DOS Times Vol 25 No 5

Basics

14. Saito Y, Tano Y. Retinal pigment (2004). Pituitary gland and pregnancy. a neonate following transplacental
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on CT, MR imaging, and SPECT imaging Neurol 1987; 44: 209-15. 52.
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Cortical blindness, a rare complication Charles C. Thomas. Palika Maternity Hospital,
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M, Cortinovis-Tourniaire P, Grimaud
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Higashigawa M, Mukouhara R, Komada
19. Foyouzi N, Frisbaek Y, Norwitz ER Y. Transient renal tubular acidosis in

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Limbal Stem Cell Deficiency

Deepali Singhal1, Gunjan Saluja2, Prafulla K. Maharana2 MD
1. Institute of Vision and Optics, VEIC, University of Crete, Greece.
2 Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi,
India.

Introduction Figure 1: A case of post chuna particle injury showing total limbal stem cell deficiency with
Limbal Stem Cells conjunctivalization and central scarring
The corneal epithelium always exists
in a state of dynamic equilibrium. “terminally differentiated cells’. can be defined by the equation: X + Y = Z,
The superficial epithelial cells are which simply states that if the corneal
constantly being shed off into the Role of limbal epithelial stem cells epithelium is to be maintained, cell loss
tear film while the limbal epithelial in epithelial cell regeneration must be balanced by cell regeneration.
cells migrate towards the center and Regeneration of the corneal epithelial Thus, migration occurs centripetally
anteriorly to maintain the corneal cells can be viewed as three separate, and circumferentially from the limbus
epithelium. Davanger and Evensen in independent phenomena. These have and vertically from the basal layer
1971, first introduced the concept that been termed as: X which represents forwards. This hypothesis was given by
epithelial cells in the limbal region proliferation of basal epithelial cells; Thoft et al and is called as the ‘X, Y, Z
are involved in the renewal of corneal Y stands for the contribution to the hypothesis’. Epithelial disease could be
epithelium1. This limbal stem cell niche cell mass by centripetal movement of thus the result of inadequate basal cell
is located at the Palisades of Vogt, a peripheral cells; and Z indicates the proliferation (decreased X), deficient
highly pigmented region because of epithelial cell loss from the surface. centripetal cell movement (decreased
melanocytes and is infiltrated with Corneal epithelial maintenance thus Y), or increased cell loss (increased Z)3.
antigen-presenting Langerhan’s cells
and suppressor T-lymphocytes. The
least differentiated cells are located in
the limbal basal epithelium and lack the
cornea-specific-keratin 3 and 12, which
is expressed in both the suprabasal
limbal epithelium and the entire
corneal epithelium. Keratin 19 (CK 19)
is expressed only in the basal limbal
epithelium in adults and over the entire
limbal and corneal epithelium in the
fetus, which suggests the persistence of
embryogenetically young (stem) cells at
the limbus in adults2.

Limbal stem cells undergo asymmetric
division and produce a daughter stem
cell, which remains within the limbus,
and a ‘transient-amplifying cell’ (TAC),
which migrates centripetally and
anteriorly. TACs undergo multiple
rounds of replication as they migrate
anteriorly and differentiate into ‘post-
mitotic cells’, which are the suprabasal
wing cells, and then finally into

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Etiology Table 1: Causes of Limbal Stem Cell Deficiency
Etiology of limbal stem cell deficiency Primary causes
(LSCD) can be either primary or Aniridia
secondary (Table 1). Primary causes Congenital erythrokerato-dermia
are due to alteration in the stromal Multiple Endocrine Deficiencies associated keratitis
microenvironment of the cornea such as Neurotrophic (neural and ischaemic) keratopathy
aniridia and congenital erythrokerato- Chronic limbitis
dermia. Secondary causes include Ectodermal dysplasia
external factors that destroy limbal Secondary causes
stem cells such as chemical (most Chemical or thermal injury
common) or thermal injuries. LSCD Stevens-Johnson Syndrome / Ocular Cicatricial Pemphigoid (OCP)
can be divided on the basis of extent Multiple surgeries or cryotherapies
of involvement that is total or partial Contact lens wear
(sectoral). Extensive microbial infection
Chronic use of topical steroids, pilocarpine, beta blockers, mitomycin C and
Clinical Presentation antibiotics
Symptoms: The symptoms of LSCD
include diminution of vision, watering, Table 2: Classification of ocular surface disease based on number of lost
photophobia, blepharospasm, and stem cells and presence or absence of conjunctival inflammation(4)
recurrent epithelial erosions with
episodes of pain associated with history Limbal stem cells lost Stage I (<50%) Stage II(>50%)
of chronic inflammation and redness. (%)
Subclinical cases of LSCD may also be
seen that may progress to symptomatic Stage A (Normal • OSSN • Aniridia
stage subsequently. Conjunctiva) • Contact lens • Long hours of contact lens wear
• Iatrogenic • Iatrogenic
Signs: Slit lamp biomicroscopy shows
dull, lustureless appearance with Stage B (Previously Thermal or Severe chemical or thermal
an irregular corneal reflex. This is inflamed conjunctiva) chemical injury injury
often associated with recurrent and
persistent epithelial defects, corneal Stage C (Currently • MMP • MMP
vascularizationandconjunctivalization, inflamed conjunctiva) • Recent Chemical • Recent chemical or thermal
scarring and calcification (Figure 1). In
severe cases, ingrowth of a fibrovascular Injury injury
pannus may be seen over the cornea • Mild SJS • Severe SJS
progressing into ulceration, melting,
and perforation. This conjunctivalised Holland EJ, Mannis MJ, Lee WB, eds. Ocular surface disease: cornea, conjunctiva and
corneal surface is stained abnormally tear film. Elsevier, 2013, Ch. 38, Table 38.1, p. 318. © 2013, Elsevier.
with fluorescein showing a stippled
staining pattern due to the increased Diagnosis of Lscd goblet cells over the corneal surface
permeability of the conjunctival It is very crucial to diagnose these confirms the diagnosis of LSCD6.
epithelium. This abnormal surface is cases of LSCD before planning corneal Immunohistochemistry can also be
thinner than adjacent normal corneal transplantation; failure of doing so used for diagnosis, which shows the
epithelium and is prone to recurrent often leads to graft failure. Most absence of a cornea-specific cytokeratin
erosions and vascularization. In cases specific diagnostic features of LSCD (CK3 and 12), and the presence of mucin
of sectoral or partial deficiency, often a on bio microscopic examination and in goblet cells.
line of demarcation is visible between with fluorescein staining include
the corneal and conjunctival cells conjunctivalisation and loss of the Management
associated with pooling of fluorescein limbal palisades of Vogt5. Kenyon and Tseng initiated limbal
dye on the thinner conjuntivalised area. stem cell transplant in humans in
Investigations 1989 by performing limbal autograft
Classification Impression cytology is the histological transplantation in cases with unilateral
Holland et al proposed a classification method used for the confirmation of ocular surface disorders5. The
for staging of the ocular surface disease diagnosis. The presence of conjunctival management of this condition depends
caused due to LSCD. Table 24.

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Table 3: Classification of epithelial transplantation procedures for severe conjunctival epitheliam if seen. This
ocular surface disease procedure may have to repeated
multiple times till repopulation
Conjunctival transplantation and migration of remaining limbal
epithelial cells takes place.
In-vivo techniques Tissue Transplanted Patients with partial stem cell
deficiency presenting with foreign
Conjunctival autograft CAU body sensation, diminution of vision
due to conjunctivalisation extending
Cadaveric conjunctival allograft c-CAU to the central cornea or persistent
epithelial defect may require surgical
Living related conjunctival allograft lr- Conjunctiva intervention. This can be managed with
CAU auto- or allo-limbal transplantation in
the deficient area. Tseng et al reported
Living non related conjunctiva allograft successful use of amniotic membrane
Lnr-CAU transplantation (AMT) and mechanical
debridement in these cases with
Ex-vivo techniques significant improvement in vision and
ocular surface.
Ex-vivo cultivated Conjunctival autograft
EVCAU Total LSCD
The main stay of management of total
Ex-vivo cultivated Cadaveric conjunctival LSCD includes limbal transplantation
allograft EVc-CAU along with removal of pannus and
Ex-vivo cultivated Living related Cultivated conjunctival tissue altered epithelium from the host
surface. Classification of the epithelial
conjunctival allograft EVlr-CAU transplantation procedures modified
by Cornea Society has been described
Ex-vivo cultivated Living non related in table 3. The source of these limbal
conjunctiva allograft EVlnr-CAU stem cells depends upon the laterality
of the condition. In unilateral cases,
Limbal Transplantation limbal auto graft can be used that is
donor tissue obtained from the normal
In-vivo techniques fellow eye. Before using the autologous
tissue it is of paramout importance to
Ex-vivo cultivated Conjunctival limbal rule out involvement of the fellow eye.
autograft EVCLAU Thus, in bilateral conditions like SJS
this technique should be avoided since
Ex-vivo cultivated Cadaveric Ex-vivo cultivated limbus/ involvement of the fellow eye can be
conjunctivallimbal allograft EVc-CLAU conjunctiva seen later. In bilateral cases, donor tissue
is obtained either from living donor or
Ex-vivo cultivated Living related from cadaver (limbal allograft)7.
conjunctivallimbal allograft EVlr-CLAU Depending upon the carrier tissue
used for limbal transplant these
Ex-vivo cultivated Living non related procedures can be divided as either
conjunctivallimbal allograft EVlnr-CLAU conjunctival limbal graft or cornea
(keratolimbal graft). Tseng et al8
Mucosal Transplantation reported the use of AMT along with
limbal transplantation in cases with
Oral mucosal autograft OMAU Oral mucosa total stem cell deficiency. AMT can be
combined with limbal transplants in
Nasal mucosal autograft NMAU Nasal mucosa cases of poor ocular surface such as SJS,
advanced ocular cicatricial pemphigoid
Intestinal mucosal autograft IMAU Intestinal mucosa

Peritoneal mucosal autograft PMAU Peritoneal mucosa

Ex-vivo cultivated mucosal transplant

Ex-vivo cultivated Oral mucosal autograft Cultivated oral mucosa
EVOMAU

Daya SM, Chan CC, Holland EJ; Members of the Cornea Society Ocular Surface
Procedures Nomenclature Committee.Cornea Society nomenclature for ocular surface
rehabilitative procedures. Cornea 2011;30:1115–1119.

upon the extent of involvement that is topical lubricants to prevent epithelial
either partial or total LSCD (Table 3). damage.
Patients with sectoral epithelial defect
Partial LSCD over the cornea and conjunctiva are
Asymptomatic cases with good vision managed with close monitoring and
and no epithelial defect can be managed mechanical scraping of the advancing
conservatively. This includes use of

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Table 4: Algorithm for an approach to treat patients with severe OSD techniques are described below.
Management of glaucoma
Tube shunt for patients on more than one topical medication Conjunctival Limbal Autograft
Correction of eyelid and eyelash abnormalities (CLAU)
Exposure: lagophthalmos, ectropion
Misdirected lashes: entropion, trichiasis, distichiasis Kenyon and Tseng described
Suppression of inflammation conjunctival limbal autografting
Topical corticosteroids and cyclosporine A (CLAU) in which, two donor lenticules
Systemic immunosuppression each containing three clock hours of
• Oral corticosteroids the limbus and adjacent conjunctiva,
• Tacrolimus or cyclosporine A were obtained from the donor eye and
• Mycophenolate or azathioprine transplanted on to the recipient16.
• Rapamicin
Ocular surface transplantation Indications and contraindications
Conjunctival limbal autograft (CLAU) for unilateral disease Conjunctival limbal autografting
Keratolimbal allograft (KLAL) for bilateral limbal deficiency with minimal to (CLAU) is a technique in which
moderate conjunctival disease limbal tissue is transplanted from
Living related conjunctival limbal allograft (lr-CLAL) for bilateral limbal the healthy eye to the contralateral
deficiency with moderate to severe conjunctival disease stem cell-deficient eye with the help
Combined conjunctival–keratolimbal allograft (C-KLAL) for bilateral limbal of a conjunctival carrier. It is reserved
deficiency with severe conjunctival disease only for unilateral cases with the
Keratoplasty advantage being no need for systemic
Lamellar (LK) for patients with stromal opacification with normal endothelium immunosuppression.
Penetrating (PK) for patients with stromal opacification with loss of endothelial
function Preoperative considerations
Keratoprosthesis (K-Pro) for patients with good fornices but not good This procedure is highly effective for
keratoplasty candidates. cases with conjunctival scarring or
Holland EJ, Mannis MJ, eds. Surgical technique for ocular surface reconstruction. inflammation since conjunctival tissue
Elsevier, 2017, Ch. 158, Box 158.1 © 2017, Elsevier. is also transplanted. Moreover, this
technique can also be used in inflamed
(OCP), and chemical injury9-13. The central corneal transplantation of an eyes unlike allografts, which are at risk
mechanism by which AMT acts include eccentrically trephined corneolimbal for rejection.
restoration of the abnormal basement transplant15.
membrane, damaged stroma and Surgical technique
normal microenvironment of stem Immunosuppression The recipient eye is prepared first by
cells. It mainly acts either as a biological Limbal transplants have a high performing a conjunctival peritomy and
bandage promoting epithelial healing incidence of immunological reactions removing abnormal corneal epithelium
under the membrane (onlay), or as due to the abundance of Langerhans along with superficial keratectomy
a stromal transplant, in which the cells and HLA-DR antigens. Thus, to remove the fibrovascular pannus.
epithelium grows over the surface immunosuppression plays a key role The conjunctiva is then undermined
of the amniotic membrane (inlay). in success of limbal transplantation. to allow it to recess posteriorly.
Various growth factors produced by This is not required in unilateral cases Hemostasis is achieved using wet
the mem- brane promote the migration since autologous tissue is being used. field cautery. Donor tissue is prepared
and proliferation of the corneal Tan et al concluded that systemic by harvesting two trapezoid-shaped
epithelium14. immunosuppression should be limbal grafts measuring approximately
Transplantation of limbal stem cells considered in all allografts even if HLA- 6 mm at the limbus and extending 5–8
can also be done along with penetrating matched donor tissue is used. mm posterior to the limbus at the 12
keratoplasty (PK) using large grafts with Few commonly used surgical and 6 o’clock positions. Dissection of
approximately 1 mm is extended onto
the cornea to ensure isolation of stem
cells. The graft is then transferred to
the recipient eye, while maintaining
the epithelial and limbal orientation.
The graft is secured with interrupted
10/0 nylon sutures on the lateral and
posterior margins. Tissue glue can be

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used for the limbal end to prevent stem limbal tissue. The limbal tissue excised for functional limbal stem cells to be
cell damage by sutures. is then placed in balanced salt solution. cultured from a more pluripotent cell
In the recipient eye, a 360-degree line, such as bone marrow. In this way,
Simple Limbal Epithelial conjunctival peritomy is done along patients with bilateral severe ocular
Transplant (SLET) with removal of fibrovascular pannus. surface disease will be able to be treated
Hemostasis is achieved with the help with an autograft technique, thereby
Sangwan et al17 devised a novel of cautery. Amniotic membrane is avoiding the potential complications of
technique termed as simple limbal then placed and secured with fibrin systemic immunosuppression.
epithelial transplantation (SLET) in glue over the bare ocular surface with
which, only one clock hour (2x2 mm) of tucking of the edges under the recessed Ex-vivo cultivated limbal epithelial
the donor limbal tissue was transplanted conjunctival margins. The limbal graft transplant (CLET)
into the recipient ocular surface. This is then cut into 8 to 10 small pieces Pellegrini et al26 first described the
technique has several advantages like and secured, epithelial side up, on the clinical use of ex vivo cultivated limbal
being a single-stage procedure, easily amniotic membrane with fibrin glue. stem cells. The transplant procedure is
affordable and not requiring any These pieces are distributed in a circular similar for all techniques as described
laboratory support while retaining the manner around the center of the cornea, above. The recipient eye is prepared by
benefit of cultivated limbal epithelial avoiding the visual axis. A soft bandage performing 360 degree peritomy with
transplantation (CLET), using minimal contact lens is then placed over the conjunctival recession followed by
donor tissue. recipient eye, followed by topical superficial keratectomy and removal of
antibiotic and steroid drops. corneal pannus. Hemostasis is achieved
They reported complete by topical phenylephrine 10% and
epithelialization with a stable corneal Keratolimbal Allograft (KLAL) wet field cautery. The cultured sheet
surface by 6 weeks along with an is transplanted onto the bare surface
improvement in visual acuity in four Keratolimbal allograft is a procedure of the host by placing the Tegapore
(66.6%) eyes. in which limbal tissue along with dressing, with the basal-surface down.
a corneal carrier is transplanted to The stem cell sheet is gently separated
Further, a long term clinical outcome the recipient eye. Since this tissue is from the tegapore and placed on the
of the same procedure was published harvested only from the cadaveric ocular surface. Thereafter, amniotic
showing the maintenance of these globes or corneoscleral rims it allows membrane is placed over the cell sheet
successful results in 75% of cases18. for transplantation of a large number of with epithelial side up and sutured just
stem cells. Thus, KLAL can be used for outside limbus with the help of 10/0
Indications and contraindications bilateral and severe stem cell deficiency Vicryl (Ethicon, Livingstone, UK).
This technique also is primarily used also. This procedure is ideally suited
in unilateral LSCD with the primary for those cases, which primarily affect Various substrates have been used for
advantage that no immunosuppression limbus with minimal involvement culturing of these stem cells like plastic,
is required. Another advantage as of conjunctiva such as aniridia and amniotic membrane, tegapore dressing
compared to CLAU is the requirement iatrogenic LSCD19,20. and other matrices such as fibrin26.
of less donor tissue minimizing the risk
to the donor fellow eye. Ex Vivo Tissue Engineered Limbal epithelial culture:
Procedures Technique
Preoperative considerations A donor corneoscleral rim after corneal
As compared to CLAU where a healthy Ex Vivo Tissue Engineered Procedures grafting is used to harvest the limbal
donor eye is ideal, in case of SLET one involve proliferation of the harvested tissue. This tissue is divided into
could cautiously proceed even if there is epithelial cells (limbal stem cells, multiple pieces, 1–2 mm in length and
mild limbal stem cell deficiency in the conjunctival cells, or mucosal epithelial then treated with trypsin and seeded
donor fellow eye. Also, the limbal tissue cells) on a substrate like amniotic into the wells of a culture plate. The
in SLET is primarily transplanted with membrane leading to the formation culture medium contains DMEM,
minimal conjunctival tissue in contrast of an epithelial sheet. This is then F12, fetal calf serum, hydrocortisone,
to CLAU. transplanted over the recipient and epidermal growth factor, and cholera
secured with the help of sutures. The toxin, with the addition of lethally
Surgical technique major advantage of this procedure as gamma-irradiated 3T3 feeder cells27,28.
SLET procedure involves preparation of compared to in-vivo transplant is the This leads to formation of confluent
the donor eye first17,19. A 2 x 2 mm area, is small amount of donor tissue required epithelial sheets with two to three layers
marked centered on the superior limbus. thus, minimizing the risk of limbal of cells in duration of 12 days, which are
Dissection of the conjunctiva is done stem cell deficiency in the donor21-25. removed, from the plate with the help
towards the limbus, which is continued
1mm into the clear cornea to harvest the In the future, the eventual goal may be

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of Dispase II (Roche, East Sussex, UK). cell deficiency is doomed to fail. of ocular surface reconstructed by pre-
The whole sheet of cells is transported served human amniotic membrane.
to the operating room in a moist • Autologous stem cell grafts have Arch Ophthalmol 115: 1360–7, 1997
chamber with the basal cells exposed a higher success rate due to lack
below a nylon dressing (Tegapore, 3M, of immunological rejection and, 12. Shimazaki J, Yang HY, Tsubota K:
St Paul, MN). hence do not require systemic Amniotic membrane transplantation
immunosuppressive therapy. for ocular surface reconstruction in pa-
Post transplant tients with chemical and thermal burns.
immunosuppression References Ophthalmology 104: 2068–76, 1997

All cases of allograft limbal transplant 1. Davanger M, Evensen A. Role of the 13. Sloper CM, Powell RJ, Dua HS:
require systemic immunosuppression pericorneal papillary structure in Tacrolimus (FK506) in the treatment
for long-term graft survival and renewal of corneal epithelium. Nature. of posterior uveitis refractory to
prevention of graft rejection. Rejection 1971 Feb 19;229(5286):560–1. cyclosporine. Ophthalmology 106: 723–
of the limbal tissue can either be 8, 1999
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and edema with donor infiltration and the corneal limbus interact with K19- Amniotic mem- brane transplantation
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Photoessay

Highlighting a case of Lipaemia
Retinalis in Young Diabetic,
with Undetected Hyper-
Cholesterolaemia

Saroj I. Sahdev MS, DOMS, DNB, FVRS., FICO (UK), Afzal Tauqir Khan MBBS, DNB , Fellow FVRS
Department of Ophthalmology, T.N.M.C & B.Y.L. Nair Charitable Hospital, Mumbai, Maharashtra, India

Keywords: Salmon fundus , Creamish vessels , Hyperlipidemia , Diabetis mellitus, Cholesterolaemia.
Abstract: Purpose: To highlight a case of young diabietic, referred for routine fundoscopy and diagnosed with Lipaemia
Retinalis, with undetected hypercholesterolaemia .
Lipaemia Retinalis is a rare ocular manifestation of deranged cholesterol levels, which may be associated with diabetics. In this
report we describe a hitherto undetected cholesterolaemia in a young diabetic referred for diabetic retinopathy evaluation. On
presentation, the 28 year old male had no ocular complaints were noted, but the fundus showed typical Lipaemia Retinalis
picture in the form of creamish yellowish discoloration of the disc, creamish milky white appearance of the vessels emerging
from the disc with salmon colour back ground retina. Macula appeared unremarkable but the foveal reflex was dull. Patient was
diagnosed to have lipemia retinalis on clinical examination and was advised lipid profile which showed significantly deranged
levels (> 2000 mg/dl TG : >1000 mg/dl HDL : 60 mg/dl LDL :> 500mg/dl VLDL : >200 mg/dl). Patient was started on statins and
fenofibrate and after one week patients lipid profile was approaching normal limits with near normal fundus.

Young diabetics can have a number appearance. Fundus changes become of the disc with creamy-milky white
of systemic abnormalities, including evident when the triglyceride levels appearance of the vessels emerging
diabetic retinopathy presenting exceed 2,500 mg/dl. Here we describe a from the disc. The generalized fundus
early. They can have associated patient who was earlier not known to showed salmon colour back ground
hypercholesterolaemia, which may be hyperlipidaemic, but detected after retina. Macula was within normal limit,
initially be neglected due to the concern the diagnosis of Lipaemia on retinal but the foveal reflex was dull. Spectral-
for sugar reports. Lipemia retinalis is a examination. domain optical coherence tomography
rare manifestation of both primary as demonstrated hyper-reflective white
well as secondary hyperlipidemia. It Case report dots in the inner nuclear and ganglion
occurs most frequently in association 34 year old male, admitted in cell layer. Rest of general and systemic
with diabetes concomitant with acidosis medicine department in view of examination, including cardiac and
of a more or less severe degree. However, diabetic ketoacidosis , was referred to skin, were within normal limits. Patient
it may also be one of the manifestations ophthalmology OPD to rule out diabetic was diagnosed to have lipemia retinalis
of familial combined hyperlipidemia, retinopathy. Patient has no ophthalmic on clinical examination, but as was
which has a prevalence of 1--2% in the complaints. He is a known case of type not a known case of hyper-lipidaemia,
general population. The characteristic 1 Diabetes Melitus since six years, on a complete lipid profile along with
fundoscopic changes include retinal irregular treatment and fluctuating sugars was requested. Tests revealed
blood vessel discoloration, which control. On examination his BCVA deranged levels Cholesterol :> 2000
ranges from salmon pink to creamish -6/6 in both eyes with N6 near vision. mg/dl; TG : >1000 mg/dl; HDL: 60 mg/
white, depending on the level of Rest of anterior segment examination dl; LDL :> 500mg/dl; VLDL : >200 mg/dl
plasma triglycerides. Changes in the was unremarkable and IOP was within and Hb 25 gm/dl. On abdominal USG –
choroidal vessels give the fundus normal limit. Fundus examination hepatomegaly as well as splenomegaly
a “salmon” coloured background revealed creamish yellow discoloration was noted. Patient was started on

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Figure 1: fundus picture of both eyes showing creamish yellowish discoloration of the disc metabolic disorder as elevations of this
and vessels from the disc upto periphery with background salmon fundus appearance. magnitude may lead to cardiovascular
consequences including heart attack or
stroke.

The ocular findings result from light
scatter induced by the triglyceride-
laden chylomicrons in the plasma.
Hyperlipidemia without accompanying
hypertriglyceridemia does not present
this clinical picture. The early signs of
lipemia retinalis occur in the peripheral
retina, and as triglyceride levels increase,
they spread to the posterior pole. At
triglyceride levels of 2500–3499 mg/dL,

Figure 2: Optical Coherence Tomography of both eyes showing multiple hyper-reflective foci in the inner layers of retina.

Atorvastatin 20 mg and Fenofibrate 160 1880, he described its “remarkable the peripheral vessels appear creamy
mg once a day. Patient was reviewed appearance”. Lipemia Retinalis, is and thin; at levels of 3500–5000 mg/dL,
after 10 days when his fundus was caused by hypertriglyceridemia with the vessels in the posterior pole assume
nearly normal and lipid levels were serum triglyceride levels typically a creamy colour; and at levels exceeding
approaching normal range as well. greater than 1000 mg/dl and commonly 5000 mg/dL, the fundus becomes
associated with high triglyceride levels salmon-coloured, with creamy arteries
Discussion in hyperlipoproteinemias types 1,3,4, and veins that can be distinguished by
Lipemia Retinalis is a rare manifestation and 5 with different underlying causes1. calibre only. The clinical appearance is
of hypertriglyceridemia showing Lipemia retinalis serves as a vital graded accordingly as early, moderate,
abnormal appearance of the retinal clinical sign of hypertriglyceridemia or marked (Stages I-III, respectively).
arteries and veins, and occasionally because acute triglyceride elevations Although our patient was
the entire fundus. Heyl’s was the may be asymptomatic at first, delaying ophthalmically asymptomatic, having
first to report Lipemia Retinalis in treatment of a potentially lethal

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Figure 3: fundus picture of both eyes after 10 days of systemic therapy (Tablet Atorvastatin 20 mg and Tablet Fenofibrate 160 mg),

DM with associated ketoacidosis. to many other systemic vascular Conclusion
Such patients can also present pathologies including cardiovascular Lipaemia Retinalis is a rare
to ophthalmologist with sudden accidents and acute myocardial manifestation of hypertriglyceridaemia
diminution of vision due to vein infarction. Retinal vascular diseases which is usually asymptomatic. In
occlusion and /or retinal ischemia. may also occur including retinal patients having multiple issues like
Fluorescein and indocyanine artery and vein occlusions. Ischemia diabetes, lipid profile may go unnoticed
angiography testing are typically secondary to vascular occlusions can . It may be worthwhile to do general
normal. SD-OCT tomography is useful lead to neovascularization and vitreous lipid work up in all diabetic patients
in demonstrating inner retinal changes haemorrhage. The treatment for as well as homocysteine levels. As
associatedwithlipemiaretinalis.Testing lipemia retinalis is primarily directed ophthalmologists, we should be on the
may demonstrate hyperreflective and at reducing serum triglyceride levels lookout even for rare manifestations
engorged retinal vessels and white dots and aim being to reduce the serum while screening patients for diabetic
in the inner nuclear and ganglion cell triglyceride levels to below 500 mg/ retinopathy. It should be stressed
layer. Electroretinography may show dl. This can be accomplished by a that a lipid disorder resulting in
decreased a- and b-wave amplitudes in number of medical treatments for lipemia retinalis causes a risk of life
both cone and rod responses2,3. lowering triglyceride and cholesterol. threatening atherosclerotic disease and
A fasting lipid profile as a general Three classes of medications are other severe complications like acute
medical examination should be sought appropriate for the management of pancreatitis. Moreover, characteristic
in a patient found to have lipemia major triglyceride elevations: fibric acid retinal findings may be the only sign
retinalis. Lipemia retinalis has also derivatives, niacin, and omega-3 fatty of lipid disturbances (which are often
been reported in association with acids5. Once triglyceride levels return asymptomatic). In such patients a
skin xanthelasmas and a pulmonary to normal, the clinical ocular findings multidisciplinary approach is necessary
cholesteroloma lung lesion as of lipemia retinalis should quickly to obtain the desirable systemic
complications following allogeneic resolve. Surgery is not specifically outcome. However, systemic treatment
bone marrow transplant for treatment indicated for the treatment of lipemia of elevated triglycerides remains an
of diffuse mixed T cell lymphoma in a retinalis. However, plasmapheresis urgent consideration.
22-year-old woman4. The differential can be used in the setting of severe
for lipemia retinalis includes branch hypertriglyceridemia to reduce References
retinal artery or vein occlusion, triglycerides in the acute setting. Ileal 1. Thomas PK, Smith EB. Ocular
hypertensive retinopathy, and diffuse bypass surgery has demonstrated
choroidal haemangioma. The elevated improvement in all lipid parameters manifestations in idiopathic
serum lipid levels associated with but should be reserved for refractory hyperlipaemia and xanthomatosis. Br J
lipemia retinalis predisposes patients cases6, Ophthalmol. 1958;42(8):501–506.
2. Özturk BT, Bozkurt B, Meşen A, et al.

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Photoessay

Spectral-Domain Optical Coherence 5. Maki KC, Bays HE, Dicklin MR. Corresponding Author:
Tomography Findings in Lipemia Treatment options for the management
Retinalis. Ophthalmic Surg Lasers of hypertriglyceridemia: strategies based Dr. Afzal Tauqir Khan
Imaging Retina. 2016 1;47. on the best-available evidence. J Clin MBBS, DNB , Fellow FVRS
Lipidol. 2012 Sep-Oct. 6(5):413-26. Department of Ophthalmology, T.N.M.C &
3. Lu CK, Chen SJ, Niu DM, et al. B.Y.L. Nair Charitable Hospital, Mumbai,
Electrophysiological changes in 6. Schaap-Fogler M, Schurr D, Schaap T, Maharashtra, India
lipaemia retinalis. Am J Ophthalmol et al. Long-term plasma exchange for
2005;139:1142-5. severe refractory hypertriglyceridemia:
a decade of experience demonstrates
4. Toren A, Nagler A. Solitary pulmonary safety and efficacy. J Clin Apher. 2009.
cholesteroloma, multiple xanthelasmas 24(6):254-8.
and lipemia retinalis complicating
hypercholesterolemia after bone
marrow transplantation. Bone Marrow
Transplant. 1996 Aug;18(2):457-9.

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Monthly Meeting Update

Curls and Curves: A Rare Cause of
Vitreous Haemorrhage

Somya Ish, Deepa Sharma
Department of Ophthalmology, ABVIMS and Dr. RML Hospital, New Delhi, India

Abstract: Fifty five year old male presented with gradual, painless diminution of vision left eye since 6 months. Left eye vision
was finger counting close to face and had brown nuclear cataract. Ultrasound B scan showed vitreous haemorrhage (VH) with
posterior vitreous detachment. Per operatively, there was a massive bleed from the stump present at the disc. After 1 week AC
wash with vitreous lavage was done. Post operatively, fundus revealed double helical prepapillary vascular loop projecting into
vitreous cavity at the centre of disc. Pre-papillary loop is a rare entity and VH associated with it is further rare.
Keywords: Prepapillary loop, vitreous haemorrhage, pars plana vitrectomy.

The main causes of vitreous lens implantation with 25 gauge pars present at the optic nerve head. There
haemorrhage include abnormal vessels plana vitrectomy. Per operatively, was no active bleeding. Post operatively,
prone to bleeding, normal retinal inadvertently there was a posterior cornea was clear and IOP was normal of
vessels that rupture under stress or capsule rent and brown coloured blood 18 mm Hg.
trauma, or extension of blood from an from vitreous cavity came into the Fundus showed a double - helical
adjacent source. Here we discuss a case anterior chamber through the rent. vascular loop projecting into the
of vitreous haemorrhage with a pre- After clearing the anterior chamber vitreous cavity at the centre of optic disc
papillary vascular loop on the optic with automated anterior vitrectomy (Figure 1). Figure 2 shows red free photo
nerve head. cutter, 25 gauge pars plana vitrectomy of the same. On fundus fluorescein
was done. Dense vitreous haemorrhage angiography (FFA), there was filling of
Case Description was present in entire vitreous cavity vascular stump in the late phase with
Fifty five year old male presented which was cleared. Retina was normal delayed filling of inferior hemiretinal
with complaints of gradual, painless except for a stump present at disc. vessels (Figure 3,4). This was suggestive
diminution of vision in his left eye Suddenly, a massive intraoperative of arterial origin of the loop with no
since 6 months. There was no history of bleed from the stump was noted which ischemic insult. OCT done through the
trauma or any surgical intervention. He could not be controlled with cautery or stump showed elevated lesion over the
had no history of any systemic illness after fluid-air exchange. Therefore at disc with a central lumen suggesting an
like diabetes or hypertension. this stage, sclerotomies were closed and arterial connection (Figure 5).
On ocular examination, Right eye was eye was left aphakic under air. After three months, non-foldable
pseudophakic with best corrected visual PMMA PCIOL with 6.0 mm optic was
acuity (BCVA) of 20/20 and Left eye was Post operatively, BCVA L/E was only placed in the sulcus and a best corrected
finger counting close to face. Left eye perception of light (PL+) with accurate visual acuity of 20/60 was achieved.
had brown nuclear cataract and there projection of rays in all quadrants. There
was no view of the fundus. Ultrasound was corneal edema with descemet’s Discussion
B scan of left eye showed moderate folds, total hyphema and blood in This case presents a rare cause of
intensity echoes in anterior and mid vitreous cavity with raised intraocular vitreous haemorrhage, a Pre-papillary
vitreous cavity with after movements pressure of 40 mm Hg. Patient was vascular loop.
suggestive of vitreous haemorrhage started on topical antibiotic, topical The incidence of this finding is
with attachment at the disc suggestive steroids, cycloplegics and topical and approximately 0.01% in the population
of posterior vitreous detachment. systemic antiglaucoma medication. without previous retinal disease1.
Patient was planned for combined It needs to be differentiated from
phacoemusification with intraocular After 1 week, patient was taken up for
AC wash and vitreous lavage. Vitreous
haemorrhage was cleared. Stump was

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Monthly Meeting Update

Figure 1: Double – Helical Vascular Loop with Arterial Figure 2: Magnified Red Free Fundus Photo Showing Pre-Papillary
Configuration Arising from the Optic Nerve Head. Loop.

Figure 3: FFA of Left Eye Showing Delayed Filling Of Inferior Figure 4: FFA of Left Eye Showing Filling of Vasular Loop and
Hemiretinal Vessels. Inferior Hemiretinal Vessels in Late Phase with no Ischaemic Area.

persistent hyaloid artery which is develops twists and turns during this involvement is extremely rare and most
a separate entity. They occur when growth period and may acquire a loop cases have been reported in adults.
evolving retinal vessels grow into like structure with a glial veil2. The visual complaints associated with
vitreous cavity within the Cloquet’s They are usually unilateral, congenital these loops are branch retinal artery
canal instead of coursing into retina. and benign in nature3. Despite of being obstruction, hyphaema, vitreous
The stimulus for this aberrant growth congenital in origin, the childhood haemorrhage and amaurosis fugax4.
pattern is not known. The vessel These complications may occur because

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Monthly Meeting Update

Figure 5: OCT from the Prepapillary Area Showing Elevated Lesion with A Central Lumen which required surgical intervention
and ERM in the Temporal Area. two times. Thus, pre-papillary loop
should be considered in the differential
diagnosis of spontaneous vitreous
haemorrhage in healthy young adults
with no systemic illness.

References
1. Wygnanski-Jaffe T, Desatnik H, Treister

G, Moisseiev J. Acquired Prepapillary
Vascular Loops. Arch Ophthalmol.
1997;115(10):1329–30
2. Degenhart W, Brown GC, Augsburger JJ,
Magargal L. Prepapillary vascular loops.
Ophthalmology. 1981;88(11):1126-31
3. Hsieh YT, Yang CM. The clinical
study of congenital looped/coiled
peripapillary retinal vessels. Eye (Lond).
2005;19(8):906-9/
4. Singh R, Fujinami K, Moore AT. Branch
retinal artery occlusion secondary to
prepapillary arterial loop. Retin Cases
Brief Rep. 2014 Spring;8(2):124-6
5. Huang J, Greenberg PB, Mega JV Jr.
Vitreous Hemorrhage in the Setting of a
Vascular Loop. Fed Pract. 2018;35(6):38–
9.
6. Teramoto S, Ohno-Matsui K, Tokoro T,
Ohno S. Bilateral large peripapillary
venous and arterial loops. Jpn J
Ophthalmol. 1999;43(5):422-5.
7. Mireskandari K, Aclimandos WA.
Probably the longest prepapillary loop
in the world. Retina. 2001;21(4):393-5.

of valsalva maneuver, vitreous traction, venous6,7, as in our case. The inferior Corresponding Author:
trauma or torsion of the loop5. There arterial arcade shows a delayed filling
was no such inciting factor for the suggesting an arterial communication Dr. Deepa Sharma
haemorrhage from the loop in our case. with the loop. Department of Ophthalmology,
Figure 1 shows a prominent double – ABVIMS and Dr. RML Hospital, New Delhi, India
helical vascular loop extending into Conclusion
the vitreous cavity from the centre To the best of our knowledge, vitreous
of optic disc which is completely haemorrhage associated with pre-
filling in the arterial phase on FFA. papillary loop is extremely rare and is
Fluorescein angiographic studies expected to clear spontaneously without
have demonstrated that arterial pre- warranting pars plana vitrectomy
papillary loops are more common than whereas our patient had massive and
uncontrolled vitreous haemorrhage

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Monthly Meeting Update

Anterior Segment Laser
Procedures - Preventing Spikes
A Journey of Four Studies

Prof. Manav Deep Singh, Dr. Nidhi Sharma, Dr. Harshika Chawla, Dr. Pradeep Aggarwal, Dr. Esha Singh
Department of Ophthalmology, ABVIMS and Dr. RML Hospital, New Delhi, India

Abstract: Background: To assess the need, best agent and justification for routine use of ocular hypotensive drugs in peri-
laser period following withdrawal of Apraclonodine from Indian market. Methods: Four consecutive studies were performed to
study different aspects of changes in intraocular pressure following various anterior segment laser procedures. The efficacy of
all available groups except prostaglandin analogues were also compared.
Results: All the studies showed little or no significant rise of intraocular pressure following YAG laser capsulotomy or iridotomy
except when very high energy was used. Superiority of any drug over others could not be concluded. The amount of rise of
intraocular pressure (IOP) as well as duration of this rise following YAG laser anterior procedure was directly proportional to
the amount of energy used.
Conclusions: There is no need to use any ocular hypotensive drugs in peri-laser period unless very high energy is used,
patient has pre-existing significantly high IOP or has advanced glaucoma. Although IOP rise following YAG procedures is low,
capsulotomy, in general, causes more rise in IOP than YAG iridotomy.
Key words: YAG laser, capsulotomy, iridotomy, peri-laser.

Background IOP spikes? Since IOP rise is for short iridotomy). The population was divided
Till early 21st century, Apraclonidine duration could a single pre-laser dose into five groups depending upon the
has been the standard treatment for of any drug prevent these spikes? drug given viz. Brimonidine 0.2%,
prevention of spikes of intraocular Could a single dose of Acetazolamide oral Acetazolamide 250, Dorzolamide
pressure (IOP) that occurred following be a cost effective alternative? And 2%, Placebo and Timolol 0.5%. The
anterior segment laser procedures like could these spikes be minimized if energy was limited to 50 mJ. Patients
posterior capsulotomy, peripheral quantum of energy used is limited to a with advanced glaucoma, recent acute
iridotomy, trabeculoplasty, iridoplasty particular amount? Although various angle closure glaucoma (ACG), pre-
etc. However, his drug was withdrawn studies had compared one or two drugs laser IOP >28 or active inflammation
from Indian market due to poor sales with or without placebo, there was were excluded. Intraocular pressure
as it has problem of tachyphylaxis. no study available in literature which was recorded at baseline, 1, 3, 5 & 24
Other a agonists were considered the had compared drugs from all groups hours using Goldmann applanation
next natural choice by default and at the same time. Thus, we planned a tonometer (GAT). Number of shots and
most people started using Brimonidine. randomized double blind single center total energy required were recorded.
While trying to develop evidence based study to find out quantum of rise of IOP Results surprised us. There was no
protocol for our own institution, we following anterior segment YAG laser significant rise of mean IOP in any
looked for relevant literature. However, procedure and extent to which this drug group, although some individual
we realized that there was not enough increase was preventable by different patients did have a rise of IOP except
evidence in literature to prove role of groups of anti-glaucoma drugs1. The in Brimonidine group. There was a
Brimonidine or any other medicine. study enrolled 174 eyes of 174 patients statistically significant rise in mean
in which YAG laser capsulotomy IOP in placebo group, however, only
Discussion (YLC) or YAG laser iridotomy (YLP) one patient had clinically significant
While searching the literature for the was indicated. Single dose was given (>5 mmHg) rise at 1, 3, & 5 hours which
above purpose, the questions that came in randomly double blind manner also became insignificant at day 1. No
to our mind were as follows: Which one hour prior to performing YAG patient had a rise of >10 mmHg (Figure
drug is most effective in controlling Laser procedure (capsulotomy or 1 & Table 1).

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Monthly Meeting Update

IOP, intraocular pressure; hr, hour; IOP-1, Pre laser IOP; PL-IOP1, Post laser IOP at 1 hr; PL-IOP3- was recorded at 1, 2, 3, 4 hours, one day,
Post laser IOP at 3 hr; PL-IOP5 Post laser IOP at 5 hr; PL-IOP24 post laser IOP at 24 hr post laser one week and one month post laser.
Figure 1 Study population was divided into
three groups based on amount of energy
Table 1: Number of patients with increase of more than 5 mmHg in IOP used i.e. those upto 40mJ (n=62), 40-80
post laser period (n=89) and those > 80 (n=30). There
was no significant rise of IOP when
Group 1 hour 3 hour 5 hour 24 hour energy upto 80 mJ was used. However,
there was a marked difference in rise of
1 00 0 0 IOP when energy of > 80 mJ was used
(Figure 3 & 4).
2 22 1 1
The observations can be summarized
3 11 1 0 as: 1) increase in IOP as well as duration
of this increase following YLC was
4 11 1 0 proportional to the quantum of energy
used for the purpose; 2) maximum
5 01 1 1 IOP recorded was 26 mmHg and 3)
only occasional patient with low
We reviewed the literature further to Asia Pacific Academy of Cataract and energy usage showed rise in IOP, that
study the subject in detail. Most studies Refractive Surgery, 2014 as a free paper. too minimal. There is a sustainable
reported very high incidence of post The question studied was “Whether argument regarding relationship of rise
laser IOP spikes2,3,4,5,6,7. However, some there existed a relationship between of IOP to energy that those cases who
studies showed very little rise.8,9,10 quantum of energy used and amount had poor quality surgery will have thick
Most of the above studies opined that of rise of IOP following Nd:YAG laser posterior capsular opacification (PCO)
rise of IOP was proportional amount capsulotomy?” It was a cross sectional and require more energy. Also, this poor
of energy, although, a few refuted observational study of 181 eyes of 181 quality surgery could have caused more
this concept11. Some studies showed patients who had undergone cataract inflammation and/ or more damage to
worsening of onset of glaucoma surgery for age related cataract and had trabecular meshwork as well, making
following YLC12. In nut shell there was posterior capsular opacification (PCO). them prone to higher rise of IOP.
a huge variation in the energy required Exclusion criteria included baseline
as well as rise of IOP. Furthermore, IOP > 21 mmHg, intra-ocular surgery In our first study, we observed that IOP
we could not find any study which other than that for cataract, active rise following YLC was more than YLPI.
quantified energy levels and directly inflammation and vitreous in anterior Understandably, because of higher
related it to rise of IOP. Thus we did chamber (AC). Less than 5 mmHg rise amount of energy used in YLC cases.
another study to find out if the amount of IOP was considered mild and that of This intrigued us to probe the effect
of rise of IOP was related to amount of > 5 to <10 or 27 mmHg was considered of higher energy levels in YLPI. The
energy at all and presented in American moderate whereas a rise of > 10 or 32 question was whether the effect of these
Academy of Ophthalmology and mmHg was considered severe. The IOP two procedures different or is IOP rise
the function of amount of energy only?
On reviewing literature, we observed
that many studies had shown increase
in IOP following YAG PI, although the
rise shown was less than those in YLC.
Similar to our study, one RCT reported a
fall in IOP rather than a rise. The reasons
for fall were probably opening of angle
or use of pilocarpine in cases of YL PI14.
Therefore, we planned another study
for YL PI in eyes with absent iris crypts
as we expected higher amount of energy
consumption in these cases. Pilocarpine
2% was used pre-laser as well as post
laser, twice a day, for 5 days. Despite use
of high quantum of energy (Table 2),

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Monthly Meeting Update

Figure 2: Rise of IOP from baseline at different time intervals. rise in IOP was either insignificant or
there was fall at different study points
Table 2: Amount of energy/ shots/ sittings (Table 3).

Group Group one Group two The results were astonishing and
(n=19) (n=21) fairly convincing that use of ocular
88.81 hypotensive drugs in peri laser period
Mean total YAG energy (milli Joules) 50.55 22.1 was not essential unless very high
Percentage energy had been used or in those cases
Mean number of laser shots 9.53 38.1 who had advanced glaucoma. This
52.4 prompted us to design our final study.
No. of laser sittings Percentage Number 9.5
1 94.7 18 The final study ‘Effect of amount of
2 5.3 01 energy on IOP and changes in anterior
3 0.0 00 segment depth among patients of
PACD undergoing YAG PI’ is yet to be
Table 3: Mean intraocular pressure following laser peripheral iridotomy published, although it was presented
in Annual conference of ‘Glaucoma
Group One Group Two Society of India’ 2018 and was adjudged
the best poster (runners up). Fifty five
IOP (Mmhg) Difference from IOP (mmHg) Difference from eyes of 55 patients of primary angle
Mean SD baseline (p Mean SD baseline (p closure disease (PACD) in which PI
value) value) was indicated were included in the
study. Those on ocular hypotensive
Baseline 20.05 ± 5.05 22.48 ± 4.41 drugs, those with previous intraocular
surgery/ inflammation and those with
One hour 20.21 ± 6.88 +0.158 (1.000) 21.67 ± 4.53 +0.810 (1.000) IOP > 28 mmHg or field defects in
central 100 were excluded. Pilocarpine
Three hour 17.79 ± 3.92 -2.263 (0.287) 20.52 ± 3.89 +1.952 (<0.003) 2% was used to make pupil non-reactive
to light before the procedure and then
One day 16.53 ± 3.82 -3.526 (0.002) 18.62 ± 3.17 +3.857 (<0.001) twice/day for five days. Post laser IOP
was recorded at 1,2,3 hours, one day and
One week 15.74 ± 3.57 -4.316 (<0.001) 17.29 ± 4.03 +5.190 (<0.001) one week and was the primary outcome
measure. Definitions of mild, moderate
SD- Standard deviation; IOP- Intraocular pressure and severe rise in IOP were same as in
our earlier studies mentioned above.
Figure 3: Comparison of intraocular pressure among Groups The results of this study, once again,
confirmed that there is very little rise
of IOP following YAG laser iridotomy
(Figure 4) even when reasonably high
amount of laser energy is used (Figure
5).

Conclusions
Thus the following conclusions can be
drawn from the above studies combined
together:

1. If limited amount of energy is used
for YAG laser capsulotomy (YLC)
or iridotomy (YLPI), no ocular
hypotensive drugs are required in
peri-laser period in un-complicated
without pre-existing glaucoma.

2. YAG capsulotomy tends to cause

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Monthly Meeting Update

Figure 4 study intraocular pressure spikes and Nd: YAG laser posterior capsulotomy. J
their prevention. Delhi J Ophthalmol. Pharmacol Pharmacother 2011; 2(2):104-
Figure 5 2015; 26(2):93-96. 106.
more IOP spikes than YLPI 2. Ladas ID, George P Pavlopoulos, Stefanos 8. Khanzada MA, Shafi JM, Kumar A, et
N Kokolakis, et al. Prophylactic use of al. Is the Nd: YAG laser a safe procedure
3. In cases of YAG laser iridotomy, acetazolamide to prevent intraocular for Posterior Capsulotomy? Pak J
IOP can even fall rather than rise in pressure elevation following Nd-YAG ophthalmol. 2008; 24(2):73-78.
post-laser period especially when laser posterior capsulotomy. British J 9. Hu CY, MD, Woung LC, MD, DMSc,
pilocarpine is used in peri-laser Ophthalmol. 1993; 77(3):136-138. Wang MC and Jian JH. Influence
period, although is a good idea 3. Dandona Lalit, MD, MPH, Dandona of laser posterior capsulotomy on
to monitor post laser IOP spikes, Rakhi, BOpt, Mandal Partha, et anterior chamber depth, refraction, and
especially in high risk cases. al. Angle-closure Glaucoma in an intraocular pressure. J Cat Ref Surg.
Urban Population in Southern India. 2000; 26(8):1183-1189.
However, due to relatively small Ophthalmology 2000; 107(9):1710-1716. 10. Zaidi M, Askari NS. Effect of Nd: YAG
sample size and single center 4. Sihota R, Agarwal HC. Profile of the Laser posterior capsulotomy on anterior
combination of studies, well subtypes of angle closure glaucoma in chamber depth, intraocular pressure and
designed large scale RCTs are tertiary hospital in North India. Indian J refractive status. Asian J ophthalmol.
indicated to confirm this novel Ophthalmol. 1998; 46(1):25-29. 2004; 5(4):2-5.
concept. 5. Robin A, MD, P Irvin, Pollack, MD. 11. Slomovic AR, Parrish RK 2nd, Foster
A comparison of Neodymium: RK and Cubillas A. Nd: YAG laser
References YAG and Argon Laser Iridotomies. posterior capsulotomy. Central corneal
1. Singh MD, Sharma N and Jain S. Anterior Ophthalmology 1984; 91(9):1011-1016. endothelial density. Arch Ophthalomol.
6. Kitazawa Y, Taniguchi T and Sugiyama 1986; 104(4):536-8.
Segment Nd: YAG Laser Procedures: To K. Use of Apraclonidine to Reduce Acute 12. Lin JC, Katz LJ, Spaeth GL, et al.
Intraocular Pressure Rise Following Intraocular pressure control after
Q-switched Nd: YAG Laser Iridotomy. Nd:YAG laser posterior capsulotomy in
Ophthalmic Surgery, lasers and Imaging eyes with glaucoma. Br J Ophthalmol.
Retina 1989; 20(1):49-52. 2008; 92(3): 337-9.
7. Singhal D, Desai R, Shastri S, et al. 13. Singh MD, Aggarwal P and Sharma
Use of topical brimonidine to prevent N. A Randomised Comparison of Two
intraocular pressure elevation following laser Iridotomy Tecniques in Patients
of Primary Angle Closure Disease with
Absent Iris Crypts. Del J Ophthalmol.
2016; 27(1):25-29.
14. De Silva DJ, Gazzard G and Foster P.
Laser iridotomy in dark iridis. Br J
Ophthalmol. 2007;91(2): 222-225.

Corresponding Author:

Prof. Manav Deep Singh
Department of Ophthalmology,
ABVIMS and Dr. RML Hospital, New Delhi, India

Note: Figure 2 not mentioned in the article text.

www.dosonline.org/dos-times DOS Times - Volume 25, Number 5, March-April 2020 69

Monthly Meeting Update

Brimonidine Induced Bilateral
Uveitis and Severe Ocular Surface
Damage in a Patient of Primary
Open Angle Glaucoma: A Case
Report and Review of Literature

Amrit Mandal, Manav Deep Singh
Department of Ophthalmology, ABVIMS and Dr. RML Hospital, New Delhi, India

Abstract: Background: Granulomatous uveitis is a rare side effect of Brimonidine. We could find 38 such cases reported in
literature.
Case: A 60 years old male with advanced primary open angle glaucoma in both eyes presented with peri-ocular swelling,
conjunctival congestion and photophobia in both eyes. His visual acuity in right eye dropped from 6/9 to 6/60. He was using
topical latanoprost 0.005%, brimonidine 0.15% and brinzolamide 1% in both eyes. Examination showed bilaterally symmetrical
swollen lids typical of brimonidine allergy. Multiple moderate sized KPs and minimal flare were present in both eyes without
posterior synechiae or cells in anterior chamber. Brimonidine was stopped and anti-allergic treatment (local and systemic) was
given. Uveitis resolved completely in 3-4 weeks, blepharitis resolved in 2 months and visual acuity improved to baseline.
Summary: This case report highlights the possibility of a rare side effect of brimonidine. It also describes features of brimonidine
induced uveitis based on our case and those reported in literature.

Brimonidine tartarate is a selective Case Report advised topical steroids and cycloplegic
a2 adrenergic receptor agonist that A 60 year old male with primary open drugs in addition to his antiglaucoma
lowers intraocular pressure by reducing angle glaucoma presented to the medications. His conditions continued
aqueous secretion and increasing outpatient department of glaucoma to worsen and he presented to us eight
uveoscleral outflow1. Brimonidine services of a tertiary centre of north months after starting his treatment.
0.15% is widely used in the treatment India with lid swelling, watering, There was no history of change of
of glaucoma and ocular hypertension redness of conjunctiva, photophobia formulation of ocular hypotensive
and is generally well tolerated. Much and diminution of vision. All his drugs since their beginning. He also
known ocular side effects associated complaints were present in both eyes had infero-temporal branch retinal
with brimonidine use include allergic for 3 months and were progressing vein occlusion in his left eye for
reactions severe enough to necessitate gradually. which he successfully underwent laser
withdrawal from the study in 7% - 15% photocoagulation. He was a known
of patients and conjunctival follicles in He was first time diagnosed with diabetic and hypertensive for past
8% of patients2-4. Since the introduction primary open angle glaucoma in 2013, three years and a heavy smoker for
of this drug in 1997, some cases have but discontinued treatment for four past 40 years. There was no history of
been associated with granulomatous years. He again presented as advanced contact. On initial evaluation, the best
anterior uveitis as a late adverse reaction primary open angle glaucoma in corrected visual acuity in right eye was
to long term use of brimonidine5. Here both eyes in 2018 and was advised 6/24 and in left eye, finger counting
we report such a case to highlight the latanoprost 0.005%, brimonidine close to face with accurate perception
characteristic features of brimonidine 0.15% and brinzolamide 1% in both of rays in all quadrants. Ocular
induced uveitis based on our case and the eyes. After five months he presented examination disclosed bilaterally
the reviewed literature. to a local ophthalmologist at the symmetrical swollen lids with
beginning of his symptoms. He was hyperaemia of periocular tissue and

70 DOS Times - Volume 25, Number 5, March-April 2020 www.dosonline.org/dos-times

Monthly Meeting Update

lower lid mechanical ectropion (Figure Figure 1: Clinical picture on presentation showing lid swelling with hyperaemia and lower
1). Slit lamp examination showed lid mechanical ectropion.
generalised congestion of conjunctiva Figure 2a: Clinical photo of cornea of right eye and left eye depicting positive corneal staining
with extensive superficial punctuate and extensive SPK’s.
keratitis (SPKs) over cornea and mutton Figure 2b: Slit lamp photo of right eye and left eye showing mutton fat keratic precipitates.
fat keratic precipitates (KPs) in both
eyes (L&R) (Figure 2a,b). Anterior
chamber examination revealed no cells
with minimal flare. Relative afferent
papillary defect was present in left
eye. Iris pigments were present over
anterior lens capsule in both eyes.
Intraocular pressure was 23mm Hg in
right eye and 22mm Hg in left eye by
Goldmann’s applanation tonometry.
Gonioscopy showed grade open angles
(Shaffer’s grading). Cup disc ratio of
0.9 was present in right eye and near
total cupping in left eye. Old retinal
photocoagulation marks were present
in the inferior and temporal quadrants
of left retina.

Patient was diagnosed to have primary
open angle glaucoma in both eyes
with bilateral granulomatous anterior
uveitis, severe ocular surface damage
and blepharitis secondary to use of
topical anti glaucoma drugs, and
left eye lasered branch retinal vein
occlusion. Investigations to rule out
systemic cause of granulomatous
uveitis like Mantoux test, chest X-ray,
serum angiotensin converting enzyme
(S.ACE) and venereal disease research
laboratory (VDRL) test were not
contributory. Though the periocular
picture was suggestive of brimonidine
allergy, we were not sure as to which
anti glaucoma drug was contributing
to granulomatous anterior uveitis. So
we stopped all topical anti glaucoma
drugs and substituted with tablet
acetazolamide 250 mg 3 times/day.
He was put on oral steroids (tablet
prednisolone 20mg OD) for one week.
Topical steroids (betamethasone 0.02%
eyedrop) six times a day along with
homatropine 2%. Frequent preservative
free lubricating eyedrops and gel along
with warm compress were also added.
Since the periocular side effects were
characteristic of brimonidine, we
started rest of antiglaucoma drugs one
by one and oral acetazolamide was

www.dosonline.org/dos-times DOS Times - Volume 25, Number 5, March-April 2020 71

Monthly Meeting Update

Table 1: Similar cases reported worldwide

Authors Cases Reported Duration of Clinical Features
Brimonidine Before
Presentation Granulomatous anterior uveitis, numerous
mutton fat KPs, AC cells and flare present posterior
Byles et al. 2000 4 Patients 11-15 months synechiae in 1 patient
Ciliary congestion, b/l mutton fat KP’s
Goyal R et al. 2000 1 patient 6 months Mutton fat KPs, AC cells +, posterior synechiae and
Cates et al. 2003 1 patient 18 months raised IOP
Granulomatous anterior uveitis, allergic
Velasque et al. 2004 1 patient 13 months conjunctivitis, blepharitis, raised IOP
B/L gross papillary conjunctivitis, corneal punctate
Nguyen EV et al. 2008 1 patient 2 years epithelial erosions,3+ cells & flare, posterior
synechiae
Hondeghem K et al. 2009 2 patients 10 months, 1 year Chemosis, conjunctival injection, KP’s
McKnight CM et al. 2012 5 patients 6 months - 5 years Conjunctivitis, blepharitis, stellate KP’s
Carrasco et al. 2013 2 patients 16 months B/L granulomatous uveitis, severe conjunctival
injection, corneal punctate epithelial erosion and
Casado A et al. 2013 1 patient 12 months moderate lid edema
Conjunctival hyperemia, follicular reaction,
Oli A et al. 2015 1 patient 1 year mutton fat KP’s, 1+ cells
Beltz et al. 2015 19 eyes of 12 7 days -5 years Ciliary congestion, mutton fat KP’s, 2+ cells & flare
patients Granulomtous KPs , concurrent granulomatous
Clemente et al. 2018 1 patient 2 years conjunctivitis
Granulomatous KPs superficial punctate erosion,
Kattige et al. 2019 1 patient 2 weeks blepharitis with meibomitis
Keratic precipitates

KP, keratic precipitates; B/L , bilateral

stopped by one week. After one month, Figure 3: Clinical picture at 2 months of treatment when the symptoms resolved
he was on brinzolamide 1%, timolol
0.5% and latanoprost 0.05%. Uveitis drug used all over the world since 1997 It has minimal cardio-pulmonary
resolved completely in 3-4 weeks with as treatment for primary open angle side effects, but ocular side effects,
standard treatment and without any glaucoma and ocular hypertension. particularly allergic reactions are
residual signs. Blepharitis and corneal
problems resolved in 2 months (Figure
3) and visual acuity improved to
baseline (6/9).
No recurrence of symptoms were seen
in 15 months of close monitoring
although, he still needs lubricants. Re-
challenge test with brimonidine was
considered but was not done due to
advanced glaucoma and alternative
medications could control IOP
effectively.

Discussion
Brimonidine tartarate is an important

72 DOS Times - Volume 25, Number 5, March-April 2020 www.dosonline.org/dos-times

Monthly Meeting Update

Table 2: Naranjo’s criteria for adverse drug reactions capsule.
yy Cells in anterior chamber and
Criteria Yes No Don't know Score
posterior synechiae are un-likely.
Previous conclusive reports on 1 00 9–13 – Definite yy Uveitis generally occurs when drug
this reaction 5–8 – Probable
1–4 – Possible is not discontinued for long time
Adverse reaction appeared after 2 -1 0 0 – Doubtful even after the appearance of peri-
the drug was administered ocular allergy.
yy There occurs quick recovery of
Adverse reaction improved when 1 00 symptoms after discontinuing
drug discontinued or specific brimonidine without any residual
antagonist administered effect.
The mechanism of anterior uveitis
Adverse reaction reappeared 2 -1 0 due to brimonidine remains
when the drug was speculative. Moorthy et al proposed
readministered two mechanisms by which drugs could
cause uveitis: direct, immediate toxic
Alternative causes (other than 0 20 reaction to the drug, or an indirect
the drug) caused the reaction pathway of immunologic sensitivity to
free drug or drug bound tissue proteins7.
Adverse reaction reappeared -1 1 0 These side effects appear to be a delayed
with placebo type hypersensitivity reaction which
manifest on chronic use of brimonidine
Toxic drug concentrations 1 00 for more than six months. A series of
measured (systemic or local) criteria (Naranjo’s criteria) have been
suggested to establish the role of drug
Adverse reaction was dose- 1 00 suspected to have caused an adverse
dependent reaction (Table 2)8. Based on these
criteria, with a score of 9, there was
Same adverse reaction to drugs 1 00 a definite role of brimonidine in the
in the same class adverse reactions in our case.

Adverse event confirmed by any 1 00 Summary and Recommendations
objective evidence Overall brimonidine is a well-tolerated
topical anti glaucoma medication.
more common compared to topical since the introduction of the drug in Granulomatous anterior uveitis is a
b-blockers2-4. Common side effects 1997. The reason why this side effect rare side effect of brimonidine therapy,
of brimonidine include hyperaemia, is so rare may be attributed to the fact which generally occurs when the drug
burning sensation, lid oedema, skin that brimonidine therapy is usually is not discontinued for a long time
puckering and conjunctival follicles. discontinued at the onset of an allergic despite appearance of other allergic
Photophobia, allergic conjunctivitis reaction. The clinical features of the reactions. Clinicians should be alert to
and corneal erosions and staining previously reported cases and the this possibility when the ocular surface
are occasional adverse effects5. duration of brimonidine therapy in signs of brimonidine allergy develop
These side effects have a maximum them have been tabulated below (Table and they should closely monitor such
occurrence after 6-9 months of therapy 1). patients for the signs and symptoms
and they resolve on cessation of described above. The uveitis responds
brimonidine4. Drug induced uveitis Based on these reports and our case, well to the standard treatment along
has been reported with a number of the important characteristic features of with cessation of brimonidine without
medications, including metipranolol, brimonidine induced uveitis are: any residual signs. An international
bisphosphonates, corticosteroids, registry of brimonidine induced uveitis
cidofovir and latanoprost. Delayed yy Uveitis is restricted to the anterior is advisable to determine its incidence.
appearance of granulomatous anterior segment.
uveitis following use of brimonidine References
eye drops has been reported previously. yy Conjunctival congestion may not be 1. Greenfield DS, Liebmann JM, Ritch
Uveitis is a rare side effect of brimonidine circum-corneal.
as on doing literature search, we could R. Brimonidine: a new alpha2
find very few cases reported worldwide yy There is presence of mutton fat
KP’s over the corneal endothelium
and iris pigments over anterior lens

www.dosonline.org/dos-times DOS Times - Volume 25, Number 5, March-April 2020 73

Monthly Meeting Update

-adrenoreceptor agonist for glaucoma and timolol 0.5% given twice daily Corresponding Author:
treatment. J Glaucoma 1997;6:250-258. in patients with glaucoma or ocular
hypertension. Brimonidine Study Group Prof. Manav Deep Singh
2. Schuman JS, Horwitz B, Choplin NT, 2. Ophthalmology 1998;105:1960-1967. Department of Ophthalmology,
et al. A 1 year study of brimonidine ABVIMS and Dr. RML Hospital, New Delhi, India
twice daily in glaucoma and ocular 5. Goyal R, Ram AR. Brimonidine
hypertension. A controlled, randomized, tartarate 0.2% (Alphagan) associated
multicenter clinical trial. Chronic granulomatous anterior uveitis. Eye
Brimonidine Study Group. Arch 2000;14:908-910.
Ophthalmol 1997;115:847-852.
6. Moorthy RS, Valluri S, Jampol LM.
3. Katz LJ. Brimonidine tartarate 0.2% Drug-induced uveitis. Surv Ophthalmol.
twice daily vs timolol 0.5% twice daily: 1999;42:557-570.
1year results in glaucoma patients.
Brimonidine Study Group. Am J 7. Naranjo C.A., Busto U., Sellers E.M. A
Ophthalmol 1999;127:20-26. method for estimating the probability of
adverse drug reactions. Clin Pharmacol
4. LeBlanc RP. Twelve-month results Ther. 1981;30:239–245.
of an ongoing randomized trial
comparing brimonidine tartarate 0.2%

74 DOS Times - Volume 25, Number 5, March-April 2020 www.dosonline.org/dos-times

Subspeciality-Cornea

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www.dosonline.org/dos-times DOS Times - Volume 25, Number 5, March-April 2020 75

DOS Times Quiz

DOS Times Quiz

March-April 2020
What is your Diagnosis?

Deepali Singhal1, Gunjan Saluja2, Prafulla K. Maharana2 MD
1. Institute of Vision and Optics, VEIC, University of Crete, Greece.
2 Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi,
India.

Corresponding Author: A 24-year-old male, referred with a
suspected intraocular tumor, presented
with diminution of vision in OS for 2
months. On examination, best-corrected
visual acuity (BCVA) was 6/9 along with
a white colored mass in the anterior
chamber. The clinical photograph and
the anterior segment optical coherence
tomography is shown below. OD was
within normal limits. What is the most
probable clinical diagnosis?

a) Primary iris cyst
b) Secondary iris cyst
c) Iris melanoma
d) Ciliary body tumor

Dr. Prafulla Kumar Maharana
Dr. Rajendra Prasad Centre for Ophthalmic
Sciences, All India Institute of Medical Sciences,
New Delhi, India.

Answer

Answer _______________________________________________________________________________________________________________________________________
Name: ________________________________________________________________________________________________ Degree: _______________________________
Designation:_________________________________________________________________________ Address:_______________________________________________
_______________________________________________________________________ State _______________________________ Pin _______________________________
Mobile No: ________________________________________________________________________________________ DOS Membership no: ___________________
Email ID: _______________________________________________________________________________________Signature: ___________________________________
Email your answer to: [email protected]

76 DOS Times - Volume 25, Number 5, March-April 2020 www.dosonline.org/dos-times

Tearsheet

Orbital Cellulitis

Definition: - Orbital cellulitis is inflammation of eye tissues behind the orbital septum

Etiology: -

 Sinusitis (most  Dacryocystitis  Dental infections(pre molar

common)  Untreated and molar teeth)

 Eczema preseptal cellulitis/  Strabismus surgery

 Furuncle Endophthalmitis  Eyelid surgery

 Facial cellulitis  Scleral buckling  Lacrimal surgery

 Trauma  Peribulbar  Cataract extraction
injection

Modified Chandlers classification

Stage 1 – Preseptal cellulitis

Stage 2 – Orbital Cellulitis

Stage 3 – Subperiosteal abscess (SPA)

Stage 4 – Orbital abscess

Stage 5 – Cavernous sinus thrombosis

Clinical features:

 Severe edema and erythema of  Diplopia

periorbital tissues  Decreased vision

 Proptosis  Fever

 Pain with eye movement

 Ophthalmoplegia

Causes of vision loss:

 Proptosis causing exposure  Choroidal infarction

keratopathy  Ischemic optic neuropathy

 Ciliary body rotation causing angle  Papilledema
closure glaucoma  Cavernous sinus thrombosis
 Direct optic nerve invasion(fungal)
 Central retinal artery occlusion  Optic nerve compression from
 Central retinal vein occlusion
 Exudative retinal detachment abscess or mucocele

 Endophthalmitis

 Choroidal effusion

Examination:

 Best-corrected visual acuity (BCVA).  Ocular motility and presence of pain

 Color vision assessment with eye movements

 Proptosis measurements using Hertel  Globe displacement

exophthalmometry  Resistance to retropulsion

 Visual field assessment  Measurement of intraocular pressure

 Assessment of pupillary function (IOP). Slit-lamp bio-microscopy

 Dilated fundus exam

Complications:

 Compressive optic neuropathy  Intracranial infectious aneurysm

 Toxic optic neuritis  Cavernous thrombosis

 Panophthalmitis  Meningitis

 Exposure keratopathy  Brain abscess

 Encephalitis  Subdural empyema

www.dosonline.org/dos-times DOS Times - Volume 25, Number 5, March-April 2020 77

Tearsheet

Medical Management:

1. Intravenous vancomycin/linezolid for MRSA

2. Second- or third-generation cephalosporin, clindamycin, or metronidazole for gram-

negative and anaerobic organisms

3. Nasal decongestant and nasal irrigation for concurrent sinusitis

4. Intranasal corticosteroid facilitate drainage by reducing mucosal edema

Indications for abscess drainage:

 Patients age 9 years old or above  Suspected anaerobic infection

 Large size of spa  Infection of dental origin

 Non-medially located spa  Orbital abscess

 Recurrent spa after prior drainage  Cases associated with retained orbital

 Frontal sinusitis foreign body especially those of organic

 Chronic sinusitis nature

 Presence of ocular complications  Fulminant infection of an ocular/adnexal
structure, e.g., endophthalmitis,

dacryocystitis etc.

 Concurrent sinusitis with completely

opacified sinuses

 Cavernous sinus or intracranial

involvement

Deepsekhar Das MD1, Sahil Agrawal MD1, Sujeeth Modaboyina MD1, Saloni Gupta MS2, Prof M.S. Bajaj MD1
1. Oculoplasty and Paediatric Ophthalmology Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India
Institute of Medical Sciences, New Delhi, India
2. Dept. Of Ophthalmology, Northern Railway Central Hospital, Connaught Place, New Delhi, India.

Corresponding Author:

Dr. Sujeeth Modaboyina MD
Oculoplasty and Paediatric Ophthalmology
Services, Dr Rajendra Prasad Centre for
Ophthalmic Sciences, All India Institute of
Medical Sciences, New Delhi, India

78 DOS Times - Volume 25, Number 5, March-April 2020 www.dosonline.org/dos-times

Tearsheet

Ocular surface neoplasia- treatment outcomes

Small Large Diffuse
< 3 clock hours 3-6 clock hours > 6 clock hours
< 5 mm dia > 5 – 15 mm
> 15 mm

Pigmented Non-pigmented Non-pigmented Pigmented
Excision biopsy + AMG + Cryotherapy

Pigmented PAM MM Excision biopsy Same as
small lesions

Atypia Without atypia Excision + cryo

+ AMT + Adj. CT CIN OSSN
CT with MMC
Cryo Observation MMC CT with
+ Chemotherapy INFN 4 – 6 cycles

(CT) Plaque RT

4 monthly follow up surgical excision
For 1 year +AMG

Then 6 monthly follow up. Monthly
follow up

www.dosonline.org/dos-times 3 monthly

DOS Times - Volume 25, Number 5, March-April 2020 79

Tearsheet

> 6 clock hours

NP tumours Map biopsy

Incision biopsy done PAM MM

CIN Invasive DF/ST/Cryo/Top CT Exenteration

CT with MMC CT with MMC Until tumour resolution
And follow up
Monthly follow up
No
For 4 months resolution
RT / Enucleation / Exenteration
Complete Partial

After complete resolution resolution

resolution

Monthly for 1 year

6 monthly follow up CT

4 monthly follow up

Sx of the residual tumour

References Medicina fluminensis, 53(2), pp.236-240. Corresponding Author:

1. Al Bayyat G, Arreaza-Kaufman D, 3. Cicinelli M, Marchese A, Bandello F, Dr. Anitha Venugopal DNB, FAICO, FICO,
Venkateswaran N, Galor A, Karp C. Update Modorati G. Clinical Management of Ocular Aravind Eye Hospital, Tirunelveli, Tamilnadu,
on pharmacotherapy for ocular surface Surface Squamous Neoplasia: A Review of India.Medical Sciences, New Delhi, India
squamous neoplasia. Eye and Vision. the Current Evidence. Ophthalmology and
2019;6(1). Therapy. 2018;7(2):247-262.

2. Merlak, M., Bilen Babić, M. and Dekanić, 4. Sayed-Ahmed I, Palioura S, Galor A, Karp
A., 2017. Treatment of ocular surface C. Diagnosis and medical management of
squamous neoplasia: Case report of ocular ocular surface squamous neoplasia. Expert
surface squamous neoplasia: Case report. Review of Ophthalmology. 2016;12(1):11-
19.

80 DOS Times - Volume 25, Number 5, March-April 2020 www.dosonline.org/dos-times

DOS Travel Fellowship for Partial Financial Assistance
to Attend Conferences

Applications are invited for DOS Fellowship for partial financial assistance to attend conference(s).

Conferences
International: Eight fellowships per year.

• Maximum of Rs. 50,000/- per fellowship will be sanctioned

Partial travel fellowship to attend AIOC: Five fellowships per year

The last date of DOS Fellowship for Partial Financial Assistance to Attend Conference(s) for receiving application is 30th
September for National Conference.

Maximum of Rs. 10,000/- per fellowship will be awarded out to five one to the winner of the DOS best paper (A C Aggarwal
Trophy) for travel to present the paper in the forthcoming AIOC.

Eligibility
• DOS Life Members (Delhi Members only)
• 75 or More DCRS Points
• Accepted paper for oral presentation, poster, video or instruction course or invited guest speakers

Time since last DOS Fellowship
Preference will be given to member who has not attended conference in last three years. However if no applicant is found
suitable the fellowship money will be passed on to next year. Members who has availed DOS fellowship once will not be
eligible for next fellowship for a minimum period of three years.

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The fellowship will be given only to presenting author. Presenting author has to obtain certificate from all other co-authors
that they are not attending the said conference or not applying for grant for the same conference. (Preference will be given to
author where other authors are not attending the same conference). If there is repeatability of same author group in that case
preference will be given to new author or new group of authors. Preference will also be given to presenter who is attending
the conference for the first time.

Quality of Paper
The applicant has to submit abstract along with full text to the DOS Fellowship Committee. The committee will review the
paper for its scientific and academic standard. The paper should be certified by the head of the department / institution, that
the work has been carried out in the institution. In case of individual practitioner he or she should mention the place of study
and give undertaking that work is genuine for invited guest speakers & instruction courses only acceptance letter is required.
The fellowship committee while scrutinizing the paper may seek further clarification from the applicant before satisfying itself
about the quality and authenticity of the paper. Only Single best paper has to be submitted by the applicant for review (6
copies). Quality of the paper will carry 50% weightage while deciding the final points.

Poster and Video
The applicant will need to submit poster and video for review.

Credit to DOS
The presenter will acknowledge DOS partial financial assistance in the abstract book / proceedings.
The author will present his or her paper in the immediate next DOS conference and it will be published in DJO / DOS Times.

Points Awarded Points
1) Age of the Applicant 10
07
a) < 35 years 05

b) 36 to 45 years

c) 45 years plus

2) Type of Presentation 12
a) Instructor/ Co-instructor of Course 07
b) Free Paper (Oral) / Video 05
c) Poster
15
3) Institutional Affiliation 20
a) Academic Institution
b) Private Practitioner

4) The points awarded for DCRS rating in the immediate past year

a) > 150 10
b) 75 – 150 5
c) < 75 Not Eligible

Documents
• Proof for age. Date of Birth Certificate
Original / attested copy of letter of acceptance of paper for oral presentation / video / poster or instruction course /

invited talks.
• Details of announcement of the conference
• Details of both International & National Conferences attended in previous three years.
• Copy of letter from other national or international agency / agencies committing to bear partial cost of conference if

any.
• Original air travel boarding passes and photocopy of the attendance certificate of the conference.
• Fellowship Money will be reimbursed only after submission of all the required documents and verified by the

committee.
• Undertaking from the applicant stating that above given information's are true.
• If found guilty the candidate is liable to be barred for future fellowships.

Application should reach Secretary’s office and should be addressed to Chairman Travel Grant Fellowship Committee
before February 20, June 30, September 30 and December 30 for International Conference and National Conference.
The committee will meet thrice in a year in the month of August, November and February within 2 weeks of last date of
receipt of applications. The committee will reply within four week of last date of submission in yes/no to the
applicant. No fellowship will be given retrospectively.

Dr. (Prof.) Namrata Sharma
Secretary,

Delhi Ophthalmological Society
Room No. 479, 4th Floor,
Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Scienses,
New Delhi – 110 029
Email: [email protected]

REVISION OF DOS CREDIT RATING SYSTEM & CALCULATIONS FOR THE AWARDS
REVISIONS of DCRS points:
i. Clinical Case Presentations & Clinical Talk will be evaluated for a total of 100 marks each
ii. Overall meeting arrangement marking will be given out of 20 by outside delegates instead of grading

system as was practiced earlier.
BEST CLINICAL CASE PRESENTATION / BEST CLINICAL TALK / BEST CASE PRESENTATION

Average of Marks awarded by all DOS member Delegates attending the monthly clinical meeting
MOST POPULAR DOS CLINICAL MONTHLY MEETING (MINOO SHROFF TROPHY)

The trophy for most popular centre for the DOS Monthly Clinical Meeting will be awarded to the institute with the
maximum attendance

BEST DOS MONTHLY CLINICAL MEETING (BODHRAJ TROPHY)
Calculation of overall meeting assessment score

Please Note: For calculation of overall meeting assessment score, only marks awarded by the external DOS member
delegates is taken into consideration
Step 1:
 The average of the two case presentations & clinical talk out of 300 marks will be calculated and reduced to 30 marks
Step 2:
 To this, will be added the overall meeting arrangement marks (for a total of 20). The total will now add up to 50

marks to compute total marking score by each delegate
Step 3:
 The average of this marking score (out of a total of 50 marks) of all external DOS member delegates will be

calculated. To this will be added the attendance score of outside delegates the institution having maximum
numbers of outside delegates will be given 50 marks, the other institutes will be given percentile score
proportinately to yield the FINAL SCORE for each centre hosting the DOS Monthly Meeting, based on which for
BodhRaj Trophy of best monthly meeting will be awarded.

POINTS TO BE NOTED:
 DCRS marking sheets will have details of time in of all delegates & marking sheets according to time of entry will be given to the

delegate upon signing in the attendance register
 All delegates will be required to hand in their completed DCRS sheets at the conclusion of the meeting, which will be counted by

DOS staff, checked and signed by head of the institute(/representative) holding the monthly meeting and DOS Secretary
(/President/DOS executive committee representative) & subsequently sealed in their presence.
 All centres are encouraged to provide their meeting programme details 4 weeks ahead of their date of programme.
 All presenters of case reports and clinical talk are required to submit their presentations to the DOS SECRETARIAT in two weeks
time following the date of the presentation by email ([email protected]) for publication in the monthly meeting korner
section of the forthcoming DOS TIMES issues.
 PLEASE NOTE THAT ALL DOS monthly meetings SHOULD commence by 11.0 am sharp. The number of speakers in the Clinical
symposium should not exceed 3

VIOLATION of the recommendations for DOS Monthly meetings will
Result in PENALIZATION of the final DCRS score of the centre

Hence forth only one instution will be dropped from calendar of monthly meeting based on DCRS rating.We
thank review Subcommittee for their efforts in reforming the guidelines for the DOS Monthly Clinical Meetings

Dr Subhash Dadeya Dr Namrata Sharma
President – DOS (2020-21) Secretary – DOS (2019-21)







Prof. (Dr.) Namrata Sharma

Secretary, Delhi Ophthalmological Society

Room No. 479, 4th Floor,
Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi-110029, India
Email: [email protected] / [email protected]
Website: www.dosonline.org