dos-july-2011

Figure 5: Right fundus photograph of a 46 year old male showing diffuse orange choroidal thickening with
exudation at the macula (Diffuse choroidal hemangioma)

• Choroidal granuloma Treatment
• Choroidal osteoma
• InÁammatory processes (eg. posterior scleritis) Asymptomatic CCH that are in an extramacular location
• Central exudative hemorrhagic chorioretinopathy and that do not have surrounding SRF can be kept under
observation. Subfoveal hemangiomas with long standing
(a) CME may also be observed because of the limited potential
for visual recovery.8
(b)
Laser photocoagulation was once considered the preferred
Figure 6: A 28 year old male with Sturge-Weber syndrome. treatment for CCH. Photocoagulation produces an adhesion
(a) Right sided facial hemangioma (Nevus ƀammeus or port wine stain) between the sensory retina and the RPE and facilitates the
absorption of SRF. Good initial reattachment rates with
(b) Contrast MRI showing an ipsilateral improvement of visual acuity have been shown with argon
leptomeningeal hemangioma and right choroidal hemangioma laser.1

Limitations

• over 50% of eyes develop recurrence of SRF after laser
treatment

• many do not gain good visual acuity even after retinal
reattachment

• repeat treatments are frequently necessary.8

Transpupillary thermotherapy (TTT) has been shown
to be effective in treating recurrences of SRF after
photocoagulation.10 In TTT, the wavelength, beam size, and
exposure time are chosen to maximise heat penetration for
optimal tumour-necrotizing effect without the coagulation
achieved with standard laser.

Limitations

• Inability to treat tumours with height more than 3.5 mm
(tumour depth penetration does not exceed 3.9 mm)11

• Inability to treat near or under the foveola (possibility of
damage to the retina by laser)

• Most tumours require multiple TTT treatments

Treatment with radiotherapy has proven to be beneÀcial
for submacular tumours, tumours with extensive SRF, large
tumours, and those that have failed photocoagulation.7,12
Radiation treatment may be applied in different forms such
as episcleral plaque brachytherapy, external beam irradiation
and proton beam irradiation. The total dosage used is about
25-50 Gy for plaque radiotherapy, 20 Gy given in 10 fractions
for external beam radiotherapy and 16.4 to 18.2 Gy in 4
fractions for proton beam radiotherapy.

The potential for radiation-related complications such as

72 l DOS Times - Vol. 17, No. 1 July, 2011

cataract, radiation optic neuropathy13, radiation retinopathy14 2. Jarrett WH 2nd, Hagler WS, Larose JH, et al. Clinical experience with
exists, particularly in juxtapapillary and macular presumed hemangioma of the choroid: radioactive phosphorus uptake
hemangiomas. These complications can be minimised by studies as an aid to differential diagnosis. Trans Sect Ophthalmol Am
using plaque radiotherapy (ruthenium 106 or iodine 125) or Acad Ophthalmol Otolaryngol 1976;81:862-870.
external beam radiotherapy delivered with precision using
stereotactic techniques.15 3. Witschel H, Font RL. Hemangioma of the choroid: a clinicopathological
study of 71 cases and a review of the literature. Surv Ophthalmol
Currently the therapy for serous RD in CCH that appears 1976;20:415-431.
to produce the best clinical results is photodynamic therapy
(PDT). PDT for treatment of diffuse choroidal hemangiomas 4. Medlock RD, Augsberger JJ, Wilkinson CP, et al: Enlargement of
has also been reported with good short term results.16 PDT circumscribed choroidal hemangiomas. Retina 1991;11:385-388.
induces vascular thrombosis without signiÀcant damage to
adjacent retina and is effective in closure of subretinal blood 5. Duke-Elder S, Perkins ES. System of ophthalmology. Vol 9, Diseases
vessels. Treatment is performed using a diode laser at 692 nm, of the uveal tract. St Louis: Mosby, 1966.
a light dose ranging from 50 to 100 J/cm2, and verteporÀn
at a dose of 6mg/m2 body surface area. Most clinicians use 6. Sanborn GE. Circumscribed choroidal hemangioma. In: Ryan SJ, ed.
the standard treatment of age related macular degeneration Retina Vol 1 4th edn. Mosby: Philadelphia,2006;829-842.
by photodynamic therapy (TAP) study protocol. Tumour
regression is most dramatic following the Àrst session of PDT 7. Sanborn GE, Augsberger JJ, Shields JA. Treatment of circumscribed
and is usually evident within 3 months.17 choroidal hemangiomas. Ophthalmology 1982;89:1374-1380.

• Poor results in cases in which previous treatments have 8. Shields CL, Honavar SG, Shields JA, et al: Circumscribed choroidal
failed.17,18 hemangioma: clinical manifestations and factors predictive of visual
outcome in 200 consecutive cases. Ophthalmology 2001;108:2237-
• It may not provide the desired results in larger tumours 2248.
as well as signiÀcantly high RD overlying the tumour
mass, due to limited penetration of the laser beam. 9. Singh AD, Kaiser PK, Sears JE. Choroidal Hemangioma. Ophthalmol
Clin N Am 2005;18:151-161.
• Multiple PDT treatments may be needed, and the
number of PDT treatments required has been found to 10. Rapizzi E, Grizzard WS, Capone A Jr. Transpupillary thermotherapy
be inversely proportional to the Ànal visual acuity. in the management of circumscribed choroidal hemangioma. Am J
Ophthalmol 1999;127:481-482.
• Delayed choroidal atrophy owing to overtreatment. The
risk of choroidal atrophy can be minimised by avoiding 11. Garcia-Arumi J, Ramsay LS, Guraya BC. Transpupillary
treatment of the surrounding normal choroid and by thermotherapy for circumscribed choroidal hemangiomas.
avoiding re-exposure to the previously treated portion Ophthalmology 2000;107:351-356;discussion 357.
of the tumour by using a single spot or multiple non
overlapping spots.19 12. Madreperia SA, Hungerford JL, Plowman PN et al. Choroidal
hemangiomas: visual and anatomic results of treatment
• High expenses. by photocoagulation or radiation therapy. Ophthalmology
1997;104:1773-1778;discussion 1779.
As the vision loss in CCH is usually caused by sub- as
well as intraretinal Áuid rather than by the tumour itself, 13. Zografos L, Egger E, Bercher L, et al. Proton beam irradiation of
any treatment modality that causes resolution of the Áuid choroidal hemangiomas. Am J Ophthalmol 1998;126:261-268.
will lead to a better functional gain. Sagong et al have
documented sustained improvement in visual acuity using 14. Zografos L, Bercher L, Chamot L, et al. Cobalt-60 treatment of
intravitreal bevacizumab in three cases of CCH with serous choroidal hemangiomas. Am J Ophthalmol 1996;121:190-199.
RD involving the fovea.20 Being a pan-VEGF inhibitor it causes
both regression of abnormal vessels as well as reduction of 15. Kivela T, Tenhunen M, Joensuu T, et al. Stereootactic radiotherapy of
leakage from them. It may be used as a primary mode of symptomatic circumscribed choroidal hemangiomas. Ophthalmology
treatment, especially for subfoveal lesions, or to decrease the 2003;110:1977-1982.
height of the overlying Áuid to make laser photocoagulation
or TTT more effective in extra foveal tumors. Recently, oral 16. Anand R. Photoynamic therapy for diffuse choroidal hemangioma
propanolol (120 mg/day) has been shown to be safe and associated with Sturge Weber syndrome. Am J Ophthalmol
effective in treating serous RD associated with CCH.21 2003;136:758-760.

Long term visual prognosis is guarded secondary to visual 17. JurkliesB, Anastassiou G, Ortmans S, et al: Photodynamic therapy
loss induced by SRF, CME, foveal distortion and treatment using verteporÀn in circumscribed choroidal hemangioma. Br J
Ophthalmol 2003;87:84-89.
side effects like choroidal atrophy, Àbrosis and RPE changes.
18. Verbraak FD, Schlingemann RO, Keunen JE, et al: Longstanding
References symptomatic choroidal hemangioma managed with limited PDT
as initial or salvage therapy. Graefes Arch Clin Exp Ophthalmol
1. Chan P, Kim I, Gragoudas E. Choroidal Hemangiomas. In: Albert 2003;241:891-898.

DM, Miller JW, eds. Albert & Jakobiec’s principles and practice of 19. Schmidt-Erfurth UM, Michels S, Kusserow C, et al. Photodynamic
therapy for symptomatic choroidal hemangioma:visual and anatomic
ophthalmology Vol. 2 3rd edn. Saunders: Philadelphia,2008;2029-2035. results. Ophthalmology 2002; 109:2284-2294.

20. Sagong M, Lee J, Chang W. Application of intravitreal bevacizumab
for circumscribed choroidal hemangioma. Korean J Ophthalmol
2009;23:127-131.

21. Sanz-Marco E, Gallego R, Diaz-Llopis M. Oral propranolol for
circumscribed choroidal hemangioma. Case Report Ophthalmol
2011;2:84-90.

www. dosonline.org l 73

Book Review

Oculoplasty: Innovative Simpler Techniques

Author: Dr. Hemand Mehta

The book titled ‘Oculoplasty – Innovative Simpler
Techniques’ by Dr. Hemant Mehta provided for a beneficial
and evocative read. A video DVD depicting the author’s
technique of ptosis surgery is incorporated.
The textbook covers the basic and simplified concepts of
oculoplasty. It is packed with self-explanatory illustrations
and high resolution photographs depicting surgical steps
and outcomes. This makes the book very appealing. The
content is presented in a logical format, starting with the
basic principles of surgical incisions, suturing techniques,
lid surgeries and skin grafts. Considerable stress has been
given to healing of large defects by secondary intention which is supported by clinical
images with some excellent results. The author has discouraged some unnecessary rituals
in skin grafting procedure like use of bolster and frost, instead has emphasized the use of
quilting sutures to anchor the graft which was initiated by him in 1973.
The depth of experience of the author makes the book interesting and provides an
opportunity to learn both basic and innovative techniques for all ophthalmologists and
oculoplasty surgeons. The author’s faith in spontaneous healing of large defects and proof
of the same in the clinical images is valuable. The chapter on clinical photography will help
the reader to produce high quality images for scientific publications and presentations.
To summarize, it is a well-written book with emphasis on simplifying oculoplastic
techniques and doing away with unnecessary rituals.

Reviwed by:
Dr. Neelam Pushker

Additional Professor,
Dr. R.P. Centre, AIIMS, New Delhi

74 l DOS Times - Vol. 17, No. 1 July, 2011

Practice Advice

Namrata Kabra

Namrata Kabra MS
Shri Ganapati Netralaya, Jalna, Maharashtra

Since the day medical services are included under CPA, should be a part of a doctor’s set up, and one need not refer a
its proving to be a nightmare while treating the difÀcult patient to another doctor only to get the BP checked. One can
cases. But few of us are unaware of the fact that we cannot be be liable, if poor BP control leads to complications.
grilled until and unless we are offering reasonable services Phone / e-mail consultations: Ophthalmologists can give
to the patient. Here is some of the information highlighted consultations on e-mail or telephone, but he can be liable,
regarding CPA which can make us sleep well. if there is negligence. One should try to avoid giving such
consultations, unless you are treating that patient, and are
Patients being classiÀed as ‘consumer’ by the Supreme Court, aware of all aspects of the case. For new cases, one should
a medical practitioner’s services have been categorized not give a prescription without seeing the patient physically.
as one that is paid for by the patient, who through that Handwriting: If a chemist ends up giving a wrong drug on an
transaction becomes a ‘consumer’ with a well deÀned palette ophthalmologist’s prescription due to illegible handwriting,
of rights protected under the Consumer Protection Act, he is liable and not the ophthalmologist. It is the duty of the
1986. These include expecting standard care and treatment chemist to call the ophthalmologist and clarify, if he has any
and protection against medical negligence. The number of doubt on the prescribed drug.
forums that a consumer-patient can approach for medical False accusations: If a patient falsely accuses an ophthalmo-
acts of omission and commission are manifold. Apart from logist, the patient not only faces dismissal of his case but also
the IMC (Indian Medical Council), he can approach the a punishment in the form of imprisonment and/or Àne.
State Consumer Forums as well as the National Human Media relations: Ophthalmologists cannot advertise.
Rights Commission. Each of these complaints can further be Soliciting of patients directly or indirectly by a physician, by
pursued right up to the apex court. a group of physicians or by institutions or organizations is
unethical.
Medical negligence is different from error of judgement. He/she cannot advertise his practice in any way. Neither
An error of judgement is a mistake committed by an can an ophthalmologist recommend/endorse any particular
ophthalmologist regarding the diagnosis or kind of drug/product. However, medical practitioners are permitted
intervention required. It is excusable, provided it is done in to make a formal announcement in press regarding the
good faith and the criteria of reasonable care and skill are following:
adhered to. Any difference of opinion is not negligence. • On starting practice
• On change of type of practice
Negligence is always a deÀciency in service. Negligence can
be a delay in starting the treatment, omission or commission Consumer Protection Act
of something, which a reasonable man would not have done.

It would do well for a practicing ophthalmologist to be aware
of what constitutes such acts of commission and omission.
Examples of omission would being with simple acts being
overlooked - like not checking the BP or taking the history of
diabetes before operating for cataract. An act of commission
would mean operating the wrong eye or an eye where
infection had not subsided.

Hereby, highlighting few Do’s and Dont’s to safeguard
oneself and avoid getting screwed at the hand of notorious
patient.

In displaying registration number: Every ophthalmologist is
expected to display the registration number accorded to him
by the State Medical Council/Medical Council of India in his
clinic and in all his prescriptions, certiÀcates and bills given
to his patients.

Indemnity Insurance: Always take indemnity insurance to
cover for negligence risk.

On MLC patients: Always inform the police about the
discharge of a patient with an MLC (medical legal case).

Keeping right instruments: A BP instrument or stethoscope

www. dosonline.org l 77

Malpractice • On resumption of another practice

• On changing address • On succeeding to another practice
• On temporary absence from duty
• Public declaration of changes.

Misleading articles: The media cannot publish a report
against an ophthalmologist without verifying from him
and putting his version also, unless they write that “the
ophthalmologist was not available for comments”. In that
case, the ophthalmologist must write to the editor and ask for
the publication of his version on the front page.

Medical Records: If the patients or authorized attendants or
legal authorities request that the medical records of the patient
be released, their demands should be duly acknowledged
and documents should be issued within a period of 72 hours.

A hospital should keep the case records of a patient for a
minimum of three years. Similarly, if an ophthalmologist is
issuing a medical certiÀcate, he should keep a copy of the
medical certiÀcate.

Supreme court has already clariÀed in its verdict that
responsibility of proving negligence lies with patient, to
protect the doctors from day to day threghtening by few evil
minds. Following the above mentioned things with good
documentation of every patient along with your services
can save you from getting screwed at the hand of notorious
patients.

So let us give our services and better sight to this world
fearlessly!

DOS Times Traders Index Page No.

Advertisers Name 1,96
2,6,52-53
M/s. KLB Instruments 10,31-32,39
M/s. Abott Medical Optics 18,28,40,51
M/s. Alcon Laboratories
M/s. Appasamy Associates 60-61
M/s. Epsilon Eye Care Pvt. Ltd. 30,54
M/s. Carl Zeiss
M/s. National Industrial Co. 79
M/s. Pharmatak 8
M/s. Allergan India 62
M/s. Medica International 76
M/s. Allied Medical/Mann 46
M/s. Raymed 80
M/s. Technolas 68
M/s. Biomedix 4
M/s. Venus Surgitech 86
M/s. Akhand Jyoti Eye Hospital 88
M/s. Eye Q Super Speciality Eye Hospital 75
M/s. Dr. Pattnaik’s Laser Eye Institute 94
M/s. Ophtho Remedies 92

78 l DOS Times - Vol. 17, No. 1 July, 2011

Community Ophthalmology

Noopur Gupta

Noopur Gupta MS, DNB, Vasundhra Misra, Praveen Vashist MD

Department of Community Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, Ansari Nagar, New Delhi

Vitamin A deÀciency disorders (VADDs) are an important Figure 1: Vitamin A deſciency as a major cause of
cause of blindness in children. In India, there are an Childhood Blindness
estimated 280,000 blind children.1 VADDs are responsible for
around one fourth of the burden of Childhood Blindness.2 In Figure 2: Vitamin A prophylaxis
India, in the 1950s and 1960s, vitamin A deÀciency was a major
cause of blindness in children below 5 years of age (Figure 1). Recent estimates by WHO shows that 62% of preschool
A Àve-year long Àeld trial demonstrated that massive dose children in India have serum retinol level <0.7Ǎmol/dl
vitamin A (200,000 IU) administration to preschool children signifying severe VAD. On the other hand, the prevalence of
reduced the incidence of xerophthalmia signiÀcantly.3 night blindness is estimated as 0.6% signifying mild VAD.
The National Prophylaxis Programme against Nutritional Approximately 16.4% of the Indian pregnant women have
Blindness due to vitamin A deÀciency was initiated in 1970 serum retinol level <0.7Ǎmol/dl implying moderate VAD.
as an urgent remedial measure to counter the unacceptably
high magnitude of xerophthalmic blindness.4 Under this
centrally sponsored scheme, all 1-5 year old children were
to be administered (Figure 2) 200,000 IU of Vitamin A orally
once in six months. This programme has been implemented
in all the states and union territories during the last 40
years. During the early 1990s, the age group of intended
beneÀciaries was changed to 9 months until 3 years5 because
the prevalence of clinical deÀciency was greatest between 6
months and 3 years of age.

The prevalence of VAD in a population is represented
by speciÀc biochemical and clinical indicators. Clinical
VAD is a severe form of Vitamin A deÀciency, resulting in
xerophthalmia, symptoms of which include night blindness,
Bitot’s spots (Figure 3), xerosis, and keratomalacia. If not
treated early enough, it can eventually leads to blindness.
Subclinical VAD, deÀned by a serum retinol concentration of
< 0.7 Ǎmol/L, is associated with increased vulnerability to a
variety of infectious diseases and, therefore, an increased risk
of mortality and morbidity.

Vitamin A deÀciency (VAD) is considered to be a major
risk factor contributing to under-5 mortality mainly from
respiratory and gastrointestinal infections, and often occurring
concurrently among children with PEM.6 Under-5 mortality
of >50/1000 live births is an indicator for assessment of VAD
being a public health problem in that population.7 VAD
diseases continue to be a public health problem in many states
in India even with the rapidly declining trends in under-5
mortality in the last few years.8 Vitamin A supplementation
has proven successful in reducing the incidence and severity
of illness, and has been associated with an overall reduction
in child mortality by 25-35%, especially from diarrhea,
measles and malaria.

Prevalence of night blindness and serum retinol level in
preschool children and pregnant women is used as an
indicator to deÀne public health importance of VADDs.

www. dosonline.org l 81

Table 1
Strategies for control of VAD

Figure 3: Slit lamp photograph (6.3x) of a patient showing A. Short term measures
conjunctival xerosis. Note the ſsh- ƀesh appearance of • Case detection among the preschool children (<6year)

the Bitot’s spot which occurs due chronic dryness, usually in urban slum areas and active case management
associated with Vitamin A deſciency. • Vitamin A prophylaxis twice a year to urban poor

More than 40% of global cases of xerophthalmia are in India. children under three year of age increasing coverage
to more than 90% through community volunteers
Strategies for control of VADDs (Table 1) • Prophylaxis for lactating mother – one dose in Àrst 6
months
Though the under-5 mortality rate in India has shown • Measles Immunization – single dose at 9 month >95%
declining trends in last 10 years but there are wide variations. coverage
It is still high in the slum population (54 /1000 live births).6 B. Medium term measures:
Therefore the strategies for prevention and control of VAD • Food supplementation programme for children
should be more focused in the urban poor. (<6year) and pregnant lactating mother
• Food fortiÀcation with Vitamin A
VAD results in subclinical and clinical manifestations C. Long term measures:
ranging from night blindness to corneal ulceration • Behavioral changes in food habits in consumption of
(Figure 4) and opacity. The deÀciency is commonly observed vitamin A enriched diet
in preschool children up to six year of age but more serious • Addressing underlying causes- malnutrition, female
deÀciency resulting in corneal ulceration and keratomalacia illiteracy, poverty, infections
(Figure 5) is observed in younger age group (1- 4 year). The
efforts for early identiÀcation and treatment of cases should Figure 4: Corneal ulceration due to Vitamin A deſciency
be focussed in the younger children in under-Àve age group.
The dietary intake during pregnancy and lactation directly It is possible that a child treated in hospital for VADD may die
affect the health of child. Effective measures are needed to of diarrhoea or malnutrition if not treated for underlying risk
improve the dietary intake and Vitamin A for pregnant and factors. There is need of comprehensive community-based
lactating women. primary health care strategies instead of vertical approach or
just clinical management in hospitals. The quality health care
In order to get the mortality reducing effect of Vitamin A facilities at primary level mainly for measles immunization,
supplementation, at least 90% coverage is required twice a early management of diarrhoeal diseases, respiratory
year in children 6 month to 5 years of age.16 Government of infections and malnutrition can bring signiÀcant reduction
India recommend vitamin A prophylaxis for all the children under 5 mortality and vitamin A diseases.
from 9 months to 3 year of age at 6 months interval. Presently
the Vitamin A prophylaxis programme is implemented under
the Reproductive and Child health (RCH) programme. Some
scientists suggest that the Vitamin A prophylaxis programme
should be phased out in India due to decreased prevalence of
VADDs and emphasis should be given to other strategies.15
But WHO recommends Vitamin A supplementation as the
fastest and most cost- effective approach for improving
the vitamin A status in a community.17 With more than
60% of Indian children having low level of serum retinol,
it is suggested that we should continue with the strategy
of Vitamin A supplementation. Our aim is to achieve 90%
coverage with 6 monthly doses among under 3-year age. This
can be achieved by involving community volunteers in the
programme.

VAD is considered as more of a multifactorial disease.
Malnutrition and Infections such as measles, diarrhoea and
respiratory infections are major risk factors leading to VAD.

82 l DOS Times - Vol. 17, No. 1 July, 2011

Table 2
Sources of Vitamin A

Sources Foods

Plant sources Carrot, Broccoli, Spinach, pumpkin,
sweet potato, Amaranth, Dark green
leafy vegetables, Papaya, Mango,
Apricot

Animal sources Egg yolk, Whole milk, butter, liver,
Cod liver oil, Chadder cheese

Table 3
Commonly Consumed foods combination that meet
Daily Dietary Requirement of Vitamin A

Vitamin A /Carotenoids 1 raw carrot or Figure 5: Bilateral keratomalacia in a child
1 mango or

2 slices papaya or deÀciencies. In India and no doubt other countries, intensive,
well-structured programme to promote the consumption of
1 peach or locally available inexpensive fruits and vegetables should
be mounted as major national programmes and given high
1 small bowl of green leafy priority.
vegetable
In India, the services of the chain of home science colleges
The major cause of VAD is the chronic dietary deÀciency in throughout the country should be enlisted for a sustained
vitamin A. Educating communities for consumption of easily programme of nutrition education targeted at rural
available and affordable food items rich in Vitamin A is one of households and aimed at increasing the intake of locally
the best strategies for prevention of VAD. Community based available vegetables and fruits as part of household diets.
education programme at regular interval can be effective in The current high wastage of vegetables and fruits due to
bringing behavioural changes in the long term. poor processing and storage facilities in the countryside must
be prevented by promoting village-based technologies for
Three types of community interventions can reduce VAD processing and storage.
in affected populations: improving availability and intake
of Vitamin A rich food, food fortiÀcation and provision of All the above-mentioned strategies cannot lead to elimination
Vitamin A supplementation. of VAD until there are efforts for the comprehensive
development of the community. Beside health sector, the
Retinol, the active form of vitamin A is rarely found in foods. efforts of other sectors like education, poverty alleviation,
Instead, precursors to retinol, fatty acid retinyl esters are agriculture, environment sanitation and water supply are
usually found in human diet. These esters are commonly equally important in the community. The example of Kerala
found in foods of animal origin, such as egg yolks, liver, state in India showed that female literacy is the single leading
whole milk, Àsh oil and butter. Plants sources do have vitamin indicators that can affect the overall development of the
A, but not in the retinol form. Plants can only synthesize community.
carotenoids, but cannot covert them to retinoid; this process
then occurs in the human body. Strategies proposed to improve Vitamin A status of infants
below 6 months of age:
Improving Vitamin A status through dietary diversiÀcation
is an economical, sustainable and long term solution to The physiologic needs for Vitamin A of infants born to
combat vitamin A deÀciency. Regular intake of foods rich in Vitamin A adequate mothers and those who are fed breast
vitamin A is of utmost importance. (Table 2) Thus bringing milk are met for at least the Àrst 6 months of life. However, in
behavioural changes and ensuring regular consumption of areas endemic for VADD and where habitual dietary intakes
VITAMIN A rich foods is of main concern. (Table 3) by mothers are less than recommended, four approaches
have been proposed.
FortiÀcation of commonly consumed food with Vitamin
A is also an effective strategy for control of VAD diseases. 1. Maternal supplementation during pregnancy.
Educating communities about consumption of Vitamin
A enriched food items is effective long-term strategy for 2. Supplementation for mothers in the Àrst 6 months post-
prevention of VAD. It is important that emphasis should partum
be given on use of food items that are easily available and
affordable to the community. The long-term goal should be 3. Direct supplementation of infants before 6 months of
to bring a behaviour change in the eating habits of people for age.
consumption of vitamin A rich food items.
4. Supplementation both for mothers during the “safe”
Vegetables and fruits are good sources not only of vitamin infertile post-partum period and for infants under 6
A but also of several other micronutrients. A balanced diet months of age.
that includes adequate amounts of a variety of vegetables
and other foods is the surest way of preventing micronutrient Summary

VAD diseases are still a public health problem in the urban
poor communities in the developing world. Government

www. dosonline.org l 83

of India in their Blindness Control programme (NPCB), Programme, Fourth Five Year Plan Technical Information: MCH No. 2,
emphasize on supplementation of vitamin A in children New Delhi: Government of India Press, 1970, pp 1-22.
for prevention of childhood blindness in the country. We 5. National consultation on beneÀts and safety of administration of vitamin
need to focus on sustainable solutions, including dietary A to Pre-school Children and Pregnant and Lactating Women. Indian
diversiÀcation and agricultural production, sanitation, Pediatrics 2001; 38: 37-42
immunization, and prevention and treatment of childhood 6. WHO. Global prevalence of VAD in populations at risk 1995–2005.
infections. There is need for strengthening primary health WHO Global Database on VAD.Geneva, World Health Organization,
care system to achieve elimination of blindness due to VAD 2009.
diseases. 7. Schultink Werner, Use of under-Àve mortality rate as an indicator for
Vitamin A deÀciency in a population, Nutrition Section, Programme
References Division, UNICEF, New York, NY 10017, ETATS-UNIS
8. World Bank, World Development Indicators - Last updated February 10,
1. Arvind Chandna, Clare Gilbert, When your eye patient is a child, 2011
Community Eye health J. 2010;23(72); 1-3 9. International Institute for Population Sciences (IIPS) and Macro
International. 2009. National Family Health Survey (NFHS-3), India,
2. J S Titiyal et.al. Causes and temporal trends of blindness and severe 2005-06: Delhi. Mumbai: IIPS. http://www.nfhsindia.org/NFHS-3%20
visual impairment in children in schools for the blind in North India, Data/Delhi_printed_version_for_website.pdf
Br.J.Ophthalmol 2003;87:941-945 10. Preventing Blindness in Children, a report of WHO/IAPB ScientiÀc
meeting, April 1999 http://www.who.int/ncd/vision2020_actionplan/
3. Swaminathan MC, Susheela TP, Thimmayamma BV. Field prophylactic documents/WHO_PBL_00.77.pdf
trial with a single annual oral massive dose of vitamin A. American
Journal of Clinical Nutrition 1970; 23:119-22.

4. Maternal and child health scheme for prophylaxis against nutritional
blindness in children caused by vitamin A deÀciency. Family Planning

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84 l DOS Times - Vol. 17, No. 1 July, 2011

Delhi Ophthalmological Society Fellowship for Partial
Financial Assistance to Attend Conferences

Applications are invited for DOS Fellowship for partial Ànancial 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
b) 36 to 45 years 07
National: Three fellowships per year (only for AIOS)
c) 45 years plus 05
• Maximum of Rs. 10,000/- per fellowship will be sanctioned
2) Type of Presentation
Eligibility
a) Instructor/ Co-instructor of Course 12
• DOS Life Members (Delhi Members only)
b) Free Paper (Oral) / Video 07
• 75 or More DCRS Points
c) Poster 05
• Accepted paper for oral presentation, poster, video or
instruction course. 3) Institutional AfÀliation

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
fellowship once will not be eligible for next fellowship for a minimum 4) DCRS Rating in the immediate previous year
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 • Proof for age. Date of Birth Certificate
new group 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
presentation / video / poster or instruction course.
Quality of Paper
• Details of announcement of the conference
The applicant has to submit abstract along with full text to the DOS
Fellowship Committee. The committee will review the paper for its • Details of both International & National Conferences attended in
scientific and academic standard. The paper should be certified by the previous three years.
head of the department / institution, that the work has been carried
out in the institution. In case of individual practitioner he or she • Copy of letter from other national or international agency / agencies
should mention the place of study and give undertaking that work is committing to bear partial cost of conference if any.
genuine. The fellowship committee while scrutinizing the paper may
seek further clarification from the applicant before satisfying itself • At least one original document should be provided, that is ticket,
about the quality and authenticity of the paper. Only Single best paper boarding pass or registration certificate along with attendance
has to be submitted by the applicant for review (6 copies). Quality of certificate of the conference.
the paper will carry 50% weightage while deciding the final points.
• Fellowship Money will be reimbursed only after submission of all
Poster and Video the required documents and verified by the committee.

The applicant will need to submit poster and video for review. • Undertaking from the applicant stating that above given informa-
tion’s are true.
Credit to DOS
• If found guilty the candidate is liable to be barred for future fellow-
The presenter will acknowledge DOS partial financial assistance ships.
in the abstract book / proceedings.
The author will present his or her paper in the immediate next DOS Application should reach Secretary’s office and should be addressed
conference and it will be published in DJO/DOS Times. to President, DOS before 31st July, 31st Octobert 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, October 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. Rohit Saxena
Room No. 479, 4th Floor,
Dr. Rajendra Prasad Centre for Ophthalmic Sciences
All India Institute of Medical Sciences,
Ansari Nagar, New Delhi – 110029
Ph.: 91-11-65705229, Fax: 91-11-26588919
E-mail: [email protected],
Website: www.dosonline.org

www. dosonline.org l 85

Forthcoming Events : National

September 2011 Contact Person & Address
2-3 HYDERABAD Dr. Rohit Saxena
Room No. 479, 4th Floor,
Course on Lamellar Corneal Surgery Dr. Rajendra Prasad Centre for
Ophthalmic Sciences,
Venue: Cornea Clinic, Apollo Hospitals, All India Institute of Medical Sciences,
Hyderabad, India Ansari Nagar, New Delhi – 110029
For more information, please contact: Ph.: 011-65705229, Fax: 26588919
E-mail: [email protected]
Dr. Rajesh Fogla, Senior Consultant, Website: www.dosonline.org
Cataract,Cornea & Laser Refractive Surgeon
Apollo Hospitals, Jubilee Hills, February 2012
Hyderabad 500033, India 2-5 KERALA
Mobile: +91 9866076750
Email: [email protected] AIOC 2012 : 70th AIOS Annual Conference
WWW : http://www.corneaclinic.com All India Ophthalmological Society
Venue: Le Meriden Convention Centre,
9-11 ANDAMAN & NICOBAR Cochin, Kerala
Island Ophthafeast Conference Secretariat:
Giridhar Eye Institute,
Venue: Port Blair, Andaman & Nicobar, India Ponneth Temple Road, Kadavanthara
Organising Secretary Cochin - 682020, Kerala, India
Email: [email protected]
Dr. Rohindra Lall Phone: +91 484 2316791, 4000581/82/83
Rohin’s Eye Hospital Fax: +91 484 4000584
23 AIR Road, Port Blair 744102
Andaman & Nicobar Islands, India April 2012
Mobile: +91-9933274092, 20-22 NEW DELHI
Phone: +91-3192-244933
Email: [email protected] Annual Conference of
Delhi Ophthalmological Society
23-25 KERALA Venue: Hotel Ashok,
Drishti 2011 KSOS (Kerala Society of Ophthalmic Chanakaya Puri, New Delhi
Contact Person & Address
Surgeons) Annual Meet Dr. Rohit Saxena
Venue: LULU international convention Centre, Room No. 479, 4th Floor,
Thrissur, Kerala Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
Organising Secretary & KSOS General Secretary All India Institute of Medical Sciences,
Ansari Nagar, New Delhi – 110029
Dr Radha Ramanan Ph.: 011-65705229, Fax: 26588919,
Little Flower Hospital, E-mail: [email protected]
Angamaly, Kerala Website: www.dosonline.org
Email: [email protected]
Website: www.ksos.in

November 2011
12-33 NEW DELHI

Mid-term Conference of
Delhi Ophthalmological Society
Venue: India Habitat Centre, Lodhi Road,
New Delhi

Forthcoming Events : International

October 2011 April 2012
22-25 ORLANDO, FLORIDA, USA 13-17 BUSAN, REPUBLIC OF KOREA

American Academy of Ophthalmology 27th Asia Paciſc Academy of Ophthalmology
Annual Conference Joint meeting with SOE
Ph.: +1415-447-0320, Fax: 1415-561-8576 Bexco, Busan, Korea
Website: www..org/annual_meeting Ph.: +82-2-583-6521
Email: [email protected]

[email protected]

www. dosonline.org l 87

Delhi Ophthalmological Society

(LIFE MEMBERSHIP FORM)

Name (In Block Letters)_______________________________________________________________________________________________
S/D/W/o ____________________________________________________________________________ Date of Birth___________________
Qualifications________________________________________________________________________ Registration No. ________________
Sub Speciality (if any) ________________________________________________________________________________________________
ADDRESS

Clinic/Hospital/Practice __________________________________________________________________________________________
_____________________________________________________________________________ Phone _______________________
Residence ____________________________________________________________________________________________________
_____________________________________________________________________________ Phone _______________________
Correspondence _______________________________________________________________________________________________
_____________________________________________________________________________ Phone _______________________
Email ____________________________________________________________ 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 l 89

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. Rohit Saxena,
Secretary, Delhi Ophthalmological Society, Room No. 479, 4th Floor, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All
India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
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.

90 l DOS Times - Vol. 17, No. 1 July, 2011

(July, 2011 to April, 2012)

DOS Times & DJO

Display Advertisements Eleven issues Three issues (Aug., Dec’11, Feb’12)
One Issue Advertisement One Issue Advertisement
• Full Page Copies 6,000 Copies 9,000
• Half Page
• Quarter Page Colour Rs. 20,000 Rs. 24,000
• Full Page Colour Rs. 12,000 Rs. 14,000
• Half page Colour Rs. 6,000 Rs. 7,000
• Quarter page B&W Rs. 10,000 Rs. 13,000
• DOS Times (Back Page) B&W Rs. 6,500 Rs. 8,000
• Front inside Cover B&W Rs. 4,000 Rs. 5,000
• Back Inside Cover Colour Rs. 60,000 Rs. 70,000
• 2 Page Centre Spread Colour Rs. 25,000 Rs. 30,000
• 2 Page Centre Spread Colour Rs. 25,000 Rs. 30,000
B&W Rs. 26,000 Rs. 30,000
Colour Rs. 50,000 Rs. 60,000

Service Tax will be charged extra @ 10.30%

Discount on Long Term Booking

¾ Six issues 5% discount

¾ Ten issues 10 % discount

¾ Fourteen issues 20 % discount

o Two pages Fourteen issue additional 8% discount

o Three pages Fourteen issues additional 10% discount

o Four pages B&W for Fourteen issues additional 15% discount

o Four pages color fourteen issues 35% discount.

o Back page booked for fourteen issues only (DOS Times & DJO).

o For Àxed placement in the Magazine / Journal an extra charge of Rs. 1500/- per page / per issues (DOS Times or

DJO).

Please send your bookings at the earliest accompanied by Demand Draft in the name of "Delhi Ophthalmological Society"
payable at New Delhi. All payments should be made in advance only.

SPECIFICATION of DOS Times & DJO: : 7.25” x 11.00”
‰ Size of Advertisement Full Page : Monthly (10 Issues in a year) (July – April)
‰ Frequency of DOS Times : Quarterly (4 Issues in a year) (July – April)
‰ Frequency of Delhi Journal Ophthalmology : Offset
‰ Model of Printing : CDR open Àle with fonts & proof
‰ Advertisement Material : Delhi Ophthalmological Society
‰ Mailing and Contact
Room No. 479, 4th Floor,
‰ Email Dr. R.P. Centre for Ophthalmic Sciences,
AIIMS, New Delhi - 110029.
Ph. 011-65705229

: [email protected]

www. dosonline.org l 91

The Quarterly Scientific Journal of Delhi Ophthalmological Society. Publishes original research
articles, review articles and clinical studies in all areas of ophthalmology. The manuscript
may be submitted in the format of one of the following:

1. Major Review
2. Original Article
3. Technique
4. Case Report
5. Update
6. Correspondence
7. Allied Ophthalmic Sciences
The articles may be submitted be email to [email protected]

Editorial Office
Dr. Rajesh Sinha
Editor DJO & Associate Professor of Ophthalmology
Room No. 479, Dr. R.P. Centre for Ophthalmic Sciences,
AIIMS, Ansari Nagar, New Delhi - 110029

NOTICE

The Annual General Body Meeting of Delhi Ophthalmological Society will be held on Sunday the 28th August,
2011 at 9:30 A.M. at Jawaharlal Nehru Auditorium, All India Institute of Medical Sciences, Ansari Nagar, New
Delhi - 110029.
The agenda for the aforesaid meeting is:
1. ConÀrmation of minutes of previous General Body Meeting held on 17th April, 2011.
2. Report of audited accounts by Treasurer for the year 2010-2011.
3. Appointment of Chartered Accountant / Auditor.
4. Any other matter.
All members are requested to attend.
Thanking you,
Sincerely yours,

Dr. Rohit Saxena
Secretary
Delhi Ophthalmological Society

www. dosonline.org l 93

Tear sheet

Digvijay Singh

Digvijay Singh MBBS
Dr. Rajendra Prasad Centre for Ophthalmic Sciences,

All India Institute of Medical Sciences, New Delhi

Scheie System of Grading

Grade Structure visible Interpretation
No risk of angle closure
O Ciliary body band No risk of angle closure
Closure rarely possible
I Ciliary body band narrow
Closure likely
II Ciliary body band not seen, Scleral spur seen Gonioscopically closed

III Schwalbe line or Anterior trabecular meshwork seen,
Posterior trabecular meshwork not seen

IV Schwalbe line not seen

Shaffer system of Grading

Grade Angle width Structure Visible Interpretation
no corneal wedge Closed, Do indentation gonioscopy
0 0° no iridocorneal contact (slit angle) imminent closure
Schwalbe’s Line High risk of closure
S <10° Trabecular Meshwork Closure unlikely
Scleral Spur Incapable of closure
1 10° Ciliary Body Band Incapable of closure

2 20°

3 25-35°

4 35-45°

Spaeth system of Grading Angle recess/ Iris insertion Level of insertion of
Iris ConÀguration width iris processes
10° A (Anterior to U - along angle recess
q - Queer (concave schwalbe’s line)
peripheral iris) 20° B (behind schwalbe’s line) V - upto Trabecular Meshwork
30° C (at the Scleral spur) W- upto Schwalbe’s line
r - Regularly straight iris 40° D (deep angle CBB seen)
s - Steeply convex iris E (extremely deep angle)

RPC System

Grade Landmark visible Grade Landmark visible
0 None, closed
1 Schwalbe line 4 Scleral spur
2 Anterior (non pigmented) TM 5 Ciliary body band
3 Posterior pigmented TM 6 Iris root

www. dosonline.org l 95