–”‹•‹… Figure 2: Figure shows the child with ABS.Except for the ocular and amniotic bands, but more often
model”, proposed by Torpin facial deformities due to the amniotic bands no other defects were malformations consistent with
present indicating that the bands had entrapped the ocular and facial ABS, as well as olygoamnion and
and Faulkner in 1966 explains structures during their development
reduction of foetal movements3.
the genesis of the defects by and misoprostol8,9. However, there is ABS can be diagnosed as early as
rupture of the amnion in early pregnancy, ‘ ϐ‹” ‡˜‹†‡…‡ ‘ˆ †‡ϐ‹‹–‡ …ƒ—•ƒŽ‹–› the 12th gestational week. In the second
with formation of amniotic bands and for any of these factors, and therefore a trimester of gestation most of ABS defects
ƒ‹‘–‹… ϐŽ—‹† Ž‘••ǡ ˆ‘ŽŽ‘™‡† „› ‡š–”—•‹‘ great number of authors considers ABS can be seen during routine ultrasound
of all or parts of the foetus into the as defects with sporadic occurrence, with examinations3. The most important
chorionic cavity6. Bands entrap parts no gender prevalence, and no strong risk ultrasound diagnostic criteria are visible
of the growing foetus which become factors. amniotic bands, constriction rings on
entangled and subject to compression, extremities and irregular amputations
which compromises foetal circulation and ABS has polymorphic clinical ‘ˆ ϐ‹‰‡”• ƒ†Ȁ‘” –‘‡• ™‹–Š –‡”‹ƒŽ
also the growth and development with ϐ‹†‹‰•ǡ „‡…ƒ—•‡ –›’‡ ‘ˆ †‡ˆ‘”‹–‹‡• syndactily. Mild defects, however, are
consecutive disturbances of anatomy and depends on the time of amniotic rupture less likely to be diagnosed prenatally,
ˆ—…–‹‘Ǥ ‘–Š‡” –Š‡‘”› –Š‡ Dz‹–”‹•‹… during pregnancy and part of the foetal in which case defects are seen after
model” proposed by Streeter in 1930 body which is entangled in the amniotic birth3. Latest ultrasound techniques–
suggested that the anomalies and the bands. Early amniotic rupture, during three-dimensional and four dimensional
ϐ‹„”‘—• „ƒ†• Šƒ˜‡ ƒ …‘‘ ‘”‹‰‹ǡ –Š‡ ϐ‹”•– Ͷͷ †ƒ›• ‘ˆ ‰‡•–ƒ–‹‘ǡ Ž‡ƒ†• ultrasound contribute to more sensitive
caused by a perturbation of developing to the most severe cranio-facial and prenatal diagnostics of ABS, and in
germinal disc of the early embryo7. visceral malformations4. Every part of complicated cases foetal magnetic
the foetal body can be damaged, but most resonance can be helpful.
Most cases of ABS are not of genetic often extremities, specially the upper Therapy of ABS is mostly surgical,
origin, and there is no recurrence in extremities are involved. Most often there with an individual approach to
siblings or children of affected adults. are minor defects, such as constriction every single case. Interdisciplinary
However, there are some reports of ABS rings or digit amputations but even minor consultation and work is very often
among families with collagen disorders, defects are multiple in 77% of cases5. needed (plastic surgeon, orthopedic
like Ehler-Danlos syndrome and other surgeon, orthodontist, ophthalmologist,
diseases that involve connective tissue If bands compress the fetal head or neurosurgeon etc)1. Lately, there have
like osteogenesis imperfecta6. Some face, different cranio-facial disturbances been some attempts of prenatal ABS
studies found a connection between ABS appear like asymmetric facial clefts, orbital treatment - foetoscopic laser cutting of
and mother’s age (specially primiparas defects (anophthalmos, microphtalmos, amniotic bands, before their compression
under the age of 25), prematurity, enophthalmos), corneal abnormalities, on the foetus makes malformations10. In
abdominal trauma, unsuccessful central nervous system malformations cases when foetal anomalies incompatible
abortion, intrauterine contraception, (anencephaly, encephalocoele, asym- with life are prenatally seen, pregnancy
chorionic villus sampling, amniocentesis, metric meningocoele) and calvaria termination is advised2.
malformations of the uterus and some defects. The involvement of the foetal
drugs like ergotamine, acetaminophen eyes is extremely rare and very few

Disha Eye Hospitals and Research Centre Pvt. Ltd., Barrackpore, Kolkata,West Bengal, India

Dr. Debarpita Chaudhury DO, DNB Dr.Arijit Mitra DO, DNB

32 DOS TIMES - SEPTEMBER-OCTOBER 2015

SNAPSHOT

ABS is not seen very often, but should amniotic band limb deformity, and a Spring ield, IL: Charles C Thomas;
be considered in every newborn with new mutation. J Am Acad Dermatol 1968.
congenital anomalies, especially defect 2007;56:S53-S54. 7. Streeter GL. Focal de iciencies in
of extremities and/or body walls. Child’s 3. Merrimen JL, McNeely PD, Bendor- fetal tissues and their relation to
karyotyping is of great importance, in Samuel RL, Schmidt MH, Fraser intrauterine amputations. Contrib
order to avoid misdiagnosis and incorrect RB. Congenital placental-cerebral Embryol Carnegie Inst. 1930;22:1-
information of recurrence risk. Due to its adhesion: an unusual case of 44.
complexity a team of specialists should amniotic band sequence. Case report. 8. Dyer JA, Chamlin S. Acquired Raised
be included in the treatment and follow- J Neurosurg 2006;104:352-5. Bands of Infancy: Association
up of children with ABS, according to 4. Jabor MA, Cronin ED. Bilateral cleft with Amniotic Bands. Pediatric
individual needs of every single patient. lip and palate and limb deformities: Dermatology 2005;22 :346-9.
a presentation of amniotic band 9. Bower C, Norwood F, Knowles
REFERENCES sequence? J Craniofac Surg S. Amniotic band syndrome: a
2000;11:388-93. population-based study in two
1. Poeuf B, Samson P, Magalon G. 5. Evans C, Marton T, Rutter S, Anumba Australian states. Paediatric and
Amniotic band syndrome. Chir Main DO, Whitby EH, Cohen MC. Cranial Perinatal Epidemiology 1993;7:395-
2008;27:S136-47. vault defects: the description of 403.
three cases that illustrate a spectrum 10. Quintero RA, Morales WJ, Phillips J,
2. Burk CJ, Aber C, Connelly EA. Ehlers- of anomalies. Pediatr Dev Pathol Kalter CS, Angel JL. In utero lysis of
Danlos syndrome type IV: keloidal 2009;12:96-102. amniotic bands. Ultrasound Obstet
plaques of the lower extremities, 6. Torpin R. Fetal Malformations Caused Gynecol 1997;10:316-20.
by Amnion Rupture During Gestation.

Financial Interest: The authors do not have any ϔinancial interest in any procedure/product mentioned in this manuscript.







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www. dos-times.org 33

SNAPSHOT

A RARE CASE OF PYOGENIC GRANULOMA

Rajni Sethia, Hemali A. Patel, Raghunandan Kothari

The commonest clinical presentation of the pyogenic granuloma is a rapidly

growing mass which, on slit lamp examination, appears as well circumscribed;

smooth surfaced, pink, polypoidal, and highly vascularized mass
Pyogenic granuloma is an exuberant proliferation
of granulation tissue that typically develops after DISCUSSION
minor trauma or surgery1. It occurs most often
on the skin of the face and extremities. Pyogenic Pyogenic granuloma usually occurs in late childhood3
granuloma of medial canthus involving caruncle is while our patient presented in 7th decade. According to A.P.
rare amongst the ocular pyogenic granuloma2. Ferry et al predisposing factors include chalazion, ocular/
adnexal surgery, accidental trauma and undetermined4. In our

We report an unusual case of left eye pyogenic granuloma case the cause was unknown.

of the medial canthus involving caruncle in a 65 year old male In the eye, it has been reported to arise at many sites,

presented to us in OPD. Our patient had a complaint of some including the eyelid skin, conjunctiva, limbus, lacrimal puncta,

mass growing in medial angle of the left eye which was noticed and veins of the ocular adnexa5. The occurrence of pyogenic

by him 5 days ago. It was acute, painless, glistening, pink and granuloma on the medial canthus is relatively rare While in

rapidly growing polypoidal mass without any past history of our case we reported an unusual site; medial canthus involving

recent ocular surgery or trauma. caruncle.

On ocular examination, best corrected visual acuity in The commonest clinical presentation of the pyogenic

both eyes was 6/6 and Intraocular presssure was 16 mmhg. On granuloma is a rapidly growing mass which, on slit lamp

local examination, we found a 7x5 mm polypoidal, nontender, examination, appears as well circumscribed; smooth surfaced,

immobile mass at medial canthus (Figure 1). It was adherent

to caruncle. It had rough surface with brownish pigmentation

and bleeded on touch. Complete ocular examination was within

normal limits.

A presumptive clinical diagnosis of left eye pyogenic

granuloma was made and the mass was surgically approached

(Excisional biopsy) and was removed in-toto (Figure 2). The

histopathological examination (Figure 3) revealed proliferation

‘ˆ …ƒ’‹ŽŽƒ”‹‡• ƒ† †‡•‡ ‹ϐŽƒƒ–‘”› ‹ϐ‹Ž–”ƒ–‡ …‘’‘•‡†

ƒ‹Ž› ‘ˆ Ž›’Š‘…›–‡•ǡ ™Š‹…Š …‘ϐ‹”‡† ‘—” †‹ƒ‰‘•‹• ‘ˆ

pyogenic granuloma.

Patient was treated postoperatively by oral antibiotic and

topical antibiotic with steroid. We followed up our patient on

7th day and then every month for 6 months.

Figure 2: Intraoperative image after excision of left eye pyogenic
granuloma

Figure 1: Left eye pyogenic granuloma of medial canthus involving Figure 3: Histopathological image of left eye pyogenic granuloma
caruncle www. dos-times.org 35

SNAPSHOT

pink, polypoidal, and highly vascularized mass at medial canthus involving pyogenic granuloma. Apropos of an
mass1. Our patient had a similar clinical caruncle. A surgical excisional biopsy is anatomo-clinical case. J Fr Ophtalmol.
presentation. a very useful treatment for it, as it serves 1994;17 :617-9.
–Š‡ ’—”’‘•‡ –‘ –”‡ƒ– ‹– ƒ† ƒŽ•‘ –‘ …‘ϐ‹” 3. Yanoff M., Duker JS. Orbit and
The histopathological picture the diagnosis. In our case excision was oculoplastics. Fiona O, Robinson J,
consists of granulation tissue consisting indicated for cosmesis as well as for relief Richard O, Collin. Ophthalmology.
‘ˆ ϐ‹„”‘„Žƒ•– ƒ† „Ž‘‘† ˜‡••‡Ž•ǡ ™‹–Š from discomfort and it gave satisfactory Elsevier, Missourie 2009;4:1300-01.
acute and chronic non-granulomatous result. 4. A.P. Ferry et al. Granuloma pyogenicum.
‹ϐŽƒƒ–‘”› …‡ŽŽ•3. Trans Am Ophthalmol 1989;87:151-53
ACKNOWLEDGMENTS 5. Ishijima K, Kase S, Noda M, Ishida S.
Differential diagnosis includes Pyogenic granuloma developing rapidly
squamous papilloma, conunctival Dr. Tandan, Pathology department after excision of corneal/conjunctival
lymphoma, foreign body granuloma and of S.B.K.S. Medical Institute & Research intraepithelial neoplasia. Nihon Ganka
ocular lymphangiectasis6. Centre, Vadodara, India Gakkai Zasshi. 2010;114:1036–39
6. Jack JK and Brad B. Eyelids. Ken N,
Small pyogenic granuloma REFERENCES Andrew P.Clinical ophthalmology-a
sometimes regresses spontaneously systemic approach.Elsevier, dinburgh.
with the topical medications but for the 1. Albert MD, Joan WM. Wetting of the 2011;7: 14-15
large ones, excisional biopsy can be done. ocular surface and dry eye Disorders. 7. Goodfellow N. Pyogenic granuloma. J
In recurrent cases, lower dose plaque Eva MC, Mona HD, Reza D Principle and Vis Commun Med. 2007;30:177-9.
radiotherapy can be applied7. practice of ophthalmology. Elsevier,
Missouri 2008;3: 802-03.
CONCLUSION
2. Cherif N1, D’Hermies F, Cori Melki
We concluded that pyogenic M, Pouliquen Y. Caruncular site of
granuloma may present as a malignant

Department of Ophthalmology, Dhiraj Hospital, S.B.K.S.Medical Institute Research Centre, Sumandeep Vidyapeeth, Piparia,Vadodara

Dr. Rajni Sethia MS Dr. Hemali A. Patel MS Dr. Raghunandan Kothari MS

36 DOS TIMES - SEPTEMBER-OCTOBER 2015

INNOVATIONS

STAB INCISION GLAUCOMA SURGERY (SIGS)

Soosan Jacob

need for the conjunctival incision to be opened excessively

Dr. Soosan Jacob MS, FRCS, DNB just for application of MMC intra-operatively. Many prominent
Senior Consultant Ophthalmologist glaucoma surgeons use the pre-op sub-conj injection of MMC
Dr.Agarwal’s Eye Hospital, Chennai, in their trabeculectomy cases as well and this is an accepted
Tamilnadu, India technique. Pre-op MMC is given tangential to limbus 6mm above

S
‹• ƒ ‡™ –‡…Š‹“—‡ ‘ˆ ‰—ƒ”†‡† ϐ‹Ž–”ƒ–‹‘ ’”‘…‡†—”‡ the superior limbus. So it is above the site of the incision. Also
that the author (SJ) introduced in late 2013. It is the needle is introduced from the temporal conjunctiva parallel
slowly but surely becoming popular amongst many to the limbus till one reaches the site of intended surgery and
Ophthalmologists who have tried it out around the then MMC injected, therefore no buttonhole occurs at the site
world. In fact, many Ophthalmologists all over India of bleb.
within and outside the Agarwal’s group have started
doing this technique and are very happy with it. There are Speculum loosened: The conjunctival and scleral cuts
many international ophthalmologists who have adopted this should be well separated to avoid them from scarring together.
technique and are now doing it - in the US, Europe, Africa and It is advisable to not have the speculum opened up too wide
the Middle East, and are pleased with the results (numerous in order to prevent loose conjunctiva from getting pushed into
personal communications). The advantages of this technique the fornices, and thus have inadequate conjunctiva to push
include simplicity, effectiveness, lack of need for special down well. Speculum with a screw that allows it to be held
instruments and devices; and being much more cost effective with desired amount of opening is preferable. The superior
as compared to many of the currently popular MIGS devices conjunctiva is pushed downwards with two non-toothed
while performing well when compared to the gold standard - forceps using a two handed sliding technique to do this. During
trabeculectomy1-10. We have done more than 200 in our main this step, the conjunctiva should be pushed inferiorly towards
branch alone. In Africa at last count in March 2015, there were 6 o clock limbus without applying posterior pressure/ pushing
116 cases done (personal communications). the globe into the orbit. It is generally possible to push the

™‘”• ‘ –Š‡ „ƒ•‹• ‘ˆ ƒ …‘’”‘‹•‡† ϐ‹Ž–‡”‹‰ –—‡ŽǤ conjunctiva down well and this gives the advantage of having
A direct trans-conjunctival corneo-scleral tunnel is created a larger distance between the scleral tunnel incision and the
which is then intentionally compromised by creation of an conjunctival cut (Figure 1A). Too closely placed scleral and
‘•–‹—Ǥ Š‹• –Š‡ ƒ…–• ƒ• ƒ ‰—ƒ”†‡† ϐ‹Ž–”ƒ–‹‘ ’”‘…‡†—”‡Ǥ conjunctival cuts may sometimes scar together and hence the
importance of pushing conjunctiva inferiorly.

One may not get as much conjunctiva to push down
supero-nasally as here the fornix is short, however superiorly,
there is always plenty of conjunctiva and one can actually push

TECHNIQUE downwards and see the fornix shallowing out with thicker
conjunctiva appearing far above. Pinching the conjunctiva

As with any other procedure, there is a learning curve and pushing downwards may not get as much of separation

and it is important to know
‹• ƒ ‡ƒ•› ƒ† ‡ˆϐ‹…‹‡– ‰—ƒ”†‡† between the conjunctival and
the technique properly. Pre- scleral tunnels. Toothed forceps

op MMC; loose speculum; a ϐ‹Ž–”ƒ–‹‘ ’”‘…‡†—”‡ –Šƒ– ‹• •Ž‘™Ž› „—– should be avoided for this step
well pushed down conjunctiva; surely becoming more widely adopted. as they may tear the conjunctiva.
•ŠƒŽŽ‘™ǡ •Š‘”–ǡ •—’‡”ϐ‹…‹ƒŽ
Creating the tunnel: The
•…Ž‡”ƒŽ –—‡Ž ™‹–Š ƒ •—’‡”ϐ‹…‹ƒŽǢ However there is a learning curve and ideal length of the incision is
good ostium and a good PI are 1.5 mm scleral component and
crucial. As is checking for AC ϐ‹‡ —ƒ…‡• –‘ –Š‡ •—”‰‡”› Œ—•– ƒ• –Š‡”‡ approximately 1 mm corneal. It

behaviour in the end. In the end, is for any other surgery does not matter as much if the

if you have a soft and stable AC corneal length ends up being

that however does not shallow bit longer as the tunnel will still

ƒ† ƒ ‰‘‘† „Ž‡„ǡ ›‘— ™‹ŽŽ ‰‡– ‰‘‘† ’‘•– ‘’ ϐ‹Ž–”ƒ–‹‘Ǥ drain. However the scleral should not be longer to prevent the

Pre-operative sub-conjunctival MMC: The use of MMC pre- tunnel from sealing off. Also the entire tunnel - both scleral and

‘’‡”ƒ–‹˜‡Ž› ‰‹˜‡• †‹ˆˆ—•‡ ϐ‹Ž–‡”‹‰ „Ž‡„• ™‹–Š ‘ •…ƒ””‹‰ ƒ† …‘”‡ƒŽ …‘’‘‡–•ǡ •Š‘—Ž† „‡ •—’‡”ϐ‹…‹ƒŽ ƒ• †‡‡’ ƒ† –Š‹…

I do it as a standard in all my regular cases now. 0.02% (0.2 upper lips tend to seal off. The metal blade should be seen

ml) is given 20 min prior to surgery in the intended site of through the overlying sclera and conjunctiva.

SIGS. 0.2 ml of 0.02% MMC is injected in the sub-conjunctival While holding the superior conjunctiva down over the

space about 6 mm from the limbus 20 minutes prior to surgery cornea with the non-dominant hand, the calliper is used to

and then surgery is started. This prevents the conjunctival mark the sclera at 1.5 mm from the limbus and the assistant

lips from scarring down. This is easy and safe and avoids the quickly transfers the 2.8 mm bevel up phaco keratome to the

www. dos-times.org 37

INNOVATIONS

surgeon’s hand. The keratome is placed Figure 1A: Superior conjunctiva is pushed downwards with two non-toothed forceps using a two
at the mark, avoiding major blood vessels JCPFGF UNKFKPI VGEJPKSWG CPF VJG MGCTVQOG WUGF VQ ETGCVG C UWRGTſEKCN UENGTCN VWPPGN OO
and the conjunctiva is pushed back over behind the limbus; Figure 1B: 6JG MGTCVQOG ETGCVGU C UWRGTſEKCN UENGTCN
OO CPF EQTPGCN
the keratome in order to assess whether (1mm) tunnel; Figure 1C: The scleral tunnel lip can be visualized by retracting the conjunctiva
it is correctly distanced from the limbus. while irrigating; Figure 1D: A 1mm Kelly’s Descemet’s punch is used to create an ostium.
…‡ …‘ϐ‹”‡†ǡ –Š‡ ‡”ƒ–‘‡ ‹• —•‡†
–‘ ƒ‡ ƒ •ŠƒŽŽ‘™ǡ •—’‡”ϐ‹…‹ƒŽ ƒ† •Š‘”– forceps (like a St Martin or a 0.12) with Tenon’s and the sclera visualized and the
tunnel through the sclera (in such a the non-dominant hand during tunnel punch reintroduced again through the
way that the blade is seen through the creation in order to have good control Tenon’s incision (Figure 1C). It is inserted
overlying conjunctiva and sclera). At the over the position of the globe while into the AC with the tip directed laterally
limbus, the tip of the blade is angulated making the tunnel. Controlling the eye and once in, it is turned posteriorly
‘”‡ ƒ–‡”‹‘”Ž› –‘ ‰‘ ‹–‘ •—’‡”ϐ‹…‹ƒŽ position with the non-dominant hand to engage the posterior corneal lip. A
cornea in order to create a shallow is important. Holding the globe rotated too horizontally held punch may not
•—’‡”ϐ‹…‹ƒŽ …‘”‡ƒŽ –—‡Ž ƒ• ™‡ŽŽǤ Š‡ upwards as well as pulling it upwards engage the lip and it has to be held at
blade then tunnels about 0.5 to 1mm out of the orbit allows a good tunnel to be an oblique angle. The ostium should be
into the cornea (not too deep but with a created. While entering the AC, direct the created before removing OVD from the
•—ˆϐ‹…‹‡–Ž› –Š‹… Ž‘™‡” Ž‹’Ȍ ƒ† ‹• –Š‡ keratome horizontally without angling it AC to avoid AC shallowing and iris getting
turned horizontally to enter the AC up either upwards towards the endothelium caught in the punch. The ostial punches
to the shoulder of the blade (Figure 1B). or downwards towards the lens. While are directed posteriorly. The ostium need
Small bleeds can occur and generally removing the keratome, it should be not be enlarged horizontally but only
stops itself. Any blood gets washed out quickly pulled out smoothly. Depressing posteriorly towards the limbus, ie. only
at the end easily on irrigation through the keratome blade posteriorly can result lengthen but do not broaden the ostium
a 26 gauge side port. It is important to in aqueous egress and shallowing of the (Figure 1D). Once it has been punched
ƒ‡ –Š‡ –—‡Ž ƒ– ƒ •—’‡”ϐ‹…‹ƒŽ †‡’–ŠǤ AC. The blade should be pulled vertically till the limbus, the remaining punches
The incision should start about 1.5 from backwards without angling it to either can be done under direct visualization by
the limbus. The tunnel should be short in side which could result in the tunnel sides retracting the conjunctival cut and lifting
length (I currently make tunnels shorter getting cut. the scleral tunnel lip. The ostium should
than seen in my early online videos). ‘Ž› „‡ ‡Žƒ”‰‡† –‹ŽŽ –Š‡ ”‡•‹•–ƒ…‡ –‘ ϐŽ‘™
Creating the ostium: A 1 mm is broken. The proximal-most edge of the
Š‡ –—‡Ž •Š‘—Ž† „‡ •—’‡”ϐ‹…‹ƒŽ Kelly’s Descemet’s punch (Appasamy tunnel should only be just seen deep in
in the sclera to give the right depth. Associates, Chennai, India) is used to the depths of the scleral tunnel on lifting
For this, the keratome should be kept make the ostium. A punch with a small the 1.5 mm scleral tunnel lip and rotating
pointing/angulating a bit upwards head is preferable over bulbous space the eye downwards. It should of course
with the heel of the keratome close to ‘……—’›‹‰ Š‡ƒ†•Ǥ ˆ–‡” ϐ‹ŽŽ‹‰ –Š‡ ™‹–Š never extend too close to or beyond the
the sclera. It is important not to make a viscoelastic in order to push the iris away, scleral incision. So take bold punches
deep scleral tunnel. The correct depth is the 1 mm punch is then inserted with the vertically backwards until you reach the
such that one is just able to see the blade tip external to the barrel (ie. Not retracted limbus. After that only nibble backwards
through the overlying lamellar sclera into the barrel). If the punch gets caught taking very small bites.
and conjunctiva. The tunnel enters the in the Tenon’s, the conjunctival incision
AC after about 1 mm lamellar corneal should be opened, the incision in the Peripheral iridectomy (PI): A PI
tunnel at approximate level of anterior
1/3rd and posterior 2/3rd of the cornea.
An important aspect of tunnel creation
is to remember to raise/ angulate the tip
of the advancing blade more anteriorly
at the limbus to change according to the
curvature of the cornea and to prevent
the corneal anterior lip from becoming
too thick. Avoid posterior pressure with
the keratome while entering the AC. A
combination of a deep corneal tunnel and
posterior pressure while entering the
AC can lead to a trapdoor hinging of the
posterior corneal lip and is to be avoided.
Too deep entries can also result in
premature entry and a tunnel that enters
straight into the AC instead of via the
corneal tunnel. This can still be salvaged
by taking a punch of the posterior scleral
lip and making sure your iridectomy is
basal and doesn’t get plugged by the iris.

It helps greatly to hold the eye at
the limbus with a strong one -toothed

38 DOS TIMES - SEPTEMBER-OCTOBER 2015

INNOVATIONS

Figure 2A: The iris is withdrawn from its root while retracting the conjunctiva; Figure 2B: A basal However, if the AC shallows, leaks should
iridectomy is done; Figure 2C: #FGSWCE[ QH QUVKWO CPF 2+ KU EJGEMGF HQT D[ CUUGUUKPI ƀQY Figure be ruled out from the side port and main
2D: A well forming bleb during OVD removal or side port irrigation is a good prognostic sign. port incisions as well as the speculum
should be loosened in case it is applying
is very easy to do and is preferable to be more towards the limbus or excise the excessive pressure on the globe. The AC
done in all cases as the punches go more plugging iris, as the case may be. Check ‹• ϐ‹ŽŽ‡† ƒ‰ƒ‹ ƒ† ‹ˆ •ŠƒŽŽ‘™‹‰ ‹• •–‹ŽŽ
posteriorly close to the iris base. A non- ˆ‘” ‹””‹‰ƒ–‹‘ ƒ‰ƒ‹Ǥ ˆ”‡‡ ϐŽ‘™ ™‹–Š‘—– seen, a releasable suture can be applied
toothed forceps is introduced and the shallowing of the AC is the end point. as in conventional trabeculectomy or
base of the iris grasped. The assistant now a compression suture can be applied
retracts the conjunctiva while the iris is Visualization: At any stage, it is directly trans-conjunctivally. The ends
withdrawn slightly through the mouth easy to view the tunnel by just retracting of the compression suture are cut long.
of scleral tunnel (Figure 2A) and cut the conjunctiva with forceps. It is also The releasable/compression suture
close to the iris base with curved Vannas possible to see the ostium by lifting up the is managed post-operatively just as in
scissors held horizontal to the limbus scleral lip with forceps (saline irrigation trabeculectomy. In our experience, have
(Figure 2B). It should be made sure that by assistant and mopping with a bud had to put a releasable suture in 4-5 cases
the iris is grasped at the base and not in helps to see clearly). Thus the scleral so far out of about 90-100 that I have
the mid-periphery of the iris or to either tunnel and the ostium ca be visualized at done and they are easy to manage.
side of the ostium. The iris should then every step whenever one would like to.
be pushed back into the AC completely Bleb expansion: OVD removal or
either with OVD injection through the Conjunctival closure: Only the irrigation from a 26G side port at the
SIGS tunnel or by gently pulling iris in conjunctiva needs to be sutured and not end causes hyrostatic expansion of the
with a rod inserted from the side port. the scleral tunnel. Care should be taken bleb (Figure 2D). A bleb that forms well
Any dispersed iris pigments in the sub- not to include Tenon’s in the conjunctival intra-operatively indicates a bleb that will
conjunctival space can be washed out. suturing. The cut edges of conjunctiva function well post-operatively as well.
should be sutured to each other in a neat
Š‡…‹‰ ϐŽ‘™ǣ Once the PI is created, and regular way without bunching it all up POST-OPERATIVE MANAGEMENT
‹• ‰‡–Ž› ‹””‹‰ƒ–‡† ‘—– ƒ† ϐ‹Ž–”ƒ–‹‘ which can induce scarring. A 10-0 nylon
checked for (Figure 2C). One trick is to suture is used as 8-0 vicryl has a broader Post-op management is similar but
just hold conjunctival edges together and needle and can cause needle track leak. easier than a trabeculectomy. One can if
look for ballooning on irrigation from side ͺǦͲ ‹…”›Ž ƒŽ•‘ ‹†—…‡• ‹ϐŽƒƒ–‹‘ required do massage, teach the patient
port. If ballooning well without having and related scarring. Conjunctival edge massage, inject 5FU in the inferior sub-
to use force and without AC deepening to edge suturing is done as a running conjunctiva, do a bleb needling on the slit
‡š…‡••‹˜‡Ž›ǡ –Š‡ ‘•–‹— ‹• •—ˆϐ‹…‹‡–Ǥ ˆ –Š‡ suture from one end of the incision to the lamp and so on.
conjunctiva does not balloon, it indicates extreme other end. Tying down a running
one of two possibilities: either the iris is suture twists the edges slightly which ADVANTAGES OF SIGS
plugging the ostium or the two scleral gives a very good leak proof closure.
Ž‹’• ƒ”‡ ‘’’‘•‹‰ ƒ† …Ž‘•‹‰ ‘ˆˆ ϐ‹Ž–”ƒ–‹‘ However it is important to not bunch The advantages that SIGS offers are
(this is the reason a short scleral tunnel up the incision. While suturing the AC numerous. The entire surgery is done
is preferred). In this case either nibble depth is monitored and any shallowing is through a single, small 2.8mm conjuntival
gently to enlarge the ostium just a little looked for. The ideal end-point is to have cut that is well away from the scleral
a soft, yet stable and well maintained AC. cut. The amount of virgin conjunctiva is
maximized and sub-conjunctival drainage
channels are largely intact. There are
Ž‡•• •—–—”‡ ƒ† ϐŽƒ’ ”‡Žƒ–‡† …‘’Ž‹…ƒ–‹‘•Ǥ
Leakage is through a biplanar tunnel and
‘– ˜‹ƒ ƒ –”‹’ƒƒ” ϐŽƒ’Ǥ …‘–”‘ŽŽ‡† Ž‡ƒ
is obtained with a posteriorly directed
ϐŽ‘™Ǥ ‹ˆˆ—•‡ ϐ‹Ž–‡”‹‰ „Ž‡„• ƒ”‡ ‘„–ƒ‹‡†
with SIGS unlike in trabeculectomy blebs
where highly elevated blebs, overhanging
blebs, bleb microtrauma with lid
movements and bleb dysesthesia can
occur. The surgery is easy, fast and less
traumatic and post-operative care is easy
and follows same general principles as
that of trabeculectomy.

CONCLUSION

To conclude, SIGS is an easy and
‡ˆϐ‹…‹‡– ‰—ƒ”†‡† ϐ‹Ž–”ƒ–‹‘ ’”‘…‡†—”‡ –Šƒ–
is slowly but surely becoming more widely
adopted. However there is a learning
…—”˜‡ ƒ† ϐ‹‡ —ƒ…‡• –‘ –Š‡ •—”‰‡”› Œ—•–
as there is for any other surgery and it is
important for the surgeon to familiarize

www. dos-times.org 39

INNOVATIONS

him/ herself with the proper technique. at: http://glaucomatoday.com/pdfs/ stab-incision-glaucoma-surgery-offers-
Adequate virgin conjunctiva should be gt0314_F7_jacob.pdf alternative-to-trabeculectomy
ƒ˜ƒ‹Žƒ„Ž‡ –‘ ƒŽŽ‘™ ’‘•–Ǧ‘’‡”ƒ–‹˜‡ ϐ‹Ž–”ƒ–‹‘ 2. Soosan Jacob, Amar Agarwal. Stab 6. Soosan Jacob. SIGS and Glaucoma
in SIGS. Cases with extensive scarred Incision Glaucoma Surgery. American Surgery. Eurotimes March 2014. http://
conjunctiva will not do well. Ideal initial Academy of Ophthalmology 2014. www.eurotimes.org/node/1216
cases to do are POAG with or without http://www.aao.org/annual-meeting- 7. Soosan Jacob, Amar Agarwal. Stab
’Šƒ…‘‡—Ž•‹ϐ‹…ƒ–‹‘Ǥ
ǡ ˜‹–”‡…–‘‹œ‡† video/stab-incision-glaucoma-surgery Incision Glaucoma Surgery (SIGS) – a
eyes, post-PK glaucoma etc. may not do as 3. Stab Incision glaucoma Surgery: 2nd ‡™ –‡…Š‹“—‡ ˆ‘” ‰—ƒ”†‡† ϐ‹Ž–”ƒ–‹‘
well just as these cases have a higher risk Prize in the ASCRS Film Festival awards, surgery with/ without simultaneous
of failure with trabeculectomy. It is also ASCRS 2014, Boston ’Šƒ…‘‡—Ž•‹ϐ‹…ƒ–‹‘Ǥ ”‡‡ ’ƒ’‡”
much more economical than many of the 4. Kaladevi Satish, Soosan Jacob. Single presentation. ESCRS, London 2014
newer MIGS devices available. SIGS also stab Trabeculectomy: New Technique 8. Soosan Jacob. Stab Incision Glaucoma
allows fast surgery - good for high volume for glaucoma Filtering Surgery for Surgery. Cataract & Refractive Surgery
’”ƒ…–‹•‡Ǥ  ƒ˜‡”ƒ‰‡ǡ ‘‡ …ƒ ϐ‹‹•Š –Š‡ Minimizing Scar Induction and Bleb Today. Aug 2014. Pg81-82. http://
SIGS in an additional 5 min time. Failure. Best paper of Session (BPOS) crstoday.com/2014/08/stab-incision-
award in Glaucoma Surgical Session at glaucoma-surgery
REFERENCES ASCRS 2014 Boston 9. SIGS technique: Eyetube OD Interview
5. Soosan Jacob, Amar Agarwal. Stab at American Society of Cataract and
1. Soosan Jacob. Stab Incision Glaucoma incision glaucoma surgery offers Refractive Surgery Boston 2014.
Surgery. Cover Story in Glaucoma alternative to trabeculectomy. 10. Soosan Jacob, Athiya Agarwal. Outcome
Today. March/April 2014; Pg50-54. Complications Consult. Ocular of Stab Incision Glaucoma Surgery with
http://glaucomatoday.com/2014/04/ Surgery News, US Edition. http:// ƒ† ™‹–Š‘—– ’Šƒ…‘‡—Ž•‹ϐ‹…ƒ–‹‘Ǥ ”‡‡
stab-incision-glaucoma-surgery. Pdf w w w. h e a l i o . c o m / o p h t h a l m o l o g y / paper presentation at ASCRS 2015, San
glaucoma/news/print/ocular- Diego.
surgery-news/%7B09c860b3-13a7-
4805-b407-4891574f0535%7D/

Financial Interest: Š‡ ƒ—–Š‘” †‘‡• ‘– Šƒ˜‡ ƒ› ϔ‹ƒ…‹ƒŽ ‹–‡”‡•– ‹ ƒ› ’”‘…‡†—”‡Ȁ’”‘†—…– ‡–‹‘‡† ‹ –Š‹• ƒ—•…”‹’–Ǥ

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40 DOS TIMES - SEPTEMBER-OCTOBER 2015

MONTHLY MEETING KORNER

OCULAR SURFACE SQUAMOUS NEOPLASIA
MASQUERADING AS SCLERITIS

Medha Sharma, Dheepak Sundar, M. Vanathi, Rachna Meel, Rohan Chawla,
Seema Kashyap, Noopur Gupta, Radhika Tandon

A35 year old male patient was admitted with Ocular surface denotes the cornea and
presenting complaints of recurrent episodes conjunctiva. The term OSSN includes
of pain, redness in right eye for two months. mild dysplasia on one end of the spectrum
Visual acuity was 20 /60 in his right eye and and invasive squamous cell carcinoma
20/20 in the left eye. The patient was on on the other end. CIN includes varying
treatment with systemic and topical steroids
over the past two months for a diagnosis of recurrent anterior
nodular scleritis. Clinical examination of the right eye revealed grades of dysplasia, ranging from mild,
a necrotizing nodule of 7mm x 5mm size, extending from moderate, severe dysplasia to carcinoma
7 o clock to 10 o clock at the temporal limbus with ciliary
in situ
congestion (Figure 1). There were two other nodules superiorly
and inferiorly with overlying intact conjunctiva. Patient had

been diagnosed to have right eye nodular four months back. A comprehensive systemic work up was done to identify
After ruling out all immunological disorders he was started on any infectious causes, which came out to be negative. Tissue
topical prednisolone acetate 1% four times a day. Patient had scraping material sent from the edge of the scleral melt to look
symptomatic improvement for two months. for nocardia , bacteria, fungal, atypical mycobacterium, also did

not show any organism. We planned patient for patch graft in

view of impending perforation and uveal show. A sample of

necrotised sclera and conjunctiva along with 2mm adjacent

healthy margin was sent for histopathology.

Patient presents two months later with redness and pain

in same eye. Visual acuity was 20/20. Slit lamp biomicroscopic

examination of the right eye showed ciliary congestion, intact

patch graft with adjoining area of scleral necrosis (Figure 2-4).

There was appearance of new nodule at 3 o’clock which was not

present when the patient was admitted for patch graft. Fundus

‡šƒ‹ƒ–‹‘ ‘ˆ –Š‡ ‹˜‘Ž˜‡† ”‹‰Š– ‡›‡ ”‡˜‡ƒŽ‡† ƒ ™‡ŽŽ †‡ϐ‹‡†

choroidal mass lesion with two clock hour exudative retinal

detachment (Figure 5). Ultrasound of the right eye showed a

mass lesion in inferotemperal quadrant with progressively

†‡…”‡ƒ•‹‰ ‹–‡”ƒŽ ”‡ϐŽ‡…–‹˜‹–› …‘ϐ‹‡† –‘ …Š‘”‘‹† ™‹–Š

adjacent thickening of choroid with exudative retinal

detachment (Figure 6,7). Gonioscopic examination revealed

normal anterior chamber angle. On ultrasonic biomicroscopy

examination there was hypoechoic mass seen with probable

extension into sclera (Figure 8,9). Histopathology examination

Figure 1: Photograph showing multiple nodules. One nodule at 10 of necrosed sclera and conjunctiva sent during patch graft

o’clock with sclera melt and adjacent necrosis. surgery revealed well differentiated squamous cell carcinoma

(Figure 10). There were no enlarged lymph

nodes in the patient. High resolution

chest tomography (HRCT), ultrasound

abdomen also did not reveal any evidence of

metastasis. Whole body Positron emission

tomography scan showed increase uptake

in the sclera corresponding to the regions of

the clinical nodules in the right eye.

While the patient was undergoing

various investigations his fundus

Figure 2: Area of necrosis and melt below the patch graft. examination after 1 week revealed

www. dos-times.org 41

MONTHLY MEETING KORNER

3 Gross examination of enucleated
globe (Figure 12) showed necrosed sclera
4 as visible clinically along with retinal
detachment. Histopathologic examination
Figure 3,4: Two months postoperative photograph. There is necrosis near patch graft. Appearance revealed numerous keratin pearls with
of new nasal nodule. ƒ”‡ƒ• ‘ˆ …ƒŽ…‹ϐ‹…ƒ–‹‘ ƒ† ‡…”‘•‹• ‹ –Š‡
region of the scleral nodules. Islands of
Figure 5: Fundus photograph showing inferior an inferior 1800 exudative retinal tumour cells were seen invading the
two clock hours exudative retinal detachment detachment with increase in the size Descemets membrane, posterior part of
with choroidal mass. of the choroidal mass lesion (Figure cornea stroma and corneoscleral limbus
11). Repeat excision biopsy from the (Figure 13,14). Malignant cells were
nodular regions showed dysplastic cells seen in the root of iris, ciliary body and
suggestive of squamous cell carcinoma on trabecular meshwork (Figure 15,16).
histopathological examination. Clinical Full thickness involvement of choroid
decision to enucleate the globe was made was also present in more than nine clock
in view of rapid intraocular invasion. hours area (Figure 17).

Ocular surface denotes the cornea
and conjunctiva. The term OSSN includes
mild dysplasia on one end of the spectrum
and invasive squamous cell carcinoma
on the other end. CIN includes varying
grades of dysplasia, ranging from mild,
moderate, severe dysplasia to carcinoma
in situ1. In older population it is third
most common tumour after melanoma
and lymphoma. Invasive squamous cell
carcinoma of conjunctiva (SCC) is less
common as compared to carcinoma
in situ. This usually tends to remain

Figure 6: Ultrasound scan through the globe showing a nodular mass Figure 7: Transverse scan of USG showing choroidal thickening
with retinal detachment inferiorly and adjacent choroidal thickening adjacent to the mass and retinal detachment.

*Cornea, **Oculoplasty, #Retina & ##Ocular Pathology Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India

*Dr. Medha Sharma MD **Dr. Dheepak Sundar MD *Dr. M.Vanathi MD **Dr. Rachna Meel MS

#Dr. Rohan Chawla MD, FRCS ##Dr. Seema Kashyap MD *Dr. Noopur Gupta MD *Dr. Radhika Tandon MD, DNB, FRCSEd

42 DOS TIMES - SEPTEMBER-OCTOBER 2015

MONTHLY MEETING KORNER

89

Figure 8,9: UBM was done using 35 mega htz probe. It showed a hypoechoic mass corresponding to the area of nodule seen clinically with focal
hyperechoic areas. There was likely invasion of the underlying sclera as suggested by the irregular anterior surface of the sclera (arrow) towards the
limbus. More posteriorly the sclera showed a discontinuity/ defect with extension of the tumor into the underlying ciliary body and choroid which
CNUQ UJQYGF HQECN J[RGT TGƀGEVKXG CTGCU UKOKNCT VQ VJQUG UGGP KP VJG PQFWNCT OCUU CPVGTKQTN[ 6JG CPINGU KP VJKU UGEVKQP YGTG UJCTR YKVJ PQ GXKFGPEG
of direct invasion of the angle.

Figure 10: Typical histopathology picture of well differentiated Figure 11: Increase in size of mass with 180° exudative retinal
squamous cell carcinoma detachment

Figure 12: Sectioned globe showing the nodules, retinal detachment. (KIWTG %QTPGC
NQY OCIPKſECVKQP UJQYKPI OCNKIPCPV EGNNU

Figure 14: Invasive squamous cell carcinoma Figure 15: Higher power of angle structure Figure 16: Histopathology showing
invading middle of corneal stroma. showing involvement of trabecular meshwork. involvement of the iris.

www. dos-times.org 43

MONTHLY MEETING KORNER

…‘ϐ‹‡† –‘ –Š‡ •—”ˆƒ…‡ ‘ˆ –Š‡ intraocular invasion and

globe. Intraocular invasion has post– intraocular invasion

been reported in about 3% to 9% specimens.

of cases2. Mucoepidermoid and Our patient was

spindle cell carcinoma, are the young immuno-competent

two common aggressive forms of male. Invasion could have

SCC, which are particularly prone progressed through the patch

to scleral or intraocular invasion graft or through the area of

and recurrence3. However our sclera thinning adjacent to site

patient was young male and of patch graft. Steroids were

it was a well differentiated also given to our patient early

squamous cell carcinoma. in course of illness, this also

Some people have could have been a contributory

postulated that the excision factor for intraocular invasion.

attempt itself can alter the tumor Malignant cells could have

‹ •‘‡ ™ƒ› ‘” ‹ϐŽ—‡…‡ –Š‡ ‹ϐ‹Ž–”ƒ–‡† –Š”‘—‰Š ‡‹••ƒ”›
local environment in such that Figure 17: %JQTQKF KU KPſNVTCVGF YKVJ KUNCPFU QH VWOQWT EGNNU veins at limbus as the Schlemm

the recurrent tumor is somehow true in every case as some have reported canal and meshwork were also

more aggressive4. But this doesn’t hold tumors of same histology grade in pre– involved.

REFERENCES 3. Cohen BH, Green WR, Iliff NT, et al. Spindle cell carcinoma of the
conjunctiva. Arch Ophthalmol. 1980;98:1809-13
1. Lee GA, Hirst LW. Ocular squamous surface neoplasia. Survey
Ophthal 1995;39:429-50 4. Erie JC, Campbell RJ, Liesegang TJ. Conjunctival and corneal
intraepithelial and invasive neoplasia. Ophthalmology
2. Finger PT, Tran HV, Turbin RE, et al. High-frequency 1986;93:176–83.
ultrasonographic evaluation of conjunctival intraepithelial
neoplasia and squamous cell carcinoma. Arch Ophthalmol
2003;121:168–72.

Clinical case presented in DOS Monthly Clinical Meeting-1 on July 26, 2015 at R.P. Centre, Jawaharlal Auditorium,
AIIMS, New Delhi

Financial Interest: Š‡ ƒ—–Š‘”• †‘ ‘– Šƒ˜‡ ƒ› ϔ‹ƒ…‹ƒŽ ‹–‡”‡•– ‹ ƒ› ’”‘…‡†—”‡Ȁ’”‘†—…– ‡–‹‘‡† ‹ –Š‹• ƒ—•…”‹’–Ǥ

44 DOS TIMES - SEPTEMBER-OCTOBER 2015

MONTHLY MEETING KORNER

BILATERAL SIMULTANEOUS CXL+INTACS FOR
PROGRESSIVE KERATOCONUS

Ramendra Bakshi

Dr. Ramendra Bakshi MS, FRCS, FMRF Bilateral simultaneous CXL with Intacs was performed
Consultant, Cornea Cataract and Refractive Surgery with the help of femtosecond laser.
Eye 7 Group of Eye Hospitals,
New Delhi, India Post op at 2 months (Figure 4) Pentacam showed
…‘•‹†‡”ƒ„Ž‡ …‘”‡ƒŽ ϐŽƒ––‡‹‰Ǥ ‹‰Š– ›‡ ͳ ͶͲǤʹǡ ʹ ͶͺǤͷǡ
A21 year old gentleman presented with Kmax 52.9 (Figure 5). Left Eye K1 42.8, K2 49.6, Kmax 53.0
complaints of progressive dimness of vision (Figure 6). UCVA improved to 6/12 Both Eyes. Post-op BCVA
both eyes since the last one year. He also gave and refraction were as follows: Right Eye E -1.50X 10 6/6 and
history of frequent change of glasses in both Left Eye -0.75X145 6/9.
eyes.
On examination his UCVA was 6/36 Right Discussion Intrastromal rings (Intacs) are used in corneal
Eye and 6/24 Left Eye. Refraction and BCVA was -2.00/-4.50x10 ectasias and improve Corneal biomechanical stability as well
improving to 6/12 Right Eye and -1.25/-4.50x160 improving ƒ• ”‡‰—Žƒ”‹œ‡ –Š‡ ‘’–‹…ƒŽ ‹‡ˆϐ‹…‹‡…› ‘ˆ –Š‡ ‹””‡‰—Žƒ” …‘”‡ƒǤ
to 6/12p Left Eye. Intraocular pressure by NCT was 16 and ICRS along with collagen cross linking has opened new vistas
14 Right and Left Eye respectively. Fundus examination was in the treatment of keratoconus and corneal ectasia. While
normal Both Eyes. There was no other ocular pathology or any cross linking stops the progression of the ectasia and reverses
associated systemic illness. ‹– –‘ •‘‡ ‡š–‡–ǡ ϐŽƒ––‡ ‘” ‘”ƒŽ‹œ‡ –Š‡ …‘”‡ƒŽ •Šƒ’‡Ǥ
Combining both the modalities together has a synergistic action
Pentacam Right Eye (Figure 1) showed K1 45.1,K2 51.7,
Kmax 55.9 Dioptres, Thinnest Pachy was 424 microns. Left Figure 2: Pentacam Left Eye along with pre-op plan
eye values (Figure 2) were K1 46.5, K2 53.2, Kmax 57.3 and
Thinnest Pachy 416 microns.

A diagnosis of progressive keratoconus both eyes was
made. Management Options available were RGP Lenses,
CXL alone, CXL followed by Intra Stromal Rings (Intacs) or
Simultaneous CXL with Intra Stromal Rings. We decided to
choose the option of simultaneous CXL with Intacs both eyes.

Refraction was transposed in positive cylinder which was
-6.50/+4.50X100 6/12 Right Eye and -5.75/+4.50X70 6/12P
Left eye. The steep axis on topography and the axis of positive
cylinder in manifest refraction correlated in both eyes which
helps to plan the incision site for placement of the rings (Figure
3).

Figure 1: Pentacam Right Eye along with pre-op plan Figure 3: FS-200, Femtosecond assisted channels for Intacs
www. dos-times.org 45

MONTHLY MEETING KORNER

Figure 4: Two months post op, Slit Lamp photo Right and Left Eye

Figure 5: Post op Pentacam Right Eye Figure 6: Post op pentacam Left eye

and can be performed simulatneously or CXL (Intacs with CXL group).The addition CONCLUSIONS
sequentially. of CXL to the Intacs procedure resulted in
greater keratoconus improvements than ICRS in conjunction with CXL
SEQUENTIAL CXL +INTACS Intacs insertion alone. CXL augmented serves a dual purpose of halting disease
the reversal effect of Intacs on the progression and normalizing the corneal
Although the progression is arrested keratoconus cone as shown by the greater shape. Improvement in UCVA & BCVA
by CXL and corneal rigidity improves changes in cylinder, K steep, K average, in occurs in the same sitting. This has a
and eventually the corneal shape is the Intacs with CXL group. synergistic action and is convenient
normalized by Intacs, yet the mechanical for the patient as in a single sitting the
ϐŽƒ––‡‹‰ ‡ˆˆ‡…– ‹• Ž‡•• –Šƒ ’”‡†‹…–‡† ǎ‹… ‡– ƒŽǤ ‹ –Š‡‹” •‡”‹‡• ‘ˆ ͳ͵ͳ procedure is complete.
Intacs nomogram. Moreover, there is a eyes with a mean follow up of 7
delay of 6-8 months in visual recovery. months evaluated the effectiveness of REFERENCES
Although each treatment step improves ‹–”ƒ…‘”‡ƒŽ ”‹„‘ϐŽƒ˜‹ ‹Œ‡…–‹‘ ˆ‘”
the cornea, a stiffer cornea that has been combined collagen crosslinking (CXL) and 1. Coskunseven E, Jankov MR, 2nd, Hafezi
–”‡ƒ–‡† „› †‡…”‡ƒ•‡• –Š‡ ϐŽƒ––‡‹‰ (ICRS) implantation. The mean manifest F, Atun S, Arslan E, Kymionis GD. Effect
effect of ICRS implantation, thus spherical refraction decreased from -3.87 of treatment sequence in combined
restricting its effect and decreasing the +/-4.55 diopters (D) to -1.25 +/- 2.31 D, intrastromal corneal rings and corneal
ƒš‹— ϐŽƒ––‡‹‰ ’‘–‡–‹ƒŽǤ the mean manifest cylinder improved collagen crosslinking for keratoconus.
from -3.89 +/- 1.97 D to -2.27 +/- 2.18 J Cataract Refract Surg. 2009;35:2084–
SIMULTANEOUS CXL+INTACS D, and the mean K reading improved 2091.
from 50.50 +/- 5.26 D to 46.03 +/- 4.51
Chan et al did a retrospective ȋƒŽŽ δǤͲͷȌǤ Š‡› …‘…Ž—†‡† –Šƒ– –Š‡ 2. Chan CC Effect of inferior-segment Intacs
nonrandomized comparative case series combined procedure was effective in with and without C3-R on keratoconus. J
comprising of 12 eyes of 9 patients who ‡”ƒ–‘…‘‹… ‡›‡•Ǥ –”ƒ…‘”‡ƒŽ ”‹„‘ϐŽƒ˜‹ Cataract Refract Surg. 2007;33:75-80.
had inferior-segment Intacs placement injection into the tunnel was safe and
without CXL (Intacs-only group) and 13 may provide more penetration without ͵Ǥ ‹Ž‹… ‡– ƒŽǤ ‹„‘ϐŽƒ˜‹ ‹Œ‡…–‹‘ ‹–‘ –Š‡
eyes of 12 patients who had inferior- epithelial removal. corneal channel for combined collagen
segment Intacs placement combined with crosslinking and intrastromal corneal ring
segment implantation. J Cataract Refract
Surg. 2012;38:878-83.

4. El-Raggal TM. Sequential versus
concurrent KERARINGS insertion
and corneal collagen cross-linking for
keratoconus. Br J Ophthalmol. 2011;95:37-
41.

Clinical case presented in DOS Monthly Clinical Meeting-1 on July 26, 2015 at R.P. Centre, Jawaharlal Auditorium,
AIIMS, New Delhi

Financial Interest: Š‡ ƒ—–Š‘” †‘‡• ‘– Šƒ˜‡ ƒ› ϔ‹ƒ…‹ƒŽ ‹–‡”‡•– ‹ ƒ› ’”‘…‡†—”‡Ȁ’”‘†—…– ‡–‹‘‡† ‹ –Š‹• ƒ—•…”‹’–Ǥ

46 DOS TIMES - SEPTEMBER-OCTOBER 2015

MONTHLY MEETING KORNER

END STAGE STEVENS JOHNSON SYNDROME:
CAN WE DO SOMETHING???

Rajat Jain, Swapnil Bhalekar

Stevens-Johnson syndrome is a rare, acute, blistering disease affecting the

•‹ ƒ† ƒ– Ž‡ƒ•– –™‘ —…‘—• ‡„”ƒ‡•Ǥ
‹• †‡ϐ‹‡† ™Š‡ –Š‡ †‡—†‡†

E cutaneous surface is less than 10% of the body surface area
nd stage ocular sequelae of Stevens Johnson initiated. As the patient had a bone severe dry ocular surface,
Syndrome (SJS) is characterised by corneal the options of keratoplasty and stem cell transplantation were
scaring and opacity in a setting of a very severe done away with. We chose to perform a new keratoprosthesis-
dry eye. The options of visual rehabilitation in LVP Keratoprosthesis for the patient. The surgery was planned
such a clinical setting are limited. We present a –‘ ’‡”ˆ‘” ‹ –™‘ •–ƒ‰‡•Ǥ Š‹Ž‡ –Š‡ ϐ‹”•– •—”‰‡”› ™‘—Ž† ‹˜‘Ž˜‡

novel technique of management of such a case. To resection of pannus over the cornea covering the ocular surface

–Š‡ „‡•– ‘ˆ ‘—” ‘™Ž‡†‰‡ǡ –Š‹• ‹• –Š‡ ϐ‹”•– •—…Š …ƒ•‡ ’‡”ˆ‘”‡† with a oral buccal mucosal graft, keratoprosthesis proper was

in this region. supposed to be implanted at the second step 2 months later.

CASE SURGERY: STAGE 1
Pannus Resection: The patient was advised to perform
History: A 21 year young male non-hypertensive, non-
diabetic male presented with severe dry eyes and decreased betadine gargles after every meal for 3 days prior to the surgery.
vision in the left eye since past 15 years. He gave a history of The surgery was performed under local anesthesia. A gauge
sudden damage to both eyes in childhood about 15 years back piece soaked in lignocaine 2% jelly was put in the sub-labial
after a severe allergic reaction to the body 15 days after fever. area of the oral cavity 30 minutes prior to the surgery. This was
The allergic reaction was severe enough to cause multiple done to anesthetise the area from which the graft was supposed
blisters on the whole body including the mouth. As per history to be harvested (Figure 2A). The eye was painted and draped
while the blisters healed in next 5-6 months, the eye condition (Figure 2B). Conjuncival peritomy was performed all around
continued to worsen after that. The right eye was lost then. and the four recti muscles were tagged. The pannus over the
He look treatment from his local doctors for the left eye for
–Š‡ ‡š– ͵ ›‡ƒ”•Ǥ ‡ Šƒ† •—ˆϐ‹…‹‡– ˜‹•‹‘ –Š‡ –‘ ’‡”ˆ‘” Š‹• Figure 1(A): Clinical examination revealed a phthisical right eye;
daily chores. Subsequently the vision had been stable for next 1(B): Left eye was severely photophobic 1(C): and showed lower lid
5 years after which it gradually deteriorated. Presently, he was entropion, minimal lid margin keratinization, vascularised pannus and
unable to perform his daily activities and was dependent on a corneal scar over a bone dry, dermalized ocular surface.
another person to even take him to the bathroom. He had been
on various combinations of lubricating eye drops in the past. He Figure 2(A): Pannus Resection: Gauge piece soaked in lignocaine 2%
also gave the history of multiple consultations for this problem jelly was placed in the area of the potential graft; 2(B): Eye was painted
wherein he was told that this disease was un-treatable. and draped; 2(C): Conjuncival peritomy and Tenon’s dissection, recti
muscles were tagged, pannus over the cornea was resected. A clear
Clinical Presentation: At presentation, he had no cornea with total cataract was observed underneath.
perception of light in his right eye and accurate projection of
rays in the left eye. On examination, right eye was phthisical
ȋ ‹‰—”‡ ͳ ȌǤ Š‡ ’ƒ–‹‡– Šƒ† †‹ˆϐ‹…—Ž–› ‹ ‘’‡‹‰ –Š‡ Ž‡ˆ– ‡›‡
due to severe photophobia (Figure 1B). Left eye showed lower
lid entropion, minimal lid margin keratinization, vascularised
pannus and a corneal scar over a bone dry, dermalized ocular
surface. Anterior chamber details were hazy and the patient
had a total cataract (Figure 1C). Intraocular pressure appeared
to be normal on digital palpation. B scan ultrasound of the
posterior segment was normal. Considering the history of a
severe drug reaction in the past with blister formation and the
presentation of a very severe dry eye, a diagnosis of Stevens
Johnson Syndrome with its consequent ocular sequelae was
made.

Management: The ocular surface lubricants were
continued and measures to maintain lid hygiene were also

www. dos-times.org 47

MONTHLY MEETING KORNER

recti muscles and intervening tenons
(Figure 4A&B).

Post-operatively the patient was
advised betadine gargles after every meal.
Systemic antibiotics, corticosteroids and
ƒ–‹Ǧ‹ϐŽƒƒ–‘”› †”—‰• ™‡”‡ ’”‡•…”‹„‡†
for the next 2 weeks. A pink, vascularised
‰”ƒˆ– ™ƒ• •‡‡ ƒˆ–‡” ͹ ™‡‡• ƒˆ–‡” –Š‡ ϐ‹”•–
surgery (Figure 4C).

Figure 3(A): Harvesting Oral Mucosal Graft: sub-labial area was exposed and cleaned with SURGERY: STAGE 2
betadine 10% solution; 3(B): 30 x 25 mm area was marked with gentian violet, 3(C): Sub-mucosal
lignocaine with adrenaline (1:1,600,000) injected 3(D): and blanching was noted 3(E,F): Marked An aphakic keratoprosthesis of
area was dissected. standard axial length was ordered.
The surgery was again done in local
Figure 4(A,B): Transplantation of Mucous Membrane Graft on ocular surface: harvested graft was anesthesia.
sutured on ocular surface using 8-0 vicryl sutures to recti muscles and intervening tenons capsule.
4(C): Pink, vascularised graft was seen after 7 weeks. The oral mucous graft was incised
in the centre and lifted from the ocular
cornea was resected. A clear cornea with mucosal graft was harvested using a surface (Figure 5A). The cornea was
total cataract was observed underneath 15 blade on Bard Parker handle, mono- trephined (Figure 5B) in central 8.5 mm
(Figure 2C) Attention was now diverted polar cautery and conjunctival scissors and the cataract was removed. LVP kpro
to the oral area. (Figure 3e&f) An adequate graft is thin was assembled in the centre of a 9 mm
and without sub-mucosal fat and button- donor graft. This was then secured with
Harvesting Oral Mucosal Graft: holes. Utmost care was taken to avoid ͳ͸ ‹–‡””—’–‡† ‘‘ϐ‹Žƒ‡– •—–—”‡•
The sub-labial area was exposed using †ƒƒ‰‡ –‘ –Š‡ —†‡”Ž›‹‰ —•…Ž‡ ϐ‹„”‡•ǡ (Figure 5C). The mucous membrane
4-0 silk sutures (Figure 3A) and cleaned nerves and vessels. The harvested graft graft was then sutured back with it
with betadine 10% solution. A 30 x was kept immersed in 5% povidone surroundings with 8-0 vicryl sutures.
25 mm area was marked with gentian iodine until used. The sub-labial area was Finally, a central 3-4 mm opening was
violet (Figure 3B) and sub-mucosal left bare to heal with secondary intention. made in the graft and the keratoprosthesis
lignocaine with adrenaline (1:1,600,000) cylinder was exposed (Figure 5D). The
was injected to separate the planes Transplantation of Mucous cut ends of the graft were tucked in
and achieve hemostasis (Figure 3C). Membrane Graft on ocular surface: under the 1mm peripheral plate of the
Considerable blanching was seen within The graft was taken and sutured on the keratoprosthesis. A lateral paramedian
2 minutes (Figure 3d). The marked ocular surface using 8-0 vicryl sutures. tarsorrhaphy was done in the end.
area was dissected and a full thickness Attachments were made with the four
Outcome: The patient was stable
and complained of pain in the graft side
on post-operative day 1. The edema at
the graft-site and at the ocular surface
gradually decreased. He had a best
corrected visual acuity of 6/12 at 1
month. The graft was vascularised and
the patient was happy (Figure 6).

DISCUSSION

Stevens-Johnson syndrome (SJS) is
a rare, acute, blistering disease affecting
the skin and at least two mucous
membranes1Ǥ
‹• †‡ϐ‹‡† ™Š‡ –Š‡
denuded cutaneous surface is less than
10% of the body surface area (BSA). It
is termed as overlapping SJS-TEN when
the detachment involves 10-30% of BSA
and TEN when over 30% of the body

1. Cornea and Ocular Surface, DrishtiCONE Eye Care, Shalimar Bagh, Delhi.
2. Consultant Eye Surgeon,Vision Care Centre, Shirur, Maharashtra

1Dr. Rajat Jain MS, FICO (UK), FLVPEI 2Dr. Swapnil Bhalekar MS, FLVPEI

48 DOS TIMES - SEPTEMBER-OCTOBER 2015

MONTHLY MEETING KORNER

surface area is denuded2. The „› ’”‘Ž‘‰‡† ‹ϐŽƒƒ–‹‘ǡ

etiology of SJS/TEN is immune persistent epithelial defects,

mediated triggered by drugs corneal melting, perforation

and less commonly by systemic and eventual graft failure20-22.

viral or Mycoplasma pneumonia Such eyes are suitable

infections3-7. The most common for keratoprosthesis. The

drugs found to be associated commonly used Kpro today are

are sulphonamide antibiotics, Boston Kpro (Dohlman, USA)

allopurinol, carbamazapine, and OOKP (Falcinelli, Italy).

phenobarbital, phenytoin, and In completely dry eyes,

oxicam-NSAIDs8. Patel et al the popular Boston type 1

reported that antimicrobials keratoprosthesis cannot be

(37.27%), anti-epileptics implanted in the standard

(35.73%) and non-steroidal anti- way as the carrier corneal

‹ϐŽƒƒ–‘”› †”—‰• ȋͳͷǤͻ͵ΨȌ graft is vulnerable to surface

were the most common culprits breakdown and melting. The

in the Indian population9. The Boston type 2 kpro is specially

reported incidence varies from designed for such eyes23.

1.2 to 6 per million patient-years The longer optical cylinder

for SJS. The incidence rises with of the type 2 kpro can be

increasing age and is strikingly Figure 5: Surgery: Stage 2 5(A): Mucous graft was centrally incised and exposed through an opening
greater in the presence of HIV lifted; 5(B): Cornea was trephined in central 8.5 mm and the cataract in the lids, which are sutured
infection10-13. The pathobiological was removed; 5(C): LVP kpro assembly was secured with 16 interrupted together. The lid skin acts
mechanisms underlying the OQPQſNCOGPV UWVWTGU 5(D): Central 3-4 mm opening was made in the as a stable epithelial cover

onset of SJS/TEN complex have graft and keratoprosthesis cylinder was exposed [Photo courtesy – Dr over the donor corneal graft
yet to be fully elucidated. It has Swapnil Bhalekar].
preventing exposure. The

both an immunological and a anatomical survival and visual

genetic basis. outcomes of the Boston type

The acute stage of SJS is 2 kpro are fair to moderate

…Šƒ”ƒ…–‡”‹•‡† „› ‹ϐŽƒƒ–‹‘ with almost 60% retention

at least two mucous membranes over 108 person years and

of the body. The most common improvement of vision to more

ocular condition seen at this than 20/200 in 70% of cases23.

stage is bilateral conjunctivitis These outcomes fare well in

which occurs in 15-75% of …‘’ƒ”‹•‘ ™‹–Š –Š‡ ‘†‹ϐ‹‡†

patients14,15. However, most osteo-odonto keratoprosthesis

patients come to the eye (MOOKP) when used in similar

clinic after having recovered indications24,25. Alternatives

•—ˆϐ‹…‹‡–Ž› ˆ”‘ –Š‡ ƒ…—–‡ •–ƒ–‡ –‘ to using type 1 designs

leave the hospital. They typically by modifying the surgical

complain of a progressively technique to enhance survival

worsening red eye. Persistent in completely dry eyes have

‹ƪƒƒ–‹‘ ƒ† —Ž…‡”ƒ–‹‘ now been described26. The

of the ocular surface along ϐ‹”•– ˜ƒ”‹ƒ–‹‘ ‹• –Š‡ —•‡ ‘ˆ ƒ

with cicatricial complications type 1 design under the cover

of the lids amount to chronic of a previously transplanted

ocular sequelae occurring in oral mucosal graft covering

up to 35% of patients16. Lid Figure 6: Post-operative 1 month with a healthy and vascularised graft the bulbar surface (Figure 7A).
and a Kpro exposed in centre.
ƒ”‰‹ ‹ϐŽƒƒ–‹‘ –ƒ”‰‡–• –Š‡ This is a two-staged procedure
meibomian glands in particular, and requires repeated mucosal

and causes widespread destruction of the of vision loss in these patients. End- trimming subsequently to create
‰Žƒ†• ƒ† –Š‡‹” ‘”‹ϐ‹…‡•ǡ ƒ† †‹•–‹…Š‹ƒ•‹•Ǥ stage disease is characterized by a dry, adequate exposure of the optical cylinder.
Contracture of the palpebral conjunctiva keratinized ocular surface which further Retraction of the mucosal cover with
leads to cicatricial entropion and limits any future corneal or limbal cell exposure of the underlying corneal graft
trichiasis17,18. These changes, along with transplantation17,18. ‹• ƒŽ•‘ ƒ ’‘••‹„‹Ž‹–›Ǥ ‘–Š‡” ‘†‹ϐ‹…ƒ–‹‘
a chronic dry eye due to loss of lacrimal ‘ˆ –Š‡ –›’‡ ͳ †‡•‹‰ ‹• –Š‡ Dz ’”‘dzǡ
gland function, contribute to corneal Patients with end stage corneal ‹ ™Š‹…Š –Š‡ ˆ”‘–Ǧ’Žƒ–‡ ‹• ‘†‹ϐ‹‡† –‘
damage later via repeated blink-related blindness in a setting of a severe dry project 1 mm above the carrier corneal
microtrauma to the corneal epithelium eye cannot be visually rehabilitated by graft allowing the mucosal graft to be
on a compromised ocular surface19. Long penetrating keratoplasty, limbal stem cell tucked under it thus preventing mucosal
term, destruction of the corneal limbal transplantation or cultivated oral mucosal overgrowth11 (Figure 7B). However, the
stem cells is the most common cause epithelial transplantation (COMET). ”‡’‘”–‡† ‘—–…‘‡• ‘ˆ ‘†‹ϐ‹‡† –›’‡
These proceures are often complicated

www. dos-times.org 49

MONTHLY MEETING KORNER

Figure 7(A): Variations in LVP Kpro Design: type 1 design under the cover of a previously syndrome. Ocular prognosis
transplanted oral mucosal graft; 7(B): ő.82 -RTQŒ KP YJKEJ VJG HTQPV RNCVG KU OQFKſGF VQ RTQLGEV and treatment. Am J Ophthalmol
mm above the carrier corneal graft allowing the mucosal graft to be tucked under it thus preventing 1963;55:893-900.
mucosal overgrowth. [reproduced from BMJ Case Rep 2014; Mar 24;2014]. 15. Patz A. Ocular involvement in
erythema multiforme. Arch Ophthal
1 designs and of the type 2 design in P, Guillaume JC. Toxic epidermal 1950;43:244-56.
completely dry eyes are limited. 16. Arstikaitis MJ. Ocular aftermath of
necrolysis (Lyell syndrome). J Am Stevens-Johnson syndrome. Arch
Though long-term outcomes are Ophthalmol 1973;90:376-9.
awaited, patients with end stage ocular Acad Dermatol 1990;23:1039-58. 17. De Rojas MV, Dart JK, Saw VP. The
sequelae of SJS are now treatable with natural history of Stevens Johnson
a potential of very good vision and a 7. Sontheimer RD, Garibaldi RA, syndrome: patterns of chronic ocular
”‡•–”‹…–‡† ˜‹•—ƒŽ ϐ‹‡Ž†Ǥ ”‘’‡” ’ƒ–‹‡– disease and the role of systemic
selection and appropriate surgical Krueger GG. Stevens-Johnson immunosuppressive therapy. Br J
planning is essential. The role of Ophthalmol 2007;91:1048-53.
pschycological councelling of the patients syndrome associated with 18. Di Pascuale MA, Espana EM, Liu
and the relatives is however paramount. DT et al. Correlation of corneal
Mycoplasma pneumoniae infections. complications with eyelid cicatricial
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Arch Dermatol 1978;114:241-4. Johnson syndrome and toxic
epidermal necrolysis syndrome.
8. Mockenhaupt M, Viboud C, Dunant Ophthalmology 2005;112:904-12.
19. Cher I. Blink-related microtrauma:
A et al. Stevens-Johnson syndrome when the ocular surface harms
itself. Clin Experiment Ophthalmol
and toxic epidermal necrolysis: 2003;31:183-90.
20. Tugal-Tutkun I, Akova YA, Foster
assessment of medication risks with CS. Penetrating keratoplasty in
cicatrizing conjunctival diseases.
emphasis on recently marketed Ophthalmology 1995;102:576-85.
21. Solomon A, Ellies P, Anderson DF et al.
drugs. The EuroSCAR-study. J Invest Long-term outcome of keratolimbal
allograft with or without penetrating
Dermatol 2008;128:35-44. keratoplasty for total limbal stem
…‡ŽŽ †‡ϐ‹…‹‡…›Ǥ ’Š–ŠƒŽ‘Ž‘‰›
9. Patel TK, Barvaliya MJ, Sharma D, 2002;109:1159-66.
22. Shimazaki J, Higa K, Morito F et
Tripathi C. A systematic review of ƒŽǤ ƒ…–‘”• ‹ϐŽ—‡…‹‰ ‘—–…‘‡•
in cultivated limbal epithelial
1. French LE. Toxic epidermal necrolysis the drug-induced Stevens-Johnson transplantation for chronic cicatricial
ocular surface disorders. Am J
and Stevens Johnson syndrome: our syndrome and toxic epidermal Ophthalmol 2007;143:945-53.
23. Pujari S, Siddique SS, Dohlman
current understanding. Allergol Int necrolysis in Indian population. CH, Chodosh J. The Boston
keratoprosthesis type II: the
2006;55:9-16. Indian J Dermatol Venereol Leprol ƒ••ƒ…Š—•‡––• ›‡ ƒ† ƒ” ϐ‹”ƒ”›
experience. Cornea 2011;30:1298-
2. Bastuji-Garin S, Rzany B, Stern 2013;79:389-98. 303.
24. Basu S, Pillai VS, Sangwan VS.
‡– ƒŽǤ Ž‹‹…ƒŽ …Žƒ••‹ϐ‹…ƒ–‹‘ ‘ˆ 10. Correia O, Chosidow O, Saiag P —…‘•ƒŽ …‘’Ž‹…ƒ–‹‘• ‘ˆ ‘†‹ϐ‹‡†
osteo-odonto keratoprosthesis in
cases of toxic epidermal necrolysis, et al. Evolving pattern of drug- chronic Stevens-Johnson syndrome.
Am J Ophthalmol 2013;156:867-73.
Stevens-Johnson syndrome, and induced toxic epidermal necrolysis. 25. Iyer G, Pillai VS, Srinivasan B et al.
Mucous membrane grafting for lid
erythema multiforme. Arch Dermatol Dermatology 1993;186:32-7. margin keratinization in Stevens-
Johnson syndrome: results. Cornea
1993;129:92-6. 11. Mockenhaupt M, Rzany B. The 2010;29:146-51.
26. Basu S, Sureka S, Shukla R,
3. Borrelli M, Schroder C, Dart JK epidemiology of serious cutaneous Sangwan V. Boston type 1 based
keratoprosthesis (Auro Kpro) and its
et al. Long-term follow-up after drug reaction. In: Williams HC, ‘†‹ϐ‹…ƒ–‹‘ ȋ ’”‘Ȍ ‹ …Š”‘‹…
Stevens Johnson syndrome. BMJ Case
submandibular gland transplantation ed. The Challenge of Dermato Rep 2014; Mar 24;2014.

in severe dry eyes secondary to Epidemiology. Boca Raton/New

cicatrizing conjunctivitis. Am J York: CRC Press, 1997:329-42.

Ophthalmol 2010;150:894-904. 12. Pitche P, Padonou CS, Kombate K et

4. McCormack JG. Mycoplasma al. [Stevens-Johnson syndrome and

pneumoniae and the erythema toxic epidermal necrolysis in Lome

multiforme--Stevens Johnson (Togo). Evolutional and etiological

syndrome. J Infect 1981;3:32-6. ’”‘ϐ‹Ž‡• ‘ˆ ͶͲ …ƒ•‡•ȐǤ  ‡”ƒ–‘Ž

5. Revuz J, Roujeau JC, Guillaume JC Venereol 2005;132:531-4.

et al. Treatment of toxic epidermal 13. Wolkenstein P, Revuz J. Drug-induced

necrolysis. Creteil’s experience. Arch severe skin reactions. Incidence,

Dermatol 1987;123:1156-8. management and prevention. Drug

6. Roujeau JC, Chosidow O, Saiag Saf 1995;13:56-68.

14. Howard GM. The Stevens-Johnson

Guest case presented in DOS Monthly Clinical Meeting, on March 2015 at Centre For Sight, Safdarjung Enclave, New Delhi

Financial Interest: Š‡ ƒ—–Š‘”• †‘ ‘– Šƒ˜‡ ƒ› ϔ‹ƒ…‹ƒŽ ‹–‡”‡•– ‹ ƒ› ’”‘…‡†—”‡Ȁ’”‘†—…– ‡–‹‘‡† ‹ –Š‹• ƒ—•…”‹’–Ǥ

50 DOS TIMES - SEPTEMBER-OCTOBER 2015

DIAGNOSTICS DISCUSSION

IDIOPATHIC POLYPOIDAL CHOROIDAL VASCULOPATHY

Shahana Mazumdar, Ritesh Narula, Ashish Kakkar

A69 years old healthy lady presented with (A) (B)
diminution of vision in the right eye since a
few days. She had lost vision in the left eye 8 Figure 2: Simultaneous Fluorescein angiography (FFA) 2A: and
years ago for which she had received injections Indocyanine green angiography (ICGA) 2B: The FFA showed pooling
in the eye. BCVA was 6/12, N12 in OD and QH F[G CV VJG OCEWNC ſNNKPI VJG 2'& YKVJ CP CTGC QH UVKRRNGF NCVG
CFCF. OS. OD (Figure 1) showed a healthy optic J[RGTƀWQTGUEGPEG VGORQTCN VQ VJG 2'& 6JG +%)# UJQYGF OCUMKPI
nerve head and pigment epithelial detachment (PED) at the QH VJG ƀWQTGUEGPEG KP VJG CTGC QH VJG 2'& YKVJ UOCNN J[RGTƀWQTGUEGPV
macula and OS showed a large area of scarring at the posterior polyps temporally.
pole. Fluorescein angiography (FFA) (Figure 2) OD revealed
’‘‘Ž‹‰ ‘ˆ –Š‡ †›‡ ƒ– –Š‡ ƒ…—Žƒ ϐ‹ŽŽ‹‰ –Š‡ ™‹–Š ƒ ƒ”‡ƒ
‘ˆ •–‹’’Ž‡† Š›’‡”ϐŽ—‘”‡•…‡…‡ –‡’‘”ƒŽ –‘ –Š‡ Ǥ
ȋ‹
though syanine green angiography) showed a dark area of
ƒ•‹‰ ‘ˆ –Š‡ ϐŽ—‘”‡•…‡…‡ ‹ –Š‡ ƒ”‡ƒ ‘ˆ –Š‡ ™‹–Š •ƒŽŽ
Š›’‡”ϐŽ—‘”‡•…‡– ’‘Ž›’• –‡’‘”ƒ”ƒŽ›Ǥ ƒ…—Žƒ ȋ ‹‰—”‡ ͵
and B) through the lesions showed a tense elevation of the RPE
with small elevations of the RPE in the area of the polyps. The
latest technique of OCT angiography (Figure 3 C and D) was
used to visualize a possible network of blood vessels in the area
though no polyps could be picked up.

Since the polyps are extrafoveal the patient is being taken
up for anti VEGF injections followed by laser photocoagulation
of the polyps. There is a potential risk of RPE rip with all
modalities of treatment and also without treatment, which has
been explained to the patient.

Figure 1: Fundus photography right eye showing pigment epithelial Figure 3A& B: OCT angiography images showing a possible vascular
detachment at the macula and altered pigmentation temporally. network temporal to the PED in the area of the polyps though no
polyps could be visualized. C&D: OCT macula (horizontal and vertical
*Retina Department ICARE Eye Hospital, NOIDA, U.P. India. scans) showing a tense PED and multiple small irregularities of the RPE
** Retina Specialist Centre For Sight, New Delhi India in the horizontal scan (C) through the area of the polyps.

The case is being presented to show the use of ICGA
–‘ …‘ϐ‹” –Š‡ †‹ƒ‰‘•‹• ‘ˆ ’”‘˜‹†‹‰ –Š‡ ‘’’‘”–—‹–›
‘ˆ ƒ ’‘–‡–‹ƒŽŽ› †‡ϐ‹‹–‹˜‡ –”‡ƒ–‡– ‘ˆ –Š‹• …‘†‹–‹‘Ǥ Ž•‘
availability of the latest technique of OCT angiography may
be used to attempt to visualize the polyps/network. OCT
angiography is an emerging technique using high resolution
OCT to visualize the retinal vasculature without injecting
any dye. More experience with this technique will unravel its
potential as a diagnostic tool.

*Dr. Shahana Majumdar MS **Dr. Ritesh Narula MS *Dr.Ashish Kakkar MD
www. dos-times.org 51

CLINICAL SPOTLIGHT - RETINA

A New dimension into Focus :

INTRAOPERATIVE SURGICAL MICROSCOPE WITH:
INTEGRATED OCT (iOCT) AND HEADS-UP DISPLAY (HUD)

– A valuable adjunct for Ophthalmic Surgery

Atul Kumar, Kavitha Duraipandi

Optical coherence tomography (OCT) is a rapid, vitreoretinal surgery at the Emory Eye Center. This allowed
noncontact, non invasive high-resolution the surgeon or assistant to move the device above the patient’s
optical biopsy of tissue microstructure which eye using the microscope foot pedal. Thus, came the evolution
has revolutionised our understanding of of microscope mounted OCT. Studies showed that the We
the pathology of various retinal disease and describe the use of a microscope-mounted SD-OCT unit that

guides therapeutic decision-making1. Seamless ‹• ‡ƒ•› –‘ ƒ••‡„Ž‡ǡ ƒ‹–ƒ‹• ƒ •–‡”‹Ž‡ •—”‰‹…ƒŽ ϐ‹‡Ž†ǡ ƒ†

integration of this technology into ophthalmic surgery has ’”‘†—…‡• ”‡’”‘†—…‹„Ž‡ ƒ† ‘”‡ –‹‡ ‡ˆϐ‹…‹‡– ‹ƒ‰‡• ‹ ƒ

now laid the foundation for a new paradigm in the surgical intraoperative setting. As with any new technology, a learning

management. curve existed7. There are few disadvantages namely:- There

Spectral-domain OCT provides more advantage over was a need to bring them into alignment with the microscope ,

conventional time-domain OCT systems in being faster and hence real time visualisation of the surgical steps was not

by obtaining more images in a shorter period of time ’‘••‹„Ž‡Ǥ Š‡ Žƒ… ‘ˆ –”—‡ …‘ƒš‹ƒŽ‹–› ƒ†‡ ‹– †‹ˆϐ‹…—Ž– –‘ ˆ‘…—• ‘

(approximately 20,000 A-scans per second compared with •’‡…‹ϐ‹… ”‡‰‹‘• ‘ˆ ‹–‡”‡•–Ǥ

400 A-scans per second on time-domain OCT) with higher This gave birth to the technology of microscope- integrated

resolution of larger retinal areas2,3. OCT device (MIOCT) which facilitated simultaneous surgical

An important limitation of typical OCT set up is that they visualisation along with high resolution SD-OCT imaging. This

are non mobile units and thus require a compliant patient who was made possible by folding the optical OCT path into the full

can sit upright. Thus, OCT imaging in uncooperative patients, beam path of the operating microscope to aid imaging8.

paediatric patients and those with musculoskeletal disorders

becomes challenging. MIOCT DESIGN

To overcome these problems, hand held mobile OCT A high-resolution MIOCT prototype device was developed

machines came into use. A portable SDOCT unit (Bioptigen Inc., to interface with an ophthalmic operating microscope (Leica

Research Triangle Park, NC) has made imaging of such patients Microsystems, Heerbrugg,

possible. An additional value of Spectral-domain OCT provides more Switzerland)9Ǥ ”‹‡ϐŽ›ǡ ƒ †‹…Š”‘‹…
the handheld SDOCT system is mirror allows folding of the

the ability to obtain noncontact, advantage over conventional time-domain MIOCT optical path into the
high-resolution, cross-sectional surgical microscope above
retinal images intraoperatively OCT systems in being faster obtaining the objective lens to permit
in the supine position4,5. Studies more images in a shorter period of time simultaneous imaging during

have shown hand held SDOCT (approximately 20,000 A-scans per surgical manipulations without
‹ƒ‰‹‰ ’”‘˜‹†‡† ƒ ‡ˆϐ‹…‹‡– second compared with 400 A-scans per altering the surgeon’s view.
method for visualizing macular This prototype microscope-

pathology. This technology may, second on time-domain OCT) integrated scanner was coupled
‹ …‡”–ƒ‹ …ƒ•‡•ǡ Š‡Ž’ …‘ϐ‹”
with a Bioptigen SDOCT imaging
or identify diseases that may
engine with a center wavelength
„‡ †‹ˆϐ‹…—Ž– –‘ ˜‹•—ƒŽ‹œ‡ †—”‹‰ •—”‰‡”›6. But the disadvantages
of 865 nm and a spectrometer equipped to acquire images at a
include the fact that the surgeon had to halt the surgery to obtain
rate of 20,000 A-scans per second. The lateral resolution was 15
images of the retinal architecture, remove all instruments from
Ɋǡ ƒ† –Š‡ ϐ‹‡Ž† ‘ˆ ˜‹‡™ ™ƒ• ͳͲ έ ͳͲ Ǥ Š‡ ƒš‹ƒŽ ”‡•‘Ž—–‹‘
the eye, stabilize the eye, and move the microscope away from
™ƒ• ͷ Ɋ ƒ† –Š‡ †‡’–Š ”ƒ‰‡ ™ƒ• ͳǤͷͷ Ǥ
–Š‡ •—”‰‹…ƒŽ ϐ‹‡Ž† ‹ ‘”†‡” –‘ ’‘•‹–‹‘ –Š‡ •…ƒ‡” ‘˜‡” –Š‡ ‡›‡Ǥ
The other microscope-integrated OCT systems that have
It didn’t gain popularity for it was time consuming and tedious.
been recently developed are the iOCT (Haag-Streit, Wedel,
To ensure maintenance of sterility, improve image quality
Germany) and RESCAN 700 (Carl Zeiss Meditec, Oberkochen,
and reproducibility, and reduce image capture time, a mount
Germany)10,11Ǥ ‹‰ŠǦ†‡ϐ‹‹–‹‘ ‹ƒ‰‡• ƒ’’‡ƒ” †‹”‡…–Ž› ‹
was built that attached to the operating microscope used for
the LUMERA 700 microscope eyepiece providing the surgeon

www. dos-times.org 53

CLINICAL SPOTLIGHT - RETINA

clear views below the surface of the Figure 1a: i- OCT reveals a macular hole during surgery with posterior hyaloids attached to one
•—”‰‹…ƒŽ ϐ‹‡Ž†ǡ –Š—• ‡ƒ„Ž‹‰ –Š‡ –‘ ƒŽ–‡”ǡ edge.
”‡ϐ‹‡ ƒ† ‹’”‘˜‡ –Š‡‹” •—”‰‹…ƒŽ †‡…‹•‹‘
making12. It takes 27,000 A-scans per Figure 1b: K 1%6 TGXGCNU RQUV +./ RGGN CP KPXGTVGF ƀCR DTKFIKPI VJG JQNG
second to produce real time 2 dimensional
images. The Rescan 700 includes cases of failed macular hole surgeries, Retinal detachment
Z-tracking for image stabilization. area of peeled ILM can be easily
visualised. Intraoperative imaging could In tractional retinal detachment, a
The microscope integrated system identify changes in the macular anatomy safe plane to initiate delamination and
permits stereoscopic heads-up display that occur during surgery that affect segmentation can be obtained with the
(HUD) allows most of the functions of visual recovery. aid of MIOCT. It helps in determining any
the OCT system to be controlled from residual traction and the adequacy of
the microscope’s foot pedal and the Epiretinal membranes and vitreo membrane peeling. In rhegmatogenous
X-Y joystick. This allows the surgeon macular traction retinal detachment, any residual sub
to take videos, snapshots and 3D OCT ”‡–‹ƒŽ ϐŽ—‹† ‹ –Š‡ ’‘•–‡”‹‘” ’‘Ž‡ …ƒ
images without interrupting the surgery. ƒ† …ƒ—•‡• †‡ϐ‹‹–‡ „‡ ‹†‡–‹ϐ‹‡† ƒ† ƒ …‘’Ž‡–‡ ϐŽ—‹† Ȃ
The stereoscopic display allows the alterations in the retinal contour and air exchange can be achieved. Other
•—”‰‡‘ –‘ •‡‡ –Š‡ •—”‰‹…ƒŽ ϐ‹‡Ž† ‹ „‘–Š diminution of vision. MIOCT helps the uses reported in literature include
a planar view and a cross sectional view surgeon to assess the area and strength removal PVD induction, removal of per
simultaneously, in real time through both of the vitreomacular adhesion. It enables ϐŽ—‘”‘…ƒ”„‘ •—„ ”‡–‹ƒŽ ”‡•‹†—‡•Ǥ
eyepieces. The OCT also has different one to identify and carefully peel the
capture modes that allow one to capture ‡„”ƒ‡• ™‹–Š‘—– †‡”‘‘ϐ‹‰ –Š‡ ˆ‘˜‡ƒŽ Myopic tractional Maculopathy
ƒ •–‹ŽŽ ˜‘Ž—‡ …—„‡ ‘” ƒ ϐ‹˜‡ Ž‹‡ ”ƒ•–‡”Ǥ cyst. Immediate normalization of the
retinal contour can be seen after removal In myopic traction Maculopathy,
OCT scans can also be stored and of the membranes. along with foveoschisis, there are multiple
”‡…ƒŽŽ‡† ˆ‘” Žƒ–‡” ”‡˜‹‡™ ƒ† DzϐŽ› –Š”‘—‰Šdz layers of vitreoschsis. A complete removal
via CALLISTO eye from ZEISS. The OCT
also has different capture modes like
clinical OCT system that allows one to
…ƒ’–—”‡ ƒ •–‹ŽŽ ˜‘Ž—‡ …—„‡ ‘” ƒ ϐ‹˜‡ Ž‹‡
raster. The Callisto video display system
on the side displays both images. The OCT
images are projected into the surgeon’s
‘’‡”ƒ–‹‰ ϐ‹‡Ž† ƒ• ƒ DzŠ‡ƒ†• —’ †‹•’Žƒ›dz
without interfering with the surgical
procedure. RESIGHT lens systems are
used for posterior segment viewing.

CLINICAL UTILIES OF MIOCT

Macular hole

Intraoperative SD-OCT imaging of
the macula could provide additional
information to predict visual outcomes.
MIOCT enables a clear visualisation and
real time visualisation of the ILM peeling.
This helps one to avoid any inadvertent
–”ƒ—ƒ –‘ –Š‡ —†‡”Ž›‹‰ ‡”˜‡ ϐ‹„”‡
layer. It will clearly show the area of ILM
peeled. With the latest surgical technique
‘ˆ ‹˜‡”–‡† ‹–‡”ƒŽ Ž‹‹–‹‰ ϐŽƒ’ǡ –Š‡
•—”‰‡‘ …ƒ ‡•—”‡ –Šƒ– –Š‡ ϐŽƒ’
covers the hole completely (Figure 1a,1b).

One can opt out of the usage of vital
dyes to visualise the ILM, as the MIOCT
imaging would guide the procedure. In

Vitreoretina Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India

Padmashree Prof. Dr.Atul Kumar MD, FAMS Dr. Kavitha Duraipandi MD, DNB, FICO
54 DOS TIMES - SEPTEMBER-OCTOBER 2015

CLINICAL SPOTLIGHT - RETINA

of the posterior cortical vitreous with peeling. Or the opposite: They think 5. Chong G, Farsiu S, Freedman SF, et
utmost care of not damaging the fovea is there’s more they need to peel, but when al. Abnormal foveal morphology
required. Multiple stains are used to stain they look at the OCT the membranes in ocular albinism imaged with
the retained hyaloid and the internal are entirely removed and they’re able to spectral domain optical coherence
limiting membrane. With the MIOCT, ϐ‹‹•Š –Š‡ ’”‘…‡†—”‡Ǥ Ž•‘ ‹ ‹˜‡”–‡† ϐŽƒ’ tomography. Arch Ophthalmol 2009;
‹†‡–‹ϐ‹…ƒ–‹‘ ‘ˆ ƒ› ”‡ƒ– ‘ˆ …‘”–‹…ƒŽ macular hole surgery, the real time OCT 127:37-44.
vitreous and peeling of ILM becomes easy ’‡”‹–• ˜‹•—ƒŽ‹•ƒ–‹‘ ‘ˆ –Š‡ ϐŽƒ’• „”‹†‰‹‰
and safe, thus averting any iatrogenic the hole. 6. Pouya n. dayani, Ramiro Maldonado,
breaks. Sina Farsiu et al. Intraoperative use
Future directions of handheld spectral domain optical
Disadvantages coherence tomography imaging
This new visualization technology in macular surgery. Retina. 2009;
The optical properties of surgical promised to change ophthalmic surgery 29:1457-68.
instruments affect the visualization of the especially for retina and cornea surgeons,
underlying retina. Metallic instruments opening us to a whole new realm of 7. Ray R, Barañano DE, Fortun JA at al.
(e.g., forceps and needles) showed high ophthalmic surgeries... Intraoperative microscope-mounted
”‡ϐŽ‡…–‹˜‹–› ™‹–Š –‘–ƒŽ •Šƒ†‘™‹‰ „‡Ž‘™ spectral domain optical coherence
the instrument. Polyamide material had The tissue the speed of SDOCT is tomography for evaluation of
ƒ ‘†‡”ƒ–‡ ”‡ϐŽ‡…–‹˜‹–› ™‹–Š •—„–‘–ƒŽ slow and not real time in the actual retinalanatomy during macular
shadowing. Silicone instrumentation sense probably and hence not ideal for surgery. Ophthalmology. 2011;
such as the tip of the Tano scraper truly guiding the surgeon during the 118:2212-7.
showed partial transmission and surgeries. Dr. Toth is currently helping to
therefore visualization of underlying develop a swept source OCT system with 8. Ehlers JP, Tao YK, Farsiu S et al.
retinal structures13. a heads up display and different display Integration of a spectral domain
options, including Goggle Glasses at Duke optical coherence tomography
Even faster acquisition speeds have University14. system into a surgical microscope
to be developed. The microscope does for intraoperative imaging. Invest
not have an inbuilt calibration system Intratissue targeted delivery of Ophthalmol Vis Sci. 2011;52:3153-9.
to measure the dimensions of the tissue pharmacotherapy using real time OCT
structure visualised. The measurements guided microscope is a near future. 9. Tao YK, Ehlers JP, Toth CA, Inapt
are taken from the screen and with the JA. Intraoperative spectral domain
aid of a correction factor, the surgeons are REFERENCES optical coherence tomography for
able to derive a measurement. An inbuilt vitreoretinal surgery. Opt Lett. 2010;
calibration system with good agreement 1. Huang D, Swanson EA, Lin CP, et 35: 3315–17.
with preoperative OCT measurements al. Optical coherence tomography.
would be of help to the surgeons. Science 1991;254:1178-81 10. Binder S, Falkner-Radler CI, Hauger
C, Matz H,, Glittenberg C. Feasibility of
The microscope along with the 2. Gupta V, Gupta P, Singh R, Dogra intrasurgical spectral-domain optical
Callisto is bulky setup. A sleek, less bulky MR, Gupta A. Spectral domain cirrus coherence tomography. Retina. 2011;
model is awaited. Though of immense Š‹‰ŠǦ†‡ϐ‹‹–‹‘ ‘’–‹…ƒŽ …‘Š‡”‡…‡ 31: 1332–36.
use, the cost of the microscope cannot be tomography is better than time-
ignored. domain stratus optical coherence 11. Ehlers JP, Kaiser PK, Srivastava SK.
tomography for evaluation of macular Intraoperative optical coherence
Clinical Impact pathologic features in uveitis. Am J tomography using the RESCAN
Ophthalmol 2008;145:1018 -22 700: preliminary results from the
Intra operative OCT appears to DISCOVER study. Br J Ophthalmol.
inform surgical decision making. In fact, 3. Koizumi H, Spaide RF, Fisher YL, 2014; 98: 1329–32.
in 10 percent or more of cases, the OCT Freund KB, Klancnik JM Jr, Yannuzzi
data actually causes surgeons to change LA. Three-dimensional evaluation of 12. Au J, Goshe J, Dupps WJ Jr et al.
their mind. For example, if the surgeons vitreomacular traction and epiretinal Intraoperative Optical Coherence
think they’ve peeled all of the membrane, membrane using spectral-domain Tomography for Enhanced Depth
they may look at the OCT and realize optical coherence tomography. Am J Visualization in Deep Anterior
there’s residual membrane that requires Ophthalmol 2008; 145:509 -17. Lamellar Keratoplasty from the
PIONEER Study. Cornea. 2015 Jun 24.
4. Scott AW, Farsiu S, Enyedi LB,
Wallace DK, Toth CA. Imaging the 13. Hahn P, Migacz J, O’Connell R, Izatt
infant retina with a hand-held JA, Toth CA. Unprocessed real-time
spectral-domain optical coherence imaging of vitreoretinal surgical
tomography device. Am J Ophthalmol maneuvers using a microscope-
2009; 147:364.e2–373.e2. integrated spectral-domain optical
coherence tomography system.
Graefes Arch Clin Exp Ophthalmol.
2013; 251: 213–20.

14. Christopher Kent. Intraoperative
OCT Coming into Focus. Review of
Ophthalmology, 2014.

Financial Interest: Š‡ ƒ—–Š‘”• †‘ ‘– Šƒ˜‡ ƒ› ϔ‹ƒ…‹ƒŽ ‹–‡”‡•– ‹ ƒ› ’”‘…‡†—”‡Ȁ’”‘†—…– ‡–‹‘‡† ‹ –Š‹• ƒ—•…”‹’–Ǥ

www. dos-times.org 55

PRACTICE REQUISITES

MULTIFOCAL ERG

Raghav Ravani

‡••‡–‹ƒŽǤ ……‡–‡”‹… ϐ‹šƒ–‹‘ …ƒ „‡ …‘’‡•ƒ–‡† ˆ‘” „›

Dr. Raghav Ravani MD ‘˜‹‰ –Š‡ ϐ‹šƒ–‹‘ –ƒ”‰‡–Ǥ
Senior Resident,Vitreo-Retina Services, Ȉ Optical correction: Appropriate for viewing distance need
Dr. Rajendra Prasad Centre for
to be used by manual adujstment of the viewing optics or

Ophthalmic Sciences,AIIMS, New Delhi by placing lenses in a holder positioned in front of the eye.

Visual electrophysiological tests are objective Ȉ Electrodes: Recording electrodes (active electrodes),
tests that help to assess the functional integrity reference electrodes & ground electrodes.
of visual pathway, starting from photoreceptor
and retinal pigment epithelial layer in retina till Ȉ Recording electrodes: These may be contact or non-
the occipital cortex. contact type of electrodes.
Visual Electrophysiological tests include:
Ȉ
ǣ ‡ƒ•—”‡• ˆ—…–‹‘ƒŽ ‹–‡‰”‹–› ‘ˆ ‡–‹ƒŽ ’‹‰‡– Ȉ Contact electrode: are optically clear & lie in contact with
…‘”‡ƒ ‹ ’”‡•‡…‡ ‘ˆ ƒ”–‹ϐ‹…‹ƒŽ ‡›‡ †”‘’• ‘” ͲǤͷΨ ‡–Š›Ž
epithelium and its interaction with photoreceptor cellulose. These can again be Unipolar or Bipolar.
Ȉ ǣ ‡ƒ•—”‡• ˆ—…–‹‘ƒŽ ‹–‡‰”‹–› ‘ˆ ‘’–‹… ‡”˜‡ ƒ† Bipolar corneal contact electrodes yield recordings with
highest Signal-to-Noise Ration (SNR). Thus provide
occipital cortex responses of larger amplitude and fewer artifacts.
Ȉ ƒ––‡” ǣ ‘„Œ‡…–‹˜‡Ž› ƒ••‡••‡• –Š‡ ƒ…—Žƒ ƒ† –Š‡ Examples of contact electrodes are: Jet Eletrode (unipolar),
Dorian Gold lens (Bipolar) and Burian-Allen Electrode
central retinal ganglion cells (unipolar or bipolar
Ȉ
ȋ —ŽŽ ϐ‹‡Ž†Ȍ ǣ ‡ƒ•—”‡• ˆ—…–‹‘ƒŽ ‹–‡‰”‹–› ‘ˆ Non Contact electrode: Need longer recording times,
repeat measurements are required to obtain comparable
photoreceptors and inner retinal layers of entire retina SNRs when using non-contact electrodes like gold-foil
Ȉ —Ž–‹ˆ‘…ƒŽ Ž‡…–”‘”‡–‹‘‰”ƒ’Š› ‡Ž‡…–”‘†‡•ǡ Ǧ Ž‘‘’ ƒ† ϐ‹„‡”Ǥ

Multifocal Electroretinography (mfERG) as the name Placement of electrodes:

mm‰ƒ‘bitrsnoeuŽ…’y‘aaps–g’1‹„ypcog˜‘9uƒogleM‹n•o9–lŽnrsao ‡›c2”uats†t a‡splea‘t abl–sh–iin‹ˆn‘esfi ifsdoecd r–ƒaˆcdŠo—Žmlasai t‡mnˆŽileŽ— metEǦrl”marϐdeeR‡‹ios…‡lisde–Gafud–iŽ‹ft‹†rosrue‘hwleun ƒryco aebs eodǤ sn ”ads f‡
ttd—raϐooam reŽeŽ™nsf‡feŽvtaǦt…geiŠϐaicnr–‹ial‹t‹‡uoeoa…chlŽcllnpŠll†ya‰eiose en ”rdloi‡decfcmMϐbicaŽntty‡llhrg…iEtueoe–nerp•aslrli oihtect–sccŠytiSiains‡ufaunli otoa•1lrt—.lece9oelr9eagtac5ielcntoaot‡sdolfp†tcEah po‡cyrrlRŽtsl‡toieeiv…ovoGait–itlg”dioy‹uneg…paeƒiwaacssŽr loavesildeȈȈȈ icenttrutGRArhaoncereotoifppiecuvdrotonheeloruadnneyrpccleEeseeaeloclie.Eetodcgrcletotlrrrcdoootaeraddg:poeeslid):ihc.eeps:ailLaacilncieesinalȈSdloaf tetebtipcremeeeir.onnaurltdlrStfiaeootntirgtmoinhofiueunxtplhl:uaooetsrnefirontarhlecechoaeninnattdadhSciouvotusirwdr(eufcioateahrr:l
sparing retinal disease with ƒ…–‹˜‹–› ƒ• ‘’’‘•‡† –‘ ˆ—ŽŽǦϐ‹‡Ž†
equipment, stimulus source
normal visual acuity may have may be any one of Cathode Ray
abnormal ERG. Here in lies the ™Š‹…Š ”‡ϐŽ‡…–• –Š‡ •—‡† ‡Ž‡…–”‹…ƒŽ Tube (CRT) (earlier versions),
utility of multifocal ERG.
ƒ…–‹˜‹–› ‘ˆ –Š‡ ”‡–‹ƒ ”‡ϐŽ‡…–‹‰ ‰Ž‘„ƒŽ Light Emitting Diode (LED),
Liquid Crystal Display (LCD)
Multifocal Electro- retinal function screen or Scanning Laser

retinography is a visual electro- Ophthalmoscopy (SLO).

physiological test of local Ȉ Stimulus: Consists of array of hexagons varying from

retinal function that measures the spatial distribution of the 61,103 to 241 in number, which are scaled / increased in

central retinal cone function. Thus Multifocal ERG responses size with retinal eccentricity from the fovea to periphery to

are recorded from cone-driven retina under light-adapted elicit equal amplitude response from all locations since the

conditions. concentration of cones decreases with increasing distance

TECHNIQUE from the fovea (Figure 1). Thus the central hexagons are
smaller than the peripheral ones.
Patient preparation: The stimulus follows a predetermined pseudo-random
„‹ƒ”› ϐŽ‹…‡” •‡“—‡…‡ ȋǮ •‡“—‡…‡ǯȌ ™Š‡”‡‹ ‡ƒ…Š •–‹—Ž—•
Ȉ Pupils: Pupils to be fully dilated. elements has a 50% chance of being illuminated every time the
Ȉ Light adaptation: For atleat 15 minutes in ordinary room frame changes.
Increasing the number of stimulus elements/hexagons
light.
Ȉ Fixation Monitoring:
‘‘†ǡ …‡–”ƒŽ ƒ† •–‡ƒ†› ϐ‹šƒ–‹‘ ‹•

www. dos-times.org 57

PRACTICE REQUISITES

improves the spatial resolution 2) of overall signal strength per

but also increases the test unit area of retina by plotting

duration. the amplitude of waveform per

Ȉ Stimulus size and Viewing unit area of retina. The center

distance: The overall ‘ˆ –Š‡ ϐ‹‡Ž† „‡‹‰ †‡”‹˜‡† ˆ”‘

stimulus pattern should smaller hexagons, show large

subtend a visual angle of 20- response and is expressed as

30 degrees on either side of nanovolts/deg2 (area of retina).

ϐ‹šƒ–‹‘Ǥ Š‡ ‡–”‘ ‹•‹‘ Normal surface plot gives a

System (Vision monitor, Dzˆ‘˜‡ƒŽ ’‡ƒdz ƒ– –Š‡ …‡–‡” ‘ˆ

Monpack 3, Metrovision, the retina. Topographic map

”ƒ…‡Ȍ •—„–‡† ƒ ϐ‹‡Ž† ‘ˆ ά ƒŽ•‘ Š‡Ž’• –‘ ‘‹–‘” ϐ‹šƒ–‹‘

͵ͲͲ Š‘”‹œ‘–ƒŽŽ› ƒ† ά ʹͶͲ by monitoring the location

vertically centred on the and depth of blind spot. But

fovea at a viewing distance 3-D plots should not be used

of 30 cm. without simultaneous display

Ȉ Frame Frequency: Most of trace array as abnormal

widely used CRT frame Figure 1: Diagramatic presentation of multifocal ERG hexagonal or delayed responses can
frequency is 75 Hz. It stimulus array with 103 elements with each having 50% probability produce normal plots and it
should never be line of being illuminated everytime the frame changes in predetermined also depends on how the local
current frequency (50 or pseudo-random sequence (‘m sequence’). amplitude is measured.

60 Hz) which may cause Ȉ Group averages:

interference artifacts. Group of responses from the

Ȉ Fixation Target: A red trace arrays can be averaged

ϐ‹šƒ–‹‘ –ƒ”‰‡– ‹• ’”‡•‡–‡† to compare quadrants,

within the central hexagon. hemiretinal areas, and normal

Š‹• …ƒ „‡ ‘†‹ϐ‹‡† v/s abnormal regions of two

in cases with eccentric eyes or successive rings from

ϐ‹šƒ–‹‘ –‘ –‡•– –Š‡ †‡•‹”‡† center to periphery. The latter

anatomical location. is especially helpful in patients
with diseases that produce
Ȉ Luminance: The luminance dysfunction with radial
symmetry.
for the stimulus is 100- Ȉ Kernels: The human
mfERG is dominated by the
200 cd/m2 in lighted state cells of the outer retina, namely
photoreceptors and bipolar
ƒ† δ ͳ …†Ȁ2 in the dark cells. The typical waveforms of
the basic mfERG response are
state. Thus the mean screen technically known as kernels.
The most commonly analysed
luminance during the test waveform ”‡•’‘•‡• ƒ”‡ –Š‡ ϐ‹”•–Ǧ‘”†‡”
and the second-order kernel
will be 50-100 cd/m2 components.
First order kernel: The waveform
Ȉ Contrast & background: is biphasic with an initial negative
†‡ϐŽ‡…–‹‘ ȋ ͳȌ ˆ‘ŽŽ‘™‡† „› ƒ ’‘•‹–‹˜‡
The Contrast between peak (P1). The response amplitudes as
measured as shown in (Figure 3).
the lighted and darkened First order kernels are obtained
by adding all the records following the
stimulus should be 90% or Figure 2: Showing measurement of amplitude and latency of ’”‡•‡–ƒ–‹‘ ‘ˆ ƒ ϐŽƒ•Š ‹ –Šƒ– Š‡šƒ‰‘
greater. The background in multifocal ERG. and subtracting all the records following
a darkframe.
region should have a in amplitude and latency and to detect Second order kernel: is a measure
luminance equal to the mean spacial variations in it. Next is to interpret of mfERG responses to adaptation by
luminance of the stimulus array to the numeric data that show amplitudes •—……‡••‹˜‡ ϐŽƒ•ŠǤ Š‹• ”‡’”‡•‡–• –Š‡
eliminate the rod response. relative to norms within averaged groups temporal non-linearity of the local
responses and is claimed by many
Test Duration: of responses. authors to arise from the inner retina.
Multifocal ERG test results are This has especially been useful in retinal
Total time is typically about 4 min for vascular occlusions.
61 elements or 8 min for 103 elements. indicated as:
The overall recording time is divided Trace array: It is the basic mfERG
into shorter segments of 15-30 s so that
subjects can rest in between and also a display and is displayed as an array of the
poor record due to noise, movement or mfERG traces using trace trace lengths
artifacts can b discarded and run again of 100 ms or more. This array shows
without losing prior data. topograpic variations and demonstrates
the quality of records. It is important to
•’‡…‹ˆ› Dz ‹‡Ž† ˜‹‡™dz ‘” Dz”‡–‹ƒŽ ˜‹‡™dz ‘

Response and Interpretation: the array along with notation of width in
degress of the trace array.
Interpretation of mfERG involves
interpreting the waveforms in the Topographic color map /
trace array to look for the variations Topographic (3-D) response density
plots: shows the 3-D topography (Figure

58 DOS TIMES - SEPTEMBER-OCTOBER 2015