51Dialogues and InsightsDOS Times - Volume 31 Number 4, January-February 2026cused. The following recommendations are proposed:1. Adopt Competency-Based Curriculaa. Implement structured, outcome-driven training with defined learning milestones.b. Use standardized assessment tools such as MiniCEX, DOPS, and global rating scales.[1]c. Mandate simulation-based training and wet lab exposure early in residency to build technical confidence.[8]2. Formalize Mentorship Structuresa. Move from informal mentoring to institutionally supported systems.b. Provide faculty training, protected time, and role recognition.c. Long-term mentorship improves surgical outcomes and professionalism.[9]3. Integrate Non-Clinical Competenciesa. Include modules on leadership, ethics, communication, and digital literacy.b. These are essential for managing healthcare systems and interdisciplinary teams.[11]4. Align National Curricula with Global Standardsa. Follow frameworks from ICO and EBO for consistency and international recognition.b. This promotes cross-border mobility and standardized care.[2]5. Invest in Global and Technological Innovationa. Expand international partnerships, digital mentorship, and AI integration in training.b. Ensure equity by providing all trainees, regardless of region, access to modern ophthalmic education.[10]As the field continues to advance, embracing innovation while upholding humanistic, evidence-based training will define the success of future ophthalmologists.ConclusionPostgraduate ophthalmology training is undergoing a transformative shift, moving beyond traditional models toward a more structured, competency-driven, and globally aligned framework. As this evolution unfolds, the integration of simulation-based learning, formal mentorship, non-clinical skill development, and technology-driven innovation will be central to preparing future ophthalmologists. Aligning local curricula with international standards such as those from the ICO and EBO ensures consistency and global mobility, while targeted investments in mentorship, ethics, and AI-enabled education will help address inequities in training access. Ultimately, the modern ophthalmologist must emerge not only as a skilled surgeon but as a reflective leader, ethical clinician, and globally competent professional, ready to meet the complex demands of 21st-century eye care with confidence and compassion.References1. Sud R, Khanduja S. Implementing competency-based medical education in post-graduate ophthalmology training: Understanding key concepts and methodologies and overcoming challenges. Indian J Ophthalmol. 2022;70(10):3743–7.2. Filipe HP, Yaïci R, Ivekovic R, Curtin D. Training requirements for the specialty of ophthalmology: Recommendations from the UEMS Section of Ophthalmology and the European Board of Ophthalmology. Acta Ophthalmol. 2025;103(1):12–8.3. Succar T, Grigg J, Beaver HA, Lee AG. A systematic review of best practices in teaching ophthalmology to medical students. Surv Ophthalmol. 2016;61(1):83–94.4. Krungkraipetch L, Krungkraipetch N. Global disparities in ophthalmology education and alignment with International Council of Ophthalmology guidelines: A systematic review. BMC Med Educ. 2025;25(1):145.5. Oetting TA, Lee AG, Beaver HA. Teaching and assessing surgical competency in ophthalmology training programs. Ophthalmic Surg Lasers Imaging. 2006;37(5):384–93.6. Lee AG, Beaver HA, Greenlee E, Oetting TA. Teaching and assessing systems-based competency in ophthalmology residency training programs. Surv Ophthalmol. 2007;52(6):687–701.7. Geary A, Wen Q, Adrianzén R, Congdon N. The impact ofdistance cataract surgical wet laboratory training on cataract surgical competency of ophthalmology residents. BMC Med Educ. 2021;21(1):475.8. Dormegny L, Lansingh VC, Lejay A, Chakfe N. Virtual reality simulation and real-life training programs for cataract surgery: A scoping review. BMC Med Educ. 2024;24(1):134.9. Bourke L, Conway C, Abdalla ME. Mentorship in surgical training: A systematic scoping review to inform a mentorship framework for ophthalmology trainees. BMC Med Educ. 2025;25(1):55.
Dialogues and InsightsDOS Times - Volume 31 Number 4, January-February 2026 5210. Camacci ML, Cayton TE, Chen MC. International experiences during United States ophthalmology residency training: Perspectives of faculty mentors. PLoS One. 2019;14(11):e0225627.11. Siddiqui ZK, Tomlinson J, Jayasuriya R. Transition from surgical trainee to consultant practice: A scoping review of non-clinical deficiencies in higher surgical training. BMC MedEduc. 2025;25(1):119.12. Wentzell DD, Chung H, Hanson C, Gooi P. Competency-based medical education in ophthalmology residency training: A review. Can J Ophthalmol. 2020;55(1):e1–e7.13. Filipe HP, Golnik K, Buque A, et al. Strive to thrive—an international partnership for developing an outcome-based curriculum for cataract surgery training by simulation. Ann Eye Sci. 2025;6(3):e28.14. Tiggelaar IG, Janszen EWM, van Elteren M, et al. Dutch postgraduate training in Global Health and Tropical Medicine: A qualitative study on graduates’ perspectives. BMC Med Educ. 2025;25(1):92.15. He B, de Smet MD, Sodhi M, Etminan M, Maberley D. A review of robotic surgical training: Establishing a curriculum and credentialing process in ophthalmology. Eye (Lond). 2021;35(12):3213–20.16. McDonnell PJ, Kirwan TJ, Brinton GS, Golnik KC. Perceptions of recent ophthalmology residency graduates regarding preparation for practice. Ophthalmology. 2007;114(2):387–91.
53Dialogues and InsightsDOS Times - Volume 31 Number 4, January-February 2026Value-Based Care in Ophthalmology: A Financial Sustainability Framework for IndiaThe Economic Burden of Preventable BlindnessIndia has 4.95 million blind citizens representing 0.36% prevalence. Annual economic losses total INR 845 billion ($ 38.4 billion), with per-capita loss of INR 170,624 per blind person.[1] Direct costs comprise INR 768 billion, with caregiver costs adding INR 141 billion annually. Visual impairment beyond blindness generates additional INR 646 billion in productivity losses. Cumulative lifetime losses reach INR 19,512 billion, with 82.3% (INR 11,779 billion) attributable to avoidable causes.[2]Cataract accounts for 62.6% of blindness despite surgical correction availability.[3] Among 101 million diabetics, 12.5-16.9% have diabetic retinopathy, with 3.6-4.0% requiring intervention (approximately 3 million patients).[4] Current cataract surgical rate of 6,500 per million population remains below target of 10,000. Out-of-pocket expenditure constitutes 47-62.6% of total health spending, driving 18% of households into catastrophic expenditure.[7]Current Payment System LimitationsFee-for-service payment models create incentive misalignment. Revenue generation occurs through Dr. Obuli Ramachandran N MD, MRCS(Ed)Centre for Sight Eye InstituteObuli Ramachandran[1] N MD, MRCS(Ed), FICO, AMPH(ISB) | Gauri Khare[1] DNB, FAICO | Soumya Jena[2] MS | Kritika Singh[3] MS1. Director, Aavinyaa Strategies, Consultant, Centre For Sight2. Vitreoretinal Fellow, Shiley Eye Institute, San Diego, USA3. Consultant, Dayal Eye Centre, GurugramAbstract: India loses INR 845 billion annually to preventable blindness. Analysis of existing infrastructure including Ayushman Bharat, Aravind Eye Care, and AI screening capabilities reveals economic feasibility of value-based payment models. Ophthalmologic interventions deliver median cost-effectiveness of $5,219 per QALY, below India’s $2,000-7,500 threshold. Implementation barriers include 1:100,000 ophthalmologist ratio and 47-62.6% out-of-pocket expenditure. Phased rollout combining bundled payments with capitation represents viable transformation pathway. Kaiser Permanente model demonstrates 73% reduction in acute care utilization through capitation-based financing.procedures rather than prevention or care coordination. A patient who never develops vision-threatening diabetic retinopathy generates no reimbursement under current structures. The same patient requiring monthly antiVEGF injections becomes a recurring revenue source. This structural design rewards volume over outcomes.[5,6]PM-JAY reimburses INR 750 for cataract surgery, covering basic consumable costs but inadequate for comprehensive perioperative care.[25] This underfunding creates pressure for high-volume, low-touch care delivery. Systematic prevention programs remain financially unsupported despite documented cost-effectiveness.International Evidence: The Kaiser Permanente ModelKaiser Permanente serves 12.6 million members through integrated structure combining nonprofit health plan, hospitals, and physician groups.[8] Capitation-based financing provides fixed per-capita budgets, aligning financial incentives with prevention and quality outcomes. This model achieves 73% reduction in acute bed utilization versus UK NHS despite comparable costs.[9,10]In ophthalmology, Kaiser achieved zero endophthalmitis in 21,501 consecutive cataract surgeries.[8] Recent implementations demonstrate scalability. Brazil’s Vera Cruz achieved 24.7% cost reduction with Net Promoter Score of 94.[11] Medicare Shared Savings Program saved $1.8 billion in 2022.[12]
Dialogues and InsightsDOS Times - Volume 31 Number 4, January-February 2026 54India’s Existing Infrastructure AdvantagesAyushman Bharat covers 500 million beneficiaries with INR 5 lakh annual coverage.[13] This represents existing population-level payment infrastructure requiring incentive realignment rather than new system creation. The platform supports capitation models through modification of reimbursement structures.Aravind Eye Care System performs over 300,000 surgeries annually at $120 per cataract versus $3,000 in US.[14] Their cross-subsidization model between paying and free patients demonstrates value-based principles at scale. LV Prasad Eye Institute operates 275+ centers serving 34.[14] million people with 50% subsidized care,[24]proving integrated care networks function in Indian conditions.Artificial intelligence screening achieves 92-93.2% sensitivity for diabetic retinopathy.[15] This enables taskshifting with technicians performing initial screening Implementation BarriersIndia has one ophthalmologist per 100,000 population.[19] This workforce limitation prevents direct replication of Kaiser’s physician group model. Current Ayushman Bharat utilization shows minimal ophthalmology claims beyond cataract surgery, indicating limited population awareness of comprehensive eye care as insured benefit.Technology infrastructure gaps persist in rural areas. AI screening requires reliable internet connectivity, trained technicians, and established referral pathways. These resources remain inconsistent across India’s 600+ districts. Equipment costs and training requirements create initial investment barriers for smaller providers.Proposed Hybrid Payment ModelPure capitation models face implementation challenges in Indian context. Pure fee-for-service perpetuates existing misalignments. A hybrid approach combining three payment mechanisms addresses these limitations.First, bundled payments for high-volume procedures. Cataract surgery reimbursement of INR 2,500-3,500 would cover preoperative evaluation, surgery, postoperative care, and quality metrics. This represents 3.3-4.7x increase over current PM-JAY rate of INR 750 but aligns with actual cost structures. Evidence from US Medicare demonstrates bundled payments improve surgeon engagement while maintaining quality.[30]Second, capitation for chronic disease management. under AI guidance, reducing specialist workload requirements. Telemedicine platforms support remote consultation and care coordination across geographic distances.Cost-Effectiveness AnalysisOphthalmologic interventions demonstrate strong cost-effectiveness. Analysis of major procedures shows median ratio of $5,219 per quality-adjusted life year (QALY), below India’s threshold of $2,000-7,500.[16,17](Table-1 presents published cost-effectiveness data for common interventions.)These ratios compare favorably to many systemic medical interventions. Cataract surgery delivers one QALY for $219-657.[27] Anti-VEGF therapy costs $876-5,760 per QALY.[28] Complex vitrectomy ranges $2,000-15,000 per QALY.[29] Despite this value proposition, 47-62.6% of costs remain out-of-pocket due to payment system limitations rather than inherent expense.[7]Intervention Cost/QALY ($) India Threshold ReferenceCataract surgery 219-657 Highly cost-effective Lansingh 2007[27]Anti-VEGF for wet AMD 876-5,760 Cost-effective Brown 2006[28]DR screening program 2,600-5,850 Cost-effective Rachapelle 2013[18]Vitrectomy for DR 2,000-15,000 Cost-effective Smiddy 2000[29]Glaucoma screening 4,100-9,800 Cost-effective Various studies[16]Table 1: Cost-effectiveness of major ophthalmologic interventions. India threshold based on WHO guidelines of 1-3x GDP per capita ($2,000-7,500 per QALY). All interventions demonstrate cost-effectiveness by international standards.
55Dialogues and InsightsDOS Times - Volume 31 Number 4, January-February 2026Existing Models and ScalabilityNational Programme for Control of Blindness performed 7.4 million cataract surgeries in 2019-2020.[19] This demonstrates operational capacity for large-scale implementation. The challenge lies in payment reform rather than service delivery infrastructure.Private sector chains operate across multiple states with standardized protocols and quality metrics. Centre for Sight maintains 83 centers across 15 states. Dr. Agarwal’s Eye Hospital operates similar networks. These corporate models demonstrate scalable delivery systems requiring only payment structure modification to incentivize prevention.ConclusionValue-based care implementation in Indian ophthalmology represents economically viable pathway based on existing infrastructure analysis. Ayushman Bharat proComponent Year 1-2 (Pilot) Year 2-3 (State) Year 3-5 (National)Population covered 5 million 20 million 77 millionDR screening costs $25 million $100 million $385 millionSurgical backlog $45-60 million $135-180 million $360-480 millionTechnology infrastructure $6-12 million $60-120 million $600-1,200 millionTotal investment $76-97 million $295-400 million $1.3-2.1 billionPrevented blindness 50,000 cases 200,000 cases 800,000 casesEconomic value $388 million $1.6 billion $6.2 billionROI ratio 4-5:1 4-5:1 3-5:1Table 2: Phased implementation costs and projected returns. DR = diabetic retinopathy. ROI = return on investment. Economic value calculated at $7,756 per prevented blindness case based on productivity and caregiver cost savings. Technology infrastructure includes EHR systems, AI screening platforms, and telemedicine capabilities.Annual payment of INR 100-150 per diabetic covers comprehensive retinopathy screening and coordination regardless of treatment necessity. This structure rewards prevention rather than procedure volume. Providers receive payment whether patients require intervention, creating financial incentive for early detection and management.Third, quality bonuses of 5-10% of base payments for meeting defined metrics. These include screening rates, complication rates, patient satisfaction scores, and visual outcome measures. Performance-based components ensure accountability while maintaining flexibility in care delivery approaches. (Table-2 outlines phased implementation timeline with cost projections.)Pilot phase implementation in 5 million population requires $25 million for diabetic retinopathy screening infrastructure, $45-60 million for cataract surgical backlog, and $6-12 million for technology systems. Total investment of $76-97 million would prevent 50,000 blindness cases worth $388 million in economic value, yielding 4-5:1 return.[1,24]vides payment platform. Indigenous models demonstrate cost-effective delivery. AI screening enables workforce optimization. Strong cost-effectiveness ratios support investment case.Hybrid payment model combining bundled payments, capitation, and quality bonuses addresses implementation barriers while maintaining financial sustainability. Phased rollout starting with select districts allows validation and refinement before national scaling.The transformation requires policy commitment to payment reform rather than new infrastructure creation. India has clinical expertise, institutional models, payment platforms, and technology enablers. Implementation depends on aligning financial incentives with prevention and quality outcomes rather than procedure volume.References1. Marmamula S, Khanna RC, Rao GN. Rapid assessment of
Dialogues and InsightsDOS Times - Volume 31 Number 4, January-February 2026 56visual impairment in India. PLoS One. 2022;17(7):e0271468.2. Malhotra S, Vashist P, Gupta N, et al. Prevalence and causes of visual impairment amongst older adults in a rural area of North India: a cross-sectional study. BMJ Open. 2022;12(8):e058156.3. Vashist P, Senjam SS, Gupta V, et al. Blindness and visual impairment and their causes in India: Results of a nationally representative survey. PLoS One. 2022;17(7):e0271736.4. Raman R, Vasconcelos JC, Rajalakshmi R. Prevalence and risk factors for diabetic retinopathy in India. J Ophthalmic Vis Res. 2021;16(2):166-172.5. Porter ME, Kaplan RS. How to pay for health care. Harv Bus Rev. 2016;94(7-8):88-98,100,134.6. Berwick DM, Nolan TW, Whittington J. The triple aim: care,health, and cost. Health Aff. 2008;27(3):759-769.7. National Health Accounts Estimates for India 2019-20. Ministry of Health and Family Welfare, Government of India; 2022.8. McCarthy D, Mueller K, Wrenn J. Kaiser Permanente: bridging the quality divide with integrated practice, group accountability, and health information technology. Commonwealth Fund. 2009;17:1-24.9. Ham C, York N, Sutch S, et al. Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme. BMJ. 2003;327(7426):1257.10. Feachem RGA, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California’s Kaiser Permanente. BMJ. 2002;324(7330):135-143.11. Carvalho FF, Daniel MM, Coimbra CJE, et al. High performance of an accountable care organization in Brazil: the Vera Cruz case. BMC Health Serv Res. 2022;22(1):412.12. Centers for Medicare & Medicaid Services. Medicare Shared Savings Program Saves Medicare More Than $1.8 Billion in2022; 2023.13. National Health Authority. Ayushman Bharat Digital Mission Dashboard; 2024.14. Prajna NV, Chandrakanth KS, Kim R, et al. The MaduraiIntraocular Lens Study. II: Clinical outcomes. Am J Ophthalmol. 1998;125(1):14-25.15. Ting DSW, Cheung CY-L, Lim G, et al. Development and validation of a deep learning system for diabetic retinopathy and related eye diseases using retinal images from multiethnic populations. JAMA. 2017;318(22):2211-2223.16. Brown MM, Brown GC, Sharma S, et al. The burden of agerelated macular degeneration: a value-based medicine analysis. Trans Am Ophthalmol Soc. 2005;103:173-186.17. Woods B, Revill P, Sculpher M, et al. Country-level costeffectiveness thresholds: initial estimates and the need forfurther research. Value Health. 2016;19(8):929-935.18. Rachapelle S, Legood R, Alavi Y, et al. The cost-utility oftelemedicine to screen for diabetic retinopathy in India. Ophthalmology. 2013;120(3):566-573.19. National Programme for Control of Blindness & Visual Impairment Annual Report 2019-2020. Ministry of Health and Family Welfare, Government of India; 2020.24. ThulasirajRD, Nirmalan PK,RamakrishnanR, et al. Blindnessand vision impairment in a rural south Indian population. Ophthalmology. 2003;110(7):1491-1498.25. Murthy GVS, Gupta SK, Bachani D, et al. Current estimates of blindness in India. Br J Ophthalmol. 2005;89(3):257-260.27. Lansingh VC, Carter MJ, Martens M. Global cost-effectivenessof cataract surgery. Ophthalmology. 2007;114(9):1670-1678.28. Brown MM, Brown GC, Sharma S, et al. Cost-effectivenessof ranibizumab for age-related macular degeneration. Curr Opin Ophthalmol. 2006;17(3):228-233.29. Smiddy WE. Economic considerations of macular hole surgery. Ophthalmology. 2000;107(11):1977-1981.30. Miller DC, Gust C, Dimick JB, et al. Large variations in Medicare payments for surgery highlight savings potential from bundled payment programs. Health Aff. 2011;30(11):2107-2115.
57Picture PerspectiveDOS Times - Volume 31 Number 4, January-February 2026CaseA 7-year-old male child was brought by his father with complaints of an abnormal appearance of the right eye for the past few months. The primary concern was a progressively increasing whitish reflex in the pupillary area. The parents also noted occasional outward deviation of the right eye. There was no history of ocular pain, redness, trauma, photophobia, or prior ocular surgery.The antenatal, perinatal, and developmental history was unremarkable. There was no history of prematurity or oxygen supplementation. Family history was non-contributory.On examination, visual acuity in the right eye was inconsistent, with occasional perception of light but unreliable responses. The left eye had normal visual acuity. A right exotropia of approximately 15 degrees was noted. Anterior segment examination was normal, with no evidence of inflammation or neovascularization. Pupillary reactions and intraocular pressure were within normal limits.Dr. Anubhav Chauhan MSMedical Officer(Specialist), Civil hospital Sundernagar, Distt. Mandi, Himachal Pradesh, IndiaFundus examination revealed a whitish-yellow reflex (leukocoria/xanthocoria). The retina showed diffuse yellowish subretinal exudation with obscuration of retinal details.CT scan demonstrated a funnel-shaped retinal detachment reaching up to the posterior lens surface along with a heterogeneously hyperdense lesion in the vitreous cavity. Importantly, there was no intraocular calcification, which is a key differentiating feature from retinoblastoma.[4,7,11]OCT imaging could not be performed adequately due to extensive exudation and total retinal detachment.Based on these findings, a provisional diagnosis of advanced Coats disease was made. However, given the presence of leukocoria, the patient was referred to a tertiary vitreoretinal center to rule out retinoblastoma and for further management.Figure 1: Whitish/yellowish fundal reflex (leucocoria/ xanthocoria).Coats Disease Presenting as Leukocoria in a Child: A Case Report and ReviewAnubhav Chauhan MS | Jitender Roodkee MBBS, DOMS | Arpit Joshi MSDepartment of Ophthalmology, Civil Hospital Sundernagar, Distt. Mandi, Himachal Pradesh, IndiaAbstract: Background: Coats disease is a rare, idiopathic retinal vascular disorder characterized by telangiectatic vessels and progressive lipid-rich exudation, often presenting in childhood. Leukocoria is a key presenting feature and necessitates urgent evaluation to exclude lifethreatening conditions such as retinoblastoma.Case Presentation: We report a case of a 7-year-old male presenting with leukocoria and exotropia in the right eye. Clinical examination and imaging revealed a funnel-shaped exudative retinal detachment without intraocular calcification, consistent with advanced Coats disease.Conclusion: Early recognition and differentiation from retinoblastoma are critical. Advanced cases require prompt referral and individualized management to preserve ocular integrity.Keywords: Coats disease, leukocoria, retinal detachment, pediatric retina, retinoblastoma differential
Picture PerspectiveDOS Times - Volume 31 Number 4, January-February 2026 58DiscussionPathophysiologyCoats disease is characterized by abnormal retinal vascular development, including telangiectasia and aneurysmal dilatations, leading to breakdown of the blood-retinal barrier and leakage of lipid-rich fluid.[1,3] Histopathological studies show endothelial cell damage and pericyte loss, contributing to increased vascular permeability.[3,8]Recent evidence suggests somatic mutations affecting vascular stability pathways may contribute to disease pathogenesis.[1,13]EpidemiologyThe disease predominantly affects males and is usually unilateral, with onset commonly in the first decade of life.[4,9] Bilateral involvement is rare. Early onset is often associated with more aggressive disease.[9,10]Clinical FeaturesThe hallmark feature is subretinal lipid exudation.Common presentations include:• Leukocoria (most common presenting sign)[4]• Decreased vision• Strabismus• AmblyopiaAdvanced disease may present with:• Exudative retinal detachment• Secondary glaucoma• Painful blind eyeAssociated findings include corneal edema, cataract, iris neovascularization, and anterior chamber cholesterolosis.[2,6]Differential DiagnosisLeukocoria in children requires urgent evaluation.The most critical differential is retinoblastoma.[4,7] Key distinguishing features include:• Presence of calcification in retinoblastoma• Absence of calcification in Coats diseaseOther differentials include:• Persistent fetal vasculature• Ocular toxocariasis• Retinal hemangioblastoma• Choroidal hemangiomaFigure 2: Funnel shaped retinal detachment reaching to the back of the lens.Figure 3: A heterogenously hyperdense lesion in the right globe extending to the vitreous.
59Picture PerspectiveDOS Times - Volume 31 Number 4, January-February 2026ComplicationsUntreated disease may lead to[6,14]:• Total retinal detachment• Neovascular glaucoma• Cataract• Cholesterosis bulbi• Phthisis bulbi• PrognosisPrognosis depends on stage at presentation. Early-stage disease has favorable outcomes, whereas advanced disease often results in poor visual recovery despite anatomical success.[4,9]ConclusionCoats disease is an important cause of leukocoria in children and must be differentiated from retinoblastoma. This case highlights the importance of imaging, particularly the absence of calcification, in diagnosis. Early detection and timely management are essential to preserve vision and prevent complications.DeclarationThe authors declare no financial or proprietary interests.References1. Ucgul AY, Özdek Ş. Coats’ disease: pathophysiology andadvances. Semin Ophthalmol. 2025;40:458–473.2. Mahesh M, Radke NV, Agrawal R, et al. International consensus guidelines on Coats disease. Am J Ophthalmol. 2026;282:162–168.3. Sigler EJ, Randolph JC, Calzada JI, et al. Current management of Coats disease. Surv Ophthalmol. 2014;59:30–46.4. Sen M, Shields CL, Honavar SG, Shields JA. Coats disease overview. Indian J Ophthalmol. 2019;67:763–771.5. Tsai ASH, Wang CT, Lee TC, et al. Treatment outcomes in Coats disease. Ophthalmol Retina. 2025;9:570–579.6. Shields JA, Eagle RC Jr, Shields CL, et al. Cholesterosis in Coats disease. Arch Ophthalmol. 1995;113:975–977.7. Shields CL, Mashayekhi A, Demirci H, et al. Differentiationof Coats disease and retinoblastoma. Ophthalmology. 2004;111:148–155.8. Reese AB. Telangiectasis of the retina. Am J Ophthalmol. 1956;42:1–8.• Endophthalmitis• Ocular toxoplasmosisImaging modalities such as CT and MRI are essential in differentiation.[7,11,15]ClassificationThe Shields classification system is widely used[4,12]:Stage 1: TelangiectasiaStage 2: ExudationStage 3: Retinal detachmentStage 4: Detachment with glaucomaStage 5: End-stage diseaseThis case corresponds to Stage 3–4 disease.InvestigationsInvestigations include:• Fundus examination• Fluorescein angiography• OCT• Ultrasound B-scan• CT/MRI imagingCT imaging is particularly valuable in excluding retinoblastoma.[7,11]ManagementTreatment is directed at ablating abnormal vessels and reducing exudation.[2,5]Early disease:• Laser photocoagulation• CryotherapyAdvanced disease:• Pars plana vitrectomy• Scleral buckling• Subretinal fluid drainageAdjunctive therapies include anti-VEGF agents and corticosteroids.[5,13,16]Recent international guidelines emphasize early diagnosis and individualized treatment.[2]
Picture PerspectiveDOS Times - Volume 31 Number 4, January-February 2026 609. Rishi P, Rishi E, Uparkar M, et al. Clinical spectrum of Coats disease. Retina. 2010;30:1531–1539.10. Smithen LM, Brown GC, Brucker AJ. Coats disease in adults. Ophthalmology. 2005;112:1072–1078.11. Mafee MF, Goldberg MF, Valvassori GE, et al. Imaging in Coats disease. Radiology. 1989;173:65–70.12. Shields CL, Shields JA. Classification of Coats disease. CurrOpin Ophthalmol. 2002;13:339–343.13. Daruich A, Matet A, Moulin A, et al. Mechanisms of exudation. Prog Retin Eye Res. 2017;56:1–19.14. Ghorbanian S, Jaulim A, Chatziralli IP. Updates in Coats disease. Ophthalmol Ther. 2012;1:1–9.15. Rootman DB, Gonzalez E, Mallipatna A, et al. DifferentiatingCoats disease and retinoblastoma. Br J Ophthalmol. 2011;95:1110–1114.16. Sun Y, Jain A, Moshfeghi DM. Anti-VEGF therapy in Coats disease. Retina. 2017;37:178–185.
61Picture PerspectiveDOS Times - Volume 31 Number 4, January-February 2026Pyogenic Granuloma of the Lacrimal Caruncle in a Lactating Female: A Case ReportIntroductionPyogenic granuloma (PG), also referred to as lobular capillary hemangioma, is a benign vascular lesion characterized by rapid growth and a tendency for spontaneous bleeding. Despite its name, the lesion is neither pyogenic nor granulomatous in nature. Instead, it represents a reactive proliferation of capillaries often triggered by local irritation, trauma, or hormonal influences.[1]Ocular pyogenic granulomas most commonly arise on the conjunctiva, eyelid, or following ocular surgery. However, involvement of the lacrimal caruncle is relatively uncommon.[2] The caruncle is a unique anatomical structure composed of modified cutaneous tissue containing sebaceous glands, sweat glands, and accessory lacrimal tissue. Due to this histological diversity, it can give rise to a wide spectrum of lesions, both benign and malignant.[3,4]The differential diagnosis of caruncular masses is broad and includes papilloma, nevus, oncocytoma, dermoid cyst, and vascular lesions, as well as malignant tumors Dr. Yogita Gupta MD, DNB, FICO, FRCS, MRCSEdSpecialist (Ophthalmology, Grade-III), Deen Dayal Upadhyay Hospital, Govt of NCT of Delhi.Aditi Prashar MBBS | Yogita Gupta MD, DNB, FICO, FRCS, MRCSEd | Amit Mehtani MS | Sushanki Chauhan MS | Minakshi Dalal MSDepartment of Ophthalmology, Deen Dayal Upadhyay Hospital, Hari Nagar, New Delhisuch as sebaceous carcinoma, melanoma, and squamous cell carcinoma.[3,4] Therefore, accurate diagnosis often necessitates histopathological examination.Case ReportA 31-year-old female presented to the ophthalmology outpatient department with complaints of bleeding from the inner corner of her left eye for the past two days. She reported noticing a small reddish swelling in the same region approximately three months prior, which had increased rapidly in size over time. The lesion was painless and not associated with redness, discharge, or visual disturbance.The patient first observed the swelling during the last trimester of her pregnancy. At that time, the lesion was small and asymptomatic, without any episodes of bleeding. At presentation, she was in the lactation period. There was no history of ocular trauma, prior surgery, chronic eye rubbing, or allergic conjunctivitis. Her systemic history was unremarkable.On ocular examination, best uncorrected visual acuity was 6/6 in both eyes. Slit-lamp examination of the left eye revealed a well-defined, reddish, polypoidal, pedunculated mass measuring approximately 5 × 4 mm arising from the lacrimal caruncle. The lesion had a smooth surface, appeared fleshy, and was nonAbstract: Pyogenic granuloma (PG) is a benign vascular proliferative lesion commonly arising on the skin and mucous membranes, including the ocular surface. Although frequently associated with prior trauma, surgery, or inflammation, its occurrence in the lacrimal caruncle remains rare. We report a case of a 31-year-old lactating female presenting with a rapidly growing, painless, bleeding mass at the medial canthus of the left eye. Clinical examination revealed a pedunculated, reddish lesion localized to the caruncle. Excision biopsy was performed, and histopathological evaluation confirmed the diagnosis of pyogenic granuloma. The postoperative course was uneventful with no recurrence at one month. This case highlights the importance of considering pyogenic granuloma in the differential diagnosis of caruncular lesions, especially in hormonally influenced states such as pregnancy and lactation, and underscores the role of surgical excision with histopathological confirmation.Keywords: Pyogenic granuloma, caruncle, medial canthus, benign capillary hemangioma
Picture PerspectiveDOS Times - Volume 31 Number 4, January-February 2026 62Figure 2: Post-operative image of the left eye showing complete resolution.Surgical ManagementThe lesion was excised under local anesthesia using 2% xylocaine infiltration. Complete excision of the mass along with its base was performed to minimize the risk of recurrence. The excised tissue was sent for histopathological examination. Postoperatively, the patient was prescribed antibiotics and analgesics for one week.Histopathological FindingsHistopathological examination revealed a polypoidal lesion lined by stratified squamous epithelium with areas of surface ulceration. The underlying stroma showed a lobular arrangement of proliferating capillaries separated by fibrous septa, along with mixed inflammatory infiltrates. These findings were consistent with pyogenic granuloma.[1]Follow-upAt one-month follow-up, there was no evidence of recurrence, and the surgical site had healed well. The patient remained asymptomatic, consistent with the favorable prognosis reported in the literature.[4]DiscussionPyogenic granuloma is a benign vascular lesion characterized by rapid growth, friability, and a tendency to bleed even with minimal trauma.[1] Although commonly seen on the conjunctiva and eyelid, its occurrence in the lacrimal caruncle is rare.[2]EtiopathogenesisThe exact pathogenesis of pyogenic granuloma is not fully understood; however, it is widely regarded as a reactive vascular proliferation rather than a true neoplasm.[1]Known predisposing factors include trauma, surgery, chronic inflammation, and hormonal influences.[1,5,6]In the present case, there was no history of trauma or surgery. However, the lesion appeared during pregnancy and enlarged rapidly thereafter, suggesting a hormonal contribution. Elevated levels of estrogen and progesterone during pregnancy are known to promote angiogenesis and vascular proliferation, which may contribute to the development of such lesions.Clinical FeaturesClinically, pyogenic granulomas present as rapidly growing, red, pedunculated or sessile lesions that may ulcerate and bleed easily.[1] They are usually painless and can vary in size.Caruncular lesions, however, require careful evaluation due to the wide range of possible benign and malignant conditions.[3,4]tender on palpation. It was firm in consistency, and transillumination was negative. There was no associated conjunctival congestion or discharge.No regional lymphadenopathy was noted. The right eye was within normal limits.Based on the clinical features, the differential diagnosis included pyogenic granuloma, squamous papilloma, dermoid cyst, dacryocele, sebaceous carcinoma, keratoacanthoma, and squamous cell carcinoma.[3,4] Given the rapid growth and recent onset of bleeding, an excision biopsy was planned.Figure 1: Magnified image of left eye caruncular pyogenic granuloma.
63Picture PerspectiveDOS Times - Volume 31 Number 4, January-February 2026Differential DiagnosisThe lacrimal caruncle may harbor various lesions due to its complex histological composition. These include benign lesions such as papilloma, nevus, and oncocytoma, as well as malignant tumors like sebaceous carcinoma and squamous cell carcinoma.[3,4]Distinguishing these lesions clinically can be challenging, and histopathological confirmation is essential in all suspicious or atypical cases.[3]HistopathologyThe characteristic histopathological feature of pyogenic granuloma is the presence of lobular aggregates of capillaries separated by fibrous septa, often accompanied by inflammatory infiltrates.[1] Surface ulceration is commonly seen in lesions prone to bleeding.ManagementComplete surgical excision remains the treatment of choice for pyogenic granuloma, particularly in atypical locations such as the caruncle.[4] This approach provides both definitive treatment and tissue for diagnosis.Alternative treatments include topical beta-blockers such as timolol and propranolol, which have shown efficacy in conjunctival pyogenic granulomas by inducing regression through vasoconstriction and inhibition of angiogenesis.[5,6] However, their role in caruncular lesions remains less well established.Laser therapy, particularly CO₂ laser, has also been used successfully in selected cases with favorable cosmetic outcomes.[7]PrognosisThe prognosis of pyogenic granuloma is excellent following complete excision, with a low rate of recurrence.[4] Incomplete removal may predispose to recurrence, emphasizing the importance of excising the lesion along with its base.ConclusionPyogenic granuloma of the lacrimal caruncle is a rare but important entity in the differential diagnosis of medial canthal masses. Hormonal influences, particularly during pregnancy and lactation, may contribute to its development.Given the wide spectrum of caruncular lesions, histopathological examination is essential for definitive diagnosis. Surgical excision remains the gold standard of management and is associated with excellent outcomes and minimal recurrence.References1. Singh A, Gupta S, Kumar S. Pyogenic granuloma of the caruncle: An unusual presentation. Nepal J Ophthalmol. 2012;4(7):160-163. doi:10.3126/nepjoph.v4i1.5843.2. Shah M, Khandekar R, Al-Rawahi H. Pyogenic granuloma of the lacrimal caruncle: A case report. Middle East Afr J Ophthalmol. 2010;17(1):79-81. doi:10.4103/0974-9233.61226.3. Shields JA, Shields CL. Caruncular tumors in 261 consecutive patients: The 2003 Montgomery Lecture, part 1. Eye (Lond).2004;18(1):13-19. doi:10.1038/sj.eye.6700567.4. Margo CE, Waltz K. Caruncular lesions. Ophthalmology. 1993;100(1):30-34. doi:10.1016/S0161-6420(93)31712-8.5. Ni N, Allen RC, Pelton RW, Sobrin L. Treatment of ocular pyogenic granuloma with topical timolol. JAMA Ophthalmol. 2016;134(9):1032-1034. doi:10.1001/jamaophthalmol.2016.2161.6. Bari E, Khademi B, Karami M. Recurrent conjunctival pyogenic granuloma successfully treated with topical propranolol: A case report and review. J Ophthalmic InflammInfect. 2023;13(1):12. doi:10.1186/s12348-023-00326-8.7. Figueiredo AR, Barbosa JC, Almeida MF, Silva JM. Pyogenic granuloma of the eyelid margin treated with CO₂ laser: Case report. Int Med Case Rep J. 2020;13:109-112. doi:10.2147/IMCRJ.S248553.
DOS Times - Volume 31 Number 4, January-February 2026 64 DOS Times - Volume 31 Number 4, January-February 2026 65The Surgeon’s FocusDOS Times - Volume 31 Number 4, January-February 2026Digging Deep: Orbital DermoidIntroductionDermoid and epidermoid are congenital benign cystic tumours. They are choriostomas, originating from aberrant primordial tissue. Hamartoma is a non-neoplastic disorganized collection of tissue, that is native to the site where it is located while choriostoma is a collection of normal tissue located in an abnormal site (i.e ectopic), non-neoplastic, formed during embryonic development when dermal or epidermal elements remain compressed and form cystic formations with a constant tendency to enlarge and progress.[1,2] About 50% of these tumours are localized in head, appearing in orbit or its surroundings. Nearly 10% of head and neck dermoids are localized in orbit.[3] Usually located in upper-orbital quadrants, near frontozygomatic or frontoethmoidal suture, respectively, cystic changes can be discovered early in dermoid.[4,5] These benign tumors are usually 1-2 cm in size, soft on palpation, ovoid in shape, not adherent to overlying skin or underlying tissue. Inner part of the cyst, is often attached to bony periosteum near suture lines. These can be very easily felt in children, while adults have unclear demarcation lines. During its growth, there is often surrounding bony remodelling due to long standing pressure from the tumor[6,7,8] choriostoma of both nervous and soft tissue types have been reported. Orbital dermoid can be classified as superficial versus deep or simple versus complicated. Superficial cysts rarely develop complications regarding growth, therefore can easily be handled surgically, however, they are frequently exposed to injuries and ruptures.[9,10,11] Deep orbital cysts are slow growing mass, sometimes forming Dr. Shreyasi SarkarMBBS, DO, DNBAssistant ProfessorDepartment of Ophthalmology, Vivekananda Instituteof Medical Sciences, RKMSP, Kolkata Shreyasi Sarkar MBBS, DO, DNB | Sweta Bhowal MBBS, MSDepartment of Ophthalmology, Vivekananda Institute of Medical Sciences, RKMSP, Kolkatathrough bony suture of orbit, including the superior orbital wall. A careful examination is necessary to separate superficial from deep as deeper ones can break through orbital wall and propagate into temporal cavity and sinuses, even into intracranial fossa.[12,13] Differentiation between dermoid and epidermoid cysts is not possible clinically. A histopathological examination shows that dermoid cysts have squamous epithelium that contains dermal appendages and produces keratin. They contain blood vessel, fat tissue, collagen, sebaceous glands and hair follicles. Colour can vary from dark yellow to white with oily, consistency can be gelatinous or solid. These cysts have different degrees of inflammation, so careful dissection is required during their removal to avoid further spread into surrounding orbital tissue.[13,14,15]Our case highlights the process of surgical excision of a large epidermoid orbital cyst, present since birth which was progressing.Case ReportA young girl of 4 year of age presented to us with a painless swelling over right eyebrow, approximately 1/3rd of it was below the supra-orbital margin and the rest 2/3rd was above it. It was present since birth, slowly increasing in size. On clinical examination, it was approximately of size 3.5 cm × 2 cm × 2cm, soft to moderately firm in consistency, globular shaped, nontender, not adherent to the surrounding structures. A bony indentation was noted radiologically. Contrast enhanced MRI scans suggested towards an intra-diploeic epidermoid cyst. An excision biopsy was performed, with supra-brow approach, parallelly, above the most prominent portion of the lesion. Submuscular dissection was carried out, to expose the lesion which was located below the muscular plane, made free of all its attachments, and taken out in-toto with the help of a cryo probe. Direct tumor touch was avoided, in order not to rupture or damage
DOS Times - Volume 31 Number 4, January-February 2026 64 DOS Times - Volume 31 Number 4, January-February 2026 65The Surgeon’s FocusDOS Times - Volume 31 Number 4, January-February 2026its capsule. Base of the lesion was completely adhered to the periosteum of the frontal bone, extending from the supra orbital region. No dermal adnexal structures such as sebaceous glands, hair follicles, or sweat glands noted on cyst wall, suggestive of epidermoid inclusion cyst. Histopathological analysis revealed cystic lesion, lined by keratinizing squamous epithelium of size 2 cm x 1.5 cm x 1.5 cm, consistent with diagnosis of epidermoid cyst. Postoperatively, healing was uneventful with minimal scarring. Figure 1: Patient showing right sided mass involving the right lateral upper eyelid below and above eyebrow.Figure 2: Patient post operative after excision of mass in toto showing healed wound. Figure 4: Histopathology slides showing grey white partly grey brown soft ovoid cyst suggestive of epidermoid cyst. Figure 3: (A) Intraoperative picture showing mass while excision (B) Postoperative measurements of excised mass in toto.
DOS Times - Volume 31 Number 4, January-February 2026 66 DOS Times - Volume 31 Number 4, January-February 2026 67The Surgeon’s FocusDOS Times - Volume 31 Number 4, January-February 2026DiscussionOrbital dermoid cysts are most common type of orbital cyst (89%) in pediatric population.[19] Indications to treat epidermoid cysts of the orbit operatively depends on symptoms like pain, restriction of extraocular movements, progressive increase in size or worsening of symptoms, like ptosis, diplopia, orbital inflammation (if cyst ruptures) or fistula, nasolacrimal duct obstruction, choroidal folds or proptosis. Rupture of cyst can be spontaneous or traumatic, resulting in an inflammatory reaction. CT or MRI helps, especially for deep complicated cysts, where bony changes are reported in around 85% of patients and 61% are noted to have visible cystic wall.[19]Calcification, fluid level and orbital fat congestion are uncommonly reported.[19]ConclusionEpidermoid cysts of eyelid are usually benign lesions that can be diagnosed clinically, and are differentiated from dermoids by radiological evaluation.[16] Complete surgical excision, i.e, en-bloc cyst excision prevents recurrence and is the treatment of choice. In cases where surgical excision is not possible, percutaneous fluoroscopy guided drainage and chemical ablation has been tried. Malignant transformation rarely occurs but, may occur in roughly 2% of cases to squamous cell carcinoma.[18]Rapid growth, pain, increased vascularisation increase suspicion and prompt histopathological examination should be done.[18] In our case, increased size of the tumor and deep seated nature of it posed a surgical challenge, Moreover as the tumour was completely adhered to the frontal bone periosteum, bony remodelling of the frontal bone was noted due to longstanding effect.References1. Youssefi B. Orbital tumors in children. J Pediatric Ophtalmol.1969;6:177-81.2. Mansour AM, Barber JC, Reinecke RD, Wang FM. Ocular choristomas. Surv Ophtalmol. 1989; 33:339-58.3. Veselinovic D, Krasic D, Stefanovic I, Veselinovic A, Radovanovic Z, Kostic A, et al.Orbital dermoid and epidermoid cysts: Case study. Srpski Arhiv Za Celokupno Lekarstvo [Internet]. 2010 Jan 1;138(11–12):755–9. Available from: https://doi.org/10.2298/sarh1012755v.4. Shields JA, Bakewell B, Augsburger JJ, Flanagan JC. Classification and incidence of space-occupying lesions ofthe orbit. A survey of645 biopsies. Arch Ophtalmol. 1984; 102:1606-11.5. Smirniotopoulos J, Chiechi M. Teratomas, dermoids and epidermoids of head and neck. Radiographics. 1995; 15:1437-55.6. Colombo F, Holbach L, Nauman G. Chronic inflammation indermoid cysts: a clinicopathologic study of 115 patients. Orbit. 2000; 19:97-107.7. Shields JA, Kaden IH, Eagle RC, Shields CL. Orbital dermoid cysts: clinicopathologic correlations, classification, andmanagement. The 1997 Josephine E. Schueler Lecture. OphtalPlast Reconstr Surg. 1997; 13:265-76.8. Pavlović BD. Dermoidna cista orbite. Srp Arh Celok Lek. 1951;49:488-9.9. Stefanović B, Litričin O, Lazarević D. Slučaj dermoidne cisteorbite. Acta Ophtalmologica Iugoslavica. 1968; 6:328-33.10. Skorin LJ. Congenital dermoid and epidermoid cysts. Optomoetry. 2001; 21:30-1.11. Schik U, Hassler W. Pediatric tumors of the orbit and optic pathway. Pediatric Neurosurg. 2003; 38:13-21.12. Pollard ZF,Calhoun MD. Deep orbital dermoid with draining sinus. Am J Ophtalmol. 1975; 79:310-3.13. ShieldsJA, ShieldsCL. Orbit cysts of childhood – classification,clinical features, and management. Surv Ophtalmol. 2004;49:281-99.14. Shawda SJ, Moseley IF. Computed tomography of orbital dermoids: a 20-year review. Clin Radiol. 1999; 54:821-5.15. Jung W, Ahn K, Park M, Kim J, Hahn S. The radiologicalspectrum of orbital pathologies that involve the lacrimal gland and the lacrimal fossa. Korean J Radiol. 2007; 8:336-42.16. Shah K, Thacker M, Mehta K, Vora C, Gogadani V. A Case ofEpidermoid Cyst of Eyelid. GAIMS J Med Sci 2023;3(2):84-8617. Rajesh E, Charumathi R. Eyelid dermoid cyst: Case report of a rare manifestation. Pan Am J Ophthalmol 2022;4:3.18. Sterner RC, Downie EM, Duncan NB, Wang Q, Vander Zee B, Potter HA, Lucarelli MJ. A Case of Malignant Transformation of an Orbital Epidermoid Cyst to Cystic Squamous Cell Carcinoma. Ophthalmic Plast Reconstr Surg. 2024 Nov-Dec 01;40(6):e223-e225. doi: 10.1097/IOP.0000000000002740. Epub 2024 Aug 13. PMID: 39136966.19. Chapter-----J. Javier Servat Evan H. Black Frank A Nesi et al. Smith and Nesi’s Ophthalmic Plastic and Reconstructive Surgery, fourth edition.
DOS Times - Volume 31 Number 4, January-February 2026 66 DOS Times - Volume 31 Number 4, January-February 2026 67The Surgeon’s FocusDOS Times - Volume 31 Number 4, January-February 2026Bilateral Electric Cataract in a Post-Electrical Burn Adolescent with Severe Facial Cicatricial Changes: A Surgical ChallengeIntroductionElectrical injuries represent a complex form of trauma with multisystem involvement. Ocular manifestations, though less frequently discussed compared to neurological or cutaneous sequelae, can be visually debilitating. Among these, electric cataract is a well-recognized delayed complication resulting from high-voltage electrical exposure (Figure-1). Cataract formation may occur weeks to months following injury and is often bilateral.The management of electric cataract becomes significantly more challenging when associated with extensive facial burns and periocular cicatricial changes. Severe scarring, eyelid distortion, and restricted palpebral aperture may compromise surgical exposure and limit the use of standard instrumentation, including lid speculums.This report describes a rare and surgically demanding case of bilateral electric cataract in a 15-year-old boy with severe facial burn contractures following highvoltage electrical injury. The case highlights the need for individualized surgical planning and modification of Dr. Shipra Singh MSAssistant Professor, Department of Ophthalmology, Lady Hardinge Medical College Shipra Singh[1] MS | Ashok Pathak[2] MSDepartment of Ophthalmology, Lady Hardinge Medical CollegeDepartment of Ophthalmology, ABVIMS & Dr RML HospitalAbstract: Electrical injuries involving the face are often associated with complex ocular sequelae, including electric cataract, compounded by severe periocular scarring following facial burns and reconstructive surgeries. We report a rare and surgically challenging case of bilateral electric cataract in a 15-year-old boy with extensive facial burn contractures, where cataract extraction—particularly in the right eye—required modification of standard surgical techniques due to inability to place a lid speculum.standard phacoemulsification techniques in the presence of extreme periocular anatomical distortion.Figure 1: Slit lamp appearance of the electric cataract.Courtesy:Fariña, Eliana & Vera-Duarte, Guillermo & Arrúa, Martin & Gonzalez, Luis. (2021). Cataract by electrocution. Case report. 10.21203/rs.3.rs-730234/v1.Case DescriptionA 15-year-old male presented with progressive, painless diminution of vision in both eyes. The visual decline had gradually worsened over the preceding months. The patient had sustained a high-voltage electrical shock injury several years earlier, resulting in severe facial burns predominantly involving the right side of the face, including the periocular region, cheek, nasal bridge, and forehead.Following the injury, he underwent multiple staged facial reconstruction procedures under the Department of Plastic Surgery. Despite successful soft tissue reconstruction, significant residual scarring and contracture
DOS Times - Volume 31 Number 4, January-February 2026 68 DOS Times - Volume 31 Number 4, January-February 2026 69The Surgeon’s FocusDOS Times - Volume 31 Number 4, January-February 2026persisted, particularly around the right periocular region.There was no history suggestive of prior ocular surgery or intraocular trauma apart from the electrical injury.Ocular ExaminationOn Presentation:• Best-corrected visual acuity in both eyes was significantly reduced almost hand movements close to face, with projection of rays accurate in all quadrants.• Slit-lamp examination revealed bilateral dense lenticular opacities consistent with electric cataract.• The anterior chambers were well formed.• Pupillary reactions were sluggish but present.• Ocular movements were full and free in both eyes.• Fundus evaluation was limited due to dense cataract; however, B-scan ultrasonography did not reveal posterior segment pathology.Periocular Examination Revealed:• Extensive cicatricial ectropion of the lower lid and upper lid post translocated scalp skin graft performed for burn reconstruction. (Figure-2a)• Distorted eyelid anatomy with scarring and reduced elasticity.• Markedly reduced palpebral fissure height in the right eye and lagophthalmos of 2mm on lid closure.(Figure-2b)• Limited ability to retract eyelids manually.• Restricted exposure of the globe.The left periocular region, although scarred, allowed relatively better exposure compared to the right.Surgical PlanningGiven the patient’s young age and bilateral visually significant cataracts, surgical intervention was planned for visual rehabilitation. Sequential cataract surgery was scheduled.Preoperative planning was crucial in this case due to:1. Severe cicatricial lid changes.2. Inability to adequately expose the globe on the right side.3. Anticipated difficulty in placing a conventional lid speculum.4. Potential challenges in achieving optimal surgical positioning.The goals were:• Safe cataract removal.• Intraocular lens implantation.• Avoidance of additional trauma to scarred tissues.• Minimization of surgical time and manipulation.Figure 2: a, b: Clinical photograph of a patient with severe facial and ocular surface chemical burn. The images demonstrate extensive cicatricial changes involving the periorbital region, including upper and lower eyelid contracture, cicatricial ectropion, loss of eyelashes, and distorted palpebral aperture. There is marked periocular scarring with exposure of the ocular surface and nasal tissue loss. (a) The left image shows the patient attempting to open the affected eye, while (b) the right image demonstrates incomplete eyelid closure secondary to cicatricial lagophthalmos.Surgery – Left EyeCataract extraction in the left eye was performed first.Although mild periocular scarring was present, a paediatric-sized lid speculum could be placed with careful manipulation. Standard clear corneal phacoemulsification was performed under topical anaesthesia. Capsulorhexis, hydro dissection, phacoemulsification, cortical aspiration, and posterior chamber intraocular lens implantation were completed uneventfully.The postoperative course was smooth, with best corrected visual acuity 6/6 in the left eye.
DOS Times - Volume 31 Number 4, January-February 2026 68 DOS Times - Volume 31 Number 4, January-February 2026 69The Surgeon’s FocusDOS Times - Volume 31 Number 4, January-February 2026Surgical Challenge – Right EyeThe right eye posed a significantly greater challenge.Intraoperative FindingsOn attempting surgery:• Placement of even a small-sized lid speculum was not possible due to severe cicatricial contracture.• Excessive force risked further tissue damage and possible skin breakdown.• Palpebral fissure opening was markedly restricted.• Globe exposure was limited.At this stage, a decision was made to modify the surgical technique rather than attempt aggressive mechanical stretching or adjunctive lid procedures.Modified Surgical ApproachA speculum-free cataract surgery approach was adopted.Key Modifications:1. Topical anaesthesia was used to maintain patient cooperation and avoid additional distortion caused by peribulbar injection.2. Lids were retracted with the help of retracting sutures ( 4-0 silk) throughout the procedure.3. A temporal clear corneal incision was chosen to optimize access and ergonomics.4. The surgical field was adjusted to align with the limited exposure.5. Movements were minimized to avoid undue stress on scarred periocular tissues.Despite restricted visualization, phacoemulsification was completed using controlled fluidics and minimal turbulence. A foldable posterior chamber intraocular lens was implanted in the capsular bag.The surgery required enhanced concentration and slow, deliberate manoeuvres. Lid retraction with two retracting sutures in the both lids was coordinated carefully to maintain exposure without exerting excess pressure.Importantly, no intraoperative complications such as posterior capsular rupture, zonular dialysis, or wound issues occurred.Postoperative OutcomeThe immediate postoperative period was uneventful and best corrected visual acuity was 6/9.On follow-up:• Corneal clarity was maintained.• Intraocular pressure remained within normal limits.• There were no signs of anterior segment inflammation beyond expected postoperative response.The visual rehabilitation achieved markedly improved the patient’s functional independence.DiscussionElectric cataract is a recognized but relatively uncommon sequela of electrical injury. The exact mechanism is believed to involve:• Thermal denaturation of lens proteins.• Direct electrical damage.• Disruption of lens epithelial cell function.• Oxidative stress mechanisms.Cataracts may develop weeks to years following injury and are frequently bilateral.What distinguished this case was not merely the presence of electric cataract but the associated severe periocular cicatricial changes.Post-burn contractures can cause:• Symblepharon.• Ectropion or entropion.• Lid margin distortion.• Reduced palpebral aperture.• Restricted globe exposure.In such situations, conventional cataract surgery techniques may not be feasible.Alternative Options ConsideredPotential alternatives in similar cases may include:• Preoperative canthotomy or cantholysis.• Temporary tarsorrhaphy release.• Combined oculoplastic intervention.
DOS Times - Volume 31 Number 4, January-February 2026 70 DOS Times - Volume 31 Number 4, January-February 2026 71The Surgeon’s FocusDOS Times - Volume 31 Number 4, January-February 2026However, these approaches may increase surgical morbidity and require staged procedures.In the present case, a less invasive strategy—modifying the cataract technique itself—proved effective.Clinical LessonsThis case reinforces several important principles:1. Individualized Planning is EssentialNo two burn patients are anatomically identical. Surgical strategy must be tailored accordingly.2. Flexibility in TechniqueThe inability to place a lid speculum does not preclude successful phacoemulsification.3. Temporal Approach AdvantageA temporal incision provides ergonomic benefit when superior access is compromised.4. Value of Topical AnaesthesiaAvoiding injection-related tissue distortion helped maintain limited exposure.5. Gentle Tissue HandlingScarred tissues are fragile and prone to breakdown. Minimal manipulation is key.ConclusionWith advances in reconstructive surgery, more patients with severe facial burns are surviving and seeking visual rehabilitation. Ophthalmologists must be prepared to manage cataracts in anatomically distorted eyes.This case also highlights the importance of interdisciplinary care. Collaboration between plastic surgeons and ophthalmologists is essential for comprehensive rehabilitation.This case underscores that challenging anatomy should prompt innovation rather than hesitation. With individualized strategy and careful technique, excellent visual outcomes are attainable even in the most demanding clinical circumstances.References1. Duke-Elder S, MacFaul PA. Injuries. Part 2: Mechanical Injuries. In: Duke-Elder S, editor. System of Ophthalmology. Vol 14. London: Henry Kimpton; 1972. p. 1052-1060.2. Solem LD, Fischer RP, Strate RG. The natural history ofelectric cataract. J Trauma. 1977;17(7):487-491.3. Sliney DH, Wolbarsht ML. Ocular effects of electrical andthermal injury. In: Safety with Lasers and Other Optical Sources. New York: Plenum Press; 1980. p. 263-278.4. Arora R, Gupta D, Goyal JL, Kaur C. Electric cataract: A case report and review of the literature. Clin Exp Optom. 2009;92(4):376-378.5. Boozalis GT, Purdue GF, Hunt JL, McCulley JP. Ocular changes from electrical burn injuries. Am J Ophthalmol. 1991;111(6):698-705.6. Yashiro K, Matsuo T, Shiraga F, Ohtsuki H. Electric cataract caused by high-voltage injury. Jpn J Ophthalmol. 1998;42(5):394-397.7. Kuckelkorn R, Schrage N, Keller G, Redbrake C. Emergency treatment of chemical and electrical eye burns. Acta Ophthalmol Scand. 2002;80(1):4-10.8. Wagoner MD. Chemical injuries of the eye: current concepts in pathophysiology and therapy. Surv Ophthalmol. 1997;41(4):275-313.9. Sharma N, Singh D, Maharana PK, et al. Ocular surface burns: Clinical features and management strategies. Indian J Ophthalmol. 2018;66(1):11-20.10. Vajpayee RB, Sharma N, Sinha R, Titiyal JS, Tandon R. Surgical management of ocular surface burns. Br J Ophthalmol. 2003;87(7):819-823.
DOS Times - Volume 31 Number 4, January-February 2026 70 DOS Times - Volume 31 Number 4, January-February 2026 71Smart Scopes & DiagnosticsDOS Times - Volume 31 Number 4, January-February 2026Beyond the Posterior Pole: How Widefield FFA and OCT-Angiography Are Redefining Retinal Vascular ImagingIntroductionRetinal vascular imaging has undergone a paradigm shift over the past two decades, evolving from conventional posterior pole photography to panoramic visualization of the peripheral retina. Traditional fundus imaging captures only 30-50° of the retina, leaving a substantial portion of the peripheral vasculature undocumented. However, many sight-threatening retinal disorders—including diabetic retinopathy, retinal vein occlusion, uveitis, and other vasculopathies—demonstrate significant peripheral pathologies that may occur without posterior pole involvement. Widefield and ultrawidefield imaging technologies have addressed this limitation by enabling visualization of the far peripheral retina in a single capture. Chaudhry et al. attempted to define widefield and ultrawidefield to address the discrepancy in the nomenclature commonly followed. Widefield images depict retinal anatomic features beyond the posterior pole, but posterior to the vortex vein ampulla, in all four quadrants. Ultra-widefield images are those showing retinal anatomic features anterior to the vortex vein ampulla in all four quadrants.[1]Concurrently, optical coherence tomography angiography (OCTA) has emerged as a non-invasive modality capable of visualizing retinal and choroidal microvasculature without dye injection.[2] The integration of widefield imaging with angiographic techniques has therefore transformed both diagnosis and management of retinal vascular disease.Dr. Aditya Sharma MSAssociate Consultant Eye 7 Eye HospitalAditya Sharma[1] MS | Uday Singh Beri[2] MSDepartment of Ophthalmology, Associate Consultant, Eye 7 Eye HospitalDepartment of Ophthalmology, Dr Shroff’s Charity Eye HospitalThis article reviews the principles, clinical applications, advantages, and limitations of widefield fluorescein angiography (WF-FFA) and OCT-angiography, with particular emphasis on distinctions between widefield and ultrawidefield imaging.Defining Field of View: Conventional, Widefield, and UltrawidefieldConventional ImagingStandard fundus cameras capture approximately 30°–50° of the retina centered on the posterior pole. Multiple images are required to document the mid-periphery and far periphery, often using montage techniques.Widefield ImagingWidefield retinal imaging typically refers to visualization of more than 50° but less than approximately 100° of the retina in a single capture.[3] (Figure-1)Figure 1: (A) Clinical photograph (B) Widefield FFA photograph of a patient with proliferative diabetic retinopathy taken venous phase, showing microaneurysms as small, bright, dot like fluorescence in all quadrants, leakage at macula (yellow arrow), NVE at inferotemporal arcade (red arrow) and multiple areas of capillary non-perfusion areas (yellow stars) [Courtesy: LHMC, New Delhi]
DOS Times - Volume 31 Number 4, January-February 2026 72 DOS Times - Volume 31 Number 4, January-February 2026 73Smart Scopes & DiagnosticsDOS Times - Volume 31 Number 4, January-February 2026Ultrawidefield ImagingUltrawidefield (UWF) imaging is generally defined as capturing at least 200° of the retina in a single image, representing approximately 82% of the retinal surface.[4] Scanning laser ophthalmoscope–based systems using ellipsoidal mirrors (e.g., Optos technology) are commonly used to achieve this expansive field. Multiple widefield images can be arranged to create a montage with field comparable to UWF imaging. (Figure-2) Ultra-widefield imaging has demonstrated superior detection of peripheral ischemia, neovascularization, and non-perfusion compared with conventional imaging.[5]Figure 2: (A, B) Montage of multiple widefield images created to observe a wider area of retina, highlights the pathologies in the periphery, but compromises on focus and depth perception [Courtesy: LHMC, New Delhi]Principles of Fluorescein AngiographyFluorescein angiography involves intravenous injection of sodium fluorescein dye, which circulates through the retinal vasculature and emits fluorescence when excited by blue light. Sequential imaging captures arterial filling, capillary transit, venous phase, and late leakage.[6]FFA remains the gold standard for evaluating:• Retinal perfusion• Vascular leakage• Microaneurysms• Neovascularization• Capillary non-perfusionWidefield Fluorescein Angiography (WF-FFA) (Figure-1B)TechniqueWidefield FFA employs either:• Specialized wide-angle lenses with standard cameras, or• Dedicated scanning laser ophthalmoscope systemsThe technique allows visualization of peripheral circulation in a single frame or minimal montage.Advantages Over Conventional FFA1. Detection of Peripheral Non-PerfusionPeripheral ischemia plays a crucial role in diseases such as diabetic retinopathy and retinal vein occlusion. Widefield FFA identifies areas of capillary dropout that are invisible on posterior pole imaging.[7]2. Identification of Peripheral NeovascularizationNeovascularization elsewhere (NVE) often develops in peripheral ischemic zones. WF-FFA improves detection rates and guides targeted laser therapy.[8]3. Improved Disease StagingPeripheral findings can alter severity classification, particularly in diabetic retinopathy, where peripheral lesions are associated with increased risk of progression and poor visual prognosis.[9]4. Guidance for Targeted Retinal PhotocoagulationInstead of panretinal photocoagulation, ischemia-guided laser therapy can be delivered selectively to non-perfused areas, reducing collateral damage.[10]Ultrawidefield Fluorescein Angiography (UWF-FFA)UWF-FFA extends these benefits further by visualizing nearly the entire retina.Clinical ImpactDiabetic RetinopathyPeripheral lesions detected on UWF imaging are associated with a significantly increased risk of disease progression.[9] UWF-FFA reveals ischemia beyond the vascular arcades, which may drive the VEGF production. (Figure-2)Retinal Vein OcclusionQuantification of ischemic index using UWF-FFA correlates with macular edema severity and neovascular complications.[11] It helps classifying into ischaemic or non-ischaemic type, thereby improving prognosis.
DOS Times - Volume 31 Number 4, January-February 2026 72 DOS Times - Volume 31 Number 4, January-February 2026 73Smart Scopes & DiagnosticsDOS Times - Volume 31 Number 4, January-February 2026UveitisPeripheral vasculitis may be the only active sign of inflammation. UWF-FFA enables detection of leakage in the far periphery, influencing immunosuppressive therapy decisions.[12]Pediatric Retinal DiseaseConditions such as retinopathy of prematurity, familial exudative vitreoretinopathy, and Coats disease often involve peripheral pathology best visualized with UWF imaging.[13] Although, UWF imaging in children requires different set of equipments (RetCam or Trinethra).Limitations of WF/UWF-FFADespite its utility, FFA has several drawbacks:• Invasive procedure requiring intravenous dye• Risk of nausea, vomiting, allergic reactions, and rarely anaphylaxis• Limited depth resolution• Leakage obscuring vascular details in late phases• Peripheral distortion in UWF images• Difficulty imaging through media opacityThese limitations have driven the development of noninvasive alternatives such as OCT-angiography.Optical Coherence Tomography Angiography (OCTA)OCTA uses motion contrast imaging to detect blood flow by comparing sequential OCT B-scans at the same location. Moving erythrocytes generate decorrelation signals, allowing reconstruction of vascular networks without dye injection.[2]Advantages• Non-invasive• Rapid acquisition• Depth-resolved imaging• Visualization of individual vascular plexuses• Quantitative metrics (e.g., vessel density, FAZ area)Layers VisualizedOCTA can separately visualize:• Superficial capillary plexus• Deep capillary plexus• Outer retina (normally avascular)• RPE-RPE fit• Choriocapillaris• Optic Nerve HeadWidefield OCT-AngiographyEarly OCTA systems were limited to small scan areas (3×3 mm or 6×6 mm). Advances in swept-source technology, faster scanning speeds, and montage techniques have enabled widefield OCTA covering up to 12×12 mm or larger composite fields.[14] (Figure-3) In recent years, the field of view of OCTA have significantly increased to 23x20 mm scan area (Canon), which are comparable to widefield FA.[15]Clinical Applications• Diabetic RetinopathyOCTA detects capillary dropout, microaneurysms, and neovascular complexes without dye leakage. Vessel density metrics correlate with disease severity.[¹6]• Retinal Vein OcclusionAreas of non-perfusion and collateral vessel formation can be delineated, aiding prognosis.[¹7]• Age-Related Macular DegenerationChoroidal neovascular membranes can be visualized in Figure 3: OCTA 8x8mm montage
DOS Times - Volume 31 Number 4, January-February 2026 74 DOS Times - Volume 31 Number 4, January-February 2026 75Smart Scopes & DiagnosticsDOS Times - Volume 31 Number 4, January-February 2026three dimensions, including subclinical lesions.[18]• Macular IschemiaOCTA is superior to FFA for quantifying foveal avascular zone enlargement and capillary rarefaction.[19]Ultrawidefield OCT-AngiographyEmerging technologies now permit ultrawidefield OCTA through:• Montage stitching of multiple scans• Swept-source systems with extended scan lengths• Motion-correction algorithmsAlthough still less extensive than UWF-FFA, these systems provide non-invasive visualization of peripheral microvasculature to the extent comparable to widefield FA.²0How do they fare? WF/UWF-FFA vs OCT-AngiographyLeakage DetectionFFA remains superior for detecting vascular leakage, as OCTA visualizes flow but not dye extravasation.Capillary Dropout DetectionOCTA and FFA fare the same in detection of dropout areas (Figure-4)Depth ResolutionOCTA provides layer-by-layer imaging, allowing differentiation between superficial and deep vascular abnormalities. (Figure-5)Peripheral CoverageCurrently, UWF-FFA offers the widest field of view, though ultrawidefield OCTA is rapidly evolving. SafetyOCTA avoids dye injection and systemic risks.QuantificationOCTA enables objective measurement of vascular parameters.Figure 4: Left side, OCTA image of a patient with branch retinal vein occlusion(BRVO). Right side, widefield FFA image of BRVO. Figure 5: OCTA of the same patient showing layer-by-layer differentiation of vasculature from superficial retinal vessels to choroid. Complementary RolesRather than competing modalities, WF/UWF-FFA and OCTA are complementary.• FFA: Best for leakage, vasculitis, dynamic circulation• OCTA: Best for microvascular structure and depth analysisIn clinical practice, both modalities are often used together to obtain comprehensive vascular assessment.Future DirectionsTechnological advancements are expected to further integrate these modalities:• Artificial intelligence for automated ischemia quantification• Widefield OCTA with peripheral coverage approaching UWF-FFA• Multimodal imaging platforms combining structural
DOS Times - Volume 31 Number 4, January-February 2026 74 DOS Times - Volume 31 Number 4, January-February 2026 75Smart Scopes & DiagnosticsDOS Times - Volume 31 Number 4, January-February 2026OCT, OCTA, and angiography• Portable widefield systems for screeningThese developments will likely enhance early detection and personalized treatment strategies.ConclusionWidefield and ultrawidefield imaging have fundamentally transformed retinal vascular assessment by extending visualization beyond the posterior pole. WF-FFA and UWF-FFA remain indispensable for detecting peripheral ischemia, neovascularization, and inflammatory activity, while OCT-angiography provides a non-invasive, depth-resolved view of retinal microvasculature.Understanding the differences between widefield and ultrawidefield imaging is crucial for appropriate modality selection. As technology advances, integration of panoramic imaging with non-invasive angiography will continue to redefine diagnostic precision and therapeutic decision-making in retinal disease.References1. Choudhry N et al. Classification and Guidelines for WidefieldImaging: Recommendations from the International WidefieldImaging Study Group. Ophthalmol Retina. 2019 Oct;3(10):843-8492. Spaide RF, Fujimoto JG, Waheed NK, Sadda SR, Staurenghi G. Optical coherence tomography angiography. Prog Retin Eye Res. 2018 May;64:1-55.3. Wessel MM, Aaker GD, Parlitsis G, Cho M, D’Amico DJ, Kiss S. Ultra-wide-field angiography improves the detectionand classification of diabetic retinopathy. Retina. 2012Apr;32(4):785-914. Silva PS, Cavallerano JD, Sun JK, Soliman AZ, Aiello LM, Aiello LP. Peripheral lesions identified by mydriatic ultrawidefield imaging: distribution and potential impact on diabeticretinopathy severity. Ophthalmology. 2013 Dec;120(12):2587-25955. Witmer MT, Kiss S. Wide-field imaging of the retina. SurvOphthalmol. 2013 Mar-Apr;58(2):143-54.6. Yannuzzi LA. Fluorescein angiography. Retina Atlas. Elsevier; 2010.7. Ghasemi Falavarjani K, Wang K, Khadamy J, Sadda SR. Ultra-wide-field imaging in diabetic retinopathy; an overview.J Curr Ophthalmol. 2016 Apr 30;28(2):57-60.8. Patel SN, Shi A, Wibbelsman TD, Klufas MA. Ultra-widefieldretinal imaging: an update on recent advances. TherapeuticAdvances in Ophthalmology. 2020;12.9. Silva PS et al. Peripheral lesions identified on ultrawidefield imaging predict increased risk of diabetic retinopathyprogression over 4 years. Ophthalmology. 2015;122(5):949–956.10. Reddy S, Hu A, Schwartz SD. Ultra Wide Field Fluorescein Angiography Guided Targeted Retinal Photocoagulation (TRP). Semin Ophthalmol. 2009 Jan-Feb;24(1):9-14.11. Tsui I, Kaines A, Havunjian MA, Hubschman S, Heilweil G, Prasad PS, Oliver SC, Yu F, Bitrian E, Hubschman JP, Friberg T, Schwartz SD. Ischemic index and neovascularization in central retinal vein occlusion. Retina. 2011 Jan;31(1):105-10. 12. Campbell JP, Leder HA, Sepah YJ, Gan T, Dunn JP, Hatef E, Cho B, Ibrahim M, Bittencourt M, Channa R, Do DV, Nguyen QD. Wide-field retinal imaging in the managementof noninfectious posterior uveitis. Am J Ophthalmol. 2012 Nov;154(5):908-911.e213. Patel CK, Buckle M. Ultra-Widefield Imaging for PediatricRetinal Disease. Asia Pac J Ophthalmol (Phila). 2018 MayJun;7(3):208-214.14. Hirano T, et al. Widefield OCT angiography using montagetechnique. Retina. 2018.15. Hamada, Mizuki et al. Practical Utility of Widefield OCTAngiography to Detect Retinal Neovascularization in Eyes with Proliferative Diabetic Retinopathy. Ophthalmology Retina. 2024 May; 8(5): 481 - 48916. de Carlo TE, Romano A, Waheed NK, Duker JS. A review of optical coherence tomography angiography (OCTA). Int J Retina Vitreous. 2015 Apr 15;1:5.17. Tsai G, Banaee T, Conti FF, Singh RP. Optical Coherence Tomography Angiography in Eyes with Retinal Vein Occlusion. J Ophthalmic Vis Res. 2018 Jul-Sep;13(3):315-332.18. Uchida A, Hu M, Babiuch A, Srivastava SK, Singh RP, Kaiser PK, Talcott K, Rachitskaya A, Ehlers JP. Optical coherence tomography angiography characteristics of choroidal neovascularization requiring varied dosing frequencies in treat-and-extend management: An analysis of the AVATAR study. PLoS One. 2019 Jun 25;14(6):e0218889.19. Samara WA, Shahlaee A, Adam MK, Khan MA, Chiang A, Maguire JI, Hsu J, Ho AC. Quantification of Diabetic MacularIschemia Using Optical Coherence Tomography Angiography and Its Relationship with Visual Acuity. Ophthalmology. 2017 Feb;124(2):235-244.20. Tan B, Chua J, Lin E, et al. Quantitative Microvascular Analysis With Wide-Field Optical Coherence Tomography Angiography in Eyes With Diabetic Retinopathy. JAMA Netw Open. 2020;3(1):e1919469
Emerging Trends & AdvancesDOS Times - Volume 31 Number 4, January-February 2026 76A “BANG” for Your Buck: Cost-Effective Glaucoma Surgery Meets MSICS Precision on a Budget: Combining MSICS and BANG for Advanced Pseudoexfoliation GlaucomaIntroductionGlaucoma is a leading cause of irreversible blindness worldwide, with a disproportionate burden in low- and middle-income countries, where delayed presentation, limited access to specialist care, and poor longterm follow-up are common.[1]Pseudoexfoliation is frequently associated with poor pupillary dilatation, zonular weakness, higher intraocular pressures, and more advanced optic nerve damage, increasing the complexity of both cataract and glaucoma surgery.[2]Manual small incision cataract surgery remains a widely practiced technique for cataract extraction in high-volume and public-sector ophthalmic services and has demonstrated favourable visual outcomes even in eyes with pseudoexfoliation.[3] Temporal MSICS offers additional advantages, including reduced surgically induced astigmatism and rapid visual rehabilitation.[4]Bent ab interno needle goniectomy was introduced as a low-cost trabecular MIGS technique using a bent hypoDr. Soumya RamaniMBBS, MS, FGO, PGDMLSProfessor, MS Ramaiah Medical College and Hospitals, New BEL Road, MSR Nagar, M S Ramaiah Nagar, Mathikere, Bangalore Soumya Ramani MBBS, MS, FGO, PGDMLS | Meghdeep J Patil MBBSDepartment of Ophthalmology, MS Ramaiah Medical College and Hospitals, Bangalore Abstract: Bent ab interno needle goniectomy (BANG) is a cost-effective, excisional Minimally Invasive Glaucoma Surgery (MIGS) technique. It uses a modified 26-gauge hypodermic needle to remove a strip of trabecular meshwork, bypassing resistance to improve aqueous outflow.In a high-pressure (36 mm Hg) case with advanced glaucoma and cataract, BANG was combined with manual small incision cataract surgery (MSICS). Under gonioscopic view, 90° of nasal meshwork was excised. Postoperatively, IOP dropped to 15 mm Hg. This conjunctiva-sparing approach is ideal for resource-limited settings where expensive implants are unaffordable and follow-up adherence is a concern.dermic needle to excise trabecular meshwork under gonioscopic guidance, creating direct access to Schlemm’s canal.[5] Studies combining BANG with cataract surgery have reported meaningful intraocular pressure reduction with a decrease in medication burden and an acceptable safety profile.[5,7]However, existing literature has largely described BANG in combination with phacoemulsification. This report describes the technique and outcome of combining temporal MSICS with BANG in a patient with pseudoexfoliation and advanced glaucoma, extending the applicability of trabecular MIGS to settings where phacoemulsification or implant-based procedures may not be feasible.Surgical TechniquePreoperative Evaluation and PlanningThe patient presented with decreased vision due to cataract and was found to have clinically evident pseudoexfoliation material, a maximum pharmacologic pupil diameter of 4 mm, advanced primary open-angle glaucoma with a cup–disc ratio of 0.8:1, and intraocular pressure of 36 mm Hg in both eyes despite maximal tolerated medical therapy. Gonioscopy revealed open angles with visible trabecular meshwork and no significant peripheral anterior synechiae in the nasal quadrant, making the eye suitable for ab interno trabecular surgery.
77Emerging Trends & AdvancesDOS Times - Volume 31 Number 4, January-February 2026Given the presence of advanced glaucoma, pseudoexfoliation-related zonular risk, financial constraints, and the anticipated inability to ensure regular long-term follow-up, a combined temporal MSICS with BANG was planned. Conventional filtering surgery was considered less suitable because of the need for intensive postoperative monitoring and bleb-related care.Anaesthesia and VisualizationSurgery was performed under peribulbar anaesthesia. The patient was positioned supine, with planned microscope tilt and head rotation to facilitate nasal angle visualization using a direct gonioscopy lens.Temporal MSICSA temporal conjunctival peritomy was created, followed by a 6–7 mm frown-shaped scleral incision approximately 1.5 mm posterior to the limbus. A self-sealing scleral tunnel was dissected into clear cornea. After entering the anterior chamber, continuous curvilinear capsulorhexis was performed. Hydrodissection and cautious nucleus rotation were undertaken, with particular care to minimize zonular stress. The nucleus was delivered using standard MSICS techniques, cortical matter was removed, and a posterior chamber intraocular lens was implanted in the capsular bag. The anterior chamber was reformed with a cohesive ophthalmic viscosurgical device in preparation for the angle procedure.Bent ab Interno Needle GoniectomyA sterile 26-gauge hypodermic needle was bent approximately 1 mm from the tip to achieve a 75–90° angulation. The Katena Gonioprism is placed over the cornea with a layer of viscoelastic. (Figure-1) Using the gonioprism, the nasal angle was visualized, identifying Schwalbe’s line, trabecular meshwork, and scleral spur (Figure-2). The bent needle was introduced into the anterior chamber through a temporal clear corneal paracentesis and engaged with the trabecular meshwork just anterior to the scleral spur. A continuous strip of trabecular meshwork was excised over approximately 90° of the nasal angle using controlled circumferential movements. (Figure-3)Blood reflux from Schlemm’s canal was observed and interpreted as confirmation of access to the conventional outflow pathway. Minor hyphema was allowed to settle inferiorly without excessive manipulation. At the concluFigure 1: Placement of the Gonioprism over the Cornea along with a layer of viscoelastic substance.Figure 2: Visualisation of the Trabecular Meshwork under Gonioprism.Figure 3: The trabecular meshwork was selectively engaged and excised using a bent 26-gauge needle under direct gonioscopic visualization.sion of the procedure, excess viscoelastic and loose blood were gently irrigated to maintain chamber stability.
Emerging Trends & AdvancesDOS Times - Volume 31 Number 4, January-February 2026 78Postoperative OutcomeThe scleral tunnel was confirmed to be watertight, and the conjunctiva was reposited. On postoperative day 1, (Figure-4) intraocular pressure in the operated eye had reduced from 36 mm Hg to 15 mm Hg on fewer topical medications. Best-corrected visual acuity was 6/9. The postoperative regimen included topical corticosteroids tapered over several weeks, with counselling regarding symptoms warranting urgent review.ConclusionCataract extraction combined with trabecular outflow–enhancing procedures is an established strategy for managing coexisting cataract and glaucoma, and bent ab interno needle goniectomy has been shown to reduce intraocular pressure when combined with phacoemulsification. Manual small incision cataract surgery continues to play a central role in cataract management in resource-limited settings, particularly in eyes with pseudoexfoliation.Figure 4: Post Operative Day 1 Slit Lamp Image.This report demonstrates, for the first time, the planned combination of temporal MSICS with bent ab interno needle goniectomy in a patient with pseudoexfoliation and advanced open-angle glaucoma. The case shows that satisfactory visual rehabilitation and meaningful intraocular pressure reduction can be achieved while preserving the conjunctiva for future surgery. This combined approach may be especially useful in patients who cannot afford implant-based procedures or are unlikely to comply with intensive postoperative follow-up.Data Availability StatementThe data supporting the findings of this study are available from the corresponding author upon reasonable request.References1. Tham YC, Li X, Wong TY, Quigley HA, Aung T, Cheng CY, etal. Global prevalence of glaucoma and projections of glaucoma burden through 2040. Ophthalmology. 2014;121(11):2081–2090.2. Desinayak N, Patidar N, Goyal S, Verma A, Rathore N, Nath M, et al. Outcome of manual small incision cataract surgery in patients with pseudoexfoliation syndrome and pseudoexfoliation glaucoma. Indian J Ophthalmol. 2024;72(2):123–130.3. Ressal SAA, Abdelrahman AM, Elhusseiny AM, Soliman TT, Hassan MA, et al. Visual outcomes and complications of manual small incision cataract surgery in patients with pseudoexfoliation. Indian J Ophthalmol. 2022;70(11):4050–4057.4. Zawar SV, Suryawanshi P, Vasavada V, Vasavada V. Safety and efficacy of temporal manual small incision cataractsurgery. Eur J Ophthalmol. 2012;22(3):363–369.5. Sheybani A, Dick HB, Ahmed IIK, et al. An alternate technique for goniotomy using a bent hypodermic needle. J Ophthalmic Vis Res. 2023;18(1):45–52.6. Bukke AN, Midha N, Dada T, Sharma R, Gupta V, Singh K, et al. Outcomes of bent ab interno needle goniectomy with cataract surgery in moderate to severe primary open-angle glaucoma. Indian J Ophthalmol. 2024;72(8)7. Kaushik S, Pandav SS, Dada T, Sharma A, Gupta V, et al. One-year outcomes of bent ab interno needle goniectomy combined with cataract surgery in primary glaucoma. Indian J Ophthalmol. 2024;72(12)