DOS Times_July-Aug19_04-02-2019_HR a

DOS Office Bearers

Dr. Rakesh Mahajan Dr. Subhash C Dadeya Dr. Namrata Sharma Dr. Hardeep Singh
President Vice President Secretary Joint Secretary

Dr. Jatinder S Bhalla Dr. Vinod Kumar Dr. Manav Deep Singh
Treasurer Editor Library Officer

Executive Members

Dr. Dewang Angmo Dr. Jatinder Bali Dr. Shantanu Gupta Dr. C. P. Khandelwal

Dr. Rahul Mayor Dr. Vipul Nayar Dr. Rajendra Prasad Dr. Kirti Singh

DOS Representative to AIOS Ex-Officio Members

Dr. Rohit Saxena Dr. Ashu Agarwal Dr. S.K. Khokhar Dr. Subhash C Dadeya Dr. Arun Baweja

Contents

Editorial Oculoplasty

05 The Challenge of Change 39 Eyelid Sebaceous Gland Carcinoma: A Review

Expert Corner Glaucoma

06 Digitally Assisted Vitreoretinal Surgery- An 43 Ocular Emergencies in Glaucoma
Emerging Technology
Retina
Surgical Technique
47 ‘Bone’ Appetit: Multimodal Imaging in Choroidal
09 Single Pass Four-Throw (SFT) Pupilloplasty Osteoma

Beyond Ophthalmology Systemic Diseases

13 An Ophthalmologist’s Prayer 51 Ocular Manifestations in Turner’s Syndrome

What’s New Monthly Meeting Update

14 Oxervate (cenegermin-bkbj) 53 Review of Advances in Improving Accuracy in IOL
Power Calculations
Subspecialities
PG Corner
Cornea
59 Fungal Keratitis
15 MiOCT Guided DMEK and DALK
18 Post Hyperopic Transepithelial Photorefractive Photoessay

Keratectomy with Annular Haze and Astigmatism 69 Half in Half Out Nucleus in Hypermature Cataract
22 Femtosecond Laser Assisted Corneal Transplantation
DOS Quiz
Lens/Cataract
Tearsheet
26 FLACS vs. Conventional Phacoemulsification
33 Ten Commandants for Posterior Capsular Rupture 72 Management of Superior Oblique Palsy

Recognition and Management

www.dosonline.org/dos-times Annual Conference

Delhi Ophthalmological Society
3rd-5th April, 2020

at Hotel Ashok, Chanakya Puri, New Delhi

DOS Times - Volume 25, Number 1, July-August 2019 01

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Volume 25 No. 1, July-August, 2019

Editor In Chief DOS Times Editorial Board
Namrata Sharma
Editorial Board National Board
Editor Dr. Parul Icchpujani
Prafulla Kumar Maharana Dr. Atul Kumar Dr. Ronnie George
Dr. Aniruddha Maiti Dr. Sushmita Kaushik
Assistant Editors Dr. Apporva Ayachit Dr. Gopal Pillai
Dr. Jitendra Jethani Dr. Usha Singh
Ritu Nagpal Siddhi Goel Dr. Mita Joshi Dr. Subhendu Boral
Dr. P. Dutta Majumdar Dr. Meena Chakrabarti
Dr. Noopur Gupta Dr. Raksha Rao
Dr. Brijesh Kakkar Dr. Kumudini Verma
Dr. Digvijay Singh Dr. Rashmin Gandhi
Dr. Ritika Sachdev Dr. Siddharth Kesarwani
Dr. Dewang Angmo Dr. Chaitra Jayadev
Dr. Rebika Dr. Bibhuti P. Sinha
Dr. Saurabh Sawhney Dr. Amit Porwal
Dr. Reena Sharma Dr. Prashant Bawankule
Dr. Rajat Jain
Deepali Singhal Sahil Agarwal Dr. Jaya Gupta
Ritika Mukhija Rahul Kumar Bafna Dr. Anita Ganger
Dr. Umang Mathur
Farin Shaikh Divya Agarwal Dr. Neera Agarwal
Mohamed Ibrahime Asif Venkatesh Nathiya Dr. Poonam Jain
Dr. Manisha Agarwal
Dr. Hardeep Singh
Dr. Anita Sethi
Dr. Tushar Agarwal
Dr. Rohit Saxena
Dr. Swati Phuljhele
Dr. Vivek Dave
Dr. Mohita Sharma
Dr. Rajesh Sinha
Dr. Aitu Arora
Dr. P.K. Pandey
Dr. H.K. Yaduvanshi
Dr. O.P. Anand

Anusha Sachan Abhijeet Beniwal

Gunjan Saluja Akshaya Balaji
www.dosonline.org/dos-times
DOS Times - Volume 25, Number 1, July-August 2019 03



Editorial

From the
Editor Desk

Prof. (Dr.) Namrata Sharma The Challenge of Change

(MD, DNB, MNAMS) Respected Seniors and Friends,
Delhi Ophthalmological Society has been a role model for all state ophthalmological
Hony. General Secretary societies as this is the largest society in terms of membership with over 9614
Delhi Ophthalmological Society members as of November, 2019.
The first state teaching program was commenced by Delhi Ophthalmological
Cornea, Cataract & Refractive Surgery Services Society in year 2008. DOS PG Teaching program conducted on 4th to 6th October,
Dr. R.P. Centre for Ophthalmic Sciences, 2019 at Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS and India
All India Institute of Medical Sciences (AIIMS) Habitat Centre has been phenomenal with wet lab-hands on training, interactive
New Delhi lectures and demonstrations with a remarkable attendance of 215 students.
Annual and winter DOS meetings have always been the most organised meeting
especially in terms of scientific exchange and trade. Live surgery is one of the
key highlights of these meetings. Winter DOS featuring enchanting live surgical
demonstrations, didactic lectures and ophthalmological quiz was held on 3rd and
4th December 2019 at Hotel Ashok, New Delhi. It was affirmed with a tremendous
response of 204 faculties and 537 delegates.
With the promise to set a new benchmark in terms of scientific knowledge exchange,
networking and trade, we look forward to welcome you all at Annual DOS, which is
scheduled on 3rd – 5th April, 2020.
Anticipating that readers will find new categories added to DOS Times like - “What’s
new”, “PG Corner”, “Career opportunities” and “Appliances” advantageous and
stimulating.
Heraclitus, a Greek philosopher, has quoted “Change is the only constant in life”.
Wishing everyone health, happiness and valour to face the changes and challenges
that new year shall bring.
Wishing you a very happy and prosperous new year!
With best wishes.

www.dosonline.org/dos-times DOS Times - Volume 25, Number 1, July-August 2019 05

Expert Corner

Digitally Assisted Vitreoretinal
Surgery- An Emerging Technology

Divya Agarwal MD, Atul Kumar MD, FRCS (Edin), FAMS
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

Conventional ophthalmic microscopes Figure 1. Surgeon performing 3D Heads up vitrectomy using NGENUITY. Others can also
are standard and established tools see and learn from the same screen used by the surgeon.
for assistance in various ophthalmic
surgeries. They possess some limitations The images from two sensors are then Improved ergonomics
like dependence on binocular eyepieces, sent to proprietary 3D image processor. As the surgeon sees final 3D image on
limited magnification, dependence on The processor simultaneously streams screen in front of him/her, it is also
vital dyes to visualise certain retinal 2D and 3D images and give the final called ‘Heads up Viewing’. It improves
structures and inability to display output of 3D images which are then surgeon’s posture and reduces fatigue.
vitrectomy machine parameters in the displayed on 4K resolution OLED 55 Cervical spine and back position
visual field of surgeon (through the inch panel. OLED provides various becomes more physiological.
ocular eyepieces). This has given rise advantages like high contrast ratio, Digital magnification with high
to development of digitally assisted natural colours and vibrant images. resolution
vitreoretinal surgery. Digitally Assisted The NGENUITY system provides
Vitreoretinal Surgery or DAVS refers Postulated Benefits excellent depth perception, image
to real-time digital image guidance of The various postulated benefits over resolution and colour-contrast.3 It is also
vitreoretinal surgery, contemporarily conventional microscopes are listed
utilizing an ultra-high-definition 3D below:2
flat-panel display.

NGENUITY® 3D Visualization
System (by Alcon, Fort Worth,
Texas, USA)
The NGENUITY device uses twin sensor
high dynamic range (HDR) camera,
image processing through proprietary
technology leading to projection of
images on advanced 3D 4K OLED 55
inch screen. Displayed 3D images can be
viewed using passive, polaroid glasses1
(Figure 1).

The HDR Camera is a 5th generation
ICM5 3D surgical camera that has
two 1920p* 1080p sensors which
capture sharp images. Image exposure
is optimised with the help of HDR
technology.

06 DOS Times - Volume 25, Number 1, July - August 2019 www.dosonline.org/dos-times

Expert Corner

Figure 2: Centre sparing ILM peeling done in a case on myopic traction maculopathy. ILM flaps and fovea is better visualised using
NGENUITY despite poor contrast of tessellated fundus.

compatible with microscope integrated Reduced exposure of dyes Newer Upgrades
optical coherence tomography (i-OCT). With the image enhancement, tissue The DATAFUSION software is a recent
Increased magnification upto 19 handling is better leading to reduced addition in NGENUITY system which
percent can be obtained along with required quantity and exposure of dyes4. acts as an overlay and integrates
increased depth resolution upto 19 Improved visualisation of retinal NGENUITY with the Constellation
percent for seeing finer details while periphery: vitrectomy system (Alcon). This helps
operating. This can be useful in macular With the improved and high the surgeon in real time tracking and
surgeries. It can provide upto 2.7 times magnification and high depth recording of machine parameters like
extended depth of field to track around resolution, peripheral retina including infusion pressure, flow rate, cutter
expanded surgical field (Figure 2). ora serrata can be visualised very well speed, etc.
Reduced phototoxicity to retina helping the surgeon in peripheral
CMOS camera and OLED illumination vitreous shaving or periphery Redshift viewing is one recent
have made it possible to digitally examination. advancement which helps the
enhance the image allowing surgeon Good teaching tool surgeon to view retinal structures in
to keep illumination very low during The entire surgical team can see and vitreous hemorrhage leading to safer
surgery as compared to conventional experience the surgery with full stereo- tissue manipulation. Digital image
microscopes. Thus, it causes very less depth just as the operating surgeon who Modulation and Virtual dyes are newer
damage to photoreceptors even in cases also looks at the same screen. Everyone advancements which are being added to
of prolonged surgeries. can see what exactly is going on in the the NGENUITY system.
Digital filters to customise view surgery5.
Various color filters can be applied The system is useful in various Limitations
digitally to enhance tissue visualisation. vitreoretinal surgeries like macular There are some limitations of this
Eg: epiretinal membranes can be hole, epiretinal membrane, diabetic emerging technology. High cost hinders
visualised better with a green filter. retinal surgery, retinal detachment its widespread use. There is a slight delay
Yellow filter facilitates internal limiting surgeries. from the occurrence of an event to when
membrane (ILM) peeling. Vitreous can the event is visualized on this display
be seen better using blue filter. device. This is because perceptual
latency of DAVS is slightly greater than
viewing through analog microscopes. In
case of slower vitreoretinal surgery, this

www.dosonline.org/dos-times DOS Times - Volume 25, Number 1, July-August 2019 07

Expert Corner

delay does not cause much discomfort. References up surgery. Graefes Arch Clin Exp
Some surgeons feel the colours of Ophthalmol Albrecht Von Graefes
images to be a bit unnatural while 1. Yin L, Sarangapani R. Assessment of Arch Klin Exp Ophthalmol. 2019
others prefer conventional microscopes visual attributes for NGENUITY® 3D Mar;257(3):473–83.
to do anterior segment manoeuvres if Visualization System 1.0 for digitally 6. Babu N, Kohli P, Jena S, Ramasamy K.
required.6 Surgeons usually take some assisted vitreoretinal surgery. Alcon Utility of digitally assisted vitreoretinal
time to accustom with DAVS. Modeling and Simulation. Alcon Data surgery systems (DAVS) for high-
on File. January 2016. volume vitreoretinal surgery centre: a
ZEISS ARTEVO 800 (by Carl Zeiss pilot study. Br J Ophthalmol. 2019 Jun
Meditec AG, Germany) 2. Franklin A, Sarangapani R, Yin L, 8;bjophthalmol-2019-314123.
This Zeiss microscope boasts of Tripathi B, Rieman C. Digital vs Analog 7. ARTEVO 800 from ZEISS [Internet].
combining Zeiss optics with digital Surgical Visualization for Vitreoretinal [cited 2019 Oct 23]. Available from:
imaging.7 It uses ‘DigitalOptics’ to Surgery. Retinal Physician. May 1, 2017. https://www.zeiss.com/meditec/int/
increase resolution and depth of field. product-portfolio/surgical-microscopes/
The surgeon can easily switch between 3. Freeman WR, Chen KC, Ho J, Chao ophthalmic-microscopes/artevo-800.
binocular view and 3D view over 4K DL, Ferreyra HA, Tripathi AB, et al. html.
screen panel. It has added advantage of Resolution, depth of field, and physician
cloud connectivity and inbuilt overlay satisfaction during Digitally Assisted Dr. Atul Kumar MD, FRCS (Edin), FAMS
system. Vitreoretinal Surgery. Retina Phila Pa. Professor, Chief
2019 Sep;39(9):1768–71. Dr. Rajendra Prasad Centre for Ophthalmic
Conclusion Sciences, All India Institute of Medical Sciences,
DAVS offer better magnification, 4. Kumar A, Hasan N, Kakkar P, Mutha V, New Delhi, India.
resolution, depth of field, ergonomics, Karthikeya R, Sundar D, et al. Comparison
reduced phototoxicity and dye exposure. of clinical outcomes between “heads-up”
It also serves as a great teaching tool. It 3D viewing system and conventional
has potential in other subspecialities microscope in macular hole surgeries: A
also like anterior segment, oculoplasty, pilot study. Indian J Ophthalmol. 2018
etc. Dec;66(12):1816–9.

5. Palácios RM, de Carvalho ACM, Maia
M, Caiado RR, Camilo DAG, Farah ME.
An experimental and clinical study
on the initial experiences of Brazilian
vitreoretinal surgeons with heads-

08 DOS Times - Volume 25, Number 1, July - August 2019 www.dosonline.org/dos-times

Surgical Technique

Single Pass Four-Throw (SFT)
Pupilloplasty

Priya Narang MS1, Amar Agarwal MS FRCS FRCO2
1 Narang Eye Care & Laser Centre, Ahmedabad, India.
2 Dr. Agarwal’s Eye Hospital & Research Centre, Chennai, India.

Pupil reconstruction is often necessary Figure 1: Animated Description of Single Pass Four-Throw Pupilloplasty. A. Using a dialer,
to avoid associated problems of glare form a loop of the distal suture end intraocularly. B. Using micro-graspers / intraocular end-
and photophobia that may arise due opening forceps externalize the loop via the paracentesis. C. Distal suture loop externalized
to irregular contour of the pupillary through the paracentesis and maintained immediately outside the paracentesis. D. Leading
margin and other iris defects. Various end of the suture is passed through the loop. E. 4 throws of the leading end are passed through
techniques have been described for the loop with care being taken to pass the suture through the loop in the same direction. F. Pull
performing pupilloplasty that include both the distal and proximal end of the suture, internalizing the helical knot.
modified Siepser’s slipknot, modified
McCanell, encerclage etc. Single pass Applications This syndrome was later recognized as
four throw (SFT) technique has been The technique of SFT has found its Urrets Zavalia syndrome and various
recently introduced and it derives its application in various scenarios. mechanisms have been descried
name due to the fact that a Single pass is regarding its etio-pathogenesis. This
taken with a 10-0 suture needle through Urrets-Zavalia syndrome syndrome was subsequently reported
the anterior chamber (AC) and 4 throws Urrets Zavalia described a series of after DALK, trabeculectomy4, argon
are taken through the loop that is clinical signs that were observed in cases laser peripheral iridoplasty5, phakic
withdrawn from the AC1. undergoing penetrating keratoplasty3. anterior chamber IOL implantation6,7,8
Ashley’s book of knots describes various The patients reported persistently deep anterior lamellar keratoplasty
forms of knots, hitches and bends that dilated pupil that was often associated (DALK)9-12, Descemet’s - stripping
are useful to secure the loop formation with raised intraocular pressure (IOP). automated endothelial keratoplasty
in various scout programs. Timber
Hitch is one such method that holds on
to the loop and incidentally SFT loop
resembles the Timber Hitch method2.
The twisting of loops forms helical
structure that prevents the knot from
opening up.

Technique
The 10-0 suture attached to long arm
needle is used that is initially passed
through the proximal and then through
the distal part of the iris leaflet that is to
be apposed. A Sinskey’s hook is passed
through the AC and a loop is withdrawn
from the AC. The suture end is passed
through the loop 4 times and both the
suture ends are withdrawn. This leads
to sliding of the loop internally and
approximation of the iris tissue (Figure
1).

www.dosonline.org/dos-times DOS Times - Volume 25, Number 1, July-August 2019 09

Surgical Technique

(DSAEK)13,14,15 goniotomy16, and Figure 2: Animated description depicting the channelizing of central rays through a pinhole
octafluoropropane injection (C3F8)17. aperture created with pinhole pupilloplasty (PPP).

The persistently dilated pupil induces Figure 3: Preoperative & postoperative images of a case of PPP.
a mechanical blockage in the anterior
chamber angle that leads to raised IOP. demonstrates that the suture loop of SFT at the level of cornea, sulcus and in
Peripheral anterior synechias (PAS) are lies parallel to the iris tissue21. This has the bag implantation of a pinhole IOL.
formed due to contact of iris tissue in a major significance in EK procedures as Performing a PPP, helps to channelize
the AC angle. Over a period of time, this the graft unfolding occurs in the center the rays through a pinhole and bars the
leads to secondary angle closure. Hence, of AC and there is always a propensity peripheral rays that arise due to higher
performing a surgical pupilloplasty in of the knot rubbing on the endothelial order aberrations thereby indirectly
these cases at the initial stage prevents side of the graft. translating in to a better vision
the formation of PAS, secondary angle Pinhole pupilloplasty postoperatively (Figure 2,3,4).
closure and eventually a persistently In an out door patient department, The procedure of PPP can be performed
raised IOP. pinhole vision is often recorded that with any technique but the authors
gives an estimate of the best possible prefer to perform PPP with SFT technique
The authors undertook a study in cases visual acuity that can be achieved in a as multiple quadrant approach is
with UZS where SFT was performed. particular case. Higher order corneal necessary to achieve a Pinhole pupil
18 The study reported opening of the aberrations lead to complex refractive and SFT method involves the least
AC angle structures on intraoperative errors with blurred vision. The number of passes that are necessary
gonioscopy as well as AS-OCT principle of pinhole has been applied to perform a pupil reconstruction22.
with a significant fall of IOP in the
postoperative period.

Secondary Angle closure

Following a silicon oil tamponade, raised
IOP and development of secondary
angle closure with formation of PAS is
a known entity. Conventional filtration
surgery often fails in these cases and
glaucoma drainage devices serve as a
good surgical option. Removal of silicon
oil is often indicated but eventually the
pros and cons of silicon oil removal need
to be weighed against the incidence
of having a retinal detachment (RD)
again. In a recently published study,
the authors put forward the concept of
performing surgical pupilloplasty with
SFT in cases with raised IOP following a
silicon oil tamponade19,20.

Endothelial keratoplasty

Pupilloplasty is often necessary and is
performed in cases undergoing EK to
prevent the escape of air from AC to
posterior cavity. Seepage of air in the
vitreous cavity leads to loss of effective
air tamponade that may result in graft
detachment.

As there is a single pass involved in SFT
technique, true knot formation does not
occur and the protrusion of the knob
of knot is not seen in the AC. AS-OCT

10 DOS Times - Volume 25, Number 1, July - August 2019 www.dosonline.org/dos-times

Surgical Technique

Figure 4: Analysis of a case of PPP post dilation with mydriatic drops. A. Case of PPP. B. yy SFT has been demonstrated to be
Same eye after dilation with mydriatic drops. C. Fundus evaluation post dilation. helpful in cases with Urrets - Zavalia
syndrome, in selected cases with
Figure 5: Preoperative & postoperative image in a case with pinhole pupilloplasty. A. secondary angle closure and for
Preoperative image in a case with higher order aberration. B. Postoperative image after PPP. performing a pinhole pupilloplasty.
Purkinje image 1 is seen in the center of PPP.
yy SFT allows pharmacological
This indirectly translates in to lesser This indirectly translates in to better mydriasis to a certain extent for
intervention in the AC. The pinhole visual image quality. posterior segment evaluation.
pupil is aimed at achieving 1.5 mm of Pharmacologic mydriasis with SFT
pupil. A pinhole marker that has a ring One of the major concerns after References
of 1.5 mm in diameter is often employed pupilloplasty procedure is the ability
to size the pinhole pupil. Alternatively to visualize posterior segment and the 1. Narang P, Agarwal A. Single-pass four-
intraoperative OCT can also be used to amount of pharmacological mydriasis throw technique for pupilloplasty. Eur J
gauge the pupil size. that can be achieved. A study was Ophthalmol 2017; 27(4): 506-508.
Centration of PPP is extremely essential undertaken to evaluate the pupil
and for that purpose the light of measurements before and after the 2. Narang P, Agarwal A. Single pass four
Lumera surgical microscope can serve instillation of mydriatics (tropicamide throw pupilloplasty knot mechanics. J
as guidance due to the Purkinje image 0.8% – phenylephrine 5.0% and Refract Surg. 2019. Article in press.
reflection seen on the corneal surface atropine 1.0%). A significant increase
(Figure 5). Purkinje image 1 (P1) is in pupil size and area was observed that 3. Urrets-Zavalia A Jr. Fixed, dilated pupil,
considered to be the main reference aided fundus visualization after single- iris atrophy and secondary glaucoma.
marker and with Lumera microscope pass 4-throw pupilloplasty23. Am J Ophthalmol 1963; 56(8): 257–265.
the P1 image comprises of a triad of light
emanating from the main illumination Key Points 4. Jain R, Assi A, Murdoch IE. Urrets-Zavalia
light and from the side ocular tubes. yy SFT is a simple and an easy technique syndrome following trabeculectomy. Br
Centering PPP with P1 image leads J Ophthalmol 2000; 84(3): 338-339.
to decrease in chord length that is a to learn and emulate.
2-dimensional distance between the yy SFT knot has a self-locking and self- 5. Espana E, Ioannidis A, Tello C, Leibman
pupillary axis and the subject fixated JM, Foster P, Ritch R. Urrets-Zavalia
coaxially sighted corneal light reflex. retaining capability that resembles a syndrome as a complication of Argon
Timber Hitch. Laser Peripheral Iridoplasty. Br J
Ophthalmol 2007; 91(4): 427–429.

6. Yuzbasioglu E, Helvacioglu F, Sencan
S. Fixed, dilated pupil after phakic
intraocular lens implantation. J Cataract
Refract Surg 2006; 32(1): 174–176.

7. Park SH, Kim SY, Kim HI, et al. Urrets-
Zavalia syndrome following iris-claw
phakic intraocular lens implantation. J
Refract Surg 2008; 24(9): 959-961.

8. Pérez-Cambrodí RJ, Piñero-Llorens
DP, Ruiz-Fortes JP, Blanes-Mompó FJ,
Cerviño-Expósito. Fixed mydriatic pupil
associated with an intraocular pressure
rise as a complication of the implant of
a Phakic Refractive Lens (PRL). Semin
Ophthalmol 2014; 29(4): 205-209.

9. Maurino V, Allan BD, Stevens JD, et
al. Fixed dilated pupil (Urrets-Zavalia
syndrome) after air/gas injection
after deep lamellar keratoplasty for
keratoconus. Am J Ophthalmol 2002;
133(2): 266-268.

10. Minasian M, Ayliffe W. Fixed dilated
pupil following deep lamellar
keratoplasty (Urrets-Zavalia syndrome).
Br J Ophthalmol 2002; 86(1):115-116.

11. Maurino V, Allan BDS, Stevens JD, Tuft
SJ. Fixed dilated pupil (Urrets-Zavalia
Syndrome) after air/gas injection
after deep lamellar keratoplasty for

www.dosonline.org/dos-times DOS Times - Volume 25, Number 1, July-August 2019 11

Surgical Technique

keratoconus. Am J Ophthalmol 2002; goniotomy in a child. J AAPOS 2012; 36: 1580-1583.
133(2): 266-268. 16(3):312-313. 22. Narang P, Agarwal A, Kumar DA,

12. Bozkurt KT, Acar BE, Acar S. Fixed dilated 17. Aralikatti AK, Tomlins PJ, Shah S. Agarwal A. Pinhole pupilloplasty (PPP):
pupilla as a common complication of Urrets-Zavalia syndrome following Small aperture optics for higher order
deep anterior lamellar keratoplasty intracameral C3F8 injection for acute corneal aberrations. J Cataract Refract
complicated with Descemet membrane corneal hydrops. Clin Experiment Surg. 2019. Article in Press.
perforation. Eur J Ophthalmol 2013; Ophthalmol 2008; 36(2):198-9. 23. Kumar DA, Agarwal A, Srinivasan
23(2): 164-170. M, Narendrakumar J, Mohanavelu A,
18. Narang P, Agarwal A. Single pass four- Krishnakumar A. Single pass four throw
13. Anwar DS, Chu CY, Prasher P, et al. throw (SFT) pupilloplasty for Urrets- (SFT) pupilloplasty: Postoperative
Features of Urrets-Zavalia syndrome Zavalia syndrome. Eur J Ophthalmol. mydriasis and fundus visibility in
after Descemet stripping automated 2018 Sep;28(5):552-558. pseudophakic eyes. J Cataract Refract
endothelial keratoplasty. Cornea 2012; Surg. 2017; 43(10): 1307-1312.
31(11): 1330-1334. 19. Narang P, Agarwal A, Agarwal A.
Silicon oil Single-pass four-throw Corresponding Author:
14. Fournié P, Ponchel C, Malecaze F, et
al. Fixed dilated pupil (Urrets-Zavalia pupilloplasty for secondary angle- Dr. Amar Agarwal MS, FRCS, FRCO
syndrome) and anterior subcapsular closure glaucoma associated with silicon Dr. Agarwal’s Eye Hospital & Research Centre,
cataract formation after Descemet oil tamponade. Eur J Ophthalmol. Chennai, India.
stripping endothelial keratoplasty. 2018 Jun 1:1120672118780809. doi:
Cornea 2009; 28(10):1184-6.
10.1177/1120672118780809. [Epub
15. Russell HC, Srinivasan S. Urrets-Zavalia ahead of print]
syndrome following Descemet’s
stripping endothelial keratoplasty triple 20. Narang P, Agarwal A, Kumar DA. Single
procedure. Clin Experiment Ophthalmol pass four-throw pupilloplasty (SFT)
2011;39(1): 85-87. for angle closure glaucoma. Indian J
Ophthalmol. Article in Press.
16. Chelnis JG, Sieminski SF, Reynolds JD.
Urrets-Zavalia syndrome following 21. Narang P, Agarwal A, Kumar DA.
Single pass 4-throw pupilloplasty for
endothelial keratoplasty. Cornea; 2017;

12 DOS Times - Volume 25, Number 1, July - August 2019 www.dosonline.org/dos-times

Beyond Ophthalmology

An Ophthalmologist’s Prayer

Kirti Singh* MD, DNB, FRCS, FAIMER, Arshi Singh** DNB, George Spaeth*** MD
*Guru Nanak Eye Centre, New Delhi, India **LVPEI, Bhubaneswar, Odisha India
*** Prof Emeritus, Wills Eye Hospital, USA.

Dear DOS family
A new section Art & Humanities in Ophthalmology is being added to DOS times, keeping in mind the vision of 2020.
Contributions of DOS members can include poetry, prose on aspects of ophthalmology or on patient doctor relationship.
Photographs with catchy captions, sketches on any encounter during your journey as an ophthalmologist. Delve into your
creative skills and mail your write up, not exceeding one page.

For the honour of opening windows of the soul, I thank Thee Corresponding Author:
For the gift of giving colours to life’s canvas, I thank Thee
As I work on your peerless creation Dr. Kirti Singh
Help me avoid all fumbling agitation Guru Nanak Eye Centre,
But O lord if only you had made the posterior capsule a little sturdier! New Delhi, India.
As knowledge bestowed by mentors guides my hand
Help my concentration, all distractions to withstand.
Dear Lord, enable me to withstand the seductions of my smart phone in OT.
When I help the person heal, let me not overrate my zeal
When the foe of disease falsifies my claim to mastery
Let me reclaim my dexterity by help of you-tube or eye wiki wizardry.
Even in triumph over the destructive forces of vision
Let me invoke your blessings for making me able
But please, please tell my patient that perfect 2020 is not always feasible.
When laurels from my peers reiterate that I’ve done well
Remind me, once again, that I am but your bell
And dear God spare me from the spectre of medicolegal litigation hell.
Let my head make learning my quest
Let my hands perform the dance with skill at its best
Let my heart tune in with your inexhaustible power bank of zest
As this trinity in my body serves as Thy minion,
And dear God remind me to take Sundays off to rest, and not attend all CME’s till the end.
I have been chosen to restore the pristine clarity of Thy hallowed sphere
Let me then celebrate my work and learn to walk tall in your world of men. Amen

www.dosonline.org/dos-times DOS Times - Volume 25, Number 1, July-August 2019 13

What’s New

Oxervate (cenegermin-bkbj)

Oxervate (cenegermin-bkbj) is a recombinant human nerve growth factor (NGF) recently approved by FDA for the treatment
of neurotrophic keratitis.

Drug
Oxervate is supplied as a solution for topical ophthalmologic administration in strength of 0.002% (20 mcg/mL) in a multiple-
dose vial manufactured by Dompe Pharmaceuticals

Mechanism of Action
NGF is an endogenous protein that helps in differentiation and maintenance of neurons by acting on several NGF receptors
which maintains corneal innervation and integrity.

Dosage
One drop 6 times a day at 2-hour intervals for eight weeks.

Indication: Neurotrophic Keratitis

Contraindication
None

Efficacy
The FDA conducted two double-masked, randomized, multi-center, controlled clinical trials. The trial in Europe included 104
patients (52 in study, 52 placebo) and 72% of patients completely healed with Oxervate therapy at 8 weeks. The other study was
conducted in the U.S., including 24 patients to each group, and complete healing was observed in 65.2% of treated patients at
8 weeks of therapy.

Adverse reactions Corresponding Author:
yy Eye pain (most common, 16%)
yy Corneal deposits
yy Foreign body sensations
yy Ocular hyperemia
yy Watering

Precaution
Contact lenses (CL) must be removed before using Oxervate, as the drug distribution
may be affected. CL can be inserted 15 minutes after administration of Oxervate.

Pregnant and lactating women: no data from the use of OXERVATE in pregnant and
lactating women to inform any drug-associated risks.
Pediatric patients.

Oxervate can be used. Dr. Prafulla Kumar Maharana
Dr. Rajendra Prasad Centre for Ophthalmic
Reference Sciences, All India Institute of Medical Sciences,
1. OXERVATE™ (cenegermin-bkbj) ophthalmic solution 0.002% (20 mcg/mL) [US package New Delhi, India.

insert]. Boston, MA: Dompé U.S. Inc.; 2018.

14 DOS Times - Volume 25, Number 1, July - August 2019 www.dosonline.org/dos-times

Subspeciality-Cornea

MiOCT Guided Descemet
Membrane Endothelial
Keratoplasty and Deep Anterior
Lamellar Keratoplasty

Namrata Sharma MD
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

miOCT (microscope integrated – missing DM in the host cornea prior to donor tissue is difficult to identify due
optical coherence tomography) has be descemetorrhexis using miOCT guides to corneal haze during the surgery.
used in various lamellar keratoplasty the surgeon to avoid unnecessary Peripheral DM folds in the graft and
procedures as an aid to decision- attempts of DM scrapping that can their orientation can be precisely
making1,2. It offers increased sensitivity result in post-operative stromal haze. assessed with this equipment and it
in hazy corneas with poor visualization. During injection of the DMEK roll can help in unfolding of donor tissue as
There is typically no need to adjust in the anterior chamber the miOCT well. This reduces the surgical time as
the angle of the OCT, as you would can help the surgeon in identifying well as inadvertent damage to the graft
with a microscope, since an entire the orientation of the DM roll in the with repeated attempts to unfold it. At
corneal “cube” is obtained and can be injector so that the orientation of the the end of the surgery, mi-OCT helps
captured to review individual frames injector is changed to allow injection of to visualise the attachment of the graft
during or after surgery. It enables to the DM roll in the correct orientation. to the host cornea. Even small areas of
visualise tissue and, to a certain extent, Also, the orientation of the DM roll in fluid pockets in the interface can be
instruments in virtual cross-section of the anterior chamber can be assessed detected with the help of miOCT which
the region of interest, thereby allowing with its help prior to injection of air. could be otherwise missed and resulted
to precisely identify different tissue This is especially important when the in unexpected post-operative graft
structures, tissue thickness, and so on, exact orientation of “S” mark on the detachment.
without interrupting the procedure
with great precision. Figure 1 - Retained DM tag visualized in miOCT removed with the help of ILM forceps in
DMEK
Descemet Membrane Endothelial
Keratoplasty
mi-OCT helps in various surgical steps
of Descemet Membrane Endothelial
Keratoplasty (DMEK)3–5. During
descemet scoring of the host cornea, any
area of retained descemet membrane
tag can be easily picked up with the
help of miOCT even in the presence
of hazy media (Figure 1). Therefore,
complete removal of the residual DM
tags can be ensured with its aid. This
is a critical step for post-operative graft
attachment.

In addition, identification of areas of

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Subspeciality-Cornea
Figure 2 - Orientation of DMEK roll in the anterior chamber Figure 3 - Depth of needle in the cornea assessed with miOCT prior
visualized in miOCT prior to injection of air (inverted DMEK roll) to injection of air in DALK

Figure 4 - miOCT guided visualisation of gap between the posterior Figure 5 – miOCT guided visualisation of the residual corneal bed
corneal stroma and DM during dissection in DALK (bare DM) after dissection of posterior corneal stroma in DALK

Even though hazy media is a relative step. Needle insertion into the stroma at dissection for excising the posterior
contraindication while selecting a 60% depth can be precisely monitored stroma (Figure 4). During posterior
case for DMEK as it results in poor with the help of miOCT (Figure 3). Air stromal dissection, any bulge of DM
visualizing of the DM tags, DMEK roll, injection into the posterior stroma can be detected on miOCT thus guiding
and S mark, with the use of miOCT while attempting to create a big bubble the surgeon to avoid accidental DM
these difficult situations during the sometimes results in diffuse stromal perforation. miOCT gives the surgeon
surgery can be overcome. opacification. The miOCT can be the confidence to attempt deeper
extremely useful at this step to identify dissection or possibly attempt another
Deep Anterior Lamellar if a big bubble has formed beneath this big bubble following first failed attempt
Keratoplasty area of stromal opacification. In case create one, when significant stroma
miOCT has been successfully used for of incomplete bubble formation this is still present. During manual DALK,
various anterior lamellar keratoplasty instrument can help us in precisely miOCT can guide the surgeon to decide
surgeries. It is extremely useful while choosing the location where a nick the end point of dissection based on the
performing deep anterior lamellar can safely be made without damaging residual corneal thickness (Figure 5).
keratoplasty (DALK) and increases the the underlying descemet membrane Graft placement onto recipient bed and
safety of this procedure. It guides the (DM). Once the anterior stroma is suturing depth can also be monitored
surgeon in assessing the trephination dissected and the bubble is punctured preventing accidental microperforation
depth in DALK for precise identification to inject OVD into the plane, the gap of DM at this step. At the end of surgery,
of the accurate preparation depth. Very created between the DM and posterior the interface can be assessed to ensure
low or extremely deep trephination stroma can be visualised through mi- complete graft attachment. miOCT is
depths would, therefore, be accurately OCT thereby guiding the plane of an invaluable tool in difficult situations
observed prior proceeding to the next

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Subspeciality-Cornea

like descemetocele and healed hydrops Assisted Descemet Stripping Automated 5. Steven P, Le Blanc C, Velten K, Lankenau
with stromal scarring. A careful Endothelial Keratoplasty From the E, Krug M, Oelckers S, et al. Optimizing
of miOCT in the various surgical PIONEER Study. Am J Ophthalmol. 2017 descemet membrane endothelial
manoeuvres of DALK can reduce Jan;173:16–22. keratoplasty using intraoperative
the chanced of DM perforation and optical coherence tomography. JAMA
conversion to penetrating keratoplasty. 2. Steven P, Le Blanc C, Lankenau E, Krug M, Ophthalmol. 2013 Sep;131(9):1135–42.
Oelckers S, Heindl LM, et al. Optimising
With improved understanding of the deep anterior lamellar keratoplasty Corresponding Author:
role of miOCT in lamellar corneal (DALK) using intraoperative online
surgeries, it has become a useful optical coherence tomography (iOCT). Dr. Namrata Sharma MD
guide for the corneal surgeons to Br J Ophthalmol. 2014 Jul;98(7):900–4. Professor, Department of Ophthalmology
further enhance the safety and clinical Dr. Rajendra Prasad Centre for Ophthalmic
outcomes of these procedures. 3. Saad A, Guilbert E, Grise-Dulac A, Sciences, All India Institute of Medical Sciences,
Sabatier P, Gatinel D. Intraoperative New Delhi, India.
References OCT-Assisted DMEK: 14 Consecutive
1. Hallahan KM, Cost B, Goshe JM, Cases. Cornea. 2015 Jul;34(7):802–7.

Dupps WJ, Srivastava SK, Ehlers JP. 4. Cost B, Goshe JM, Srivastava S, Ehlers
Intraoperative Interface Fluid Dynamics JP. Intraoperative optical coherence
and Clinical Outcomes for Intraoperative tomography-assisted descemet
Optical Coherence Tomography-
membrane endothelial keratoplasty in
the DISCOVER study. Am J Ophthalmol.

2015 Sep;160(3):430–7.

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Subspeciality-Cornea

Post Hyperopic Transepithelial
Photorefractive Keratectomy with
Annular Haze and Astigmatism

Sanjana Vatsa MS, FPRS, FCRS, Shana Sood DNB
Dr. Agarwals Eye Hospital, Chennai, India.

Abstract: Photorefractive Keratectomy (PRK) is a commonly performed refractive procedure for the correction of low to
moderate myopia and hyperopia. There are various methods of performing PRK such as alcohol assisted PRK, transepithelial
PRK (tPRK) etc. Here in we report a 34 year old male patient who underwent tPRK in both eyes for correction of hyperopia and
developed annular haze in mid periphery of the cornea with resulting astigmatism and blurring of vision.
Keywords: Photorefractive Keratectomy, Hyperopia, Transepithelial PRK, Corneal haze, Astigmatism

A 34 year old male patient came to us done and it showed central steepening was introduced in the late 1990s as a 2
with the complaints of blurred vision with regular with-the-rule (WTR) step procedure, where removal of the
in both eyes since 3 months. Patient astigmatism (Figure 5&6). epithelium was carried out with laser
gave the history of refractive surgery Patient was re- started on steroid eye phototherapeutic ablation followed by
done 3 months back elsewhere. The drops (Fluoromethalone 4 times/day) a laser refractive ablation of the stroma.
previous records of the patient showed along with cyclosporine 0.1 % eye drop This technique was not widely used due
that hyperopic tPRK was performed twice / day and lubricants. Patient was to the prolonged surgery time with the
in both eyes. No other surgical details advised to wear UV protective glasses older generation of lasers and increased
were available. during sun exposure. Further follow pain and lack of adjusted nomograms
up is required to determine the degree and unpredictable results2,3.
Pre- operative subjective refraction of haze, astigmatism reduction and Newer generation of faster lasers and
was +2.00D/+0.75@90 in the right improvement in visual acuity. improved ablation nomograms have
eye and +2.50D/+2.00D@80 in the left allowed development of a single-step
eye. Preoperative topography was are Discussion tPRK which allows removing the
follows (Figure 1&2). Correction of hyperopia has epithelium and stroma in a single step
always been challenging owing to with 1 ablation profile. This profile is
Post operatively patient was started on refractive surprises, regression and calculated by estimating the peripheral
antibiotics and steroids (Prednisolone unpredictability of results. Commonly epithelial thickness and the data is
acetate eye drops) and lubricants. performed laser procedures for the superimposed on the corneal wavefront
Patient was not compliant with the correction of low-moderate hyperopia guided aspheric ablation profiles.
medications and he stopped the steroid are PRK and LASIK1.
eye drops after 2 weeks post operatively. Complications of mechanical Advantages of tprk
debridement in PRK and flap- yy Reduced surgical time
IOP was within normal limits. Slit lamp related complications in LASIK have yy Less post operative pain compared
examination revealed annular haze rekindled the interest in alternative
in the mid periphery of the cornea in surface ablation techniques. tPRK to the conventional alcohol assisted
both eyes (Figure 3&4). Dilated retinal PRK.
examination was within normal limits.
Both eyes corneal topography was

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Subspeciality-Cornea

Figure 1 & 2: Preoperative topography of Right eye and Left eye respectively

Refraction details were as follows induction of irregular astigmatism
and better visual outcomes.
Right Eye

Uncorrected Visual Acuity (UCVA) - 6/18(P), improving to 6/9 with Pinhole (PH) Disadvantages of tprk
Subjective refraction Corneal Haze

Sphere Cyl Axis Vision The total excimer laser energy load
used is higher and this causes increase
Distant +0.50 -2.00 180 6/6-2 of the temperature of the stromal tissue
which is the main risk factor for haze
Near -- -- -- N6 formation6.

Left Eye

UCVA - 6/36, improving to 6/9 with PH Unlike in a myopic PRK where central
Subjective refraction haze affects the visual acuity, hyperopic
PRK can cause peripheral subepithelial
Sphere Cyl Axis Vision haze where the visual axis is spared and
thus does not affect effect the visual
Distant +2.00 -4.50 175 6/9 acuity directly. However, it can induce
astigmatism and refractive regression.
Near -- -- -- N6 It can also cause glare and halos which
resolves over time.
yy More suited for treatment of excavations.
irregular corneal astigmatism with yy The topographic map corresponds
customised topography-guided
transepithelial ablation. more closely with the epithelial
surface than with the stromal surface. Regression And Irregular
Customised ablation of epithelial Astigmatism
yy Epithelium acts as a natural surface based on the thickness leads
mask with thinning over stromal to smoother ablation and lesser Small optical zones produce an abrupt
protrusions and thickening over

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Subspeciality-Cornea

Figure 3 & 4: Three months post op of right eye and left eye respectively showing annular Uneven epithelial healing with
haze in the mid periphery of cornea. epithelial thickness more in the mid
periphery than in the centre can also
lead to irregular astigmatism. It is seen
more with higher correction in cases of
moderate- high hyperopia than in low
hyperopia.

Intra-Operative Modifications To
Be Considered For Better Results
Prevention of Irregular Astigmatism
And Regression

Consider aspheric ablation profile

Keep the optical zone and transition
zone larger. Williams et.al9. showed

Figure 5 & 6: Post op topography of right eye and left eye respectively showing central steepening with regular WTR astigmatism.

transition between ablated and non removal and variable ablation depths that using an optic zone diameter of 5
ablated areas, inducing aggressive tissue which in turn accounts for the mm with a transition zone diameter of
regeneration resulting in regression. In suboptimal results7. 9 mm produces more accurate results
addition, there is a high probability of This is usually seen in 2 -step tPRK with reduced hyperopic regression.
decentration with small optical zones where epithelial removal is done first
which causes irregular astigmatism followed by stromal ablation. Recently, The energy delivered to the central and
It was postulated that lower laser energy a one-step, combined surface and peripheral cornea needs to be adjusted
delivered to the curved periphery of stromal ablative variant of tPRK yielded based on epithelial thickness profile.
the cornea, as compared to the centre better results8. This helps in even epithelial removal
in PRK, results in uneven epithelium and also reduces stromal dehydration8.

20 DOS Times - Volume 25, Number 1, July - August 2019 www.dosonline.org/dos-times

Subspeciality-Cornea

Angle kappa should be considered and et al. Pain after epithelial removal Refract Surg. 2005;31:127-135.
ablation should be well centered on the by ethanol-assisted mechanical 8. Corones F, Gobbi PG, Vigo L, Brancato
visual axis10. versus transepithelial excimer laser
debridement. J Refract Surg 2000; R. Photorefractive keratectomy for
Prevention of Haze 16:519–522 hyperopia: long-term nonlinear and
vector analysis of refractive outcome.
yy Use of Mitomycin- C on stromal bed 3. Lee HK, Lee KS, Kim JK, et al. Epithelial Ophthalmology.1999;106:1976-1982.
after ablation healing and clinical outcomes in excimer 9. Williams DK. One-year results of
laser photorefractive surgery following laser vision correction for low to
yy Flushing of the eye with chilled BSS three epithelial removal techniques: moderate hyperopia. Ophthalmology
yy Use of topical steroids for a longer mechanical, alcohol, and excimer laser. 2000;107:72–5.
Am J Ophthalmol 2005; 139:56–63. 10. Kanellopoulos AJ. Topography-guided
time with a check on intraocular hyperopic and hyperopic astigmatism
pressure 4. Camellin M, Arba Mosquera S. femtosecond laser-assisted LASIK: long-
yy Strict UV protection for a minimum Simultaneous aspheric wavefront- term experience with the 400 Hz eye-Q
of 3 months post operatively guided transepithelial photorefractive excimer platform. Clin Ophthalmol.
yy Avoiding deeper ablations keratectomy and phototherapeutic 2012;6:895-901.
Conclusion keratectomy to correct aberrations and
Because of risk of corneal haze and refractive errors after corneal surgery. Corresponding Author:
regression with higher attempted J Cataract Refract Surg 2010; 36:1173–
corrections, tPRK can be considered 1180. Dr. Sanjana Vatsa MBBS, MS, FPRS, FCRS
as a safe option for correction of low Cornea and Refractive Services
hyperopia. 5. Allan BD, Hassan H. Topography- Dr. Agarwals Eye Hospital, Chennai, India.
guided transepithelial photorefractive
References keratectomy for irregular astigmatism
1. McGhee CN, Ormonde S, Kohnen using a 213 nm solid-state laser. J
Cataract Refract Surg 2013; 39:97–104.
T, Lawless M, Brahma A, Comaish I.
The surgical correction of moderate 6. Adib Moghaddam S, Arba Mosquera
hypermetropia: the management S,Walter Fincke R. et.al. Transepithelial
controversy. Br J Ophthalmol. 2002; Photorefractive Keratectomy for
86:815-822 Hyperopia: A 12-Month Bicentral Study.
2. Kanitkar KD, Camp J, Humble H, J Refract Surg. 2016 Mar; 32(3):172-80.

7. Yoon G, Macrae S, Williams DR, Cox IG.
Causes of spherical aberration induced
by laser refractive surgery. J Cataract

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Subspeciality-Cornea

Femtosecond Laser Assisted
Corneal Transplantation

Vijay Kumar Sharma MS, Alok Sati MS, Santosh Kumar MS, Yogesh Yadav MBBS
Army Hospital Research and Referral, Delhi, India.

The femtosecond laser is a focusable and is capable, to a certain extent, of customised to closest measurement
infrared laser that delivers ultrashort passing through optically hazy media, using preoperative ASOCT for
pulses in the femtosecond duration such as an oedematous cornea. It can be measuring depth of corneal opacity.
range. Contiguous pulses are placed applied in multiple geometric patterns A comparative advantages and
at a definite depth within the cornea, including vertical, spiral, or zig-zag cuts. disadvantages of Femtosecond assisted
thus resecting only targeted tissue. This and microkeratome assisted anterior
surgical device allows cutting of corneal Uses lamellar keratoplasty is given in
tissue in a number of reproducible, Femtosecond Laser assisted sutureless (Table-1).
customised transplant designs, anterior lamellar keratoplasty
and allows the use of sagittal plane (F-ALK) Femtosecond Laser assisted deep
trephination profiles, such as zigzag, anterior lamellar keratoplasty
top-hat, Christmas tree and mushroom F-ALK is being increasingly used (F-DALK)
shapes to improve wound stability and, for sutureless anterior lamellar
probably, postoperative astigmatism1-5. keratoplasty. Common indications There are many reports in the literature
It has mainly been used in refractive include Salzman nodular degeneration, about technique and outcome of F-DALK
surgery, for example, for flap preparation spheroidal degeneration, anterior using femtosecond laser platform. In
in Laser in Situ Keratomileusis (LASIK), corneal dystrophies, corneal opacities most of these reports, F-DALK has been
for intrastromal corneal ring segments limited to anterior 150-200 microns of performed in advanced keratoconus
(ICRS) implantation in keratoconus corneal thickness8. patients9-11. The use of femtosecond
patients or astigmatic keratotomy6,7. laser for precise side-cut preparation
Advantages can affect the final topographical and
Principle yy Early visual rehabilitation visual outcome of the patient as this
The femtosecond laser is an infrared yy No suture related complications technology is more precise than manual
laser (wavelength: 1,053 nm) with yy Minimal astigmatism trephination and is able to customise
ultra-short pulse duration (10–15 yy Lesser failure rate the side-cut shape and size of the donor
s). Due to short pulse duration, the yy Donor and recipient cut can be and recipient cornea for each patient.
femtosecond laser has the ability to Studies have shown at least similar
deliver laser energy with minimal
collateral damage to the adjacent tissue. Figure-1: showing preoperative and postoperative photographs of a patient with spheroidal
It makes femtosecond laser highly degeneration who underwent FALK
focussed and accurate. Thermal damage
to neighbouring tissue in the cornea
has been measured to be in the order
of 1 micron. Femtosecond laser acts by
principle of photo-disruption, causing
small volumes of tissue to vaporize
resulting in the formation of cavitation
gas (carbon dioxide and water) bubbles.
Furthermore, the femtosecond laser
is unique in that it can be focused
anywhere within or behind the cornea

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Subspeciality-Cornea

Table-1 Difference between F-ALK and SALK (Microkeratome assisted) visual outcome in F-DALK procedure
compared to manual DALK if not better
FALK SALK (Microkeratome Assisted) in terms of visual acuity. However, these
studies have not evaluated the contrast
More predictable side cut and overall Less predictable side cut and overall sensitivity and abberometric indices.
diameter of the graft but less predictable diameter (Figure 2) shows a patient with healed
base cut affected by grade of opacity keratitis with anterior 354 micron
scarring on ASOCT who underwent
May not penetrate through thickly Can cut through any opaque cornea F-DALK at Army Hospital R&R.
opaque cornea

Margins can be appropriately Can’t be programmed Femtosecond Laser assisted descemet
programmed for best graft host apposition stripping automated endothelial
keratoplasty (F-DSAEK)
High cost Low cost

Enables surgeon to perform customised Customised depth can’t be planned. It
depth anterior lamellar keratoplasty depends on the microkeratome blade
guided by ASOCT size which are of fixed sizes The FSL also has been used to prepare
lamellar donor buttons for DSAEK.
Old-generation FSLs for DSAEK
caused poorer cut quality than
microkeratomes. Therefore, the visual
acuity after F-DSAEK was reported to
be lower than that after conventional
DSAEK. Lamellar cuts are restricted to
depth adjustments by microkeratome
head sizes, and the button thickness is
poorly reproducible. Buttons created
with FSL are more planar shaped and
thinner which could be beneficial
for visual outcomes. New-generation
high frequency FSLs can create
much smoother buttons. However,
the smoothness and regularity of
the stromal interface still need to be
optimised with better laser settings12-15.
With appropriate FS settings, the
double-layer profile may create
smoother and more even interfaces
across both the mid-stroma and the
buttons’ side. With newer-generation
FSLs, there is no significant difference
in contrast sensitivity, stray light and
Best Spectacle-Corrected Visual Acuity
(BSCVA) between the F-DSAEK and
PKP.

Femtosecond Laser assisted
penetrating keratoplasty (F-PKP)

Figure 2: (a) Preop photograph of left cornea (b&c) Cornea being cut at 400 microns depth Femtosecond lasers are capable of
using Visumax Femtosecond platform. (d&e) Intraoperative photographs showing removal creating circular or multiplanar
of anterior cut part of cornea and suturing donor lenticule (f) First postoperative day incisions for corneal trephinations
photograph of patient after F-DALK. for PKP, which potentially increase
graft-host interface surface area, better
wound apposition, fit and stability.
That is possible only in relatively clear
corneas, and not in the limbal region. As
a result, F-PKP combines the excellent

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Subspeciality-Cornea

Figure 3: Recipient cornea undergoing femtosecond laser full thickness incision with standard 2. Farid M, Steinert RF. Femtosecond laser-
setting parameters assisted corneal surgery. Curr Opin
Ophthalmol 2010;21:288–92.
visual outcomes of PKP with the and complete suturing is required in
wound-healing advantages of DALK. In both conventional and femtosecond 3. Bahar I, Kaiserman I, Lange AP, et al.
addition, less endothelial damage, less assisted penetrating keratoplasty. Femtosecond laser versus manual
undercutting of the cornea, and more Hence visual and refractive outcomes dissection for top hat penetrating
wound healing response occurs with are comparative in both the techniques. keratoplasty. Br J Ophthalmol
FSLs. Faster healing may lead to an earlier More randomised controlled trials 2009;93:73–8.
functional recovery. Various studies are required for further evaluation
have mentioned several transplant of various issues like donor recipient 4. Birnbaum F, Wiggermann A, Maier PC,
forms including conventional circular, disparity, best incision profile for et al. Clinical results of 123 femtosecond
top-hat, mushroom, zigzag, decagonal optimal outcome and strength and laser-assisted penetrating keratoplasties.
or Christmas tree designs16-20. stability of F-PKP vis-a-vis conventional Graefes Arch Clin Exp Ophthalmol
The diameter of the posterior penetrating keratoplasty. Published Online First: 11 May 2012.
surface of the donor can be adjusted Doi:10.1007/ 00417-012-2054-0.
in F-PKP according to different Conclusion
purposes. In patients with endothelial With development of newer generation 5. Price FW Jr, Price MO. Femtosecond
insufficiency, the top-hat configuration ophthalmic femtosecond laser laser shaped penetrating keratoplasty:
increases the amount of endothelial platforms, it has become possible to one-year results utilizing a top-hat
cells transplanted. In patients precisely cut the cornea at desired level configuration. Am J Ophthalmol
with keratoconus, a mushroom with least collateral damage achieving 2008;145:210–14.
configuration maximises retention of best outcomes. This technique will
the host’s endothelium and minimises revolutionise the lamellar corneal 6. Shousha MA, Yoo SH. New therapeutic
the possibility of graft rejection. This procedures further. Presently, high modalities in femtosecond laser-assisted
adjustment is not available in Visumax cost and lack of portability are limiting corneal surgery. Int Ophthalmol Clin
femtosecond Laser which has only factors for widespread use of this 2010;50:149–60.
vertical cut and these patterns can’t be modern technology.
planned (Figure 3). 7. Ertan A, Kamburoglu G. Intacs
Although the theoretical advantage of References implantation using a femtosecond
less astigmatism is proposed though 1. Tan DT, Dart JK, Holland EJ, et al. Corneal laser for management of keratoconus:
astigmatism depends on surgeon factor Comparison of 306 cases in different
transplantation. Lancet 2012;379:1749– stages. J Cataract Refract Surg
61. 2008;34:1521–6.

8. Yoo SH, Kymionis GD, Koreishi A, et al.
Femtosecond Laser–Assisted Sutureless
Anterior Lamellar Keratoplasty
Ophthalmology 2008;115:1303–1307.

9. Reinhart WJ, Musch DC, Jacobs DS, et al.
Deep anterior lamellar keratoplasty as an
alternative to penetrating keratoplasty
a report by the American academy
of ophthalmology. Ophthalmology
2011;118:209–18.

10. Funnell CL, Ball J, Noble BA. Comparative
cohort study of the outcomes of deep
lamellar keratoplasty and penetrating
keratoplasty for keratoconus. Eye (Lond)
2006;20:527–32.

11. Price FW Jr, Price MO, Grandin JC, et
al. Deep anterior lamellar keratoplasty
with femtosecond-laser zigzag incisions.
J Cataract Refract Surg 2009;35:804–8.

12. Cheng YY, Pels E, Nuijts RM.
Femtosecond-laser-assisted Descemet’s
stripping endothelial keratoplasty. J
Cataract Refract Surg 2007;33:152–5.

13. Cheng YY, van den Berg TJ, Schouten
JS, et al. Quality of vision after
femtosecond laser-assisted descemet
stripping endothelial keratoplasty and
penetrating keratoplasty: a randomized,

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Subspeciality-Cornea

multicentre clinical trial. Am J Invest Ophthalmol Vis Sci2012;53:2571– 20. Chamberlain WD, Rush SW, Mathers
Ophthalmol 2011;152:556–66. 9. WD, et al. Comparison of femtosecond
laser-assisted keratoplasty versus
14. Rousseau A, Bensalem A, Garnier V, 17. Bahar I, Kaiserman I, McAllum P, et al. conventional penetrating keratoplasty.
et al. Interface quality of endothelial Femtosecond laser-assisted penetrating Ophthalmology 2011;118:486–91.
keratoplasty buttons obtained with keratoplasty: stability evaluation of
optimised femtosecond laser settings. Br different wound configurations. Cornea Corresponding Author:
J Ophthalmol 2012;96:122–7. 2008;27:209–11.
Dr. Vijay Kumar Sharma MS
15. Cheng YY, Pels E, Nuijts RM. 18. Proust H, Baeteman C, Matonti F, et al. Army Hospital Research and Referral,
Femtosecond-laser-assisted Descement’s Femtosecond laser-assisted decagonal Delhi, India.
stripping endothelial keratoplasty. J penetrating keratoplasty. Am J
Cataract Refract Surg 2007;33:152–5. Ophthalmol 2011;151:29–34.

16. Angunawela RI, Riau A, Chaurasia SS, et 19. Farid M, Steinert RF, Gaster RN, et al.
al. Manual suction versus femtosecond Comparison of penetrating keratoplasty
laser trephination for penetrating performed with a femtosecond laser
keratoplasty: intraocular pressure, zig-zag incision versus conventional
endothelial cell damage, incision blade trephination. Ophthalmology
geometry, and wound healing responses. 2009;116:1638–43.

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Subspeciality-Cataract

FLACS vs. Conventional
Phacoemulsification

J.S. Bhalla MS
Deen Dayal Upadhyay Hospital, Hari Nagar, New Delhi, India.

Femtosecond laser-assisted cataract wavelength is in the near-infrared power output. The benefit of these
surgery (FLACS) represents a spectrum, which is not absorbed by features in ophthalmic microsurgery is
potential paradigm shift in cataract optically clear tissues at low power that it spares delicate, adjacent tissues
surgery. Advocates of the technology densities1 and is unaffected by corneal from collateral damage-a problem,
herald FLACS as a revolution that magnification. To a certain extent, it can which has hampered the use of other,
promises superior outcomes and an also transmit through optically denser longer wavelength laser systems.
improved safety profile for patients. media such as oedematous or mildly
Conversely, detractors point to the opacified cornea2,3. This permits precise As with the NdYAG laser, FSL cuts tissue
large financial costs involved and claim focusing of a 3 μm spot, accurate to through a process of photodisruption
that similar results are achievable within 5 μm inside the anterior chamber. (in contrast to excimer and argon
with conventional small-incision Second, although argon, excimer, and lasers that use photoablation and
phacoemulsification. This review NdYAG lasers involve nanosecond (10- photocoagulation, respectively10). The
provides a balanced and comprehensive 9 s) pulses, the Ndglass FSL employs highly focused FSL increases the power
account of the development of FLACS an ultrafast pulse time of 10-15 s. This density at the target, leading to the light
since its inception. It explains the allows far smaller amounts of energy energy being absorbed by optically
physiology and mechanics underlying to be used while maintaining similar clear tissue. This generates a plasma of
the technology, and critically reviews free electrons and ionised molecules
the outcomes and implications of initial A that rapidly expand and collapse,
studies. The benefits and limitations B causing microcavitation bubbles and
of using femtosecond laser accuracy C an acoustic shock wave that separate
to create corneal incisions, anterior Figure 1. Highly focused femtosecond laser and incise the target tissue. In contrast
capsulotomy, and lens fragmentation pulses create plasma that rapidly expands with NdYAG lasers, the microcavitation
are explored, with reference to the main in a cavitation bubble, separating target bubbles produced with FSL are much
platforms, which currently offer FLACS. tissue. A: Highly focused femtosecond laser smaller, hence the reduced collateral
Economic considerations are discussed, pulses. B: Formation of cavitation bubbles. damage.
in addition to the practicalities C: Cavitation bubbles enlarge and coalesce
associated with the implementation to allow separation of tissue. Preoperative planning for FLACS
of FLACS in a healthcare setting. surgery
The influence on surgical training First, detailed planning of each stage of
and skills is considered and possible the operation is required. This involves
future applications of the technology assessing the anatomy of the patient’s
introduced. While in its infancy, eye, taking into account pupil diameter,
FLACS sets out the exciting possibility anterior chamber depth, and thickness
of a new level of precision in cataract of the lens and cornea.
surgery. Whether it gains widespread
acceptance is likely to be influenced by Docking the eye
a complex interplay of scientific and After the planning stage is complete,
socio-economic factors in years to come. the patient’s eye is docked into the
laser platform in a method similar to
FLACS physiology and mechanics that which is used in laser refractive
surgery. Docking of the eye into the
The femtosecond laser LASIK interface is known to cause a
significant rise in intraocular pressure.
Femtosecond lasers are advantageous Although this has been linked to
for two key reasons. First, the 1053 nm

26 DOS Times - Volume 25, Number 1, July - August 2019 www.dosonline.org/dos-times

Subspeciality-Cataract

complications such as LASIK-induced these four domains will lead to cataract porcine eyes have been reported by
optic neuropathy5, it is generally well surgery becoming faster and safer, with other authors21. Whether this increased
tolerated by the younger refractive better visual outcomes7. tensile strength is similar in human eyes
surgery population.6But it is more and leads to clinically relevant benefits,
problematic in elderly cataract patients, Limbal relaxing incisions in terms of lower rates of capsular tear,
with the risk of ischaemic retinal A potential application of FLACS is in remains to be seen.
and optic nerve injury. In particular, the creation of highly accurate, reliable
patients with advanced glaucoma may astigmatic LRIs. Manual LRIs can be However, there is currently no long-
be at risk of ‘snuff-out’. For this reason, technically challenging, with many term data to prove the more precise
the developers of FLACS platforms have surgeons reluctant to perform them due laser capsulotomy ultimately leads
been compelled to devise alternative to concerns related to inaccuracy and to significantly better visual and
methods of stabilising the patient’s the small risk of corneal perforation. refractive outcomes than a manual
eye within the optical system, while capsulorrhexis performed by an
reducing intraocular pressure rise and Corneal wound construction experienced surgeon. Particularly with
anatomical distortion. The self-sealing CCI, used by the simple, monofocal IOLs, the differences
majority of cataract surgeons to gain may be unnoticeable.
Intraoperative anterior segment access to the anterior chamber8, is
imaging another aspect of cataract surgery In their landmark study from 2009,
The third step in the procedure involves which femtosecond technology aims which evaluated the LenSx platform,
high-resolution, three-dimensional, to improve. The length and shape of Nagy et al20 demonstrated FSL
wide-field imaging of the anterior the incisions are important factors capsulotomies to be significantly more
segment. Detailed visualisation of the in corneal wound safety, with square accurate and reproducible in terms of
cornea, iris, iridocorneal angle, and surface architecture being associated size, circularity and centration than
lens (including anterior and posterior with less wound leakage9,10 and Manual Capsulorrhexis.
capsule) is the key to success and consequently a lower risk of hypotony,
safety with FLACS. Inaccuracy at this iris prolapse, and endophthalmitis. A Lens liquefaction and
stage increases the risk of incomplete well-constructed three-step CCI reduces fragmentation
capsulotomy, imprecise corneal the risk of ‘wound slippage’, which can Complications in cataract surgery most
incisions, damage to the iris, and result in induced astigmatism. Damage frequently occur during or because of
posterior capsular rupture. to Descemet’s membrane and gaping phacoemulsification itself31. Intraocular
at the internal aspect of the corneal manipulation of the rapidly oscillating
The treatment stage wound are also commonly found with ultrasound probe at this stage increases
Following docking and visualisation, manual CCIs11. This can lead to delayed the risk of injury to the capsule, iris, and
the treatment stage is initiated. Each healing and an increased risk of corneal cornea. Thermal injury to the corneal
laser incision is constructed in the decompensation12. wound may also occur. FLACS has been
posteroanterior plane, a principle designed to pretreat the lens, by using
that elegantly employs the posterior Anterior capsulotomy liquefaction or fragmentation patterns
microcavitation bubbles to scatter the The capsulotomy is closely related to the to segment the nucleus and soften harder
laser beam and reduce the amount of effective lens position (ELP) and it has cataracts,6 thus decreasing the amount
energy reaching the retina. By keeping been found that imprecise estimation of intraocular instrumentation and
the bubbles posterior to the laser target, of the ELP is the single biggest cause of movement.Palanker et al’s randomised
the focus of the laser beam is maintained inaccurate IOL power calculation16, 17. case-controlled study of 59 human eyes
and this avoids scatter before the target Tilt, rotation, decentration, and changes in vivo found that phacoemulsification
tissue. in ELP may have even more profound energy was reduced by 39% in eyes
effects with toric, accommodating treated with FLACS compared with
Applications and potential and multifocal IOLs18. Ideally, the standard cataract surgery.
benefits capsulotomy should be perfectly
Femtosecond laser currently has circular and overlapping the IOL optic Macular edema, diabetic
four applications in cataract surgery: by 0.5 mm for 360 degrees13. maculopathy, and ARMD
astigmatic limbal relaxing incisions Subclinical macular edema is a
(LRIs), corneal wound construction, FSL capsulotomies in porcine eyes have common complication of conventional
anterior capsulotomy (or laser- been shown to be able to withstand phacoemulsification. In a study
incised capsulorrhexis), and lens greater amounts of stretch than manual comparing the macular effects of FLACS
fragmentation6. It is envisaged that the capsulorhexes20. Similar results related vs conventional surgery with a ‘divide
introduction of femtosecond laser in to the strength of the capsular edge in and conquer’ technique, significantly
less thickening of the inner macular

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Subspeciality-Cataract

Figure 2. Adjacent femtosecond laser pulses may be placed close together to virtually corneal incisions aim to be self-sealing,
eliminate intervening tissue bridges, aiding in the free dissection of the capsulorrhexis, for stromal hydration may still be required,
example. A: Adjacent femtosecond laser pulses placed in close proximity. B: Expansion of particularly during the learning curve36.
cavitation bubbles. C: Separation of tissue as cavitation bubbles expand.
Corneal limitations
ring was found in the FLACS group at 1 may also be a relative contraindication. Corneal incisions are currently
week postoperatively (mean difference designed to be incomplete, so the
of 21.68 μm, P<0.001)33. This difference Practicalities and limitations anterior chamber is not breached before
between the FLACS and control groups The docking process the patient enters the operating theatre
reduced after 1 month and no longer The FLACS platforms are strongly and the ocular surface and adnexa are
attained statistical significance, but reliant upon the compliance and other sterilized.
the authors suggested that reduced characteristicsofpatients.Poormobility,
subclinical oedema in the early tremor, an inability to lie flat, deep set Capsular complications
postoperative phase could be beneficial eyes, and narrow palpebral apertures FSL capsulotomy requires pupillary
for patients at risk of developing may impair the docking process and dilatation in the order of 7–8 mm, and
clinically significant cystoid macular therefore are relative contraindications. therefore marked corectopia, poor
oedema later on. Also, a reduced Bali et al35 encountered this in 5 of 200 dilatation, and posterior synechiae
inflammatory response in the eye may eyes, but in each case the footswitch are relative contraindications. In
decrease the risk of ARMD progression. was released and the laser was not addition, FLACS has been associated
initiated. It has been suggested that with an increased risk of capsular
Complex cataract cases movement of redundant conjunctiva, or block syndrome (CBS), in which
FLACS is possible, and may even the appearance of a meniscus, may alert posterior capsule rupture (PCR) and
help improve outcomes, in trauma the operating surgeon to an impending lens dislocation occurs following
cases with white cataract formation loss of suction. hydrodissection37. In Roberts et al’s37
or anterior capsule rupture. Anterior Movement of redundant conjunctiva, series of the first 50 patients undergoing
capsular lacerations complicate or the appearance of a meniscus, may FLACS at their facility, two eyes were
the construction of the manual alert the operating surgeon to an complicated by intraoperative CBS.
capsulorrhexis, but the increased impending loss of suction. Corneal The theory behind this is that FSL lens
delicacy and accuracy of femtosecond opacification may hamper absorption fragmentation results in intralenticular
lasers may be able to overcome this. of the laser, and therefore affect the gas, which expands the nuclear volume.
However, the high precision of FLACS quality of corneal incisions. Similarly, The near-perfect edge of the FSL
does currently depend on a stable lens it may result in dispersion of laser capsulotomy is then thought to form
and so lens fragmentation may not be energy, although the extent of corneal a seal around the expanded nucleus.
an option if phacodonesis has occurred opacification and oedema through This restricts the flow of fluid around
as a consequence of trauma. Similarly, which FSL can pass without significant the lens, resulting in posterior pressure
unstable lenses in the context of scatter is not yet known. Although the on the capsule and posterior capsular
pseudoexfoliation or zonular dialysis rupture. It should be noted that, with
adjustments to the technique and
increased awareness of the risk of CBS,
no further cases have occurred at this
particular facility.

Grade of cataract
At present, limitations exist regarding
the nature of cataracts that can
be treated. Lens fragmentation
has an upper limit of capability of
LOCS grade 4.0 cataracts, therefore
brunescent cataracts may require
conventional phacoemulsification, or
even extracapsular cataract surgery.
Posterior subcapsular cataracts may
also rely upon an alternative approach,
as the safety margin for FLACS has been
suggested as at least 400 μm from the

28 DOS Times - Volume 25, Number 1, July - August 2019 www.dosonline.org/dos-times

Subspeciality-Cataract

Table 1: Manual CCC vs PPC vs Femto capsulotomy

Comparison of various studies evaluating capsulotomy edges in different anterior capsulotomy techniques

Type of capsulotomy Author Study type Sample size Capsulotomy edges

Femtosecond laser Pisciotta etal42 Comparative study 60 Irregular sawtooth shaped
edges

PPC Hooshmand etal29 Prospective 100 eyes Frayed edges
2018 multicenter case series

Comparison between Thompson etal30 2016 A 3 arm study in 44 eyes Ppcedege significantly
CCC, Femtosecond paired human cadaver stronger than femtosecond
laser and PPC eyes laser and manual CCC

PPC Chang etal28 2016 Human cadaver eyes 20 eyes Smooth and regular
and new Zealand
white rabbits

Femtosecond laser Abell etal23 2014 Prospective cohort 1626 eyes Rough edge postage stamp
configuration

Femtosecond laser Kovas etal26 2014 Prospective 79 eyes Low PCO

Femtosecond laser Auffarth etal25 2013 experimental Fresh pig eyes Stronger anterior capsule
opening than the std
manually performed
capsulotomy

Femtosecond laser Roberts etal24 2013 Prospective 1500 eyes Low rate of capsular tear
interventional

Femtosecond laser Nagy etal27 2011 Prospective 111 eyes Better overlap of capsular
margins and better centration
of IOL

Manual CCC Gimbel etal22 1990 prospective 158 eyes Strong capsular rim that
resists tearing

Figure 3. Scanning Electron Microscopy of anterior and posterior lens capsule after manual posterior capsule.
capsulorrhexis vs rhexis made by Femto laser.
Surgical time
In the experience of Bali et al,35 the
average time spent in theatre was 18.3
0-5.1 min (n=200), comparing closely
to conventional phacoemulsification,
where an average time of 15.66-3.10 min
was spent per case in the control group.

Learning curve
FLACS will certainly require a period
of training under supervision, just as
with phacoemulsification. Surgeons
will need to learn to dock the eye to
the laser, as well as understand how to
interpret the anatomical images, adjust
the laser parameters and deliver energy
safely. Furthermore, with training
programmes throughout the world
adopting a more competency-based
structure, standards across different
platforms would have to be considered

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Subspeciality-Cataract

Reimbursment Rules that, its potential applications extend. A
case series of eight patients has reported
Table 2: Reimbursement rules in different countries and popularity of FLACS success using FLACS with 25-gauge
phacovitrectomy,40 which paves the
Country Reimbursment Annual No of Flacs way for combining the technology
Recommendation Procedure Performed In with other ophthalmic procedures.
The Country Accurate capsulotomies will improve
the precision of intraocular lenses, and
United Kingdom Flacs Only For RCT No Data Available the use of decentred intraocular lenses
for strabismus is a potential use.41 If
Netherlands No Reimbursment No Data Available FLACS gains widespread acceptance, its
improved precision and accuracy may
Germany Govt Health Insurance Total Cataract 800,000 pave the way for further advances in
No Pvt Health Insurance Flacs No Data IOL design.
Yes
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Financial considerations FLACS has its limitations and may 5. Lee AG, Kohnen T, Ebner R, Bennett
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is not yet widespread, even in high- Furthermore, little is known about the neuropathy associated with laser in situ
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life, prospective multicenter study cataract, for example? Skilled cataract Femtosecond laser-assisted cataract
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surgery and phacoemulsification, the FLACS platform and deal with any 43–52.
showed equal results and complications complications that may arise. In certain
between the two procedures, but he circumstances, conversion from FLACS 7. Naranjo-Tackman R. How a femtosecond
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The study was fully granted by French surgery may be required. cataract surgery? CurrOpinOphthalmol
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Conclusion immediate future. Weight would 8. Leaming DV. Practice styles and
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2010; 36: 1048–1049. technique. J Cataract Refract Surg T, Gergely R, Knorz MC. Intraocular
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and longitudinal displacement. Arch Ophthalmology 2018;125:340-4 Dr. J.S. Bhalla MS, DNB, MNAMS
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34. Nagy ZZ, Kranitz K, Takacs A, Filkorn

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Subspeciality-Cataract

Ten Commandants for Posterior
Capsular Rupture Recognition and
Management

Mohan Rajan DNB, MNAMS, FRCS, Ph.D, Sujatha Mohan DO, FRCS SACF, M. Ravishankar DO, DHM, MBA, MHS,
Sriram DO, DNB
Rajan Eye Care Hospital Pvt Ltd., Chennai, Tamil Nadu, India.

Cataract surgery is the most commonly yy Cystoid macular edema (Figure 1)
performed surgical procedure in yy Retinal detachment (Figure 2)
ophthalmology and despite tremendous yy Endophthalmitis (Figure 3)
technical and technological yy Secondary Glaucoma
advancements, posterior capsular rent Early Signs of PCR
still occurs. During phacoemulsification procedure
the surgeon may experience a few signs
Early recognition combined with and some changes in the intraocular
advances in instrumentation has environment which may be very early
enabled effective management of signs of posterior capsular rupture.
posterior capsule rupture during They are:
phacoemulsification. However, Figure 1. Cystoid macular edema.
improper management may lead to yy Sudden deepening of anterior Figure 2. Retinal detachment.
serious complications with a higher chamber Figure 3. Endophthalmitis.
incidence of permanent visual
disability. yy Loss of nucleus followability
yy Lens tilt or deepening of the posterior
Stages at which Posterior Capsular
Rupture (PCR) can occur chamber
Ten Commandments of Posterior
Posterior Capsular Rupture Capsular Rupture
Authors suggest following Ten
(PCR) can occur in any stage of Commandments for preventing and
phacoemulsification Cataract Surgery. managing posterior capsule rupture.
The following are the stages in which
you should anticipate and prevent Commandment 1.
Posterior Capsular Rupture. Anticipation of Posterior Capsular
Rupture
yy During Hydrodissection
yy During nucleus removal Posterior capsular rupture should be
yy During Cortex removal anticipated1 in the following conditions
yy During Posterior capsule vacuuming where it is commonly seen in:
yy During IOL Implantation.
Improperly managed PCR can lead to: yy Traumatic cataract (Figure 4)
yy Post vitrectomized eyes (Figure 5)
If posterior capsular rupture is not yy Posterior polar cataracts (Figure 6)
managed properly it can lead to severe yy Hard brown cataract (Figure 7)
complications and cause impairment
of vision and even visual loss. The
complications which may occur are:

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Subspeciality-Cataract

Figure 4. Traumatic cataract. Figure 5. Cataract post vitrectomy. Figure 6. Posterior polar cataract.

Figure 7. Hard brown cataract. Figure 8. Sudden deepening of anterior Figure 9. Posterior capsulorhexis.
chamber.

Commandment 2 and 3 tear like: bimanual vitrectomy (Figure 10)
Recognition of Posterior Capsular and also bimanual irrigation and
Rupture yy Posterior polar cataract3,8 aspiration
yy Traumatic cataract yy In such situations the vitreous acts
The posterior capsular rupture has to yy Previous vitreoretinal surgery like a slinky
be recognized very early to prevent the Small Posterior Capsular Tear yy Use separate infusion and aspiration
further complications which may arise In case of small posterior capsular as well as cutting the vitreous with
intraoperative or postoperatively. The tear4,9, the following steps are to be the vitrector
following signs are to be recognized taken to prevent it becoming a large tear yy AC maintainer should always be
during the procedure. used in such situation
yy It is wiser to convert the small yy Do a complete central core
yy Sudden deepening of anterior posterior capsular tear into a vitrectomy. Remove the vitreous
chamber and posterior chamber posterior capsulorhexis (Figure 9). from the anterior chamber and also
(Figure 8) from behind the posterior capsular
yy Better use the microrhexis forceps or tear.
yy Loss of nucleus followability Utrata forceps yy The AC maintainer tamponades5
yy During hydrodissection beware of the break and prevents the tear from
yy Inject high molecular viscoelastic, extending further and decreases
“Pupil Snap Sign”- First tell - tale sign, sodium hyaluronate to tamponade hydration of vitreous.
and sudden constriction of the pupil the tear; it also pushes the posterior yy The intraocular lens is implanted in
yy Tilting of the nucleus may also be capsule backwards the sulcus area if posterior capsular
noticed support is inadequate.
Important Clinical Pearls Large Posterior Capsular Tear
It is always better to avoid In case of large posterior capsular Vitrectomy Technique
hydrodissection in certain complicated tear4,9 with vitreous loss the following yy Anterior vitrectomy is to be
cataracts where the posterior capsule steps are to be done.
may have a preexisting dehiscence2 or
yy It is important to always perform

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Subspeciality-Cataract

Figure 10. Bimanual vitrectomy. Figure 11a-c. show that PC tear is enlarging Figure 12. Injecting viscoelastic.
due to sudden withdrawal of the phaco
performed definitely and adequately probe. Figure 13a-c. Gentle removal of the phaco
when there is vitreous loss. probe.
yy Use always automated vitrector Probe hydration, probable enlargement of
which is much safer and makes life After the chamber is well formed with the tear and even cause further loss of
easy for the surgeon. viscoelastic, the phaco probe is to be vitreous (Figure 14a, 14b.).
yy During vitrectomy bimanual removed gently (Figure 13a-c) and then
technique is to be employed to the operating surgeon should assess
prevent hydration of vitreous and the situation and plan further course of
enlargement of the break. action.
yy Use high cutting rate around 2000 to Commandment 7
3000 / min. Bimanual Irrigation and Aspiration
yy The suction level should be low Bimanual irrigation and aspiration is
about 100 to 150 mmHg. done to remove the residual cortex as it
yy Do not pull the vitreous, but it has an advantage over coaxial irrigation
should be cut in place and allowed to and aspiration. Because the coaxial
fall back. technique leads to increase in vitreous
yy Always avoid excessive movement
of vitrectomy probe.
Commandment 4.
Do Not Pull Out
Do not panic when you see any signs
of a posterior capsular tear, it is very
important not to withdraw the phaco
probe (Figure 11a-c) immediately,
which will lead to extension of the tear
and even loss of nuclear fragments into
the vitreous cavity.

Commandment 5.
A high molecular weight viscoelastic
(preferably Viscoat) is injected through
the side port (Figure 12) which allows
the anterior chamber to be well formed
and prevents the extension of the
posterior capsular tear.

Commandment 6.
Gentle withdrawal of the Phaco

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Subspeciality-Cataract

Figure 14a&b. Coaxial irrigation aspiration. Figure 17. Assessment of the Capsule.
Figure 15 a & b. Triamcinolone is used to stain vitreous. Figure 18. Single piece IOL.

Figure 16a. Parsplana Vitrectomy. Figure 16b. Vitrectomy cutter. Figure 19. Three piece IOL.

Commandment 8. through the parsplana using a 20gauge intraocular lens to be implanted.
Central Anterior Vitrectomy (Use system or by placing a trocar and Decision Regarding IOL
TRICOT) cannula using a 23 gauge / 25 gauge Implantation
Preservative free triamcinolone (Figure vitreous cutter (Figure 16a&b). A foldable single piece intraocular lens
15a&b) to be used to stain the vitreous Commandment 9. (Figure 18) can be implanted into the
in order to ensure there is no vitreous Careful Assessment of the Capsule bag if the posterior capsular rupture is
strands extending into the anterior It is very important to assess the 360° small in size, after converting it into a
chamber and the incision wound area. structural integrity and the strength posterior capsulorhexis, provided there
It is mandatory to use the vitreous of the anterior capsule (Figure 17) and is adequate capsular support the IOL.
cutter separately on the right side port as well as the posterior capsule. This If the posterior capsular tear is large,
and the irrigation in the left side port. assessment would make the surgeon a multipiece intraocular lens can be
Now check for capsule integrity. understand the exact support of the placed in the sulcus and supporting it
Anterior vitrectomy can also be done by capturing the rhexis margin6 (Figure
19) with the optic of the IOL.

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Subspeciality-Cataract

If there is deficiency or total absence Figure 20. Anterior Chamber IOL. Figure 24. Whole Nucleus drop.
of capsular support then the following
intraocular lens implantation can be Figure 21. Iris claw lens. Figure 25. Anterior Assisted Levitation
considered appropriately on individual (AAL).
case basis: Figure 22. Sutured scleral-fixated IOL.
Figure 26. Posterior Assisted Levitation
yy Anterior chamber IOL (Figure 20). Figure 23. Glued IOL. (PAL).
yy Iris claw (Retro fixated) (Figure 21). Summary recognition of posterior capsular tear
yy Sutured scleral-fixated IOL (Figure The incidence of PCR can be decreased along with prompt management of
significantly by identifying the presence capsular tear and vitreous prolapse is
22). of predisposing factors and appropriate key to the good postoperative outcome.
yy Glued IOL (Figure 23). modification of the surgical plan. Early References
Commandment 10. 1. Arup Chakrabarti, Nazneen Nazm,
Nucleus Drop
Posterior capsular rent: Prevention
If whole nucleus drop occurs (Figure and management, Indian Journal of
24), do not chase the nucleus with the Ophthalmology Year : 2017, Volume : 65,
phaco probe. Issue : 12, Pages : 1359-1369.
2. Rasik B Vajpayee et al, Management
Do a three port pars plana vitrectomy of Posterior Capsule Tears, Survey
and make the nucleus mobile. Then use of Ophthalmology May–June, 2001,
the fragmatome to emulsify the nucleus Volume 45, Issue 6, Pages : 473–488.
in the mid vitreous cavity.

If the nucleus is still seen in the anterior
vitreous or pupillary area then one may
attempt the following techniques for
safe removal.

yy Anterior assisted levitation (AAL)
(Figure 25) through the limbus

yy Posterior assisted levitation (PAL)
(Figure 26) through the pars plana

yy Do not attempt PAL in young
patients and high myopics as the
incidence of retinal tear and retinal
detachment is high in the group.

Appropriate Nucleus Management
Anterior chamber should be stabilized
with viscoelastic, if the nuclear pieces
are in the anterior chamber they should
be removed with the phaco probe after
lowering all parameters. If the nuclear
fragments are in the anterior vitreous
they can be removed by posterior
assisted levitation7 (PAL) through pars
plana route.

If the nucleus has completely
descended into the posterior vitreous
further management is to be done by 3
port pars plana vitrectomy and nucleus
fragments are removed by a phaco
fragmatome.

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Subspeciality-Cataract

3. Robert H. Osher, Bernard C.-Y. Yu, Kim, Seung Youn Jea, Optic capture Corresponding Author:
Douglas D. Koch, Posterior polar in the anterior capsulorhexis during
cataracts: A predisposition to combined cataract and vitreoretinal Dr. Mohan Rajan
intraoperative posterior capsular surgery, Journal of Cataract & Refractive Rajan Eye Care Hospital Pvt Ltd.,
rupture Journal of Cataract & Refractive Surgery, September 2010, Vol. 36, Issue Chennai, Tamil Nadu, India.
Surgery, March 1990, Vol. 16, Issue 2, 9, p1449–1452.
p157–162.
7. Tova Lifshitz, Jaime Levy, Posterior
4. Howard Vance Gimbel, Posterior assisted levitation: Long-term follow-up
Capsule Tears Using Phaco- data, Journal of Cataract & Refractive
emulsification Causes, Prevention and Surgery, March 2005, Vol. 31, Issue 3,
Management, European Journal of p499–502.
Implant and Refractive Surgery, March
1990, Vol. 2, Issue 1, p63–69. 8. Laura J. Rongé, Contributing Writer,
Posterior Capsular Rupture During
5. Sofia Androudi, Periklis D Brazitikos, et Cataract Surgery, EyeNet Magazine,
al, Posterior capsule rupture and vitreous September 2005.
loss during phacoemulsification with or
without the use of an anterior chamber 9. P Traianidis, G Sakkias, S Avramides,
maintainer, Journal of Cataract and Prevention and Management of Posterior
Refractive Surgery, February 2004, Capsule Rupture, European journal of
Volume 30, Issue 2, Pages 449–452. ophthalmology, October 1996, 6(4):379-
82.
6. Joo Eun Lee, Jeong Hyo Ahn, Wan Soo

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Subspeciality-Oculoplasty

Eyelid Sebaceous Gland
Carcinoma: A Review

Sahil Agrawal MD1, Saloni Gupta MS2, Deepsekhar Das MD1, Rachna Meel MD1,
Neelam Pushker MD1, Mandeep S. Bajaj MD1
1Oculoplasty and Paediatric Ophthalmology Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi, India.
2Department of Ophthalmology, Northern Railway Central Hospital, Connaught Place, New Delhi, India.

Sebaceous Gland Carcinoma (SGC) ab
is a neoplasm that occurs most
frequently in the periocular area. It Figure 1a. Clinical presentation showing large mass of the right lower eyelid with loss of eye
has been known to be notorious as it lash and distorted lid margin architecture. Figure 1b. Same patient on lid eversion shows an
masquerades benign lesions and hence extensive tumor.
delay in diagnosis. The terms sebaceous
carcinoma, sebaceous cell carcinoma, Aetiology it from benign nodules (Figure 1a, 1b).
meibomian gland carcinoma all mean Most arise de novo, and not from a pre- They may be nodular or pedunculated
the same. existing sebaceous adenoma, sebaceous and may show keratinization, confusing
hyperplasia, or sebaceous nevus. Other to be a cutaneous horn. If ulcerated may
Demography predisposing factors include irradiation, mimic a basal cell carcinoma. Tumor
Eyelid SGC is commonly seen in the immunosuppression, and use of arising at the eyelid margin are of Zeis
age group 55 to 70 years. It may also diuretics5. Immunodeficiency state of gland origin and free from tarsus.
develop in younger patients with a HIV and HPV have also been found A diffuse unilateral thickening (Diffuse
history of irradiation for bilateral to be associated with SGC. Aberrant Pseudo inflammatory Pattern) of
hereditary retinoblastoma. It can also retinoid receptors on tarsus including the eyelid extending into forniceal/
be seen following facial irradiation for RAR alpha, beta, and gamma, and RXR bulbar conjunctiva in an elderly
benign conditions like acne, cutaneous alpha, beta, and gamma have also been patient presenting with blepharitis not
haemangioma, and eczema. Females implicated in the pathogenesis. responsive to treatment should raise
have higher preponderance to the the suspicion of SGC and a biopsy is
disease1,2. Clinical Features indicated. If the blepharitis is bilateral
The most common presentation and symmetrical, then carcinoma is less
Site of Origin is a painless, firm, sessile to round, likely6,7 (Figure 3).
Sebaceous glands are present in plenty subcutaneous nodule in the eyelid, As said above primary SGC of the
in the ocular region. The upper tarsus generally fixed to the tarsus. Overlying lacrimal gland in rare. A chronic
(meibomian glands) along with cilia skin is generally free and movable in unilateral blepharoconjunctivitis that
(Zeis gland) has a greater number of early stages. As it encroaches on the was either not previously recognized
sebaceous glands compared to the epidermis, it assumes a yellow colour or was treated locally as a benign
lower lid, hence SGC of the upper eyelid due to the presence of lipid in the mass. inflammatory lesion may locally invade
is more commonly seen, followed Disruption of eyelid architecture and eye the lacrimal gland via the involved
by that of lower eyelid, caruncle, lash loss should help in differentiating
bulbar conjunctiva and rarely the
lacrimal gland3,4,16. It may also exhibit a
multicentric origin because of pagetoid
invasion.
Extra- orbital origin is about 25%, of
which mainly occurs in the head and
neck region (most commonly being the
parotids).

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Subspeciality-Oculoplasty b
a

cd
Figure 3. Diffuse conjunctival involvement
by SGC presenting as chronic conjunctivitis.

ef

Figure 2a,b. Pre and Post operative picture of SGC patients who underwent excision with Figure 4: HPE showing abundant foamy,
frozen section with control of surgical margins repaired with Hughes flap, (c,d). repaired finely vacuolated cytoplasm and well
with Cutler Beard flap, (e,f). repaired with direct closure. defined cellular outline.

tarsus. In neglected or recurrent case, Pagetoid spread i.e. the intraepidermal Impression cytology may be tried to
extensive orbital invasion may be seen. (or intraepithelial) spread of malignant detect conjunctival intraepithelial
cells into the eyelid epidermis or spread. The procedure is limited by
Histopathology conjunctival epithelium is an important the fact that small number of cells are
Gross examination: - The excised mass feature. It is similar to that observed in obtained and there is lack of tissue
is an unencapsulated infiltrating yellow Paget’s disease of the nipple and been organization.
colour mass due to the presence of reported to occur from 44–80% of cases. Pagetoid spread allows the tumor to
lipids. Tumor can be seen arising from Pagetoid spread lead to multicentric involve the ocular tissue more than may
tarsus plate. origin of the tumor, though true be clinically suspected. A rose Bengal
multicentricity can also be seen. stain helps in identifying the spread,
Microscopic examination: - Lobules if any and is to be followed by map
of atypical sebaceous cells of varied Investigations biopsy for determining and confirming
sizes containing foamy vacuolated A thorough clinical examination with the extent of disease. It involves tissue
cytoplasm and large hyperchromatic high index of suspicion, followed by biopsy from conjunctiva palpebral
nuclei with prominent nucleoli are excisional or full thickness incisional (upper and lower 3 each) and bulbar
seen. They stain positive for fat. (Oil biopsy, is essential for confirmation of
red-O stain)8 (Figure 4). the diagnosis.

In case of poorly differentiated SGC use of various IHCs come into role

Immunohistochemistry Sebaceous Cell Ca Squamous Cell Ca Basal Cell Ca
-
EMA ++ -
-
Cam 5.2 +-

BRST 1 +-

SGC also show positivity for adipophilin and perilipin

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Subspeciality-Oculoplasty

conjunctiva (3 superior, 3 inferior, one Prior to surgical excision, it is Figure 5. Diffuse disease involving deep
each temporal and nasal) from 14 sites9. imperative to examine for pagetoid orbital tissue who after Neo adjuvant
spread or multicentric origin by double chemotherapy underwent debulking.
In case of diffuse and extensive tumor, eversion of the eyelids, and look for
orbital imaging is necessary. any conjunctival changes such as Carboplatin and 5-Fluorouracil have
telangiectasia, papillary change, or a been used as chemotherapeutic agents
SGC most commonly metastasizes to mass. If suspected wide local excision of in SGC. In cases of large SGC with or
regional lymph nodes10. Examination the lid lesion should be accompanied by without orbital spread, neo adjuvant
of preauricular and cervical areas is map biopsies. chemotherapy downstages the
necessary to detect possible lymph node disease and allows easy and excellent
metastasis, which if significant requires If there is conjunctival stromal invasion debulking15 (Figure 5).
FNAB. Distant metastasis to lung, liver, on map biopsies, wide local excision
brain, and bone is rare. of all affected eyelid and conjunctiva Prognostic Features
followed by repair using rotational or There are many factors which impart
Management advancement tarsal flaps and buccal a poorer prognosis at the time of
The goals of management should be in mucosa or amniotic membrane grafting diagnosis16.
the following order of priority: is done.
yy Presence of symptoms greater than 6
yy Tumor control (patient’s life span) Topical mitomycin C has also been months,
yy Globe salvage tried for such pagetoid invasion. MMC
yy Vision salvage is not effective in stromal invasion13,14. yy Tumor size of greater than 1 cm
yy Patient comfort In epibulbar and pagetoid extension of yy Involvement of both upper and
yy Acceptable cosmesis. SGC, cryotherapy is a useful adjunct to
Different treatment modalities for surgery, and helps avoid exenteration. lower eyelids
SGC include local excision, orbital yy On HPE, vascular or lymphatic
exenteration, radical neck dissection, Exenteration is reserved for cases of
radiation, or chemotherapy depending unresectable orbital extension for invasion, orbital invasion, poor
on the stage of the tumor at the time of diffuse disease or lesions involving deep cytological differentiation, an
presentation. orbital tissue without any evidence infiltrative growth pattern, and/or
of distant metastasis. Eyelid sparing pagetoid spread.
For small and circumscribed lesion, exenteration can be carried out if the A strict follow-up to look for local
a planned excisional biopsy is eyelid skin is free of disease on frozen tumor recurrence and regional lymph
undertaken. In case of gross eyelid sections. node should be done every 3 months for
disease wide local excision with control a year, every 6 months for 3 years, and
of surgical margins (5-6mm of normal In case of regional nodal disease every year thereafter.
tissue) and frozen section analysis or without distant metastasis, radical neck
Mohs micrography is the main stay dissection is indicated. References
of treatment with continuation of the 1. Kass LG, Hornblass A. Sebaceous
resection until the margins are clear Radiotherapy and systemic
histopathologically11. chemotherapy, in general, is reserved carcinoma of the ocular adnexa. Surv
for patients who are not candidates Ophthalmol. 1989;33:477–90.
The advantages of Moh’s micrographic for surgical procedures either due to 2. Song A, Carter KD, Syed NA, Song J, Nerad
surgery, in comparison to a advanced age or disease, for palliation JA. Sebaceous cell carcinoma of the
conventional excision are; (1) definitive in widespread disease, and for patients ocular adnexa: Clinical presentations,
margin excision and (2) minimal loss of who refuse exenteration for advanced histopathology, and outcomes. Ophthal
surrounding normal tissue12. local disease. Because of its adverse Plast Reconstr Surg. 2008;24:194–200.
side effects and higher recurrence rate 3. Doxanas MT, Green WR. Sebaceous
Caruncular lesions after removal should compared to surgery, radiotherapy gland carcinoma: Review of 40 cases.
be supplemented with cryotherapy is usually avoided or may even be Arch Ophthalmol 1984; 102:245–249. 24.
as they not lend to wide margins. contraindicated. It does not allow 4. Wolfe JT III, Yeatts RP, Wick MR, et al.
For advanced primary lesions with histological confirmation of tumor
suspicion, incisional biopsy removing classification and eradication and
full thickness of the eyelid is preferred also finally recurrences following
to establish diagnosis. radiotherapy are difficult to treat
surgically because of poor healing of
irradiated tissues

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Subspeciality-Oculoplasty

Sebaceous carcinoma of the eyelid: errors 10. Boniuk M, Zimmerman LE Sebaceous in the Management of Extensive Eyelid
in clinical and pathologic diagnosis. Am carcinoma of the eyelid, eyebrow, Sebaceous Gland Carcinoma: A study
J Surg Pathol 1984; 8:597–606. caruncle, and orbit. Trans Am Acad of 10 Cases. Ophthalmic Plast Reconstr
Ophthalmol Otolaryngol. 1968 Jul-Aug; Surg. 2016 Jan-Feb; 32(1):35-9.
5. Khan JA, Grove AS Jr, Joseph MP, 72(4):619-42. 16. Rao NA, Hidayat AA, McLean IW,
Goodman M. Sebaceous carcinoma. Zimmerman LE. Sebaceous carcinomas
Diuretic use, lacrimal system spread, 11. Shields JA, Demirci H, Marr BP, Eagle of the ocular adnexa: A clinicopathologic
and surgical margins. Ophthalmic Plast RC Jr., Shields CL. Sebaceous carcinoma study of 104 cases, with five-year follow-
Reconstr Surg. 1989; 5(4):227-34. of the ocular region: A review. Surv up data. Pathol. 1982 Feb; 13(2):113-22.
Ophthalmol 2005;50:103-22.
6. Condon GP, Brownstein S, Codere F. Corresponding Author:
Sebaceous carcinoma of the eyelid 12. Ratz JL, Luu-Duong S, Kulwin DR.
masquerading as superior limbic Sebaceous carcinoma of the eyelid Dr. Sahil Agrawal MD
keratoconjunctivitis. Arch Ophthalmol treated with Mohs’ surgery J Am Acad Oculoplasty and Paediatric Ophthalmology
1985; 103:1525–1529. Dermatol. 1986 Apr; 14(4):668-73. Services, Dr. Rajendra Prasad Centre for
Ophthalmic Sciences,
7. Gloor P, Ansari I, Sinard J. Sebaceous 13. Shields CL, Naseripour M, Shields JA, All India Institute of Medical Sciences,
carcinoma presenting as a unilateral Eagle RC Jr. Topical mitomycin-C for New Delhi, India.
papillary conjunctivitis. Am J pagetoid invasion of the conjunctiva
Ophthalmol 1999; 127:458–459. by eyelid sebaceous gland carcinoma.
Ophthalmology 2002; 109:2129–2133.
8. Pereira PR, Odashiro AN, Rodrigues
Reyes AA, et al. Histopathological 14. Tumuluri K, Kourt G, Martin P.
review of sebaceous carcinoma of the Mitomycin C in sebaceous gland
eyelids. J Cutan Pathol 2005; 32:496-501. carcinoma with pagetoid spread. Br J
Ophthalmol 2004; 88:718–719.
9. Putterman AM. Conjunctival map
biopsy to determine pagetoid spread. 15. Kaliki S, Ayyar A, Nair AG et al.
Am J Ophthalmol 1986; 102:87–90. Neoadjuvant Systemic Chemotherapy

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42 DOS Times - Volume 25, Number 1, July - August 2019 www.dosonline.org/dos-times

Subspeciality-Glaucoma

Ocular Emergencies in Glaucoma

Madhu Bhoot DNB, Priti Kumari MS
Glaucoma Department, Dr. Shroff’s Charity Eye Hosptial, Daryaganj, New Delhi, India

Abstract: Glaucoma is a disease which causes chronic damage to optic nerve and ganglion cells. But, certain forms of primary
and secondary angle closure and secondary open angle glaucomas can be more acute in presentation. These comprise of the
emergencies in glaucoma like acute angle closure, phacogenic glaucoma and traumatic hyphema. They generally present with
redness and diminution in vision and hence it needs to be differentiated from other eye emergencies presenting with similar
complaints. In these situations, delay in diagnosis can result in permanent damage to optic nerve and development of chronic
glaucoma. Visual outcome and potential in such situations depend on timely referral and appropriate management. This article
will be focusing on various types of emergencies in glaucoma including the signs, symptoms and treatment. This can help in
better identification of the disease and it’s management, giving patient best possible chance to get appropriate treatment for
his/her disease.
Keywords: Glaucoma, emergencies, acute angle closure, phacogenic, hyphema.

Early identification and proper Figure 1a. Acute angle closure with corneal Figure1b. Following YAG laser iridotomy
treatment of glaucoma emergencies are oedema.
fundamental in the primary care setting hyperopia, family history of angle should be elicited3.
as the outcome largely depends on closure, advancing age, female gender, During an acute attack, medical
timely management. These conditions East Asian, Inuit or Latino ethnicity, therapy is initiated to lower the intra-
are sight-threatening and require shallow peripheral anterior chamber ocular pressure and break the attack.
emergent recognition and treatment to and short axial length2. Primary treatment is usually with a
preserve vision. Clinicians must be able Diagnosis requires a detailed history hyperosmotic agent such as intravenous
to quickly and accurately triage these and physical exam. History must 20% mannitol 1-2 g/kg, or oral glycerol
emergencies so that patients are given include use of drugs like dilating drops, 1-1.5g/kg, as iris sphincter muscle may
the best possible chance for therapeutic anti-cholinergics, sulfonamides and not respond well to topical agents in the
success. The most important glaucoma antidepressants. Family history of acute presence of high intra-ocular pressure.
emergencies are acute angle closure glaucoma or previous laser iridotomy Oral (500mg) or parenteral (5-10 ml/
glaucoma, lens related glaucoma’s and in first-degree relative and previous kg) acetazolamide may also be effective
traumatic hyphema1. intermittent attacks of angle closure during an acute attack in lowering the

Acute angle closure glaucoma
Patients often present with severe eye
pain, frontal headache, nausea and
vomiting, blurred vision, halos around
lights and conjunctival injection.
Clinical signs include an elevated
IOP, ciliary flush, corneal edema, mid-
dilated and sluggishly reacting pupil,
shallow anterior chamber, sometimes
glaukom-flecken (Figure 1a). The angle
is observed to be closed on gonioscopic
examination. Risk factors include axial

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Subspeciality-Glaucoma

intraocular pressure. Topical steroids
along with a combination of a topical
B-blocker (such as timolol) and topical
adrenergic agent (such as brimonidine)
should be started thereafter. Analgesics
and anti-emetics can be given as
symptomatic treatment. (Management
algorithm) YAG laser iridotomy of the
eyes should be done as soon as cornea
clears (Figure 1b).

Lens related glaucoma Figure2a. Phacomorphic glaucoma. Figure 2b. Phacomorphic glaucoma.
(Phacogenic glaucoma)
The lens may cause both open-angle Table 1 Open-angle
and angle-closure glaucomas (Table 1). Angle-closure Phacolytic glaucoma
Phacomorphic glaucoma Lens particle glaucoma
Phacomorphic glaucoma Phaco-antigenic glaucoma

Phacomorphic angle-closure is a acetazolamide, 500mg (2 tabs of 250mg mature cataract, capsular wrinkling
secondary angle-closure caused by stat), analgesics and anti-emetics, topical and open angle with a deep anterior
increase in lens thickness. Patients corticosteroids and a combination of chamber. Small chunks of white
present with clinical picture similar to beta blocker (caution with Asthma particles are often seen circulating in
that of acute angle closure glaucoma or COPD) and alpha agonist. I/V the aqueous (Figure 3a). Cellular debris
with signs of conjunctival injection, mannitol to be considered, if oral may be seen lining the anterior chamber
corneal oedema, mid-dilated pupil, agents are unavailable, not tolerated, or angle and a pseudo-hypopyon may be
shallow anterior chamber, closed angle contraindicated as in diabetes mellitus. present. The lack of KP’s differentiates
and mature cataract (Figure 2a and b). A laser iridotomy will not relieve angle- it from phaco-antigenic glaucoma.
closure in advanced cases where the Diagnosis requires a detailed history
Reported risk factors are age > 60 years, lens is large enough to directly push and clinical examination, gonioscopy
axial length < 23.7, narrow anterior the peripheral iris into the trabecular of both eyes, ultrasonography (to
chamber and female gender4-7. Diagnosis meshwork. Only definitive treatment ensure that posterior segment has no
requires a detailed history and clinical is cataract extraction by manual SICS pathology) and biometry. Differential
examination, gonioscopy of both or Phacoemulsification. SICS was found diagnosis includes phaco anaphylactic
eyes, ultrasonography (to ensure that to be faster than Phacoemulsification (9 glaucoma, phacomorphic glaucoma,
posterior segment has no pathology) min vs 12 min). Risks during cataract acute angle closure glaucoma, lens
and biometry. History of use of systemic surgery are difficult capsulotomy, iris particle glaucoma, uveitic glaucoma
drugs which can cause lens swelling prolapse and descemet’s detachment10. and angle recession glaucoma11.
Management requires emergency
like Thiazide diuretics, Sulfonamide Phacolytic glaucoma admission and I/V Mannitol, topical
drugs, Carbonic anhydrase inhibitors, An inflammatory glaucoma caused by steroids, Cycloplegics, anti-glaucoma
Tetracycline, Anticonvulsant leakage of soluble lens protein into the therapy (aqueous suppressants).
(Topiramate) and Miotics (cause zonule anterior chamber through the capsule Definitive treatment requires cataract
laxity and forward movement of lens iris of a mature cataract. It is commonly extraction (Figure 3b).
diaphragm) should be noted. Biometry seen in elderly patients with advanced Lens particle glaucoma
parameters include a lens thickness of cataract. Patients presents with It is associated with a grossly disrupted
at least 5 mm (the average lens thickness sudden onset of pain, redness and poor lens capsule following cataract
is 4.63 mm)8, and an anterior chamber vision. Clinical examination reveals extraction, capsulotomy or ocular
depth less than 2 mm9. conjunctival hyperemia, corneal trauma. Usually occurs within weeks
oedema, raised IOP, heavy flare and
Differential diagnosis includes cells but no keratic precipitates (KP’S),
phacolytic glaucoma, lens particle
glaucoma, acute angle closure glaucoma
and uveitic glaucoma.

Initial goal is to stabilize the eye by
breaking the acute attack and lowering
the IOP using medical or laser treatment.
Medical treatment is initiated with oral

44 DOS Times - Volume 25, Number 1, July - August 2019 www.dosonline.org/dos-times

Subspeciality-Glaucoma

Figure 3a. Phacolytic glaucoma. Figure 3b. Phacolytic glaucoma following the anterior chamber, surgical removal
surgery. of the lens material should be done.

Management Algorithm Phaco-antigenic glaucoma

Immediate It is a granulomatous antigenic reaction
I.V/oral Acetazolamide or I.V/oral Osmotics. to one’s own lens protein. It occurs due
Topical – Pilocarpine 2% b blockers, a agonist steroids to rupture of lens capsule following
surgery or penetrating trauma. It is
1-2 hours more common in the elderly population
with a peak incidence in the sixth
Attack broken Attack not broken to seventh decade. Usually develops
1-14 days after the initial insult to the
Iridotomy Repeat i.v. CAI or lens capsule. Patients present with
Osmotics photophobia, pain and redness of the
eye. Clinical picture reveals moderate
Clear cornea anterior chamber reaction with keratic
precipitates, posterior synechiae and
Not to forget Iridotomy Iridotomy residual lens material in the anterior
of fellow eye chamber. There may be associated
vitritis and cystoid macular edema.
of the initial surgery or trauma but peripheral anterior synechiae12. Management of these patients is with
may have late presentation also. Management requires admission and topical steroids and cycloplegics. When
These lens particles obstruct the I/V mannitol along with anti-glaucoma associated with high IOP, aqueous
trabecular meshwork or there may therapy to control IOP, topical steroids suppressants are indicated. If medical
be inflammatory response to these in mild to moderate amounts to control treatment fails, surgical removal of the
lens particles. Clinical picture reveals inflammation and cycloplegics to lens material should be done.
photophobia, ciliary injection, anterior prevent posterior synechiae formation.
chamber cells and flare, lens fragments Intensive steroids should not be given Traumatic Hyphema
in aqueous, mutton fat keratic as it may delay absorption of free lens Hyphema refers to blood in anterior
precipitates. With time there may be protein. If glaucoma is severe and/or chamber. It is associated with trauma,
development of posterior synechiae and there is large amount of lens material in manual intraocular or laser surgery.
It occurs due to disruption of blood
vessels of iris or ciliary body. A thorough
evaluation of the mechanism of
injury and time of injury is important.
History of use of medications (Aspirin,
Warfarin), Sickle cell disease,
coagulopathy, bleeding gums and
epistaxis should be noted. Patients may
have variable presentation depending
on the etiology. They may present with
headache, pain, redness, photophobia
or blurred vision. There may be blood
or clot or both in the anterior chamber.
Gonioscopy should be delayed as there
is risk of re-bleeding. Gentle B-scan
should be done if anterior chamber is
filled with blood and CT scan should be
advised if there is suspected fracture or
intra-ocular foreign body13.

Goal of management is to decrease
bleeding and control the pressure
with IOP-lowering drops. Complete
bed rest with head end elevated with

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Subspeciality-Glaucoma

limited activities, shield over involved 2. Wormald RPL, Jones E. Glaucoma: acute 11. Epstein DL. Phacolytic glaucoma. In:
eye, cycloplegics, steroids and aqueous and chronic primary angle-closure. BMJ Fraunfelder FT, Roy FH, eds. Current
suppressants is advised. Carbonic Clin Evid. 2015 Dec 8;2015:0703. Ocular Therapy. Philadelphia: WB
anhydrase inhibitors, PG analogues Saunders, 1980; 463-5
and pilocarpine should be avoided. 3. Sun X, Yi D, et al. Primary angle closure
Indications for surgery are IOP above 50 glaucoma: What we know and what we 12. Papaconstantinou D, Georgalas I,
mm Hg for 5 days, IOP above 35 mm Hg don’t know. Progress in retinal and eye Kourtis N, Krassas A, Diagourtas A,
for 7 days, or the presence of hyphema research 2017 57:26-29 Koutsandrea C, Georgopoulos G. Lens-
more than 9 days. This is essential to induced glaucoma in the elderly. Clin
circumvent complications of glaucoma 4. Lee JW, Lai JS, Lam RF, Wong BK, Yick Interv Aging. 2009;4:331-6.
and corneal blood staining. Patients DW, et al. (2011) Retrospective analysis
should be observed closely in the initial of the risk factors for developing 13. Gharaibeh A, Savage HI, Scherer RW,
week as there are chances of re-bleed. phacomorphic glaucoma. Indian J Goldberg MF, Lindsley K. Medical
Hospitalization of these patients is Ophthalmol 59: 471-474. interventions for traumatic hyphema.
needed when there is uncontrolled IOP, Cochrane Database Syst Rev. 2011 Jan
total hyphema or risk of re-bleed14. 5. Tomey KF, al-Rajhi AA (1992) 19;(1):CD00543.
Neodymium:YAG laser iridotomy in the
Conclusion initial management of phacomorphic 14. Pressure Samar B, Hussain I, Nawaz.
All the emergencies in glaucoma can glaucoma. Ophthalmology 99: 660-665. Management of Traumatic Hyphema
result in permanent loss of vision and with Raised Intraocular pressure. Pak J
development of chronic glaucoma, if 6. Prajna NV, Ramakrishnan R, Krishnadas Ophthalmol 2007, 23: (4).
not managed on time. More the delay R, Manoharan N (1996) Lens induced
in time of presentation more can be the glaucomas--visual results and risk Corresponding Author:
damage. Hence, timely identification factors for final visual acuity. Indian J
and treatment of these forms of Ophthalmol 44: 149-155. Dr. Madhu Bhoot DNB
glaucoma is important. A thorough Glaucoma Department,
slit lamp evaluation can help us in 7. Angra SK, Pradhan R, Garg SP (1991) Dr. Shroff’s Charity Eye Hosptial, Daryaganj,
picking up signs of these conditions Cataract induced glaucoma--an insight New Delhi, India
and providing the best and earliest into management. Indian J Ophthalmol
treatment possible. This can help in 39: 97-101.
restoring vision of the patient and
salvaging eye from permanent damage. 8. Hoffer KJ (1993) Axial dimension of
the human cataractous lens. Arch
References Ophthalmol 111: 914-918.
1. Collington NJ. Emergencies in glaucoma:
9. Lee SJ, Lee CK, Kim WS (2010)
a review.Bull Soc Belge Ophtalmol. Long-term therapeutic efficacy of
2005;(296):71-81. phacoemulsification with intraocular
lens implantation in patients with
phacomorphic glaucoma. J Cataract
Refract Surg 36: 783-789.

10. Kaplowitz KB, Kapoor KG. An Evidence-
Based Approach to Phacomorphic
Glaucoma. J Clinic Experiment
Ophthalmol 2012; S1:006.

46 DOS Times - Volume 25, Number 1, July - August 2019 www.dosonline.org/dos-times

Subspeciality-Retina

‘Bone’ Appetit: Multimodal
Imaging in Choroidal Osteoma

Prathama Sarkar MS, DNB, Amit Mehtani MS, DNB
Department of Ophthalmology, Deen Dayal Upadhyay Hospital, New Delhi, India

Abstract: A 20-year-old female presented with 2 months history of decreased visual acuity and metamorphopsia in the left eye.
Fundus examination showed a well defined orangish red lesion in the macular region. Diagnosis of choroidal osteoma was
established using various imaging modalities. The patient was followed up for 12 months with no treatment in the interim.
The lesion was noted not to have enlarged with improvement in the visual acuity. We report an interesting case where with the
help of multimodal imaging techniques, subretinal fluid was noted in the absence of evident choroidal neovascularisation in a
case of choroidal osteoma.
Keywords: Choroidal osteoma, calcification - decalcification, imaging modalities, spontaneous resolution, Sub-retinal fluid.

Choroidal osteoma was first reported left eye for past 2 months. There was no with central retinal thickness of 397
by Gass et al.1 in 1978 as a benign relevant associated medical or previous microns in left eye (Figure 2c).
choroidal tumor of unknown aetiology ocular history. Swept source OCT (Figure 2d)
characterised by the presence of On general physical examination, there illustrated a typical sponge-like pattern
cancellous bone within the choroid. were no palpable neck swellings, lymph compromised of dense hyper-reflective
It typically presents as a unilateral nodes nor lump in the breast. BCVA in dots spread into a hyporeflective matrix
lesion in 75% of cases and commonly the right eye was 6/6 and 6/12 in the left with shadowing being present.
seen in healthy females in their eye. The anterior segment finding in Early mid frame hyperflourescence
2nd or 3rd decades of life. Its most both the eyes were within normal limit. in posterior pole around macula that
common symptoms are blurred vision, However, a lesion was noted over left progressed till late frame was seen in
metamorphopsia and scotoma. The eye macula on fundus evaluation. fundus flourescein angiography (Figure
clinical appearance of the tumor may Fundus photograph of right eye (Figure 2e).
vary corresponding to the grade of 1a) showed a normal posterior pole. The ICGA (Figure 2f) demonstrated
calcification. In the left eye (Figure 2a) a round, an early central hypoflourescence
Over time, ocular ultrasound (US), irregularly elevated, orangish red at posterior pole around macula.
fluorescein angiography (FAF), optical lesion ~ 4 DD in macular area with well Mid frame showed a stippled
coherence tomography (OCT) and demarcated borders and an irregular hyperflourescence in the lesion which
swept source OCT (SS-OCT) have been geographic outline was seen. Irregular increased till late frames.
widely used for diagnosis and follow-up orange pigment clumps on the surface The ultrasound illustrated densely
of CO. were present along with multiple hyperechoic band at level of choroid
In this case report we intend to bring short branching vessels. Neuro-sensory with posterior acoustic shadowing
forward the various imaging modalities detachment was also noted. (pseudo-optic nerve) which persisted
that help us in diagnosing and managing Fundus autoflourescence (Figure 2b) even on decreasing the gain.
the case of choroidal osteoma. showed hyper- autoflourescent changes Corresponding high intensity spike was
around macula corresponding to the seen in USG A scan.
Case report area of pigmentary clumps. Thus, diagnosis of choroidal osteoma
A 20 year old female presented to the Spectral domain OCT revealed presence with serous retinal detachment
ophthalmology OPD with complains of of SRF, a dome shaped RPE detachment was established using all the above
gradual, painless and progressive loss
of vision with metamorphopsia in the

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Subspeciality-Retina

ab affected eyes will maintain this visual
acuity. Our patient also had presented to
cd us with BCVA in left eye of 6/12 which
ef improved to 6/6 at end of one year.

Figure 1. OD - (a) Fundus photograph: normal posterior pole. (b) FA is normal (c) SD –OCT: Ophthalmoscopic examination usually
normal foveal contour. (d) SS-OCT: normal foveal contour and choroid. (e) FFA: normal reveals a round or oval, irregularly
perfusion of the retina. No leaks till late frame. (f) ICGA: normal flourescence pattern till elevated, rosy to yellow white tumor
late frames. in the choroid. In case of calcification,
it may appear thicker and more orange.
mentioned diagnostic modalities. Discussion However, the areas of decalcification
Patient was followed up for over one Choroidal osteomas are benign appear as thin, atrophic, yellowish-
year without any treatment in the choroidal ossified tumors mostly gray regions within the osteoma.
interim. Lesion was noted to not have found in juxtapapillary area. At initial The presence of multiple short
enlarged with resolution of SRF and a examination, about four of five patients branching vessels on the surface of
stable vision of 6/6. will have visual acuity better than or osteoma is another typical feature that
equal to 6/ 18. However, only one-half of distinguishes osteomas from choroidal
hemangiomas and metastatic tumors.
In some cases associated accumulation
of SRF can also be seen which is due to
concurrent RPE detachment and RPE
dysfunction.

FAF imaging reveals the areas of
lipofuschin accumulation, which may
be a marker for the tumor growth.
Areas of hyper-autoflourescence may
be seen in the region of impending
decalcification with metabolically
stressed RPE.

This sponge-like pattern seen in SS-OCT
is mostly due to spongy bone consisting
of dense bony trabeculae surrounding
marrow spaces with loose connective
tissue and vessels.

Fluorescein angiography reveals early
hyperfluorescence in a mottled pattern,
more commonly in hypopigmented
areas, because of prominence of the
normal choroidal lobular perfusion due
to the vascular supply of the cancellous
bone. In the late phases, there is diffuse
staining corresponding to marrow
spaces occur within the tumor.

ICG can show small feeder blood vessels
on the anterior surface of the tumour
during the early phases. These vessels
may leak. The bony areas of the tumour
show variable blockage of the choroidal
vasculature.

Ultrasonography shows a highly
reflective, irregularly elevated mass
with increased acoustic shadowing

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