EDITORIAL
Dear Colleagues,
This year also the Mansoon has been satisfactory for Delhi, Kirti Singh et. al have provided good review and their re-
similarly Delhi Ophthalmological Society has started this sults, it is really interesting to read this article.
new season with good academic opening DOS Times July
issue and Delhi Journal of Ophthalmology (DJO) has come Epilenticular IOL implantation in traumatic cataracts the
out, I hope most members have received them. In this issue article by B. Ghosh is very informative. This surgical tech-
of DOS Times, we have published articles covering different nique does decrease the chances of visual axis opacity in
especiality ranging from ophthalmoplasty, cornea, glaucoma paediatic age group. It will be interesting to have prospec-
and retina. We hope the members will enjoy reading this tive comparative study with routine anterior route surgery,
issue and apply all practical tips to their day to day practice. as most anterior segment surgeon will be more comfortable
with conventional surgery.
Management pearls for common problems like Acute Angle
Closure Glaucoma, Canalicular injury will definitely be ben- We are fortunate to have the opinion of senior members of
eficial. Effective management of potentially blinding condi- society, Prof. H. K. Tewari , Prof. R.V. Azad & Dr. Cyrus M.
tion like corneal ulcer depend on proper and comprehen- Shroff on CSR. The concept provided by them make the is-
sive investigation the article by Sharma N. et. al covers this sue very clear, I thank Dr. Nikhil Pal for coordinating this
important topic. Newer surgical technique of glaucoma focus on CSR. The entire Editorial board of DOS Times is
drainage implants is in clinical practice for last few decades trying to make DOS Times more informative and useful for
but it has not become very popular mainly because of post all spectrum of members. I request for your contribution to
operative complications and problem associated with them DOS Times publication so that members will benefit from
your experiences.
Dr. Jeewan S. Titiyal
Secretary, DOS
Programme for DOS Monthly Clinical Meeting for August 2004
Venue: Auditorium, Sir Ganga Ram Hospital, Rajendra Nagar, New Delhi
Date & Time : 29th August, 2004 (Sunday) at 10.00 A.M.
Case Presentation
1. Choroidal Osteoma ........................................................................................ Dr. Deepti Manocha 10 Min
2. Neovascular Glaucoma with Cataract with bound down pupil ................. Dr. Piyush Kapoor 10 Min
Clinical Talk
• Diabetic Retinopathy – What is the Indian scenario ? ............................... Prof. H.K. Tewari 20 Min
Mini Symposium: What am I doing differently in 2004 ?
Chairman: Dr. A.K. Grover
1. Cataract with pre-existing astigmatism : How do I manage it ? .............. Dr. Harbans Lal, 10 Min
Dr. Anita Sethi
10 Min
2. Nucleus emulsification – Minimizing energy use : 10 Min
Direct chop with burs mode ......................................................................... Dr. A.K. Grover 10 Min
10 Min
3. Ocular motility disorders associated with congenital ptosis ...................... Dr. Zia Chaudhuri 10 Min
4. Jaw winking plosis : Striving for perfection ................................................ Dr. A.K. Grover
5. Sunk nucleus and IOL : An innovative approach ....................................... Dr. S.N. Jha
6. Management of SRNVM : What is new ? ................................................... Dr. Amit Khosla
Panel Discussions : 60 min + Host Faculty
Ophthalmology in 2010
Guest Faculty : Prof. Vimla Menon • Prof. J.C. Das • Dr. Ajay Dave
August, 2004 39 DOS Times - Vol.10, No.2
MANAGEMENT PEARLS
Acute Angle Closure Glaucoma
Viney Gupta MD, Deven Tuli MS,
Primary Acute ACG is a sudden rise of IOP in an eye with Neovascular Glaucoma: New vessels are generally evident and
occludable angles associated with pain in eye, headache and anterior chamber is not shallow as in an acute angle closure
sensation of vomiting. The occludable angle may occur due to a attack.
relative papillary block, or a thick lens or a plateau iris.
Glaucomatocyclitic Crisis: Although there is a mild inflammation
Precipitating factors : Emotional stress, near work in dim lit the angles remain open and anterior chamber is of normal depth
conditions, watching a movie in a dark theater, acute in both eyes.
hyperglycemia, pharmacological dilation, general anesthesia, and
rarely ciliary body tumors/cysts, trauma, uveal melanoma and Acute anterior uveitis: The IOP is proportional to the anterior
secondaries to the eye, can precipitate an acute angle closure chamber reaction in uveitis while in primary angle closure attack
attack. the inflammation is minimal compared to the elevation of IOP.
The anterior chamber is normal depth and pupil is constricted in
Drug induced angle closure glaucoma : Drugs like tropiamate comparison to acute angle closure attack.
(antiepileptic) and paroxetine (antidepressant) can induce bilateral
angle closure attacks probably due to cilio retinal effusion. Management :
Symptoms : Blurred vision with haloes around lights, severe Lowering the IOP is the first priority. This allows cornea to clear
pain in eyes with redness and frontal headache on the affected and allows definitive treatments to be undertaken. The drugs of
side, nausea vomiting and rarely palpitations with abdominal choice are hyper osmotic agents. Mannitol is used as 20%
cramps. In some patients the attack may be associated with solution. It acts over ½ - 1hour (5-7 ml/kg body wt) The two
minimal pain and no congestion. mechanisms by which it works are, the central actions via
osmoreceptors in the brain and the local actions of shrinking the
Signs : Elevated IOP > 45mmHg, corneal edema, shallow or flat vitreous and pulling back the iris – lens diaphragm. The
anterior chamber, circum ciliary congestion, pupil is mid dilated alternative agents, which can also be used in conjunction to
with reduced or no reactivity. Fundus shows disc edema, with mannitol, are syrup glycerol used as 50% solution. Lime juice is
venous congestion and splinter hemorrhages or it may be a normal added to make it palatable. Where available intravenous
disc or may show glaucomatous excavation. There may be some acetazolamide should be considered. Oral acetazolomide 500 mg
inflammation and rarely a hypopyon if the attack is long standing. is given followed by three times a day. It is routinely used for
lowering of IOP with hyperosmotics. As cornea gets clearer the
Signs suggestive of an earlier ACG attack : Patchy iris atrophy systemic therapy should be followed up with frequent pilocarpine
with spiraling of iris contour, presence of posterior synechiae. A drop installation. This breaks the pupillary block by producing
vertically oval pupil is seen due to sphincter ischemia “ miosis. Use of pilocarpine prior to hyperosmotics does not work
Glaukomflecken” on the anterior lens surface are seen. Peripheral because of poor intraocular penetration and the sphincter pupillae
anterior synechiae present on gonioscopy and decreased being unresponsive due to high IOP. Corneal edema could be
endothelial count on specular microscopy. A CRVO may occur relieved by using hypertonic saline drops or glycerin eye drops.
as a result of an acute attack. Special Maneuvers : In case the conventional management stated
above does not work, one should consider special techniques.
Differential diagnosis :
Compression gonioscopy – possible with Zeiss 4 mirror
Phacomorphic glaucoma : Generally the cataractous gonioscope. Displaces the aqueous from the central anterior
lens is thickened and examination of the other eye chamber to peripheral chamber. This may break the pupillary block
reveals an open angle. But if the angle is shallow in the and allow an iridotomy to be carried out. An alternative is to
other eye it is wise to do a prophylactic iridotomy in indent the central cornea with cotton tipped applicator that works
both eyes after IOP control. similarly.
Glaucoma Services, Argon laser iridoplasty – works by contracting iris tissue and
R.P. Centre for Ophthalmic Sciences may help break pupillary block. Iridoplasty could be considered
AIIMS, New Delhi as a replacement for iridotomy in cases with persistent corneal
edema, nanophthalmos, ciliary body effusion or post RD surgery.
August, 2004 40 DOS Times - Vol.10, No.2
Definitive Management : Alternatively in such cases when the attack cannot be broken
medically and iridotomy is not possible due to corneal edema it
Iridotomy – should be under taken in all cases. Even if synechiae is suggested to perform a surgical iridectomy and then patient
are present, it helps relieve appositional closure of the angle. It is should be observed on medical therapy , if required filtering
curative if the cumulative extent of synechiae is less than 180-270 surgery can be performed a few weeks later when the eye is less
degrees. Nd: YAG is the laser of choice, though it is advantageous inflamed.
to work with argon and Nd: YAG laser in tandem; initial spots
with argon prime out or “soften” the edematous iris adequately Suggested Reading :
and Nd: YAG is used to disrupt the remaining layers of the iris.
After a successful laser iridotomy for an acute attack, one must 1. Tello C, Rothman R, Ishikawa H, Ritch R. Differential
dilate pupil and repeat IOP and an indentation gonioscopy Diagnosis of the Angle – Closure Glaucoma Ophthal-
mology Clinics of North America. 2000.13.443.
It is mandatory to do a prophylactic iridotomy in the fellow eye
as well. There is a high chance of an acute attack in the fellow eye 2. Sihota R, Lakshmaiah NC, Agarwal HC, Pandey RM,
due to anxiety induced sympathetic stimulation. Tityal JS, Ocular Parameters in the subgroups of angle
closure glaucoma. Clinical and Experimental Ophthal-
O mology 2000.28.129-134
Trabeculectomy – Presence of synechiae greater than 270 3. Kim YY, Jung HR. Classifying the Nomenclature for
circumference of the angle will normally require Trabeculectomy Primary angle closure Glaucoma. Survey of Ophthal-
for optimum IOP control. Trabeculectomy can be tried in medically mology 1997.42-125
unresponsive acute attacks however the success rates are low
due to surgery being done in an inflamed “ hot eye” .
AAcuctue tAeCAGCatGtackAttack
Oral / I/V hyperosmotics, topical steroids, beta blockers, Pilocarpine 2%
Corneal indentation using Zeiss type gonioprism.
Analgesics
If severe vomiting (I/V Metoclopromide)
Attack broken Attack not
Constrict Pupil broken
Schedule Nd:
YAG PI in both Clear cornea Cloudy Cornea
eyes if not already Nd: YAG PI
performed Use glycerin eye
drops
August, 2004
Trial of laser
iridoplasty
Attack not broken
Trabeculectomy ↓ I/V
mannitol
41 DOS Times - Vol.10, No.2
CURRENT PRACTICE
Glaucoma Drainage Implants
Kirti Singh, MD, DNB, FRCS., Rekha Yadav, MD., J.C. Das, MD
Glaucoma drainage devices are implanted into glaucoma fil- this upper limit only sacrifices area and adds to motility problems.
tering fistula’s in order to establish a permanently patent filtering The posterior location of the plate helps to bypass the scarred
tract. Earlier they were called as Seton’s since these devices ini- limbal area.
tially were foreign solid structures, such as threads, wires or hairs.
Now the term tube shunt implants is used since the structure Types of implants :
consists of an open tube in the anterior chamber attached to an
explant/ plate located outside the chamber. The plate is made of 1. Non-valved / non restrictive implants
PMMA/polypropylene/silcone rubber and tube of silicone rub- - Molteno, Baerveldt, Schocket.
ber (Fig 1). Fibroblasts do not adhere to these biologically inert
materials thereby a permanent conduit of aqueous is established, 2. Valved / restrictive implants
from anterior chamber to an area away from the surgical site (ex- - Ahmed , Krupin , Joseph, Optimed, White.
ternal reservoir), where the effect of surgical inflammation is neg-
ligible, thereby scarring is minimized. Indications:
History : These devices are basically indicated in situations with ex-
tensive conjunctival scarring , multiple failed trabeculectomy’s
The first attempt to implant a drainage device was made by including those with the use of antifibrotics, or where occlusion
Rollet and Moreau in 1907 when they performed a double para- of the sclerostomy site by inner tissue is extremely likely to occur.
centesis and used horse hair through the corneal punctures to
treat patients with painful absolute glaucoma. Molteno in 1969 • Previously failed filtration procedures in acquired or con-
scientifically explained the pathophysiology of bleb resistance, genital glaucoma
and designed a functioning implant with an episcleral plate and
tube. His pioneering work on modulation of bleb inflammation, by • Neovascular glaucoma.
an anti-inflammatory regimen of corticosteroids, fluphenamic acid • Silicone-oil glaucoma.
and colchicines, to ensure long term implant patency coupled • Aphakic / Pseudophakic glaucoma.
with the astounding results of his implant revolutionized this so • Complicated glaucomas- eg. Aniridia/ICE/ Uveitis
far experimental and anecdotal surgery. His implant has stood the • Traumatized eyes with conjunctival scarring
test of time and became a prototype for all future implants. He can • Dryness which precludes standard glaucoma surgery .
rightly be called the “Father of glaucoma drainage implants.”
Surgical Technique:
Implant functioning:
All devices are primed with balanced salt solution to check
The basic design of all modern devices consists of a plastic it’s patency before insertion. In case of non-valved implant the
tube that extends from the anterior chamber to a plate, disc or glaucoma drainage device is disabled before insertion to prevent
encircling band beneath conjunctiva and Tenon’s capsule, called an excessive early IOP drop. This can be done by ligating it by an
the explant which is connected to the tube which enters the ante- absorbable or a prolene suture, called as the Latina suture (Fig
rior chamber. The tube design is favoured because it bypasses 2). A fornix-based conjunctival flap with radial relaxing incisions/
peripheral synechiae, limbal scarring as well as keeps the scleros- limbal based flap is made. The plate part of the glaucoma drainage
tomy patent. The posterior explant stimulates fibro- vascular en- device is inserted beneath the Tenon’s capsule preferably in the
capsulation and allows aqueous to passively flow across a pres- supero-temporal followed by the supero-medial quadrant if the
sure gradient, across the capsule wall to be subsequently ab- former area is scarred (Fig 3).
sorbed by conjunctival capillaries and lymphatics. Except for ini-
tial transient leak of aqueous around the tube’s insertion, the Inferior quadrant placement is usually avoided. The anterior
main mode of aqueous transport is via the tube only. The inflam- edge of the implant should be at least 8 mm away from the limbus.
matory reaction initiates a hypertensive phase lasting for weeks, Nonabsorbable- 8-0 or 10-0 nylon sutures are used to anchor the
before a stable sate of IOP is reached. implant plate to the sclera through the fixation holes (Fig 4). The
tubing length is then assessed by laying the tube across the
The devices differ according to the size and shape of the cornea till its beveled end just enters 2-3 mm inside the anterior
external component and the materials from which they are made. chamber. A 5x 8 mm partial thickness limbal based scleral flap is
Up to a certain upper limit the extent of aqueous drainage is pro- dissected so as to cover the proximal 5mm of tube as it exits the
portional to the surface area of the explant. Increasing it beyond anterior chamber. Anterior chamber is entered beneath the scleral
flap, using a 23/24 gauge needle, to ensure a snug fit to the tube
Guru Nanak Eye Centre, (Fig 5). The tube is then cut, the proximal end beveled, and placed
Maulana Azad Medical College, New Delhi. in the anterior chamber through the 23 gauge needle paracente-
sis. The tube is secured to the sclera with a two to three 9-0/10-0
nylon sutures. The anterior most suture is tied in a cross to mini-
August, 2004 42 DOS Times - Vol.10, No.2
Fig. 1: Functioning Tube Fig. 2 : Baerveldt implant with Latina suture Fig. 3 : Ahmed implant being inserted in
superotemporal quadrant
mize movements of the tube (Fig 6). The scleral flap is approxi- ing or even removing the tube. Cause is excessive flow of
mated and the conjunctiva - Tenon’s capsule flap is sutured. A aqueous through the tube, rarely leakage around the tube
separate paracentesis is made in a separate quadrant through arising from too large an entry incision .
which anterior chamber is formed at the end of surgery and maybe
later on if needed. 2) Hyphema- transient and usually resolves, in cases of
neovascular glaucoma it may be massive enough to cause
Modification of basic technique IOP rise and tube blockage. The latter maybe prevented by
anterior retinal cryopexy in NVG cases prior to surgery.
1) To avoid erosion through sclera and conjunctival flaps at
limbus, a rectangle of preserved donor sclera/ fascia lata / 3) Corneal endothelial touch – usually seen when the tube has
dura of approximately 5x7mm over the tube at the limbus can not been placed accurately or the bevel has not been cut in
be used, if the patient’s own sclera is thin. the proximal orifice. The other reason for this complication is
shallow anterior chamber. This maybe exacerbated by blink-
2) In non valved implants - a two-stage approach is used in ing or eye rubbing.
which the shunt is placed in the conjunctival space in the
first. After 4-6 weeks when the fibrous capsule has devel- 4) Elevated IOP : Early post operative IOP elevation may be
oped, the tube is inserted into the anterior chamber in the due to obstruction of tube by fibrin, blood, iris tissue, or
second stage. The formed capsule forms a bleb which limits vitreous. This occurs in 5-11% of cases (Fig. 9). Laser tube
excessive aqueous outflow. The interim period between the revision by Nd:YAG/ Nd:YLF is on temporary benefit. but
two stages is tided over by a trabeculectomy which invari- still this non invasive procedure should be attempted first.
ably fails by the time of second stage. Intracameral injection of tissue plasminogen activator is an
expensive option, but may work. The ultimate solution is
3) Temporary occlusion of the tube with an absorbable vicryl tube revision. Late IOP elevation, is usually due to an exces-
suture 6 0/8 0, or a nylon Latina suture (10- 0) must be done sively thick fibrous capsule. This can be dealt by removing a
in non valved implants to prevent post-op hypotony. The portion of the capsule beneath the conjunctival flap.
vicryl absorbs after the first month, but the nylon one has to
pulled out through a preplaced tract in the inferior conjunc- Late complications – occurring within weeks or monthS :
tiva (Fig 7).
1. Increased IOP- cause may be tube blockage, non function-
4) The tube maybe inserted through a pars plana incision into ing bleb, resurgence of disease eg uveitis, rubeosis, fibrous
the vitreous cavity in aphakic eyes, in which a vitrectomy ingrowth.
has been performed, in eyes with very shallow anterior cham-
ber or sometimes in corneal graft eyes (Fig 8). 2. Endothelial touch - intermittent or constant leads to endot-
helial decompensation. If progressive tube repositioning and
5) Scleral tunnel for implantation of devices involves creation of tight anchorage maybe indicated.
a scleral tunnel beginning 10 mm behind the limbus and ex-
tending to the anterior chamber. 3. Tube exposure/ migration/ extrusion - Tube exposure inci-
dence varies from 0- 15% (Fig 10). To prevent it prophylactic
Post operative care includes use of topi- use of donor sclera to cover it in areas of scleral thinning,
cal steroids, antibiotics, cycloplegics and
sometimes systemic steroids.
Complications :
These can be divided into early and late
complications.
Early- occurring within few days-
1) Hypotony / choroidal detachment: Can Tube lying outside
be prevented by temporarily obstructing Fig. 5 : Entry with 23 gauge needle
the tube lumen. Manage by reforming an-
terior chamber via the paracentesis, ligat-
Fig. 4: Ahmed implant secured to sclera
August, 2004 43 DOS Times - Vol.10, No.2
Fig. 6: Anchor tube to sclera Fig. 8 : Tube shunt through Pars plana area Fig. 7 : Latina suture – 10-0 nylon
with cross suture – 10–0 Nylon in first stage
adequate anchorage to scleral bed by sutures, the superficial antifibrotic use must be attempted before utilizing drainage im-
flap must be evenly dissected. Treatment of this complica- plant surgery. On the other hand we must not hesitate to use this
tion may be initially by rotating an adjacent partial; thickness valuable option for fear of loosing the eye by causing complica-
flap to cover the tube but ultimately a fresh site needs to be tions and thereby land up in loosing the eye to the glaucomatous
selected. Tube migration is usually due to slippage of an- process.
choring sutures.
Practical pearls to practice in Glaucoma drainage device
4. Insufficient aqueous absorption inspite of patent tube - thick- implantation:
ened fibrous capsule over the distal end of the tube or less
surface area of drainage. Persisting inflammation is a com- • Stab incisons- careful placement and of adequate length so
mon culprit and a stringent antifibrotic regimen consisting of as to provide a snug fit, made with the help of a 23 gauge
steroids and non steroidal anti inflammatory needle.
5. Others - Cataract progression in almost 36%/ • Obliquely beveled tube tip- anterior obliquity, pointed end
Endophthalmitis/ Retinal detachment. makes tube insertion easier, larger surface area facing away
from the iris, laser revision, if required, is easier.
6. Ocular Motility Disturbance : Exotropia, hypertropia, or limi-
tation of ocular rotation, usually occurs with larger, plates • Correct alignment of the tube with adequately tight anchor-
eg; Baerveldt and Krupin implant but can also occur with ing sutures .
smaller plates. This is usually due to bulk effects or from
direct impingement on or scarring of the rectus/ oblique • Longer tube length the lesser of an evil to a short tube.
muscles. Diplopia occurring commonly with Baerveldt’s im-
plants led to the discontinuation of 500 mm sq. explant and • Prevent flat chamber – valved tubes, two staged procedure.
its redesigning with fenestrations to allow fibrous ingrowth, Insert tube after filling chamber with viscoelastic from para-
thereby reducing the bleb height. Placing the implant in the centesis side port.
spacious supero-temporal quadrant minimizes this complica-
tion • If aphakic- preventive core vitrectomy to prevent vitreous
blocking the tube at a later date.
7. Loss of visual acuity : Occurs due to hypotonous
maculopathy, retinal detachment, vitreous hemorrhage and Suggested Readings :
cystoid macular edema.
1. Rosenberg LF, Krupin T. Implants in Glaucoma Surgery in
8. Epithelial down growth- in fornix based conjunctival flaps The Glaucomas- 2nd edition by Ritch R, Shjields MB, Krupin
careful closure of conjunctiva keeping the epithelium facing T. Mosby 1996.
away from the tubes is advocated. This complication is mini-
mized by limbal based flaps. 2. Sherwod MB. Complications of Silicone tube drainage de-
vices in Complications of glaucoma therapy by Sherwood
The use of glaucoma drainage implants should be reserved MB, Spaeth GL, Slack 1990, New Jersey.
for refractory glaucomas. Glaucoma filtering surgery and
3. Zorab A: The reduction of tension in chronic glaucoma. Oph-
thalmoscope 10:258,1912
4. Molteno ACB. New implant for glaucoma clinical trial. Br J
Ophthalmol 1969, 32: 69.
5. Minckler DS. Perspectives on Glau-
coma drainage implants. New Devel-
opments in glaucoma, Ophthalmol-
ogy Clinics of North America. 1995,
8(2): 383- 393.
6. Singh Kirti et al. Evaluation of Nd:Yag
laser membranectomy in blocked
tubes after glaucoma tube shunt sur-
gery. Am J Ophthalmol 1997; 124 (6) :
781-86.
Fig. 9 : Blocked tube Fig. 10 : Erosion of conjunctiva
August, 2004 44 DOS Times - Vol.10, No.2
FOCUS
Central Serous Chorioretinopathy
the sympathetic-parasympathetic drive that maintains auto-
regulation within the choroidal vasculature may be defective
in patients with CSR.
RVA: CSR is a disease characterized by accumulation of trans-
parent fluid at the posterior pole of the fundus causing a
circumscribed area of detachment of the neurosensory retina,
Dr. H.K. Tewari Dr. R.V. Azad Dr. C.M. Shroff usually involving the macula. The exact etiological factor in
CSR is not clearly identified and has aroused much specula-
Central Serous Chorioretinopathy(CSR) is a maculopathy tion. Although the precise pathophysiologic event leading
characterized by episodes of serous detachment of the neurosen- to macular detachment in CSC is not known, most ophthal-
sory retina and retinal pigment epithelium, typically affecting mologists today believe that the pathology begins with a
healthy young adults. The knowledge of the etiology, natural nonspecific disturbance of the choroidal circulation. Alter-
history, clinical manifestations and treatment of this maculopathy ation in the exudative state of the choroid may lead to serous
have continuously evolved. detachment of the RPE and a mechanical disruption of this
tissue layer, possibly a small opening or a “blow out” of RPE,
Dr Nikhil Pal (NP), Senior Resident from Vitreoretina Ser- leading to the characteristic fluorescein leak. This sequence
vices at R.P. Centre for Ophthalmic Sciences, AIIMS, New Delhi, of events is believed to produce detachment of the neuro-
asked Prof. Hem Kumar Tewari (HKT), Senior Honorary Con- sensory retina and a myriad of secondary RPE and choroidal
sultant, Sir Ganga Ram Hospital, New Delhi, Formerly Prof. & manifestations. Multifocal areas of exudative change in the
Chief, R.P. Centre, AIIMS, New Delhi ; Prof. Raj Vardhan Azad inner choroid seem to be the hallmark or precursor of subse-
(RVA), Professor in Vitreoretina Unit at R.P. Centre, AIIMS, New quent clinical events. Earlier pathophysiologic mechanisms
Delhi and Dr Cyrus M Shroff (CMS), Consultant Vitreoretina & considered include focal RPE dysfunction (Spitnaz), diffuse
Medical Director at Shroff Eye Centre, Kailash Colony, New RPE dysfunction(Marmor) and multifactorial causes
Delhi for their views on different aspects of this disease. Their (Yannuzzi).
replies are given in the text. CMS: It appears that the primary abnormality in CSCR is
1. Is CSR disappearing? diffuse dysfunction of the choroid and RPE which creates a
HKT: Although we have no prevalence studies, the disease pressure head for fluid leakage and an opportunity for breaks
is certainly not on the decrease. to appear in the retinal pigment epithelial barrier. Simulta-
RVA: No, with continued stress in day today life in every neously it also weakens retinal adhesiveness to the RPE and
sphere, CSR is infact increasing. It mainly affects patients in impairs outward transport of fluid. The typical CSR leak may
the age group 20-45 years, especially in males mostly healthy be an epiphenomenon that occurs because a few RPE cells
having Type A personality with psychological stress. CSR decompensate over a region of blocked/inflamed choroidal
will continue to affect till these risk factors continue to exist capillaries. Besides Fundus fluorescein angiography has
in the modern world. often shown multifocal areas of RPE damage. ICG – A has
CMS: No CSR is certainly not disappearing. In fact give the consistently shown choroidal vascular abnormalities that
fact that there is an increasing recognition of the correlation extend well beyond the focal site of leakage.
of CSCR with exposure to increased levels of endogonous or 3. What is the role of stress and endogenous steroid in CSR?
exogeous glucocorticoids, the incidence of this condition is
likely to increase. HKT: Stress is considered to be a strong risk factor for the
2. What is the current thinking about pathogenesis of CSR? development of CSR. It probably acts by transiently disturb-
ing the above mentioned autoregulation. Studies at our cen-
HKT: An increase in choroidal hyperpermeability causes a tre have shown elevated serum and urinary cortisol levels in
breach in the outer blood retinal barrier. Leakage of fluid across
this area(s) results patients with CSR,
in development of hence defining the role
localized serous played by steroids in
retinal detachment. the pathogenesis of
What triggers the CSR. It is also not un-
choroidal hyper- common to find pa-
permeability is tients on systemic cor-
poorly understood ticosteroids developing
but we have found CSR.
evidence that an
imbalance between
August, 2004 45 DOS Times - Vol.10, No.2
RVA : Psychologic stress is known to produce hypotha- are no retinal hemorrhages or exudates. Some patients may
lamic-pituitary-adrenal axis abnormalities such as endogenous develop fibrin formation; these lesions appear more yellow
cortisol excess, a finding known to develop in some patients and can be mistaken for active choroiditis. In later phases
with CSCR. Use of antibiotics, antihistamines, multi-system there may be yellow deposits in the involved area and some
autoimmune diseases, untreated hypertension, alcohol use, retinal pigment epithelial changes.
and tobacco use have been identified as risk factors for CSR.
The precise mechanisms by which these various risk factors Several forms of CSR have been described (types1-3),
associated with psychologic stress contribute to the patho- unifocal/ multifocal and, typical/ atypical.
genesis of CSCR cannot be determined. Some of the reported
associations could result from psychologic, neuroimmuno- RVA: Patients usually notice a minor blurring of vision but
logic, neuroendocrine, or biochemical adaptations to stress. sometimes significant detioration in vision can occur. Visual
Exogenous steroids and pregnancy could contribute to CSCR acuity in acute stage usually averages 6/12 but may range
development by similar neuroendocrine mechanisms. from 6/6 to 6/60.It may be associated with micropsia, chro-
matopsia, central scotoma, increasing hyperopia, generalized
CMS: Adrenergic stress can act upon either the choroidal darkening of visual field and increased recovery time after
vasculature or the RPE directly through known 1 & b adren- exposure to bright light. CSR has been classified into follow-
ergic receptors. Therefore the association of CSR with Type ing types histologically (Spitnaz classification)
A personality. Japanese studies have shown that systemic
administration of adrenaline (with or without cortico-steroids) Type I – Detachment of sensory retina
led to the appearance of multifocal serous exudation in
animals.CSCR is associated with different conditions with Type II- RPE detachment
increased levels of exogenous or endogenous steroids.
Cushing’s syndrome, type A behaviour, stressful events, Type III- Intermediate type- both sensory retina and RPE are
pregnancy, systemic administration of cortico-steroids. elevated
4. Is TB still in the list of etiology of CSR? Clinically, CSR is classified into Typical and Atypical CSR.
Typical CSR includes cases with 1) BCVA 6/60 or better 2)
HKT: Our earlier studies did indicate that atypical CSR pa- Macular detachment <3 DD 3) Pinpoint inkblot or smockstack
tients might have a tubercular etiology as a significant num- leakage on FFA. 4) Spontaneous resolution
ber of them responded to anti-tubercular therapy. We have
also been able to induce CSR like picture in rhesus monkey Atypical CSR is characterized by 1) Profound loss of vision,
eyes by injecting live bacilli into the suprachoroidal space at BCVA < 6/60 2)Large area of macular detachment(>3 DD)
the macular area. The etiological agent is still being debated 3)Irregular, double or multiple leakage on FFA with large col-
and it is difficult to ascertain any direct relationship until one lection of serous fluid 4) Non-resolution spontaneously
is able to fulfill Virchow’s criteria- which in retinal diseases is
that much more difficult. Interestingly, in the patients who CMS: Typical CSR presents as a unilateral central scotoma in
responded to antitubercular therapy, all TB related investiga- a young man in his thirties or forties. Examination with indi-
tions were comparable with the controls (CXR, Mantoux and rect ophthalmoscopy or slit lamp biomicroscopy shows a
ESR). As laser has proven efficacy currently, the etiological circumscribed circular or oval area of neurosensory detach-
debate is unlikely to initiate a re-think on the therapeutic ment at the posterior pole with or without one or more pig-
approach. ment epithelial detachments. In most cases this would re-
solve spontaneously over 8-12 weeks leaving some derange-
ment of contrast sensitivity, micropsia or macropsia.
RVA: Clinical evidence show that Classical/Typical CSR does In some cases CSR may present with slow deterioration of
not have a tubercular aetiology. Therapeutic evidence sug- central vision. These are visually the chronic cases with
gests that most of these resolve spontaneously and do not ‘sick RPE’. Still others may present with more acute loss of
respond to Anti-Tubercular therapy.Laboratory evidence also vision – usually the type II CSR of which some may be of
does not favour a tubercular aetiology. Tubercular aetilogy Tuberculous etiology.
on the other hand may play a role in the cases of Atypical 6. What are the investigative modalities in CSR in order of
CSR. importance and essentiality?
CMS: Yes TB is very much in the list of etiology of ‘atypical HKT: The first essential is to clinically rule out possibilities
CSR” as enumerated many decades ago by Dr. B. Patnaik and of optic disc pit, shallow rhegmatogenous retinal detach-
re-iterated by Dr. Donald Gass. ment (particularly, inferior and related to retinal dialysis),
Harada disease and concurrent choroidal neovascular mem-
5. What is the clinical presentation and types of CSR? brane. Having done this, no investigations are needed if it
the first attack and has been there only for less than 3 months.
HKT: Most patients are males and present in the 2nd-4th de- If indications to laser are present or the clinical features are
cade. Most cases are unilateral. The initial complaints are of atypical, fluorescein angiography would be necessary. ICG
a positive central scotoma, mild blurring of vision or microp- and OCT add no additional value to the treatment consider-
sia. On examination, there a localized, well circumscribed, trans- ations; they should be undertaken merely as academic/ study
lucent blister in the macular area. Some patients may have tools.
associated retinal pigment epithelial detachment(s). There
August, 2004 46 DOS Times - Vol.10, No.2
RVA: i) Slit lamp biomicroscopy(90 D/78 D) on the indications and side effects of laser. The usual indica-
tion is persistence of the detachment/ angiographic leak be-
ii) Indirect ophthalmoscopy yond 3-4 months. Patients who may benefit from early laser
are those in whom the disease had become chronic in the
iii) FFA- single or multiple leaks, ink blot (80%) or smoke- fellow eye, those with multifocal leaks and those who are
stack progression very disturbed occupationally by the central scotoma. It is
important to emphasize that leaks less than 300-500 microns
Generally, these 3 are enough but sometimes OCT may help from the foveal avascular zone must not be treated early. The
in looking for resolution when FFA is not able to guide. Role patient should be asked to provide an informed consent with
of performing ICG remains questionable though it may con- the knowledge that laser is not likely to decrease the risk of
firm multiple choroidal vascular hyperpermeability recurrences and may prevent better recovery of contrast sen-
sitivity.
CMS: i) Slit lamp Biomicroscopy with 78 D lens or a contact
lens RVA: In Typical CSR, Nontreatment is a effective manage-
ment modality since the visual prognosis is very good, the
ii) Fundus fluorescein angiography average spontaneous resolution time being 3 months.
iii) Optical coherence tomography (OCT) Laser photocoagulation has specific indications, only has-
tens visual recovery and may effect contrast sensitivity. In-
iv) Indocyanine Green Angiography dications are a) Bilateral CSR b) chronic CSR duration of
attack more than 3 months c) recurrence in same eye d)
7. What is the role of RPED in development of CSR? fellow eye has severe visual impairment because of CSR ear-
lier e) patients occupation demands early resolution of symp-
HKT:A direct relation does not seem to exist, as many pa- toms or CSR severely interfere with patients job. Usually,
tients with CSR have no concurrent RPED, while several with Double frequency nd-Yag /Argon green laser is used to seal
RPED alone do not develop into CSR. An observation is that the defect in RPE and stop the transfer of fluid from choroid
patients with RPED generally tend to take longer to resolve. to neurosensory retina. This leads to activation of RPE pump
Moreover, RPED should not be lasered as this could precipi- which soon clears serous detachment of fluid.
tate development of choroidal neovascularization.
Acetazolamide - We conducted a study at our centre and
RVA: A small detachment of the RPE is frequently detectable found that it does enhance the absorption of subretinal fluid,
within the area of the serous retinal elevation. Usually, the but role as a therapeutic modality is not definite. Moreover,
RPE detachment is small and appears as a grayish or yellow- side effects of Acetazolamide limit its long-term use.
ish, well-circumscribed elevation at the level of the RPE. Many
times, the RPE detachment may be outside the area of appar- Antitubercular drugs- Non-classical multifocal CSR has been
ent sensory retinal detachment or several RPE detachments treated with INH-300mg and PAS 12g/d for 6 months and
may be detectable. Occasionally, an RPE detachment without shown equivocal results.
an overlying serous retinal detachment will be observed.
Rarely, the area of the RPE detachment may be obscured by a Role of anti-stress medication- There is no proven study so
whitish fibrinous subretinal exudate overlying its surface. far which has indicated the use of tranquilizers. Small dose of
Atenolol have been tried but without any advantage.
CMS: Most serous detachments are preceeded by a small
focal RPE detachment at the site of leakage. This is relevant NSAIDs – Have no role to play
to the manner in which pathologically elevated choroidal pres-
sure initially affects overlying RPE. PDT- It is reserved for treating chronic CSR induced CNVM
according to the
8. What are the entities under atypical CSR
parameters outlined by the TAP Study seems effective. Fur-
RVA: Nonclassical CSR is defined as CSR with central de- ther studies are needed to verify treatment safety and the
tachment (>3 DD) with areas of pigment epithelial detach- time and rate of recurrences.
ment, marked visual detioration and showing big, irregular ,
circular, double or multiple leks on FFA which are resistant to CMS: Without going into the details of each, this may be
natural resolution. The differential diagnosis include i) macu- summarized as
lar edema ii) subretinal neovascularization iii) choroidal he-
mangioma iv) Harada disease v)choroidal melanoma vi)inferior (a) Observation. Supportive therapy – to cut down stress.
quadrant retinal detachment involving macula
(b) If CSCR is precipitated by use of cortico-steroids for
CMS: Atypical/unusual form with distinctive characteristics another condition, try to substitute steroids with an-
are:- other therapy if possible.
(i) Chronic CSCR or diffuse retinal pigment epitheliopathy (c) When tuberculosis is strongly suspected as an etiology
– ATT.
(ii) Acute bullous retinal detachment
(d) Laser Photocoagulation – Focal to RPE leak if spontane-
(iii) Serous detachment with exudative deposits and ous resolution has not occurred in 2-3 months or if early
subretinal fibrosis. resolution is necessary. This is provided the leak is not
juxta or subfoveal.
9. What is the management of CSR?
(e) PDT or ICG enhanced diode laser for subfoveal leaks
HKT: Stop steroids if the patient has developed CSR while and variants like chronic CSR with diffuse areas of RPE
on steroids or if it has been prescribed elsewhere with a mis- leak on FA/ICG.
taken initial diagnosis. Reassure the patient about its rela-
tively innocuous nature in most cases and also to work on DOS Times - Vol.10, No.2
decreasing any stress he/she is under. Educate the patient
August, 2004 47
MANAGEMENT PEARLS
How to Investigate a Case of Corneal Ulcer
Namrata Sharma, MD, Tushar Agarwal, MD,
Rajesh Sinha, MD, FRCS, Rasik B Vajpayee, MS, FRCSEd
Corneal ulcer is an ocular emergency and if not managed Transport of sample
properly in time, can lead to serious sight threatening complica-
tions. Empirical treatment with broad spectrum antibiotic has to The single scraping sample obtained may either be trans-
be started immediately after thorough clinical evaluation and after ported in a liquid transport culture medium (indirect method) or
procuring the samples for microbiological evaluation. One should inoculation of the multiple scrapes may be done directly onto the
not wait for the results of the investigations; however, these mi- agar plates.
crobiological investigations help in making accurate etiological
diagnosis and in modification of therapy in presence of non-im- Corneal Scraping
provement with the initial treatment.
Corneal scraping is performed under topical anesthesia. The
Collection and Transport of Samples anesthetic agent which is preferred is 0.5% Proparacaine, as it is
least bacteriostatic as compared to other anesthetic agents such
Time of sample collection as tetracaine and xylocaine.
Whenever a patient presents to you, samples should be col- General anesthesia and sedation may be required in children,
lected, unless there are definite signs of healing. Emperical treat- uncooperative adults or mentally impaired patients.
ment can be started with broad spectrum antibiotics or it can be
initiated based on the results of smear examination and if re- A lid speculum may be applied gently to separate the lids
quired, modified in accordance with the culture and sensitivity taking care not to cause undue pressure on the eyeball. The pa-
results. tient is seated in front of a slit lamp. A more convenient and better
option is performing the procedure under an operating micro-
Types of samples scope. Any mucous or debris on and around the ulcer is carefully
cleaned with a sterile swab stick. Then, using a Kimura Spatula or
1. Eyelid, Corneal and conjunctival Swabs a bard Parker Knife, the leading edges and base of the ulcer are
2. Corneal scrapings scraped. Multiple scrapings must be obtained to enhance the
3. Corneal biopsy yield of the organisms. One should be careful not to touch the
4. Anterior chamber (AC) tap eyelids or the lashes while collecting the sample to avoid con-
tamination. More recently, calcium alginate swabs moistened with
The most valuable sample for microbiological examination is trypticase soy broth provides another method of collecting cor-
the corneal scraping. The samples should also be obtained from neal specimens.
the contact lenses, contact lens case and contact lens solutions if
the patient gives prior history of use of contact lenses. Difficulties in sampling
Sample collection gadgets There may be various situations where it may be difficult to ob-
tain the samples for corneal scraping. These include the follow-
The various sample collection gadgets, which are available ing:
and can be used are the platinum spatula, 26-gauge needle, Bard
Parker blade #57, hypodermic needle, surgical blade no 15 and 1. In small and less severe and non-suppurative cases of kerati-
calcium alginate swab. The platinum spatula has been tradition- tis there may be insufficient material to inoculate.
ally used for corneal scraping. However, we feel that 26-gauge
needle is very useful in obtaining sample from the edges and base 2. In advanced keratitis with severe keratolysis and descemeto-
of the ulcer particularly for direct plating as multiple needles can cele, it may not be possible to obtain multiple scrapings.
be used for multiple samples.
3. In some cases the overlying epithelium may be intact and it
Cornea & Refractive Surgery Services may be required to disrupt the corneal epithelium using a
R.P. Centre for Ophthalmic Sciences surgical blade. In cases of deep stromal keratitis, microsurgi-
AIIMS, New Delhi - 110 029 cal scissors, a no. 11 Bard Parker blade or a small trephine
may be used to obtain the sample adequately.
August, 2004 48 DOS Times - Vol.10, No.2
Corneal Biopsy Gram Stain Procedure
• Fix smear by either of the following methods:
Sometimes repeated smear examinations and cultures of cor- • Place in methanol for 5-10 min and allow to air dry: pre-
neal scrapings harvested by standard method do not demon-
strate presence of any microorganisms. This may be true for cer- ferred method
tain cases of deep mycotic keratitis and intrastromal abscesses. • Pass the slide, through flame two or three times. Allow
In such cases, a diagnostic superficial keratectomy or cor- cooling.
neal biopsy may be necessary to harvest microbe-infested tissue • Flood the slide with crystal violet stain. - Allow stain to
to make an accurate microbiological diagnosis. Corneal biopsy is
superior to scraping for isolating fungus from a case of mycotic remain for 1 minute
keratitis. • Rinse gently with tap water.
• Flood slide with Gram’s iodine solution. Allow solution to
Procedure
remain for 1 minute.
The procedure is performed under an operating microscope • Rinse gently with tap water.
under topical anesthesia. A dermatologic 2-3 mm trephine or a • Dip the slide into absolute alcohol for 5 seconds.
small Elliot microtrephine is advanced into the anterior corneal • Rinse gently with tap water.
stroma, to incorporate both infected and clinically normal tissue. • Flood the slide with Safranin stain. Allow stain to remain
Care is taken to avoid the visual axis as far as possible. Subse-
quently a crescent blade or Bard Parker knife is used to undermine for 30 seconds.
the tissue, which may then be cut with a surgical blade or • Rinse gently with tap water.
microscissors. The corneal biopsy specimen thus obtained should • Allow to air dry.
be divided into pieces and should be subjected to smear examina-
tion, cultures and histopathological examination and special stains performed in outpatient area. We therefore, recommend simple
are used, if required. microscopic examination of corneal scraping using 10% KOH
preparation as minimum investigation in all cases of suppurative
Microbiological Investigations keratitis.
Smears are prepared by scraping the ulcer and gently trans- Giemsa Staining
ferring the material on to the glass slide. At least four slides are
prepared. One for Gram staining, second for Giemsa staining, third Giemsa stain is one of the Romanowsky type stain, which
for KOH wet preparation and fourth for viral antigen detection. uses eosin, methylene blue and azure dyes. It stains the DNA in
the nuclei of the human cells and cytoplasmic RNA in the lym-
Gram’s Staining phocytes.
Gram’s stain classifies the bacteria into two major groups This stain differentiates bacteria from fungi, and also identi-
based on the cell wall of the bacteria. Gram-positive bacteria re- fies chlamydia inclusion bodies and cysts and trophozoites of
tain the gentian violet- iodine complex and appear blue-purple, Acanthamoeba species. With Giemsa technique the bacteria ap-
whereas the Gram-negative bacteria lose their gentian violet – pear dark blue in colour. The yeast cells and fungal hyphae ab-
iodine complex with decolorization step and appear pink when sorb the stain and appear purple or blue while the cell walls and
counterstained with safranin. the septations do not stain. The conventional Giemsa stain takes
60 minutes to perform, although a rapid 15-minute modification of
If performed correctly, Gram’s stain identifies the organism the stain is also available.
correctly in upto 75% of the cases caused by a single organism
and in 37% cases of polymicrobial keratitis. Overall, Gram’s stain Special Stains
is accurate in 61% of cases of bacterial keratitis.
Ziehl-Neelson acid-fast stain: Mycobacteria, Actionomyces,
Potassium hydroxide wet mount preparation Nocardia..
The scraped material is spread out as thinly as possible with Mycobacteria are acid fast, Nocardia stain variably whereas
the help of spatula on the slide. One drop of 10% KOH solution is Actionomyces are non-acid fast.
put on the scrapings and a slide cover is placed. The slide is
examined under a microscope. The KOH helps in loosening the Fluorochromatic stains
corneal stromal lamellae and exposing more fungal filaments. It
also stains the filaments in a very light yellow color. 10% KOH Fluorochromatic stains such as acridine-orange and
mount examined by conventional microscope is a useful test in calcofluor-white require the use of an epifluorescence microscope
helping identification of fungi and Acanthamoeba. The test has to visualize the organisms and the cells.
high sensitivity (92%) and a high specificity (96%) and can be
August, 2004 49 DOS Times - Vol.10, No.2
Acridine Orange This is an ideal medium for the isolation of the anaerobic
bacteria. A PRAS brucella blood agar plate enriched with vitamin
The acridine orange is a chemoflorescent dye, which stains K and hemin allows the growth of the anaerobes within 4 to 7
fungi and bacteria yellow-orange against a green background days.
when the ph is acidic and a fluorescent microscope is used. It is
a valuable stain as it identifies gram-positive and gram-negative Sabouraud’s agar
bacteria, yeast and hyphal forms of fungi and both the trophozo-
ite and cyst form of Acanthamoeba. Sabouraud’s glucose and peptone agar is a universal non-
selective media, which are incubated at room temperature. Yeast
Calcofluor white extract is added to improve nutritional characteristics and an anti-
biotic such as gentamicin or chloramphenicol is added to inhibit
Calcofluor white binds to chitin and cellulose. Because the bacterial contamination. The Sabouraud’s agar should not con-
cell walls of the yeast and filamentous fungi are composed of tain any additives such as cycloheximide as this inhibits
chitin and cellulose, these organisms stain bright green with saprophytic fungi commonly responsible for ocular infections.
calcofluor white under epifluorescent microscope. The cysts of
Acanthamoeba likewise also have chitin and cellulose and also Duration of isolation of organism
stain bright green. The trophozoites of Acanthamoeba stain red-
dish –orange in color. Most aerobic bacteria responsible for keratitis are seen on
standard culture media within 48 hours. In some cases the patho-
Modified Grocott-Gomori Methenamine-Silver Nitrate Stain gen may be recognized in 12 to 15 hours.
The Grocott-Gomori methenamine-silver nitrate stain is a his- Aerobic cultures of the corneal specimens should be held for
topathologic stain used to show fungi and has been modified for 7 days, anaerobic cultures for 7 to 14 days and Mycobacterial and
the examination of corneal scrapings. For fungal infections, this fungal cultures for 4 to 6 weeks before being reported as no growth.
stain is more reliable than the Gram, Giemsa, or KOH stain.
Interpretation of culture results
Culture specimens
The interpretation of the culture results should be made with
The corneal scrapings are routinely inoculated onto Blood regard to the clinical situation, the adequacy of the sample and
agar plate, chocolate agar plate, Sabouraud’s dextrose agar plate the possibility of contamination by organisms present on the
(if fungus is suspected) and anaerobic media (if anaerobes are skin, eyelids and conjunctiva.
suspected). The selective media agar plates are inoculated by
streaking the platinum spatula lightly over the surface to produce Positive culture
a row of separate inoculation marks in a C shaped configuration.
A reported culture positive rate in presumed infectious kerati-
Blood Agar tis varies from 40 to 73 %. Criteria for a significant positive culture
by some investigators include the clinical signs of keratitis plus
Enriched media such as blood and chocolate agar help to one of the following: (i) growth of the organism in two or more
isolate the fastidious organisms. Blood agar is the standard me- media (ii) confluent growth of a known ocular pathogen in one
dium for the isolation of aerobic bacteria at 35 0C and helps to solid medium or (iii) growth in one medium of an organism with
support the growth of most saprophytic fungi at room tempera- positive smear results or growth of same organism in liquid media.
ture. Jones criteria for positive culture include: clinical signs of infec-
tion plus isolation of bacteria (10 or more colonies) on one solid
Chocolate Agar medium and one additional medium, or isolation of fungi (any
detectable growth) on any two media or one medium in the pres-
Chocolate agar is prepared by the heat denaturation of blood ence of a positive smear.
and provides hemin (X factor) and diphosphopyridine nucleotide
(V factor) essential for the growth of Heamophilus. It should be Serological Investigations
incubated at 35 0C with 10 % carbondioxide. It also supports the
growth of Neisseria and Moraxella. These techniques (e.g. polymerase chain reaction) detect
whether DNA and RNA from a particular organism is present, but
Thioglycolate broth do not detect the viability of the organism.
Thioglycolate broth grows aerobic and anaerobic bacteria at The advantages of Polymerase chain reaction (PCR) include
35 0 C. It consists of the basic nutrients required to support the greater speed than culture methods (up to 4 hours) and the ability
growth of aerobic bacteria and also has sulf-hydryl compound to analyze specimens far from where they are collected.
that acts as an oxygen-reducing agent to facilitate the recovery of
the anaerobic bacteria. It also supports a number of saprophytic Mixed Organisms/Polymicrobial keratitis
fungi.
Polymicrobial keratitis is a distinct clinical entity. More than
Pre-reduced anaerobically sterilized media (PRAS) one organism in corneal cultures may be identified in 6 to 32 % of
August, 2004 50 DOS Times - Vol.10, No.2
cases depending on the laboratory techniques and the criteria for methods provide greater information about the ocular infections.
positive or negative culture. The most frequent combination in Once a MIC value of a particular antibiotic is found out the bacte-
mixed microbial infections is an aerobic gram-positive coccus and ricidal effect of the antibiotic may be titrated by subculuturing the
a gram-negative rod. clear broth on the antibiotic free zone.
Antimicrobial Susceptibility Testing Minimal Bactericidal concentration (MBC) is the concentra-
tion of the antibiotic which reduces the growth of the bacterial
The preferred methods for testing the susceptibility of the strain by 99.9%. The minimum antibacterial concentration (MAC)
antimicrobial agents are the standard disk diffusion method and is the inhibitory effect of the antibacterial agent, which is ob-
the micro-dilution techniques. The quantitative minimal inhibi- served in 5.5 hours in which 90% of the bacterial population is
tory concentration (MIC) determinations by the broth microdilution inhibited.
Media for various organisms
Routine Culture media Growth Incubation Temperature
350C
Soybean casein digest broth (trypticase soy broth ) Saturation of swabs 350C
Blood Agar plate Aerobic bacteria 350C
Facultative anaerobic bacteria 350C
Room temperature
Fungi Room temperature
Chocolate Agar plate Aerobic bacteria 350C
350C
Facultative anaerobic bacteria 350C
350C
Neisseria 350C with 3 -10% CO2
Haemophilus
Moraxella
Thioglycolate broth Aerobic bacteria
Anaerobic bacteria
Sabouraud’s dextrose agar plate with antibiotic Fungi
Brain Heart infusion broth plate with antibiotic Fungi
Special Culture Media
Cooked meat broth Anaerobic bacteria
Schaedler agar Anaerobic bacteria
Thayer Martin Blood agar plate Neisseria
Brucella blood agar plate Anaerobic bacteria
Lowenstein-Jensen media Myocobacteria species
Middlebrook-Cohn agar Myocobacteria
Nocardia 350C with 3 to 10 % CO2
Suggested Reading
1. Hyndiuk RA, Seideman S : Clinical and laboratory techniques in the corneal specimens in cases of suspected bacterial keratitis. J Clin
external ocular disease and endophthalmitis. In Fedukowicz H, edi- Microbiol. 2003 Jul ; 41(7) : 3192-7.
tor : External infections of the eye : bacterial, viral and mycotic, ed 3. Benson WH, Lanier JD. Comparison of techniques for culturing
2, New York, 1978, Appleton - Century - Crofts. cornealulcers. Ophthalmology. 1992 May; 99(5) : 800-4.
2. Kaye SB, Rao PG, Smith G, Scott JA, Hoyles S, Morton CE, 4. Popescu A, Doyle RJ. The Gram stain after more than a century.
Willoughby C, Batterbury M, Harvey G. Simplifying Collection of Biotech Histochem. 1996 May; 71(3) : 145-51.
August, 2004 51 DOS Times - Vol.10, No.2
APPLIANCES
Corneal Topography
Bharti S., M.S., Samantaray D., M.S.
Corneal topography measures the shape or curvature of the insertion on videokeratoscopic axis. Keratometric index n' is not a
anterior corneal surface. It is an indispensable tool for preopera- true refractive index of the cornea, but an approximated index to
tive screening, surgical planning, assessment of surgical outcomes, yield the total corneal power as a single refracting surface by
detection and management of complications , refinement of surgi- compensating for the negative power of the posterior surface.
cal techniques and development of new procedures.
Origins of Corneal TopographyAnalysis
In 1847,Henry Goode invented a target disk consisting of a
series of concentric circles, which Antonio then went on to incor-
porate into his instruments. In late 1940 quantitative interpreta-
tion of photokeratographs were made without great success. In
1981 Rowsey et.al presented an evaluation of a qualitative kerato-
scope and also advocated the qualitative interpretation of kerato-
scope photographs by visual inspection. In 1987, the colour coded
topographic map, a simpler and more effective method that allows
instant pattern recognition was introduced by Maguire et.al.
Principles of Corneal Topography Two approaches for the calculation of the corneal radius of
1. Placido- Disk Based System. curvature. The instantaneous radius is mathematically more
2. Non Placido Disk Based System. accurate
Placido-Disk Based System The Instantaneous Power is calculated based on a floating cen-
ter of curvature by means of a standard mathematical method for
Modern Corneal topography was first developed using placido- determining the local radius of curvature.
disk technology, which is most widely accepted, used and under-
stood. The placido target is a series of concentric illuminated P inst. =(n-1)/r inst
rings (mires) that vary with the model and are projected onto the
cornea. These are reflected by the convex mirror like corneal sur- r inst is the radius of curvature for any given point on the cornea.
face and are imaged, along with the cornea, by a video camera.
The two-dimensional digital image is stored in computer memory The method is more sensitive to small measurement error than the
and analyzed to reconstruct the three dimensional corneal shape. axial power calculation, which can introduce unwanted "noise"
The size and distortion of ring patterns are basis for the calcula- artifact in the color-coded map.
tion. The ring location relative to the center of the pattern deter-
mines radial distance, and the size of rings and spacing between Refractive power (secondary focal point power)
the rings determines the radius of curvature. Closely spaced rings
indicates higher corneal powers and widely spaced rings repre- P ref=n/f And f=Z/tan (Qi-Qr)
sent lower corneal power. Axial power is calculated using a fixed
center of curvature on the video keratoscopic axis for calculating f: is the distance from the vertex normal to the secondary focal
the power at all points along the semimeridians on the corneal point. Z: is the dimension along the videokeratometric axis from
surface. the vertex normal to the surface point Qi and Qr are the angle of
incidence and refraction respectively.
P(axial)=(n-1)/r axial
Axial Power: Produces inaccurate refractive power values for the
n'=1.3375 (the keratometric index of refraction) peripheral portions of the cornea because it does not encompass
the effects of spherical aberrations.
r axial is the distance from the corneal surface to a point of
Instantaneous Power: Better estimates of the peripheral corneal
power than the axial power formula.
Bharti Eye Foundation The Refractive power (secondary focal length power) analysis is
East Patel Nagar, New Delhi, India theoretically valued and provides realistic values for the corneal
August, 2004 52 DOS Times - Vol.10, No.2
phy. Warm colors-Red and orange are used to represent relatively
higher powers (Steeper curvatures). Green and yellow are used
for powers associated with normal corneas and cool colors hues
of blue are used to denote relatively lower powers (flatter curva-
tures). This concept along with standard scales provides an intui-
tive basis for the interpretation of corneal topography. Currently
on the market topographers have their own standard color scales,
and the actual power values, intervals and colors used differ from
machine to machine.
Schematic description of terms used to calculate refractive power. Elevation Map: Elevation map is the true representation of cor-
F: intersection of refracted ray with videokeratograph axis; C: neal topography, as opposed to a derivative form. It is highly
Center of curvature; A: Intersection of normal with useful in contact lens fitting and keratoconus shape analysis. In
videokeratograph axis; f: focal distance( Distance from the vertex placido disk systems, the corneal height is calculated from the
normal to the secondary focal point) ; y: height of corneal location curvature data, whereas in the non-placido disk system, height
from videokeratoscope axis; z: distance relative to tangent plane at information is first obtained and than the curvature is derived.
apex ; Ov: angle of incidence; Or: angle of refraction
Quantitative Iidices : The colour coded map is a qualitative dis-
power in the periphery. It shows the residual corneal spherical play of the data, which is designed to allow rapid and easy pattern
aberration in the periphery but can not show the radial refractive reorganization. However, there have been several means to ana-
index gradients present in the lens of the eye. lyze the data mathematically so that the information is represented
as quantitative indexes. Simulated keratometry is a relatively simple
Non Placido disk system: corneal index that is equivalent to the conventional keratometer
reading and is offered by all topography devices.
Scanning Slit: the principle of optical beam scanning topogra-
phy is similar to a slit lamp corneal photography. An image of a slit Analysis of Topography In Clinical Practice
light intersecting the cornea is used to obtain a localized impres-
sion of the profile of both corneal surfaces. Two slits are used, A detailed appreciation of topography is critical for preop-
positioned at the angle of 45 deg to the right and left of the instru- erative screening and postoperative evaluation of refractive sur-
ment axis. Twenty images are captured from each direction. To gery patients, contact lens fitting and for diagnosis of keratoco-
obtain more information concerning the central 7mm of the cor- nus. Corneal topography is a very sensitive investigation and
nea, there is an overlapping of the slits from the right and left side. has the ability to reveal early and subtle corneal changes associ-
ated with conditions such as corneal warpage in a contact lens
Rasterstereography: In this grid is projected onto the tear wearer and mild form of keratoconus.
film surface and the diffuse scattering is recorded from a known
angle. Because the normal cornea is nearly transparent and does Astigmatism Patterns :
no effectively scatter light, the tear film is stained with fluorescein
and an excitation source (cobalt blue light) is used to cause the Symmetric bowtie pattern : Regular astigmatism is said to occur
grid patter on the cornea to fluoresce. when the corneal surface is toric rather than spherical and there
are two principal meridians of curvature, one flat and the other
Laser Holographic Interferometry: This measures the anterior steep, oriented at 90 degrees to one another. This type of astigma-
corneal surface by means of the wave interference technique cat- tism is most commonly represented by the symmetric bowtie pat-
egorized as laser holography. The output of a low energy diode tern. The orientation of bowtie indicates the axis of cylinder, ex-
laser is focused via the system optics on the corneal surface. pressed in positive cylinder form. In regular astigmatism informa-
Reflected waves of light pass from the corneal surface into an tion provided by the computer generated map is expected to cor-
optical system that transmits the light to a holographic grid. By relate to data provided by keratometry and refraction.
analysis this return wave relative to the reference wave, three-
dimensional corneal shape information can be extracted. Asymmetric bowtie pattern
Display Format Irregular Astigamatism : In complex cases, topographic maps
demonstrate regions of different corneal powers distributed ir-
Color -Coded Map: Scaling regularly over the corneal surface.
The color coded contour map of corneal power has been Contact Lens Wear
adopted as a standard presentation scheme in corneal topogra-
The changes induced by contact lens wear is termed as cor-
neal warping. The corneal changes induced by contact lenses
were characterized by central irregular astigmatism, less of radial
symmetry and reversal of the normal corneal topographic pattern
August, 2004 53 DOS Times - Vol.10, No.2
of progressive flattering from the center to the periphery which areas identified and the residual myopic ablation is performed.
can be demonstrated using computer assisted corneal topogra- New generation topographers such as those based on
phy analysis. All patients with a history of contact lens wear rasterphotogrametry or slit- scan techniques, can describe cor-
should have repeated refractions and corneal topographies until neal topography in terms of height deviation from a best fit sphere.
stabilization is documented. These data can be directly translated into corneal tissue thick-
ness to be removed by eximer laser ablations to reduce astigma-
Keratoconus: the preoperative topographic screening prior tism, which should greatly simplify the programming of ablation
to a keratorefractive procedure has largely focused on keratoco- depth and location and should facilitate direct data transfer from
nus, primarily because this seems to be the most commonly found the topographer to the laser.
anomaly. Specific topographic features of keratoconus have been
described by Ratbinowitz and Mc Donnell one is inferior Size of Ablation and its relationship to Pupil
steepenning (more frequently temporal) and other one superim-
posed asymmetric bowtie pattern. The last parameter is termed as The topographer can measure the approximate size of pupil
I-S value and is calculated by measuring the dioptic power of 5 both in low and high
points at 30 deg intervals along the inferior cornea, with each
point being 3mm from the central cornea. The sum of the Dioptoric Illumination and act as a guide to the desired ablation size for
power of the five superior points is then subtracted from the sum laser refractive surgery
of the Dioptic power of the 5 inferior points. If the central corneal
power is greater than 47.2 D or if the I-S value is greater than 1.4D Conclusion
the patient is considered a keratoconus suspect ( Keratoconus
fruste). If the central corneal power is greater than 48.7D or the I- Computer assisted analysis of corneal topography is an es-
S value greater than 1.4D the cornea is classified as keratoconus sential diagnostic tool for evaluating the corneal surface, it pro-
(it do not correspond to a transplanted cornea or that has sus- vides detailed information about the corneal contour that cannot
tained trauma). be obtained from refraction, keratoscope image, or keratometry
before and after keratorefractive procedures. This helps to refine
Post operative corneal Topography' after Excimer Laser Re- the techniques of keratorefractive surgery and provides crusial
fractive Surgery Topography is required for evaluating centration insight into the long term stability of corneas thet have under-
after LASIK, identifying the characteristic topographic ablation gone the procedures.
patterns, assessing the optical quality of the ablation zone and in
monitoring post operative changes in corneal topography over
time.
The common ablation pattern following Excimer laser PRK or
LASIK is central uniform homogeneous pattern of flattening.
Centration of the ablation after LASIK : Analysis of corneal
topography is now the estabalished method for evaluating the
centration of the ablation relative to the papillary center, which is
now generally regarded as the optimal point that determines the
quality of the foveal image. Centration error of 0.2mm or less are
visually insignificant where as errors of 0.5 to 0.8 mm are visually
significant.
Optical Quality of the ablation Zone
Corneal topography analysis is used to assess the optical
quality of ablation zone through the use of the surface regularity
index (SRI). SRI is a measure of central corneal optical quality
(smoothness) and is highly correlated with BCVA. The more regu-
lar the surface, the lower the SRI and thus a perfectly smooth
surface would have a SRI of zero. The SRI attains a maximal value
immediately after LASIK and which subsequently decreases with
increasing time from surgery.
Corneal Topography in astigmatic refractive surgery
A topographic map of the irregularly astigmatic cornea is
obtained. The localised areas of steepening are identify by their
hot colours. Selective ablations are performed based on the steep
August, 2004 54 DOS Times - Vol.10, No.2
!! Attention !! Submission of Article for DJO
Dear DOS Members
Greetings to you from the desk of Editor Delhi Ophthalmological Society,
Delhi Ophthalmological Society, a 55-year-old society of more than 3000 ophthalmologists is engaged in
the task of promoting Scientific Exchange and interaction.
Delhi Journal of Ophthalmology (DJO) is a quarterly journal brought out by the Society that aims at
providing a platform to its readers for free exchange of ideas and information. We accept, for publication
original articles, case reports, investigative research & review articles in DJO. You are hereby requested
to kindly contribute your work and knowledge by publishing your article(s) in the Delhi Journal of
Ophthalmology.
You may submit the article as a printed copy along with a properly labeled floppy to the address below
mentioned or “Email submission to [email protected] and/or [email protected] .The guidelines for
electronic submissions are:
1. The document should be in MS-Word .doc or .rtf format. (virus free)
2. The photographs / scans (minimum resolution of 300 dpi and CMYK colour in either .jpg or .tif format.)
With warm personal regards,
Prof. Kamlesh
Editor, DJO
D-1/17, Bharti Nagar, New Delhi – 110003, INDIA
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August, 2004 55 DOS Times - Vol.10, No.2
MANAGEMENT PEARLS
Management of Canalicular Injury
Vijay B. Wagh, MD Harish Pathak, MD M. S. Bajaj, MD
The lacrimal drainage apparatus consists of the puncta on tions (e.g. Fluorescien) has been recommended in locating the
the upper lid and the lower lid, the canaliculi, the common canali- medial aspect of the canaliculus. The use of magnification by
culus, the lacrimal sac, and the nasolacrimal duct. Injuries to the either surgical loupes or the operating microscope usually allows
canalicular portion of the tear drainage system can occur as iso- for visualization of the white cuff of the severed canaliculus.
lated injuries or as one component of more extensive injuries,
including multiple marginal lid lacerations, orbital fractures, and Management
globe injuries. The medial extent of the canaliculus interrupts the
posterior arm of the medial canthal ligament. Because of its super- Tetanus prophylaxis must be confirmed in any contaminated
ficial location in the medial lid, the canalicular system is vulner- injury. Rabies prophylaxis with both active and passive immuni-
able to trauma. Lacerations of the canalicular system result from zation may be necessary in certain carnivore bites; in most do-
direct or indirect trauma. Direct trauma includes severing the lac- mestic dog bites, it is not necessary. Postoperatively, most sur-
rimal portion of the lid with objects, such as glass, coat hangers, geons prescribe a broad-spectrum antibiotic, such as cephalexin,
knives, dog bites, cat claws, fingernails, or other sharp objects. for the patient.
Indirect trauma results from blunt injury to the ocular adnexa from
such mechanisms as blows to the face, blunt weapons, or falls Acute microscopic repair with either an operating microscope
onto blunt objects. or surgical loupes is required to reanastomosis the severed ends
of the canaliculi. In most injuries, this repair can be accomplished
If the canalicular system is not repaired initially, tearing can within 48 hours of the trauma. Successful repairs have been re-
result from the disruption of the lacrimal anatomy and the medial ported within 5 days of the injury to prevent scarring and epithe-
canthal area can have an abnormal appearance. Primary repair can lialization of the wound. Animal bites should be addressed imme-
restore both lid function and position. Once the lacrimal system is diately because of the significant contamination present in the
scarred, it cannot be functionally repaired. wound.
The mechanism of injury must be elicited during the history. Repairs on children must be performed under general anes-
Delineating the mechanism of injury helps to establish the extent thesia. For most adults, repairs can be performed with monitored
of injury, the possibility of associated ocular damage, the degree anesthesia with intravenous sedation. In those patients with ex-
of contamination, and the risk for retained foreign bodies. tensive ocular adnexal trauma or more extensive injuries, general
anesthesia may be the preferred anesthetic approach. Local he-
Examination mostasis and anesthesia are augmented with nasal vasoconstric-
tors, such as 4% cocaine or phenylephrine soaked cottonoids,
In the setting of acute trauma, attention to life-threatening and a local injection of 2% lidocaine with 1:100,000 epinephrine
and then visual-threatening injuries, particularly an open globe, (in adults) or 0.5% lidocaine with 1:200,000 epinephrine (in chil-
must take precedence over examination or repair of any adnexal dren) to the area of the lacrimal sac and in both the superior and
injury. the inferior medial eyelid.
Any lid laceration medial to the pupil should be considered Familiarity with the anatomy of the medial canthal area is
to involve the canalicular system until proven otherwise. To check essential for accurate repair of the canalicular. The puncta must
for disruption of the system, the puncta can be dilated, followed be dilated, and a Bowman probe must be passed delicately through
by insertion of a Bowman probe. Another method of confirming a the canaliculus. The severed end of the canaliculus is a shiny
canalicular laceration includes irrigating substances, such as fluo- white cuff of tissue at the edge of the lumen. Most surgeons favor
rescein stained balanced saline solution, through the system with silicone intubations of the system, with repair of the pericanalicular
visualization of the dye in the wound. Examination of the orbit for injury. This can be accomplished with either bicanalicular intuba-
any associated injuries (eg, orbital fractures) must be performed. tion (either by passing the stent ends through the nasolacrimal
Fractures of the maxillary bone in the area of the nasolacrimal duct duct or by using a modified eyed pigtail probe) or monocanalicular
can cause difficulty in silicone intubation through the nasolacri- intubation
mal duct.
Completing the repair
Laboratory studies only include those needed by emergency
trauma care providers. The lacrimal system laceration does not Once the canaliculus has been intubated, and the laceration
require laboratory studies. Injection of air, water, or various solu- has been bridged, the medial canthal tendon structures should be
carefully reconstructed. This is to ensure that the punctum is
R.P. Centre for Ophthalmic Sciences returned to its normal position medially. If a notch is present in the
AIIMS, New Delhi - 110 029 medial eyelid, the patient will have tearing despite a successful
August, 2004 56 DOS Times - Vol.10, No.2
canalicular repair. It is therefore extremely important to get a good (within 24 hours of the injury) and should always be intubated
eyelid margin repair. While direct microscopic anastomosis of the with a silicone stent. Familiarity with canalicular repairs allows the
canaliculus has been advocated, this may actually induce more surgeon to provide a service to emergency rooms that most other
trauma to the canalicular epithelium and result in a greater risk of specialties are hesitant to provide.
stenosis. We prefer simply to approximate the pericanalicular soft
tissues. This invariably will bring the canalicular ends together Complications:
over the indwelling stent.
Premature loss of the stent can occur with bicanalicular re-
A 6-0-polyglactin suture is placed in the pericanalicular tis- pair with passage of the stent through the nasolacrimal duct. The
sue of the distal cut end of the laceration, or the medial tarsus if stent can prolapse through the puncta, raising concern of the
the laceration is more lateral. The suture is then fixated to the patient and family members. When the eyed pigtail probe method
medial canthal tendon near the proximal end of the laceration. The is used, the knot can rotate and cause conjunctival irritation. The
remainder of the laceration is then closed in a routine manner. The puncta can erode from any of the stent materials used to repair the
silicone stents should be left in place for at least 3 months. laceration. Pyogenic granulomas may form adjacent to the stent.
Nasal irritation or nosebleeds may occur from stents passed
The silicone stent is removed 3 months to 6 months after the through the nose. Despite acute repair, chronic epiphora may
repair depending on the extent of the trauma. Canalicular injuries develop. The medial lids may become webbed because of op-
resulting from sports injuries could potentially be avoided with posed lacerations.
proper headgear. Those lacerations resulting from assault often
are alcohol abuse related. Close surveillance of toddler interac- Prognosis:
tions with the family pet or a known dog may be helpful in pre-
venting a significant number of canalicular lacerations in tod- The success rate with canalicular repair ranges from 20-100%.
dlers. The success rate rises to 86-95% with microscopic reanastomosis
of the severed canaliculus with silicone intubation of the lacrimal
In summary, repairing canalicular lacerations can be a simple system.
and successful procedure if the surgeon is aware of all the op-
tions available. Canalicular lacerations should be repaired promptly The balance between tear production and outflow must be
explained to patients. In addition, limitations secondary to the
extent or nature of the trauma must be discussed with the patient.
NOTICE
ANNUAL GENERAL BODY MEETING
The Annual General Body Meeting of Delhi Ophthalmological Society will be
held on (Sunday) the 29th August 2004 at 9.00 A.M. at Sir Ganga Ram
Hospital, Rajender Nagar, New Delhi.
All members are kindly requested to make it convenient to attend.
Dr. Jeewan S. Titiyal
Secretary, DOS
August, 2004 57 DOS Times - Vol.10, No.2
JOURNAL ABSTRACTS
Long-term outcomes in Asians after acute Anterior vitrectomy is desirable along with
primary angle closure show 17.8% of primary PCCC in children younger than 5
subjects examined were blind in the years with congenital cataracts
attack eye, and almost half had
glaucomatous optic nerve damage. Vasavada A, Desai J. J Cataract Refract Surg. 1997;23 Suppl
1:645-51.
Aung T, Friedman DS, Chew PT, Ang LP, Gazzard G, Lai YF, Yip Iladevi Cataract & IOL Research Centre, Ahmedabad, India.
L, Lai H, Quigley H, Seah SK. Ophthalmology. 2004 Aug;
111(8): 1464-9. To determine whether anterior vitrectomy is necessary along with
primary posterior capsulorhexis in children less than 5 years of
Glaucoma Department, Singapore National Eye Center, and Na- age with congenital cataracts. This prospective study comprised
tional University of Singapore 18 eyes of 16 children whose mean age was 2.3 years (range 3
months to 5 years). Primary posterior continuous curvilinear
Cross-sectional observational case series aimed to determine the capsulorhexis (PCCC) and posterior chamber intraocular lens (IOL)
long-term outcome of Asian eyes with an acute attack of primary implantation were performed in all eyes. No vitrectomy was done
angle closure (APAC) and to identify risk factors at presentation in 8 eyes (Group 1); an anterior vitrectomy was performed in 10
associated with the development of glaucomatous optic nerve eyes (Group 2). Optic capture through the posterior capsule was
damage. 90 individuals who were initially seen with APAC 4 to 10 achieved in 3 eyes in Group 1 and in 5 eyes in Group 2. Average
years previously at 2 Singapore hospitals were included. All sub- follow-up was 13.3 months. Five eyes (62.5%) in Group 1 needed
jects underwent a complete eye examination, including visual acu- secondary pars plana vitrectomy because the visual axis was ob-
ity, visual field testing, dilated eye examination, and optic nerve scured; no eye in Group 2 needed a secondary procedure. Four
head photography. The optic discs were judged clinically and Group 1 eyes developed significant complications (updrawn pu-
photographically as to whether there was glaucomatous optic pil, decentration, occlusio pupillae, transient glaucoma). While
neuropathy present, and visual fields were assessed for corre- no Group 2 eye developed a serious complication, some degree of
sponding visual field loss. All visual fields and optic nerve pho- pigment dispersion was noted in all the eyes. The authors con-
tographs underwent a second evaluation by an experienced, but clude that anterior vitrectomy is desirable along with primary PCCC
masked, glaucoma specialist, who assessed whether the changes in children younger than 5 years with congenital cataracts.
were compatible with glaucoma. The main outcome measures were
blindness (defined as best-corrected visual acuity worse than 6/ Posterior continuous curvilinear
60 and/or central visual field of less than 20 degrees in the attack capsulorhexis and optic capture of the
eye) and glaucomatous optic neuropathy (GON). Results showed intraocular lens to prevent secondary
a total of 90 of 170 eligible subjects (65.2%) were examined. All opacification in pediatric cataract
subjects were Asian and were predominantly Chinese (78 sub- surgery
jects [86.7%]). There were 61 females (67.8%), and the age of the
subjects was 62.0+/-9.0 years (mean +/- standard deviation) at the Gimbel HV
time of APAC, with a mean duration of 6.3+/-1.5 years from the
time of theAPAC episode to the study examination. Sixteen (17.8%) Gimbel Eye Centre, Calgary, Alberta, Canada
subjects were blind in the attack eye; half of the cases of blind-
ness were caused by glaucoma. Forty-three subjects (47.8%) had Authors evaluated the safety and efficacy of posterior continu-
GON, with 13 eyes (15.5%) having markedly cupped optic discs ous curvilinear capsulorhexis with optic capture n preventing sec-
(cup-to-disc ratio >0.9). Thirty-eight eyes (58%) had best-cor- ondary opacification of the visual axis in pediatric eyes having
rected vision worse than 6/9, with cataract responsible for close cataract surgery and intraocular lens (IOL) implantation. Poste-
to half the cases of poor vision. There were no identifiable risk rior continuous curvilinear capsulorhexis with optic capture of
factors related to the APAC episode that were significantly asso- the IOL was performed in 18 of 19 consecutive pediatric cataract
ciated with the presence of GON. Authors conclude several years patients (ages 2 1/2 to 12 years). Heparin-coated IOLs with 6
after being seen with APAC, 17.8% of subjects examined were degree angulation of the haptics were implanted in all eyes. Only
blind in the attack eye, and almost half had glaucomatous optic eyes with a minimum of 18 months follow-up (n = 16) were ana-
nerve damage. Vision was also reduced in a large number of indi- lyzed. Results show mean follow-up in the 16 eyes was 35.5 months
viduals, largely from un-operated cataract. Subjects with APAC +/- 9.45 (SD), ranging from 19 to 49 months. To date, the visual
would benefit from regular follow-up to monitor for visual field
decline and glaucoma development.
August, 2004 58 DOS Times - Vol.10, No.2
axis has remained clear in all eyes. No anterior vitrectomy was temperature gradients of WhiteStar micropulse technology us-
purposefully performed in any eye. Gimbal concludes posterior ing bimanual phacoemulsification without an irrigation sleeve
continuous curvilinear capsulorhexis with optic capture of the through a 1.2 mm incision. Ten patients had bimanual
heparin-coated IOL appeared to successfully prevent secondary phacoemulsification using micropulse technology without an ir-
opacification of the visual axis in pediatric cataract cases. rigation sleeve through a 1.2 mm clear corneal incision. A thermo-
couple consisting of a 30-gauge copper wire was inserted into
Efficacy and wound-temperature gradient clear cornea directly adjacent to the wound to digitally record
of whitestar phacoemulsification through temperature gradients at the wound. Endothelial cell counts were
a 1.2 mm incision evaluated preoperatively and postoperatively in all patients. All
10 patients maintained corneal clarity with no sign of thermal
Donnenfeld ED, Olson RJ, Solomon R, Finger PT, Biser SA, Perry damage to the wound. The maximum corneal wound tempera-
HD, Doshi S. tures during phacoemulsification ranged from 24 degrees C to 34
Department of Ophthalmology, North Shore University Hospi- degrees C, well below the temperature of collagen shrinkage. The
tal, Manhasset, New York, USA endothelial cell loss at 3 months was 7%. Because of the de-
The purpose of the study was to evaluate the efficacy and wound- creased thermal effect with WhiteStar technology, an irrigation
sleeve over the phacoemulsification needle is superfluous. As a
result, bimanual phacoemulsification can be safely performed
through a 1.2 mm incision.
Where is my copy of DOS Times ?
Dear DOS members, anyone who could not receive
DOS Times from the month of July, 2004 onwards.
Please Contact:
President DOS : Dr. GURBAX SINGH
Email:[email protected]
or
Secretary DOS : Dr. JEEWAN S. TITIYAL
Email:[email protected]
Methodology for Monthly Clinical Meeting:
Criteria for Selection
Formula: Institution's Marks Attendance of institution (N) x3
Average marks A (outside delegates) x 0.7 +
maximum attendance in any monthly meeting (Nx)
Total marks by outside delegates (M) Nx= Highest attendance of all meetings
A=——————————————————------------------------------ N= Total number of delegates
n= Total number of internal delegates
Total number of outside delegates (N-n)
N= Total Attendance of an instituton
(Outside + internal delegates)
August, 2004 59 DOS Times - Vol.10, No.2
DOS Credit Rating System (DCRS)
DOS has always been in the forefront of efforts to ensure In a bid to strengthen our efforts in this direction DOS had
that its members remain abreast with the latest developments DOS Credit Rating System (DCRS), the details of which are
in Ophthalmology. Among the important objectives formu- givenbelow.OurPrimaryobjectiveistopromotevalue-based
lated by the founders of our constitution was the cultivation knowledgeandskillsinOphthalmologyforourmembersand
give recognition and credit for efforts made by individual
and promotion of the Science of Ophthalmology in Delhi. memberstoachievestandardsofacademicexcellenceinOph-
Therapidstridesinskillsandknowledgehavecreatedaneed
thalmic Practice.
for an extremely intensive Continuing Medical Education
programme.
DOS CREDIT RATING SYSTEM (DCRS) Max.
DCRS
1) Attending Monthly Clinical Meeting* †(For full attendence) 10 90
2) Making Case Presentation at Monthly Meeting** 15 —
3) Delivering a Clinical Talk at Monthly Meeting** 15 —
4) Free Paper Presentation at Annual Conference (To Presenter)** 15 30
5) Speaker/Instructor**in : Monthly Symposium 15 30
15 30
: Mid Term Symposium 15 30
: Annual Conference 20 —
6) Registered Delegate at Mid Term DOS Conference 30 —
7) Registered Delegate at Annual DOS Conference 30 60
8) Full Article publication in Delhi Journal of Ophthalmology/DOS Times 10 20
9) Letter to editor in DOS Times 15 30
10) Letter to editor in DJO
——————————————————————————————————————————————
If any of the presentations is given an Award – Additional attendance at its meeting is higher (i.e. more than the average
20 bonus Credits. attendence of the eight monthly meetings).
——————————————————————
Member who have earned 100 Credits, are entitled to: * Based on Signature in DCAC
** Subject to Submission of Full Text to Secretary, DOS
a) CertificateofAcademicExcellenceinOphthalmicPrac- † Credits will be reduced in case attendence is only for part of
tice. themeeting.
b) Eligible for DOS Travel fellowship for attending con- DCRS !! Attention !!
ference.
* Members are requested to sign on monthly meeting atten-
If any member earns 200 Credits, he/she shall, in addition dance register and put their membership number.
to above, be awarded Certificate of Distinguished Resource-
Teacher of the Society. * The DCRS paper will be issued only after the valid signa-
ture of the member in the attendance register.
Institutionalassessmentforbestperformancewillbebased
onthetotalscoreofmemberswhoattenddividedbynumberof * Please submit your DCRS papers to the designated DOS
members who attended. Institutional assessment regarding Staff only.
decision to retain the institute for the next year will be based
on total score by all delegates who attend the meeting divided * The collected DCRS papers will be countersigned by Presi-
by average attendence of all 8 meetings. dent and Secretary and sealed immediately after the meeting
is over.
Please note that the Institutions’ grading increases if the
August, 2004 60 DOS Times - Vol.10, No.2
BOOK REVIEW
Manual Small Incision Cataract Surgery
Key to Reducing Blindness from Developing World
Jeewan S. Titiyal, MD, Harish Pathak, MD
There is little doubt that ultrasonic practical knowledge to ophthalmologist who are interested in
phacoemulsification has become the SICS and it should form part of the every day practical library of
gold standard for cataract surgery in the cataract surgeons - whether they practice in the developing world
developed world since Charles Kelman or developed world. The popularity of this book is reflected by
first invented the technique for cataract its great sale in USA and Europe and very soon it will be edited in
removal in 1967. However, this method Spanish.
of phacoemulsification is of limited use
in many developing countries, because Monthly Meetings Calendar
of the high cost of basic equipment, the For The Year 2004-2005
extra surgical training required and the
density of the cataracts, which are found 1st August, 2004 (Sunday)
in these regions. This is unfortunate as it is accepted that the
developing world is where most of the present cataract blindness Army Hospital (R&R)
backlog exists. Given such surgical challenges, manual small
incision cataract surgery has now emerged as the first practical 29th Auguest, 2004 (Sunday)
alternative to providing phacoemulsificaton, especially as it can
achieve rapid postoperative recovery with minimal surgery related Sir Ganga Ram Hospital
complications.
25th September, 2004 (Saturday)
The Clinical Practice in Small Incision Cataract Surgery by Hindu Rao Hospital
Jaypee Brothers Medical Publsihers, New Delhi represents and
reflect this new era of cataract surgery. The 633 page text is edited 30th October, 2004 (Saturday)
by a group of international ophthalmologists - Ashok Garg MD,
Luther L.Fry MD, Geoffrey Tabin MD, Francisco J Gutierrez- R.P. Centre for Ophthalmic Sciences
Carmona MD and Suresh Pandey MD. 21st November, 2004 (Sunday)
The colourful volume aims to provide the latest knowledge DOS Midterm Conference
on modern techniques in small incision cataract surgery to 27th November, 2004 (Saturday)
ophthalmologists who are interested in manual small incision Dr. Shroff’s Charity Eye Hospital
cataract surgery. It is divided into four sections, which cover 18th December, 2004 (Saturday)
many topics, including preoperative evaluations, minimal incision Venu Eye Hospital & Research Centre
techniques, postoperative complications and management and 29th January, 2005 (Saturday)
recent advances in nucleus delivery and intraocular surgery. Other
important chapters are modern IOL materials and implantation Safdarjung Hospital
techniques, manual phacofragmentation, SICS with glaucoma 26th February, 2005 (Saturday)
surgery and management of complications.
M.A.M.C. (GNEC)
In essence, this book provides a missing reference text for 27th March, 2005 (Sunday)
performing extracapsular surgery in the developing world, where
phacoemulsification is not always appropriate. It also provides a Mohan Eye Institute
cogent argument for using manual small incision cataract surgery 2nd & 3rd April, 2005 (Saturday & Sunday)
to address the growing backlog of cataract blindness in the
developing world. In so doing, the authors have created a Annual DOS Conference
beautiful, well illustrated text which provides extensive and
August, 2004 61 DOS Times - Vol.10, No.2
!! Congratulations !!
• Prof. H.K. Tewari superannuated as Chief Rajendra Prasad Centre for Ophthalmic
Sciences, AIIMS, New Delhi. We all wish him best for his future assignments at Sir Ganga
Ram Hospital and Centre for Sight.
• Prof. Supriyo Ghose being Chief of Dr. R.P. Centre, AIIMS, New Delhi.
• Dr. Ranjan Paul for successfully completing obsership at Moorfields Eye Hospital,
London.
• Dr. Sanjeev Mittal for successful completion of IFOS/ICO fellowship in
Medical Retina at Yanma University, Japan.
Attention DOS Members
The Hi-tech DOS Library is started functioning on Ground Floor, Dr. R.P. Centre, Delhi Ophthalmic
Sciences, AIIMS, New Delhi-110029 from 12.00 Noon to 9.00 P.M. on week days and 10.00 A.M.
- 1.00 P.M. on Saturday, Sunday. The Library will remain closed on Gazetted Holidays. Members
are requested to utilise the facilities available i.e. Computer, Video Viewing, Latest Books and
Journals. The latest addition is BJO (Indian edition). We are planning to subscribe two journals.
Member can give suggestion in this regard.
Dr. Lalit Verma
Library Officer, DOS
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Ph : 0120-2642256
August, 2004 62 DOS Times - Vol.10, No.2
MANAGEMENT PEARLS
Management of Posterior Capsular
Opacification in Children
Jeewan S Titiyal, MD, Rajesh Sinha MD, FRCS
We would like to communicate an important observation Fluffy material in the
which we encountered following YAG laser posterior capsulotomy visual axis after YAG
for posterior capsular opacification in older children. Capsulotomy in
paediatric pseudophakic
Posterior capsular opacification (PCO) is one of the common- eye
est causes of diminution of vision in children following cataract
surgery1. In these cases mostly the after cataract is thick and cases as it gives a permanently clear visual axis, which is so es-
fibrous and hence the management of PCO in these cases is a sential in these amblyopia prone children. It should be preferred
difficult proposition2. YAG laser posterior capsulotomy has been even in those children, in whom YAG laser posterior capsulotomy
the preferred modality for the treatment of PCO in adults and in is possible by increasing the laser energy. It also avoids multiple
older children who are co-operative enough to undergo laser. sittings of laser that is often needed in such cases which carries
However, we noticed that even in older children the after cataract risk of posterior segment complications and damage to the optic
is thick and fibrous. By increasing the energy of laser an opening of the intraocular lens if implanted. Pars plana membranectomy is
can be made in the capsule in many cases. But this opening doesn’t also combined with anterior vitrectomy which is very essential as
stretch as in adults. Hence this fibrous capsule needs to be cut anterior vitreous face acts as a scaffold for the proliferation of
with laser. In many of such cases whitish flocculent pieces of the lens epithelial cells. Hence we recommend that in pediatric eyes
cut capsule has been found suspended in the visual axis (Fig. 1). with thick and fibrous posterior capsular opacification, pars plana
This is perhaps because of the fact that vitreous is in gel form in membranectomy should be preferred over YAG laser posterior
children unlike adults in whom there is some amount of vitreous capsulotomy.
degeneration and liquefaction permitting these pieces, if present,
to settle down. As these pieces remain suspended in the visual References
axis, these results in scattering and deterioration in the quality
and quantity of vision. Again, these eyes require multiple sittings 1. MacEwen CJ, Dutton GN. Neodynium- YAG laser in the man-
of YAG capsulotomy, as these after-cataracts have a tendancy for agement of posterior capsular opacification – complications
repeated proliferation with vitreous face acting as a scaffold, which and current trends. Trans Ophthalmol Soc UK, 1986; 105:
invariably damages the intraocular lens. Pars plana 337- 344.
membranectomy with anterior vitrectomy is a better choice in such
2. Maltzmann BA, Wagner RS, Caputo AR. Neodynium: YAG
Cornea & Refractive Surgery Services laser surgery: The treatment of pediatric cataract disease.
R.P. Centre for Ophthalmic Sciences Ann Ophthalmol 1986; 18: 245- 246.
AIIMS, New Delhi - 110 029
DOS Credit Rating System Report Card
DCRS July 2004 – Army Hospital (R&R)
Total no. of Delegates (valid DCRS forms) .................................................................................................................................. 84
Delegates from Out side (N) ........................................................................................................................................................ 75
Delegates from Army Hospital (n) ................................................................................................................................................ 9
Overall assessment by outside delegates (M) ..................................................................................................................... 610.5
Assessment of case presentation-I (Dr. Lt. Col. R. Maggon) by outside delegates ............................................................... 549
Assessment of case presentation-II (Dr. Lt. Col. (Mrs.) Madhu Bhaduria) by outside delegates ...................................... 541.5
Assessment of clinical talk (Dr. Col. Ajay Banajee) by outside delegates .......................................................................... 572.5
Total no. of invalid DCRS forms ..................................................................................................................................................... 3
August, 2004 63 DOS Times - Vol.10, No.2
CURRENT PRACTICE
Sutureless Epilenticular IOL Implantation in
Pediatric Cataracts
Basudeb Ghosh MD, MNAMS, Priyanka Jain MS, Amit Bhatia MS, DNB
Management of cataract in child is a challenge. Child's eye is using an angled bevel-up crescent knife. The MVR blade is then
not just a miniature of adult eye, but it is growing, differentiating advanced along and under the tunneled incision and advanced
and highly predisposed to amblyopia if visual axis is obstructed till the tip is seen in the pupillary axis. Pars plana lensectomy is
for longer duration. Of the various surgical modalities available then performed with shallow anterior vitrectomy. A 360-degree
primary intraocular lens implanatation has the most favourable rim of anterior and posterior capsule along with the cortex is left
prognosis. A major obstacle however, to visual rehabilitation af- behind. An air bubble is left behind in the anterior chamber through
ter cataract extraction is occurrence of posterior capsular opacifi- the side port incision to maintain the tamponade on the
cation. The incidence of posterior capsular opacification in these corneoscleral incision site. Integrity of corneoscleral tunnel and
cases has been reported to be as high as 95.8%. Acrylic IOLs tunnel for cutter is checked by keeping the irrigation on. Apply-
have been successfully inserted through small incisions in pedi- ing gentle pressure on the globe checked the sclerotomy tunnel
atric eyes and have shown good results. One of the technique to for infusion. Tunnels should be sutured if found not self-sealing.
prevent posterior capsular opacification is posterior capsulorhexis Conjunctival closure is achieved with diathermy.
with optic capture of intraocular lens, but this technique is techni-
cally demanding and requires normal capsulocortical relationship Epilenticular IOL implantation is a primary procedure that
which is frequently altered in cases of traumatic cataracts. More- is easier to perform, provides a well-centered IOL and most impor-
over after cataract can form if anterior vitrectomy is not performed tantly maintains a clear visual axis. Because the IOL is implanted
as anterior vitreous face acts as scaffold for lens epithelial migra- in the ciliary sulcus, its insertion is independent of posterior cap-
tion. Vasavada reported that anterior vitreous face is more reac- sular status. It therefore ensures posterior chamber IOL insertion
tive in children and inflammatory response is severe, fibrous mem- in whom posterior capsular status is not known or in which there
brane can form on intact vitreous face and can cause central opaci- is a large capsular tear, as in cases of traumatic cataracts which
fication. This has lead to the concept of performing primary pos- account for 14% of pediatric cataracts. Scleral rigidity being low
terior capsulotomy and anterior vitrectomy at the time of cataract in children leads to scleral collapse and increased vitreous pres-
extraction and IOL implantation in children. Epilenticular IOL im-
plantation is another successful technique where the IOL is in- sure. This in turn Fig 1: Surgical steps a) Entry into the
serted over the cataractous lens through limbal incision and then leads to problems like anterior chamber through self-sealing
pars plana lensectomy and anterior vitrectomy is performed leav- difficulty in IOL inser-
ing behind the peripheral rim of anterior and posterior capsule, tion, recurrent iris corneosceral tunnel.
which supports and maintains well-centered IOL and maintains prolapse, shallowing
clear papillary axis allowing earlier patient rehabilitation. of anterior chamber
and problems in
Surgical Technique corneoscleral sutur-
ing. This not only in-
The surgery is performed under coaxial operating microscope. creases the operative
After cleaning and draping, a wide fornix based peritomy is per-
formed from 3 O' clock to 9 O' clock. A superior 5.5 - 6.5 mm scleral time but also causes
tunnel incision is made approximately 2.5mm posterior to the lim- trauma to iris, in-
bus. The incision is then tunneled into the
cornea making a corneal valve. The intraocu-
lar lens is implanted into the ciliary sulcus
over the cataractous lens. Two self-sealing
sclerotomy ports are then made at 10 O' clock
to 2 O' clock position, 2.5 - 3.0 mm posterior
to limbus, for the infusion cannula and the
vitrectomy cutter. The intended sclerotomy
is marked using calipers and a 0.25 mm scleral
deep incision created 2 mm posterior to it b) The intended sclerotomy is marked and a c) The MVR blade is then advanced along and
0.25 mm scleral deep incision created 2 mm under the tunneled incision and advanced till
Guru Nanak Eye Centre,
Maulana Azad Medical College, New Delhi posterior to it using an angled bevel-up the tip is seen in the pupillary axis.
crescent knife.
August, 2004 64 DOS Times - Vol.10, No.2
d) In the bag lensectomy performed, pupillary e) Air injected into anterior chamber All 54 eyes maintained a clear pupil-
axis is clear with 360 rim of anterior and for tamponade. lary axis from immediate postoperative
posterior capsules. period to the last follow up. The periph-
eral cortical matter enveloped between the
anterior and posterior capsule did not
cause much inflammatory response. Mild
postoperative inflammatory response was
seen in 22.2% eyes, which resolved with
frequent topical steroids. All eyes had vi-
sual acuity of 6/12 or better (55.5 % were
6/9, & 16.67 were 6/6). Mean surgically in-
duced astigmatism was less than 1.5 D in
creased incidence of iritis and papillary deformity. Tunneled all eyes, less than 1.0 D in 61.6% eyes and less than 0.5 D in
corneoscleral incision on the other hand has advantage of pro- 16.67% eyes. Wound stability was high in all except one, in whom
viding reliable wound apposition, and also prevents intraopera- a conjunctival bleb was formed, which resolved by day 4 with
tive iris prolapse and maintains the anterior chamber well. Su- pressure bandage.
tured pars plana ports increase the incidence of fibroplasias at
the wound site, traction and mechanical problems like retinal To conclude, the technique of sutureless IOL implantation
breaks, detachment and hemorrhage. Sutureless pars plana ports in childhood cataract is a very viable option, as it allows allows
are reported to have low incidence of retinal or vitreous hernia- posterior chamber intraocular lens implantation irrespective of
tion into the wound, minimize fibroplasias at the wound site and type of cataract, decreases not only preoperative problems and
negates all suture related problems. Although sutureless operative time, but also decreases postoperative reaction and
corneoscleral tunnels are widely accepted in adults, not many other complications. It allows a well-centered intraocular lens
studies have been conducted in children. In children there is only implantation and maintains a clear papillary axis. Patient rehabili-
one study which has evaluated use of sutureless pars plana ante- tation is also reasonably fast.
rior vitrectomy through self-sealing sclerotomies which concludes
that although scleral rigidity is low in children, the self sealing References
effect of this technique is good with the integrity of eyeball well
maintained. 1. Sinskey RM, Stoppel JO. Long term results of intraocular lens
implantation in pediatric patients. J Cataract Refract
B. Ghosh et al (GNEC) - Evaluated epilenticular intraocular lens Surg,1993;19:405-408.
implantation using tunneled incisions in traumatic cataract in chil-
dren and young adults. 2. Koenig SB, Ruttum MS. Pseudophakia for traumatic cataracts in
children. Ophthalmology,1993;100:1218-1224.
This prospective study included 54 eyes of childhood traumatic
cataract having mean age of 7.1 years (4 - 12 years). The most 3. Knight-Manan D, O'keefe M, Bowell R. Outcome and complica-
common causes of trauma were injuries with stick (33.3%) or bow tions of intraocular lenses in children with cataract. J Cataract Re-
and arrow (22.2%). All types of injuries were seen more com- fract Surg,1996;22:730-736.
monly in boys than in girls (M:F,2:1). Patients with active inflam-
mation, infection, significant corneal opacities, secondary glau- 4. Apple DJ, Trivedi RH, Pandey SK. Pediatric cataract. Surv
coma and gross posterior segment abnormalities were excluded Ophthalmol,2000;45(1):150-168.
from the study. The follow up ranged from 3-9months.
5. Gimbel HV. Posterior capsulorhexis with optic capture in pediatric
cataract and intraocular lens surgery. Ophthalmol-
ogy,1996;103:1871-1875.
6. Vajpayee RB, Augra SK, Honavar SG. Pre-existing posterior cap-
sular breaks from perforating ocular injuries. J Cataract Refract
Surg,1994;20:291-294.
7. Buckly EG, Klombers LA, Seaber
JH. Management of posterior cap-
sule during pediatric intraocular
lens implantation. Am J
Ophthalmol, 1993;115:722-758.
8. Vasavada A, Desai J. Primary pos-
terior capsulorhexis with and with-
out anterior vitrectomy in congeni-
tal cataract. J Cataract Refract
Surg,1997;23supp:645-651.
9. Dennis SC Lam, John KH Chua,
Alfred TS. Sutureless pars plana
vitrectomy through self sealing
sclerotomies in children. Arch
Ophthalmol, 2000;118.
Fig 2: a) Preop partially absorbed traumatic cataract b) Postop day 1 , clear papillary axis, minimal reaction,
with posterior synechiae. air bubble in anterior chamber and visual acuity 6/6.
August, 2004 65 DOS Times - Vol.10, No.2
TEAR SHEET NO. 12
Ocular Lesions in AIDS
A. Ocular Adnexal Lesions
1. Herpes Zoster Ophthalmicus
2. Kaposi’s sarcoma of eyelid and conjunctiva
3. Mollusum Contagiosum of eyelid
4. Conjunctival microvasculopathy
5. Pyogenic injection of eyelid and adenexa
6. Allergic injective conjunctivitis
B. Anterior Segment Lesions
1. Dry eye
2. Infective keratitis (varicella zoster, herpes simplex, microsporidia)
3. Anterior uveitis
- Cidofir induced
- Rifabutin induced
- Spill over from cytomegalovirus retinitis
4. Herpes zoster ophthalmicus
C. Posterior Segment Lesions
1. HIV Retinopathy
2. Cytomegalo virus Retinitis
3. Progressive outer retinal necrosis (PORN)
4. Acute Retinal necrosis (ARN)
5. Herpes zoster Retinopathy
6. Pneumocystis carini choroidopathy
7. Ocular syphilis
8. Fungal endophthalmitis (cryptococcus, candida)
9. Mycobacterial Infection
10. Toxoplasmic Retinochoroiditis
D. Orbital Lesions
1. Burkits lymphoma
2. Orbital cellulitis (Aspergillus)
E. Neuro-ophthalmic Lesions
1. Cranial nerve palsies
2. Lagophthalmos
3. Optic Neuropathy
August, 2004 – Harish Pathak, MD Vijay B. Wagh, MD
Dr. R.P. Centre, AIIMS, New Delhi
66 DOS Times - Vol.10, No.2
DOS QUIZ
DOS QUIZ NO. 12
1. Most common system disease associated with angiod streak is ............................................................................
2. Ocular feature of Aicardi Syndrome is ....................................................................................................................
3. Corneal Dystrophy with features of both granular & lattice dystrophies............................................................
4. Park three step test is described for diagnosis ........................................................................................................
5. Retinal Astrocytoma is associated with ..................................................................................................................
6. Most common cause of unilateral proptosis is ........................................................................................................
7. Type 3 Blepharophimosis syndrome is characterized by .......................................................................................
8. Which type of Juvenile rheumatoid arthritis is associated with uveitis ................................................................
9. Drug of choice for single dose treatment of trachoma is ........................................................................................
10. Ferry line is seen in ...................................................................................................................................................
Rules:
Please send your entries to the DOS office latest by 10th September, 2004.
Prize Rs.500/- Courtesy: Syntho Pharmaceuticals
ANSWERS OF DOS QUIZ NO. 10
1. Best material for frontalis sling surgery is .............................................. Autogenous fascia lata sling
2. M.C. acute optic neuropathy in old age group ...................................... Non arteritic
3. Concentration of topical amphotericin B in fungal keratitis? ................... 0.15%
4. Concentration of Hyaturanate in Healon 5 ............................................ 2.3%
5. Most common dye used in photodynamic therapy ................................ Verteporfin
6. Father of Retinal detachment fingery .................................................... Gonin
7. Angle of mirror in Gold man single mirror genioscope ........................... 62O
8. Most common lid tumour in India is ..................................................... Sebaceous cell carcinoma
9. Double wall sign on USG is seen in ..................................................... Hydatid cyst
10. PCO is minimum with which IOL optic material ................................... Acrylic (single piece Acrysof)
August, 2004 67 DOS Times - Vol.10, No.2
FORTHCOMING EVENTS
INTERNATIONAL NATIONAL
XXII Congress of the ECRS 9th Dr. R.K. Seth's Memorial Symposium on
"Diabetic Retinopathy: An Overview"
Date : 18-22 September, 2004
Temple House, Road Date : 2nd October, 2004
Blackrock, Co Dublin, Ireland Venue : India Habitat Centre, Lodhi Road, New Delhi
Venue : Paris, France Contact : S. Zafar
Contact: ESCRS Venu Eye Institute & Research Centre,
Tel : +353-1-209-1100 Fax : +353-1-209-1112 1/31 Sheikh Sarai Institutional Area,
Email : [email protected] Phase - II, New Delhi - 110017,
Web : www.escrs.org Ph : 29251951, 29251155, 29252417, 29250757
Fax : 011-29252370
American Academy of Ophthalmology Email : [email protected], [email protected]
23-26th October, 2004 DOS Midterm Conference
New Orleans, LA, USA
American Academy of Ophthalmology 21st November, 2004
Tel : + 1-415-561-8500 Ext. 304 Contact : Dr. Jeewan S. Titiyal
Fax : + 1-415-561-8583 Secretary DOS
Web : www.aao.org R.No. 476, 4th Floor,
Dr. R.P. Centre for Ophthalmic Sciences
20th Asia Pacific Academy of Ophthalmology AIIMS, Ansari Nagar, New Delhi – 110029
Congress Ph : 91-011-26589549, 265888852-65 Ext. 3146
Fax : 91-011-26588919
27-31st March, 2005 Email : [email protected]
Kuala Lumpur, Malaysia Website : www.dosonline.org
The 20th Asia Pacific Academy of Ophthalmology
Congress 63rd All India Ophthalmological Society
Tel : +603-7956-3113 Fax : +603-7960-8297 Conference
Email : [email protected]
Web : www.apao2005.com.my 13-16th January, 2005
Contact : Dr. B. K. Tripathy
5th International Glaucoma Symposium Organising Secretary,
Bimal Tripathy Lane, Mahatab Road,
20th March, 2005 – 2nd April, 2005 Cuttack – 753001, Orissa
Cape Tow, South Africa Ph : 0671-2310111, 2332483 Fax : 0671-2330111
Contact : Kenes International E-mail : [email protected]
Tel : +41-22-908-04-88 Fax : +41-22-7322850
Email : [email protected] Annual DOS Conference
Website : www.kenes.com/glaucoma
2nd & 3rd April, 2005
ASCRS/ASOA Meeting Congress Contact : Dr. Jeewan S. Titiyal
Secretary DOS
16-20th April, 2005 R.No. 476, Dr. R.P. Centre for Ophthalmic Sciences,
Washington, DC AIIMS, Ansari Nagar, New Delhi – 110029
Contact : ASCRS Ph : 91-011-26589549, 265888852-65 Ext. 3146
Tel : +1-703-591-2220 Fax : +1-703-591-0614 Fax : 91-011-26588919 Email : [email protected]
Web : www.ascrs.org Website : www.dosonline.org
August, 2004 68 DOS Times - Vol.10, No.2
DELHI OPHTHALMOLOGICAL SOCIETY
(LIFE MEMBERSHIP FORM)
Name (In Block Letters) __________________________________________________________________________
S/D/W/o _____________________________________________________________ Date of Birth _____________
Qualifications _________________________________________________________ Registration No. __________
Sub Speciality (if any) ___________________________________________________________________________
ADDRESS
Clinic/Hospital/Practice ______________________________________________________________________
_______________________________________________________________ Phone __________________
Residence ________________________________________________________________________________
_______________________________________________________________ Phone __________________
Correspondence ___________________________________________________________________________
_______________________________________________________________ Phone __________________
Email ___________________________________________________________ Fax No. ________________
Proposed by
Dr. ____________________________________ Membership No. _________ Signature __________________
Seconded by
Dr. ____________________________________ Membership No. _________ Signature __________________
[Must submit a photocopy of the MBBS/MD/DO Certificate for our records.]
I agree to become a life member of the Delhi Ophthalmological Society and shall abide by the Rules and
Regulations of the Society.
(Please Note : Life membership fee Rs. 3100/- payable by DD for outstation members. Local Cheques acceptable, payable
to Delhi Ophthalmological Society)
Please find enclosed Rs.____________in words _______________________________________________________ by Cash/
Cheque/DD No._______________________ Dated_____________ Drawn on_______________________________________
Signature of Applicant
with Date
Three specimen signatures for I.D. Card.
FOR OFFICIAL USE ONLY
Dr.___________________________________________________________________has been admitted as Life Member of
the Delhi Ophthalmological Society by the General Body in their meeting held on________________________________
His/her membership No. is _______________. Fee received by Cash/Cheque/DD No._______________ dated__________
drawn on __________________________________________________________________.
(Secretary DOS)
August, 2004 69 DOS Times - Vol.10, No.2
INSTRUCTIONS
1. The Society reserve all rights to accepts or reject the application.
2. No reasons shall be given for any application rejected by the Society.
3. No application for membership will be accepted unless it is complete in all respects and accompanied by a
Demand Draft of Rs. 3100/- in favour of “Delhi Ophthalmological Society” payable at New Delhi.
4. Every new member is entitled to received Society’s Bulletin (DOS Times) and Annual proceedings of the
Society free.
5. Every new member will initially be admitted provisionally and shall be deemed to have become a full member
only after formal ratification by the General Body and issue of Ratification order by the Society. Only then he
or she will be eligible to vote, or apply for any Fellowship/Award, propose or contest for any election of the
Society.
6. Application for the membership along with the Bank Draft for the membership fee should be addressed to Dr.
Jeewan S. Titiyal, Secretary, Delhi Ophthalmological Society, R.No. 476, 4th Floor, Dr. R.P. Centre for Oph-
thalmic Sciences, AIIMS, Ansari Nagar, New Delhi – 110029.
7. Licence Size Coloured Photograph is to be pasted on the form in the space provided and two Stamp/ Licences
Size Coloured photographs are required to be sent along with this form for issue of Laminated Photo Identity
Card (to be issued only after the Membership ratification).
!!Attention!!
Case Presentation in the Monthly Meetings
by Non Institutional Members
There will be one non Institutional case presentation/Clinical talk by one of
the DOS member during the monthly meeting. The presentation will be done
by a non Institutional member where monthly meetings are not being held.
The presenter will be allowed to present a case or a clinical talk for same
amount of time as it is given for other presentations in the monthly meeting.
Interested members should contact secretary DOS at least two weeks before
the monthly meeting with details of their presentation. If there are more
than one request then they will be given opportunity in the next monthly
meeting. The
President and Secretary will review the presentation for its clinical and sci-
entific contents. These non Institutional presentation will be graded for the
best case presentation/Clincal talk as it is done for Institutional presenta-
tions and they will be eligible for best presentation award.
August, 2004 70 DOS Times - Vol.10, No.2
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