Contents
E5 ditorial Clinical Monthly Meeting
Focus 55 Clinical Case-1: Intacs for Post Lasik Ectasia
11 Dacrocystorhinostomy (DCR) Ramendra Bakshi, Mahipal S Sachdev
59 Clinical Case-2: Flipped Iris Claw Lens
Ikeda Charu Khurana, Mahipal S. Sachdev, Hemlata Gupta,
Dinesh Talwar, HK Tewari, Avnindra Gupta, Ritika Sachdev, Ritesh Narula
Retina F65 orthcoming Events
19 Retinal Artery Macroaneurysm Columns
Vinod Kumar Aggarwal, Kshitiz Kumar, Bhuvan Chanana, Jolly Rohatgi 69 Membership Form
25 Hypertensive Retinopathy Tear sheet
Parag K. Shah, Saurabh Arora 78 Immunosuppressives Monitoring Side Effects
SQuint Neeraj Jain, Lalit Duggal, Amit Khosla
31 Adjustable Sutures in Squint Surgery
Yuvika Bansal, Gaurav Goyal, Shilpa Goel
39 Prescribing Glasses in Children: Pearls and Practices
Priyanka Arora, Suma Ganesh, Manish Sharma, Varshini Shanker
Miscellaneous
45 United we Win Divided we Lose
Vipin Sahni MS
51 Scheme for Participation of Voluntary Organisations
www.dosonline.org 3
Editorial
My Dear Friends and Colleagues,
I hope you had a useful and an enjoyable midterm conference. We tried hard to make it more useful,
more relevant and more entertaining and thank the delegates for their enthusiastic participation in all the
conference events.
Action Stations Again!
Let us Retrain Ourselves if we wish to remain updated. Ophthalmology changes faster than the refresh
button on our webpage and it is tough to keep pace with it!
Fellowships are the best and the most successful way of real and actual training. DOS is now just on the take
off stage of introducing exciting fellowships at prestigious Delhi Eye Hospitals and we begin with “Hands
on Phacotraining workshops of 15 days duration”.
Phaco training continues to be the need of the hour and we are expecting a big rush of applicants.
In addition we are soon going to embark upon this exciting new project for different subspecialities in Ophthal and fellowships and
observer ships under the banner of DOS is our dream for the near future.
DOS Outreach Programmes
It is ironic. Out of 10000 Ophthalmologists in India, more than 1500 are in Delhi and NCR. However public awareness about serious
blinding diseases like Glaucoma, Diabetic Retinopathy, Amblyopia and Other Causes of Childhood Blindness is abysmally low.
This has to change and the time has now come.
Let us together do it under the banner of DOS. As a first step we have already distributed 10000 posters on Diabetic Retinopathy
to the Physicians and GPs in Delhi for display in their clinics and hospitals. This is the DOS Diabetic Retinopathy Public Education
Programme.
The next step is to execute Diabetic Retinopathy Screening Projects in different Hospitals and Clinics with the help of our members
and there on to other causes like Glaucoma etc.
We are trying to put innovative thoughts into execution and we need the help and encouragement from our members. Give us your
views and your ideas and let us zoom ahead into yet unchartered arenas.
Yours Truly.
Thanking you,
Dr Amit Khosla
Secretary,
Delhi Ophthalmological Society
Editor-in-chief
Amit Khosla MD, DNB
Advisor DOS Correspondents DOS Office
H.K. Tewari MD, FAMS, DNB Rajpal MD Nidhi Tanwar MD Room No. 2225, 2nd Floor,
Ashok K. Grover MS FRCS S.P. Garg MD, MNAMS Gagan Bhatia DOMS New Building, Sir Ganga Ram Hospital,
J.K.S. Parihar MS, DNB A.K. Singh MS Vipul Nayar DOMS, DNB, MNAMS Rajender Nagar, New Delhi - 110 060
Shashi N. Jha MD J.L. Goyal MD, DNB Daraius Shroff MS Tel.: 91-11-65705229
Sudershan Khokhar MD Ritika Sachdev MS
Email: [email protected]
Editorial Board Rajiv Sudan MD Deependra Vikram Singh MD Website: www.dosonline.org
Neera Agarwal MS Sanjiv Mohan MS
Ruchi Goel MS, DNB, FICS Poonam Jain MS Ajay Kumar Agarwal MS, DNB Cover Design by: Amit Chauhan
Sanjeev Gupta MD, DNB Neeraj Verma MS Anuj Mehta MS Published by: Dr. Amit Khosla for Delhi Ophthalmological Society
Sanjay Khanna MS Vivek Gupta MD, DNB Naginder Vashisht MD
Y.C. Gupta MS Amit Gupta MD Deven Tuli MS Printers: Symmetrix
Sarita Beri MD S.K. Mishra MS Prakash Agarwal MD E-mail: [email protected]
Devindra Sood MS J.S. Guha MS V. Rajshekhar MS
Umang Mathur MS Manisha Agarwal MS Jasmita Popli MS
Rajesh Sinha MD, DNB Hardeep Singh MD Himanshu R. Gupta MS
Rohit Saxena MD Kapil Midha MD
Hemlata Gupta MS, DNB
www.dosonline.org 5
AT TENTION ! DOST VENUE
MD / MS / DNB / DO / OPHTHALMOLOGY 8th & 9th January, 2011
A Two Days Exhaustive Saturday & Sunday,
DOSOPHTHALMOLOGY STUDENTS Ophthalmology Training Army Hospital (R&R),
TEACHING Auditorium,
PROGRAMME Delhi Cantt., Delhi
The Delhi Ophthalmological Society organizes it's third Highlights Glaucoma
Retina
Teaching Programme “DOST-3” aimed at teaching OSCE / Case Presentation Cornea
the Post Graduate (MD/MS/DNB/ DO Ophthalmology) Basic Sciences Squint
Students all over India. A two day exhaustive course Lens Cataract
for Post-Graduate Students. Oculoplasty
Refraction
All the Members & Students are welcome to attend !
Registration Fee Upto
15th December, 2010
Category
DOS Member / Student 300
Non Members / Student 500
SIRI FORT LASER EYE CENTRE
A Centre for Retina & Vitreous Surgery
8, Siri Fort Road, New Delhi - 110 049
Ph.: 65293455, E-mail: [email protected]
Emergency Retina Care
Helpline for
Endophthalmitis Contact:
Nucleus Drop
ROP (Retinopathy of Prematurity)
Ocular Trauma
6 DOS Times - Vol. 16, No. 5, November 2010
DOS Skill Transfer Workshop
on Basic Oculoplasty
Dear DOS Member/Student,
The Skill Transfer Workshop on Basic Oculoplasty will be held on Sunday, 19th December, 2010 at
Auditorium, Gurunanak Eye Centre, MAMC, Maharaja Ranjit Singh Marg, New Delhi from 9:00 a.m. to
4:10 p.m.
Detailed Programme Skill Transfer Workshop on Basic Oculoplasty
Time Topic Presenter
9.00 am Registration Dr. Sonam
9.10 am Welcome Address Dr. A.K. Grover
9.15 am Important steps in work up of a case of Ptosis Dr. Ruchi Goel
9.25 am Management of Ptosis depending on etiology, age and severity
10.10 am Evaluation of a case of Epiphora & Surgical treatment of Ectropion Dr. V.P.Gupta
Dr. K.P.S.Malik
10.50 am Tea Break Dr. Vasundhara Oberoi
11.00 am Management of Entropion & trichiasis Dr. Neelam Pushkar
11.40 pm Aging eyes: Surgical approach
12.00 noon Aging eyes: How to treat with Botox Dr. RajAnand
12.20 pm Contracted socket, unstable prosthesis-when to intervene and how? Dr. Sushil Kumar
Dr. K.K.Saxena
1:00 pm Lunch Dr. Sushil Kumar
1.30 pm Management of Micro Ophthalmic Socket Dr.Anita Sethi
2.00 pm External DCR Dr. Saurabh Kamal
2.30 pm Role of Xray, CT and MRI in case of orbital mass/trauma
3.00 pm Role of Ultrasonography in diagnosis and management of orbital diseases
3.30 pm Enucleation & Evisceration
4.00 pm Common benign lid lesions-management
4.10 pm Vote of thanks
Dr. P.V. Chadha Dr. Ruchi Goel Dr. Amit Khosla
President Workshop Co-Ordinator Secretary
www.dosonline.org 7
Plea se join us in New Delhi
TRENDS IN
Conference Secretariat :
Dr. Amit Khosla, Secretary
Delhi Ophthalmological Society
Room No. 2225, 2nd Floor
Sir Ganga Ram Hospital
Rajinder Nagar, New Delhi - 110029, India
Email : [email protected]
Website : www.dosonline.org
8 DOS Times - Vol. 16, No. 5, November 2010
TRENDS IN ANNUAL CONFERENCE OF
INDIA Delhi
Ophthalmological
Society
15th to 17th April, 2011,
Friday, Saturday & Sunday
Ashok Hotel, Chanakyapuri,
New Delhi, India
INVITATION
Dear friends & colleagues,
Greetings from Delhi Ophthalmological Society. We wish to invite you to our 62nd Annual Conference from 15th to 17th April 2011
at Hotel Ashok, Delhi. Indian Ophthalmology is highly advanced and Ophthalmology in Delhi is vibrant and alive. Delhi has perhaps
the maximum number of Ophthalmologists, the largest number of Ophthalmology training institutes and the largest number of
Ophthalmology residents in the world. All subspecialities of Ophthalmology are highly developed and all surgeries-classic and
recent advances are routinely performed.
The Delhi Ophthalmological Society is the Largest State Society in India with over 5000 members and The Annual Conference of our
society is a 3 day celebration of Ophthalmology-live surgeries and wet labs, workshops, instruction courses and free papers showcasing
original research work. Ophthalmologists of International repute participate in this conference. This year our theme is
"Trends in Ophthalmology" and we will be abundantly pleased to welcome you to our conference and our city.
Delhi, the Capital city of India is a modern metropolis with all the world class facilities and a grand historical legacy. A brand new airport,
comparable to the best in the world awaits your arrival. Wide roads and swank radiotaxis provide excellent connectivity. The Delhi
Metro Rail is fast, clean and punctual and there is a fast express link from the airport to the heart of the city. Delhi's air is clean and
highly breathable. It is one of the greenest cities in the world. Your stay will be extremely comfortable. Our hotels are among the world's
best and provide unmatched service. Indian cuisine is appreciated and duplicated the world over and Delhi Restaurants will provide you
with a memorable culinary experience and the taste of India in Delhi.
The comfortable and Airconditioned Shopping Malls in and around Delhi always have a festive atmosphere and your shopping
experience is bound to be incredible. In addition there are the traditional local markets like Karol Bagh and Chandni Chowk to provide you
with the local flavour. Connaught Place in the heart of Delhi is a huge commercial centre built in a circular fashion. It was built by the
British and is an icon for the city. There are number of theaters playing the classical and latest movies from Hollywood and Bollywood.
The Golden Triangle Tour (Delhi-Agra-Jaipur-Delhi) offers you with an opportunity to witness the great Indian heritage.
I wish forward to welcome you to Delhi in the pleasant month of April.
Yours truly
Dr P.V. Chadha Dr Amit Khosla
President, Delhi Ophthalmological Society Secretary, Delhi Ophthalmological Society
Highlights Meet the Masters
Free Paper
Live Surgery Trade Exhibition
Instruction Courses Gala Dinner
Scientific Sessions E-Poster
Video Assisted Courses
Video Stations
Film Festival
SAVE TIME Submit your registration, faculty form & abstract online
for the Annual DOS Conference at
www.dosonline.org
www.dosonline.org 9
Dacrocystorhinostomy (DCR) Focus
Dr. Lakshmi Mahesh Dr. V.P. Gupta Dr. E. Ravindra Mohan Dr. Vaitheeswaran Krishna Dr. Satanshu Mathur
MD MD, DNB MD, FRCS (Ed) MS, FRCS MS
Dacryocystorhinostomy (DCR) is a commonly performed surgical procedure to restore the flow of tears when the
Nasolacrimal duct is blocked. Toti first described the external approach in 1904 and since then numerous modifications
have been made to the original technique. As much this procedure has evoked interest, so has it invited controversies.
There are a number of queries that a general Ophthalmologist has in mind while dealing with various different aspects of
Nasolacrimal duct obstruction especially regarding the preferred approach to surgery; external or endonasal, previously
failed surgeries, post traumatic cases etc. We question some of the masters from the field of Oculoplastics to shed light
upon various issues pertaining to this procedure.
Dr. Lakshmi Mahesh, (LM): MD, Consultant Orbit & Oculoplastic Surgeon, Department of Ophthalmology, Manipal
Hospital, Airport Road, Bangalore . Dr. V.P. Gupta (VPG): (Professor) MD, DNB. Oculoplasty, Orbital Tumors & Anterior
Segment, Head, Deptt. Of Ophthalmology, U.C.M.S. & G.T.B. Hospital, Delhi - 110095. Dr. E. Ravindra Mohan (ERM):
MD, FRCS (Ed), Senior Consultant, Ophthalmology,Oculplasty & Orbital Surgery, Global Hospitals & Health City, Chennai,
Tamil Nadu. Dr. Vaitheeswaran Krishna (VK): MS, FRCS, Senior Specialists, Department of Ophthalmology, St. Stephen’s
Hospital, St. Stephen’s Marg, Tis Hazari, Delhi. Dr. Satanshu Mathur (SM): MS, Medical Director & Consultant, Hi-Tech
Eye institute & Laser Center, Doctors Lane, Kashipur, Uttarakhand.
Dr. Vikas Menon (VM): DNB, FLVPEI Ophthalmic Plastic Surgery, Orbit and Ocular Oncology, Centre For Sight, New Delhi.
VM: What do you prefer in your routine practice – External Syringing can give some additional information-especially
or Endonasal DCR / Laser? a delayed mucosal regurgitation even if the initial contents
are clear.
LM: I prefer both External and Endo nasal depending on the
clinical situation and the age of the patient .Prefer external VPG: Yes, just before the surgery.
for elderly patients and endonasal for the younger patients
broadly. However differs on case wise basis too.I don’t ERM: Yes. The nature of the regurgitant and delay gives us a good
perform Laser DCR. idea of the size of the sac and nature of infection.One can
also pick up a canalicular block as also a lacrimal fistula
VPG: I prefer External DCR in G.T.B. Hospital, Delhi. that may not be obvious. As a surgeon, all this information
is useful in planning and carrying out the operation.
ERM: External DCR. The operation is highly successful,needs
limited instrumentation,and can be routinely performed VK: The syringing is important to clear out the mucous and
under local anaesthesia in half an hour or so,all features discharge that accumulates in the sac with nasolacrimal
which make it my primary procedure of choice. duct obstruction. This allows easy dissection around the
sac during surgery preventing early sac perforation as well
VK: My preferred technique is a modified external as prevents postoperative infection of tissues spaces.
dacrocystorhinostomy using a caruncular incision. The
endonasal approach is preferred in previous surgical SM: Yes.
failures.
VM: What anaesthesia do you prefer for external DCR?
SM: Laser DCR.
LM: Local anaesthesia. GA in select cases and pediatric cases.
VM: If regurgitation is positive do you still do preoperative
syringing? VPG: Infraorbital and nasociliary blocks, infiltration at incision
site and nasal packing.
LM: Mostly yes, especially if the regurgitation is not present
through both puncta or if there is clear regurgitation etc., ERM: Local anaesthesia, consisting of 2 % ligocaine with 1:200,000
Adrenaline, and 0.5 % Bupivacaine in equal volumes, 10
www.dosonline.org 11
cc or so. The exceptions, where I perform surgery under dissection 8. Hemostasis using bipolar cautery 9.Donot
general anaesthesia are paediatric cases or traumatic NLDO pry bone 10. Injection of xylicaine with adrenaline in sac
cases with extensive bony injuries and callus formation wall / nasal mucosa before flaps 11. Hypotensive anesthesia
where the comfort and quality of anaesthesia achieved may under GA.
be sub-optimal.
Management of intraoperative hemorrhage: elevate head
VK: Regional anesthesia with an infratrochlear block and local end, check blood pressure, ensure proper oxygenation,
infiltration suffices in most cases. An additional nasal Identify the source/s of bleeding and manage accordingly:
infiltration may be required in the endonasal approach. wound edges: angular / accessory angular vein, muscle, 2.
General anesthesia is required in paediatric cases. Sutura notha vessels 3. Osteotomy edges 4. Plexus of veins
between lac fascia and lac sac mucosa 5. Nasal mucosa
SM: Local anaesthesia, consisting of Infractrochclear and 6. Anterior ethmoidal artery bleeding; ligate / cauterize
infracorbital blocks and around sac and intranasal packing bleeders, proper wound retraction, apply pressure with
using lidocain 2% with 1/00,000 adrenalin. cottonoids, repeat nasal pack, push it towards superior
meatus very gently, intramucosal adrenaline injection,
VM: Where do you give incision in external DCR? bone wax for bony bleeding; use of suction , suture
posterior flap, insert bicanalicular silicone stent.
LM: 4 to 5 mm medial to the medial canthus.
ERM: Stoppage of all blood thinners, preferably 2 weeks prior
VPG: I prefer an incision which is 3-4 mm medial to medial to surgery with the concurrence of the patient’s treating
canthus in External DCR. cardiologist or physician. Routine checking of pre-operative
bleeding time, clotting time, prothrombin time, partial
ERM: At a natural crease, curvilinear in shape and usually at a thromboplastin time, and platelet counts is part of the
greater distance from the medial canthus than the 3mm workup, with bleeding time and clotting time being the
standard incision. In case the angular vein is seen just mandatory basic minimum
underlying the mark for the incision, I go a mm medial to
it. The 3mm incision tends to cause webbing if one is not Hypotensive anaesthesia is extremely useful when DCR
careful have used the straight incision placed about 11 mm is being performed under general anaesthesia. Intra-
from the medial canthus, but do not see any advantage in operatively, I use a radiofrequency unit for a bloodless
the same. incision and for coagulation of bleeders, adrenaline soaked
gauze, pressure haemostasis; Abgel and Surgicel in selected
VK: Normally the surgery is performed by a transcaruncular case; bone wax in the rare instances where troublesome
incision. bleeding cannot be stopped with all the above measures.
It is important to remember that the wax is only an
SM: Incision is placed 3mm nasal to medial canthus. intraoperative tool and must be meticulously removed after
hemostasis is achieved, Abgel and Surgicel can, however be
VM: What preoperative and intraoperative measures do you left in the surgical field for continued postoperative effect.
take to reduce intraoperative bleeding?
VK: Preoperative:
LM: I get a preop check with the physician, bleeding parameters
checked especially the PT & PTT, pre op oyxmetazoline 1. Rule out systemic disorders such as hypertension or
nasal drops three days prior to surgery and a good nasal coagulation disorders
pack before the surgery soon after the local injection either
with 4% xylocaine with adrenaline or only oxymetazoline 2. Rule out nasal pathologies that may cause excessive
pack in hypertensive patients. I also inject a small amount bleeding such as the presence of a growth or polyp
of local anethetic to the nasal mucosa to blanch it before I
make the flaps. With these precautions the blood loss can 3. Preoperative use of nasal decongestants such as
be reduced to a bare minimum. xylometazoline or oxymetazoline.
VPG: Preoperative measures: 4. Rule out active infection
1. History of bleeding tendencies, intake of anticoagulants, Intraoperative
antiplatelets, NSAID, and management accordingly 2.
Stop intake of these drugs atleast 3days prior to surgery. 3. 1. Local xylocaine with adrenaline infiltration
Preoperative investigations: BT, CT, PT. 4. Do not operate
in presence of acute or subacute inflammation.5. Nasal 2. Nasal pack with decongestants in patients where excessive
Packing preop. 6. Control of hypertension, 7. Proper bleeding is expected or encountered.
sedation,
3. Use of local pressure to reduce or stop bleeds. This remains
2. Intraoperative measures: the most effective measure to ensure a bloodless and clean
field.
1. Reverse trendlenberg position at the table, 2. Proper
nasal pack, 3. Vasoconstrictive anesthetic agents, 4. Correct 4. Use of radiofrequency ablation in cutting mode for
placement of incision,5. Proper wound retraction: use dissection and coagulation mode to stop bleeding.
of cat’s paw retractors, 6. Identify angular vein, ligate,
cauterize or retract with cat’s paw retractors. 7. Blunt 5. Local use of fibrin as drops when there is an general ooze
with no bleeder located. This is also used at the end of the
12 DOS Times - Vol. 16, No. 5, November 2010
surgery to prevent postoperative bleeds and also to seal the ERM: Whenever haemostasis, visualization and size of the flaps is
caruncular incision. adequate,2 flaps; else 1 flap. In the latter situation, I prefer
to excise some of the redundant posterior sac and nasal
6. In case of a bone bleed due to opening of vessels supplying mucosal tissue to prevent it from falling back or causing
the bone, pressure with bone wax may be helpful. unacceptable granulation, scarring and adhesions.
7. Surgicell and surgical heamostatic foam may be useful in VK: In external DCR, I suture only the anterior flaps. However,
cases with severe bleeds. with the transcaruncular approach as with the endonasal
approach, there are no flaps raised in most cases.
SM: Pre-operative measures consists of 1. discontinue any
anticoagulant or aspirin medicine, 2. control of BP SM: Only anterior flap.
3. intranasal packing of 2% lidocaine with 1:100000
adrenaline for 10 minutes, 4. instillation of nasal drops 2-3 VM: Do you suture the flaps to the Periosteum or
times 10 minutes before surgery. subcutaneuous tissue?
Preoperative measures taken are 1. Local anaesthesia LM: Yes, the anterior flaps are sutured either to the perioteum
consisting of lidocaine 2% with 1/100,000 adrenaline 2. or to the resutured superficial part of the medial canthal
Incision site should avoid angular vein 3. Do not cut muscle ligament.
fibres but undermine posteriorly 4. Use of radiofrequency
to cut nasal mucosa 5. topical use of botropase. VPG: I suture the flaps to the periosteum or subcutaneuous
tissue (orbicularis muscle) only if the flaps appear large
VM: Do you prefer cutting medial canthal tendon in external and redundant e.g. in cases of lacrimal mucocele.
DCR?
ERM: Only if there is no healthy nasal mucosa to attach the
LM: Yes, very much as only this will give a good exposure to anterior sac flap to, a relatively uncommon situation if the
the fundus of the sac where the canaliculi invariably open bony ostium is punched out carefully, the nasal mucosa is
almost in all cases. After all, we are only severing only carefully lifted off the bone using “lignodissection” with a
the superficial part of the tendon and the deeper part curved cannula, and nasal mucosal flaps are fashioned and
behind the sac which is more essential for the integrity handled gently.
of the canthal region is not disturbed. I also reanchor this
anteriorflaps and anchor this to the anterior flaps with a VK: When flaps are raised, they are sutured to the periosteum.
suture to prevent the buckling in of the anterior flap and
also re-establish anatomical integrity in this area. SM: Suture to nasal mucosal flap.
VPG: No. But, there should be no ego, it may be divided if need be VM: Do you use Mitomycin “C” in DCR? What concentiation
for better exposure and meticulously sutured while closing do you use?
the wound to prevent iatrogenic telecanthus.
LM: No.
ERM: Yes. Helps to get to the top of the sac; does not result in
any disfigurement or telecanthus. The important anatomic VPG: MMC has no role in primary external DCR. Even in failed
landmark of the anterior lacrimal crest is easy to identify DCR, I have stopped using MMC due to excellent results
in it’s entire extent after dividing the medial palpebral of my technique in failed DCR.
ligament.
ERM: No.
VK: Normal a transcaruncular approach allows easy access to
the lacrimal sac without having to disinsert the medial VK: Mitomycin C in concentrations of 0.2mg/ml is used in cases
canthal ligament. The approach to the sac being more with previous failure of lacrimal surgery or those cases with
direct, this step has been totally done away now in most chances of failure deemed higher than normal.
of our lacrimal surgical interventions.
SM: Mitomycin-c is used only in laser DCR and in complicated,
SM: Medial canthal tendon is cut but suture later on. previous failed cases. Conc. Used is 0.4 mg/ml.
VM: In external DCR DO you suture both the anterior and VM: When do you syringing post operatively?
posterior flaps or only the anterior flaps?
LM: I do it on the table and the following day after surgery. I also
LM: I like to suture both the posterior and anterior flaps. It offers do it for about 5 to 6 visits post-operatively spread over 5
instant mucosal lining and success rate is far better than to 6 weeks. In outstation patients it is tailored according to
with single flaps. their duration of stay in the city. In Endo DCR, I prefer nasal
curettage at the end of a week after surgery and another
VPG: Previously, I used to fashion both the anterior and posterior after 3 to 4 weeks after surgery. This helps especially in cases
flaps flaps in external DCR. For last several years I have where I have done the stenting.
switched on to make only the anterior flap of nasal mucosa
by making U-shaped incision; create both anterior & VPG: I do not advocate syringing post operatively.
posterior flaps from lacrimal sac, excise the posterior sac
flap and suture the two anterior flaps. ERM: Day 1 if feasible; if not, on first visit. Thereafter on all
postoperative visits till a month or so.
VK: Usually on postoperative day 1. Thereafter the patient is
followed up at routine intervals for a minimum period of
3 months.
www.dosonline.org 13
SM: Post operative syringing in external DCR is done on 1st & ERM: Patients with a roomy nasal cavity, no associaterd nasal
8th week. In laser DCR (without intubation) syringing on pathology.
1st, 2nd, 4th & 8th week.
VK: Typically an uncomplicated case with good intranasal
VM: What are your success rate with external and endonasal visibility in a cooperative patient would be ideal for
DCR? beginning an endonasal technique.
LM: Around 97% in both. In External it is slightly higher. SM: For beginning endonasal DCR one should select cases with
no nasal pathology/obstruction.
VPG: The success rate of external DCR in my hands still remain
100%. VM: What are the tips you like to give to beginners for
endonasal DCR?
ERM: Based on a review of cases done, about 95% for external
and 85% for endoscopic, done with an expert endoscopic LM: Know the anatomy well, do a good number of endo nasal
ENT surgeon. evaluations in the OPD set up, learn to do good nasal
packing and take the help of an ENT colleague from the
VK: The external DCR has a success rate of over 90%. The beginning.
endonasal procedure has a success rate of around 85%. The
endonasal procedure is typically reserved for failures and VPG: NA.
those with known nasal pathologies.
VM: Read and learn nasal anatomy well. Assisst an experienced
SM: Success rate with external DCR is >90% with endonasal ENT surgeon for a variety of cases done using nasal
DCR is 75-80%. endoscopy; perform diagnostic nasal endoscopic
examination in atleast a hundred pre-op and post op cases
VM: Any particular situation where you would prefer doing and then begin surgery with an ENT colleague available at
an endonasal over external DCR? short notice if not in the same theatre.
LM: Preferably in younger patients, those who have a residual VK: 1. To study thouroghly the anatomy of the nose with
chronic abscess (where the skin is not ideal for incision), particularly reference to the lateral wall.
when the patient is keen only on an endonasal etc.,
2. To ensure good anesthesia and cooperation of the
VPG: I always perform external DCR. I have performed external patient.
DCR even patients with 2 to 4 times failed endoscopic /
external DCRs with enviable success rates. 3. Good. visibility and hemostasis should be ensured
at all times.
ERM: Any patient who wants to avoid a visible scar; patients
needing bilateral simultaneous surgery; those with SM: Become familiar with nasal anatomy and nasal endooscopes,
significant nasal pathology which would need two stage observing & performing few cases under guidance of
surgery if external DCR is planned-grossly deviated nasal expert surgeon, use general anaesthesia in first few cases,
septum, nasal polyps, concha bullosa. revision surgery in cases of failed DCR through endonasal
route gives good practice of removal of scar tissue without
VK: The endonasal is typically preferred in failures when a requiring much bone removal.
rapid recanalisation may be achieved and patency ensured
without much difficulty. The ostium may be treated with VM: Do you commonly do the stenting with Endonasal DCR?
Mitomycin under direct visualisation.The endonasal
procedure is also the modality of choice when there is a LM: No, only when there is an upper level block.
pre-existent nasal pathology which could be treated at the
same sitting. VPG: NA.
SM: Young & female patients to avoid cutaneous scar, - ERM: Only in cases I would do stenting for an External DCR-
Nasal pathology cases where pathology can be treated suspect canalicular system, traumatic NLDO, pediatric
simultaneously in same sitting which is important cause NLDO, failed previous surgery (revision surgery).
of Ext. DCR failure.
VK: Stenting is used only occasionally.
VM: Which type of cases one should select for beginning
endonasal DCR? SM: No.
LM: Preferably those with mucoceles, roomy nasal cavity VM: What is your experience for transcanalicular diode laser
without nasal septal deviation, dacryocystitis without assisted Dacryocystorhinostomy?
trauma, other pathology etc.,
LM: Nil- I believe the success of the surgery lies in a good bony
VPG: All ophthalmologists should learn to do an external DCR. ostium. Laser doesn’t seem to have the scope for this at
IF they donot want to do DCR, case should be referred to the present time.
any lacrimal surgeon who can perform an external DCR
with invisible scar and high success rate. VPG: NA.
ERM: Five cases; worked for long enough to perform cataract
surgery in 4. One needed external DCR for primary failure.
All were community patients for camp cataract surgery.
14 DOS Times - Vol. 16, No. 5, November 2010
VK: Endocanalicular laser DCR is perhaps the procedure with cases, scarring leads to canalicular blocks, ostial closure
least morbidity, the approach being through a natural despite meticulous technique and precutions.
orifice. It is easily performed under local anesthesia and
is a very rapid procedure which may be done as a day VK: DCR failure may be presaccal or postsaccal. Presaccal
care. As such it may be used for presaccal and postsaccal causes of failure is commonly due to canalicular block.
obstructions. We had seen failures in the initial series, Postsaccal causes are primarily due to osteal stenosis or
which have been dealt with lacrimal intubation and closure either bony or due to fibroblastic growth. Improper
mitomycin c application. position of ostea and poor sac opening are other causes of
postsaccal failures.
SM: I am doing TCLAD for last 4 years. Advantages are –
Reduced surgical time, No scar, No bleeding, No disruption SM: 1. Osteotmy site improper & size inadequate, 2. Occulusion
to medial canthal ligament, Preserve lacrimal pump of osteotomy or mucosal flap by scaring, 3. Canalicular
mechanism, Short learning curve. occlusion, 4. Sac opening is inadequate, 5. Nasal pathology,
6. DCR fistula thickly stenosed.
Disadvantages are – Cost, without intubation success rate
is not very good (>50% after one year). VM: How do you proceed with failed DCR cases?
VM: Do you prefer intubating the canaliculuas following the LM: Get an ENT evaluation if it has not been done, try to
laser DCR? treat for a while with topical antibiotics (esp. in patients
reluctant for another surgery within a short span), do a
LM: Not applicable. nasal endoscopic evaluation, try an endoscopic widening
of the ostium, get a CT DCG done in cases where the
VPG: NA. cause of failure is still not clear/or if there had been any
other associated problem to begin with and lastly revise
ERM: Not done in the few cases I have done. the surgery with Endoscopy/External DCR depending on
the case. CT DCG also helps in identifying the residual
VK: Lacrimal intubation after laser dcr procedure enhances dilatation of sac, site of closure of ostium etc., with respect
success rates of the procedure. to the status of the adjacent bone.
SM: Yes, now I prefer as failure rate is high after 1 year without VPG: I follow the basic principles of technique for primary DCR.
intubation. Operation can be done under local or general anesthesia.
A skin incision slightly larger than that of primary DCR
VM: What are the common causes of DCR failure? is made. The orbicularis muscle is separated by blunt
dissection. The anterior limb of the medial canthal tendon
LM: In- adequate size bony window, excessive scarring, post may be divide if required, must be sutured while closing
operative nasal congestion, unidentified nasal or sinus the wound. The fibrotic scar tissue over the surgical site
pathology etc., Hence I believe in pre-op ENT evaluation is meticulously dissected and excised with Westcott
in my cases. scissors. The periosteum over anterior lacrimal crest
is elevated. The presence of the lacrimal sac and bony
VPG: Common causes of failure of primary DCR operation: ostium and the nasolacrimal anastomosis of the previous
surgery are explored, identified, verified and evaluated.
1. Inappropriate size or location of ostium: small osteotomy, The bone was removed over the virgin nasal mucosa until
too anterior osteotomy, bone opposite common canaliculus an approximately 14 × 18 mm length of bony ostium was
not removed achieved. In all cases, care was taken to excise the thick
frontal process of the maxillary bone at the level of the
2. Non-perforation of sac; anastomosis of flaps of lacrimal common canaliculus superiorly, and the superomedial part
fascia with nasal mucosal flaps of the bony nasolacrimal canal inferiorly. The upper and
lower lacrimal canaliculi were evaluated with a Bowman
3. Common canalicular obstruction probe, and any obstruction was noted. In cases without
canalicular obstruction, the Bowman probe was introduced
4. Scarring within rhinostomy: Massive granulation and through the upper canaliculus and the lacrimal sac was
scarring, due to primary or secondary haemorrhage and tented. In the presence of medial canalicular or common
infection from unopposed mucosal flaps canalicular obstruction, tare managed accordingly. The
fibrotic tissues over the lacrimal sac were carefully excised,
5. Sump syndrome and the sac incision was performed with a cataract /
Hudson. MVR knife. At this step, care was taken to make
6. Active systemic disease a full-thickness incision on the sac wall and enter the sac
lumen. Anterior and posterior lacrimal sac flaps were
7. DCR to air cell fashioned in presence of sufficient lacrimal sac mucosa,
otherwise only the anterior flap was prepared in cases
8. Intervening ethmoid with small and fibrotic lacrimal sacs. Posterior sac flap
is excised. Only anterior nasal mucosal flap is prepared.
9. Brisk introperative bleeding
10. Three or more of the above
ERM: Poor surgical technique in the vast majority of cases-
inadequate hemostasis, lack of gentleness in tissue
handling, poorly designed ostia and flaps, inappropriate
suturing techniques, poor quality instrumentation. In some
www.dosonline.org 15
Flaps sutured as in primary DCR. If no nasal mucosal flap Additional management problems in such cases include
is available, sac flap may be sutured to periosteum, and presence of skin scar, lid deformity, traumatic telecanthus,
secured to orbicularis muscle. If no sac flap is available, depressed nasal bone, malunited bones in operative area,
mucous membrane graft may be used and sutured to nasal thick bones etc.
mucosal flap. Mostly, I also intubate the lacrimal passages
using BCSI. Intraoperative MMC / 5 FU for a variable ERM: Pre-operative diagnostic nasal endoscopy and a
period have also been used in such cases. computerized tomographic dacryo-cystorrhinostomy
(CT-DCG) are extremely useful and must be performed
ERM: A diagnostic nasal endoscopy and syringing tells us the whenever feasible. Surgery under general anesthesia;
story, and identifies the problem. Endoscopic revision bicanalicular intubation in all except the most straight
surgery with bicanalicular intubation is a good choice forward cases.
in cases without canalicular issues. If upper system is
compromised, a revision external DCR with intubation is VK: Post-traumatic blocks are best treated by a combined
ideal. approach with a presaccal and endonasal exploration.
The patency can be restored with the combined approach.
VK: First, the block is assessed for location, pre or post saccal. Lacrimal intubation is usually helpful in maintaining
Presaccal obstructions are dealt with using lacrimal patency.
intubation. The laser procedure is helpful in these cases.
SM: Landmarks are altered because of bony trauma, structures
The post saccal blocks are best dealt with nasal endoscopy are more difficult to identify. Thick bone is often
with restoration of patency. Mitomycin C may be used encountered. DCR can be combined with bicanalicular
in case of fibroproliferative growth. Intubation may nasal intubation.
occasionally be required where canalicular patency also is
suspect. VM: How do you manage patients who keep complaining of
watering even after a successful DCR?
SM: Diagnosis of failed DCR is confirmed by syringing, nasal
endoscopy, canalicular endoscopy & imaging. Management LM: Make sure there is no lacrimal sump syndrome, laxity of
depends upon cause of failure. 1. Osteotomy site improper medial canthus, puncta or lids, keep checking the patency,
– make new opening, size inadequate-enlarge by laser, 2. forced blinking exercises to help the pump mechanism,
Scar tissue – excision of scar or destruction by laser can treatment of associated allergic conjunctivitis, meibomitis
be done endoscopicaly, 3. Canalicular occlusion-open by or blepharitis. Also an ENT evalution to check if they have
trephine or microdrill & do intubation, 4. Sac opening allergic rhinitis etc.,
inadequate-open it & enlarge, 5. Nasal pathology-correct
it. VPG: We do not encounter such cases. Search for the etiology
of watering in such cases e.g. lower lid ectropion, punctal
VM: What is your experience with Injection Botox for bi problems, lid laxity or lacrimal pump failure, Sump
canalicular block? syndrome, partial blocks etc. Management depends on
the etiology. Preoperative selection of cases, meticulous
LM: Nil operative technique, avoiding repeated syringings in
postoperative period would prevent frequent occurrence
VPG: I prefer a conj. – DCR. Injection Botox can cause ptosis, of such cases.
diplopia, dry eye etc.
ERM: Dye disappearance test to look for physiological and
ERM: Nil. functional patency; orbicularis exercises; local massage.
Diagnostic nasal endoscopy to rule out soft granulation
VK: The use of Botox in difficult cases of epiphora affords or early scarring at ostium site.
immediate relief in symptoms. Two or even lesser units
in case of the elderly injected into the lacrimal gland VK: Persistent watering with a patent outflow pathway could
transconjunctivallly with the needle directed away from be due to multiple causes including an underlying dry
the levator muscle provides improvement in symptoms eye syndrome that may manfest in the postoperative
within 3-7 days without associated problems. period. The patient is assessed and treated accordingly. An
enhanced sensitivity to tearing may also cause reporting of
SM: No experience, we use Trephine / Microdrill with bilateral minor physiological tearing such as when exposed to cold
intubation in such case. air droughts. These require counselling and support.
VM: How do you manage post traumatic NLD Obstruction? SM: Causes of watering even after successful anastomosis are
flow related-dependent on balance between Rate of tear
LM: Get a CT Scan done and 3D reconstruction in cases with production (less evapotation) and Rate of drainage.
extensive trauma to the orbit (which will help future
reconstruction), CT DCG in cases where the position of 1. Increase watering may be due to reflex lacrimation from
the sac is not clear, to note diverticula, other soft tissue corneal.
pathology after trauma etc.,
2. Lacrimal drainage is affected by nasal pathology, Inadequate
VPG: I follow the basic principles of technique for primary canalicular conductance due to swelling, small Anastomosis
DCR and failed DCR. Preoperative DCG may be done. between sac & nasal mucosa, Abnormal lower lid position
16 DOS Times - Vol. 16, No. 5, November 2010
& movement, and by Punctual apposition & function. Once VPG: Various technical problems of paediatric DCR include:
case is established can manage accordingly. small space, small anatomy, difficulty in visualizing normal
anatomy, poorly defined and rapidly changing anatomy,
VM: What is the indication of doing DCR in children and flat and poorly developed anterior lacrimal crest, shallow
what is the minimum age at which it is recommended? lacrimal fossa, anteriorly placed ethmoidal cells, improper
placement of rhinostomy site, delicate bones and flaps,
LM: Failed probing, repeated infection, lacrimal abscess etc., more bleeding due to general anaesthesia (50 ml blood
Recommend DCR by the age of 4-5 years. However if loss in an infant may be lifethreatening) & vigorous
there is acute infection/repeat abscess formation we need proliferation of granulation or scar tissue. Rapidly growing
to intervene earlier. fascial bone centres may get retarded leading to depressed
bridge of nose postoperatively.
VPG: Dacryocystorhinostomy (DCR) for congenital NLDO is
indicated in failed probings, failed BCSI, failed balloon ERM: Basically, the pronounced and obvious anatomic landmarks
catheter dilatation, diverticulum in the sac, NLD cannot seen in lacrimal surgery in an adult are less prominent in a
be perforated due to bony obstruction & recurrent child. Bone is less thick and the overall space available to
bilateral dacryocystitis with risk of septicemia. Surgery work is less. Most other steps and issues remain the same.
at a very young age is usually necessary in cases of severe
dacryocystitis associated with agenesis of the intraosseous VK: The size of the bony ostium needs to be tailored according to
portion of the nasolacrimal duct, or in the very rare the size of the lacrimal fossa. Prescribed adult dimensions
situation of amblyopia secondary to a large dacryocele would be too large and may compromise the nasal bridge
unresponsive to probing. anteriorly.
DCR is generally deferred till 3 years of age due to various SM: Anatomy is not very clear in children, it may result in
technical problems of pediatric DCR. Some lacrimal difficulty in selecting proper site of osteotomy, Lacrimal
surgeons are of the view that the DCR should be deferred bone is very thin in children so easy to initiate osteotomy,
till 18 months of age. Few lacrimal surgeons have performed general anaesthesia is must in children, endonasal DCR in
DCR in infants 2 weeks to 1 year without any unexpected children can be technically difficult as nasal passage is very
complications. I have done DCR in infancy in few cases narrow.
without any operative or postoperative complications with
long term follow-up which included evaluation with CT VM: How much interval do you recommend between DCR
scan. and cataract surgery?
ERM: In my clinical practice, over the last decade and a half, the LM: Preferable for at least a month as this gives adequate time
need for DCR in the pediatric age group has come down for internal healing as well.
significantly. The possible reasons may be improved and
earlier access to probing, improved success of probing due VPG: 2-3 weeks.
to use of nasal endoscopic control, silastic bicanalicular
intubation, frequent performance of necessary associated ERM: If the surgical wounds have healed, with no nidus of
procedures like turbinate infracture or turbinectomy. Also, infection, and drainage of tears has resumed, I do not see
access to balloon dacryoplasty, limited due to the cost any reason to delay cataract surgery. With the widespread
involved, may help to avoid DCR surgery. There is greater availability of nasal endoscopy, it is always advisable to
understanding of nasal factors in the failure of probing Only perform one to rule out a nidus of infection intranasally
after exhausting the less invasive options is a DCR carried eg. crusts, prior to clearing the patient for surgery, Laser
out. I have not done DCR surgery for children below 5 DCR is a procedure with serious limitations, when seen
years or so. from the perspective of an Oculoplastic Surgeon. However,
if successful, one may proceed with cataract surgery within
VK: Persistent. epiphora in children despite repeated probings a few days.
is an indication for dcr in ages 4 and above.
VK: A period of patent outflow without signs of inflammation
SM: 1. Multiple failed probing, 2. Persistent discharge, 3. Trauma and infection for a minimum postoperative period of three
weeks.
Minimum age recommended is 4 years.
SM: Minimum time between two surgeries should be 15 days.
VM: How is doing a pediatric DCR different from an adult
DCR?
LM: In the external approach the sac is located more posteriorly DOS Correspondent
and the tissues are very delicate (fashion flaps accordingly). Vikas Menon DNB
In Endoscopic surgery we require finer instruments as the
access is minimal .Some of the instruments used for ear
surgery are helpful. I prefer to take the help of an ENT
surgeon in some of the difficult cases.
www.dosonline.org 17
Retinal Artery Macroaneurysm Retina
Vinod Kumar Aggarwal MS, DNB, MNAMS, FRCS, Kshitiz Kumar MS,
Bhuvan Chanana MD, DNB, Jolly Rohatgi MS
Aneurysmal alterations of the retinal vasculature are not three orders of arteriolar bifurcation. They tend to be 100-250μm
infrequent in clinical ophthalmic practice. These changes in size and are often located at the site of an arteriolar bifurcation
most commonly involve the retinal veins or capillaries, usually or an arteriovenous crossing. The superotemporal artery is the
seen as a sequel to venous occlusive disease, sickle cell disease, or most commonly reported site of RAM probably because such
radiation retinopathy. Larger aneurysms may also arise directly involvement is most likely to cause visual impairment.3
from the major retinal arteries. Although mentioned sporadically
in the earlier literature,1,2 the entity currently well known as Retinal An elderly woman in sixth or seventh decade with an established
artery macroaneurysm (RAM) was formally described in 1973 history of systemic hypertension is a typical presentation.2,4,5
by Robertson.2 Most cases are unilateral and only 10% of patients have bilateral
disease. Multiple aneurysms can be found in some patients,
Definition and description involving different arteries in same eye. Approximately 10% of
macroaneurysms are pulsatile on initial presentation, which could
RAMs are fusiform or saccular dilatations of the retinal arterioles be a sign of impending rupture.4-6
that occur in the posterior fundus, usually arising within the first
Signs and Symptoms
Presentation is variable. Although a patient with RAM may be
asymptomatic if the macula is not involved, the most common
(a)
(c)
(b)
(d)
Figure 1(a): Retinal artery macroaneurysm (RAM) Figure 1(c): Surrounding blocked fluorescence
along the inferotemporal artery with macular around the RAM from hemorrhage
exudation. Figure 1(b): Fluorescein angiogram
showing filling of the RAM in the arterial phase Figure 1(d): Late phase angiogram showing staining
of the vessel with macular leakage
Department of Ophthalmology
University College of Medical Sciences and G.T.B. Hospital, New Delhi 19
www.dosonline.org
(a) (a)
(b)
(b)
*
Figure 2(a): Retinal artery macroaneurysm (RAM) along (c)
the inferotemporal artery with surrounding retinal and
(altered) subretinal hemorrhages Figure 2(b): Vertical Optical
Coherence Tomography (OCT) scan showing subfoveal serous
macular detachment (asterisk) and macular edema
presentation is with progressive decline in visual acuity. This results
from collection of serous fluid within the retina, producing diffuse,
focal or cystoid macular edema, or from macular detachment
due to collection within subretinal space (Figure 2). The edema
may be due to direct aneurysmal leakage or leakage from small
incompetent vessels surrounding the aneurysm. Macular edema
is considered a common early complication of RAMs, occurring
in approximately one-third of cases. Lipid exudates can also cause
a gradual decrease in vision by migrating into the macula - they
frequently demonstrate a circinate pattern (Figure 1a).
Patients may also present with sudden, severe visual loss resulting Figure 3(a): Retinal artery macroaneurysm (RAM) along the
from rupture of the aneurysm with hemorrhage into the subretinal superotemporal artery with surrounding hemorrhages,
space, the subinternal limiting membrane space, the subhyaloid involving the fovea as well. Figure 3(b): Resolution of
space, and/or the vitreous cavity (Multilayered hemorrhages) the hemorrhages and the RAM at 4 months following
(Figure 3a,4a). The so called ‘hourglass hemorrhage’ consists perianeurysmal laser photocoagulation.
of simultaneous subretinal and preretinal collections of blood.
A nonclearing vitreous hemorrhage may be the result of a Figure 3(c): Fluorescein angiogram showing the laser spots
macroaneurysm and must be suspected in a typical patient.
staining of the vessel wall to marked leakage. The involved artery
Investigations is typically patent but may be narrowed proximal and distal to
the macroaneurysm (Figure 1 a-d). Partial filling may be seen in
RAM typically fills uniformly in early arterial phase of Fluorescein spontaneously involuting or thrombosed aneurysms. Capillary
angiography (FA). Late phase appearance may vary from mild
20 DOS Times - Vol. 16, No. 5, November 2010
(a) (b)
Figure 4(a): Retinal artery macroaneurysm (RAM) along the superotemporal artery with surrounding retinal and
subretinal hemorrhages along with a subhyaloid hemorrhage. Macular exudation is also present. Figure 4(b): Resolution of
the hemorrhages and decrease in macular exudation at 2 months following perianeurysmal laser photocoagulation.
microaneurysms and nonperfusion, intraretinal microvascular macula, causing permanent structural damage to the retinal
abnormalities, telangiectasis, and fluorescein dye leakage in pigment epithelium (RPE) and photoreceptors, and usually results
surrounding areas may accompany the FA picture. in permanent central visual loss. Sub RPE blood is uncommon.5
In cases of dense overlying hemorrhage, FA shows only blocked The macular exudative response may resolve with involution of the
fluorescence. Indocyanine green angiography (ICG) may be useful macroaneurysm but often results in permanent structural damage.
in viewing the macroaneurysm in such cases as its absorption Late complications resulting from chronic macular edema include
and emission peak in the near infrared range allow the light to cystoid macular edema (CME), ERM and macular hole formation.
penetrate to a greater extent through the hemorrhage. Chronic macular edema and structural damage from macular
exudate are the most common causes of poor visual outcome in
OCT of the macular area reveals any involvement of macula patients with RAMs.6,7
(Figure 2) which may consist of macular edema (commonly
cystoid), serous macular detachment, submacular or intraretinal Differential Diagnosis
hard exudates, epiretinal membrane (ERM) and macular hole.
RAMs can mimic other ocular diseases and are frequently
Natural History misdiagnosed. The differential diagnosis includes retinal
telangiectasia, venous macroaneurysms of retinal vein occlusion,
RAMs may remain stationary over long periods. Eventually, diabetic retinopathy, retinal capillary angioma, age-related
the majority will follow a course of thrombosis, fibrosis, and macular degeneration with a macular disciform scar, idiopathic
spontaneous involution. However, extensive hemorrhagic activity ERM.
may be present due to a ruptured lesion or blood oozing from
a small dehiscence in the wall of the aneurysm. The ultimate Branch retinal vein occlusions (BRVO) have been reported to
prognosis depends upon: masquerade as RAMs;8 this is known as the Bonnet sign. The
classic Bonnet sign consists of intraretinal hemorrhage at an
• the location of the hemorrhage and exudate arteriovenous crossing simulating a macroaneurysm.9
• the severity and duration of macular involvement IRVAN (idiopathic retinal vasculitis, aneurysms, and neuroretinitis)
syndrome is a rare and distinct entity of multiple aneurysms
Intraretinal hemorrhages generally resolve completely, with little involving all the major retinal arteries, neuroretinopathy, vitreous
or no effect on vision. Similarly, vitreous hemorrhages gradually and anterior chamber inflammation, and angiographic evidence of
resorb with visual function returning to near normal in the arteritis found in young age. This entity can also mimic RAM.10-12
vast majority of cases, however vitreous floaters may persist.
Hemorrhages in the preretinal space generally resolve, and prior Management
visual acuity is resumed; however, ERM formation can result.
Also, toxic damage to the photoreceptors may occur if the blood Robertson emphasized that the majority of macroaneurysms
remains for a long period of time. Hemorrhages in the subretinal spontaneously resolve and good visual function is retained.
space may produce secondary morphologic changes within the Treatment may be required in some cases particularly those with
www.dosonline.org 21
macular involvement. Laser photocoagulation is the accepted 4. Abdel-Khalek MN, RichardsonJ. Retinal macroaneurysm: natural
modality for treatment of RAM (Figure 3,4). This can be applied history and guidelines for treatment. Br J Ophthalmol 1986; 70:
directly to the aneurysm or it can be perianeurysmal. The former 2-11.
however carries the risk of hemorrhage and arterial closure.13
Argon or frequency doubled Nd:YAG lasers can be used with 5. Lavin MJ, Marsh RJ, Peart S, Rehman A. Retinal arterial
long duration burns (0.2–0.5 seconds) and large spot sizes (500 macroaneurysms: a retrospective study of 40 patients. Br J
μm in diameter). Ophthalmol 1987; 71: 817-825.
Nd:YAG laser hyaloidotomy can be employed in the treatment 6. Palestine AG, Robertson DM, Goldstein BG. Macroaneurysms of
of dense premacular hemorrhage due to RAM in order to speed the retinal arteries. Am J Ophthalmol 1982; 93: 164.
visual recovery and prevent toxic damge to the photoreceptors,
which may compromise the final visual outcome.14-17 7. Yang CS, Tsai DC, LeeF, Hsu WM. Retinal artery macroaneurysm:
risk factors of poor visual outcome. Ophthalmologica 2005; 219:
Subretinal bleed away from the macular area can be managed 366-372.
conservatively. The various options available to treat submacular
hemorrhage include pneumatic displacement using SF6 or C3F8 8. Spalter HF. Retinal Macroaneurysms: a new masquerade syndrome.
gas with or without the use of intravitreal tissue plasminogen Trans Am Ophthalmol Soc 1982; 80: 113.
activator (t-PA).18-20 Prone positioning must be maintained for
at least 24 hours in order to compress the macula directly and 9. Kimmel AS, Magargal LE. Temporal branch retinal vein obstruction
displace the submacular hemorrhage inferiorly. In cases of dense masquerading as a retinal artery macroaneurysm : the bonnet sign.
old subretinal bleed pars plana vitrectomy may be required.18 Ann Ophthalmol 1989; 21: 251.
Recently anti-VEGF drugs like Avastin and Lucentis have been 10. Wiznia RA. Development of a retinal artery macroaneurysm at
used to treat macular edema associated with RAM and to hasten the site of a previously detected retinal artery embolus. Am J
the resolution of multilayered hemorrhages.21 Ophthalmol 1992; 114: 642-643.
The following recommendations regarding management of 11. Kincaid J, Schatz H. Bilateral retinal arteritis with multiple
patients with RAM can be made: aneurysmal dilations. Retina 1983; 3: 171-178.
• Patients with no macular involvement and good visual 12. Chang TS, Aylward W, Davis JL, et al. Idiopathic retinal vasculitis,
function should be closely followed. aneurysms, and neuro-retinitis. Ophthalmology 1995; 102: 1089-
1097.
• Patients with decreased visual acuity secondary to retinal or
vitreous hemorrhage, without significant edema or exudation, 13. Panton RW, Goldberg MF, Farber MD. Retinal arterial
should be observed to allow clearing and spontaneous macroaneurysms: risk factors and natural history. Br J Ophthalmol
improvement. 1990; 74: 595-600.
• Patients with macular edema, exudation, or serous macular 14. Raymond LA. Neodymium:YAG laser treatment for hemorrhages
detachment should be treated. Treatment is also indicated if under the internal limiting membrane and posterior hyaloid face
documented deterioration in vision occurs. in the macula. Ophthalmology 1995; 102: 406-411.
• Macroaneurysms that increase in size or are pulsatile in nature 15. Ijima H, Satoh S, Tsukahara S. Nd:YAG laser photodisruption for
may be more likely to rupture and hemorrhage. If visual preretinal hemorrhage due to retinal macroaneurysm. Retina 1998;
function remains good, close observation without treatment 18: 430-434.
is warranted.
16. Ulbig MW, Mangouritsas G, Rothbacher HH, et al. Long-term
• Recurrent vitreous hemorrhages secondary to the same results after drainage of premacular subhyaloid hemorrhage into
macroaneurysm are reported to be rare; however, if this the vitreous with a pulsed ND:YAG laser. Arch Ophthalmol 1998;
occurrs it might merit photocoagulation therapy. 116: 1465-1469.
To summarise, RAMs comprise a distinct retinal vascular 17. Gedik S, Gur S, Yilmaz G, Akova YA. Retinal arterial macroaneurysm
disorder. Most commonly seen in elderly females, the disorder rupture following fundus fluorescein angiography and treatment
is often associated with underlying hypertension and systemic with Nd:YAG laser membranectomy. Ophthalmic Surg Lasers
arteriosclerotic disease. The natural history is one of gradual and Imaging 2007; 38: 154-156.
spontaneous involution with good visual prognosis in the majority
of cases; however, retinal or vitreous hemorrhage and macular 18. Ohji M, Saito Y, Hayashi A, et al. Pneumatic displacement of
edema, with resultant loss of vision, can occur. subretinal hemorrhage without tissue plasminogen activator. Arch
Ophthalmol 1998; 116: 1326-1332.
References
19. Heriot WJ. Intravitreal gas and tPA: an outpatient procedure for
submacular hemorrhage. Paper presented at American Academy of
Ophthalmology Annual Vitreoretinal Update, Oct 1996, Chicago,
IL.
20. Hassan AS, Johnson MW, Schneiderman TE, et al. Management
of submacular hemorrhage with intravitreous tissue plasminogen
activator injection and pneumatic displacement. Ophthalmology
1999; 106: 1900-1907.
21. Jonas JB, Schmidbauer M. Intravitreal bevacizumab for retinal
macroaneurysm. Acta Ophthalmol 2010; 88:e284.
1. Rabb MF, Gagliano DA, Teske MP. Retinal arterial macroaneurysms. First Author
Surv Ophthalmol 1988; 33: 73-96. Vinod Kumar Aggarwal MS, DNB, MNAMS, FRCS
2. Robertson DM. Macroaneurysms of the retinal arteries. Trans Am
Acad Ophthalmol Otolaryngol 1973; 77: OP55.
3. Gass JDM. Stereoscopic atlas of macular diseases: diagnosis and
treatment, Vol. 1. 4th edn. St Louis, Mosby-Year Book, 1997 pp
472–476.
22 DOS Times - Vol. 16, No. 5, November 2010
Hypertensive Retinopathy Retina
Parag K. Shah DNB, Saurabh Arora DNB
Hypertension is a worldwide problem that affects approximately • The choroidal arterioles undergo fibrinoid necrosis in
one billion, and ranked as the fourth largest mortality severe hypertension leading to the infarction of segments
risk factor in the world. It is associated with cardiovascular of the choriocapillaris, wherein patches of overlying retinal
risk and systemic target organ damage. As per previous1 and pigment epithelium (RPE) may appear yellow (Elschnig’s
current2 reports of the Joint National Committee on Prevention, spots) (Figure E), which may become hyper pigmented with
Detection, Evaluation, and Treatment of High Blood Pressure a margin of hypo pigmentation as they resolve.
(JNC), retinopathy is considered as one of the several markers
of target organ damage in hypertension. On the basis of the JNC • Less commonly, linear RPE hyperplasia may develop (Figure
criteria, the presence of retinopathy may be an indication for F) over infarcted choroidal arterioles (Siegrist’s streaks) and
initiating antihypertensive treatment, even in people with stage 1 localized bullous neurosensory or RPE detachments may be
hypertension (blood pressure, 140 to 159/90 to 99 mm Hg) who observed.
have no other evidence of target-organ damage.
Generalised retinal–arteriolar narrowing and arteriovenous
Hypertension has profound ocular effects resulting in a range of nipping are markers of vascular damage from chronic
clinical signs referred to as hypertensive retinopathy, hypertensive hypertension. In contrast, other signs (focal arteriolar narrowing,
choroidopathy, and hypertensive optic neuropathy. retinal hemorrhages, microaneurysms, and cotton-wool spots)
were related to current but not previous blood-pressure levels
Pathophysiology and clinical manifestations and may therefore be more indicative of the severity of recent
hypertension.3
Retinal circulation undergoes a series of retinal micro vascular
changes evident as clinical signs in hypertension, either directly Classification systems
by elevated blood pressure or indirectly via vasoactive substances
(angiotensin II, endothelin-1 and decreased basal nitric oxide Marcus Gunn first described hypertensive retinopathy in the 19th
activity). century in a series of patients with hypertension and renal disease.4
The underlying pathophysiology of these signs can be divided In 1939, Keith, Wagener and Barker classified into four grades of
into stages.3 retinopathy5 in an effort to quantify hypertension severity and
enable prediction of mortality (Table 1).
• In the initial, vasoconstrictive stage, there is vasospasm
and an increase in retinal arteriolar tone owing to local Table 1: Keith, Wagener and Barker hypertensive retinopathy
autoregulatory mechanisms clinically evident as generalized classification
narrowing of the retinal arterioles.
Grade Features
• Persistently elevated blood pressure leads to intimal
thickening, hyperplasia of the media wall, and hyaline I Mild generalized retinal arteriolar narrowing
degeneration in the subsequent, sclerotic stage. This stage
corresponds to more severe generalized and focal areas of II Definite focal narrowing & arteriovenous nipping
arteriolar narrowing, changes in the arteriolar and venular
junctions (i.e., arteriovenous nicking or nipping [Figure III I & II along with retinal hemorrhages, cotton-wool
A]), and alterations in the arteriolar light reflex due to spots & exudates
opacification (i.e., widening and accentuation of the central
light reflex described as “silver wiring” or “copper wiring” IV Severe grade III & papilloedema
[Figure B]).
• This is followed by an exudative stage, in which there is
disruption of the blood–retina barrier, necrosis of the
smooth muscles and endothelial cells, exudation of blood
(haemorrhages), lipids (hard exudates), and retinal ischemia
(cotton-wool spots). (Figure C).
• When hypertension becomes very severe, intracranial
pressure may become elevated with subsequent effects on the
optic nerve manifested as optic nerve ischemia and optic disc
swelling (papilledema) referred to as malignant hypertension
or hypertensive optic neuropathy (Figure D).
Department of Retina & Vitreous, Figure- A: Line diagram shows increased rigidity of
Aravind Eye Hospital, the artery, which compresses the less rigid vein
Avinashi Road, Coimbatore,Tamilnadu
www.dosonline.org 25
Figure- B: Fundus photo of RE shows silver wire appearance of the arterioles (white arrow)
Figure- C: Fundus photo of RE shows superficial hemorrhages, cotton-wool spots, hard exudates and evolving macular star
Figure- D: Fundus photo of LE showing disc edema along with macular edema,
superficial hemorrhages, cotton-wool spots and hard exudates
Figure- E: Fundus photo of supero temporal quadrant of RE showing multiple Elschnig’s spots (black arrows)
The 3 year survival was 70% for patients with grade 1 hypertensive A more recent three-grade classification of hypertensive
retinopathy compared with 6% for patients with grade 4 retinopathy by Wong and Mitchell8 is based on the relative severity
retinopathy.6 of hypertensive retinopathy signs and their relation to systemic
disease (Table 3).
In 1953, Scheie7 proposed a widely adopted five-stage classification
system in which the changes of hypertension and arteriolosclerosis Complications of hypertensive retinopathy9
were graded separately and correlated with concomitant changes
in the arteriolar light reflexes along with the color and appearance A) Artery occlusion
of the retinal arterioles (Table 2).
B) Vein occlusion
Table 2: Scheie’s classification C) Macro aneurysm
D) Anterior ischemic optic neuropathy
Grade Features E) Diabetic retinopathy
0 No changes F) Age-related macular degeneration
1 Barely detectable arterial narrowing G) Glaucoma
2 Obvious arterial narrowing with focal Relation to systemic disease
irregularities plus light reflex changes Recent studies evaluating fundus findings of hypertensive
3 Grade 2 plus copper wiring & retinal hemorrhages retinopathy and their relation to systemic disease are given below.
/ exudates The Blue Mountains Eye Study10 suggested that arteriolar
4 Grade 3 plus silver wiring & papilloedema narrowing might be linked to the occurrence and development
of hypertension.
26 DOS Times - Vol. 16, No. 5, November 2010
Table 3: Wong & Mitchell three-grade classification
Grade Retinal Signs Systemic Associations
None No detectable signs None
Mild Modest association with risk of clinical stroke,
Generalized or focal arteriolar narrowing, subclinical stroke, cardiovascular mortality
Moderate arteriovenous nicking, opacification (“copper wiring”)
of arteriolar wall or a combination of these signs Strong association with risk of clinical stroke,
Malignant subclinical stroke, cognitive decline and death
Hemorrhages (blot, dot or flame-shaped), from cardiovascular causes
cotton-wool spots, hard exudates, micro aneurysms, Strong association with death
or a combination of these signs
Signs of moderate retinopathy plus swelling
of the optic disc
Figure- F: Fundus photo showing Siegrist streaks (black arrows)
Figure- G: OCT picture showing serous macular detachment in malignant hypertension
The Atherosclerosis Risk in Communities (ARIC) study Management8 (Based on Wong and Mitchell classification)
demonstrated an association between retinal exudates,
hemorrhages and micro aneurysms with a two to four fold higher • Mild hypertensive retinopathy: Routine care, closer blood
risk of stroke, cognitive decline, white matter lesions, cerebral pressure monitoring, better control of hypertension.
atrophy and stroke mortality along with two-fold higher risk of
congestive heart failure and three-fold higher risk of heart failure • Moderate hypertensive retinopathy: May need physician
events.11 referral, diabetes should be excluded, possible indication for
hypertensive treatment & other cardiovascular risk factors.
The Multi-Ethnic Study of Atherosclerosis12 found that narrower
retinal arterioles were associated with lower hyperemic myocardial • Severe hypertensive retinopathy: Urgent treatment.
blood flow and perfusion reserve in asymptomatic adults,
suggesting that retinal arteriolar narrowing serves as an indicator Recent approaches in imaging technologies
of coronary micro vascular disease.
The ability to digitize retinal photographs allows the assessment
The Beaver Dam Eye Study13 evaluated the prevalence and 5-year of vessel diameter and subsequent calculation of the arteriole-
incidence of retinal micro vascular signs were much higher in to-venule ratio14, wherein a lower ratio reflects general arteriolar
hypertensive participants wherein poor blood pressure control narrowing.
had a higher risk of developing retinopathy compared with well
controlled hypertensive participants. The development of scanning laser doppler flowmetry with
automatic full-field perfusion imaging analysis allows precise
These studies highlight the importance of fundoscopic screening assessment of wall-to-lumen ratio, wall thickness, and wall cross-
with digital imaging techniques and computer analysis sectional area of the retinal arteriole.15
underscoring the fundus examination as a reliable and useful tool
in hypertensive disease detection and monitoring. Presence of serous macular detachment on optical coherence
tomography (Figure G), has recently been suggested to be
www.dosonline.org a stronger marker for malignant hypertension compared to
papilledema (100% vs 64%).16
27
The more commonly described feature of macular star or macular 6. Wong TY, Klein R, Klein BE, et al. Retinal Micro vascular
edema actually occur secondary to macular SRD. Abnormalities and their Relationship with Hypertension,
Cardiovascular Disease, and Mortality. Surv Ophthal 2001;46:59–80.
Conclusion9
7. Scheie HG. Evaluation of ophthalmoscopic changes of hypertension
Hypertension remains a major health issue worldwide, with and arteriolar sclerosis. Arch Ophthalmol 1953;49:117.
profound, often silent, multisystemic effects. Hypertensive
microvasculature changes in eye are of predictive and prognostic 8. Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med.
value in the management of systemic complications secondary to 2004;351:2310-7.
hypertension, including diabetes, cardiovascular, cerebrovascular
and other systemic vascular diseases. 9. Della Croce JT, Vitale AT. Hypertension and the eye. Curr Opin
Ophthalmol. 2008;19:493-8.
Although current recommendations for management of
hypertension do not mandate routine ophthalmoscopic 10. Smith W, Wang JJ, Wong TY, et al. Retinal arteriolar narrowing
examination, newer screening tools such as digital imaging and is associated with 5-year incident severe hypertension: the Blue
computer analysis may permit an early and consistent detection Mountains Eye Study. Hypertension 2004;44:442–447.
that may be important in identifying and managing modifiable
risk factors and provide prognostic information for cardiovascular 11. Wong TY, Klein R, Sharrett AR, et al. Retinal arteriolar narrowing
risk and disease progression. and risk of coronary heart disease in men and women. The
Atherosclerosis Risk in Communities Study. JAMA 2002; 287:1153–
References 1159.
1. The Sixth Report of the Joint National Committee on Prevention, 12. Wang L, Wong TY, Sharrett AR, et al. Relationship between retinal
Detection, Evaluation, and Treatment of High Blood Pressure. arteriolar narrowing and myocardial perfusion: multiethnic study
Arch Intern Med 1997; 157:2413-46. [Erratum, Arch Intern Med of atherosclerosis. Hypertension 2008;51:119–126.
1998;158:573.]
13. Klein R, Klein BEK, Moss SE, et al. The relation of systemic
2. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of hypertension to changes in the retinal vasculature: The Beaver Dam
the Joint National Committee on Prevention, Detection, Evaluation, Eye Study. Trans Am Ophthalmol Soc 1997;95:329–350.
and Treatment of High Blood Pressure: the JNC 7 report. JAMA
2003;289:2560-72. [Erratum, JAMA 2003;290:197.] 14. Hubbard LD, Brothers RJ, King WN, et al. Methods for evaluation
of retinal micro vascular abnormalities associated with hypertension
3. Wong TY, Mitchell P. The eye in hypertension. Lancet. 2007;369:425- /sclerosis in the Atherosclerosis Risk in Communities Study.
35. Ophthalmology 1999;106: 2269-2280.
4. Gunn RM. Ophthalmoscopic evidence of (1) arterial changes 15. Michelson G, Welzenbach J, Pal I, Harazny J. Automatic full field
associated with chronic renal diseases and (2) of increased arterial analysis of perfusion images gained by scanning laser Doppler
tension. Trans Ophthalmol Soc U K 1892;12:124-5. flowmetry. Br J Ophthalmol 1998; 82:1294–1300.
5. Wong TY, McIntosh R. Hypertensive retinopathy signs as risk 16. Shukla D, Ramchandani B, Vignesh TP, Rajendran A, Neelakantan
indicators of cardiovascular morbidity and mortality. Br Med Bull N. Localized Serous Retinal Detachment of Macula as a Marker of
2005;73–74:57–70. Malignant Hypertension. Ophthalmic Surg Lasers Imaging. 2010
Mar 9:1-7. doi: 10.3928/15428877-20100215-74.
Author
Saurabh Arora DNB
Congratulations
The following have being elected office bearers of the Glaucoma Society of India
President: Dr. Harsh Kumar, Secretary: Dr. Devindra Sood, Treasurer: Dr. Viney Gupta
Dr. Devindra Sood has been admitted as Fellow of American College of Surgeons this year’.
28 DOS Times - Vol. 16, No. 5, November 2010
Adjustable Sutures in Squint Surgery Squint
Yuvika Bansal MS, Gaurav Goyal MS, Shilpa Goel MS
The ability to modify the site of muscle insertion and control Weak muscles
the deviation in immediate postoperative period forms the • Paralytic strabismus.
basis for adjustable sutures1,2,3. Their use in strabismus surgery • Myasthenia gravis.
affords the surgeon the opportunity to inspect the ocular Restrictive phenomenon
alignment achieved after the surgery in alert patient and allows • Graves ophthalmology
the adjustment of muscles avoiding resurgery. • Post scleral buckling and glaucoma valve surgery.
• After pterygium surgery.
Historical perspective • After cataract and post anaesthetic injury.
Ability to adjust the muscle insertion to globe was first described • Scarring from trauma
in 1941. Jampolsky renewed the interest in 1975. Limbal and • Slipped (recovered),lost and disinserted muscle.
fornix conjunctival approaches of adjustment have been described.
Adjustments performed 3 to 4 days were found to decrease patient
discomfort. Adjustment as long as 2weeks has been described.
Intraoperative under local anaesthesia with prism cover testing
has also been described.
Adjustable techniques
Adjustable sutures are intended to facilitate primarily ocular (a)
alignment and decrease the need for reoperations.
Indications
• It is difficult to predict the outcome of conventional surgery.
• Slipped, lost or disinserted muscle4
• Incomitant strabismus like: duane, myasthenia gravis,
paralytic strabismus.
• Long standing complex strabismus.
• Horizontal or vertical recti weakening or strengthening in a
cooperative patient.
• There is risk of postoperative diplopia, optimal position
within the fusional range can be selected thus minimising
the postoperative diplopia.
• Reoperations when the amount of muscle surgery is difficult
to gauge and its effect is unpredictable.
• Scarring, tethering and contracture of muscles when result is (b)
unpredictable like in dysthyroid disease, blow out, following
retinal detachment surgery.4
Optimal candidates for adjustable suture technique
Sensory anomalies
• Large sensory deviations with poor vision.
• Central fusion disruption.
• Adult strabismus with scotoma.
Guru Nanak Eye Centre, Figure 1(a): Conjunctival recession till insertion
Maharaja Ranjit Singh Marg, New Delhi Figure 1(b): Deferral suture closure of one corner of
www.dosonline.org conjunctival incision
31
(a) (b)
Figure 2(a): conjunctival traction suture applied distal to the incision at the edge of muscle insertion
Figure 2(b): traction on this suture postoperatively exposes the surgical site for suture adjustment
• Combined vertical, horizontal or torsional deviations.
• Large eyes (axial myopia) and small (microphthalmic)
eyes.
Contraindications
• Most significant is uncooperative patient.
• Very high myopes with thin sclera may not be good candidates
because of risk of globe perforation.
Adjustable techniques
Preoperative considerations
• Ability to cooperate is checked by touching the conjunctiva on
medial and lateral aspects with a cotton swab after applying
topical anaesthesia- cotton bud test.
• Decision on the type of conjunctival incision fornix or limbal
approach is made.fornix based incisions are avoided in elderly
because of friable conjunctiva.
Figure 3: Two ends of muscle are tied, one needle is • Assessment of type of adjustment technique to be done is
removed, remaining needle is passed through conjunctiva made- it is better to place adjustable suture on a recessed
muscle especially if that muscle is stiff.
Techniques
• Reoperations Site modifications for adjustable sutures
• Incomitant strabismus like duane. Limbal: two techniques are used to facilitate adjustable sutures
through limbal incision. (Figure 1)
• Vertical strabismus including dissociated vertical
deviation. • Conjunctiva may be recessed till the level of original muscle
insertion to allow access to adjustable sutures.
32 DOS Times - Vol. 16, No. 5, November 2010
(a) (b)
Figure 4(a): after determining desired placement of muscle, half bow knot is tied
Figure 4(b): knot is untied for adjustment and converted to a permanent knot when alignment is satisfactory
• Adjustment can be made on conjunctival surface. muscle
sutures are tied together and needle of one end is removed.
second needle is passed through conjunctiva (Figure 3)
Adjustment can be done without manipulating conjunctiva5
Adjustment Techniques
Half bow tie technique (Figure 4) can be applied to a recessed or
resected muscle.
• Partial thickness scleral traction sutures are passed 90* away
from the muscle 1 to 2 m from limbus and traction applied
to give exposure of limbal area.
• Conjunctival marking suture is applied and two radial
relaxing incisions are then made.
• Muscle is identified by passing muscle hook against the globe
though opening in the tenons capsule.
• In both recession and resection sutures are passed through
original insertion.In recession hang back technique is used,
Figure 5 • muscle is held at the desired position, suture ends are tied in
a half bow technique.
• One corner of limbal incision is left deferring suture closure
Resection is done in conventional way and then two scleral
till the adjustment is made. • bites are taken at the edges of insertion site at 35 to 45 degree
angle towards the midline of muscle stump.
Fornix based
If adjustment is required bow is untied muscle position
• Retraction suture can be placed distal to incision at the edge • is adjusted and bow retied, procedure is repeated until
of muscle insertion prior to end of the procedure (Figure 2) alignment is achieved.
Bow is converted in a permanent knot.
www.dosonline.org 33
(a) (b)
Figure 5(a): knot is placed along the muscle suture
Figure 5(b): suture ends are cut if alignment is satisfactory
(c) (d)
Figure 5(c): muscle can be advanced and tied Figure 5(d): further recessed and muscle tied
Construction of bow is very important to prevent premature Sliding noose technique (Figure 6): muscle is secured and
conversion to a permanent knot. disinserted in a routine fashion.
Pulling on loose end opens the bow, while pulling on loop converts • Muscle insertion is identified and spatulated needles are
in to a permanent knot. passed through half thickness securing muscle.
Traction knot (Figure 5): utilizes the friction caused by knots • Scleral bites are centred on insertion and needles are passed
placed in muscle sutures as they pass in the scleral tunnel. is a crossed sword technique.
• free ends are allowed to extend from the wound. • Needles are removed, sutures are pulled anteriorly to abut
scleral insertion.
• If alignment is satisfactory sutures anterior to the knots are
cut ,no manipulation is required. • Needle holder is clamped across sutures at equal distance
approx 7mm from sclera and square knot is tied. joined
• If adjustment is required muscle can be pulled with suture sutures are called pole suture.
and knot tied.
• Stop is created by passing a Vicryl suture across the pole suture
• If recession is required knots can be pulled through scleral to form a noose. (Figure 6c)
suture tunnels by grasping the sutures posteriorly and then
permanent knot tied.
34 DOS Times - Vol. 16, No. 5, November 2010
Figure 6(a): Crossed sword technique. • For resection,pole suture is pulled to bring muscle anteriorly
and globe is pushed towards the muscle to be advanced.
(Figure 6f)
• Once muscle is advanced noose is slided posteriorly to fix it.
Pole suture is tied and excess suture is cut.
Ripcord technique: indicated when large amount of adjustment
is required and other methods of adjustment cannot be used.
Recession (Figure 7) needles are passed through sclera at desired
level of recession.
• Muscle is allowed to hang back 2-3 mm and ripcord suture
is passed through the knot before tying it.
• If earlier amount of recession was satisfactory then ripcord
is pulled advancing muscle to new scleral insertion.
Figure 6(b): Square knot and pole suture
Figure 6(d): ends of noose are tied in a bucket
handle for manipulation
Figure 6(c): Stop is created by Vicryl suture Figure 6(e): Recession technique
tied in a noose fashion across pole suture
35
• Ends of noose are tied together to provide bucket handle
manipulation. (Figure 6d)
• For recession, pole suture is released and globe is retracted
away from the recessed muscle. noose will act as stop against
sclera. (Figure 6e)
www.dosonline.org
(b)
(c)
(d)
Figure 6(f): Resection technique
Figure 7(b): Ripcord is passed under muscle suture knot
Figure 7(c): when tied muscle is advanced to desired
recession mark Figure 7(d): Ripcord can be cut if recession
is desired postoperatively
Figure 7(a): muscle allowed to hang back • If adjustment is required then ripcord suture is cut to give
added recession.
Resection (Figure 8)
a) standard resection is performed and before tying muscle knot
muscle is allowed to hang back 2 to 3 mm from desired mark.
b) Ripcord suture is passed under knot and muscle advanced to
original insertion point.
36 DOS Times - Vol. 16, No. 5, November 2010
Figure 8
c) If further recession is required ripcord suture is cut. Complications
d) If alignment is satisfactory no further improvement is • Broken suture at adjustment is a feared complication- ends
required. can be identified and adjustment performed.
Postoperative adjustment (principles) • Slippage or lost muscle.
• Patient should be alert and cooperative and able to fixate on • Changing measurements post operatively-unstable
accommodative target with refractive error corrected. adjustments can be found in myasthenia ,guillain barre
syndrome.
• Prism bar cover testing is done not only in primary but side
gazes in horizontal adjustments and vertical gazes for vertical • Suture irritation due to exposed sutures.
adjustments.
• Oculocardiac reflex can be minimized by ensuring topical
• Incomitance in side gazes should be taken care of. anaesthesia, avoiding lid speculum during adjustment.
• Overcorrection in primary gaze caused by resection of • Adjusting sutures may pull on adnexal tissue.
antagonist can not be relieved by adjusting a recessed muscle.
• Other complications like hyphema at the time of adjustment,
• 1mm of adjustment causes 2.5 to 4 pd change in ocular adhesions forming between the lids and superior rectus
alignment. in patients having lid surgery and superior rectus surgery
simultaneously.
Procedure
References
• Adjustment is done preferably 24hrs after surgery.
1. Arthur L. Rosenbaum, Alvina Pauline Santiago, Lance M. Siegel.
• Eye patch is removed and assessment of deviation is done Clinical strabismus management: principles and surgical techniques.
provided patient is free of anaesthesia. 435-47.
• Topical anaesthesia is ensured. 2. Beglan AW, Davis JS, Day R etal: Preferred post operative alignment
after congenital esotropia surgery.AM Ophtha 1990:22-269.
• Assistant is asked to give gentle traction on lids and patient
is asked to fix on object in direction which gives maximum 3. Captuo AR, Guo S, Wagner RS etal:Long term follow up of
exposure. extraocular muscle surgery of congenital esotropia .Am Orthopt J
1991;41-67.
• Rest steps followed as per technique.
4. David G Hunter, R.Scott Dingeman and Bharti R.N. Pediatric
Common pitfalls: pitfalls that need to be avoided: Ophthalmology: Current thought and a practical Guide.Page-214.
• Muscle is not secured properly and adequately 5. David K. Coats, Scott E. Olitsky. Strabismus surgery and
complications.142-8.
• Scleral bites are insufficient.
• Adjustable suture knots are not exposed.
Author
Yuvika Bansal MS
www.dosonline.org 37
Prescribing Glasses in Children: Squint
Pearls and Practices
Priyanka Arora MS, Suma Ganesh MS, DNB, Manish Sharma MS, Varshini Shanker DNB
Children are not simply young adults. They have unique visual patient to a non accommodative target. In very small children,
needs based on their visual demands and their developing near retinoscopy is very useful in estimating the refractive error.
visual system. Spectacle needs of adults cannot simply be It is performed at a distance of 50 cm when the child is seated in
extrapolated onto young children. It is however well established parent’s lap in a dark room. Use retinoscope light of low intensity
that uncorrected refractive error in childhood can be associated as target and add an adjustment factor of -1.25 to the retinoscopy
with development of amblyopia and strabismus. The most frequent value.
decision that a practising ophthalmologist needs to make in his
clinical practice is whether to correct a refractive error in a child When to prescribe?
or not.
Prescribing for myopia: Fluctuating myopia may be found
Children are not young adults in premature infants during the neonatal period . Congenital
myopia occurs in a small number of full term neonates, often with
In adults, the decision to prescribe glasses depends upon the associated astigmatism and strabismus. In infants and preschool
difference between uncorrected and best corrected visual acuity. children, only extreme myopia needs to be treated. However in
This however is not possible in most preschool children as they older school going children, full correction for myopia is required
will not provide a reasonable, reliable and repeatable visual acuity. (Table1)
Therefore the level of refractive error needs to be determined by
cycloplegic refraction. In addition to being difficult to examine, Prescribing for astigmatism: Symmetric astigmatism <1.50D in
children also have different visual demands. The working distance preschool children needs no correction unless associated with
of a preschool child is just 1-2 meters and therefore sharply focused high hyperopia or high myopia. In school going children, any
distance acuity is not needed, especially till the age of 3 years. Thus cylindrical prescription that improves visual acuity should be
in contrast to older children and adults, there is minimal need to treated. In preschool children, the threshold for prescribing glasses
correct mild symmetrical myopia in young children. Also, children is lowered down to 0.75 D if it is at an oblique axis i.e. 15 degrees
have different accommodative abilities as compared to adults. from 90 or 180 axes (Table 1).
Healthy children in their first decade of life typically possess 12
D or more of accommodation. So, even moderate uncorrected Table 1: When and how much to prescribe
hyperopia does not affect visual acuity in young children . Another
major problem is their constantly changing refractive error and Preschool children Early school years Late school years
their plastic visual cortex which poses them to an increased risk
of developing amblyopia from anisometropia or high uncorrected MYOPIA Only extreme myopia Myopia >-1.50 DS Full correction of
refractive errors.
>-4.00 DS needs to be treated Myopia
Various issues need to be dealt with while making a decision
regarding prescription of glasses in children. These include -Astigmatism >1.50 DS Astigmatism 1.0 to Any cylindrical correction
the need for cycloplegic refraction, the proper technique of that improves uncorrected
refraction and to determine the level of refractive error that may ASTIGMATISM -Oblique astigmatism 1.50 D needs to be visual acuity
be amblyogenic in a particular child. Other doubts and dielemmas
include when to prescribe and how much to prescribe? The rest >0.75 DS Treated
of the article will discuss the various recommendations and
guidelines that would help one to determine the need for glass -Astigmatism with high
prescription in young children.
hyperopia or myopia
Cycloplegic refraction: Cycloplegic refraction is mandatory to
obtain the refractive error and determine the spectacle needs of Prescribing for hyperopia: Prescribing spectacles for hyperopia
children. It is must in all children below 12 years of age . Preferred presents unique challenges. Uncorrected hyperopia can produce
cycloplegic agent is 1% atropine sulphate till the age of 2 years. For accommodative esotropia, strabismic amblyopia, and isoametropic
children older than 2years, 1% cyclopentolate provides adequate (refractive) amblyopia. Consensus-based guidelines have been
cycloplegia and can be used in children upto the age of 12 years. provided by the American Academy of Ophthalmology (Table 2).
For children aged 4 years or older, hyperopic refraction should
Technique of retinoscopy: One should seat himself at the same be prescribed in presence of decreased visual acuity, binocular
level and at an arm’s length along the line of sight from the anomalies, functional vision problems, or learning or academic
difficulties. Low to moderate hyperopia in asymptomatic school
Paediatric Ophthalmology and going children, in the absence of strabismus or amblyopia does
Strabismus Department not require treatment. Children with Down syndrome are often
hypo-accommodators and thus they may benefit from spectacle
Dr. Shroff’s Charity Eye Hospital, Daryaganj, Delhi correction at lower thresholds for hyperopia.
Consideration for anisometropia: Anisometropia is a very
powerful amblyogenic factor and thus needs a special mention.
Each 0.25 D difference in refractive error of both eyes produces
a retinal image size difference of 0.5%. Upto 5-6 % difference can
www.dosonline.org 39
Table 2: Guidelines for prescribing glasses in preverbal children (Iso ametropia)
Iso ametropia 0-1 years 1-2 years 2-3 years
Myopia -4.00 D -4.00 D -3.00 D
+6.00 D +5.00 D +4.50 D
Hyperopia
(without esotropia) +2.00 D +2.00 D > +1.5 D
Hyperopia
(with esotropia) 2.50 D 2.00 D > 1.50 D
Astigmatism
Table 3: Guidelines for prescribing glasses in preverbal children (Anisometropia)
Anisometropia 0-1 years 1-2 years 2-3 years Figure 1: Prescribing glasses in presence of strabismus
Myopia -2.50 D -2.50 D -2.00 D
Hyperopia +2.50 D +2.50 D +1.50 D clinical decision making while prescribing glasses in children.
(without esotropia) Special attention should be given while prescribing in presence
Astigmatism 2.50 D 2.00 D > 2.00 D of strabismus.
be tolerated, but any difference greater than this is significantly References
amblyogenic. PEDIG and AAO preferred practice patterns (Table
3) recommend 2.0 D as threshold value in cases of anisometropia , . 1. Atkinson J. Infant vision screening: predication and prevention
of strabismus and amblyopia from refractive screening in the
Partial versus full cycloplegic correction: How much to prescribe? Cambridge Photorefraction Program. In: Simons K, ed. Early visual
development, normal and abnormal. Oxford: Oxford University
In presence of esotropia, full cycloplegic refraction should be Press, 1993:335–348
prescribed. However, in absence of any strabismus, reduce upto
2.00 D from cycloplegic refraction in children with ametropic 2. Atkinson J, Braddick O, Bobier W, et al. Two infant vision screening
hyperopia. While in children with anisometropic hyperopia, programmes: prediction and prevention of strabismus and
symmetrical reduction in cycloplegic refraction should be amblyopia from photo- and videorefractive screening. Eye 1996;10:
done, but it should not be more than 1.5 D as the children with 189–98
anisometropic amblyopia have defective accommodation . In
cases with myopia and astigmatism, full correction is to be given. 3. Glasser A, Campbell MC. Presbyopia and the optical changes in the
human crystalline lens with age. Vision Res 1998;38: 209-29
Special situations
4. Robaei D, Rose K, Ojaimi E, Kifley A, Huynh S, Mitchell P. Visual
Prescribing glasses in children with strabismus acuity and the causes of visual loss in a population-based sample of
6-year-old Australian children. Ophthalmology 2005;112:1275–82
Refractive correction in strabismus is important as it provides a
sharp retinal image which helps in fusion. Moreover, it assists in 5. Fotedar R et al. Necessity of Cycloplegia for Assessing Refractive
producing balance between accommodation and convergence. Error in 12-Year-Old Children: A Population-Based Study. Am J
In children with esotropia with hyperopia, full cycloplegic Ophthalmol 2007;144:307–09.
refraction is prescribed (Figure 1). While those with myopia are
given minimum minus that improves vision. Bifocals should be 6. Fledelius H: Prematurity and the eye. Acta Ophthalmologica (Suppl)
considered in children with high AC/A ratio. However, children 128, 1976
with exotropia, full correction for myopia and minimum plus for
hyperopia must be prescribed. Over correcting minus lenses may 7. Donahue SP. Prescribing Spectacles in Children: A Pediatric
be prescribed in young children with exotropia and those with Ophthalmologist’s Approach. Optometry and Vision Science 2007;
high AC/A ratio. 84(2): p110-14
Other situations that need a special mention include retinopathy 8. American Academy of Ophthalmology. Pediatric Eye Evaluations,
of prematurity in preterm children, who have a tendency to Preferred Practice Pattern. San Francisco: American Academy of
develop myopia. These children should be screened frequently Ophthalmology; 2002
and refractive error corrected promptly. Also, refractive errors are
more common in congenital glaucoma and need to be looked for 9. American Academy of Ophthalmology. Pediatric Eye Evaluations,
and managed promptly. Preferred Practice Pattern. San Francisco: American Academy of
Ophthalmology; 2002.
To summarize, as for now, no evidence based guidelines
are available for prescribing glasses in children. However, 10. Schmidt P, Maguire M, Dobson V, Quinn G, Ciner E, Cyert L, Kulp
consensus based guidelines provided by American Academy MT, Moore B, Orel-Bixler D, Redford M, Ying GS. Comparison of
of Ophthalmology provide the most acceptable useful guide to preschool vision screening tests as administered by licensed eye care
professionals in the Vision in Preschoolers Study. Ophthalmology
2004;111:637–50.
11. Rutstein RP, Contemporary issues in amblyopia treatment.
Optometry 2005;76:570-8.
First Author
Priyanka Arora MS
40 DOS Times - Vol. 16, No. 5, November 2010
United we Win Divided we Lose Miscellaneous
Vipin Sahni MS
In India scene of the ophthalmic practice is rapidly changing. • Two or more ophthalmic practitioners join together to form
If you go through the advertisements published in DOS times a small joint practice.
you can see a change coming in the mind set of ophthalmic
practitioners. Some months ago we saw an advertisement, “If A group can be formed by two or more ophthalmologists joining
you have it then come and join us”, but now you can see the hands. They can belong to same city/area or different cities. It is
advertisements that say ‘Practice available for collaboration or not necessary that they open or create a center. They can form a
sale’. This is the change which has occurred in our society. Few group just practicing as they are (at different locations). Even then
groups from the south are now spreading their arms in the north; they are benefitted.
another few are from Delhi spreading into nearby towns of UP,
Uttarakhand and Haryana. This is the change which USA has Recently I was travelling abroad with a group of ophthalmologists,
scene in late eighties and early nineties. Dr AK one of them, who is 54 years of age, asked me, and he
wanted some other practicing ophthalmologist of the same city
With many large groups joining the race to acquire more and Dr BK should join him. They had already discussed this but were
more ophthalmic practices, even the best practices of large and not able to arrive at any conclusion Dr AK is an old practitioner,
medium class towns are feeling pressure to join one of the groups has Larger and bigger setup, he do both anterior and posterior
to sustain their livelihood. To save yourself from being acquired segments, whereas Dr BK has half of the practice he is new and
or losing your hard earn practice people are under pressure to does not work in posterior segment. He asked me - how they
join one or other group. Remember the childhood story; where should go forward to form a group practice?
father give one stick to his sons which they break easily, but when
father gave bunch of sticks to his sons nobody was able to break it. I suggested to him to continue their OPD at their respective places,
Than the father says if you are united nobody can defeat you. The as their patients will keep on coming there for years. For at least
same moral comes in hand here. When you form a strong group one year they should start Indore and other work (Lasers, FFA,
nobody will be able to defeat you. Field, OCT etc.) at the place which is larger and has more facilities.
Later on they should create a new facility in a joint name. In this
There are some benefits of forming a group in ophthalmic practice way, it shall be easy to judge and come to conclusion whether
their group is successful or they should go in for their individual
• The cost of marketing can be shared practice.
• Competition will decrease Now let us talk about big metropolis where there are thousands
of practising ophthalmologists. Few of them join to form a
• Cross referrals will be a big help group, suppose GoodEYE group. GoodEYE group is formed
by ten ophthalmologists. All of them are practicing in different
• Knowledge and experience of others will come handy. locations of a big city in north India and all of them are doing
good individual practice. Let us see how they are benefitted by
• Resources can be shared forming a group.
• Can have a good bargain and deals in purchases. Suppose together they put 5000 foldables. They pool in the order
and one of them bargains with companies for an annual supply
Now let us talk about how the groups can be formed. There are of 5000 IOLs they can get it much cheaper. Or three/four of them
many ways in which groups can be formed - want to buy a new OCT, they can bargain with companies for that,
and can get substantial discount which is not possible if they buy
• The most common way of forming a group is when one of it individually even from the same company.
the leading practitioners keeps on adding new doctors to the
practice and after few years this becomes a big organisation, Now if they want to advertise in TOI, none of them can give a half
which then starts opening branches in other parts of city/ page advertisement and reap in its benefits. But collectively they
state/country and finally becomes a big group. (Most of the can give multiple half pages advertisements from GoodEYE group
groups are formed in this way) of eye centers with addresses of all the centers. If the cost of one
such insertion is two lacs then they will be pooling only twenty
• A Corporate group interested in health industry can open thousand each and enjoying the ad coverage and penetration for
hospitals/eye centers at various places. Hospital. two lacs.
• Many doctors of the same city/nearby city can join hands and Take another example, If Dr CK practises in Shalimarbagh and
open new centre (many LASIK LASER centers have come up operates a patient of Sarita Vihar the latter can refer him to one
in this way.) other group member Dr DK who practises in Sarita Vihar or
nearby for post op care. In this way one can increase the practice
• A group of doctors/friends can merge/acquire practices of among the group members. Otherwise patient will later go to
existing doctors with the help of venture capital. Later they any other ophthalmologist who is not a part of your group, and
can add new hospitals into their group. one can lose the patients family forever in spite of doing good
Kaushalya Devi Eye Institute
Pilibhit / Shahjahanpur, U.P.
www.dosonline.org 45
surgery. In case you are not able to manage some patient or have • Expensive equipments like fundus cameras, OCT, lasers etc.
some complications, you can discuss among the group members can be shared.
or send for the second opinion to one of group members. Then
the patient will come back to you for further management. Thus • Patients can be better-served, even better if several sub-
forming a group will increase cross references to all the group specialists are present; care is better coordinated, and a
members and benefit all of them. patient’s all needs can be addressed at a single location.
If few doctors of the nearby cities like Meerut, Muzaffar Nagar, • It’s much easier to afford superior talent, (best possible staff
and Roorkee also join to make a group they can also get the same and advisers) as their cost is borne by several doctors working
benefits. Even if far off people Delhi, Ambala, Ludhiana, and together.
Chandigarh join hands to form a group, then also they can have
some benefits of the group. • With a partner, you have someone with whom you can share
your success and failures.
Actually jealousy among friends or colleagues is the major factor
keeping everyone divided, which the companies & other people • The quality of care will be higher in group practices for two
are benefiting from. In 2001 when we bought LASIK then other reasons. First, because each surgeon can obviously inculcate
company went to one of our colleague and told him that we were good habits of his colleagues, especially if periodic group
doing so many LASIKS every week and reaping in big bucks. The discussions are conducted.
colleague who had a good relationship with me never discussed
it with me and bought a new LASIK machine. Our city being • As a member of a group practice, you have an in-house pool
small, there were not enough patients for two LASIKs, so both of thoughts to help you improve your ideas, and a safety check
of us went into trouble and paid the loan from our collections of to help you avoid following through with poor ideas. (An
cataract practice. ideal combination is when one surgeon is oriented to cost
containment, and his partner may be oriented to revenue-
Some of my colleagues ask me different questions about what to enhancement or one may be master in marketing and other
do if - in public relations.)
• They have good Cataract practice but they cannot do phaco • There is greater practice security. When a solo surgeon falls
– They should get a full time ophthalmologist who can do ill, the practice comes to an immediate halt. In group other
phaco surgeries or at least call visiting ophthalmologist who surgeons can keep the practice moving until the partner is
can do phaco surgeries. They should also call experts for other back in action.
super specialities like retina glaucoma and plastics etc. This
way forming a group will further strengthen their practice. • There can be significant lifestyle benefits. It’s possible to
arrange giving leaves to each doctor
• They have mediocre practice and they don’t know phaco –
They should get a partner ophthalmologist from nearby town I hope that with the above ideas, you and your partners will be
who can do phaco surgeries, this will increase their practice. able to judge better about the group. Let us talk of a hypothetical
situation of new famto-second laser coming for doing cataract
• They have small young practice and don’t know phaco – they surgery. If cost of equipment is 35,000,000/- . You are a practicing
should first go for phaco training and learn good phaco then surgeon with good practice doing 500-1000 cataracts per year.
restart practice. Time consumed in learning phaco should be Presently you charge 10,000/- to 30,000/- for cataracts. If you buy
an investment to the practice. this system yourself, and borrow money from a bank then you have
to pay at least 50,000,000/- in five years. For this you have to pay
The economic and professional advantages of group practice are 10,000,000/- each year. For this you have to do at least 250 cases
compelling, and may surpass your desire for independence. With at the rate of 40,000/- each. This looks very difficult at the present
the government bringing in new legislation, lone practice will be moment. But if ten ophthalmologists join hands then initially each
difficult to sustain. Group practic ‘at the same center’ have a lot one has to invest only 3,50,0000/- and system is yours. You don’t
of advantages. have to pay anything to banks. If each one of you brings only one
hundred cases for 35,000/- each (which is nominal increment on
Benefits of Group Practice at the same centre present charges) you take home your investment in the very first
year. That is the beauty of group practice.
• High fixed overhead expenses are shared and divided.
With rising cost of facility like rent and other maintenance, I have seen even the best friends do not discuss practice matters
electricity expenses, maintenance and running of DG set, or place orders collectively. Since we are divided others are bound
Taxes levied by local authorities, staff salary all can be divided to win. “United we win, divided we lose”.
among the partners.
Author
Vipin Sahni MS
46 DOS Times - Vol. 16, No. 5, November 2010
Scheme for Participation of Voluntary Organisations Miscellaneous
Non-recurring Grant-in-aid for Eye Banks in utilized in the prescribed format (Annexure IX) and submit
Government/Voluntary Sector monthly report to the District Health Society.
Non-recurring Grant-in-aid for Eye Banks in Government/ iii) The NGO should be committed to collect at-least 200 eye balls
Voluntary Sector (upto maximum Rs. 15.00 lakhs); in the next two years. In case of difficult terrain (eg. North
eastern states), relaxed criteria of 100 cataract operation
The objective of this scheme is to promote Eye banking activity including other eye disease operations shall be applicable.
in the country through Government facilities, NGOs and other
stake holders to get adequate tissue for corneal transplantation Procedure for Approval of Grants
for treatment of corneal blindness.
Two copies of application in prescribed formats (Annexure I)
Financial assistance would be submitted by applicant NGO along with necessary
documents in support of qualifying criteria to the State Programme
Under the scheme, financial assistance will be provided up to a Officer (SPO), NPCB. The SPO would examine the proposal in
maximum of Rs. 15 Lakh for purchase of equipment, furniture terms of eligibility criteria, and depute a team of expert(s) (2-3)
and fixtures (list attached) from the State to visit the NGO for assessing present facilities
and requirements. This entire work should be completed within
Eligibility criteria maximum of three months from the date of receipt of applications
complete in all respects. The SPO may thereafter, forward his
The organization should: recommendation to the competent authority for final disposal.
i) Satisfy general eligibility conditions mentioned at page no. 2 The clauses on Competent authority, Release of Grant,
of the document. Penalties, Disposal of Assets, Monitoring and Evaluation,
Audited Statement of Accounts & Utilization Certificate shall be
ii) Should fit into the definition of Eye Bank as mentioned at the same as mentioned in the earlier scheme i.e. Scheme No I.
page no. 3 of the document.
iii) Organizations having experience in providing eye care List of equipments that can be procured from Non-Recurring GIA
services will be given preference. to NGOs for an Eye Bank
iv) Should have collected at-least 100 Eye Balls in any of the S.No. Equipment/Furnishing
preceding two years of application. In case of difficult terrain
(eg. North eastern states), relaxed criteria of 25 Pair of Eyes 1. Slit Lamp Microscope
shall be applicable 2. Specular Microscope
3. Laminar Flow
OR 4. Serology Equipment
5. Instruments for corneal excision and enucleation
v) Should have conducted at least 600 cataract operations
including other eye disease operations in the proceeding two including containers
years. In case of difficult terrain (eg. North eastern states), 6. Autoclave
relaxed criteria of 300 cataract operation including other eye 7. Keratoplasty instruments
disease operations shall be applicable. 8. Transport Facility (One 2 Wheeler)
9. Refrigerator
Infrastructure Requirement 10. Computer & Accessories
11. Telephone Line
a) Manpower Requirement: 12. Air-Conditioner
13. Renovation, Repair, Furniture & Fixtures
• Ophthalmic Surgeons (Full time / on Panel) 1
Maximum Assistance = Rs. 15 Lakh
• Ophthalmic Technician 1
• Eye Donation Counselor / Social Worker / Health
Educator / Clerk 2
Expected Output NGOs receiving non-recurring grants shall
i) Utilize the entire grant within period of 12 months from the
receipt of grant after following due procedures
ii) Provide & maintain detailed records of Eye Balls collected and
www.dosonline.org 51
Non-recurring Grant-in-aid for Eye Donation Society (District Programme Manager), NPCB. The DPM would
Centres in Government/Voluntary Sector examine the proposal in terms of eligibility criteria and inspect of
the NGO for assessing present facilities and requirements within
Non-recurring Grant-in-aid for Eye Donation Centres a period of one month from the date of receipt of applications
(EDC) in Government/Voluntary Sector (upto maximum complete in all respects. The DPM may thereafter, forward his
Rs. 1.00 lakh) recommendation to the competent authority for final disposal.
Eye Donation Centre Competent authority
For the purpose of the above scheme, an Eye Donation Centre State programme Officer (SPO), NPCB would be the competent
will mean an organization that is: authority to approve / reject applications in writing giving reasons
for rejection, in case of disapproval.
i) Is affiliated to a registered Eye Bank
Release of Grant
ii) Harvest corneal tissue and collect blood for serology;
The NPCB shall release funds for this scheme to State Health
iii) Ensure safe transportation of tissue to the parent eye bank Society on the basis of proposal in the State PIP. The State Health
Society shall release Grant-in-aid to the District Health Society
iv) Provide a round the clock public response system for eye who in turn shall released the funds to the approved grantees
donation; installments on Execution of bond on a hundred Rupee Non-
Judicial Stamp paper by the grantee institution / NGO in the
v) Coordinate with donor families and hospitals to motivate eye prescribed Pro forma (Annexure IV).
donation;
The clauses on Penalties, Disposal of Assets, Monitoring
vi) Conduct Public and professional awareness on eye donation and Evaluation, Audited Statement of Accounts & Utilization
be provided; Certificate shall be the same as mentioned in the earlier
scheme i.e. Scheme No. I.
Financial Assistance
List of Equipment/ furnishings for an Eye Bank Eye /Donation
Under the scheme, financial assistance will be provided up to a Centre
maximum of Rs. 1 Lakh (Rupees One Lakh Only) for the purchase
of equipment as per list given end of the scheme. S.No. Equipment/Furnishing
Eligibility criteria 1. Refrigerator
a) Should satisfy general eligibility conditions mentioned at 2. Enucleation set
page no. 2 of the document (except the 2 year clause, i.e. new
organization can also apply) 3. Containers for corneal sets
b) The organization should have the following staff as a 4. Corneal Sets
minimum requirement:
5. Autoclave available
Sl. No. Personnel Number
6. Device and / or material for Health Education
1. Ophthalmic Technician 1 activities
2. Eye Donation Counselor/ 7. Vehicle (Two wheeler)
Social Worker / Health Educator 1
Expected Output: NGOs receiving non-recurring grants shall Donation Centre Recurring Grant-in-aid to Eye
Banks & Eye Donation Centre in Government /
i) Utilise the entire grant within period of 12 months from the Voluntary Sector
receipt of grant after following due procedures
Recurring Grant-in-aid to Eye Banks & Eye Donation
ii) Provide & maintain detailed records of Eye Balls collected Centre in Government/Voluntary Sector
and deposited in linked Eye Bank in the prescribed format
(Annexure X) and submit monthly report to the District The objective of this scheme is to promote Eye banking activity
Health Society. in the country through Government facilities, NGOs and other
stake holders to get adequate tissue for corneal transplantation
iii) The NGO should be committed to collect at-least 20 eye balls for treatment of corneal blindness.
in the next two years.
Eye Bank (EB)
Procedure for Approval of Grants
Financial Assistance : Under the scheme, financial assistance will
Two copies of application in prescribed formats (Annexure I) be provided
would be submitted by applicant NGO along with necessary
documents in support of qualifying criteria to the District Health
52 DOS Times - Vol. 16, No. 5, November 2010
i) Recurring Assistance of Rs.1500 per pair of eyes towards Procedure for Approval of Grants
honorarium of Eye Bank staff, consumables including
preservation material & media, transportation/ POL and The total no of eye balls collected in month would be given by the
contingencies. Eye Bank & Eye Donation Centre in the format given Annexure
–IX, X respectively) to the District Health Society. The claims shall
ii) Recurring Assistance of Rs. 1000 per pair of eyes collected be verified by the DPM/DPO and settle within 3 months from the
towards honorarium of eye donation centre staff, consumables day of receipt of claims complete in all respects.
including preservation material & media, transportation/
travel cost/POL and contingencies. Recurring GIA would be Competent Authority
paid through affiliated Eye Bank.
District Programme Manager (DPM) of the District would be the
Eligibility Criteria: The organization should competent authority to approve / reject applications in writing
giving reasons for rejection, in case of disapproval.
• Should satisfy general eligibility conditions mentioned at
page no. 2 of the document (except the 2 year clause, i.e. new Reprint from Scheme for Participation of
organization can also apply) Voluntary Organisation, National Programme
for Control of Blindness July, 2009 Edition.
• Should fit into the definition of Eye Bank & Eye Donation
Centre as mentioned at page no. 3 & 11 of the document.
Infrastructure Requirement: same as mentioned in Scheme no. II
for Eye Bank and Scheme no. III for Eye Donation Centre.
www.dosonline.org 53
Intacs for Post Lasik Ectasia Clinical Meeting: Clinical Case-1
Ramendra Bakshi MS, FRCS, Mahipal S Sachdev MD
A22 year old female presented to us with complaints of • Center At: Centre of Pupil (Intacs SK)
diminution of vision in both eyes. She gave history of LASIK
done elsewhere 2 years ago. Few months post LASIK she noticed • Inner Channel Diameter: 6.0 MM
dimness of vision in both eyes. She was diagnosed as having post-
LASIK Ectasia BE, (RE>LE). 1 year ago, Corneal collagen cross • Outer Channel Diameter: 7.3 MM
linking with Riboflavin (C3R) had been done elsewhere in both
eyes to arrest the Ectasia. Post-operatively, her UCVA improved to 6/24 from FC5M, whilst
BCVA improved 6/10 at 1 month follow up
On examination
Post-op manifest refraction reduced to -1.50/-1.50x70 6/10 RE.
Unaided visual acuity was CF5M in the RE and 6/15 in the LE.
Pre-op refraction was 3.25/-4.00x65 6/18 in the RE, and -1.5x160 Pentacam showed a decrease in keratometry (pre-op K1 39.5, K2
6/6 in the LE. Slit Lamp examination in the Right Eye showed 43.0 to post-op K1 37.6, K2 41.7 D) (Figure 3,4).
clear evidence of Ectasia whereas the left eye cornea appeared
normal. Intraocular pressure by non-contact tonometry (NCT) Disccussion
was 12mm Hg RE and 14mm Hg LE. Rest of the Ant Segment
was within normal limits in both eyes. Fundus by indirect Corneal ectasia is an infrequent but potentially serious
ophthalmoscopy was within normal limits both eyes. She was complication of refractive surgery and occurs more commonly
advised corneal topography (Oculus Pentacam) which showed after laser in situ keratomileusis (LASIK). Several possible
evidence of post LASIK Ectasia in the Right Eye. (Figure 1) Serial alternatives to manage post-LASIK ectasia have been reported,
corneal topographies during the past 1 year showed stabilization including scleral fitted gas-permeable contact lenses, Collagen
of the ectasia in both eyes post C3R. crosslinking, deep lamellar keratoplasty, and intrastromal corneal
ring segment (ICRS) implantation. C3R followed by INTACS
Intracorneal Ring Segment (INTACS SK) with Femtosecond Laser is a new treatment modality for such patients C3R inhibits the
RE was planned for further improvement in UCVA and BCVA. progression of corneal ectasia, whereas ICRS (INTACS) is a
minimally invasive procedure which significantly flattens and
• Surgical Plan (Figure 2) regularizes the cornea without affecting the biomechanical
properties of the cornea as the underlying cause of the ectasia
• MR: 3.25/-4.00 x 65
Indications for INTACS
• Incision Site:165
• Patients who are contact lens intolerant
• Incision Depth:460 Microns
• Who have central clear corneas
• Inferior:0.45 SK
• Who have a thickness of 450 microns or greater at the
proposed incision site
• Who have corneal transplantation as the only remaining
option to improve their functional vision
0.45 SK
Figure 1: Pre-operative pentacam Figure 2: Surgical plan for INTACS SK RE
of the Right Eye
55
Centre For Sight
B-5/24, Safdarjung Enclave, New Delhi
www.dosonline.org
Figure 4: One week post-operative with single
segment inferiorly
Figure 3: One week post-operative Pentacam Intacs for severe keratoconus cases. In a case series by Pallikaris
RE after INTACS et al, 2010, INTACS SK (severe keratoconus or steep "K") have
earlier been reported to improve visual acuity in patients with
Contraindications for INTACS post-laser in situ keratomileusis corneal ectasia.1,2 Intracorneal
ring segment implantation have also been reported to be a useful
• Patients with collagen vascular, autoimmune or option for the treatment of coma-like aberrations and astigmatism
immunodeficiency diseases in post-LASIK corneal ectasia.3 In a few case reports published
earlier, implantation of a single Intacs segment inferiorly (as in
• Pregnant or nursing mothers our case) improved progressive myopia and regular and irregular
astigmatism in eyes with post LASIK ectasia.4
• Ocular conditions such as recurrent corneal erosion
syndrome or corneal dystrophy Conclusions
• Patients on isoretinoin, amiodarone, sumatriptan INTACS is a minimally invasive procedure for the management
of Post LASIK Ectasia. INTACS implantation significantly flattens
• Large pupillary diameter >7.0 mm and regularizes the cornea, improving the UCVA and BCVA and
aberrations. INTACS coupled with C3R is a safe and effective
Description of the device procedure for the management of post-LASIK Ectasia
Composed of 2 clear segments, each having an arc length of 150 References
degrees which are made of PMMA and available in 11 thickness
from 0.210mm - 0.450mm. 2 INTACS segments ranging from 1. Kymionis GD, Bouzoukis DI, Portaliou DM, Pallikaris IG. New
0.210-0.450mm may be implanted depending on the orientation INTACS SK implantation in patients with post-laser in situ
of the cone and the amount of myopia and astigmatism to be keratomileusis corneal ectasia. Cornea. 2010 Feb;29(2):214-6.
reduced. The determination of which thickness of the INTACS
segment to implant depends upon pre-operative manifest 2. Kymionis GD et al,Management of post-LASIK corneal ectasia
refraction, spherical equivalent, location of the cone and degree with Intacs inserts: one-year results. Arch Ophthalmol. 2003
of asymmetric astigmatism. Mar;121(3):322-6.
Intacs-SK are newly developed implants (rings) with smaller 3. Piñero DP, Alio JL, Uceda-Montanes A, El Kady B, Pascual I.
implantation diameter (6 mm) yet still outside the central optical Intracorneal ring segment implantation in corneas with post-
zone, and are designed to treat steeper corneas. Intacs SK have laser in situ keratomileusis keratectasia.Ophthalmology. 2009
elliptical cross section and come in two sizes (0.400 and 0.450 Sep;116(9):1665-74
mm). Intacs-SK are designed to maximize the effectiveness of
4. Pokroy R, Levinger S, Hirsh A. Single Intacs segment for post-laser
in situ keratomileusis keratectasia. J Cataract Refract Surg. 2004
Aug;30(8):1685-95.
First Author
Ramendra Bakshi MS, FRCS
56 DOS Times - Vol. 16, No. 5, November 2010
Flipped Iris Claw Lens Clinical Meeting: Clinical Case-2
Charu Khurana MS, DNB, Mahipal S. Sachdev MD, Hemlata Gupta, Dinesh Talwar MD, HK Tewari MD,
Avnindra Gupta MS, FRCS, Ritika Sachdev MBBS, Ritesh Narula MS
A72 year old woman presented with sudden, painless, dimness Figure 2: Blocked fluorescence corresponding with areas of
of vision in the right eye since 10 days. She had been operated sub-retinal hemorrhage at the posterior pole in the right eye
for cataract in both eyes 12 years ago elsewhere. She had no other
systemic complaints.
On examination, she had an uncorrected visual acuity (UCVA)
of 6/60 in both eyes which improved with +3.00DS/ -1DC° X 90
to 6/36 in the right eye and with +1.00 DS/ -2.5 DC x 80° to 6/45
in the left eye. Her intra-ocular pressure (IOP) was 14 mm Hg in
both eyes. She had an iris claw lens in her right eye and a posterior
chamber intraocular lens (IOL) in the left eye.
Fundus examination in the right eye showed a large, dense
sub-foveal hemorrhage with areas of de-hemoglobinized blood
inferiorly (Figure 1). On fluorescein angiography (FA), blocked
fluorescence was seen corresponding with areas of hemorrhage
(Figure 2). An elevated foveal contour with shadowing obscuring
the underlying retinal pigment epithelium (RPE) details was seen
on OCT (Figure 3). The left eye had old, pigmented macular
scarring.
The patient was administered intra-vitreal injection of 0.3 cc
undiluted C3F8 with 0.1 cc of 50μg of tissue plasminogen activator
(tPA) in the right eye and advised to maintain prone position for
2 weeks. Her post-operative recovery was uneventful in the first
2 weeks and her IOP was normal.
2 weeks after the intra-vitreal injection her best corrected visual
acuity (BCVA) was maintained at 6/36 and fundus examination
revealed decreased density of sub-retinal hemorrhage especially
Figure 1: Dense sub-retinal hemorrhage with areas of Figure 3: OCT of the right eye shows backscattering and
de-hemoglobinized blood inferiorly in the right eye obscured RPE details due to sub-retinal hemorrhage
Centre for Sight Group of Eye Hospitals, in the sub-foveal area (Figure 4a&b). Pooling of the dye and
New Delhi pin-point areas of hyperfluoroscence were seen on FA. The C3F8
bubble seen in the vitreous cavity on indirect ophthalmoscopy
www.dosonline.org was less than 1/8th of its original size.
On the 16th post-operative day, the C3F8 bubble was seen in the
anterior chamber (Figure 5). On the 18th day, the patient reported
a sudden dimness of vision. Her UCVA was finger counting at 1m
which improved to 6/36 with +13 DS/-0.75 Cyl x 20°. The iris claw
lens was seen lying perpendicular to the iris plane with the claws
still enclaved in the iris tissue at 2 and 8 o’clock (Figure 6). There
was no endothelial touch and the IOP was normal.
IOL repositioning was done and anterior vitrectomy was required
to return the lens to its original position (Figure 7). 1 week later (3
59
(a) (b)
Figure 4(a&b): 2 weeks after C3F8 injection, stable iris claw lens and reduced density of
sub-retinal hemorrhage as compared to Figure 1
Figure 5: C3F8 bubble Figure 6: Flipped iris claw lens lying perpendicular to iris
seen in plane. Note that the claws or haptics are still well enclaved
anterior chamber in the iris tissue and there is no endothelial touch
weeks after the C3F8 injection) the patient had a BCVA of 6/24p, complications include dislocation (traumatic or spontaneous),
the IOL was stable and IOP was in the normal range (Figure 8). pupil distortion, glaucoma, endothelial cell damage, uveitis,
pigment dispersion, cystoid macular edema, choroidal detachment
Discussion and retinal detachment4-10.
A retrospective analysis of the lens flip revealed that the small Various studies have reported an incidence of iris claw lens
C3F8 bubble (almost 1/10th of the original size) pushed the iris dislocation of 2-8% due to trauma, perforation of the iris by the
claw lens from behind and migrated into the anterior chamber. It haptic as well as spontaneous dislocation11-14. The iris claw lens
flipped the lens completely by 180 degrees but when it got absorbed is attached to the peripheral iris with pincer like haptics/ claws
between the 16th and 18th day, the lens returned midway and lay (enclavation). Superficial fixation carries the risk of late erosion
perpendicular to the iris plane by 90 degrees. Re-positioning of and dislocation. It is recommended that for reliable fixation, a thick
the lens combined with anterior vitrectomy was performed and fold of iris up to the posterior pigment epithelium is captured15.
the lens settled back in its previous position, remaining enclaved Surgical repositioning of the iris claw lenses requires special
in the iris tissue through-out the procedure. instrumentation, may be technically difficult and does not ensure
against further dislocation16.
Iris claw lenses were designed by Jan Worst in 1978 and used
for primary and secondary IOL implantation after extra and This case demonstrates an unusual flipping of the iris claw lens
intra-capsular cataract extraction1-3. The commonly reported caused by a C3F8 gas bubble which was injected into the vitreous
60 DOS Times - Vol. 16, No. 5, November 2010
Salient Features of Lens re-positioning
Figure 7: Re-positioning of the flipped iris claw lens followed by anterior
vitrectomy to return the lens to its original position
2. Worst JGF, Los LI. Some aspects of implant surgery. Eur J Implant
Refract Surg 1991; 3:157–167
3. Singh D. Iris claw lens--six years experience. Indian J Ophthalmol
1986;34:181-2
4. Risco JM, Cameron JA. Dislocation of a phakic intraocular lens. Am
J Ophthalmol 1994 Nov 15; 118(5):666-7
5. Singhal S, Sridhar MS. Late spontaneous dislocation (disenclavation)
of iris-claw intraocular lenses. J Cataract Refract Surg 2005 Jul;
31(7):1441-3
6. Yoon H, Macaluso DC, Moshirfar M, Lundergan M. Traumatic
dislocation of an Ophtec Artisan phakic intraocular lens. J Refract
Surg 2002; 18:481–483
Figure 8: Stable iris claw lens after lens 7. Coullet J, Mahieu L, Malecaze F, Fournié P, Leparmentier A, Moalic
re-positioning and anterior vitrectomy S, Arné JL. Severe endothelial cell loss following uneventful angle-
supported phakic intraocular lens implantation for high myopia. J
cavity for treatment of a posterior segment pathology. It is Cataract Refract Surg 2007 Aug; 33(8):1477-81
recommended that strict prone positioning should be maintained
until the gas bubble is completely absorbed in all patients with 8. Sminia ML, Odenthal MT, Wenniger-Prick LJ, Gortzak-Moorstein
iris claw lenses as the lens continues to be unstable even 12 years Moorstein N, Vo¨lker-Dieben HJ. Traumatic pediatric cataract:
after its implantation. a decade of follow-up after Artisan aphakia intraocular lens
implantation. J AAPOS 2007; 11:555–558
References
9. Singh D. Iris claw type intraocular lenses. Indian J Ophthalmol
1. Worst JGF, Massaro RG, Ludwig HHH. The introduction 1982;30:457-9
of an artificial lens into the eye using Binkhorst’s technique.
Ophthalmologica 1972; 164:387–389; discussion, 389–391 10. Foss AJ, Rosen PH, Cooling RJ. Retinal detachment following
anterior chamber lens implantation for the correction of ultra-high
myopia in phakic eyes. Br J Ophthalmol 1993 Apr; 77(4):212-3
11. Van der Meulen IJ, Gunning FP, Vermeulen MG, de Smet MD.
Artisan lens implantation to correct aphakia after vitrectomy for
www.dosonline.org 61
retained nuclear lens fragments. J Cataract Refract Surg 2004; 14. Risco JM, Cameron JA. Dislocation of a phakic intraocular lens
30:2585–2589 [letter]. Am J Ophthalmol 1994; 118: 666–667
12. Perez-Santonja JJ, Bueno JL, Zato MA. Surgical correction of high 15. Van der Meulen IJ, Gunning FP, Vermeulen MG, de Smet MD.
myopia in phakic eyes with Worst-Fechner myopia intraocular Artisan lens implantation to correct aphakia after vitrectomy for
lenses. J Refract Surg 1997; 13:268–81 retained nuclear lens fragments. J Cataract Refract Surg 2004;
30:2585–2589
13. Budo C, Hessloehl JC, Izak M, Luyten GP, Menezo JL, Sener BA,
Tassignon MJ, Termote H, Worst JG. Multicenter study of the 16. Gicquel JJ, Langman ME, Dua HS. Iris claw lenses in aphakia. Br J
Artisan phakic intraocular lens. J Cataract Refract Surg 2000 Aug; Ophthalmol 2009 Oct; 93(10):1273-5
26(8):1163-71
First Author
Charu Khurana MS, DNB
Delhi Ophthalmological Society
Monthly Clinical Meeting, November 2010
Venue: Conference Hall, Dr. Shroff ’s Charity Eye Hospital, Daryaganj, New Delhi- 110002
Date & Time: 21st November 2010 (Sunday) 5:30 P.M.
Clinical Cases: : Dr. S.P. Choudhary
1 The Big Oil Leak!
Discussant: Dr. Cyrus Shroff
2. The bugging Bug : Dr. Manisha Acharya
Discussant: Dr. Umang Mathur
Clinical Talk: : Dr. Manisha Agrawal
Changing trends in the management of ARMD
Mini Symposium: Beyond the Clinic…..
Chairperson: Dr. Noshir M. Shroff Co-Chairperson: Dr. Suneeta Dubey, Dr. Suma Ganesh
1. Eye Care 24x7 : Dr. Sandeep Buttan
2. Vision after Life : Dr. Umang Mathur
3. Beyond vision…. : Dr. Raman Mehta/
4. Small Intervention, Big Impact Dr. Sandeep Butan
: Dr. Manish Sharma
10 Early Bird Prizes
Sponsored by : Allergan Eye Care
62 DOS Times - Vol. 16, No. 5, November 2010
Forthcoming Events: National
November, 2010 18-19 JAIPUR
Annual Conference of Strabismological Society of India
12-14 NEW DELHI Contact Person:
20th Annual Conference of Glaucoma Society of India Dr. Virendra Agarwal
& 5th International Congress on Glaucoma Surgery 104, Shyam Anukampa, Opp. HDFC,
Venue: Le Meridien Hotel, Janpath, New Delhi & Ahinsa Circle, C-Scheme, JAIPUR
India Habitat Centre, Lodhi Road, New Delhi (M) 09829017147, 09414043006
Conference Secretariat: Website: www.strabismusindia.com
Dr. Harsh Kumar
D-8/8127, Vasant Kunj, New Delhi-70 January 2011
(M): 9810442537, Tel.: 91-11-4519910, 25513051,
Fax: 91-11-26122053 16-17 CHENNAI
Chrysalis 2011
27-28 NEW DELHI International Conference on Oculofacial Reconstructive
Mid-term Conference and Aesthetics Surgery
Delhi Ophthalmological Society Organizing Secretary
Venue: India Habitat Centre, Lodhi Road, New Delhi Dr. Shubhra Goel
Contact Person & Address E-mail: [email protected]
Dr. Amit Khosla, Secretary DOS Ph.: 044-28254177, Mobile: 91-9382832910,
Room No. 2225, 2nd Floor, New Building, Website: www.sankaranethralaya.org/chrysalis2011
Sir Ganga Ram Hospital,
Rajinder Nagar, New Delhi - 110 060 February 2011
Ph.: 011-65705229, E-mail: [email protected]
Website: www.dosonline.org 3-6 GUJARAT
69th AIOS Annual Conference
December 2010 Gujarat University Convention Centre, Ahemadabad
Conference Secretary,
2-4 MYSORE Dr. Tejas D. Shah
19th Annual Conference of Vitreo Retina Society - Amdavad Eye Laser Hospitals Pvt. Ltd.
India 2010 Vision Complex, Polytechnic Cross Roads,
Organizing Secretary, Ahmedabad, 380015. India
Retina Institute of Karnataka Fixed: +91 79 26303208, Fax: +91 79 26303308
#122, 5th Main Road, (Next to Venlakh Hospital) Website: www.aioc2011.com,
Chamarajpet, Bangalore - 18 E-mail: [email protected]
Ph: +91-80-22410106 / 536 (Hospital) Conference Help Line: 96248 96248
Fax: +91-80-26607811
E-mail: [email protected] April 2010
4-5 VARANASI 15-17 NEW DELHI
45th Annual Conference of U.P. State Annual Conference
Ophthalmological Society Delhi Ophthalmological Society
For more information : Venue: Hotel Ashok, Chanakya Puri, New Delhi
Dr. M.K. Singh Contact Person & Address
Organising Secretary Dr. Amit Khosla, Secretary DOS
Deptt. of Ophthalmology Institute of Medical Sciences Room No. 2225, 2nd Floor, New Building,
Banaras Hindu University Varanasi Sir Ganga Ram Hospital,
Mob.-9415812264,0542-6703601 Rajinder Nagar, New Delhi - 110 060
E-mail: [email protected] Ph.: 011-65705229, E-mail: [email protected],
Website: www.dosonline.org
www.dosonline.org 65
Forthcoming Events: International
March, 2011
20-24 SYDNEY, AUSTRALIA
APAO
Venue: Sydney, Australia
Further Information:
Congress Secretariat
GPO Box 3270
Sydney NSW 2001
Ph: +61 (0) 2 9254 5000
Fax: +61 (0) 2 9251 3552
Email: [email protected]
Monthly Clinical Meetings Calendar 2010-2011
Max Eye Hospital Midterm Conference of DOS
25th July, 2010 (Sunday) 27th & 28th November, 2009 (Saturday - Sunday)
Sir Ganga Ram Hospital Bharti Eye Foundation
29th August, 2010 (Sunday) 26th December, 2010 (Sunday)
Army Hospital (R&R) Guru Nanak Eye Centre
26th September, 2010 (Sunday) 30th January, 2011 (Sunday)
Centre for Sight Safdarjung Hospital
31st October, 2010 (Sunday) 27th February, 2011 (Sunday)
Shroff Charity Eye Hospital Mohan Eye Institute
21st November, 2010 (Sunday) 27th March, 2011 (Sunday)
Annual Conference of DOS 15th to 17th April, 2011 (Sunday)
www.dosonline.org 67
Delhi Ophthalmological Society
SUBMISSION online www:dosonline.org
(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 ____________________________________________________________ Mobile No. _____________________________
Proposed by
Dr. _______________________________________________ Membership No. __________ Signature _________________________
Seconded by
Dr. _______________________________________________ Membership No. __________ Signature _________________________
[Must submit a photocopy of the MBBS/MD/DO & State Medical Council / MCI Certificate for our records.]
I agree to become a life member of the Delhi Ophthalmological Society and shall abide by the Rules and Regula-
tions of the Society.
(Please Note : Life membership fee Rs. 3100/- payable by DD for outstation members. Local Cheques acceptable, payable to Delhi Ophthalmo-
logical Society)
Please find enclosed Rs.___________in words ____________________________________________________ by Cash
Cheque/DD No.____________________ Dated_____________ Drawn on______________________________________
Signature of Applicant Three specimen signatures for I.D. Card.
with Date
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)
www.dosonline.org 69
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 receive 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. Amit Khosla,
Secretary, Delhi Ophthalmological Society, Room No. 2225, 2nd Floor, New Building, Sir Ganga Ram Hospital, Rajinder Nagar,
New Delhi - 110 060
7. Licence Size Coloured Photograph is to be pasted on the form in the space provided and two Stamp/ Licence 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).
8. Applications for ‘Delhi Life Member’ should either reside or practice in Delhi. The proof of residence may be in the form Passport/
Licence/Voters Identity Card/Ration Card/Electyricity Bill/MTNL (Landline) Telephone Bill.
70 DOS Times - Vol. 16, No. 5, November 2010
Delhi Ophthalmological Society
Monthly Clinical Meeting, December 2010
Venue: Bharti Eye Hospital, E-52 Greater Kailash-1, New Delhi 110048
Date & Time: 26th December 2010 (Sunday) 11:30 a.m.
BREAKFAST (South Indian) 10:30 am - 11:30 am
Clinical Session: 11:30 am onwards
Clinical Cases: : Dr. Dharitri Samantaray
1 Recurrent Optic Neuritis in a child
Discussant: Dr. Archana G Mahajan
2. Goldman Favre Syndrome- Unusual Presentation : Dr. Meetu Bansal
Discussant: Dr. Neeraj Wadhwa
Clinical Talk: : Dr. Sudhank Bharti
Eyeing the Future - Femtosecond Laser Cataract Surgery
Mini Symposium: Newer Doctrines in Paediatric Ophthalmology
Chairman: Dr. Sudhank Bharti Co-Chairman: Dr. Prem Tanwar, Dr. S. Zafar,
Moderator: Dr. Archana G. Mahajan
1. Paediatric Catarct : Dr. Rajendra Prasad
2. Refractive errors & Contact Lens in Children : Dr.Sudhir Bhatia
3. Management of Squint in Children : Dr.Archana G Mahajan
4. Paediatric Glaucoma : Dr.Deven Tuli
20 Early Bird Prizes and Buffet Lunch
Sponsored by: Raymed Pharma
Online Journal Available
Dear DOS Members,
The DOS members can get the full text articles of the current issues as well as many back issues of these subscribed
journals. You need to send the request for the article needed via email: [email protected] We will email
you full text.
Dr. Harbansh Lal
Library Officer, DOS
E-mail ID is: [email protected]
1. Acta Ophthalmologica –(2008-2010) 11. International Ophthalmology Clinics –(2000-2010)
2. Acta Ophthalmologica Scandinavica –(2001-2007) 12. Journal of Glaucoma –(2001-2010)
3. Acta Ophthalmologica Scandinavica Supplement –(2002-2005) 13. Journal of Neuro-Ophthalmology –(2001-2010)
4. Archives of Ophthalmology –(1995-2010) 14. Journal of Pediatric Ophthalmology & Strabismus –(2008-2009)
5. British Journal of Ophthalmology –(2008-2010) 15. Journal of Refractive Surgery –(2008-2009)
6. Clinical & Experimental Ophthalmology –(2001-2010) 16. Ophthalmic Plastic & Reconstructive Surgery –(2000-2010)
7. Contemporary Ophthalmology –(2005-2010) 17. Ophthalmic Surgery, Lasers & Imaging –(2008-2009)
8. Cornea –(2000-2010) 18. Ophthalmology Management –(2008-2010)
9. Current Opinion in Ophthalmology –(1999-2010) 19. Retina –(2000-2010)
10. Evidence-Based Ophthalmology –(2008-2010) 20. Techniques in Ophthalmology –(2003-2010)
www.dosonline.org 73
Delhi Ophthalmological Society Fellowship for Partial
Financial Assistance to Attend Conferences
Applications are invited for DOS Fellowship for partial financial assistance to attend conference(s).
Conferences Points Awarded
International: Three fellowships per year (Two fellowships can be 1) Age of the Applicant Points
awarded at a time if committee feels that papers are very good)
a) < 35 years 10
• Maximum of Rs. 35,000/- per fellowship will be sanctioned
National: Three fellowships per year (Only for AIOS) b) 36 to 45 years 07
• Maximum of Rs. 10,000/- per fellowship will be sanctioned c) 45 years plus 05
Eligibility 2) Type of Presentation
• DOS Life Members (Delhi Members only) a) Instructor/ Co-instructor of Course 12
• 75 or More DCRS Points b) Free Paper (Oral) / Video 07
• Accepted paper for oral presentation, poster, video or instruction c) Poster 05
course. 3) Institutional Affiliation
Time since last DOS Fellowship a) Academic Institution 15
Preference will be given to member who has not attended conference in
last three years. However if no applicant is found suitable the fellowship b) Private Practitioner 20
money will be passed on to next year. Members who has availed DOS 4) DCRS Rating in the immediate previous year
fellowship once will not be eligible for next fellowship for a minimum
period of three years. a) 75-150 05
Authorship
b) > 150 08
The fellowship will be given only to presenting author. Presenting
author has to obtain certificate from all other co-authors that they are c) < 75 not eligible for fellowship
not attending the said conference or not applying for grant for the same
conference. (Preference will be given to author where other authors are Documents
not attending the same conference). If there is repeatability of same author
group in that case preference will be given to new author or new group • Proof for age. Date of Birth Certificate
of authors. Preference will also be given to presenter who is attending
the conference for the first time. • Original / attested copy of letter of acceptance of paper for oral pre-
Quality of Paper sentation / video / poster or instruction course.
The applicant has to submit abstract along with full text to the DOS • Details of announcement of the conference
Fellowship Committee. The committee will review the paper for its
scientific and academic standard. The paper should be certified by the • Details of both International & National Conferences attended in
head of the department / institution, that the work has been carried out previous three years.
in the institution. In case of individual practitioner he or she should
mention the place of study and give undertaking that work is genuine. • Copy of letter from other national or international agency / agencies
The fellowship committee while scrutinizing the paper may seek further committing to bear partial cost of conference if any.
clarification from the applicant before satisfying itself about the quality
and authenticity of the paper. Only Single best paper has to be submitted • At least one original document should be provided, that is ticket,
by the applicant for review (6 copies). Quality of the paper will carry boarding pass or registration certificate along with attendance cer-
50% weightage while deciding the final points. tificate of the conference.
Poster and Video
• Fellowship Money will be reimbursed only after submission of all
The applicant will need to submit poster and video for review. the required documents and verified by the committee.
Credit to DOS
• Undertaking from the applicant stating that above given information’s
The presenter will acknowledge DOS partial financial assistance in are true.
the abstract book / proceedings.
The author will present his or her paper in the immediate next DOS • If found guilty the candidate is liable to be barred for future fellow-
conference and it will be published in DJO/DOS Times. ships.
Application should reach Secretary’s office and should be addressed
to President, DOS before 30th July, 31st October and 31st January
for International Conference and before 30th September for National
Conference. The committee will meet thrice in a year in the month of
August, November and February with in 2 weeks of last date of receipt
of applications. The committee will reply within four week of last date
of submission in yes/no to the applicant. No fellowship will be given
retrospectively, that means prior sanction of executive will be necessary.
Dr. Amit Khosla
Secretary
Delhi Ophthalmological Society
Room No. 2225, 2nd Floor, New Building,
Sir Ganga Ram Hospital, Rajinder Nagar
New Delhi - 110060
Ph : 011-65705229
Email : [email protected]
www.dosonline.org 75
Immunosuppressives Monitoring Side Effects
Investigation Monitoring Side effect Tear Sheet
Steroid CBC Blood pressure Hyperglycemia
FBS Blood Sugar Hypertension
SGOT Urine Routine & Osteoporosis
SGPT Microscopy
Serum Calcium
Serum Phosphorus
Chest X-ray (PA view)
Dexa scan (optional)
*Methotrexate CBC CBC Leucopenia
SGOT Serum creatitine Hepatic dysfunction
SGPT SGPT
Serum creatinine
Urine Routine &
Microscopy
**Azathioprine CBC CBC Dose related toxicity
Serum creatinine SGOT Hematological toxicity
SGOT SGPT Hepatic toxicity
Urine Routine & TPMT enzyme deficiency
Microscopy causes idiosyncratic toxicity
Chest X-ray
(PA view)
Mycofenolate CBC CBC Hematological toxicity
Mofetil Serum creatinine SGOT Hepatic toxicity
SGOT SGPT
SGPT
Chest X-ray
(PA view)
Anti TNF CBC CBC Infection (most commonly
ESR SGOT tuberculosis)
SGOT SGPT
SGPT Serum creatinine
montoux test, TB
quantifaon gold
CECT
Chest & abdomen
*Methotrexate ® To start with 10mg / week then 12.5mg for 2 weeks which can be gradually increase
to the maximum of 20-25mg with CBC every monthly initially than every 3 month.
**Azathioprine ® 50mg / day which can be increased to the maximum of 150 mg with CBC every week
1Neeraj Jain MBBS, DNB, 1Lalit Duggal FRCP MD, MBBS, 2Amit Khosla MD, DNB,
1. Department of Rheumatoid & Clinical Immunology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi
2. Department of Ophthalmology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi
78 DOS Times - Vol. 16, No. 5, November 2010
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