DOS_mar_2009

Contents

E5 ditorial Miscellaneous

Refractive Surgery 37 Medical Negligence in India

Anil Mittal

7 Femtosecond Laser orthcoming Events

F43Sudhank Bharti, Jitendra Jethani, Kenshuk Marwah, Abhishek Sharma

Cataract

11 Simultaneous Corneal Tunnel and Side Por t Infection Following M45 embership Form

Phacoemulsification Columns
Jeewan S Titiyal, Namrata Sharma, Rajesh Sinha
53 DOS Quiz
15 Phacocele
Saurabh Sawhney, Ashima Agarwal
Amar Agarwal, Gaurav Prakash, Soosan Jacob, Dhiya Ashok Kumar

19 Electric Cataract: A Case Report and Review of Literature

Jitendra Jethani, Kenshuk Marwah, Abhishek Sharma

Systemic Diseases

23 Ocular Manifestations in Acute Phase of Leptospirosis T57 earsheet

Deepika Singhal, Manisha Shastri, Roopali Desai, Sejai Desai, Keratoprosthesis Overview
Deepak Saxena, Pradeep Kumar Jaya Gupta, Radhika Tandon

Clinical Monthly Meeting

27 Clinical Case - AGV in Refractory Glaucoma in Marfan’s Syndrome

Deven Tuli, Sudhank Bharti, Sudhir Bhatia, Dharitri Samantaray

33 Clinical Talk - Imaging Techniques in Macular Disorders:

FFA Vs OCT
Meenakshi Thakar, Rouli Sud

www.dosonline.org 3



Editorial

Dear Colleagues,

The Diamond Jubilee conference annual meeting of the Delhi Ophthalmological Society was held
between 20th and 22nd March 2009 this year. There were a total of 2,242 delegates who had registered for
this year’s conference. The theme of this year’s conference was “Evolution and Revolution in
ophthalmology” There were 10 International faculty speakers from various parts of the would such as
USA, UK, Australia, Switzerland, Singapore and Saudi Arabia and 370 national faculty speakers from various parts of the country.
On the preconference day, the live surgical demonstration was done from 3 hospitals - R P Centre for Ophthalmic Sciences, Bharti
Eye Hospital and Centre for Sight. There were 24 live surgeries of phacoemulsification with foldable intraocular lens implantation,
Descemets stripping automated endothelial keratoplasty ( DSAEK) , Toric ICL surgery and Femtosecond laser surgery.
There were 24 wet labs in phacoemulsification with foldable intraocular lens implantation, Toric IOL marking station, Contact
lenses, Intralase LASIK, OCT, Laser DCR, Selective laser trabeculoplasty and ocular response analyzer.
A total of 56 scientific sessions were held in various disciplines of ophthalmology in 8 halls. There were 7 free paper sessions held
and a new award session was instituted in the Cornea free paper session i.e. Dr T P Agarwal Trophy. There were 78 free paper
presentations and 60 poster displays. Six video stations were displayed which were viewed by over 1,300 delegates.
DOS-ALCON film festival was launched for the first time in which 28 video presentations were received. A quiz was also held for
the young ophthalmologists.
A large area in the front lawns of Ashok hotel was dedicated to the trade exhibition. There 8 major sponsors, 9 co-sponsors along
with stalls. Various ophthalmic equipments as well as the wet laboratories adorned the trade exhibition.
100 Early bird prizes were given on all days. Tea and snacks were available round the clock. “Run for vision” was organized on 21st
March 2009 in which over 100 delegates participated.
The annual dinner & cultural evening was organized on 21st March, 2009 at Suncity Garden. For the first time there was a laser show
and a fire cracker show. It was attended by 2,800 delegates.
DOS elections were held on 22nd March 2009 where the new executive as well as the office bearers were elected. On behalf of the
preceding executive and the office bearers , we wish them all the best for the next term.
Long live DOS!

Thanking you,

Namrata Sharma
Secretary,
Delhi Ophthalmological Society

Femtosecond Laser Refractive Surgery

Sudhank Bharti MS

The name Femto came from a danish word for the number 15. The first commercially available femtosecond lasers for tissue
One femtosecond, the unit used to measure the speed of some processing were oscillator-amplifier systems, a term that denotes a
chemistry reactions (or transient stages) is equal to 10 to the power two step process. These lasers begin the cutting process by generating
minus 15. short femtosecond pulses. However, their energy expenditure is too
low to achieve photodisruption or photoablation, so an amplifier
Femtosecond laser is an ultra-fast radiation that has a temporal strengthens the pulses to the desired degree of pulse energy, in the
resolution correspondent to the speed, or rate of some chemical range of microjoules. This amplification step enables the cupping of
reactions. With experiments utilizing that technique it is possible to the corneal tissue. These two step systems had two primary
observe atoms in molecules in the course of some chemical reactions disadvantages: they were expensive and complicated to operate.
in gases, liquids and solids, and also in catalytic processes and Their calibrations were very sensitive to the environment, such as
biological ones. changes in temperature and humidity and to any physical movement
of the machine. This is why the original oscillator-amplified lasers
“Femtosecond laser” is a laser that can produce a pulse of photons were not usable .
that is shorter than a nanosecond. (A nanosecond is 1000
femtoseconds.). The ultrashort-pulse laser represents a major Today’s oscillator-amplified femtosecond lasers have changed with
advancement in cutting technology. By ionizing the material being development and now are what designers refer to as plug-and-play.
cut, removing it atom by atom, the cutting technique allows precise They are designed as so-called industrial laser systems and do not
machining of everything from steel to tooth enamel to very soft have the same sensitivities as their predecessors.
materials like heart tissue.
New femtosecond technology
Each pulse of this machining system is extremely short, lasting just
50 to 1,000 femtoseconds (or quadrillionths of a second). These Today’s femtosecond laser’s oscillator technology has advanced
ultrashort pulses are too brief to transfer heat or shock to the material beyond the point of needing an amplifier. Engineers of the FEMTO
being cut, which means that cutting, drilling, and machining occur LDV femtosecond surgical laser(Ziemer Group AG, Port,
with virtually no damage to surrounding material. Furthermore, Switzerland), have strengthened the focus of the optics and increased
this revolutionary laser can cut with extreme precision, making the laser’s repetition rate in order to decrease the threshold for
hairline cuts in thick materials along a computer-generated path. photodisruption. In simpler terms, the laser uses less energy per
pulse to cut the tissue, in the range of tens of nanojoules. These
With each short pulse of femtosecond laser cutter, material is heated advancements eliminated the need for an amplifier, thus reducing
to temperatures far beyond the boiling point, producing an ionized the number of components of the original FEMTO laser and making
plasma, while leaving surrounding material cool. The pulse deposits this newest version simpler to operate as well as more compact,
its energy so quickly that it does not interact at all with the plume of affordable, and reliable. Furthermore, because it delivers lower pulses
vaporized material, which would distort and bend the incoming beam of energy, the FEMTO LDV laser is much more gentle on the corneal
and produce a rough-edged cut. The plasma plume leaves the surface tissue that surrounds the ablation site.
very rapidly, ensuring that it is well beyond the cut edges before the
arrival of the next laser pulse. And because only a very thin layer of The amount of tissue disruption correlates with the strength of each
material is removed during each pulse of the laser, the cut surface is
very smooth and does not require subsequent cleanup.

A conventional infrared laser (wavelength 1053 nanometers LDV Flap Making
and pulse more than 1 nanosecond) causes jagged edges and
drag. Femtosecond laser with same wavelength with a pulse 7

of 350 femtoseconds creates a clean cut and no slag

Bharti Eye Hospital
E-52, Greater Kailash-1, New Delhi
E-mail: [email protected] & Tel No. 011-25889900

www.dosonline.org

LDV Bubbles

a very large NA and a very small focal volume. Its focal length is
about 1 mm, which is very close to the eye. For this reason,all of the
laser’s optics have to be contained in the headpiece that delivers the
laser pulses to the patient’s eye.

Scanning Time

laser’s pulse energies. Thus, the oscillator systems that use less energy The typical amplified lasers deliver their pulses line by line in either
cause less tissue disruption and are a little more precise than other a horizontal or a spiral pattern, each within a circular ablation zone.
types of lasers, but they also use a smaller focal point and therefore This pattern is achieved by two moveable mirrors that are controlled
must deliver many more treatment pulses to photoablate the same by a motor. The state-of-the-art approach for controlling the ablation
sized area . Consequently, lasers with small focal points require longer pattern is with pulses delivered with a 10- to 200-kHz repetition rate.
ablation times or else higher rates of repetition. The system delivers one pulse every 5 to 100 microseconds, which
allows it time to control every single pulse. A megahertz repetition
Thus, oscillation femtosecond lasers have repetition rates in the rate leaves only nanoseconds between each pulse, and no scanner
megahertz regime, whereas amplifier systems have repetition rates technology is fully able to handle such a high repetition rate. The
in the range of kilohertz. LDV system uses a single internal unit to generate a line of multiple
pulses.
High Numerical Aperture
They are delivered so quickly that the naked eye cannot distinguish
The focal spot size of a laser’s beam depends on two factors: the individual pulses; the operator sees only a line of ablation inside the
optic’s focal length (the shorter the focal length, the smaller the cornea. Ziemer calls this technology of generating a line so quickly
focus) and the diameter of the original laser beam or the focusing fast scan.
lens, respectively (the larger the original beam’s diameter, the smaller
the focal spot size). The relationship of the lens’ diameter to the The LDV system uses a single internal unit to generate a line of
beam’s focal length is the numerical aperture (NA) of the optical multiple pulses in a process called fast scan.This line has a length of
system. A high NA denotes a large-diameter lens and/or a short less than 1 mm and a diameter of a single laser spot,which is less
focal length. If you want the beam’s focus to be very small, you have than 1 ìm. In contrast to the amplified lasers, where the ablation
to use a very short focal length, which necessitates a short working zone is scanned spot by spot, the LDV’s scanning delivers the ablation
distance from the eye. A larger, more comfortable focal length zone line by line, in a process called slow scan
requires a large-diameter lens. All femtosecond lasers that work
with an amplified system have relatively low NAs, in the range of 0.3 This line has a length of less than 1 mm and a diameter of a single
(the diameter of the lens over the focal length), but they have a laser spot, which is less than 1 µm. In contrast to the amplified lasers,
working distance of several centimeters. The FEMTO LDV laser has where the ablation zone is scanned spot by spot, the LDV delivers
the ablation zone line by line. This process is called slow scan.

Important feature of the oscillator concept is its low-pulse energy,
which reduces the size of the cavitation bubbles formed during the

8 DOS Times - Vol. 14, No. 9, March 2009

Moreover,flap displacements always occurs in eyes that are very dry.
I have not experienced flap displacements in my cases.

Patient recovery

At 1 month after LASIK, the thickness of a flap Although some surgeons place a lot of importance on the strength
(as measured by OCT) was 109 ± 3.7 mm of the laser’s energy delivery, we believe the truer measure of a
(range, 101 to 116 mm). laser’s efficacy is how violently it disrupts corneal tissue. Therefore,
it is clear that a laser with a lowenergy expenditure per pulse (such as
cutting process. The smaller bubbles allow surgeons to position the the LDV) creates less mechanical trauma to the cornea compared
cut more precisely. with a laser with a high output of energy per pulse (such as the
IntraLase). Thus, flap healing and visual acuities after FEMTO LDV
Flap thickness cuts are quite comparable to what we have seen with the latest
mechanical microkeratomes. All of our patients achieve UCVAs of
In general, femtosecond lasers produce a much more reliable flap between 20/20 and 20/25 on postoperative day 1. We have not seen
thickness compared with mechanical microkeratomes. We have any incidence of transient light sensitivity, as some of IntraLase
experienced cases with these microkeratomes in which we could not patientshave experienced, and LDV eyes have much less rednessand
proceed with the excimer ablation because the resulting stromal bed bleeding in the conjunctiva. We attribute these superior outcomes
was too thin. This issue never occurs with the FEMTO LDV, because to the LDV’s oscillator technology and smaller cavitation bubbles,
its distribution is so tight. Our standard flap thickness is 110 µm, and which seem to preserve corneal tissue better than other devices.
we have never cut beyond ±10 µm of a flap’s target.
Conclusions

The Femtosecond laser produces flaps with a very small deviation in
thickness compared with different types of microkeratomes. Also,
the FEMTO LDV creates flaps of the same thickness between the
right andleft eyes, whereas mechanical microkeratomes always
create7- to 10-µm thinner flaps in the left eye.

Sub-Bowman’s Keratomilleusis (SBK) & Lepto-LASIK I want to stress that the FEMTO LDV has a quick learning curve.

I have used the FEMTO LDV to make 90.0-µm flaps in 20 eyes Compared with the flap-cutting outcomes of available mechanical
undergoing primary LASIK surgery. I have experienced no major microkeratomes, the FEMTO LDV laser produces thinner flaps and
complications and only a small number of minor ones, and a flap thickness that is more predictable.
importantly, I have been able to fully complete each surgery.
According to pachymetry the flap thickness in the right eyes was 90.0 Other parameters, such as the width of the flap’s hinge, are also
±5.5 µm, and in the left eyes, it was 90 ±4.6 µm. Three flaps were more predictable, thus allowing the surgeon more control of the cut.
thicker than 100 µm (the thickest was 107 µm), three flaps were Like any surgical device, the FEMTO
between 71 and 80 µm, and one flap was thinner than 70 µm (67
µm). (I was able to lift and reposition the extremely thin flap without LDV involves a learning curve. Surgeons quickly learn to operate it
tearing or even wrinkling it, ( and I consider this a testimony to the with minimal problems, however, and most complications are easily
machine’s efficacy. Remeber that epithelium is 55-60 µm and if the corrected, as I have described. In cutting thinner flaps, the surgeon
flap thickness is 90 µm the stroma in this flap is approx 35 µm). preserves more corneal tissue, farther away from the 250-µm ectasia
barrier. This makes the flap procedure safer and enables surgeons
The average flap diameter was 9.12 mm (range, 8.0 to 10.0 mm), to treat higher degrees of ametropia.
with a standard deviation of 0.20 mm. The length of the flaps’ hinges
was 4.0 mm (aimed 4.2 mm) on average (range, 2.0 to 5.2 mm), and
the standard deviation was 0.40 mm.

Flap Displacements

Flap displacement is much more rare with the femtosecond laser
than with a mechanical microkeratome because of the angle of the
cut. Mechanical microkeratomes approach the cornea at
approximately a 26º angle, but a femtosecond laser cuts at 70º.

Author
Sudhank Bharti MS

www.dosonline.org 9

Simultaneous Corneal Tunnel and Side Port Infection Cataract
Following Phacoemulsification

Jeewan S Titiyal MD, Namrata Sharma MD, Rajesh Sinha MD, FRCS

Infection after a successful and uneventful phacoemulsification at both the sites. There was reduction in the severity of symptoms
is a disaster. We would like to discuss a case in which simultaneous and the frequency of fortified cefazolin (5%) and gatifloxacin (0.3%)
discrete infections of corneal tunnel and side port were noted after eye drops were reduced to one hourly alternately during the day
an uneventful phacoemulsification. time and 4 hourly each during night time. On 4th day, the
microbiological culture report showed growth of coagulase negative
A 54-year-old male diabetic patient with age related cataract Staphylococcus that was sensitive to both cefazolin and gatifloxacin.
underwent phacoemulsification in right eye. One week later, he came There was symptomatic as well as clinical improvement in the
to us with complaint of pain, redness, watering and photophobia. keratitis. The topical antibiotics were continued with a reduced
On examination, his uncorrected visual acuity was 6/24 and the best frequency of 2 hourly each only during waking hours. On seventh
corrected visual acuity was 6/12 on the Snellen’s acuity drum. On slit day of initiation of treatment, the keratitis resolved completely. There
lamp biomicroscopy, two separate areas of corneal infiltration were was presence of faint corneal scars adjacent to the phaco tunnel and
noted. The two discrete areas of infiltration were corresponding to the side port. The UCVA in the affected eye was 6/18 and the BCVA
the corneal phaco wound and the side port (Figure 1). There was was 6/9. The patient was prescribed gatifloxacin eye drops QID and
presence of stromal edema in the central part of the cornea. Scraping lubricants (polyvinyl alcohol) QID for 2 more weeks.
of the two areas of infiltrate was performed; smear was made for
gram’s stain and KOH wet mount, and the sample was sent for Infections of the self sealing corneal wound for phacoemulsification
culture and antibiotic sensitivity. Smear showed presence of gram and side port have been reported in the literature1,2. However, to the
positive cocci and KOH wet mount did not reveal any fungal hyphae. best of our knowledge, there is no clinical report of two simultaneous
The patient was put on the empirical treatment with fortified cefazolin and discrete infections involving the phaco wound and the side port
(5%) and gatifloxacin (0.3%) eye drops half hourly alternately during separately.
the day time and 2 hourly each during night time along with 2%
homatropine eye drops QID. In the present case, the micro-organism implicated in the
development of keratitis was coagulase negative Staphylococcus, which
Two days later, there was reduction in the amount of the infiltrates is a part of the bacterial flora of the cul-de-sac. There was some
amount of corneal edema present after the surgery, which could be
a reason for reduced corneal immunity and this may be implicated
for the development of infectious keratitis of the phaco wound and
the side port. More-over, the patient was a known diabetic and he
was put on topical steroids after the surgery which could be the
other risk factors precipitating infection.

Figure 1: Discrete corneal infiltrates Bacterial contamination of the anterior chamber has been reported3-
involving corneal tunnel and side 4 after uncomplicated phacoemulsification. This usually does not
port following phacoemulsification result in the development of infectious keratitis due to the small
inoculum sizes, as well as the corneal immunity and the ability of the
anterior chamber to clear small bacterial loads. However, it may
result in development of infectious keratitis if the bulbar conjunctiva
is heavily loaded with the micro-organism and there is lowered corneal
immunity as seen in eyes with postoperative corneal edema. In
general, it has been found that the prognosis following bacterial
keratitis is better than fungal keratitis and most patients achieve a
best corrected visual acuity of better than 20/405. In the present case,
the keratitis resolved within seven days and the best corrected visual
acuity was 6/9 (20/30). To prevent the occurrence of wound infections,
we have now started injecting and hydrating the wound with 0.1 ml
of 0.1% vancomycin sulfate routinely in all the cases. Further, we
recommend a meticulous follow-up in eyes with postoperative
corneal edema after phacoemulsification particularly in diabetics.

Rajendra Prasad Centre for Ophthalmic Sciences References
All India Institute of Medical Sciences,
Ansari Nagar, New Delhi 1. Kau HC, Tsai CC, Kao SC, Hsu WM, Liu JH. Corneal ulcer of the side

www.dosonline.org 11

port after phacoemulsification induced by Acinetobacter baumannii. J 4. John T, Sims M, Hoffmann C. Intraocular bacterial contamination

Cataract Refract Surg. 2002; 28(5): 895- 7. during sutureless, small incision, single-port phacoemulsification. J

2. Garg P, Mahesh S, Bansal AK, Gopinathan U, Rao GN. Fungal infection Cataract Refract Surg. 2000; 26 (12): 1786- 91.

of sutureless self-sealing incision for cataract surgery. Ophthalmology 5. Cosar CB, Cohen EJ, Rapuano CJ, Laibson PR. Clear corneal wound

2003; 110(11): 2173- 7. infection after phacoemulsification. Arch Ophthalmol 2001; 119 (12):

3. Samad A, Solomon LD, Miller MA, Mendelson J. Anterior chamber 1755- 1779.

contamination after uncomplicated phacoemulsification and

intraocular lens implantation. Am J Ophthalmol. 1995 Aug;120(2):143-

50.

Author
Rajesh Sinha MD, FRCS

12 DOS Times - Vol. 14, No. 9, March 2009

Phacocele Cataract

Amar Agarwal MS, FRCS, FRCOphth, Gaurav Prakash MD, Soosan Jacob MS, FRCS, Dhiya Ashok Kumar MD

Post traumatic dislocation of crystalline lens into the Glued IOL
subconjunctival space (phacocele) is a rare entity.1-3 A phacocele
can masquerade as an occult scleral perforation with uveal prolapse. Two partial thickness limbal based scleral flaps about 3 mm x 3 mm
This can be diagnosed with the help of high resolution anterior are created exactly 180 degrees diagonally apart and about 1.5mm
segment optical coherence tomography (AS OCT). The problem from the limbus. This is followed by vitrectomy to remove all vitreous
comes in managing such a case as there is no capsular support present. traction. Two straight sclerotomies with an 18 G needle are made
about 1.5mm from the limbus under the existing scleral flaps. While
A 50 year old female was referred to us with sudden diminution of the IOL is being introduced with the left hand of the surgeon using a
vision after blunt trauma with a clenched fist three days back. Slit McPherson forceps, an end gripping micro rhexis forceps (Micro
lamp examination revealed chemosis and superonasal conjunctival Surgical Technology, USA) is passed through the inferior sclerotomy.
swelling with grayish discoloration along with aphakia and a superior The tip of the leading haptic is then grasped with the micro rhexis
iris defect (Figure 1). A clinical diagnosis of occult scleral perforation forceps, pulled through the inferior sclerotomy following the curve
with uveal prolapse and dislocation of the crystalline lens was made.
However, indirect ophthalmoscopy and posterior segment
ultrasound could not localize the lens. Anterior segment OCT (Carl
Zeiss Meditec, Inc, CA, USA) localized a heterogeneous reflecting
body in the area of the swelling, suggesting a possible phacocele
(Figure 2).

Surgical Management

The conjunctiva was first opened up. On exploration the lens was Figure 2: Anterior segment OCT
found in the superonasal subconjunctival space (Figure 3). The lens showing the phacocele
was removed with the help of a vectis. The scleral laceration was
explored and sutured. Subsequently bimanual vitrectomy was done.
There was no capsular support present. In such cases the alternatives
of lens implantation are either an AC IOL or a scleral fixated IOL
with sutures. We decided to implant a 6.5 mm PMMA posterior
chamber Glued IOL using the novel technique of ‘fibrin glue-assisted
sutureless posterior chamber intraocular lens implantation’ (Figure
4).

Figure 1: Phacocele. Note the subconjunctival Figure 3: Conjunctiva explored and
swelling. The lens has been dislocated into the the lens localted and removed.
Note the scleral laceration
subconjunctival space
15
Dr. Agarwal’s Group of Eye Hospitals
19 Cathedral Road, Chennai

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stability as the haptics are tucked in a scleral tunnel. Then, the
reconstituted fibrin glue (Tissel, Baxter, USA) prepared is injected
under the superior and inferior scleral flaps. Local pressure is given
over the flaps for about 10 to 20 seconds for the formation of fibrin
polypeptides. Conjunctiva is also closed with the same fibrin glue.
Post operative monitoring of the anterior segment, sub-conjunctival
area and IOL centeration was done by AS OCT and direct
visualization.

Discussion

Figure 4: Glued IOL: Fibrin glue-assisted Anterior segment OCT is a non contact investigative modality for
sutureless posterior chamber intraocular assessment of the relations of the cornea, lens and the angle.
Additionally, the subconjunctival potential space can also be visualized
lens implantation with this method. OCT has been used to delineate structures in
penetrating trauma. However, to the best of our knowledge, the use
of this unique imaging modality for assessment of anterior segment
structures in blunt trauma and in localization of anteriorly dislocated
crystalline lens has not been previously reported. Alos this patient
was implanted with a Glued IOL and 3 weeks post op the vision was
20/20.

of the haptic and is externalized under the inferior scleral flap. References
Similarly, the trailing haptic is also externalized through the superior
sclerotomy under the scleral flap The haptic can bend and break if u 1. Sunita Agarwal, Athiya Agarwal, Amar Agarwal: Phacoemulsification
are pulling it in wrong direction or if u are not holding it in the tip. –Two volume set; Third edition Slack;2004; USA,
Hence while externalising, hold the haptic exactly in the tip and pull
it along the curve of the haptic. There is no exact length that has to be 2. Amar Agarwal: Phaco Nightmares; Conquering cataract catastrophes;
externalised. The enire haptic length which comes out depends upon Slack Inc, 2006, USA
the centration and size of IOL.Half of the length of the haptic brought
outside gives good stability. With a 22 G needle a scleral tunnel is 3. Amar Agarwal: Handbook of ophthalmology; Slack Inc, 2005, USA
made at the edge of the scleral flap. The tip of the haptic is then
tucked in the tunnel in the same direction. This gives the IOL extra

First Author
Amar Agarwal MS, FRCS, FRCOphth

Answer Quiz No. 9

Extra Word: DRUGS

4. MOXIFLOXACIN 3. BEVACIZUMAB 2. ACYCLOVIR 1. ATROPINE
5. ACETAZOLAMIDE

16 DOS Times - Vol. 14, No. 9, March 2009



Electric Cataract: A Case Report and Review of Literature Cataract

Jitendra Jethani* MS, DO, DNB, Kenshuk Marwah** MBBS, Abhishek Sharma** MBBS

Electric trauma producing cataract is rare; however, there have patient was advised cataract surgery but was lost to followup.
been few cases reported in literature. Such cataracts are known
to develop in several months later. We report such a case of electric Damage from lightening shock leading to cataract has been recorded
cataract in a young adult.1 since 1722 by St. Yves,3 certainly it would have been present long ago,
but was the first documentation of such a case. Electric current as
Case report proved by Weeks and Alexander4 passes through the animal body
as though it were passing through a structureless gel, always choosing
A 24 year old man complained of gradual and painless diminution of the shortest path from contact to contact without deflection by
vision in both eyes. He underwent right eye cataract surgery with anatomical landmarks.
intraocular lens (IOL) implantation 6 months back. The history of
the patient revealed an injury from a high-voltage electric cable that The amount of energy delivered depends on the resistance between
accidentally touched and left a scar on his scalp with loss of hair a two points. Loflus5 has found that the usual skin resistance is between
year back. His corrected visual acuity was 20/30 in right eye and 20/ 3000- 5000 ohms but that may be reduced by wetting to around 3000
100 in left eye. Loss of vision was gradual in both eyes. ohms. It is known that lower the resistance greater the internal injuries,
higher the resistance greater the surface burns.
The lids, conjunctiva, cornea, and pupils showed no abnormality in
either eye. Right eye had a posterior chamber IOL (PCIOL). Fundus Considerable evidence points to an alteration in permeability of the
examination was unremarkable in right eye and faintly visible in left lens capsule as a factor in production of electric cataract. Alteration
eye. Slit lamp examination revealed PCIOL in right eye and left eye in diffusion of proteins from the shocked lens and decreased ability
showed multiple, mid-peripheral snowflake-like anterior subcapsular of these lenses to absorb water. Lens changes occur shortly after
lens opacities. (Figure 1) Also a central cortical opacity with shrunken shock, but severe visual reduction may be considerably delayed.
anterior capsule was seen. There was a complete cleavage of cortex Early changes consisted of accentuation of the anterior suture line
and a separation was visible in retroillumination. (Figure 1) The followed by anterior subcapsular vacuolization, superficial anterior
punctuate, linear or scale like opacities

Large blebs appeared beneath the posterior capsule later replaced
by irregular filamentous opacities. Cataract develops in approximately
the same degree and pattern as in eyes shocked with the alternating
currents. Localized shocks in one eye doesn’t produce cataract in
other eye.

The involvement of crystalline lens exclusively with sparing of other
ocular structures is rare as in our case. Our case as has been reported1
previously shows that visual outcome is usually good in electric
cataracts if the posterior segment is normal.

Reference

1. Raina UK, Tuli D. Bilateral electrical cataract. BJO 1999; 83: 1091

2. Long JC. Electric cataract: report of three cases. Am J Ophthalmol
1966;61:1235–9

3. Long JC. A clinical and experimental study of electrical cataract. Trans
of American Ophthl Soc. 1962; 60: 471- 516

4. Weeks AW, Alexander L. The distribution of current in the animal
body, J. Indust. Hyg. & Toxicol.1939; 21:517- 520

5. Loftus JJ. Electrical injuries. J. Irish medical association.1957: 41:94-96

Figure 1: The upper picture shows the snow flake
opacities anteriorly with the central opacity in lens.
The pupil, cornea and conjunctiva are normal. The lower
photograph shows the lens in retroillumination with the
separation of cortex from the capsular bag is evident.

*Pediatric Ophthalmology and Strabismus Clinic, First Author
T. V. Patel Eye Institute, Haribhakti Complex, Salatwada, Baroda Jitendra Jethani MS, DO, DNB

**M&J Western Regional Institute of Ophthalmology, 19
Civil Hospital, Ahmedabad

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Ocular Manifestations in Acute Phase of Leptospirosis Systemic Diseases

Deepika Singhal MS*, Manisha Shastri MS*, Roopali Desai MS*, Sejai Desai DOMS*,
Deepak Saxena MD**, Pradeep Kumar MD***

Surat city witnessed major floods during the month of August acute systemic phase varies from 2% to 90%. However, in some
2006 due to heavy rainfall in catchments of Tapi river in instances, the ocular manifestations may be sub-clinical or of such
Maharashtra & Madhya Pradesh. Almost 85 – 90 % of the city low order as to be overlooked.5,6 During this stage conjunctival
remained submerged for more than five to six days. Post flood there congestion without any conjunctival discharge, chemosis, and sub-
was an upsurge in fever cases presenting with organ involvement conjunctival hemorrhage may be seen
and were suspected to be Leptospirosis, a zoonotic disease known to (Figure 2&3). Presence of yellow sclera and circum-corneal congestion
occur in South Gujarat since 19941. However, its occurrence has been is regarded as pathognomic sign of severe systemic leptospirosis
documented so far only in the rural areas of districts of Surat, Navsari (Figure 4).7 However, the most sought term suffusion, referring to a
and Valsad2. It was for the first time that cases of Leptospirosis were conjunctival congestion, has historically been linked to findings of
reported in Surat city. leptospirosis7,8. Formal ophthalmologic evaluation of the eye during
the acute phase of leptospirosis may reveal dilation of the
Leptospires are very thin, spiral-shaped, tightly coiled, gram-negative conjunctival vasculature, subconjunctival hemorrhage, and retinal
aerobic, spirochetes with a unique flexuous type of motility (Figure vasculitis.8
1). The genus is divided into two species: the pathogenic Leptospires
interrogans and non-pathogenic Leptospires biflexa. Infected rodents
and other animals pass the bacteria in their urine contaminating the
soil and water reservoirs. They enter the humans through an intact
mucosa or abraded skin, resulting in a bacteraemia, disseminating
into various organs such as the kidneys, liver, lungs, heart and the
central nervous system. A febrile illness, headache, redness of eye,
severe fatigue and muscle pain may be the clinical features of the
leptospiremic acute phase; however the severity of fever varies from
asymptomatic presentation to mild, moderate or severe form and is
not sufficiently characteristic for an early diagnosis.3,4 After 4 to 7
days of the initial bacteraemia, the leptospires are rapidly eliminated
by the immune system from all host tissues except from
immunologically privileged places like the brain and eyes. Ocular
involvement is seen both in the systemic bacteraemic phase as well
as in the immunological phase. The incidence of ocular signs during

Figure 2: Conjuntival suffssion in a
suspected case of Leptospirosis

Figure 1: Electromicroscopic view of Figure 3: Conjuntival suffussion
the Leptospira pathognomic of Leptospirosis

*Department of Ophthalmology, Surat Municipal Institute of Medical 23
Education & Research (SMIMER) Surat.

**Indian Institute of Public Health, Gandhinagar.
***Department of Community Medicine,
BJ Medical College, Ahmedabad.

www.dosonline.org

Table 1: Age Sex distribution of the study population

Age group Male Female Total

Figure 4: Yellowish Sclera one of the <20 16 (19.75) 4 (4.9) 20 (24.69)
pathognomic sign of Leptosiprosis 21-30 27 (33.3) 4 (4.9) 31 (38.27)
31-40 10 (12.3) 2 (2.5) 12 (14.8)
41-50 7 (8.6) 2 (2.5) 9 (11.1)
51-60 5 (6.1) 2 (2.5) 7 (8.6)
61 & more 2 (2.4) 0 (0) 2 (2.5)
Total 67 (82.7) 14 (17.3) 81 (100)

Table 2: Distribution study population according to the Sera
report and their outcome

Confirmation of clinical diagnosis of leptospirosis relies on laboratory Test Result Expired Discharged Total
testing. MAT is currently considered a gold standard test. However,
methodological complexities, including the requirement for a ELISA +ve 6 44 50 (61.7)
continuous supply of live organisms, high specificity for individual Rapid +ve 0 10 10 (12.4)
sero-groups leading to false negativity, and subjective errors in the ELISA –ve 5 16 21 (25.9)
reading limit its use.9 Analysis of paired serum is recommended, Total 11 70 81 (100)
either sero-conversion or a four-fold or greater rise in antibody titer
is considered diagnostic for systemic leptospirosis, whereas in the
chronic stage or in ocular leptospirosis, a titer above 1:100 dilutions
is taken as significant.10

Aims & Objectives (17.3%). Age group of 21 – 40 years accounted for more than 50% of
the total cases. Reasons that can be attributed for this high percentage
The present study was undertaken to study the ocular involvement of infection in this group was history of exposure to flood water
in acute phase of Leptospirosis and to study the various ophthalmic (90%) ; most people in affected areas gave history of moving in
manifestations in serologically positive & negative cases of flooded water to secure relief supplies, rescue or shifting to safer
Leptospirosis admitted in the hospital . places.

Material & method Above table shows the distribution of study population according to
the sera report and their outcome. Cases which showed either first
The present study was carried out in teaching hospital of SMIMER ELISA as positive or showed increased titer in second ELISA (first
between August and 2nd week of September. Inclusion criteria one may be negative) were considered as ELISA Positive. Proportion
included all hospitalized cases in SMIMER who were clinically of such cases was 61.72 percent; rest were ELISA –ve 25.9 percent. In
suspected with Leptospirosis as per the suspected case definition by 12.4 percent cases only rapid test was performed and was available
NICD.12 The patients were examined and their details were collected for interpretation labeled as Lepto +ve.
in a pre-tested & pre designed proforma to record demographic
characteristics, history & duration of exposure along with clinical Over all Case fatality rate (CFR) was 13.5 percent , however in those
feature with an emphasis on specific ocular complaints like pain, who were ELISA +ve CFR was 12% as compared to a CFR of 23.8%
discharge, redness and other ocular complaints.11 in ELISA –ve cases.

Rapid Test status and / or First ELISA status (a titer above 1:100 Table no.3 narrates the distribution of study population according
dilutions) or sero-conversion or a four-fold or greater rise in antibody to the Presenting Symptoms & major organ involvement (other
titer after second sera (which was collected after 14 days of first sera) than Ophthalmic involvement ) Out of 81 cases studied most
was considered diagnostic for systemic leptospirosis to classify a common presenting symptom was Fever present in 61 (87.6%) cases.
patient serologically as positive or negative. However 18.26% of the cases had Pulmonary involvement followed
by Renal involvement in 12.5% cases.
The data was collected & analyzed by help of EPI Info version 6.01
using Chi-square test to estimate the statistical significance. Table 4 describes the distribution of the study population according
to various ocular manifestations . In all 33 out of 81 cases presented
Observations with one or more than one type of ocular manifestations. Most
common ocular manifestation was Conjunctival Suffusion in 23.7
Table no.1 narrates the age-sex distribution of the study population.
Out of 81 cases, more cases were amongst males (82.7%) than females

24 DOS Times - Vol. 14, No. 9, March 2009

Table 3. Distribution of study population according to the may be misinterpreted as idiopathic uveitis by the ophthalmologists.
Presenting Symptoms & major organ involvement (other There exists a definite possibility of underestimating the incidence
than Ophthalmic involvement ) of uveitis associated with leptospirosis. If the diagnosis is
misinterpreted, young patients with hypopyon uveitis with a history
Symptoms / Organ Involved N (%) of joint pain (during systemic leptospirosis) may mislead the
ophthalmologist to diagnose other uveitic entities that are associated
Fever 71 (68.26) with arthralgia such as Behcet’s syndrome or HLA B27 related uveitis.
Lungs 19 (18.26) There is a definite need for development of clinical prediction rules
Renal 13 (12.5) to detect the initial ocular presentation of leptospiral and its
Others 11 (10.5) complications and also needs an urgent need for more specific and
Total 104 accessible molecular methods to confirm the clinical diagnosis of
leptospirosis.

References

1. Gujarat Document on Letospirosis ; Proceedings of V Annual Congress
of Indian Leptospirosis Society 2005; 20-22 January 2005,Surat India.

Table 4: Distribution according to the various Ocular 2. Kumar P. Evaluation of Scoring based diagnostic tool of WHO for
manifestations (n=33) Leptospirosis: Community Experience in South Gujarat: Proceedings
of V Annual Congress of Indian Leptospirosis Society 2005; 20-22
Symptom N (%) January 2005,Surat India.

Conjuntival Suffusion 23 (23.7) 3. Faine S, Alder B, Bolin C. Leptospira and Leptospirosis, 2nd edn.
Icterus 19 (19.5) Melbourne, Australia: Medisci; 1999
Venous Fullness 15 (15.5)
Sub conjuntival Hemorrhage 21 (21.6) 4. Bharti AR, Nally JE, Ricaldi JN, Matthias MA, Diaz MM, Lovett MA.
Others 19 (19.5) Leptospirosis: a zoonotic disease of global importance. Lancet Infect
Total 97 (100) Dis 2003;3:757-71

5. Rathinam SR, Namperumalsamy P. Leptospirosis. Ocular Immunol
Inflamm. 1999;7:109-18

6. Martins MG, Matos KT, da Silva MV, de Abreu MT. Ocular
manifestations in the acute phase of Leptospirosis. Ocular Immunol
Inflam 1998;6:75-9

Table 5: Distribution of Study population as per Sera Report 7. Chu KM , R Ratinam , P Namperumalasamy , D Dean 1998 :
& Ocular manifestations (n=33) Identification of Leptospiral species in pathogenesis of uveities and
detrmination of clinical ocular characterstics in South India J. Infectious
Sera Report Ocular Manifestations P Value df Dis.177;1314-1321
Present Absent
8. Patrick W Hickey, MD, FAAP, A P of Pediatrics, Uniformed Services
ELISA +ve 27 23 0.02 at a X2 2 University, Division of Pediatric Infectious Disease, Department of
ELISA -ve 4 17 value of 7.41 Pediatrics, Walter Reed Army Medical Center
Rapid +ve 2 8
9. Lupidi R, Cinco M, Balanzin D. Serological follow-up of patients
percent followed by Sub conjuntival hemorrhage in 21.6percent involved in a localized outbreak of Leptospirosis. J Clin Microbiol
population. 1991;29:805-9

The above table describes the association of the ocular manifestations 10. Fanie S: Leptospirosis Topley & Wilson Microbiology & Microbial
with the sera reports. 33 cases out of 81 presented with one or more infections 1998 ,9th Ed.Vol.849-869
ocular manifestations , however 69.6% (23 out of 33) presented with
Conjuntival suffusion, most sensitive predictor of Leptospirosis in a 11. Saxena Deepak , Kumar P ; Use of WHO Algorithm for field bases
patient with fever & history of occupational exposure. The difference detection of suspected cases of Leptospirosis, BODHI ,Vol.13 No. 3,July
in serum status and the ocular manifestations was found significant August 2006.
statistically.
12. CD Alert Leptospirosis :Prevention & Control Vol 9:No.12

Discussion First Author
Deepika Singhal MS
Ophthalmic diagnosis of systemic leptospirosis is often missed at
peripheral centres; subsequently patients may develop uveitis, which

www.dosonline.org 25

AGV in Refractory Glaucoma in Marfan’s Syndrome Clinical Meeting: Clinical Case

Deven Tuli MS, Sudhank Bharti MS, Sudhir Bhatia MS, Dharitri Samantaray MS

17 year old male with Marfan’s syndrome and developmental releasable sutures or Ahmed Glaucoma valve (AGV) and we chose
glaucoma and cataractous ectopia lentis underwent bilateral the latter.
combined lensectomy + trabeculectomy at 4 years of age. He was
since lost to follow up and was seen 2 years back with loss of vision Post AGV course- Day 1 revealed VA 6/12 with glasses, IOP 7 mmHg,
right eye. On examination, that time, was noticed to have old total tube was well covered and well positioned with minimal AC reaction.
RD (PL negative) in right eye (RE). RE also revealed aphakia with Day 14 examination was VA 6/9 with glasses, IOP 10 mmHg, tube
scarred bleb and IOP 14 mmHg on no glaucoma medication. Left well covered and well positioned and AC quiet
eye (LE) on examination was VA 6/9 with glasses, aphakia, IOP 35 (Figure 3).
mmHg, and scarred bleb (Figure 1). Gonioscopy was Grade 3-4 all
quadrants with iris processes, and a scarred sclerostomy. LE C: D Discussion
ratio was 0.6:1. A lattice with break was cryoed. Patient was placed
on 3 glaucoma medications- Dorzolamide-Timolol and Brimonidine. Glaucoma in Marfan’s syndrome is due to angle anomaly including
IOP in last two years has ranged 14-26 mmHg on above treatment thickened trabecular sheets, decreased outflow facility along with
with irregular compliance. scleral-TM collapse (Low rigidity); anterior iris insertion and iris
processes make up the juvenile angles. Associated ectopia lentis and
On last examination, two months back, left eye was VA 6/9 with lens induced glaucomas contribute.
glasses (+8.0/+1.0/110) with CD ratio .7 x .8. Field revealed paracentral
defects and HRT was outside normal limits. Incidence of glaucoma in Marfan’s syndrome is about 5%. Suggested
first treatment is Goniotomy/ Trabeculotomy in newborn glaucoma
Family history is negative for glaucoma or marfan’s syndrome. There variant and Augmented Trabeculectomy in juvenile variant.
is no history of cardiac-vascular illness in patient. Anthropometry Glaucoma Drainage Device (GDD) is the current preferred practice
was Marfanoid (Figure 2) with Height 183 cms, Weight 76 kg, Arm for a patient like ours with juvenile age with failed trabeculectomy
span 1.1 (Increased) and Upper: Lower segment ratio 0.85 (Reduced). and aphakia. Only isolated reports of past GDD models in marfan’s
Vitals stable and CVS exam was unremarkable. glaucoma are available in literature and AGV reports are sparse.
IOP control is mostly satisfactory.
This case is a challenge in glaucoma management. The patient has a
refractory glaucoma due to young age, marfan’s syndrome, aphakia In planning AGV in marfan’s, selection of site for base plate anchoring
and failed trabeculectomy. Added concerns are single eyed status should be judicious avoiding areas of scleral thinning and ectasia and
and moderate-advanced glaucoma needing low target. there is higher chance of tube erosion and retraction owing to lower
scleral rigidity. Future course of our case- there is a hypertensive
Intervention Options were ReTrab augmented with MMC and

Figure 1: Left eye showing aphakia and Figure 2: Marfanoid features
scarred trabeculectomy
27
Bharti Eye Hospital
E-52, Greater Kailash-1, New Delhi

www.dosonline.org

References

1. Izquierdo NJ, Traboulsi EI, Enger C, Maumenee IH. Glaucoma in the
Marfan syndrome. Trans Am Ophthalmol Soc 1992; 90:111-7;
discussion118-22.

2. Alme AM, Ingvoldstad DD, Hejkal TW, Margalit E. Adult onset
buphthalmos in a patient with marfan syndrome. J Glaucoma. 2008
Oct-Nov;17(7):567-8.

3. Dureau P. Pathophysiology of zonular diseases. Curr Opin Ophthalmol.
2008 Jan;19(1):27-30. Review.

4. Challa P, Hauser MA, Luna CC, Freedman SF, Pericak-Vance M, Yang
J, McDonald MT, Allingham RR. Juvenile bilateral lens dislocation
and glaucoma associated with a novel mutation in the fibrillin 1 gene.
Mol Vis. 2006 Aug 28;12:1009-15.

Figure 3: Day 14 photograph showing the AGV 5. Wu-Chen WY, Letson RD, Summers CG. Functional and structural
tube well positioned in AC and well covered with outcomes following lensectomy for ectopia lentis. J AAPOS. 2005
Aug;9(4):353-7.
scleral graft. IOP is 10 mmHg
6. Whitelaw CM, Anwar S, Adès LC, Gole GA, Elder JE, Savarirayan R.
Primary trabeculodysgenesis in association with neonatal Marfan
syndrome. Am J Med Genet A. 2004 Aug 1;128A(4):418-21.

7. Krupin T. Marfan syndrome, lens subluxation, and open-angle

phase lasting 2-4 months with AGV due to encapsulation of base glaucoma. J Glaucoma 1999; 8:396-9.

plate and that when seen can be managed with short course of

glaucoma medication or if required needling and mitomycin C

injections. Also we would watch out for tube retraction and tube

blockage in our patient.

First Author
Deven Tuli MS

28 DOS Times - Vol. 14, No. 9, March 2009

Imaging Techniques in Macular Disorders: Clinical Talk
FFA Vs OCT

Meenakshi Thakar MD, FRCS, Rouli Sud DO, DNB

Flourescein Angiography and Optical Coherence Tomography Indirect evidence
are important imaging techniques for macular disorders. Often
in our practice we order both these investigations, but judicious • Loss of foveal depression
choice of investigations should be such that relevant information is
obtained without being a burden on patient’s time and pocket. • Sensory retinal elevation

Flourescein Angiography is a dynamic representation of physiologic • Retinal thickening
events. A good judgment of blood ocular barriers i.e. blood retinal
and RPE choroidal barriers is obtained. A two dimensional anatomy • Cystic spaces
is seen in a single planar cut. Morphology of the vessels from arteriole
to capillaries is delineated. OCT on the other hand is a relatively new • PED
investigative modality which shows the Z Axis or the axial plane of
the various layers of retina and choroid in detail. However presence of a well defined thickness/ fragmentation/
elevation of RPE complex on OCT is only suggestive of CNV and
only the presence of subretinal &/or intraretinal fluid is confirmatory.

The role of these investigations will be discussed in a few common Another drawback of OCT is its inability to differentiate between
macular disorders. blood and fibrosis which give similar high reflectivity and thickening
of RPE -Choriocapillaris complex. Thus it has a high sensitivity (95.
ARMD 65%) but a relatively low specificity (59.01%) in detecting CNVM.

A wet ARMD shows the following features on Angiography Advantages of OCT include

Classic: This may be further classified as Extrafoveal, subfoveal or • Can detect conversion from dry to wet ARMD
Juxtafoveal based on their location in the macula.
• Helps to differentiate ARMD from RAP, Juxtafoveal
Occult: This includes fibrovascular PED and late leakage of telengiectasia
indeterminate type
• Picks up RPE rip, CME
The management of ARMD by any type of laser treatment i. e. PDT
or conventional laser requires an angiogram. Therefore, in the PDT • May identify a well defined membrane under haemorrhage
era, angiography had been the gold standard. It helped to confirm
the diagnosis, determine the pattern, boundaries, composition & While monitoring treatment indicators of active CNVM on OCT
location of the lesion with respect to the FAZ, decided if treatment is are persisting serous elevation and cystic spaces whereas inactive
to be given & by which modality and guided the follow up. CNVM shows fibrosis, decreased sensory elevation and cysts and
restored foveal anatomy.
Drawbacks of angiography include

• Invasive procedure with known complications

• After PDT it is not always possible to determine non-activity
leading to repeated PDT

OCT has now become an established modality in diagnosis and
management of ARMD

OCT findings in ARMD include

Direct evidence

• Fusiform thickening of RPE

• RPE reduplication Figure 1: Fundus photograph and corresponding
• Shadowing under RPE fluorescein angiogram of a patient following PDT.

Though hyperflourescence is persisting on FA,
OCT shows absence of intraretinal fluid

Guru Nanak Eye Centre 33
Maharaja Ranjit Singh Marg, New Delhi

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Thus the role of OCT in ARMD may be summarized as: Figure 2: Fluorescein angiogram of a
diabetic patient showing macular ischemia
• Establishes a baseline retinal thickness, volume & extent of CNV.
It is useful especially when CNV is obscured on FA by thin layer proved very valuable as it affects our line of management. However
of blood/fluid perfusion abnormalities such as macular ischemia can only be
diagnosed on FA and it is specifically indicated when ischemia is
• Diagnosis of early occult CNV especially in patients with soft suspected.
confluent drusens, RPE tear, CME In a retrospective study conducted by Kozak et al patients with
confirmed or suspected ME over a period of 12 months of different
• Defines boundary of CNV for laser & confirms complete closure causes were studied. On FA- HRA confocal scanning laser
after treatment ophthalmoscope presence of late phase leakage in the foveal area
was defined as ME.
• Follow up response to treatment quantitatively i. e. (SRF/ On high resolution OCT macular map protocol of 6 radial scans
intraretinal fluid/ both) centered on the fovea were taken. ME was defined as loss of central
foveal contour, presence of intraretinal cysts, subretinal fluid, or
The efficacy of OCT guided follow up and subsequent further diffuse thickening of the foveal & perifoveal area of > 250 microns. It
treatment of exudative SRNVM was substantiated by PrONTO was found that both FA and high resolution OCT are highly sensitive
(Prospective OCT imaging of patients with neovascular AMD treated techniques and correlate well in the detection of ME. However,there
with intraocular ranibizumab [Lucentis]) study. Patients included in is a small chance that when performed alone they might miss existing
the study had any type of neovascular lesion involving the fovea, a subtle ME.
central retinal thickness on OCT of >300 µm, and visual acuity of 20/ In a study conducted by Soliman et al diabetic changes on OCT were
40 to 20/400. Macular cysts (intraretinal fluid) were seen in 90% of defined as
eyes, subretinal fluid in 75%, and pigment epithelial detachment in • No change
72. 5%. Three consecutive monthly injections with intravitreal • Local ONL thickening
ranibizumab (0. 5 mg) were given. Subsequently, from month 3 • Diffuse ONL thickening
through month 24, patients were examined monthly with OCT and • Cystoid expansion of ONL
every 3 months with angiography. Additional injections were • Cystoid expansion of INL
performed if there was a loss of five letters or more visual acuity or • Serous detachment of neural retina
evidence of any subretinal fluid, persisting fluid, new haemorrhage Changes on FA were defined as:
or, an increase in central retinal thickness of 100 µm or more on • Focal leakage
OCT. The improvement in visual acuity was associated with a decrease • Diffuse leakage
in central retinal thickness on OCT. Based on these results, OCT • Petaloid cystoid leakage
appears to be a useful tool for guiding retreatment decisions for
patients with neovascular AMD.

Thus though the diagnosis and management of ARMD in PDT era
was primarily FA dependent,with the advent of Anti VEGF, it has
become less FA & more OCT dependent. When combination
therapy is planned then both modalities are of equal importance.

Our suggested approach is to order OCT first when there is a
suspicion of CNV. If positive then proceed with FA. If treating
exudative AMD, OCT & FA should be done at baseline. After
treatment & in follow up do OCT to detect persistence/recurrence
of CNV. If PDT is being planned then FA should be done.

Macular edema

Diabetic macular edema has been classically divided into three types
based on angiography findings:

• Diffuse leakage

• Focal leakage

• Ischemic

However on OCT due to the better delineation of anatomical
structures diabetic macular edema has been further classified as:

• Spongy retinal thickness

• Cystoid macular edema

• Serous retinal detachment

• Taut posterior hyaloid membrane

• Foveal Tractional retinal detachment

Serous foveal detachment is a particular condition in which OCT has

34 DOS Times - Vol. 14, No. 9, March 2009

only modality which picks up macular ischemia causing severe visual
loss in diabetic patients with a relatively normal looking fundus.
Therefore OCT is the preferred investigation in these cases and FA
is only rarely indicated.

Future of Imaging

Many new investigative modalities are being developed which will
further enhance our imaging capabilities. These include:

Figure 3: OCT showing marked vitreomacular Digital FFA- New methods of digital capture and digital storage
traction in a diabetic patient have improved quality of images obtained. Images can also be stored,
transmitted and re-analysed including quantitative methods and
wider fields of view.

SLO based systems like HRT allow simultaneous FFA and ICG.

Wide field OPTOS system allowing high quality peripheral
angiograms which are especially useful in cases of periphlebitis.

Fundus Autoflorescence Imaging (FAF)- Allows topographic mapping
of lipofuscin distribution in the RPE cell monolayer. This helps in the
early detection of RPE disease, such as ARMD and can predict the
expected change of RPE in future.

Thus in the current scenario both OCT and FFA play an important
though sometimes overlapping role in the diagnosis and
management of patients of macular disease.

References

Figure 4: OCT showing CME with ERM in 1. Kozak I, et al. Discrepancy between fluorescein angiography and optical
a patient with unexplained visual loss coherence tomography in detection of macular disease. Retina
post cataract surgery 2008;28:538-543

2. Van de Moere A,sandhu SS,Talks SJ. Correlation of fluorescein
angiography and optical coherence tomography following
photodynamic therapy for choroidal neovascular membranes. Br J
Ophthalmol 2006;90:304-306.

3. Kang SE ,et al. The correlation between fluorescein angiography and

optical coherence tomographic features in clinically significant diabetic

• Honeycomb cystoid leakage macular edema. Am J Ophthalmol 2004;137:313-322.

4. Soliman ,et al. correlation between intraretinal changes in diabetic

They concluded that FFA is superior to OCT in detecting very early macular edema seen in fluorescein angiography and optical coherence

changes of macular edema. OCT is superior to FFA in advanced tomography. Acta Ophthalmol. 2008:86:34-39.

stages of macular edema especially serous foveal detachment. 5. Mirza RG,et al. Optical coherence tomography use in evaluation of
Petaloid cystic changes on FFA correspond to cystic changes in ONL
the vitreoretinal interface;a review. Survey of Ophthalmology July-

and honeycomb cystic changes on FFA correspond to cystic changes aug 2007;52:397-421.

in INL . 6. Eter et al. Comparison of fluorescein angiography and optical coherence

In a patient with diabetic maculopathy both OCT and FA are tomography for patients with choroidal neovascular membranes
recommended as baseline investigations. OCT picks up structural following photodynamic therapy. Retina 2005;25:691-696.

abnormalities like thickened posterior hyaloid face,vitreomacular 7. Bresnick GH. diabetic macular edema :a review. Ophthalmology

traction etc. whereas FA rules out presence of macular ischemia. 1986;93:989-997.

The line of management can be decided accordingly. If structural

abnormalities are present then pars plana vitrectomy with ERM +/-

ILM peeling is indicated with or without intravitreal triamcinolone

or Anti VEGF. In the absence of structural abnormalities standard

macular laser (grid/focal) is done which may be preceded by posterior

subtenons triamcinolone or intravitreal triamcinolone/ Anti VEGF.

Subsequent follow up and treatment is again guided by angiographic

and OCT changes.

OCT has proved extremely useful in cases with unexplained visual First Author
loss. It helps to pick up subtle changes which may be missed on Meenakshi Thakar MD, FRCS
ophthalmoscopy. For example in a patient complaining of
deterioration of vision post cataract surgery OCT may pick up early
CME or the presence of ERM or a small PED. However FA is the

www.dosonline.org 35

Medical Negligence in India Miscellaneous

Anil Mittal Advocate

It has been observed by the Supreme Court of India in Jacob Medical Mal-Practice
Mathews1 Case that the service rendered by the medical
professional to human beings is probably the noblest of all and It is professional negligence by act or omission by a health care
hence there is need for protecting doctors from frivolous and provider in which care provided deviates from accepted standards
unjust prosecution. Indiscriminate prosecution of medical of practice in the medical community and causes injury to the
professional for negligence is counter productive and it does no patient. Professional negligence or medical negligence may be
service or good to the society. A medical practioner, faced with an defined as want of reasonable degree of care or skill or willful
emergency, ordinarily tries his best to redeem the patient out of negligence on the part of the medical practitioner in the treatment
his sufferings. He does not gain anything by acting with negligence of a patient with whom a relationship of professional attendant is
or by omitting to do an act. Obviously, therefore, it will be for the established, so as to lead to bodily injury or to loss of life.
patient to clearly makeout the case of negligence before a medical
practioner is charged with or proceeded against criminally. Criminal Medical Negligence
Supreme Court further says, a surgeon with shaking hands under
fear of legal action cannot perform a successful operation and a A doctor can be prosecuted for negligence under criminal law
quivering physician cannot administer the end dose of medicine only if the hazard taken by the him was of such a nature that the
to his patient if his hands are trembling with the fear of facing a injury which resulted was most likely iminent. To prosecute a
criminal prosecution. Discretion being the better part of valour, a medical professional for negligence under criminal law it must be
medical practicner would feel better advised to leave a terminal shown that the doctor did something or failed to do something
patient to his own fate in the case of an emergency where the which in the given facts and circumstances no medical professional
chance of success may be bleak rather than taking the risk of in his ordinary sense and competence would have done or failed
making a last ditch effort towards saving the patient and facing a to do. Many a patients prefer recourse to criminal process as a
criminal prosecution if his effort fails. Such timidity forced upon a tool for pressurizing the medical professional for extracting uncalled
doctor would be a disservice to the society. for or unjust compensation. Such malicious proceeding has to be
guarded against.
However at the same it, it is also true that the medical profession
has, to an extent, become commercialized and there are many Sections 80 and 88 of the Indian Penal Code contain defences for
doctors who depart from their Hippocratic oath for their selfish doctors accused of criminal liability. Under Section 80 (accident in
ends of making money. Thus there is a need to curb such a tendency doing a lawful act) nothing is an offence that is done by accident or
and a doctor indulging in any such mal-practice or acting negligently misfortune and without any criminal intention or knowledge in
need to be held accountable under Civil Law or Consumer the doing of a lawful act in a lawful manner by lawful means and
Protection Act or under Criminal law depending upon the facts of with proper care and caution. According to Section 88, a person
the case. cannot be accused of an offence if he performs an act in good faith
for the other’s benefit, does not intend to cause harm even if there
Professional Negligence: Meaning and Concept is a risk, and the patient has explicitly or implicitly given consent.

Negligence is culpable carelessness - conduct which involves an Standard of Care
unreasonably great risk of causing harm to another. Alderson B.
defined negligence as omission to do something which a reasonable The standard to be applied for judging, whether the person charged
man, guided upon those considerations which ordinarily regulate has been negligent or not, would be that of an ordinary competent
the conduct of human affairs would do, or doing something which person exercising ordinary skill in that profession. The practitioner
a prudent and reasonable man would not do. Negligence excludes must bring to his task a reasonable degree of skill and knowledge
wrongful intention since negligence and wrongful intent are and must exercise a reasonable degree of care. Neither the very
mutually exclusive. The question in every case would be whether highest nor a very low degree of care and competence judged in
the medical practitioner in fact attained the degree of due care the light of the particular circumstances of each case is what the
established by law. law requires.

Negligence is the breach of a legal duty to care. It means carelessness The standard was laid down in Bolam’s case by McNair, J. It was
in a matter in which the law mandates carefulness. Persons who stated that:
offer medical advice and treatment implicitly state that they have
the skill and knowledge to do so, that they have the skill to decide “The test is the standard of the ordinary skilled man exercising and
whether to take a case, to decide the treatment, and to administer professing to have that special skill . . . A man need not possess the
that treatment. A breach of this duty gives a patient the right to highest expert skill; it is well established law that it is sufficient if he
initiate action against doctor for negligence. exercises the ordinary skill of an ordinary competent man exercising
that particular art.”
B-5/3, Safdarjung Enclave
New Delhi-110029 The Bolam test has been followed and approved by various
subsequent judicial pronouncements and has continued to be well
www.dosonline.org received.

37

Standard of Care Applicable to Hospitals the medical profession within the ambit of a ‘service’ as defined in
the Consumer Protection Act, 1986. The Consumer Protection Act
The same standard of care is applicable to hospitals as to individual will not come to the rescue of patients if the service is rendered free
physicians with the difference that the basis of liability of hospitals is of charge, or if they have paid only a nominal registration fee.
based on corporate liability. Also, the hospital will be responsible for
acts of negligence of its staff. This applies equally to nursing staff and However, recently in the case of Martin F. D’Souza Vs. Mohd.
senior doctors who undertake treatment in the hospital. Ishfaq, the Supreme Court has directed all the Forum constituted
under the Consumer Protection Act,1986 and also the ploice not to
Error of Judgement; Whether Negligence issue notice or take cognizance of complaint against a doctor without
first refering the matter to a competent doctor or committee of
The courts have held that no human being is inffaliable and in the doctors, specialized in the field relating to which the medical
present state of science even the most eminent specialist may be at negligence is attributed, and only after that doctor or committee
fault in detecting the true nature of diseased condition. The very reports that there is a prima facie case of medical negligence, should
nature of the profession is such that there may be more than one notice be issued to the concerned doctor/hospital.
course of treatment for a patient and errors in the judgement are a
common practice. As error of judgement doest not of itself amount Doctors - To Do
to negligence. Whether an error of judgement amount to negligence
or not would depend on the naure of error. 1. Always mention the additional precautions to patients and that
too must be in comprehensible terms .
Duties Owed to a Patient:
2. Side affects along with cure of this must be mentioned to patients.
• A duty of care in deciding whether to undertake the case,
3. In case of any deviation from standard care, mention reasons.
• A duty of care in deciding what treatment to give. Mention whether prognosis explained.

• A duty of care in the administration of that treatment. 4. Consultation must be made if not sure of certain symptoms
and disease.
A breach of any of these duties gives a right of action for negligence
to the patient. 5. If after completing the examination the patient/attendant feels
that something has been left out and wants something to be re-
Legal Aspect: examined, oblige him.

The law does not aim to punish all acts of a doctor that caused injury 6. Mention “diagnosis under review” or “under evaluation” until
to a patient. It is concerned only with negligent acts. Medical the diagnosis is finally settled.
negligence arises from an act or omission by a medical practitioner,
which no reasonably competent and careful practitioner would have 7. If the patient/attendants are erring on any count (history not
committed. What is expected of a medical practitioner is ‘reasonably reliable, refusing investigations, refusing admission) make a note
skilful behavior’ adopting the ‘ordinary skills’ and practices of the of it or seek written refusal preferably in local language with
profession with ‘ordinary care’. If a medical practitioner has taken proper witness.
reasonable care, then he cannot be held liable. A mere difference in
opinion, error of judgement, patient not getting cured despite correct 8. Record history of drug allergy, write names of drugs clearly and
treatment and operation not being successful without any negligence mention clear method and interval of administration.
on the part of the surgeon etc. are not grounds for fastening liability
on doctor. 9. Mention likely side effects and action to be taken if they occur.

Civil Law and Negligence: 10. Mention if patient/attendant is under effect of alcohol/drugs.

No human being is perfect and even the most renowned specialist 11. If you are not sure what disease the patient has after a thorough
could make a mistake in detecting or diagnosing the true nature of a workup, get a consultation.
disease. Doctors must exercise an ordinary degree of skill. However,
they cannot give a warranty of the perfection of their skill or a 12. Develop a list of physicians you trust and respect in each of the
guarantee of cure. If the doctor has adopted the right course of specialties. Nurture your relationship with them and consult
treatment, if he is skilled and has worked with a method and manner them about difficult cases.
best suited to the patient, he cannot be blamed for negligence even
if the patient is not totally cured. If a doctor has adopted a practice 13. Whenever referring a patient provide him with a referring note.
that is considered “proper” by a reasonable body of medical In case of emergency, wring up the concerned doctor in the
professionals who are skilled in that particular field, he or she will patient’s presence. Show your concern.
not be held negligent only because something went wrong.
14. Always keep with you and refer the latest edition of the standard
Liability Under the Consumer Protection Act: textbook of your branch of medicine.

The Consumer Protection Act, 1986 is a legislation which has speedy 15. Always subscribe to one standard journal and participate in at
justice as one of its objectives. Medical practitioners from all fields of least two updates/conferences every year.
medicine such as Allopathic, Homeopathy, and Naturopathy can be
liable under the Consumer Protection Act. In 1995, the Supreme 16. Update not only your knowledge and skill but also that of your
Court decision in Indian Medical Association v. V.P. Shantha2 brought staff.

17. Update the facilities and equipments according to prevailing
current standards in your area.

38 DOS Times - Vol. 14, No. 9, March 2009

18. Always obtain a legally valid consent before undertaking a • Duty of care in deciding whether to undertake the case
surgical/diagnostic procedure.
• Duty of care in deciding what treatment to give
19. In case of MTP/Sterilization, always follow the guidelines
issued by the Government of India. • Duty of care in the administration of that treatment

20. In complex medical situation, a doctor would be expected to • In case of injured persons brought for medical treatment he
conduct more frequent and more extensive examination with should instantaneously be given medical aid and thereafter
all ancillary assistance. procedural criminal law should be allowed to operate as there
is no legal impediment to doctors to attend to such cases
21. In all instances of ‘swab cases’ and ‘instrumental cases’, the immediately.
surgeon in-charge is generally held directly or vicariously liable
for negligence, so he must personally ensure everything to Rights
escape the liability.
• Right to refuse to take the case
22. The period for the responsibility of the surgeon extends to
and includes the post operative care. He must, therefore, • Right to be reimbursed for services
ensure proper post-operative care to the patient.
• Right to withhold information
23. In case of death of the patient, police or hospital authorities
must be informed without the loss of time so as to take it with • Right to retain medical documents
autopsy and post-mortem.
• Right to reputation
24. A proper legal and medical advice must be made before
sending reply to the notice sent by the patient or his Preventive Steps for Doctors to Avoid Litigation
representative or to the complaint referred to you from a
consumer court/civil court/criminal court. Primary Prevention

25. In case the hospital/clinic claims to provide 24 hours emergency 1. Human element in medical care determines the patient’s/
service, availability of necessary equipments in working order attendant’s reaction to an untoward event. Tactless
and competent staff within reasonable time is mandatory. handling, trivial indignations or unpleasant remarks are the
causes of large number of legal actions brought against doctors
Doctors- Don’t Do and hospitals.

1. Prescription should never be made without examining the 2. Behavior of entire system including receptionist, junior staff,
patient and shouldn’t assume the words of patient to be true. cleaners etc., should be continuously monitored specially in a
stressful circumstances.
2. Don’t refuse if the patient/attendants want to leave against
medical advice as its their right. 3. Commercial behavior should be discouraged. All the queries
of the patient should be answered without minding their
3. Don’t refuse the patient’s right to know about diagnosis and repeated questioning.
treatment of his illness.
4. Doctor should not be averse to any suggestion of seeking a
4. Don’t refuse first-aid/medical care to accidents and emergency second opinion.
cases even if it is a medico-legal cases.
5. Doctors who are open minded and communicative are much
5. Don’t smoke while examining the patient. less likely to be complained against as patients are generally
forgiving of errors made by a friendly and concerned medical
6. Don’t examine a patient when you are sick, exhausted or professional.
under influence of alcohol or under any intoxicating substance.
7. Risk should be discussed and family of the patient should be
7. Don’t operate on both eyes simultaneously unless there is made aware of the possible outcome of diagnostic and
real, documented emergency. treatment efforts.

8. In case of an elective surgery on both eyes simultaneously, be 8. Adopting attitude and body language of respect, care and
extra cautious and get all pre-operative work-up done and concern is important.
record it.
9. Big nursing homes and hospitals should constitute grievance
9. Don’t perform radial keratotomy on a teenager or in cases redressal cells.
who have unstable myopia.
Secondary Prevention
10. When you are not sure what and why to do, consult your
senior/specialist/colleague. Second prevention constitutes

11. Never talk loose of your colleagues, despite intense (I) Proper documentation
professional rivalry. Never criticize your brother in profession.
Proper documentation of date, time and history, investigations,
Rights and Duties of Doctor treatment and instructions to the staff and patient is necessary.The
gravity of the condition of the patient should neither be exaggerated
Duties
39
www.dosonline.org

nor minimised. is absolutely necessary to carry out sterilization of instruments,
cotton, pads, linen, etc., and the damage occurred because of its
(II) Preservation and supply of records absence in working condition. The doctors were held liable.

Medical record pertaining to indoor patients should be maintained If a risk is known to occur commonly and the same is not explained
for three years from the commencement of the treatment so that before taking consent would constitute negligence. For example, a
the same can be used in case of case filed in the Court. In case of person who has been blind in one eye for many years is offered an
request the medical record are required to be supplied within 72 operation in hope of restoring some degree of vision should be
hours. warned of one in fourteen thousand chance of sympathetic opthalmia
developing in other eye, which could render him blind in both eyes.
(III) Legally valid consent
Adverse reaction of a medicine in itself would not constitute
Consent plays a remarkable legitimate role in the field of negligence. negligence as response of the patient to the medicine differs from
However, the consent should be free, without any undue influence person to person but if the doctor has failed to take all necessary
or pressure and obtained from a person above the age of 18 years. precautions excepted from reasonably prudent doctor like asking
Consent should be obtained after providing adequate information for history of allergy, performing sensitivity test, etc., it may amount
and should be in a language understood by the person giving consent. to negligence.

Third Prevention Harm/damage occurring following a telephonic advice would
constitute negligence and practice of giving medical advice on
Professional indemnity insurance telephone should be avoided.

To meet the claim of compensation which may be awarded against a Conclusion
doctor for medical negligence also called deficiency in service under
the Consumer Protection Act, it has now become essentially for It is important to understand that besides the travails of doctors,
every doctor to obtain a professional indemnity insurance cover medico-legal cases are not beneficial to patients or his family either.
from any recognized insurance company. In only a slender five per cent cases, the complainants walk away
with handsome compensation. But more than that, the surge of
Fourth Prevention medico-legal cases has engendered defensive medicine - a practice
whereby doctors order medical tests or procedures of doubtful
Forming medical defense societies and strong peer support to clinical value to protect themselves from malpractice suits. Such
effectively contest legal cases. practice needs to be discouraged as the standard of care also applies
to defensive medicine.
Some Instances of Negligence/Deficiency in Service

Failure to write prescription legibly may amount to negligence/
deficiency in service.

Failure to have equipment such as oxygen cylinder, suction machine,
insulator/ventilator, etc., in working order will constitute negligence.
Current practices, infrastructure, paramedical and other staff,
hygiene and sterility should be observed strictly. Thus, in Sarwat Ali
Khan vs. Prof. R. Gogi and others Original Petition No.181 of 1997,
decided on 18.7.2007 by the National Consumer Commission, the
facts were that out of 52 cataract operations performed between
26th and 28th September, 1995 in an eye hospital 14 persons lost their
vision in the operated eye. An enquiry revealed that in the Operation
Theatre two autoclaves were not working properly. This equipment

40 DOS Times - Vol. 14, No. 9, March 2009

Forthcoming Events : National

March 2009 October 2009
20-22 NEW DELHI
2-4 BHAVNAGAR, GUJARAT
Annual Conference of
Delhi Ophthalmological Society 37th Annual Gujarat Ophthalmological Conference
Contact Person & Address Vision-2009
Dr. Namrata Sharma Contact Person & Address
Room No. 474, 4th Floor, Dr. Nilesh Parekh
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, 22, ‘VINAY’ Behind Central Salt, Opp. New Filter Tank,
All India Institute of Medical Sciences, Bhavnagar-364002
Ansari Nagar, New Delhi – 110029 Mobile : +09428408788, Fax : +91-0278-2566388
Ph.: 011-65705229, Fax: 26588919, Email : [email protected]
E-mail: [email protected], Website: www.dosonline.org Website : http://www.iirsi.com

July 2009
20-22 CHENNAI

Indian Intraocular Implant & Refractive
Surgery Convention
Hotel Taj Coromandel, Chennai
Tel : +91-44-2811 2811 Fax : +91-44-2811 5871
Email : [email protected]
Website : http://www.iirsi.com

Forthcoming Events : International

March, 2009 16-19 INDONESIA

17-22 CHICAGO Asia Pacific Academy of Ophthalmology (APAO)
Indonesian Ophthalmologists Association (IOA)
Illinois Eye Review Department of Ophthalmology
Chicago, Illinois, United States Faculty of Medicine, Universitas Indonesia,
Contact Name: Cindy Jalan Salemba Raya No. 6, Jakarta - 10430, Indonesia
Phone: 312.996.6590 Fax: 312.996.7770 Phone : (62-21) 3190 7282, Fax : (62-21) 392 7516
Email: [email protected] E-mail : [email protected]
Web Site: http://www.IllinoisEyeReview.org

April, 2009 June, 2009

4-8 SAN FRANCISCO, CA, USA 13-16 NETHERLANDS

ASCRS/ASOA Symposium and Congress SOE 2009, 17th Congress of the European Society
Francisco, USA of Ophthalmology,
Phone: 701 591 2220 / Fax: 1703 591 0614 Contact: Congrex Sweden AB
Web Site: http://www.ascrs.org Attn: SOE 2009, P.O. Box 5619
SE-114 86 Stockholm, Sweden
16-18 GENEVA, SWITZERLAND Tel: +46 8 459 66 00, Fax: +46 8 661 91 25
E-mail: [email protected]
4th International Congress on Glaucoma Surgery
Organising Secretariat September, 2009
O.I.C. Srl - Organizzazione Internazionale Congressi
Viale Matteotti, 7 - 50121 Firenze, Italy 12-16 BARCELONA, SPAIN
Phone: 39/055/50351, Fax: 39/055/5001912
E-mail: [email protected] XXVII Congress of the ESCRS
Phone: +35312091100, Fax: 35312091112
Email: [email protected], Web Site: http://www.escrs.org

May, 2009

3-7 FLORIDA

Greater Fort Lauderdale/Broward County
Convention Center
1950, Eisenhower Blvd.,
Fort Lauderdale, Florida - 33316
Phone: 1.240.221.2900, Email: [email protected]

www.dosonline.org 43

Delhi Ophthalmological Society

(LIFE MEMBERSHIP FORM)

Name (In Block Letters) ___________________________________________________________________________
S/D/W/o _____________________________________________________________ Date of Birth _____________
Qualifications __________________________________________________________ Registration No. __________
Sub Speciality (if any) ____________________________________________________________________________
ADDRESS

Clinic/Hospital/Practice _______________________________________________________________________
________________________________________________________________ Phone __________________
Residence _________________________________________________________________________________
________________________________________________________________ Phone __________________
Correspondence ____________________________________________________________________________
________________________________________________________________ Phone __________________
Email ___________________________________________________________ Fax No. _________________
Proposed by
Dr. _____________________________________ Membership No. ________ Signature ___________________
Seconded by
Dr. _____________________________________ Membership No. ________ Signature ___________________
[Must submit a photocopy of the MBBS/MD/DO & 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
Regulations of the Society.
(Please Note : Life membership fee Rs. 3100/- payable by DD for outstation members. Local Cheques acceptable, payable
to Delhi Ophthalmological Society)
Please find enclosed Rs.___________in words ____________________________________________________ by Cash
Cheque/DD No.____________________ Dated_____________ Drawn on______________________________________

Three specimen signatures for I.D. Card. Signature of Applicant
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)

wwwwww.d.odososonlninlien.eo.orgrg 45

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. Namrata Sharma,
Secretary, Delhi Ophthalmological Society, R.No. 474, 4th Floor, Dr. R.P. Centre for Ophthalmic Sciences, AIIMS, 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.

46 DDOOSSTTiimmeess --VVooll.. 1144,, NNoo. 98, MFeabrrcuhar2y0029009

DOS Credit Rating System Report Card 49
(July, 2008 - March, 2009)

DCRS July 2008 – Dr. R.P. Centre for Ophthalmic Sciences

Total No. of Delegates as per Attendance Register ........................................................................................................... 209
Total No. of form received from Delegates .......................................................................................................................... 147
Delegates from Out side (N) ................................................................................................................................................ 100
Delegates from Dr. R.P. Centre for Ophthalmic Sciences (n) .............................................................................................. 39
Overall assessment by outside delegates (M) ................................................................................................................... 767
Assessment of case presentation-I (Dr. Rachna Meel) by outside delegates ................................................................ 679
Assessment of case presentation-II (Dr. Prashant Naithani) by outside delegates ....................................................... 750
Assessment of clinical talk (Prof. Rajvardhan Azad) by outside delegates ...................................................................... 727
Cancelled Forms ....................................................................................................................................................................... 7

DCRS August 2008 – Venu Eye Institute & Research Centre

Total No. of Delegates as per Attendance Register ............................................................................................................. 95
Total No. of form received from Delegates ......................................................................................................................... 71
Delegates from Out side (N) .................................................................................................................................................. 48
Delegates from Venu Eye Institute & Research Centre (n) .................................................................................................. 22
Overall assessment by outside delegates (M) ................................................................................................................ 368.5
Assessment of case presentation-I (Dr. Archana Sood) by outside delegates ............................................................... 317
Assessment of case presentation-II (Dr. Aditi Agarwal) by outside delegates ................................................................. 334
Assessment of Clinical Talk (Dr. Ramendra Bakshi) by outside delegates ................................................................. 358.5
Cancelled Forms ....................................................................................................................................................................... 1

DCRS September 2008 – Army Hospital (R&R)

Total No. of Delegates as per Attendance Register ........................................................................................................... 138
Total No. of form received from Delegates .......................................................................................................................... 100
Delegates from Out side (N) .................................................................................................................................................. 91
Delegates from Army Hospital (R&R) (n) ................................................................................................................................ 5
Overall assessment by outside delegates (M) ................................................................................................................... 677
Assessment of case presentation-I (Dr. S.K. Dhar) by outside delegates .................................................................... 524.5
Assessment of case presentation-II (Dr. Jaya Kaushik) by outside delegates ............................................................... 597
Assessment of Clinical Talk (Dr. J.K.S. Parihar) by outside delegates ............................................................................ 654
Cancelled Forms ....................................................................................................................................................................... 4

DCRS October 2008 – Sir Ganga Ram Hospital

Total No. of Delegates as per Attendance Register ........................................................................................................... 100
Total No. of form received from Delegates ............................................................................................................................ 77
Delegates from Out side (N) .................................................................................................................................................. 69
Delegates from Sir Ganga Ram Hospital (n) ......................................................................................................................... 6
Overall assessment by outside delegates (M) ................................................................................................................ 537.5
Assessment of case presentation-I (Dr. Nayanshi Sood) by outside delegates ............................................................. 292
Assessment of case presentation-II (Dr. Nidhi Tanwar) by outside delegates ............................................................. 420.5
Assessment of Clinical Talk (Dr. S. N. Jha) by outside delegates .................................................................................... 470
Cancelled Forms ....................................................................................................................................................................... 2

DCRS November 2008 – Centre for Sight

Total No. of Delegates as per Attendance Register ............................................................................................................. 83
Total No. of form received from Delegates ............................................................................................................................ 71
Delegates from Out side (N) .................................................................................................................................................. 64
Delegates from Centre for Sight (n) ......................................................................................................................................... 6
Overall assessment by outside delegates (M) ................................................................................................................... 517
Assessment of case presentation-I (Dr. Madhu Karna by outside delegates ................................................................. 351
Assessment of case presentation-II (Dr. Vikas Menon) by outside delegates ................................................................ 389
Assessment of Clinical Talk (Dr. Mahipal S. Sachdev ) by outside delegates ................................................................. 536
Cancelled Forms ....................................................................................................................................................................... 1

www.dosonline.org

DCRS December 2008 – Mohan Eye Insitute

Total No. of Delegates as per Attendance Register ............................................................................................................. 94
Total No. of form received from Delegates ............................................................................................................................ 81
Delegates from Out side (N) .................................................................................................................................................. 70
Delegates from Mohan Eye Insitute (n) ................................................................................................................................. 11
Overall assessment by outside delegates (M) ................................................................................................................... 524
Assessment of case presentation-I (Dr. Shalini Kumari) by outside delegates ........................................................... 278.5
Assessment of case presentation-II (Dr. Parul Lokwani) by outside delegates .............................................................. 364
Assessment of Clinical Talk (Dr. Lalit Choudhary) by outside delegates ............................................ Not to be evaluated
Cancelled Forms ....................................................................................................................................................................... 0

DCRS January 2009 – Dr. Shroff’s Charity Eye Hospital

Total No. of Delegates as per Attendance Register ............................................................................................................. 86
Total No. of form received from Delegates ............................................................................................................................ 70
Delegates from Out side (N) .................................................................................................................................................. 55
Delegates from Dr. Shroff’s Charity Eye Hospital (n) ........................................................................................................... 15
Overall assessment by outside delegates (M) ................................................................................................................... 449
Assessment of case presentation-I (Dr. Julie Pegu) by outside delegates ..................................................................... 393
Assessment of case presentation-II (Dr. Ritesh Narula) by outside delegates ........................................................... 420.5
Assessment of Clinical Talk (Dr. Cyrus Shroff) by outside delegates ............................................................................ 455.5
Cancelled Forms ....................................................................................................................................................................... 1

DCRS Febuary, 2009 – Guru Nanak Eye Centre

Total No. of Delegates as per Attendance Register ........................................................................................................... 117
Total No. of form received from Delegates ............................................................................................................................ 90
Delegates from Out side (N) .................................................................................................................................................. 65
Delegates from Guru Nanak Eye Centre (n) ......................................................................................................................... 23
Overall assessment by outside delegates (M) ................................................................................................................ 516.5
Assessment of case presentation-I (Dr. Lanalyn) by outside delegates ....................................................................... 356.5
Assessment of case presentation-II (Dr. Monika) by outside delegates ....................................................................... 391.5
Assessment of Clinical Talk (Dr.Meenakshi Thakar) by outside delegates .................................................................. 451.5
Cancelled Forms ....................................................................................................................................................................... 3

DCRS March, 2009 – Bharti Eye Hospital

Total No. of Delegates as per Attendance Register ............................................................................................................. 84
Total No. of form received from Delegates ............................................................................................................................ 68
Delegates from Out side (N) .................................................................................................................................................. 60
Delegates from Bharti Eye Hospital (n) ................................................................................................................................... 5
Overall assessment by outside delegates (M) ................................................................................................................ 475.5
Assessment of case presentation-I (Dr. S. Zafar) by outside delegates .......................................................................... 354
Assessment of case presentation-II (Dr. Deven Tuli) by outside delegates ................................................................. 403.5
Assessment of Clinical Talk (Dr. Neeraj Wadhwa) by outside delegates ..................................................................... 430.2
Cancelled Forms ....................................................................................................................................................................... 3

50 DOS Times - Vol. 14, No. 9, March 2009

DOS Credit Rating System (DCRS)

DOS has always been in the forefront of efforts to ensure In a bid to strengthen our efforts in this direction DOS had
that its members remain abreast with the latest developments DOS Credit Rating System (DCRS), the details of which are
in Ophthalmology. Among the important objectives given below. Our Primary objective is to promote value-
formulated by the founders of our constitution was the based knowledge and skills in Ophthalmology for our
cultivation and promotion of the Science of Ophthalmology members and give recognition and credit for efforts made
in Delhi. by individual members to achieve standards of academic
excellence in Ophthalmic Practice.
The rapid strides in skills and knowledge have created a need
for an extremely intensive Continuing Medical Education
programme.

DOS CREDIT RATING SYSTEM (DCRS) Max.

DCRS

1) Attending Monthly Clinical Meeting* † (For full attendence) 10 90

2) Making Case Presentation at Monthly Meeting** 10 10

3) Delivering a Clinical Talk at Monthly Meeting** 10 10

4) Free Paper Presentation at Annual Conference (To Presenter)** 10 20

5) Speaker/Instructor** in : Monthly Symposium 10 10

: Mid Term Symposium 15 10

: Annual Conference 15 30

6) Registered Delegate at Mid Term DOS Conference 10 10

7) Registered Delegate at Annual DOS Conference 10 10

8) Full Article publication in Delhi Journal of Ophthalmology/DOS Times 15 45

9) Letter to editor in DOS Times 5 10

10) Letter to editor in DJO 5 10

11) > 3 Bonus points for Monthy Clinical Meeting: 10 bonus points ——
12) > 5 Bonus points for Monthy Clinical Meeting: 30 bonus points ——
13) All Monthly Clinical Meeting: 50 Bonus Points ——

——————————————————————————————————————————————

If any of the presentations is given an Award – * Based on Signature in DCAC
Additional 20 bonus Credits. ** Subject to Submission of Full Text to Secretary, DOS
Member who have earned 100 Credits, are entitled † Credits will be reduced in case attendance is only for part
a) Certificate of Academic Excellence in Ophthalmic
b) Eligible for DOSTravel fellowship for attending conference. of the meeting.

If any member earns 200 Credits, he/she shall, in addition to DCRS !! Attention !!
above, be awarded Certificate of Distinguished Resource-
Teacher of the Society. * Members are requited to sign on monthly meeting
attendance register and put their membership number.
Institutional assessment for best performance will be based
on the total score of members who attend divided by num- * The DCRS paper will be issued only after the valid
ber of members who attended. Institutional assessment re- signature of the member in the attendance register.
garding decision to retain the institute for the next year will
be based on total score. * Please submit your DCRS papers to the designated DOS
Staff only.
Please note that the Institutions’ grading increases if the at-
tendance at its meeting is higher (i.e. more than the average * The collected DCRS papers will be countersigned by
attendance of the eight monthly meetings). President and Secretary and sealed immediately after the
meeting is over.

www.dosonline.org 51

DOS Quiz Columns

Anagram Time

Each of the following words is a jumbled ophthalmic or related term. There is, however, an extra letter in every set of letters. These
extra letters will also form a five letter ophthalmic word when unjumbled.

So get cracking.

1. OPTINEARS ___ ___ ___ ___ ___ ___ ___ ___ ____

2. GOCCILARVY ___ ___ ___ ___ ___ ___ ___ ___ ___ ____

3. BRAVEBUMZCAI ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ____

4. FIXMIXCOOLDNA ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ____

5. AAZULMEEDACOIT ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ____

Saurabh Sawhney DO, DNB Ashima Aggarwal MS, DNB
Insight Eye Clinic, New Delhi

Answers on page number 16

ICARE Eye Hospital & PG Shri Swami Anant Parkashanand Memorial
Institute invites Consultant Dharmarth Eye Hospital, Kurukshetra

Ophthalmologists for the 1. Wanted Ophthalmologists well
Subspecialties of Pediatrics, versed in Phacoemulsification for
Oculoplasty, Vitreo-Retina, Cornea & well equipped with advanced
Refractive Surgery, Glaucoma. Work technology & well established grand
experience preferred. hospital.
Contact: ICARE Eye Hospital.
9811357232, [email protected] 2. Handsome salary (negotiable) with
rent free accommodation within
wwwww.dwo.dsonsolinelin.oer.gorg premises.

3. Contact telephonically or personally
within a week on following address:-

Shri Swami Anant Parkashanand
Memorial Dharmarth Eye Hospital,
Rajendra Nagar, Kurukshetra – 136118

Contact No. 01744-292800

Mobile No. 09896660755

5353