Editor-in-chief Editorial Capsule Practice Requisites
3 World of Ophthalmic 47 Intraoperative Wavefront
M. Vanathi Conferences Aberrometry - New Paradigm
Towards Achieving Near
Section Editors Featuring Sections Perfection in Cataract Surgery
Cataract & Refractive Retina & Uvea
Cataract Monthly Meeting Korner
Umang Mathur Pradeep Venketesh 9 Multifocal and Accommodative 55 Ocular Reconstruction in a
Saurabh Sawhney Parijat Chandra Intraocular Lens Implantation Severe Dog Bite
in Children 57 Eyelid Margin Basal Cell
Sanjiv Mohan Manisha Aggarwal Carcinoma Management in a
S. Khokhar Shahana Majumdhar Cornea Background of Leser Trelat
15 Techniques of Collagen Syndrome
Cornea & Oular Surface Rohan Chawla Cross-linking in Thin
Uma Sridhar Ravi Bypareddy Corneas: An Update Clinical Spotlight Cornea
Deepa Gupta Ophthalmoplasty & 19 Descemet Membrane 61 Intraoperative OCT in
Endothelial Keratoplasty Anterior Segment Imaging–
Umang Mathur Ocular Oncology (DMEK) Present and Future
Ramendra Bakshi Neelam Pushker
Manisha Acharya Maya Hada Ocular Surface Eye Banking
25 Uses of Amniotic Membrane in 65 Donor Corneal Tissue
Noopur Gupta Sangeeta Abrol Cornea Practice Evaluation
Glaucoma Rachna Meel
Glaucoma DOS TIMES Quiz
Dewang Angmo Squint & 29 Practical Protocols in 71 QUIZ - Episode 3
Reena Sharma Neuro-ophthalmology Glaucoma Management
Sunita Dubey Digvijay Singh
Viney Gupta Zia Chaudhuri Ocular Oncology DOS Crossword
Kanak Tyagi Suma Ganesh 35 Intra-arterial Chemotherapy 73 DOS CROSSWORD-
Delhi Advisory Board for Retinoblastoma: Episode 3
Y.R. Sharma Mahipal Sachdev International Perspective
Atul Kumar Radhika Tandon Quick Picks
P.V. Chadha Jolly Rohtagi Diagnostics Discussion 75 Thyroid Eye Disease
39 Use of ASOCT in Keratitis
Noshir M. Shroff J.C. Das Correspondence Portal
Rajendra Khanna B.P. Gulliani Snapshot 77 Undesirable Systemic Effects
41 Nevus of Ota- Case Report of Cyclopentolate
Vimla Menon Ritu Arora
H.K. Yaduvanshi Kamlesh Innovations News Watch
45 Innovative Surgical Technique 83 DESK – I : Oculoplastics
Anita Panda G.K. Das Fornix Formation using a 85 NEB Eye Donation
Pradeep Sharma Lalit Verma Flexi Symblepharon Ring Fortnight Celebrations
Ramanjit Sihota Tanuj Dada
www. dos-times.org 1
Harish Gandhi Abhishek Dagar
Anup Goswami Sarita Beri
Rajpal P.K. Sahu
Mandeep Bajaj Kamlesh
B. Ghosh Taru Dewan
Rajiv Garg H.S. Sethi
R.B. Jain H.K. Tewari
National Advisory Board
R.D. Ravindran Barun Nayak
Debashish Bhattacharya Venketesh Prajna
R. Revathi S. Natarajan
Yogesh Shah Amod Gupta
Arup Charaborti Jagat Ram
Anita Raghavan Amar Agarwal
Chandna Chakraborti Mangat Ram Dogra
Sushmita Shah D. Ramamurthy
Sushmita Kaushik T.P. Lahane
Pravin Vadavalli Samar Basak
Somshiela Murthy Cyrus Mehta
Sri Ganesh Mahesh Shanmugam
M.S. Ravindra J. Biswas
Rohit Shetty Srinivas Rao
Mallika Goyal Nikhil Gokale
Partha Biswas Santosh Honavar
Nirmal Frederick Arulmozhi Varman
Abhay Vasavada Mohan Rajan
Mukesh Taneja Rakhi Kusumesh
Shalini Mohan Gopal S. Pillai
Ragini Parekh Subendu Boral
Tejas Shah Gunjan Prakash
Sujith Vengayil Pravin More
M. Kumaran Sajjad Ahmed Shiekh
Punith Kumar Santhan Gopal
Elankumaran
DOS Correspondents
Anita Ganger Dewang Angmo
Rebika Dhiman Shikha Yadav
Manish Mahabir Manu Saini
Raghav Ravani Meenakshi Wadwani
Sridevi Mayank Bansal
Saranya
DOS TIMES
Editorial Assistance & Layout: SUNIL KUMAR
Printer: New Pusphak Printers
Cover Design: Aman Dua
DOS Times will hitherto be published once every two months by Dr. M.
Vanathi, on behalf of Delhi Ophthalmological Society, DOS Secretariat,
Dr. R.P. Centre, AIIMS, New Delhi. All solicited & unsolicited manuscripts
submitted to DOS TIMES are subject to editorial review before acceptance.
DOS TIMES is not responsible for the statements made by the contributors.
All advertising material is expected to conform to ethical standards and
acceptance does not imply endorsement by DOS TIMES. ISSN 0972-0723
DOS EXECUTIVE MEMBERS
Executive Committee:
ϐ
Dr. Cyrus M. Shroff Dr. Rishi Mohan Dr. M. Vanathi
President Vice President General Secretary
Dr. Arun Baweja Dr. Vipul Nayar Dr. Ruchi Goel Dr. Devn Tuli
Joint Secretary Treasurer Editor ϐ
DOS Representative to AIOS
Executive Members
Dr. Jatinder Singh Bhalla Dr. Bhuvan Chanana Dr. Anshul Goyal Dr. Avnindra Gupta Dr. Ajay Aurora
Dr. Rajat Jain Dr. Deepankur Mahajan Dr. J. K.S. Parihar Dr. Manavdeep Singh Dr. Namrata Sharma
Ǧ ϐ
Dr. Rajendra Khanna Dr. Rajesh Sinha Dr. Sanjeev Gupta
Ex-President Ex-Secretary Ex-Treasurer
DOS HALL OF FAME Tejpal Saini B. Pattnaik DOS General Secretaries
DOS PRESIDENTS Satish Sabharwal Satinder Sabharwal
A.K. Grover Hari Mohan Arun Sangal
S.N. Mitter A.C. Chadha N.C. Singhal J.C. Das R.S. Garkal R.V. Azad
H.S. Trehan M.S. Boparai Madan Mohan Gurbax Singh S.R.K. Malik B. Ghosh
Tej Pal Saini N.N. Sood Pratap Narain Noshir M. Shroff Madan Mohan Mahipal Sachdev
L.P. Agarwal P.K. Jain (Brig.) R.C. Sharma Mahipal S. Sachdev J.C. Bhutani Atul Kumar
D.C. Bhutani L.D. Sota Lalit Verma S.C. Sabharwal Lalit Verma
R.C. Aggarwal L.D. Sota B.N. Khanna S. Bharti A.C. Chadha Dinesh Talwar
S.K. Angra R.N. Sabharwal Sharad Lakhotia Pratap Narain Harsh Kumar
S.N. Kaul D.K. Mehta P.V. Chadha S.K. Angra J S. Titiyal
S.N. Kaul Y. Dayal N.L. Bajaj B.P. Guliani G. Mukherjee Harbansh Lal
H.S. Trehan K.P.S. Malik Mathew M. Krishna Harbansh Lal H.K. Tewari Namrata Sharma
Hari Mohan R.B. Jain J S. Titiyal Amit Khosla
R.S. Garkal G. Mukherjee Prem Prakash Rajendra Khanna R. Kalsi Rohit Saxena
J.C. Bhutani R.V. Azad D.K. Sen Cyrus Shroff D.K. Mehta Rajesh Sinha
S.R.K. Malik P.C. Bhatia M. Vanathi
P.K. Khosla K.P.S. Malik
K. Lall
A.K. Gupta
Sincere thanks to all DOS OFFICE STAFF : ϐ
ǣ Parveen Kumar DOS Accountant: Sandeep Kumar DOS TIMES Assistant: Sunil Kumar
DJO Assistant: Varun Kumar Library Attendant: Niyaj Ahmad ϐ
ǣ Harshpal
2 DOS TIMES - NOVEMBER-DECEMBER 2015
EDITORIAL CAPSULE
ORLD OF PHTHALMIC ONFERENCES
Greatness is not where we stand…but in the direction we are moving…
Ȇ
Dear Members
I am indeed amazed at the amount of enthusiasm and capability of
Ǥ ϐ
ϐ
string of conferences over the last few weeks is indicative of the fact that
the thirst for knowledge never dies. When one knows better, one performs
better. Learning does not happen by chance. One has to seek out knowledge
diligently and apply the learned message in practice to make the mark; to
show the difference.
We at Delhi Ophthalmological Society are yet again on the portal of Dr. M.Vanathi
ϐ
Ǥ
ʹͲͳͷ
ϐ
now. It promises an assembly of interesting discussions wrapped in an interactive package to reach out with ever
increasing appeal to our ophthalmic audience. We welcome all our young ophthalmologists to participate actively
by presenting their academic work as POSTERS and VIDEOS. We have also opened up the more interesting section
of OPHTHALMIC PHOTOGRAPHY to all, thus encouraging private practioners as well to share their interesting
experiences through this ophthalmic photography presentation. We look forward to displaying the award winning
entries in our next issue of DOS TIMES.
This winter midterm meeting also promises the introduction of new sections of Innovations, video based
presentations and case based discussions. The forthcoming new section holds the promise of ophthalmic
entertainment at its ever best. We at DOS await to welcome you all wholeheartedly to a whole new experience
in the world of Ophthalmic Conferences. Lo! Come…. Behold …. and relish the richness of Ophthalmic Learning..
On the closing note, this issue of DOS Times brings to you lots of facts in anterior segment practice including
collagen crosslinking, amniotic membrane transplantation, AS-OCT, intraoperative anteriorsegment imaging,
Ǥ ϐ
assembly of article in this issue useful and look forward to your continued patronage in all our academic activities.
Dr. M.Vanathi MD
Additional Prof. of Ophthalmology
Cornea, Cataract & Refractive Services
Dr. R.P. Centre for Ophthalmic Sciences
All India Institute of Medical Sciences
New Delhi-110029, India
[email protected]
www. dos-times.org 3
'HDU &ROOHDJXHV DQG )ULHQGV
2Q %HKDOI RI WKH ([HFXWLYH &RPPLWWHH RI 'HOKL 2SKWKDOPRORJLFDO 6RFLHW\ LW JLYHV XV JUHDW SOHDVXUH WR LQYLWH \RX WR WKH :LQWHU &RQIHUHQFH RI 'HOKL
2SKWKDOPRORJLFDO 6RFLHW\ '26 WR EH KHOG RQ 'HFHPEHU ² LQ 0DQHNVKDZ &HQWUH 'HOKL &DQWW 1HZ 'HOKL :,17(5 '26
2SKWKDOPLF 5HQGH]YRXV DLPV WR EULQJ WRJHWKHU HPLQHQW VSHDNHUV DQG GHOHJDWHV IURP DOO RYHU ,QGLD WR VKDUH WKH ODWHVW LQ WKH &XUUHQW &RQFHSWV LQ DOO
IDFHWV RI RSKWKDOPRORJ\ 1HZ ,QWURGXFWLRQV ZLOO LQFOXGH WKH SK\VLFDO 3RVWHU 6HVVLRQV WKH FRPSHWLWLYH VHVVLRQ LQ 2SKWKDOPLF 3KRWRJUDSK\ DQG DQ
H[FLWLQJ 1HZ 6SHFLDO 6HVVLRQ :H DOVR KRSH WR FDSWLYDWH \RXU LQWHUHVW ZLWK DQ DFDGHPLF H[WUDYDJDQ]D RI OLYH VXUJHU\ VHVVLRQV ZHW ODEV
LQQRYDWLRQV \RXQJ RSKWKDOPRORJLVWV YLGHR VHVVLRQV DQG PDVWHUFODVV VHVVLRQV
1HZ 'HOKL LV D YLEUDQW FLW\ RI FRORXUV DQG FKDUP ZLWK D GHHS KLVWRULFDO DQG FXOWXUDO KHULWDJH ,W SURYLGHV DQ DPD]LQJ DUHQD RI VRFLDO HYHQWV ZKLFK
IXUWKHU PDNH WKH SOHDVDQW 'HOKL ZLQWHU PRUH HQMR\DEOH
:H DUH FRQÀGHQW WKDW WKLV '26 :,17(5 &21)(5(1&( ZLOO SURYLGH PXFK WR VHH OHDUQ DQG WDNH DZD\ DV ORQJ ODVWLQJ PHPRULHV :H XUJH \RX
WR VWHS LQ WR VKDUH RXU RSKWKDOPLF H[SHULHQFHV WR UHOLVK WKH SRWHQWLDO RI WKH ,QGLDQ 2SKWKDOPLF ,QGXVWU\ FKHULVK WKH ULFKQHVV RI RXU DFDGHPLF
H[WUDYDJDQ]D DQG WR MRLQ LQ WKH LQWHUDFWLYH OLYHO\ DXGLHQFH SROO LQ RXU IRUWKFRPLQJ 1HZ 6HVVLRQ
'U &\UXV 6KURII 'U 0 9DQDWKL
3UHVLGHQW *HQHUDO 6HFUHWDU\
5(*,675$7,21 '(7$,/6
&DWHJRU\ 7LOO WK 2FW 7LOO WK 1RY 7LOO WK 1RY 2Q 6SRW
,15 ,15
'26 0(0%(56
0HPEHU 'HOHJDWH ,15 ,15
0HPEHU 5HVLGHQW
,15 ,15 ,15 ,15
121 0(0%(56 ,15 ,15 ,15 ,15
1RQ 0HPEHU 2SKWKDOPRORJLVW
5HVLGHQW 7UDLQHHV LQ 2SKWKDOPRORJ\ ,15 ,15 ,15 ,15
2SWRPHWULVW ,15 ,15 ,15 ,15
6SRXVH &KLOG ,15 ,15 ,15 ,15
7UDGH 'HOHJDWH ,15 ,15 ,15 ,15
3$67 35(6,'(17 6(1,25 &,7,=(1 ! <($56 &RPSOLPHQWDU\
3DVW 3UHVLGHQW '26 RU $,26 &RPSOLPHQWDU\
6HQLRU &LWL]HQ ! \HDUV
1RWH
%DQN FKDUJH RI 5V DSSOLFDEOH RQ DOO RQOLQH WUDQVDFWLRQ ,QFOXVLYH RI 6HUYLFH 7D[
3URRI RI UHVLGHQF\ OHWWHU UHTXLUHG IURP +2' DORQJ ZLWK WKH 5HJLVWUDWLRQ IRUP )RU 6SRW 5HJLVWUDWLRQ &RPSOHWH .LW VXEMHFW WR DYDLODELOLW\
3KRWR , FDUG ZLOO EH UHTXLUHG DW WKH WLPH RI FROOHFWLRQ RI UHJLVWUDWLRQ NLW
'26 (;(&87,9( 9LFH 3UHVLGHQW 'U 5LVKL 0RKDQ *HQHUDO 6HFUHWDU\ 'U 0 9DQDWKL
3UHVLGHQW 'U &\UXV 6KURII
([HFXWLYH 0HPEHUV
-RLQW 6HFUHWDU\ 'U $UXQ %DZHMD 'U - 6 %KDOOD 'U %KXYDQ &KDQDQD
7UHDVXUHU 'U 9LSXO 1D\DU 'U $QVKXO *R\DO 'U $YQLQGUD *XSWD
(GLWRU 'U 5XFKL *RHO 'U 5DMDW -DLQ 'U 'HHSDQNXU 0DKDMDQ
/LEUDU\ 2IÀFHU 'U 'HYHQ 7XOL 'U - . 6 3DULKDU 'U 0DQDY 'HHS 6LQJK
'26 5HSUHVHQWDWLYH WR $,26 'U $MD\ $XURUD 'U 1DPUDWD 6KDUPD
([ 2IÀFLR 0HPEHUV 'U 5DMHQGUD .KDQQD 'U 5DMHVK 6LQKD 'U 6DQMHHY *XSWD
)RU )XUWKHU 'HWDLOV &RQWDFW
'U 0 9DQDWKL
*HQHUDO 6HFUHWDU\
5RRP 1R WK )ORRU 'U 5 3 &HQWUH $,,06 1HZ 'HOKL
(PDLO ZLQWHUGRV #JPDLO FRP , :HE ZZZ ZLQWHUGRV FRP
CATARACT
MULTIFOCAL AND ACCOMMODATIVE
INTRAOCULAR LENS IMPLANTATION IN CHILDREN
Muralidhar Ramappa
and out at will. There are children who do not wear spectacles
Dr. Muralidhar Ramappa MD or contact lenses secondary to behavioral issues related to
Consultant, Cornea and Anterior Segment, syndromes, neurologic or other medical issues. Multifocal
L.V. Prasad Eye Institute, Kallam Anji Reddy Campus, IOLs have been suggested for these children (or young adults)
L.V. Prasad Marg, Banjara Hills, Hyderabad with special needs who develop cataracts requiring surgical
One of the most intriguing challenges of modern intervention. There is a dearth of literature in children after
cataract surgery is the restoration of the multifocal IOLs with long-term outcomes2,3. This article focuses
accommodative ability in a pseudophakic eye. on the multifocal and accommodative IOL designs available and
Although monofocal IOLs does offer excellent those under investigation at this time (Table 1).
visual function, they do not restore any of the
remarkable accommodation that is lost when MULTIFOCAL IOLS
Multifocal IOL designs are based on the concept of
the crystalline lens is removed from a child. With that said, simultaneous vision. These IOLs focus light toward distant,
subjects with small pupil size, myopic astigmatism, corneal near, and sometimes intermediate focal points to provide the
aberrations, corneal multifocality and subjects with good visual patient near and distant targets4. Visual disturbances can arise
perception can have an increased range of what has been called from light focused in multiple areas. The quality of the vision
“pseudo-accommodation” with monofocal IOLs. Monovision produced by a multifocal IOL is based on several factors i.e.,
techniques (one eye corrected for distance and the other for pupil size, shape of the IOL and the IOL’s refractive or diffractive
near) have been used as a partial substitute for the absence characteristics. Haloes around lights, glare, and decreased
of accommodation, but it may be at the cost of binocularity. contrast sensitivity are potential problems with multifocal
Typically, if a monofocal IOL power is selected for distance IOLs4. For example, when attention is to light rays focused for
correction, the family is informed that glasses will be needed the distant focal point, the retina still receives light for the near
for near and intermediate vision. However, it is notable how focal point, and these out of focus light rays may be interpreted
many times parents report that as glare and lower contrast
their bilaterally pseudophakic
child functions well at near
ǯ ϐ
sensitivity. Currently, many
arm’s length; so multifocal IOLs are multifocal IOLs have adopted
even when looking over the aspheric designs to improve
bifocals or when they are not
being worn at all. While this is better alternative to provide unaided contrast sensitivity4. Advantages
near visual correction. The quality of are that many designs are
not universal for all children, similar to current foldable
it is a common occurrence that the image produced by a multifocal IOL
cannot be explained simply by depends on pupillary size, IOL’s design monofocal IOLs implanted
in routine cataract surgery;
depth of focus with the pupillary whether it is refractive or diffractive ϐ
miosis that occurs with technique is required. Multifocal
attempted accommodation. IOLs currently give more
ϐ Ǧ predictable results for near
accommodation in children implanted with multifocal IOLs vision when compared with single optic accommodating IOLs5.
needs a comparison group of age-matched children with similar IOL design variables: Different areas of the IOL have
residual refractive errors who were implanted with monofocal different focal planes, usually for near and distant vision. At any
IOLs. given time, one image is in focus at the retina, and the second
Newer IOLs designs have enabled adult cataract surgeons image is highly defocused with very little structure. Distant
to both neutralize corneal astigmatism and re-establish a the objects are focused by the distance power of the lens and
range of near and far vision without spectacles. The success of defocused by the near power. For near objects, the opposite is
multifocal IOLs in the adult population has lead to a growing true; near objects are focused by the near power of the lens and
interest in implanting them in children1. Unlike most adults defocused by the distance power.
who have cataract surgery with IOL placement, children have Optics: Multifocal IOLs can be broadly categorized as
excellent accommodation; so multifocal IOLs are often viewed, diffractive or refractive.
as an attractive way to mediate the loss of the ability to zoom in Refractive IOLs: Refractive multifocal IOLs direct the light
www. dos-times.org 9
CATARACT
depth of focus for intermediate and
near distances8,9. This essentially adds
a little refractive multifocal feature to
the accommodative lens design. The
Crystalens AO is an aspheric version.
One study comparing the Crystalens
HD to a monofocal IOL found a mean
accommodating range of 1.5±0.0D in the
Crystalens HD group and 1.0±0.0D in
the monofocal IOL group9Ǥ ϐ
(Lenstec, St. Petersburg, FL) is another
single optic accommodating IOL (not yet
approved in the United States). Vitreous
pressure and possibly ciliary muscle
Figure 1: %NCUUKſECVKQP QH 2TGOKWO +PVTCQEWNCT NGPUGU
+1.U
ϐ
lens to increase higher order aberrations
at different focal points using concentric equal light to both focal points6. The such as coma, trefoil, and spherical
zones of varying dioptric power within ReSTOR IOL (Alcon Laboratories, Fort
the optic. The principle is similar to the Worth, TX) is an example of an apodized aberration, which augment the depth of
bifocal spectacle. These are also referred diffractive multifocal IOL. Nonapodized
to as multizonal refractive IOLs6. As the diffractive multifocal IOLs have diffractive ϐ10.
pupil size changes, the number of zones ϐ
in use varies, and eventually the relative to the periphery. Thus, these lenses Dual-Optic Accommodating
proportion of light directed to the near distribute light to the near and distant
and distant focal points changes as well6. focal points in constant proportions; IOLS: To maximize the amplitude of
Thus, image quality can vary depending regardless of the pupil size4. Current
on pupil size. The ReZOOM lens (Abbott examples of nonapodized diffractive accommodation, the dual optic IOL
Medical Optics, Santa Ana, CA) is an multifocal IOLs are the Tecnis multifocal
example of a refractive multifocal IOL IOL (Abbott Medical Optics), and the design was developed9. The degree of
(Figure 1). AT LISA 809 IOL (Carl Zeiss Meditec
Company, Hennigsdorf, Germany). accommodation depends on two decisive
Diffractive IOLs: Diffractive IOLs
have closely arranged concentric rings on factors i.e., the range of axial displacement
one of the surfaces of the lens to divide
incoming light into multiple beams; they of the optic of IOL and the power of the
add together in phase at a predetermined
point on the optical axis for near focus, displaced IOL11,12. For example, a +19D lens
while the overall curvature of the lens
provides the distance focus. The number in the bag with 1mm of axial displacement
of the rings, spacing and step heights
vary by IOL design and manufacturer yields a +1.2D change in accommodative
(Figure 2). The apodized design consists
of concentric rings showing a decrease in power. However, a +32D lens in the
height from the taller central diffractive
steps to the shorter outer steps6. The bag with the same displacement gives
perceived advantages of apodisation
include the fact that the gradual change in +2.6D of accommodative change11.
in step height decreases sudden shifts in
optical boundaries, reducing distracting The same model suggests limited
out-of-focus light rays that produce glare
and haloes when viewing distant objects ACCOMMODATIVE IOLs accommodation (0.3 to 1.9 D) for 1 mm
through a large pupil. As the pupil size
increases, more light is focused to the In accommo-dative IOLs, a shift in the of axial displacement for IOL powers in
distant focal point. The rationale for this
design is that in mesopic conditions with focal length of the IOL-eye optical system the +15 to +25D range. In a dual-optic
dim light when the pupils are large, such
as driving at night, distance vision is the is induced by a change in the ciliary system, moving a strong plus power
priority. In most situations, humans rely
on near vision in well-lit environments, muscle tension. In contrast to multifocal lens coupled to a stationary negative
ϐ
in daylight, when the pupil is constricted. IOLs, accommodative IOLs are free from minus lens should result in a greater
In these situations, apodization directs
glare and haloes and results in improved accommodative change compared with
contrast sensitivity since these lenses are a single optic system11,12. The Synchrony
designed to focus light at the desired focal IOL (Visiogen, Abbott Medical Optics,
point7. Accommodating IOLs are the most AMO, Santa Ana, Calif.) is an example
diverse in terms of design. of a dual-optic accommodating IOL.
Single-optic Accommodating This dual lens system rather resembles
IOLs: The presumed mechanism of a Galilean telescope, with an anterior
accommodation is a forward axial shift convex lens connected to the posterior
in the optic of the IOL and changes in the concave lens7. However, there are some
lens architecture as a result of contraction notable distinctions between a dual
of the ciliary muscle7. Theoretically, the lens accommodative IOL and a Galilean
accommodation is achieved by combined telescope. The dual lens accommodative
mechanisms. Change in the lens position, IOL is designed to provide vergence in the
lens architecture changes and it is range of an IOL (+ 15 to +30 D), whereas a
believed that pseudo accommodation Galilean telescope produces 0 vergence12.
might also play a role8. In the case of the
ϐ ǡ
CrystaLens (Bausch and Lomb, Rochester, could result in uncomfortable aniseikonia
NY), the optic may curve anteriorly, which in a patient who has a telescope implanted
changes the radius of curvature of the in 1 eye and a single-optic IOL in the other.
anterior surface of the optic, resulting in ϐ
more near vision4,8. The Crystalens HD is limited to 2.5%, which is within the
variant has a small refractive number reported 8% tolerance before patients
add centered in the optic to improve notice aniseikonia12. When the IOL is in the
10 DOS TIMES - NOVEMBER-DECEMBER 2015
CATARACT
Table-1: Characteristics of multifocal and accommodative IOLs
Brand Type of IOL Optic size Incision IOL Material Light Near Accommodation
name of size design distribution addition range
IOL Acrylic at IOL
Diffractive 6mm 2.2mm Single hydrophobic Pupil size plane
Restore apodized 6mm 2.2.mm piece Acrylic dependent 3D
(Alcon) hydrophilic Near 41% &
Technis Diffractive-non 1.5mm Single distant 41% 4D
(AMO) apodized 2.8mm or multi
2.7mm piece
AT Lisa 809 Diffractive 6mm 2.5mm Hydrophobic Near 35% & 3.5D
(Carl Zeiss) Single surface Distant 65% _
ReZOOM Refractive 6mm piece _
(AMO) Acrylic Pupil size
Crysta lens Single optic 5mm Multi hydrophobic dependent 1.5D
(B&L) Accommodative 5.75mm piece
ϐ Silicone _
(Lenstec) Single optic- Multi
Accommodative piece High water _ _
ϐ
The content _ _ 3.22±0.88
Synchrony Single HEMA
IOL optic
(Visiogen, Silicone
Abbott Dual optic Not 3.8mm Dual
Medical optic
Optics, accommodative
ϐ
AMO, Santa
Ana, Calif.)
bag, tension from the capsule compresses to children older than 10 years of age. of eyes grew 0–0.5 mm, 37.8% grew 0.5-
the optics closer together. When As 80–90% of eye growth occurs in the 1.5mm, and 5.1% grew more than 1.5
accommodation is attempted, the ciliary ϐ ʹ ǡ mm. The authors calculated the dioptric
muscle contracts, relaxing tension in the that multifocal IOL implantation could change if a patient followed the average
bag. The dual IOL optics separate due to be offered in a younger population14. growth and found it to be 4 diopters
the stored energy in the bridging haptics. The multifocal IOL requires precise between ages 10 and 20 years. This study
Pressure from the vitreous face supports measurements, calculations and suggests caution in the use of multifocal
the posterior optic so the anterior optic positioning for satisfactory performance. IOLs during the second decade of life.
moves forward during accommodation12. For the optimal performance of multifocal
The haptics are designed to allow 1.5 IOLs, it has been found that a residual Jacobi et al2 performed a prospective
mm of optic movement. In one study, hyperopia up to 0.50 D helps in minimizing case study on 35 eyes in children aged
the mean accommodative range of the halos and to maintain distance and near 2–14 years implanted with zonal-
Synchrony was 3.22±0.88D compared visual acuity15. In addition, postoperative progressive multifocal IOLs. The average
with a monofocal IOL which measured residual refractive error plays a critical age at implantation was 6.1 years (3.4
1.65±0.58 D7. A disadvantage of the role in enhancing patient satisfaction15. years) with an average follow-up of
Synchrony is a larger 3.8mm incision The multifocal IOL designs do not 27.4 months (12.7 months). All patients
required for implantation7. In post function as well when the eye grows and showed improved vision, with 71%
vitrectomy eyes, it is unclear how well becomes myopic. Ironically, an eye with a having 20/40 vision or better and 31%
dual optic accommodating systems multifocal IOL eye may actually be more having 20/25 vision or better. The
perform. spectacle-dependent than a monofocal average distance vision was 20/35 and
IOL eye when a myopic shift occurs. average near vision was 20/55. The near
CLINICAL STUDIES With multifocal IOLs in mind, Wilson vision improved to 20/35 with the use of
et al13 looked at axial length changes in additional plus lenses. In the cases with
Wilson et al have published their the second decade of life and noted an bilateral multifocal IOL implantation,
understanding about refractive change average axial length of 23.36 mm at 11.5 spectacle dependence was reported in
during eye growth as well as amblyopia years of age and 23.86mm at 15.2 years 67% of patients. Reported complications
secondary to the loss of contrast of age. Average growth during this time include; posterior synechiae (54%),
sensitivity associated with multifocal frame was 0.53mm. However; there was
ϐ
ȋͶΨȌǡ
IOLs1,13. As recommended by their study, variable growth throughout the second ϐ
ȋ͵ͶΨȌǡ
these issues can be partially dealt with decade of life. Their data showed 57.1% ϐ
by restricting the use of multifocal lens (11%). Of nine children who underwent
www. dos-times.org 11
CATARACT
bilateral implantation, six cases (67%) importantly, there is a dearth of published at near preferentially. Multifocality, if
reported wearing glasses throughout data regarding pediatric multifocal IOL it has a role to play in children, will be
the day, two with bifocals and four with Ǥ ǡ ϐ
useful mainly in bilateral implantations.
distance-only glasses. Among those older proper evidence-based assessments of a In eyes with a small, eccentric, or non-
than age 6 years of age at last follow- therapy. Postoperative healing following reacting pupil19,20, it is prudent to choose
up, three children (16%) reported glare primary implantation in children will a lens which gives optimal performance
and halos. The optical performance of a
ϐ
irrespective of pupillary size. The
multifocal IOL is highly sensitive to lens related to the posterior capsule or architecture of corneal incision, location,
tilt and decentration. Seventeen percent ǡ
ǡ ϐ
ϐ ǡ
of patients in the study by Jacobi et al2 changes anteriorly. While a component
ϐ
required surgical intervention to treat of this correlates positively with age on induced astigmatism. Astigmatism
IOL decentration. The pediatric capsule at the time of surgery, proper surgical induced deterioration of both distance
is well known to experience aggressive technique including posterior capsule and intermediate visual acuity was
ϐ
ϐ
management (i.e. polishing, posterior ϐ
surgery. Any shift in IOL position i.e., tilt, capsulorhexis with or without anterior than monofocal IOLs21. Therefore care
decentration can potentially deteriorate vitrectomy) at the time of surgery can should be taken to avoid the extent
the optical performance of theses IOLs. decrease the observed complication rate of surgically induced astigmatism by
of lens decentration, posterior synechiae appropriately designing the wound
To the best of our knowledge at this
ϐ
architecture or choosing the correct
point of time, there are no publications surgery. The trade off for slightly greater toric multifocal IO22-24. Finally, knowledge
on accommodating IOL usage in children glare disability and decreased contrast of the myopic shift that may occur
for the treatment of aphakia was found in sensitivity is the increased depth of focus after implantation much be taken into
available databases (PubMed, Cochrane provided by multifocal IOLs16 ,17. account and planned for. Appropriate
Library and Google Scholar). expectations for long-term spectacle use
To summarize: Ultimately, it is our need to be emphasized to avoid patient
OPTIMIZING RESULTS belief that accommodating IOLs will and family disappointment.
surpass multifocal IOLs and eventually,
In the editorial that accompanied multifocal IOLs will be remembered CONCLUSION
the Jacobi et al article, Hunter urged as a historical steppingstone prior to
caution, especially when implanting these the development of high performing Several inherent limitations of
IOLs in younger children when surgical accommodating IOLs. The concept of multifocal IOLs have, so far, restricted
complications may be more common. simultaneous images and the splitting their use in the pediatric population. As
Decentration of the IOL could disrupt of available light with its loss of contrast IOL designs continue to improve, the
the multifocality of the IOL and posterior sensitivity and potential for photopsias newer generation multifocal IOLs seem
synechiae could cover up the IOL zones will last in the marketplace so long as a to be addressing the problems of glare,
and functionally convert it to a monofocal better alternative is not yet available. halos, optical aberrations, and poor
lens. He was particularly cautious about However, but at this time, multifocality is intermediate vision. Accommodating
using these lenses in children at risk the more successful and popular option IOL designs will also improve and will
for amblyopia. He points out that the for correcting presbyopia in adults. For eventually command a larger share
reduction in contrast sensitivity from children, the fact that these lenses have a of the IOL market. The multifocal IOL
the multifocal lens design may not be long track record in adults makes them a may play a pivotal part for selected
large, but it may nevertheless induce viable consideration for certain children. pediatric patients, especially if surgeon
a corresponding degree of amblyopia. Pediatric surgeons must carefully and parent expectations are clearly
Tychsen, however, expressed a different consider the rather vast literature now ϐ Ǥ
view13,14. The minimally degraded available from adult use and the small cataract surgeon is obligated to proceed
contrast sensitivity of a multifocal IOL, amount of pediatric data when deciding cautiously in the young amblyopia patient
according to Tyschen, is not an important whether their patient is a good candidate as the decision of which IOL to implant
disadvantage. Rather, the multifocal IOL for multifocal IOL implantation. Proper will affect not only visual acuity but
may give the child a zone of some 3½ preoperative evaluation, lens selection, also general visual maturation. Further
diopters of optical “play” and this may astigmatism control and postoperative study is needed before these IOLs can
aid in their amblyopia therapy. Managing care are paramount when considering the be recommended for routine use in the
expectations is important. Children who multifocal IOL implantation. An accurate pediatric patient.
are in their growing years are not likely biometry is essential in obviating the
to be spectacle-free long-term. Tychsen need for spectacles dependency after REFERENCES
recommends using the multifocal IOL to multifocal IOL implantation.18 Status
provide the growing child with a broader of the fellow eye should be considered 1. Wilson ME, Trivedi RH. Choice of
band of potentially clear, less amblyogenic to avoid conditions that may preclude intraocular lens for pediatric cataract
vision with and without glasses. optimal results, such as extreme surgery: survey of AAPOS members.
aniseikonia. Unilateral multifocal IOL Journal of cataract and refractive
Rychwalski3 in his editorial on the implantation in a child who has normal surgery 2007;33:1666-68.
utility of multifocal IOLs in the pediatric accommodation in a non-cataractous
age group, has raised several pertinent fellow eye is questionable since the 2. Jacobi PC, Dietlein TS, Konen W.
issues relevant for determining the accommodating eye will always be used Multifocal intraocular lens implantation
suitability of primary multifocal IOL in pediatric cataract surgery.
implantation in pediatric patients. Most Ophthalmology 2001;108:1375-80.
12 DOS TIMES - NOVEMBER-DECEMBER 2015
CATARACT
3. Rychwalski PJ. Multifocal IOL controls. J Refract Surg 2010;26:723- ophthalmology 1992;114:405-08.
implantation in children: is the future 30. 19. Koch DD, Samuelson SW, Haft EA, Merin
clear? Journal of cataract and refractive 11. McLeod SD PV, Ting A. A dual optic
surgery 2010;36:2019-21. accommodating foldable intraocular LM. Pupillary size and responsiveness.
lens. Br J Ophthalmol 2003;87:1083- Implications for selection of a bifocal
4. Kim MJ, Zheleznyak L, Macrae S, Tchah 85. intraocular lens. Ophthalmology
H, Yoon G. Objective evaluation of 12. McLeod SD VL, Portney V, et al. . 1991;98:1030-35.
through-focus optical performance Synchrony dual-optic accommodating 20. Koch DD, Samuelson SW, Villarreal R,
of presbyopia-correcting intraocular intraocular lens. Part 1: optical and Haft EA, Kohnen T. Changes in pupil size
lenses using an optical bench system. biomechanical principles and design
ϐ
Journal of cataract and refractive considerations. J Cataract Refract Surg posterior chamber lens implantation:
surgery 2011;37:1305-12. 2007;33:37-46. consequences for multifocal lenses.
13. Wilson ME, Trivedi RH, Burger Journal of cataract and refractive
5. Mesci C, Erbil HH, Olgun A, Yaylali SA. BM. Eye growth in the second surgery 1996;22:579-84.
Visual performances with monofocal, decade of life: implications for 21. Hayashi K, Hayashi H, Nakao F, Hayashi
accommodating, and multifocal the implantation of a multifocal Ǥ ϐ
intraocular lenses in patients with intraocular lens. Transactions of the and monofocal intraocular lenses.
unilateral cataract. American journal of American Ophthalmological Society American journal of ophthalmology
ophthalmology 2010;150:609-18. 2009;107:120-24. 2000;130:477-82.
14. Gordon RA, Donzis PB. Refractive 22. Visser N, Bauer NJ, Nuijts RM. Residual
6. Davison JA SM. History and development of the human eye. Archives astigmatism following toric intraocular
development of the apodized diffractive of ophthalmology 1985;103:785-89. lens implantation related to pupil size. J
intraocular lens. J Cataract Refract Surg 15. Lee ES, Lee SY, Jeong SY, et al. Effect of Refract Surg 2012;28:729-32.
2006;32:849-58. postoperative refractive error on visual 23. Mojzis P, Pinero DP, Ctvrteckova
acuity and patient satisfaction after V, Rydlova I. Analysis of internal
7. Bohorquez V AR. Long-term reading implantation of the Array multifocal astigmatism and higher order
performance in patients with bilateral intraocular lens. Journal of cataract and aberrations in eyes implanted with
dual-optic accommodating intraocular refractive surgery 2005;31:1960-65. a new diffractive multifocal toric
lenses. . J Cataract Refract Surg 16. Auffarth GU, Hunold W, Wesendahl intraocular lens. Graefe’s archive
2010;36:1880-86. TA, Mehdorn E. Depth of focus and for clinical and experimental
functional results in patients with ophthalmology = Albrecht von Graefes
8. Commander J PR. Accommodating multifocal intraocular lenses: a long- Archiv fur klinische und experimentelle
intraocular lenses: theory and practice. term follow-up. Journal of cataract and Ophthalmologie 2012.
Int Ophthalmology Clin 2010;50:107- refractive surgery 1993;19:685-89. 24. Khoramnia R, Auffarth GU, Rabsilber
17. 17. Ravalico G, Baccara F, Rinaldi G. TM, Holzer MP. Implantation of a
Contrast sensitivity in multifocal multifocal toric intraocular lens with a
9. Alio JL, Pinero DP, Plaza-Puche AB, intraocular lenses. Journal of cataract surface-embedded near segment after
Chan MJ. Visual outcomes and optical and refractive surgery 1993;19:22-25. repeated LASIK treatments. Journal
performance of a monofocal intraocular 18. Holladay JT, Hoffer KJ. Intraocular of cataract and refractive surgery
lens and a new-generation multifocal lens power calculations for multifocal 2012;38:2049-52.
intraocular lens. Journal of cataract and intraocular lenses. American journal of
refractive surgery 2011;37:241-50.
ͳͲǤ Ǥ ϐ
IOL Study Group. US FDA clinical
ϐ
accommodating IOL: comparison to
concurrent agematched monofocal
Financial Interest: ϔ
Ȁ
Ǥ
thPGT eachingProgramme
rd thJanuary
!
" !
#$ %$ & '(&
)
www. dos-times.org 13
CORNEA
TECHNIQUES OF COLLAGEN CROSS-LINKING IN THIN
CORNEAS: AN UPDATE
Abhishek Dave, Umang Mathur
Corneal Collagen Cross-linking (CXL) with damage or other side effects were seen. The stromal swelling
ϐ ȋ Ȍ
ϐ
to increase the biomechanical and biochemical due to formation of collagen free “lakes” within the hydrophilic
stability of the corneal tissue. Spoerl et al were stromal proteoglycans. Raiskup and Spoerl4 published 1 year
ϐ ϐ results of hypoosmolar CXL in 32 eyes. Their technique differed
UVA irradiation to achieve crosslinking of corneal ϐ ͲǤͳΨ
collagen. This novel procedure was developed in Dresden solution every 2 minutes for 30 minutes. During irrardiation
ͳͻͻͲǯǤ ϐ ϐ ʹ
of this technology was introduced by Wollensak et al1 in minutes. They reported stabilization of ectasia in terms of
2003 (Germany). Since then CXL has become the standard mean K- value and BCVA. No side effects were observed with
of care for progressive keratoconus, after numerous clinical no stromal scarring. None of these studies however took into
ϐ
Ǥ note the endothelial specular count pre and post operatively.
ϐ Ǧ ǡ
So a subclinical damage to the endothelium cannot be ruled
Ǧϐ
out and one has to be cautious of the absolute safety of
links. These photochemically produced free radicals as well as the procedure. Also the result obtained have been modest
the UV-A light, both, can damage the corneal endothelial cell, (stabilization achieved) in comparison to isoosmolar CXL in
lens or the retina. To protect the endothelium and other intra- corneas with stromal thickness > 400 μm. This raises a doubt
ocular structures, CXL inclusion criteria require a minimum ϐ
corneal thickness of 400 μm after epithelial debridement. as non-swollen keratoconus corneas. CXL might be expected
Unfortunately, in advanced keratoconus progressive corneal
ϐ
thinning often leads to a ϐ
swollen cornea because of
was introduced by Wollensak in 2003
remaining stromal thickness of (Germany). Since then CXL has become lower relative concentration
less than 400 μm especially in of collagen in the hydrated
the cone-apex region. Several stroma. Another concern was
ϐ
raised by Kaya et al5 when
attempted lately to overcome the standard of care for progressive they demonstrated through
this major limitation of CXL2. keratoconus, after numerous clinical ϐ
We will be reviewing the swelling effect of hypoosmolar
techniques available today for studies have established its safety and ϐ Ǥ
cross linking thin corneas. can probably be avoided
ϐ
Ǥ by repeated application
CXL WITH HYPO- ϐ Ǧ ǡ
ϐ
OSMOLAR RIBOFLAVIN free radical mediated covalent inter and during the irradiation process
Ǧϐ
Ǥ also rather than isoosmolar
To treat corneas thinner ϐǤ
than 400 μm, Hafezi et al3,
ϐ
ϐ
CXL still needs to be established by detailed studies. Failure of
by swelling the cornea to increase stromal thickness before
ϐ
UV irradiation. Their technique involved applying isoosmolar
has been reported. The patient with a post epithelial removal
ϐ ͲǤͳΨ ʹͲΨ ϐǡ ͵
corneal thickness of 268 μm still showed progression of 1.9 D
minutes for 30 minutes, on 9.0 mm of de-epithelialized cornea.
after 3 months of CXL, though no endothelial adverse events
Ultrasound pachymetry is then performed at the thinnest point.
were noted. The author concluded in order to prevent ectasia
ϐ
a minimum stromal thickness of 330 μm should be present so
ȋϐ ͲǤͷΨ ͲǤͻΨ
Ȍ
as to achieve a minimum cross linked stromal thicknesss of 250
20 seconds for 5 more minutes or till the minimum corneal
μm (75% of 330 μm)6.
ͶͲͲ ρǤ
ϐ
0.1% is administered every 5 minutes. They treated 20 patients PACHYMETRY GUIDED EPITHELIAL DEBRIDEMENT
with minimum stromal thickness 320-400 μm post epithelial
removal. They reported stabilization of ectasia in 12 patients Another method for cross linking in thin corneas, proposed
and regression in 8 patients. No clinical signs of endothelial by Kymionis et al7, is customized pachymetric guided epithelial
www. dos-times.org 15
CORNEA
debridement. The technique involves of cross-linking. Wollensak et al9 in rabbit cable. The negative electrode (a stainless
mechanically removing 8.0 mm diameter steel grid of 8.0 mm diameter) is inserted
of corneal epithelium while preserving a models showed that corneal cross-linking in a special rubber ring that is applied to
small localized island corresponding to the cornea by means of a suction ring,
the thinnest area or the area of maximum without epithelial debridement (using whereas the positive electrode is placed
topographic steepening. They cross on the patient’s forehead by means of a
linked 2 patients with this technique with benzalkonium chloride–containing patch. After the blepharostat is applied,
thinnest pachymetry of 380 and 375 μm. the iontophoresis device for corneal
Postoperative results showed stabilization proxymetacaine eyedrops) reduced the application is placed on the cornea using
of ectasia with no endothelial cell density
Ǥ ϐ
reduction. Preservation of epithelium biomechanical effect by approximately
Ϊ ȋ ϐ
over the thinnest area also has possible 0.1% dextran-free solution enriched
advantage of prevention of local stromal ϐ
with ethylenediaminetetraacetic acid
dehydration and apart from blocking ǡ
ϐ
excessive UV radiation in this susceptible crosslinking. Transepithelial CXL in to allow quick passage into the corneal
area. The effect of cross linking with this stroma through an intact epithelium
technique was studied with AS-OCT and 20 patients with bilateral progressive with corneal iontophoresis; Sooft Italia
confocal microscopic imaging by Kaya et SpA) from the open proximal side,
al8. Haze formation and demarcation line
ϐ until the grid is totally covered. The
were present only in the deepithelialized device is then connected to a constant
stroma and evidently absent under areas solution, containing trometamol and current generator initially set at 0.5
which had an intact epithelium. Further
ͳǤͲ ϐ
confocal microscopy revealed keratocyte EDTA (ethylenediaminetetraacetic) the individual tolerance. Iontophoresis
loss with intense stromal edema only in is then performed for 5 minutes. The
the deepithelialized areas. For CXL to be sodium salt, was undertaken by Filippello corneal device is then removed before
effective it is vital for the thinnest areas performing UVA irradiation (10 mW/
to achieve crosslinking. But here this et al10. They reported a statistically cm2 for 9 mins). Total treatment time is
area seems to be spared from the effect around 15 minutes. Recently Vinciguerra
ǡ ϐ
ϐ
et al12 have published their preliminary
procedure in doubt. Even after partial results of a prospective non-randomized
epithelial removal in a grid pattern, the topographic parameters and concluded clinical trial of I-CXL for progressive
ϐ Ǧ keratoconus. They treated 20 patients and
homogenous, which might compromise that the treatment appeared to halt found that all topographic parameters
ϐ
Ǧ
Ǥ (including maximum keratometry)
keratoconus progression. Trometamol were stable during the follow-up, but
TRANSEPITHELIAL CXL (TE-CXL) θ Ǧϐ
is a biologically inert low-toxicity amino trend toward improve¬ment. Minimum
Epithelial debridement for CXL has corneal thickness values were stable for
been associated with complications like alcohol used as buffering solution and up to 12 months postoperatively. None
post-operative pain, infectious keratitis, of the pa¬tients showed a progression
stromal haze and corneal thinning Sodium EDTA is a well-known chelator
Ǥ ϐ
and melting. Transepithelial CXL was change in the endothelial cell count
introduced in order to prevent these of calcium and magnesium ions. Their postoperatively. They concluded that
adverse events as well as for its possible I-CXL has the potential to become a valid
role in treating thinner corneas. Initial combination breaks intercellular bonds, alternative to halt the progression of
experimental studies in porcine corneas keratoconus while reducing postoperative
demonstrated that complete epithelial thus facilitating the penetration of patient pain, risk of infection, and
ϐ treatment time in select patients. Further
Ǥ ϐ
ϐ
Ǥ studies are in progress to assess its long-
or tetracaine administration or grid like ϐ
ϐ
Applying a similar technique of to standard CXL.
ϐ
ϐ
transepithelial CXL in ultrathin corneas
(thinnest pachymetry 331-389 μm)
ϐ
Spaeda et al11. Though both these studies
reported no endothelial toxicity but that
still remains a concern because improper
ϐ
not be effective in absorbing all the UV
radiation.
IONTOPHORESIS RIBOFLAVIN
DELIVERY FOR TRANSEPITHELIAL
CXL (I-CXL)
In other specialities (ex.
dermatology), iontophoresis has been
adopted for a long time. It is a non-invasive
technique in which a small electric
current is applied to enhance an ionized
drug’s penetration. Preclinical results
have shown that CXL with iontophoresis
(I-CXL) is able to increase the
ϐ
stroma when compared to TE-CXL. The
iontophoresis system (I-ON CXL; Sooft
Italia SpA, Italy) is composed of a power
supply, 2 electrodes, and a connection
Cornea & Refractive Surgery Services, Dr. Shroff ’s Charity Eye Hospital, New Delhi. India
Dr.Abhishek Dave MD Dr. Umang Mathur MS
16 DOS TIMES - NOVEMBER-DECEMBER 2015
CORNEA
CONTACT LENS-ASSISTED CXL recently described by Sachdev14 et al in 3. Hafezi F, Mrochen M, Iseli HP, Seiler T.
a small sample of 3 patients. The cross- Collagen crosslinking with ultraviolet-A
(CACXL) linking procedure is planned along with ϐ
a femtosecond assisted small-incision in thin corneas. J Cataract Refract Surg.
It’s a novel technique described by lenticule extraction (SMILE) in another 2009;35:621.
Jacob13 et al. Here an ultraviolet barrier- patient with moderate myopia. The
ϐ refractive lenticule of about 80-100 μm 4. Raiskup F, Spoerl E. Corneal cross-linking
is kept on the cornea and the CXL is and diameter of 6.2 mm is extracted Ǧ ϐ
performed. In CACXL, a thickness of more and stored in McCarey-Kaufman thin keratoconic corneas. Am J Ophthalmol.
than 400 μm is attained by cre¬ating media. This lenticule is then placed 2011;152:28-32.
extra pre-corneal layers composed of pre- over the debrided epithelium of the
ϐ ϐ
patient to be cross-linked. The stromal ͷǤ ǡ ǡ Ç Y Ǥ
lens. After 9 mm epithelial debridement
ϐ
corneal thickness measurements during
Ǧ ϐ ͲǤͳΨ
Ǥ ϐ corneal collagen cross-linking with
T500 is applied every 3 minutes for 30 routinely and UV-A irradiation done. ϐ
Ǥ ϐ The authors reported no intraoperative corneas. Cornea. 2012;31:486-90.
daily disposable soft contact lens (14- or postoperative complications. Corneal
mm diameter, 8.6-mm basal curvature; topography was stable at 6 months and 6. Hafezi F. Limitation of collagen cross-linking
Bausch & Lomb) of 0.09-mm (90 μm) ϐ
ϐ ǣ
ϐ
endothelial cell density. The demarcation failure in an extremely thin cornea. Cornea.
ϐ line was observed at around 280-300 2011;30:917-9.
ȋǦ ϐ μm. A corneal lenticule is probably a
for 30 minutes) is placed on the cornea. more physiological manner of increasing 7. Kymionis GD, Diakonis VF, Coskunseven E,
Corneal thickness is rechecked to be stromal thickness as its biologic and Jankov M, Yoo SH, Pallikaris IG. Customized
above 400 μm. The cornea is then exposed absorptive properties are the same as pachymetric guided epithelial debridement
to ultraviolet-A irradiation for the next 30 those of the cornea to be treated. Again for corneal collagen cross linking. BMC
ϐ the technique needs to be proven with a Ophthalmol. 2009;28:9-10.
every 3 minutes. They treated 14 eyes larger sample size with longer follow ups.
with this technique and reported a mean ͺǤ ǡ ǡ Ǥ ϐ
depth of stromal demarcation line at Thus even with so many techniques corneal collagen cross-linking using a
ʹͷʹǤͻ ά ͶͲǤͺ Ɋ ȋǣ ʹͲͺ ͵Ͳ ɊȌǤ available for cross-linking thin corneas custom epithelial debridement technique in
ϐ
ϐ Ǥ thin corneas: a confocal microscopy study. J
loss and the corneal topography was quest for the same continues. Moreover Refract Surg. 2011;27:444-50.
stable at the last follow-up. They claimed it is not sure whether severely thinned
an apparent advantage of not being corneas, with low concentration of 9. Wollensak G, Iomdina E. Biomechanical
dependent on the swelling properties collagen can ever be cross-linked as well and histological changes after corneal
of the cornea unlike hypotonic CXL.
ϐ
Ǥ crosslinking with and without epithelial
However larger prospective randomized debridement. J Cataract Refract Surg.
controlled studies are needed before REFERENCES 2009;35:540-6.
validating the results.
ͳǤ
ǡ ǡ ǣ ϐȀ 10. Filippello M, Stagni E, O’Brart D.
STROMAL EXPANSION WITH SMILE ultraviolet-A-induced collagen cross-linking Transepithelial corneal collagen crosslinking:
for the treatment of keratoconus. Am J Bilateral study. J Cataract Refract Surg.
LENTICULE Ophthalmol 2003; 135:620-7. 2012;38:283-91.
A new technique of tailored stromal 2. Padmanabhan P, Dave A. Collagen cross- 11. Spadea L, Mencucci R. Transepithelial
expansion with a refractive lenticule linking in thin corneas. Indian J Ophthalmol corneal collagen cross-linking in ultrathin
for cross linking thin corneas has been 2013;61:422-4. keratoconic corneas. Clin Ophthalmol.
2012;6:1785-92.
12. Vinciguerra P, Randleman JB, Romano
V, Legrottaglie EF, Rosetta P, Camesasca
FI, Piscopo R, Azzolini C, Vinciguerra R.
Transepithelial iontophoresis corneal
collagen cross-linking for progressive
keratoconus: initial clinical outcomes. J
Refract Surg. 2014;30:746-53.
13. Jacob S, Kumar DA, Agarwal A, Basu S, Sinha
P, Agarwal A. Contact lens-assisted collagen
cross-linking (CACXL): A new technique for
cross-linking thin corneas. J Refract Surg.
2014;30:366-72.
14. Sachdev MS, Gupta D, Sachdev G, Sachdev R.
Tailored stromal expansion with a refractive
lenticule for crosslinking the ultrathin
cornea. J Cataract Refract Surg. 2015;41:918-
23.
Financial Interest: ϔ
Ȁ
Ǥ
HEARTY CONGRATULATIONS
Prof. Pradeep Sharma of Dr Rajendra Prasad Centre for
Ophthalmic Sciences, AIIMS, New Delhi has been conferred
upon the prestigious “PHILIP KNAPP LECTURE” at the
American Association for Pediatric Ophthalmology and
Strabismus (AAPOS) Annual Meeting in Vancouver, Canada,
ʹͲͳǤ ϐ Ǧ
this prestigious honour.
www. dos-times.org 17
CORNEA
DESCEMET MEMBRANE ENDOTHELIAL
KERATOPLASTY (DMEK)
Sunita Chaurasia
Table 1: Differences between the DSEK and DMEK graft
Dr. Sunita Chaurasia MD DSEK DMEK
L.V. Prasad Eye Institute, Kallam Anji Reddy Campus,
L.V. Prasad Marg, Banjara Hills, Hyderabad Lenticule with more mass Scroll with little mass
Endothelial keratoplasty has undergone a rapid Can be seen through corneal Always needs Trypan blue
evolution in the last decade1-3Ǥ ϐ
introduced was deep lamellar endothelial edema staining
keratoplasty (DLEK). Though this technique
had advantages over penetrating keratoplasty, it Maintains its shape, Easily changes its
failed to get widely adopted, because it required Predictable right-side up (As
challenging dissection and excision of host posterior stromal the way we place it)
ϐǡ
tissue. The second technique was Descemet’s stripping
endothelial keratoplasty (DSEK), which involved stripping on the outer side of scroll,
the Descemet membrane followed by insertion of posterior
lamellar graft that included posterior stroma, Descemet the tightness of which is
membrane and endothelium. The technique became widely
adopted due to its ease, versatile applications, excellent visual variable
outcomes and various other advantages over penetrating
keratoplasty. Currently, DSEK is the most popular surgery Harder to move the graft once Can eject out if AC
worldwide for the management of endothelial diseases. The
third technique Descemet membrane endothelial keratoplasty in the eye pressurized, Graft moves
(DMEK) involves removal of host Descemet membrane and
replacement with a Descemet membrane- endothelial complex. easily once unfolded
DMEK offers better visual potential, faster rehabilitation, and
lower rejection risk than the other approaches for endothelial Donor Graft Preparation
dysfunction1,4. By transplanting less tissue, DMEK is the most
anatomic replacement of the diseased endothelium. The donor endothelium can be isolated by peeling it from
the adjacent stroma or by injecting air to create a ‘big bubble’,
DMEK- SURGICAL TECHNIQUE similar to the way that host Descemet’s membrane is separated
from stroma in deep anterior lamellar keratoplasty (DALK)4-8.
By virtue of a thinner graft, handling of DMEK graft is The direct peeling method under immersion is more popular
very different from DSEK. Table 1 shows the salient differences and has a high success rate (>99%)8.
between the DSEK and DMEK graft. The surgical technique
involves isolation of donor DM and endothelium, recipient A brief description of donor preparation is described here
descemetorhexis followed by donor insertion and positioning (Figure 1 a-c):
of the graft. Ȉ
Ǧ
DMEK offers better visual potential, faster
ϐ
rehabilitation, and lower rejection risk solution or placed on a punch block
than the other approaches for endothelial Ȉ
dysfunction. By transplanting less tissue, using a Sinskey or aY-hook.
DMEK is the most anatomic replacement Ȉ
of the diseased endothelium scored edge, which is then freed circumferentially with a
ϐ ȋ
Ǥǡ ǡ ȌǤ
Ȉ
partially peeled in all quadrants, leaving the center portion
attached. A bimanual peel technique can be performed to
reduce the risk of tearing the DM.
Ȉ ϐ
trephined lightly into stroma to the desired diameter.
Ȉ
ϐ
central peel to completely detach DM. The detached DM
scrolls with the endothelium on the outside.
Recipient Eye Preparation
Two side port entries and a 2.8-3.0 mm superior or
temporal main incision are made. The epithelial surface is
marked to the desired graft size and DM scoring and stripping
is performed using a reverse Sinskey hook. Descemetorhexis
can be done under air or viscoelastic to maintain the anterior
www. dos-times.org 19
CORNEA
Graft loading Insertion
(a) The DM scroll is stained with trypan
blue and delivered into the anterior
chamber using either an intraocular lens
injector (Figure 2 a,b) or a glass pipette.
Various IOL injectors have been used for
graft delivery (Ex. Staar ICL cartridge,
Staar Surgical, Monrovia; Carl-Zeiss
inserters, Jena, Germany; and Viscoject,
ǡ ϐǡ ȌǤ
Dapena et al7 recommend aspiration of
the scroll into a glass pipette or injector.
Insertion should be done in soft recipient
eye to avoid graft extrusion. Following
graft insertion, the main incision site is
sutured.
(b) Graft Unfolding, positioning and
attachment (Figure 2 c-f)
The DM graft is partially unscrolled
with jets of BSS through the sideport
incisions. The anterior chamber is kept
shallow to promote unfolding of the DM
scroll. Proper orientation of the graft is
ϐǤ ǡ
chamber is kept devoid of air bubbles.
Once proper orientation is ascertained,
a small air bubble, 0.02mL in volume or
roughly pupil-sized, is injected beneath
a properly oriented donor. The graft
is unscrolled by gentle strokes on the
corneal surface and using short bursts of
ϐ
Ǥ
(c) The anterior chamber is kept shallow to
promote unfolding of the DM scroll. A
ϐ
unfolding the graft completely. Dapena
et al7 suggest inject and expand an
air bubble between the graft and host
ϐ Ǥ
This bubble is then removed entirely
and replaced with another between the
graft and iris to appose the unrolled graft
against host cornea.
Figure 1(a-c): &/'- )TCHV 2TGRCTCVKQP prior to donor insertion. A peripheral Identifying Graft Orientation
inferior iridotomy (PI) is performed at
chamber. Care should be taken to strip this time to allow for a a more aggressive The correct orientation and
the DM adequately as retained tags of ϐ
Ǥ
ϐ
DM can interfere with the attachment of anterior chamber is important (Figure
the DMEK graft. If viscoelastic is used, 3a-c). Following methods can help in
meticulous removal should be performed
ϐ
graft:
Ȉ ȋ ͷͳͲ Ǣ
Eidolon Optical, Natlick, MA)9
Ȉ
attached to the microscope10
Ȉ
endoilluminator11
Ȉ
graft with a letter -S during graft
ϐ
20 DOS TIMES - NOVEMBER-DECEMBER 2015
CORNEA
(a) (b)
(c) (d)
(e) (f)
Figure 2(a-f): &/'- )TCHV NQCFKPI KPUGTVKQP CPF RQUKVKQPKPI
the right orientation during its
ϐ DMEK-CHALLENGES AND
manipulation in the anterior for donor attachment. An intra operative
chamber12. PI helps in reducing the risk of post LIMITATIONS
operative papillary block. In cases where
Air Fill for DMEK and Post op PI is not done, it is important to examine Preparation of a DMEK graft is
Management the patient after 45 to 60 minutes and let more challenging than previous forms
out some air to avoid papillary block. of transplantation because of the
Compared to DSEK grafts, DMEK ϐ
grafts do not attach as readily and Descemet’s membrane–endothelial cell
complex. Early reports indicate a tissue
www. dos-times.org 21
CORNEA (b) (c)
(a)
Figure 3(a-c): &/'- )TCHV QTKGPVCVKQP KP VJG CPVGTKQT EJCODGT
complication rate of 0–16%, (a) shift represented correction of
although in one study, half of (b) myopia due to stromal swelling
the cases were successfully (c) when the endothelium was
converted to DSEK using the dysfunctional.
damaged tissue with no adverse
effects. An increasing number COMPLICATIONS
of eye banks in the US are now
providing pre-stripped DMEK Graft detachment remains
donor tissue. a primary complication with
DMEK and occurs at a higher
Delivery and positioning of incidence than DSEK. Guerra et
such a thin layer of tissue can be al14 reported a 62% rebubbling
challenging. Once the Descemet’s rate in a prospective series
scroll has been inserted into of eyes undergoing DMEK for
the eye, it must be gently Fuchs, PBK, or failed previous
unscrolled while minimizing graft (n=136). In that study,
contact with and damage to the many DMEK grafts were
endothelium. Orientation and injected using an IOL inserter
even successfully identifying with a viscoelastic plug. The
orientation of the graft can be a rates have shown to have
challenge dropped to 14% after switching
to graft delivery systems with
DMEK is not suitable for all no use viscoelastic13Ǥ ϐ
eyes and proper case selection is detachments may result in
important for surgical success. It primary graft failure if left
is not recommended in eyes with untreated. Attention should be
aphakia or large iris defects, and paid to the scrolled edges of
eyes with glaucoma drainage the detachment, as it will help
devices. It is technically more only if the graft is in correct
ϐ
orientation (Figure 5 a,b).
pars plana vitrectomy because
of the deep anterior chamber The primary graft failure
that makes unfolding harder. rate is reported to range from
3 to 20%4,19,20. It improves with
VISUAL ACUITY AND surgeons experience and has
been reported to be similar to
REFRACTIVE OUTCOMES DSEK in the hands of experts1.
The potential sources Graft rejection is rare with
DMEK. This may be due to
of visual degradation in decreased antigenic stimulus in
the absence of donor stromal
DSEK graft include increased tissue and the sequestration of
donor endothelial cells deep to
posterior corneal higher order DM. Dapena et al21 reported only
1 case (0.8%) of rejection over an average
aberrations and light scattering 2 years’ follow-up in a series of 120 eyes
that underwent large-diameter DMEK
from the stromal interface. Figure 4(a-c): &/'- RQUV QR KOCIGU (9.0 to 10.0mm) for Fuchs or PBK. Anshu
Also, a mismatch between the et al22 conducted a comparative case
series of eyes with identical postoperative
donor and the recipient can steroid regimen and 2-year follow-up
after DMEK (n=141), DSEK (n=598), and
lead to folds in the graft which can limit 20/24 in DMEK eyes versus 20/32 in PK (n=30). The incidence of rejection
episodes was 0.7% for DMEK, 9% for
the quality of the vision. Compared with DSEK eyes (P=0.004). When surveyed, DSEK, and 17% for PK. DMEK eyes had a
DSEK, DMEK conforms better to the 85% of patients appreciated better
posterior corneal surface and eliminates visual quality and faster recovery in their
stromal thickness variation providing DMEK eye. Furthermore, DMEK eyes had
ϐ
ȋ ϐ
Ǧ
4 a-c)13. Guerra et al14 retrospectively aberrations than DSAEK and PK15.
studied patients who underwent DSEK Most new studies on refractive
in one eye and DMEK in the fellow eye results after DMEK show an average
(n=15). One year after surgery, best- postoperative hyperopic shift of +0.49D
corrected visual acuity (BCVA) averaged to =0.75 D16-18. It is speculated that the
22 DOS TIMES - NOVEMBER-DECEMBER 2015
CORNEA
(a) (b)
Figure 5(a): 'PFQVJGNKCN NC[GT YTQPI UKFG WR (b): 'PFQVJGNKCN NC[GT EQTTGEV UKFG WR
15- fold lesser risk of rejection than DSEK 7. Tenkman LR, Price FW, Price MO. keratoplasty. Ophthalmology.
eyes and 20-fold lower risk than PK eyes. Descemet membrane endothelial
keratoplasty donor preparation: 2012;119:528-35.
SUMMARY Navigating challenges and improving
ϐ
Ǥ ʹͲͳͶǡ͵͵ǣ͵ͳͻǦʹͷǤ 15. Röck T, Bartz-Schmidt KU, Röck D,
DMEK provides a near anatomical
replacement of dysfunctional host 8. Burkhart ZN, Feng MT, Price MO, et Yoeruek E. Refractive changes after
endothelium and has set new benchmarks al. Hand-held slit beam techniques to
for rejection risk and visual outcomes facilitate DMEK and DALK. Cornea. Descemet membrane endothelial
following endothelial replacement. 2013;32:722-4
DMEK is providing new insights into how keratoplasty]. Ophthalmologe.
different corneal layers contribute to 9. Saad A, Guilbert E, Grise-Dulac A,
immunogenicity and immune tolerance Sabatier P, Gatinel D. Intraoperative 2014;111:649-53.
and into the key factors that limit vision OCT-Assisted DMEK: 14 Consecutive
after endothelial keratoplasty. Cases. Cornea. 2015;34:802-7. 16. Laaser K, Bachmann BO, Horn FK, et
REFERENCES 10. Jacob S, Agarwal A, Agarwal A, al. Descemet membrane endothelial
Narasimhan S, Kumar DA, Sivagnanam
1. Price MO, Price FW Jr. Descemet’s S. Endoilluminator-assisted keratoplasty combined with
membrane endothelial keratoplasty transcorneal illumination for Descemet
surgery: update on the evidence and membrane endothelial keratoplasty:
ϐ
hurdles to acceptance. Curr Opin enhanced intraoperative visualization
Ophthalmol 2013;24:329-35. of the graft in corneal decompensation lens implantation: advanced triple
secondary to pseudophakic bullous
2. Price MO, Price FW. Descemet’s keratopathy. J Cataract Refract Surg. procedure. Am J Ophthalmol.
stripping endothelial keratoplasty. Curr 2014;40:1332-6.
Opin Ophthalmol. 2007;18:290–94. 2012;154:47–55.
11. Veldman PB, Dye PK, Holiman JD,
3. Price MO, Price FW Jr. Endothelial Mayko ZM, Sáles CS, Straiko MD, 17. Schoenberg ED, Price FW Jr, Miller J,
keratoplasty-A review. Clinical and Stoeger CG, Terry MA. Stamping an S on
Experimental Ophthalmology 2010; DMEK Donor Tissue to Prevent Upside- McKee Y, Price MO. Refractive outcomes
38: 128–40. Down Grafts: Laboratory Validation
and Detailed Preparation Technique of Descemet membrane endothelial
4. Feng MT, PriceMO, Price FW Jr. Update Description. Cornea. 2015;34:1175-8.
on Descemet membrane endothelial keratoplasty triple procedures
keratoplasty. International Ophthalmol 12. Chaurasia S, Price FW Jr, Gunderson
Clin. 2013;53:31-45. L, Price MO. Descemet’s membrane (combined with cataract surgery). J
endothelial keratoplasty: clinical results
5. Mckee HD, Irion LC, Carley FM, et al. of single versus triple procedures Cataract Refract Surg. 2015;41:1182-9.
Donor preparation using pneumatic (combined with cataract surgery).
dissection in endothelial keratoplasty: Ophthalmology. 2014;121:454-8. 18. Ham L, Dapena I, van Luijk C, et al.
DMEK or DSEK? Cornea. 2012;31:798–
800. 13. Guerra FP, Anshu A, Price MO, et al. Descemet membrane endothelial
Descemet’s membrane endothelial
6. Dapena I, Moutsouris K, Droutsas K, et keratoplasty: prospective study keratoplasty (DMEK) for Fuchs
al. Standardized ‘‘no-touch’’ technique of 1-year visual outcomes, graft
for descemet membrane endothelial survival, and endothelial cell loss. endothelial dystrophy: review of
keratoplasty. Arch Ophthalmol. Ophthalmology. 2011;118:2368–73.
2011;129:88–94. ϐ ͷͲ
Ǥ Ǥ
14. Rudolph M, Laaser K, Bachmann BO,
Cursiefen C, Epstein D, Kruse FE. 2009;23:1990–98.
Corneal higher-order aberrations after
Descemet’s membrane endothelial 19. Price MO, Giebel AW, Fairchild KM, et
al. Descemet’s membrane endothelial
keratoplasty: prospective multicenter
study of visual and refractive
outcomes and endothelial survival.
Ophthalmology. 2009;116:2361-68.
20. Dapena I, Ham L, Netukova M, et al.
Incidence of early allograft rejection
after Descemet membrane endothelial
keratoplasty. Cornea. 2011;30:1341–
45.
21. Anshu A, Price MO, Price FW Jr.
Risk of corneal transplant rejection
ϐ
ǯ
membrane endothelial keratoplasty.
Ophthalmology. 2012;119:536–40.
Financial Interest: ϔ
Ȁ
Ǥ
www. dos-times.org 23
OCULAR SURFACE
USES OF AMNIOTIC MEMBRANE IN
CORNEA PRACTICE
Jayeeta Bose, Minakshi Sheokand
The structural integrity, transparency and elasticity of the amniotic basement
membrane makes it currently the most widely accepted tissue replacement for
ocular surface reconstruction
The amniotic membrane is the innermost layer of
the three layers forming the fetal membranes. It
is a translucent membrane composed of an inner
layer of epithelial cells. Outside the amnion is the
chorion layer comprising of connective tissue
containing the fetal (chorioallantoic) vessels.
The outermost layer of the fetal membranes, the deciduas M
capsularis, is the only component of the fetal membranes of BM
ϐ Ǥ
ͳͻͳͲ ϐ
use of amniotic membrane in skin transplantation1. There after E
it has been used in surgical procedures related to the genito-
ǡ ǡ Ǥ ϐ
documented ophthalmological application was in the 1940s
when it was used in the treatment of ocular burns2,3.
The human amniotic membrane (AM) is a 0.02 mm to 0.5
ϐǦ ǡ
ǣ
epithelial monolayer, thick basement membrane and avascular
hypocellular stromal matrix. The epithelium consists of a
single layer of cuboidal cells with a large number of microvilli
on the apical surface. The basement membrane is a thin layer
ϐ Ǥ
Histologically the basement membrane closely resembles Figure 1: *KUVQRCVJQNQI[ QH #OPKQVKE OGODTCPG
#/ UJQYKPI
that of the conjunctiva4. This compact layer contributes to GRKVJGNKWO
' DCUGOGPV OGODTCPG
$/ CPF OCVTKZ
/
the tensile strength of the membrane. The stroma comprises
ϐ Ǥ Though the laminins are very effective in facilitating corneal
The basement membrane of amnion is one of the thickest epithelial cell adhesion, Type V collagen helps in the epithelial
membranes found in human tissue. This layer is resistant cell anchorage to the stroma8Ǥ
ϐǡ
to current cryopreservation techniques. The structural hepatocyte and transforming growth factor (TGF). These
integrity, transparency and elasticity of the amniotic basement growth factors can stimulate epithelialization and modulate
membrane makes it currently the most widely accepted tissue ϐ9.
replacement for ocular surface reconstruction (Figure 1).
The AM stromal matrix, rich in fetal hyaluronic acid
It is known to promote epithelial cell migration, adhesion
Ⱦ ǡ ϐ
and differentiation. It is an ideal substrate for supporting
ϐ
the growth of epithelial progenitor cells by prolonging their
ϐ10. This action
lifespan, maintaining their clonigenicity and preventing explains why AMT helps reduce scars during conjunctival surface
epithelial cell apoptosis5. This action explains why AMT reconstruction, prevents recurrent scarring after pterygium
facilitates epithelialization for persistant epithelial defects removal and reduces corneal haze following photorefractive
(PED) with stromal ulceration6. In tissue cultures, AM supports keratectomy. The stromal matrix also suppresses expression of
epithelial cells grown from explant cultures and maintains their
ϐ
normal morphology and differentiation.
ǡ
Ǧͳǡ Ǧʹǡ Ǧͺǡ ɀǡ
ǦȾǡ
ϐ
The resultant cultured epithelium can be transplanted derived growth factor11. The AM attracts and sequesters
with the AM to reconstruct damaged corneas7. The basement ϐ
ϐ
membrane of the AM, cornea and conjunctiva contains collagen various forms of protease inhibitors12. This may explain some
ǡ ǡ ϐ
4. Ǧϐ Ǥ
www. dos-times.org 25
OCULAR SURFACE
AMNIOTIC MEMBRANE GRAFT screened against transmissible diseases ϐǡ
thereby eliminating the slightest risk with the stromal side up. The second
PROCUREMENT, PROCESSING AND of disease transmission that may be membrane acts as a protective bandage
associated with fresh AM. In addition to ϐ
PRESERVATION this 30 preserved grafts can be prepared growing on it.
from one placenta unlike tissue wastage
Amniotic membrane is obtained while using fresh AM. Dry preserved AM Filling-in or multiple layered
from prospective donors undergoing is easily available in market and can be technique-In this technique the entire
Caesarean section, who are negative for stored at room temperature for 2 to 5
ϐ
communicable diseases including HIV, years unlike cryo preserved AM which of Amniotic membrane trimmed to
hepatitis and syphilis. Different protocols requires stringent storage conditions. the size of defect. In Multiple layers of
exist for the processing and storage13,14. There are certain concerns when using amniotic membrane, stacked one on top
According to Kim et al, the placenta fresh AM. Ideally, serologic tests on the ǡ
ϐ
is cleaned with balanced salt solution maternal donor must be done both at the
Ǥ ϐ
containing a cocktail of antibiotics (50 time of procurement of the donor tissue is slightly larger than the others, is placed
Ȁ
ǡ ͷͲ ɊȀ
ǡ and again six months later. This dual epithelial side up, and sutured to the
100 mg/ml of neomycin as well as 2.5 testing eliminates the slightest risk of corneal surface.
mg/ml of amphotericin B) under sterile disease transmission. With the fresh AM
conditions14. The amnion is separated the time interval from tissue procurement Orientation of Membrane: The
from the chorion by blunt dissection. The to transplantation is short and prevents epithelial side of the membrane is smooth
separated membranes are cut in different repeat testing of the donor. Patients have compared to the stromal (chorionic) side.
sizes placed on nitrocellulose paper strips to be brought to the hospital at a short The stromal surface of the membrane is
with the epithelial side up. Dulbecco notice unlike with preserved AM, which ϐ
DzǦ
ϐ Ȁ
ȋͳǣͳȌ ϐ
like” strand than can be raised with
used for cryopreservation and the tissues surgery19. A distinct disadvantage is sponge.
are frozen at -80 degrees until further wastage of unused tissue with non-
use15. Amnion stored in 50-85% glycerol preserved AM as opposed to frozen AM. INDICATIONS OF AMNIOTIC
is reliable and effective for over a year,
with the added advantage of antibacterial PRINCIPLES OF SURGERY MEMBRANE USE IN OPHTHALMIC
properties16. Human AM deprived of
amniotic epithelial cells by incubation The main objectives of AMT are ocular SURGERY
with EDTA when freeze dried, vacuum surface reconstruction, promotion of
packed and sterilized with gamma- epithelialization, providing symptomatic Corneal ulcers: Amniotic membrane
irradiation at 25kGy retained most of
ϐǤ has been used for both infectious
the physical, biological and morphologic basic principles are:- and sterile ulcers with thinning and
characteristics of cryopreserved AM17. perforation by application in layers to
Infrared spectral scanning showed no Inlay or graft technique: The AM is build thickness to the defect21 and to
degradation or change in the dried secured with its epithelial side up act as a provide bulk for the defect in promoting
gamma irradiated amniotic tissue after scaffold for the epithelial cells, which then faster healing and avoiding cornea
2 and 5 years of storage. Lyophilized merges with the host tissue, it is referred transplantation. Sridhar et al22 achieved
AMs were found to be impermeable to to as a graft20. a success rate of 94.7% with shield
various strains of bacteria. Amniotic ulcers by using Amniotic membrane
membranes processed by air-drying are Overlay or patch technique: transplantation combined with surgical
also found to be stable and can be stored When used as a patch it is expected that debridement.
under different environmental conditions epithelialization will occur beneath the
without compromising their clinical membrane, with the membrane acting Ocular Surface Reconstruction in
performance18. as a bandage. A patch also reduces ϔ
ǣ Cicatrizing diseases
ϐ
of the ocular surface - Chemical or thermal
FRESH VERSUS PRESERVED
ϐǤ burns, Stevens–Johnson syndrome (SJS),
and cicatricial pemphigoid in which
AMNIOTIC MEMBRANE Combined Approach: Two Amniotic membrane transplantation
membranes can be used, one epithelial is usually combined with some form
Both fresh and preserved AM have side up and the other down. The inner of stem cell transplantation, which
been found to function equally well when membrane applied to the ocular surface may be performed simultaneously or
transplanted onto the ocular surface19. is sutured with the epithelial side up, to subsequently, after the surface has been
(Figure 2) Advantage with preserved AM act as a graft. The other, usually larger adequately prepared by AMT (Figure 3).
is that it is well processed and thoroughly
Acute chemical burns: These can
lead to complete corneal erosion and
Venu Eye Institute & Research Centre, Sheikh Sarai, New Delhi
Dr. Jayeeta Bose MS Dr. Minakshi Sheokand MS
26 DOS TIMES - NOVEMBER-DECEMBER 2015
OCULAR SURFACE
Figure 2: (TGUJ CPF &T[
>RTGUGTXGF COPKQVKE OGODTCPG
Figure 3: 5.'6
5KORNG NKODCN GRKVJGNKCN EGNN et al24 ϐ
Figure 4: #/6 KP C EJGOKECN KPLWT[ RCVKGPV
VTCPURNCPVCVKQP CNQPI YKVJ #/6 KP C .5%& membrane in pterygium surgery and YKVJ U[ODNGRJCTQP
RCVKGPV recommended that it can be used as an
ϐ
conjunctiva. It may act either as a patch
blood vessel rupture at the limbus and of primary pterygium where the or a graft depending on the state of
recurrence rate was inherently low. the underlying corneal stroma once
in the conjunctiva. The overriding aims ϐ
Transplantation for Symptomatic removed.
of treatment are to prevent necrosis and Bullous Keratopathy: Amniotic
membrane transplantation has also Bulbar and Fornicial or Palpebral
scarring and to achieve epithelialization. been used effectively for the treatment Cover: In lid surgery and conjunctival
of symptomatic bullous keratopathy. The surgery, especially after release of
Early AMT improves functional outcomes technique was described by Pires et al25. symblepharon or excision of pterygium,
The bullous epithelium was debrided the membrane may be used as a patch or
in term of promiting epithelialisation and and the exposed stroma covered with graft to cover areas of denuded sclera or
an amniotic membrane graft sutured in episclera. In fornix reconstruction, fornix-
ϐǡ place and in turn covered with a bandage deepening sutures may need to be placed
contact lens. and tied on the skin surface over bolsters.
scarring sequel in the late stage after
Glaucoma Surgery: Amniotic Total Ocular Surface Cover: In
chemical burns23 (Figure 4). ϐ severe ocular surface burns when
surgery, as an adjunct to reduce scarring, extensive areas of the corneal and
Transplantation for Persistent for repair of leaking blebs, and as a conjunctival epithelium have been
cover for valve implants and exposed destroyed, the membrane can be used to
Epithelial Defects (PED) that are pericardium patch. cover the entire ocular surface. A large
patch of membrane is placed over the
refractory to convential treatment like SURGICAL PRINCIPLES lids and with a blunt instrument such as
a squint hook, the membrane is tucked
lubrication, elimination of toxic drugs, Clinical Applications into the fornices so that a double layer
is formed, one covering the palpebral
BCL and punctual occlusion. An intact The suture material used in surface and one covering the bulbar
conjunction with the amniotic membrane surface and cornea. Fornix-deepening
corneal epithelium is a decisive factor is usually 10-O nylon, 8- to 10-O vicryl or sutures are placed and tied on the skin
prolene. The sutures may be interrupted, over bolsters, superiorly, inferiorly,
in ocular surface stability. AM is used running, or mattress in type. Mattress medially, and temporally.
sutures are generally placed tangential to
clinically as a basement membrane the limbus, tacking the membrane to the COMPLICATIONS OF AMT
ϐ
Ǥ
substitute in patients with persistent In the immediate postoperative
Partial Or Subtotal Corneal Cover: period one may come across hematoma
epithelial defects both with and without when a small non-healing area is covered formation under the membrane26.
by a membrane of appropriate size and The blood usually absorbs or may need
corneal ulceration. held in place with a few sutures. It is drainage, by making a small opening
usually trimmed manually to a size and in the graft, if excessive. Premature
Conjunctival Reconstruction- ϐ
Ǥ
degradation of the membrane and
cover is usually required in bullous
Amniotic membrane has also been used keratopathy or as a graft in association
with auto or allo- limbal transplant. The
to reconstitute the conjunctival surface sutured membrane is covered with a
bandage contact lens
following resection of conjunctival tumors
Complete Corneal Cover: In large
or other lesions such as melanomas, corneal epithelial defects or in association
with limbal transplant operations, it may
haemangiomas and OSSN. When used as be necessary to suture the membrane 360
degree around the limbus to peritomized
a graft to cover the conjunctival wound it
provides a substrate for the migration of
conjunctival epithelial cells. It has been
used in conjunction with beta irradiation
and mitomycin C.
Pterygium Excision: Prabhasawat
www. dos-times.org 27
OCULAR SURFACE
cheese wiring may need frequent repeat 9. Sato H, Shimazaki J, Shinozaki N. 19. Adds PJ, Hunt CJ, Dart JK. Amniotic
Role of growth factors for ocular membrane grafts, “fresh” or frozen? A
transplantations. Occasionally, a residual surface reconstruction after amniotic clinical and in vitro comparison. Br J
membrane transplantation. Invest Ophthalmol 2001;85:905-7.
subepithelial membrane may persist in Ophthalmol Vis Sci 1998;39:428.
20. Sippel KC, Ma JJ, Foster CS. Amniotic
some cases and inadvertently opacify 10. Lee SB, Li DQ, Tan DT, Meller DC, Tseng membrane surgery. Curr Opin
SC. Suppression of TGF b signalling in Ophthalmol 2001;12:269-81.
the visual axis. The incidence of post
ϐ
ϐ 21. Kruse FE, Rohrschneider K, Volcker
cryopreserved AMT microbial infections amniotic membrane. Curr Eye Res HE. Multilayer amniotic membrane
2000;20:325-34. transplantation for reconstruction of
is as low as 1.6%27. This value is much deep corneal ulcers. Ophthalmology.
11. Solomon A, Rosenblatt M, Monroy D, Ji 1999;106:1504-11.
lower than the 8% reported with use of ǡ ϐ ǡ Ǥ
of Interleukin 1 alpha and Interleukin 1 22. Sridhar MS, Sangwan VS, Bansal
fresh AM. Gram-positive organisms are beta in the human limbal epithelial cells AK, Rao GN. Amniotic membrane
cultured on the amniotic membrane transplantation in the management
the most frequent isolates28. Gabler et stromal matrix. Br J Ophthalmol of shield ulcers of vernal
2001;85:444-9. keratoconjunctivitis. Ophthalmology
al reported a case of sterile hypopyon 2001;108:1218-22.
12. Shimmura S, Shimazaki J, Ohashi Y,
after repeated AMT29Ǥ
ϐ
Ǥ ϐ
23. Meller D, Pires RT, Mack RJ, Figueirido
of amniotic membrane transplantation F, Heiligenhaus A, Park WC, et al .
in about 12.8% of cases30. The key to in ocular surface disorders. Cornea Amniotic membrane transplantation
2001;20:408-13. for acute chemical and thermal burns.
reducing postoperative complications is Ophthalmology 2000;107:980-9.
13. Shimazaki J, Yang HY, Tsubota K.
meticulous selection of both donor and Amniotic membrane transplantation 24. Prabhasawat P, Barton K, Burkett G,
for ocular surface reconstruction in Tseng SC: Comparison of conjunctival
recipient and maintaining high standards patients with chemical and thermal autografts, amniotic membrane
burns. Ophthalmology 1997;104:2068- grafts, and primary closure for
of quality assurance. 76. pterygium excision. Ophthalmology
1997;104:974-85.
REFERENCES 14. Kim JC, Tseng SC. Transplantation of
preserved human amniotic membrane 25. Pires RT, Tseng SC, Prabhasawat P:
1. Davis JW: Skin transplantation with for surface reconstruction in severely Amniotic membrane transplantation
a review of 550 cases at the Johns damaged rabbit corneas. Cornea for symptomatic bullous keratopathy.
Hopkins Hospital. Johns Hopkins Med J 1995;14:473-84. Arch Ophthalmol 1999;117:1291–7.
1910;15:307.
15. Kruse FE, Joussen AM, Rohrschneider 26. Dua HS, Gomes JA, King AJ, Maharajan
2. Bose B: Burn wound dressing with K, You L, Sinn B, Baumann J, et al. VS. The amniotic membrane in
human amniotic membrane. Ann R Coll Cryopreserved human amniotic ophthalmology. Surv Ophthalmol
Surg Engl 1979;61:444-7. membrane for ocular surface 2004;49:51-77.
reconstruction. Graefes Arch Clin Exp
3. Gruss JS, Jirsch DW: Human amniotic Ophthalmol 2000;238:68-75. 27. Marangon FB, Alfonso EC, Miller D,
membrane: a versatile wound dressing. Remonda NM, Marcus S, Tseng SC.
Can Med Assoc J1978;118:1237-46. 16. Maral T, Borman H, Arslan H, Incidence of microbial infection after
Demirhan B, Akinbingol G, Haberal amniotic membrane transplantation.
4. Fukuda K, Chikama T, Nakamura M, M. Effectiveness of human amnion Cornea 2004;23:264-9.
Nishida T. Differential distribution of preserved long-term in glycerol as a
sub-chains of the basement membrane temporary biological dressing. Burns 28. Khokhar S, Sharma N, Kumar H, Soni
components type IV collagen 1999;25:625-35. A. Infection after use of nonpreserved
and laminin among the amniotic human amniotic membrane for the
membrane, cornea and conunctiva. 17. Nakamura T, Yoshitani M, Rigby H, reconstruction of the ocular surface.
Cornea 1999;18:73-9. Fullwood NJ, Ito W, Inatomi T, et al. Cornea 2001;20:773-4.
Sterilized, freeze-dried amniotic
5. Grueterich M, Tseng SC. Human limbal membrane: A useful substrate for 29. Gabler B, Lohmann CP. Hypopyon
progenitor cells expanded on intact ocular surface reconstruction. Invest after repeated transplantation of
amniotic membrane ex-vivo . Arch Ophthalmol Vis Sci 2004;45:93-9. human amniotic membrane onto
Ophthalmol 2002;120:783-90. the corneal surface.Ophthalmology
18. Singh R, Gupta P, Kumar P, Kumar 2000;107:1344-6.
6. Lee SH, Tseng CG. Amniotic membrane A, Chacharkar MP. Properties of air
transplantation for persistent dried radiation processed amniotic 30. Anderson SB, de Souza RF, Hoffmann-
epithelial defects with ulceration. Am J membranes under different storage Rummelt C, Seitz B. Corneal
Ophthalmol 1997;123:303-12. conditions. Cell Tissue Bank 2003;4:95-
ϐ
100. transplantation. Br J Ophthalmol
7. Tsai RJ. Corneal surface reconstruction 2003;87:587-91.
by amniotic membrane with cultivated
autologus limbo-corneal epithelium.
Invest Ophthalmol Vis Sci 1998;39:429.
8. Modesti A, Kalebic T, Scarpa S, Togo
S, Grotendorst G, Liotta LA, et al .
Type V collagen in human amnion is
ͳʹ ϐ
pericellular interstitium. Eur J Cell Biol
1984;35:246-55.
Financial Interest: ϔ
Ȁ
Ǥ
28 DOS TIMES - NOVEMBER-DECEMBER 2015
GLAUCOMA
PRACTICAL PROTOCOLS IN
GLAUCOMA MANAGEMENT
Manav Deep Singh, Sonali Gupta, Shikha Jain, Nidhi Sharma
Glaucoma is a progressive optic neuropathy that results in structural changes in
ϐ
impairment or blindness
This article gives highly practical perspective to
the management of glaucoma. surgery tonometry. Rebound tonometry can be used for
With dedicated time and staff, glaucoma speciality pediatric patients. However, none of these instruments
clinic can go a long way in better management of are mandatory except GAT plus any one instrument with
this disease. However, it is neither a substitute which IOP can be measured in supine position (Perkins/
Tonopen or Schiotz in that order).
for clinical skills nor experience nor gaining 6. Gonioscopy is a tool for differentiation of open and
knowledge on the subject. closed angles and can diagnose congenital defects, signs
ϐǡ
ǡ ǡ Ǧ
INTRODUCTION vascularisation etc.
7. Assessment of amount of damage is done by automated
Glaucoma is a progressive optic neuropathy that results
in structural changes in the optic nerve head and typical visual ϐ
ϐ
same program. Imaging is required only in selected cases
blindness. Glaucoma may arise secondary to other causes such or for research.
ǡ ǡ
ϐ ͺǤ ϐ
ϐ
processes such as anterior uveitis. Most cases of glaucoma are, defects due to eye disease are not glaucomatous. All
however, primary glaucoma- either open-angle glaucoma, or cuppings are not pathological and all pathological cuppings
closed-angle glaucoma. are not glaucoma. The test for glaucoma diagnosis is
demonstration of progression over a period of time.
All ophthalmologists should manage glaucoma 9. Normal tension glaucoma (NTG) is a diagnosis of exclusion.
Meticulous record keeping is the backbone of It is not very common, at least in India, although western
glaucoma management studies report otherwise Diurnal variation test over 24
Early detection is important. At the same time, over hours and demonstration of progression are required to be
diagnosis should be avoided able to diagnose NTG. Possibility of died down glaucoma
ǡ ϐ
should be considered.
case, more experienced colleague ͳͲǤ
ϐ
Ten Commandments in glaucoma diagnosis are: of progression - whether by clinical examination or by
1. Asymmetry {of cup:disc ratio/ neuro-retinal rim thickness/ investigations.
intraocular pressure (IOP)} is the hallmark of glaucoma PRE GLAUCOMA-CLINIC ASSESSMENT
2. Too much asymmetry in the above parameters/
Patients with borderline suspicion of glaucoma, and who
unilateralism is hallmark of secondary glaucoma. ǡ ϐ
Unilateral glaucoma is secondary unless proved otherwise. ǯ ϐ
3. Disc size is of immense importance in the assessment of appointment for glaucoma clinic. Obvious cases of glaucoma
glaucomatous damage. A cup of 0.8 may be normal for a are referred to Glaucoma clinic immediately along with a
large disc and 0.2 is possible in a patient of glaucoma in a ϐ
Ǥ
small disc. emergency.
ͶǤ ϐ ȋ Ȍ
done in red free photograph of fundus and its clinical WORKUP IN GLAUCOMA CLINIC
assessment may often be deceptive.
5. The gold standard instrument for measurement of IOP in ϐ ǡ
ǡ
cases of glaucoma is Goldmann applanation tonometry detailed history and standard ophthalmological examination
(GAT). Non contact tonometry can be used as a screening including Applanation tonometry (AT) and gonioscopy are
tool. Tonopen is good for scarred/irregular corneas performed. Central corneal thickness (CCT) is measured using
and Dynamic Contour Tonometry for post-refractive ultrasonic pachymeter. The order of examination remains
www. dos-times.org 29
GLAUCOMA
ϐ ǡ
like forward bowing, if present, is also Indications of Laser Iridotomy
an interval in between any two of these noted. Effort is made to assess if the angles
investigations to keep corneal clarity and are occludable. In cases of developmental in PACD
minimize the effect of compression by the or juvenile glaucoma, degree of angle
previous investigation.
ϐǤ - All PAC and PACG patients
- Fellow eyes of patients
ANTERIOR SEGMENT EXAMINATION PRIMARY ANGLE CLOSURE DISEASE
with acute attack or PACG
During the anterior segment Primary angle closure disease - Critically narrow angles- <
examination, it is important to note the (PACD) is divided into Primary angle
pupillary ruff, since its atrophy may closure suspect (PACS), Primary angle 10°/ appositional closure/
signify previous acute or sub-acute closure (PAC) or Primary angle closure only Schwalbe’s line visible
attacks of angle closure. Presence of glaucoma (PACG) based of the following - Symptomatic patients-
pigment on the lens/ corneal endothelium criteria. On gonioscopy, eyes with narrow evening low grade brow
ϐ
ϐ aches
ϐǤ structures not visible beyond anterior - Pupillary ruff changes
is also specially looked for. trabecular meshwork. Ǧ
ϐ
- Cannot come for follow up
All unilateral glaucomas, except a. Primary angle closure suspect - Need for frequent
for very early cases, should be (PACS): dilatations- e.g. for retinal
considered secondary and all diseases
efforts be made to look for the No evidence of past angle closure,
cause. Looking for pupillary normal intraocular pressure and no disc Laser PI being an innocuous
ruff changes with special care ϐ
Ǥ procedure, it is better to err
is essential in PACG suspects who have gone into acute attack or are on the side of doing this for
suffering from chronic angle closure and PACS rather than missing
GONIOSCOPY do not fall in category b or c, fall in this the opportunity of a curative
category. management for future PACG
For all cases, Gonioscopy is to be
performed. Initial examination is done b. Primary angle closure (PAC): Selection of Location
with a beam of low height without Evidence of past angle closure or
encroaching pupillary margin to assess raised intraocular pressure or both but 1. The most preferred location is
angle width. However, beam is later made
ϐ
supero-nasal because:
brighter and height increased to see c. Primary angle closure i. Less likely to cause macular damage
opening of angle and also to assess details glaucoma (PACG):
of the angle. The preferred gonioscope is Evidence of past angle closure attack by the laser.
two mirror Goldmann type with the use and/or raised intraocular pressure and ii. Less likely to result in lenticular
of 2% methylcellulose as coupling agent.
Ȁ ϐ
Ǥ
Manipulation gonioscopy and over the hill damage in case side port is created
viewing of angle is essential part of this Protocol for laser iridotomy during any future surgery.
investigation. Indentation gonioscopy iii. It is covered with upper lid hence no
is performed using 4 mirror Sussaman/ One needs to remember that diplopia.
Zeiss gonioscope to differentiate between angle closure glaucoma is almost as As far as radial location is concerned,
appositional and synechial closure. common as open angle among Indians. it is best performed at the junction of
Ensure that no pressure is applied on Additionally, this is far more disabling peripheral one-third and central two-
cornea while doing Gonioscopy otherwise than POAG and results of surgery are thirds.
corneal folds will obscure the view. The also poor. Therefore, need of looking for Extreme peripheral location should
ϐ
subtle signs of angle closure cannot be be avoided because:
seen, degree of angle recession, if present, over-emphasized. Laser PI being a very i. Failure is common due to poor view.
evidence of past closure in the form of innocuous procedure, it is better to err on ii. May result in iridodialysis.
peripheral anterior synechiae or pigment the side of doing this rather than missing iii. Assessment of its patency may
clumps, abnormal vascularisation or any the opportunity of curative management
ϐ
adventitious structures. Contour of iris, of early PACD, which eventually may pilocarpine is over.
become visually disabling. Central location should be avoided
since:
i. It can cause damage to collaret.
ii. Frequently closes down soon after
achieving patency.
PGIMER, Dr. Ram Manohar Lohia Hospital, New Delhi
Dr. Manav Deep Singh MS Dr. Sonali Gupta MS Dr. Shikha Jain MS Dr. Nidhi Sharma MS
30 DOS TIMES - NOVEMBER-DECEMBER 2015
GLAUCOMA
iii. Can cause diplopia. Figure 1: #TIQP NCUGT OCTMU KP FTWO UVKEM Figure 2: #TIQP NCUGT OCTMU KP FTWO UVKEM
2. Presence of crypts: The presence HCUJKQP HCUJKQP YKVJ EGPVTCN QRGPKPI FQPG YKVJ ;#)
NCUGT
of crypts that takes priority for deciding Ȉ Pilocarpine 2% eye drops are
the location even if it happens to be ϐ ǡ Figure 3: +TKU JGOQTTJCIG YJKNG RGTHQTOKPI
inferior or extreme peripheral. However, times, starting one hour before ;#) NCUGT 2+
it is never to be performed in the area of iridotomy.
collaret. Thin areas in collarets are not > 40 mJ to avoid ocular
crypts. Iris here is boggy and PI will close Ȉ One drop of Proparacaine 0.5% eye hypotensive drugs
immediately after penetration. drop is used as a local anaesthetic. Ȉ
ϐ
3. Amount of energy/ mode: Ȉ Abraham iridotomy lens is used Ȉ ͵ǦͶ Ȁ
ϐ along with 2% methylcellulose day post laser X 7 days and
two 2-5 mJ per pulse depending on the as coupling agent. The use of lens pilocarpine BD x 5 days
available machine. In case of very thick stabilizes the eye and improves
iris or absent iris crypts, burst mode with cooperation of patient as well as Post Laser iridotomy
two pulses/ shot may be considered. In focus of laser beam. Most glaucoma patients are steroid
the absence of iris crypts, argon laser
shots are applied in drumstick manner to Ȉ Patient is examined for the presence responders. Post laser, a steroid with low
stretch iris at mid periphery (Figure 1,2). or absence of iris crypts. potential for steroid induced glaucoma
Once this is done, YAG energy is applied like loteprednol eye drops is given 3-4
in the central stretched iris using double Ȉ It is the presence or absence of times a day, depending on the energy
shot (burst mode). The settings are spot crypts and not the iris thickness that used, for a week.
size 100 μ, duration 100 msec., energy determines the amount of energy
100-250 mJ. required. If crypts are present, less In case less than 40 mJ YAG laser
energy is required. energy is used, no ocular hypotensive
4. Total number of shots/ energy: In agent is generally needed except in
the presence of crypts, generally patency Ȉ If crypts are absent, we use the very high risk cases. However, it is good
is achieved using single pulse. Few more drumstick technique of sequential practice to check IOP 1-2 hours following
shots may be given to obtain optimum double frequency YAG followed by PI. D agonists are the most effective ocular
size of the opening (1-2 mm- minimum YAG laser. Generally, a single shot hypotensives for post laser spikes. Within
size 0.75 mm). However two pulses/ ϐ
Ǥ this group, apraclonidine was considered
shot may be considered in the absence of followed by 2-3 shots for extension the best. However, it is no more available
crypts. One should not exceed maximum in Indian market. Therefore, the best drug
total energy of 40-80 mJ, depending on Ȉ Patency is considered to be achieved available in India is Brimonidine. If high
the machine, in one sitting. ϐ energy is required for laser iridotomy,
out from behind, clear red glow is this drug may be instilled three times a
One may need to abandon the seen without iris strands or ciliary day for a week.
procedure if there is hemorrhage, iris processes are seen through the
ϐ
Ǥ iridotomy.
ʹΨ ϐ
ϐ
given to keep iris stretched to maintain
a new location or try after sometime (as Procedure of Laser Iridotomy
Ǥ ϐ
early as half an hour) or next day because effect is over at the one week examination.
ϐ Ȉ
Ǥ
and no penetration will take place. supero-nasal quadrant at Patient is called for evaluation after
the junction of peripheral a week and patency of the iridotomy is
ǣ In one-third and central two-
case of excessive pigment release or third. Never in collaret
minor bleeding, iridotomy can be tried
after 30 minutes. In case of haemorrhage Ȉ
ȋ ͵Ȍ
ϐǡ
pupil non-responsive to
1-3 days later, after giving frequent light.
topical steroids. Long delay in the hope
ϐ Ȉ
iridotomy may lead to formation of Ȉ
ǡ
posterior synechiae or peripheral anterior
synechiae apart from inconvenience. the drumstick technique
of argon laser before YAG
After a successful Laser iridotomy, laser.
patient is further managed as a case Ȉ
of open angle glaucoma with a few
exceptions.
Procedure of PI
Ȉ At least two readings of applanation
tonometry are recorded using sterile
precautions, before performing
Nd:YAG laser iridotomy.
www. dos-times.org 31
GLAUCOMA
assessed and IOP measured. If iridotomy Brimonidine can increase hyperemia, decide whether to treat or observe.
is patent, gonioscopy is performed to dorzolamide can cause ciliary body It is generally accepted that patients
assess how much the angle has opened congestion and PG analogous can cause with IOP >27 should be treated
and for better assessment of PAS. breakdown of blood aqueous barrier
Ȁ ϐ
The patient is dilated with eye drop and, thus, fall lower in the preference of attributable to high IOP can be
Tropicamide 1% and mid dilated IOP their use. Topical steroids are instilled demonstrated2.
is measured. Phenylephrine is avoided four times/ day to reduce associated Ȉ
ȋ
Ȍ
Ǧ ϐǡ
ϐǤ suspects: in patients with
whereas maximum IOP rise takes place glaucomatous damage but IOP
during mid- dilatation; secondly, there Peripheral iridotomy is done the
ϐ
is no antidote if patient goes into acute next day once the cornea is clear. Oral hours (to avoid diagnosis of NTG for
attack and thirdly, dilatation is very fast acetazolamide is withdrawn depending patients of POAG with peaks of high
but constriction is slow, thus, patient may on IOP and patient is started on routine ϐ
ȌǤ
develop acute attack after leaving the treatment. Ȉ ȋʹͳǦʹͶ
clinic. Routine dilated ophthalmological mm Hg), with or without evidence
examination and disc evaluation are then In occasional cases, the pupil does of glaucomatous damage, to
carried out. not constrict with pilocarpine eye drops differentiate between Ocular
ϐ
Hypertension and POAG and to
In case IOP rises on dilatation of edematous and iris boggy. Carefully done decide whether to treat or not.
pupil, then it is considered as a case of paracentesis may help in making cornea Ȉ ǤǤ
plateau iris syndrome and patient is kept clearer and PI possible. The threshold for moderate/ advanced glaucomatous
on long term pilocarpine or is taken up lens extraction is very low in these cases. damage with high IOP but not high
for trabeculectomy. The most important In case a mild cataract is present, it can be enough to explain the loss.
criterion to decide in favour of surgery
ϐ
ȋʹȌ ϐ
ǡ
ϐ ϐ
3-4 weeks later, if required. We generally known as diurnal control, helps to assess
ϐ avoid combined phaco-trabeculectomy in if target pressure remains achieved round
defects. The purpose of PI is to bypass these cases as they are prone to severe the clock. This is helpful in advanced cases
pupil in case of papillary block and all ϐǤ
Ȁ ϐ
cases of PACD are not exclusively due to is another option in these situations.
ϐ
pupillary block. In case of angle crowding However the results in Indian eyes have Ǥ ϐ
as the mechanism of PACD or extensive not been reported to be satisfactory with DV done before starting treatment.
PAS, PI will not be effective. this method hence it is not performed in
our centre. Diurnal variation is not
In case IOP does not rise on dilatation indicated in angle closure
of pupil, further management is like a ANGLES OPEN ON GONIOSCOPY glaucoma cases unless a mixed
case of POAG. mechanism is suspected
When the angles are found to be
In case angles open up following PI open, intraocular pressure is high, typical (3) Others: DV also gives us
and IOP remains within normal range disc changes are observed and no cause following advantages:
ϐ
of secondary glaucoma can be detected,
of PACS including fellow eyes of eyes the presence of ‘Primary Open Angle It may reveal the peak IOP levels, the
with PACG, disease is taken as cured. Glaucoma’ (POAG) is considered. Perform time of the day when the peak occurs and
However, three monthly assessments ϐ ϐ
in the beginning may be progressively assessment of pressure at which loss examination period- all have implications
reduced to yearly follow up which is ϐ
Ǥ on planning the treatment, including
generally done lifelong. The minimum maximum IOP ever reached and the timing of instillation of drugs.
work up includes VA, IOP measurement period for which the disease has been Ȉ Ǧ εʹǡ
and undilated fundus examination every present is determined by history taking,
visit along with at least yearly dilated careful scrutiny of old records and doing irrespective of the corneal thickness.
ǡ
ǡ ϐ a Diurnal Variation. If poor follow up is expected, we start
charting. therapy even at 25 mmHg and above
Diurnal Variation (DV) off unless corneal thickness is >600μ.
Management of acute angle closure drugs is done to record (a) the Ȉ Ǧ
Ǧ
maximum IOP (b) range of IOP therapy if high IOP readings are seen
attack and (c) time of maximum IOP. in DV along with defects found on
Diurnal variation on drugs is Ǥ ϐ
If a patient presents in an acute ϐ
to start therapy with RNFL defects
attack of primary angle closure1, we start of the drugs being used demonstrated on imaging alone.
intravenous mannitol (hyperosmotic
agent) immediately. Once intraocular Indications of Diurnal Variation Central Corneal Thickness
pressure falls down to 40 mm Hg, topical
pilocarpine 2% is instilled every thirty ȋͳȌ
ϐ Ȁ
Next step in the work up is to
minutes for four times or till pupil baseline information: DV off drugs in measure CCT. The preferred instrument
constricts, followed by four hourly for patients with is contact type ultrasonic pachymeter. It
one day. Oral acetazolamide one tablet Ȉ
ȋ Ȍ Ȃ requires same precautions for its use as
6 hourly and timolol 0.5% eye drops BD those for GAT.
are started and patient is called next day. know the maximum IOP levels to
32 DOS TIMES - NOVEMBER-DECEMBER 2015
GLAUCOMA
CCT is measured because the IOP is ǯ ϐǡ
disease may be followed up with longer
falsely recorded higher in thicker corneas the patient usually undergoes prior to the intervals, maybe upto six months.
and lower in thinner corneas. Corneal ϐ
thickness of 500 microns to 550 microns and correlated with the examination Longer follow up of 6 months or
is taken as normal. ϐǤ more is usually not recommended but
may be done in
In case the thickness is greater or
ϐǡ Ȉ
lesser than this range, a correction factor ǡ ϐ
Ȉ
is applied to the IOP. Taking the baseline and life expectancy of the patient, a target Ȉ
as 540 microns, the correction factor is IOP is decided and further management is
calculated as 1 mm Hg of pressure for decided accordingly3. stable
every 14 microns from baseline. This Ȉ
factor is subtracted from the measured Patient guidance
IOP in case of thicker corneas and is therapy and glaucoma inoperable for
added in case of thinner corneas. Individualize the management various reasons
considering the patient’s socio-economic
The corrected IOP is taken as the status, daily work schedule, systemic Work up during follow up visits
reference value for deciding the target status and drug allergies.
IOP for a particular patient and also for Ȉ ϐ
those with ocular hypertension. Inform the side effects of the drugs Ȉ
being prescribed. Communication
Provocative tests about the present status/ prognosis and every patient and should be revised
general information about the disease is periodically.
These have a limited role and are an important part of the management. It Ȉ
indicated only in few cases. Various tests is a lifelong disease and development of Ȉ
can be: a bond between patient and doctor goes done every 3-4 months but at least
a.) Water drinking test (for POAG) a long way. once every year.
Ȉ
Ȉ ϐ
The lifestyle changes and how to
Ǥ ϐ
stomach and made to drink 1L apply eye drops are also explained. The done in patients with evidence of
of water lifestyle changes include avoiding liquids progression/ advanced disease/
Ȉ
ͳͷǦʹͲ in quantity of 500 ml or more in a short
ϐȀ
for 1-2 hours interval especially empty stomach, OHT patients not on treatment.
Ȉ Ǧͺ avoiding tobacco, exercises involving total Ȉ
ϐ
inversion of body like ‘sheersh aasan’, case there is unexplained rise of IOP
b.) Dark room test (for PACD) ‘kapaal bhaati’ pranayaam and tight neck and yearly in cases of angle closure
Ȉ ties. All the patients are encouraged to do glaucoma
room for 60-90 min
ϐǦ Ȉ
Ȉ
degree relatives examined. Ȉ
illumination BCVA- look for cause- like uveitis,
Ȉ ͺ Follow up of patients neovascularisation of iris, cataract,
suggestive of narrow angle retinal pathologies etc.
glaucoma Glaucoma is not only an under- Ȉ Ǧ
c.) Prone position test (for PACD) diagnosed but also an over-diagnosed rule out secondary glaucoma and
i. Patient is made to lie down in disease. If patient appears to have been perform gonioscopy to look for
prone position for 30-45 min unnecessarily treated, medicines are additional factors.
ii. Rise of IOP more than 8-10mm stopped and patient is followed up at But for the constraint of space,
Hg is positive 2-4 weeks, then 2 months and then 3-4 these protocols may be made far more
Combined Prone and Dark room months with IOP measurement and six exhaustive than presented here. We
test (for PACD) ϐǤ leave that job to the individual heads
iii. Prone test in dark room done of progression is detected over one year, of glaucoma practice in each individual
for 30-45 min then the patient is followed up every 6-12 institution/ group practice.
iv. Rise of IOP to 10mm Hg more monthly for a total of 5-6 years when he
than baseline is taken as positive can be declared as not having glaucoma. REFERENCES
ARRIVING AT A DIAGNOSIS Stable patient, in whom a medication 1. Weinreb RN, Friedman DS. Angle
has been altered, should routinely be closure and angle closure glaucoma.
After determining the corrected seen within approximately one month of Consensus series 3;2006. Kugler
IOP and the status of angles, patients the change. Publications: The Hague, Netherlands
are dilated for fundus examination p.21-26.
and details of optic disc are recorded Patients with stable disease in
diagrammatically along with the optic whom satisfactory IOP control has been 2. Terminology and Guidelines for
disc size. achieved should be followed at three to Glaucoma: European glaucoma society
four months’ interval. IV edn.2014. p. 33-38.
Stable patients with less severe 3. Terminology and Guidelines for
Glaucoma: European glaucoma society
ǤʹͲͲ͵Ǥ Ǥ ϐ
Ǥ
Financial Interest: ϔ
Ȁ
Ǥ
www. dos-times.org 33
OCULAR ONCOLOGY
INTRA-ARTERIAL CHEMOTHERAPY FOR RETINOBLASTOMA:
INTERNATIONAL PERSPECTIVE
Sudheer Ambekar, Victor M. Villegas, Eric Peterson, Timothy G. Murray
Retinoblastoma (RB) is the most common and multiple cycles are routinely needed. Bone marrow
intraocular malignancy in children affecting suppression, ototoxicity, nephrotoxicity and risk of induction
about 1 in 15,000 live births1. Early diagnosis of secondary cancers have been reported6-7. Trilateral RB may
is of utmost importance because small tumors be prevented in hereditary cases by treatment with systemic
have the best prognosis. Historically, leukocoria chemotherapy8-9. Combined therapy has been shown to have
has been the most important sign1. However, if better globe salvage rates than chemotherapy alone in both
the primary tumor is peripheral, leukocoria in primary position early and advanced RB10-13.
and sensory strabismus may be clinically apparent in advanced A recent study on macular retinoblastoma outcomes
stages of RB and may delay ophthalmological evaluation2. showed that chemoreduction with transpupillary
Therapies for RB have dramatically advanced during the last thermotherapy of both foveal and extrafoveal tumors achieve
ͳͲ Ǥ ϐ
tumor control in 83% of R-E group V tumors14. All tumors
to directly ocular and intra-arterial chemotherapy is currently less than R-E group V tumors achieved 100% control. Despite
underway. Technological changes and strategies focus on local ablative foveal laser treatment, 56% of eyes had better than
treatments due to decreased morbidity to patients and excellent 20/80 visual acuity.
tumor response. New treatments are providing new hope to Enucleation remains the standard treatment of Group
patients, especially to those with the most severe disease. E RB15. Histopathologic analysis may determine if adjuvant
Management of RB tumors requires a multidisciplinary treatment is necessary depending on high-risk criteria at the
approach that may include an ocular oncologist, pediatric time of enucleation16. Adjuvant therapy postenucleation has
oncologist, pediatric ophthalmologist, pediatrician, been shown to decrease metastasis in advanced RB from 24%
interventional radiologist, and ocular pathologist. of children to 4%17.
Individualized treatment, considering factors such as the
ϐ
ȋ Ȍ ǡ ǡ
INTRA-ARTERIAL CHEMOTHERAPY
tumors, age of patient, family history, and prior treatment
must be considered1,3. RB treatment is aimed at child survival. In 2004, Japanese physicians revolutionized the treatment
Globe salvage and preservation of vision are secondary goals. of RB by introducing the technique of infusing melphalan
Early diagnosis remains the most crucial step in decreasing directly into the ophthalmic artery18. The study technique
morbidity and mortality2. consisted of catheterization of the internal carotid artery and
occlusion of a micro-balloon distal to the ophthalmic artery.
Treatment of small tumors may only require transpupillary During the temporary occlusion, melphalan was infused into
thermotherapy4. Laser treatments may be repeated monthly the ophthalmic artery. The Japanese study performed 563
until complete tumor regression is documented5. It is important intra-arterial chemotherapy procedures in 187 patients with no
to follow up patients closely to monitor for recurrence. reported serious complications including stroke. The youngest
If recurrence is present, adjuvant chemotherapy may be patient to be treated was 1 month of age. The most common
considered. complications were mild transient bradycardia, periorbital
erythema and swelling. The study concluded that melphalan
The classic three-drug systemic treatment (carboplatin, could be successfully administered to the ophthalmic artery
ǡ Ȍ
ϐ
ͻΨ ϐ
ϐ
18.
Therapies for RB have dramatically After the initial description of the intra-arterial procedure,
advanced during the last 10 years. A
ϐ
ϐ
technique in patients with advanced RB. Subsequently,
chemotherapy to directly ocular and Abramson and associates developed a technique that allowed
repeated cannulation of the ophthalmic artery in young children
with advanced retinoblastoma without the need to occlude the
intra-arterial chemotherapy is currently
ϐ ȋ ͳȌ19. The
underway. Technological changes and
ϐ
strategies focus on local treatments due control and stabilization of vision in children with R-E Group
to decreased morbidity to patients and V tumors without severe side effects19-20. Only 1 patient from
excellent tumor response. their studies had disease progression that needed enucleation.
No patient received systemic chemotherapy or radiation.
Further studies by the same group reported 4 patients with
www. dos-times.org 35
OCULAR ONCOLOGY
bilateral R-E Group V who were
ϐ
initially treated bilaterally20. All change23-24.
patients avoided enucleation or Most recently, a trend
Ǥ ϐ
towards three-drug intra-
effects were observed. arterial treatment (carboplatin,
Recent studies performed melphalan, and topotecan) has
at the Wills Eye Hospital have been reported25. Twenty-six
ϐ
Ǧ eyes of 25 patients received
arterial chemotherapy21. The the three-drug chemotherapy
study analyzed 70 eyes of 67 for treatment of advanced
patients following ophthalmic retinoblastoma. In the three-
artery chemotherapy infusion drug therapy, dose ranges were
ϐ
Ǥ 2.5-7.5 mg for melphalan, 0.3-
The mean patient age at 0.6 mg for topotecan, and 25-50
initiation of treatment was mg for carboplatin, and median
30 months. The treatment infusions per eye was 2 (range
was primary in 36 eyes and 1-4). The Kaplan-Meier estimate
secondary in 34 eyes. Globe Figure 1: &KIKVCNN[ UWDVTCEVGF UGNGEVKXG CTVGTKQITCO KOCIG QH VJG of ocular survival at 24 months
salvage was achieved in 72% QRJVJCNOKE CTVGT[ YKVJQWV DCNNQQP QEENWUKQP
was 75%. Electroretinogram
of primary-treated cases and showed improvement greater
in 62% of secondary-treated cases. eyelid edema (5%), forehead hyperemia than 2 μV in 4 eyes (15%), loss greater
ϐ
ǡ
ȋʹΨȌ
ϐ ȋ͵ʹΨȌǤ than 25 μV in 12 eyes (46%), and no
globe salvage for group B (100%), group Serious complications included severe change greater than 25μV in 10 eyes
C (100%), group D (94%), and group bronchospasm and hypotension (1.1%), (39%). Other large studies have also
E (36%). The common complications vitreous hemorrhage (1.5%) and retro- reported successful treatment with this
included transient eyelid edema, orbital hemorrhage (0.3%). There was no regimen21Ǥ ϐ
blepharoptosis, and forehead hyperemia. patient with stroke, seizure, neurologic selective intra-arterial combination
ϐ
impairment, limb ischemia, or death. therapy with carboplatin, carboplatin,
were present including stroke, seizure, and melphalan is effective in the
neurologic impairment, limb ischemia, DISCUSSION treatment of RB and decreases the toxic
secondary leukemia, metastasis, or window during treatment especially in
death. Similar studies performed at the ϐ
Ǧ patients that need bilateral therapy.
Bascom Palmer Eye Institute evaluating delivery of other chemotherapeutic agents
selective ophthalmic artery infusion with has prompted various small studies. Sequential intravenous chemo-
melphalan in patients with R-E Group V This strategy has been investigated therapy followed by intra-arterial
tumors that have failed prior systemic to avoid melphalan dose restriction chemotherapy (bridge chemotherapy) for
chemotherapy and laser consolidation during bilateral therapy. Francis et al young infants with retinoblastoma may
showed comparable results22. recently reported the use of single agent be considered in cases were cannulation
carboplatin at doses ranging from 25 to 40 of the ophthalmic artery is not possible26.
UNIVERSITY OF MIAMI EXPERIENCE mg, and cumulative doses from 25 to 100 Further studies will elucidate the optimal
mg, in 3 cases where high-dose melphalan timing for bridging.
Between January 2008 and was needed in the contralateral eye
December 2014, 74 patients with 78 eyes and systemic toxicity limited the use of Intra-arterial chemotherapy delivers
underwent IAC in 268 sessions (mean melphalan to 1 eye23. Tumor regression high-dose chemotherapy to eyes of
age 88 months; range 2 months to 95 was seen with as little as 1 cycle. No children with RB. The 5-year experience
months). 84% of the patients received IAC systemic adverse effects were seen. has demonstrated the effectiveness of
in ophthalmic artery. Each eye received a Similar results have been shown with this novel therapy both as salvage and
median of 4 IAC sessions per eye (range, intra-arterial infusion of both carboplatin primary management. No deaths or
1-7). After IAC with a mean follow-up of and topotecan24. In addition, analysis of strokes have been observed, but vision-
18 months, globe salvage was achieved electroretinogram responses following threatening vascular complications
in 76% of the cases (Figure 2-5). The infusions containing carboplatin only have been reported to date. Long-term
main complications included transient and carboplatin with topotecan revealed studies evaluating selective intra-arterial
chemotherapy are needed to determine
ϐ
Ǥ
1. Department of Neurological Surgery, University of Miami, Miller School of Medicine, Miami, Florida
2. Murray Ocular Oncology and Retina, University of Miami, Miller School of Medicine, Miami, Florida
Dr. Sudheer Ambekar MCh1 Dr.Victor M.Villegas MD2 Dr. Eric Peterson MD1 Dr.Timothy G. Murray MD, MBA2
36 DOS TIMES - NOVEMBER-DECEMBER 2015
OCULAR ONCOLOGY
Figure 2: +PKVKCN RTGUGPVCVKQP QH RCVKGPV YKVJ TGVKPQDNCUVQOC Figure 3: (QNNQY WR GZCOKPCVKQP CV OQPVJU CHVGT ſTUV E[ENG QH KPVTC
CTVGTKCN EJGOQVJGTCR[
Figure 4: (QNNQY WR GZCOKPCVKQP CV OQPVJU UJQYKPI VWOQT TGITGUUKQP Figure 5: (QNNQY WR GZCOKPCVKQP CV OQPVJU UJQYKPI VWOQT TGITGUUKQP
CHVGT UGEQPF E[ENG QH KPVTC CTVGTKCN EJGOQVJGTCR[ CHVGT HQWTVJ E[ENG QH KPVTC CTVGTKCN EJGOQVJGTCR[
Minimizing systemic adverse events in REFERENCES control, local complications, and
patients with RB with local chemotherapy visual outcomes for eyes treated with
ϐ
ϐ
Ǥ 1. Shields CL, Shields JA. Basic understanding chemotherapy and repetitive foveal laser
ϐ
ϐ
ablation. Ophthalmology. 2007;114:162–
the most from systemic chemotherapy of retinoblastoma. Curr Opin Ophthalmol. 69.
to prevent late-onset intracranial 2006;17:228–34. 6. Jehanne M, Lumbroso-Le Rouic L,
malignancies9. Savignoni A, et al. Analysis of ototoxicity
2. Leander C, Fu LC, Pena A, et al. Impact of in young children receiving carboplatin in
CONCLUSION an education program on late diagnosis the context of conservative management
of retinoblastoma in Honduras. Pediatr of unilateral or bilateral retinoblastoma.
Intra-arterial chemo-therapy is Blood Cancer. 2007;49:817–19. Pediatr Blood Cancer. 2009;52:637-43.
safe and effective compared to systemic 7. Bartuma K, Pal N, Kosek S, Holm S,
chemotherapy in the management of 3. Shields CL, Shields JA. Retinoblastoma All-Ericsson C. A 10-year experience
patients with retinoblastoma measuring management: advances in enucleation, of outcome in chemotherapy-treated
more than 3mm in apical height. Further intravenous chemoreduction, and hereditary retinoblastoma. Acta
advances in ocular oncology leading to intra-arterial chemotherapy. Curr Opin Ophthalmol. 2013 Oct 7
newer therapies are anticipated in the Ophthalmol. 2010;21:203–212. 8. De Potter P, Shields CL, Shields JA. Clinical
future. variations of trilateral retinoblastoma: a
4. Shields CL, Santos MC, Diniz W, et al. report of 13 cases. J Pediatr Ophthalmol
Thermotherapy for retinoblastoma. Arch Strabismus. 1994;31:26–31.
Ophthalmol. 1999;117:885–93. 9. Shields CL, Meadows AT, Shields JA,
ͷǤ
ϐ ǡ
ǡ ǡ www. dos-times.org 37
Toledano S, Murray TG. Macular
retinoblastoma: evaluation of tumor
OCULAR ONCOLOGY
Carvalho C, Smith AF. Chemoreduction for ablation. Ophthalmology. 2007;114:162– chemotherapy for retinoblastoma in 70
retinoblastoma may prevent intracranial 69. eyes: outcomes based on the international
neuroblastic malignancy (trilateral 15. Honavar SG, Singh AD. Management of
ϐ
Ǥ
retinoblastoma). Arch Ophthalmol. advanced retinoblastoma. Ophthalmol Ophthalmology. 2014;121:1453-60.
2001;119:1269–72. Clin North Am. 2005;18:65–73. 22. Mutapcic L, Murray TG, Aziz-Sultan
10. Shields CL, Mashayekhi A, Au AK, et 16. Eagle RC Jr. High-risk features and tumor MA, et al. Supraselective Intra-Arterial
Ǥ ϐ
differentiation in retinoblastoma: a Chemotherapy: Evaluation of Treatment
Retinoblastoma predicts chemoreduction retrospective histopathologic study. Arch Related Complications in Advanced
success. Ophthalmology. 2006;113:2276– Pathol Lab Med. 2009;133:1203–09. Refractory Retinoblastoma. Clin
80. 17. Honavar SG, Singh AD, Shields CL, et al. Ophthalmol. 2010 In press.
11. Rodriguez-Galindo C, Wilson MW, Haik Postenucleation adjuvant therapy in high- 23. Francis JH, Gobin YP, Brodie SE, Marr BP,
BG, et al. Treatment of intraocular risk retinoblastoma. Arch Ophthalmol. Dunkel IJ, Abramson DH. Experience of
retinoblastoma with vincristine and 2002;120:923–31. intra-arterial chemosurgery with single
carboplatin. J Clin Oncol. 2003;21:2019– 18. Yamane T, Kaneko A, Mohri M. The agent carboplatin for retinoblastoma. Br J
25. technique of ophthalmic arterial infusion Ophthalmol. 2012;96:1270-1.
12. Gombos DS, Kelly A, Coen PG, Kingston JE, therapy for patients with intraocular 24. Francis JH, Gobin YP, Dunkel IJ, Marr
Hungerford JL. Retinoblastoma treated retinoblastoma. Int J Clin Oncol. BP, Brodie SE, Jonna G, Abramson DH.
with primary chemotherapy alone: the 2004;9:69–73. Carboplatin +/- topotecan ophthalmic
ϐ
ǡ
ǡ 19. Abramson DH, Dunkel IJ, Brodie SE, artery chemosurgery for intraocular
age. Br J Ophthalmol. 2002; 86:80–83. Kim JW, Gobin YP. A phase I/II study of retinoblastoma. PLoS One. 2013;8:
13. Shields CL, Mashayekhi A, Cater J, Shelil A, direct intraarterial (ophthalmic artery) e72441.
Meadows AT, Shields JA. Chemoreduction chemotherapy with melphalan for 25. Marr BP, Brodie SE, Dunkel IJ, Gobin YP,
for retinoblastoma: analysis of tumor intraocular retinoblastoma initial results. Abramson DH. Three-drug intra-arterial
control and risks for recurrence in 457 Ophthalmology. 2008;115:1398–1404.. chemotherapy using simultaneous
tumors. Trans Am Ophthalmol Soc. 20. Abramson DH, Dunkel IJ, Brodie SE, carboplatin, topotecan and melphalan for
2004;102:35–44. Marr B, Gobin YP. Superselective intraocular retinoblastoma: preliminary
ͳͶǤ
ϐ ǡ
ǡ ǡ Ophthalmic Artery Chemotherapy as results. Br J Ophthalmol. 2012;96:1300-3.
Toledano S, Murray TG. Macular Primary Treatment for Retinoblastoma 26. Gobin YP, Dunkel IJ, Marr BP, Francis JH,
retinoblastoma: evaluation of tumor (Chemosurgery). Ophthalmology. 2010 Brodie SE, Abramson DH. Combined,
control, local complications, and 21. Shields CL, Manjandavida FP, Lally SE, sequential intravenous and intra-arterial
visual outcomes for eyes treated with Pieretti G, Arepalli SA, Caywood EH, chemotherapy (bridge chemotherapy) for
chemotherapy and repetitive foveal laser Jabbour P, Shields JA. Intra-arterial young infants with retinoblastoma. PLoS
One. 2012;7:e44322.
Financial Interest: ϔ
Ȁ
Ǥ
38 DOS TIMES - NOVEMBER-DECEMBER 2015
DIAGNOSTICS DISCUSSION
USE OF ASOCT IN KERATITIS
Rishi Swarup, Krishna Priya KVR, B. Indira
A29 year old male presented to the corneal clinic point the clinical diagnosis was revised as possible microbial
with the complaints of pain redness, irritation keratitis.
and photophobia in right eye since 10 days. He
gives history of swimming in a new pool since Spectral Corneal OCT was performed to assess the depth of
last 2 months. Not associated with any other ǡ
ϐ
ϐ
Ǥ ǡ involvement of stroma. This was quite unlike anterior stromal
multiple, coarse, diffuse punctate epithelial lesions were ϐ
ǡ
noticed on cornea (Figure1 a & b). which is characteristic of Adenoviral EKC. (Figure 3a) shows
anterior segment OCT in present case which was diagnosed
The differential diagnoses at that point of time were as Microsporidial keratitis on microbiological analysis. (Figure
Microsporidial Epithelial Keratitis, Adenoviral Epidemic 3b) shows anterior segment OCT in a representative case of
ȋ Ȍ ǡ ǯ ϐ
Adenoviral EKC.
keratitis (Thygesons SPKs). Initially, it was clinically diagnosed
to be Adenoviral EKC and was treated with steroid, lubricant Epithelium was scraped and sent for smear and on acid
eyedrops and antibiotic eye ointment. Patient returned to clinic
ǡ
ϐ
in 4 days with worsening of symptoms (Figure2a and b). At this the clinical diagnosis of Microsporidial Keratitis.
(a) (b)
Figure 1(a): &KHHWUG +NNWOKPCVKQP Figure 1(b): (QECN KNNWOKPCVKQP (b)
(a)
Figure 2(a): 5NKV KNNWOKPCVKQP Figure 2(b):(QECN +NNWOKPCVKQP
www. dos-times.org 39
DIAGNOSTICS DISCUSSION
Anterior segment OCT-Present case (Figure 3a), Adenoviral EKC (Figure 3b)
(a) (b)
Figure 3(a): 'RKVJGNKCN J[RGT TGƀGEVKXKV[ CNQPG UGGP KP OKETQURQTKFKCN MGTCVKVKU Figure 3(b): 'RKVJGNKCN CPVGTKQT UVTQOCN J[RGT TGƀGEVKXKV[ YJKEJ KU UGGP
KP #FGPQXKTCN 'RKFGOKE -GTCVQEQPLWPEVKXKVKU
4GRTGUGPVCVKXG 1%6 RKEVWTG
CLINICAL COURSE Alcohol was applied over the diseased CONCLUSION
epithelium using a 9 mm alcohol well for
After debridement of all the clinically a duration of 30 seconds. The affected Spectral Corneal OCT may thus be
affected epithelium, the patient was put epithelium was then removed using a dry used as a non-invasive tool to differentiate
on topical antibiotics and lubricants. merocel sponge. Bandage contact lens the two clinical conditions that present
However, as the epithelium healed, was applied. Post-operatively the patient with a similar clinical picture but have
epithelial punctate lesions reappeared received topical antibiotics, lubricants different management approaches.
and the patient became symptomatic in a and surface steroid drops for a duration
weeks time. It was postulated that simple of 1 month. The epithelium healed and Alcohol may play a microbicidal
debridement did not completely eliminate remained recurrence free for a duration role in preventing recurrence of
the microbe and therefore alcohol assisted of 1 year post-operatively. microsporidial keratitis in addition to
epithelectomy was performed. 20% aiding removal of diseased epithelium,
ϐ
using an OCT.
Swarup Eye Centre, Hyderabad, India
Dr. Rishi Swarup FRCS Dr. Krishna Priya KVR DO B. Indira Bsc (Opt.)
Financial Interest: ϔ
Ȁ
Ǥ
40 DOS TIMES - NOVEMBER-DECEMBER 2015
SNAPSHOT
NEVUS OF OTA- CASE REPORT
Chandana Chakraborti, Nabanita Barua
Nevus of Ota, also known as oculodermal melanosis (ODM) is an uncommon entity.
We report two cases of nevus of Ota with various ocular and systemic features as
these two cases had some rare presentations like hard palate, external auditory
meatus pigmentation involvement
Nevus of Ota (nevus fusculocoeruleus
Ȍ ϐ
within normal limit. Gonioscopy showed open angle in both
in 1939 by Japanese dermatologist Dr. M.T. eyes. IOP was 14 mm Hg both eyes. She had pigmentation
Ota1. Condition is mostly unilateral (90% over hard palate also (Figure 6). Patient was prescribed near
cases), affecting females (1:4.8). It has two correction and followed up yearly for glaucoma or any uveal
peaks, infancy and adolescent suggesting pathology.
ϐ
2. It comprises of a spectrum of ocular DISCUSSION
and dermatological manifestations. Ocular manifestations are
increased pigmentation of episclera, uveal tract, trabecular The aetiopathogenesis of naevus of Ota suggests incomplete
meshwork, sclera, retrobulbar fat, disc and retina1. Common migration of melanocytes from the neural crest to the epidermis
dermatological signs are increased pigmentation of face along during the embryonic stage2. The lesion may progress during
ophthalmic and maxillary branch of trigeminal nerve. Rarely puberty and in postmenopausal women, supporting hormonal
there may be involvement of hard palate, orbit,meninges,
tympanic membrane, intranasal and oral mucosa3. The disorder
is more common in Asian, Hispanic and Africans, although
the transformation to malignant uveal, orbital and meningeal
melanoma is more common in light skinned population4.
Regular follow up for early detection of ocular complication is
required.
CASE 1 Figure 1: 7PKNCVGTCN RKIOGPVCVKQP QH NGHV EJGGM CPF HQTJGCF
Eighteen year old male presented with increased
pigmentation of left periorbital skin since last three months.
He had black hair and dark complexion. Examination revealed
best corrected visual acuity (BCVA) 20/20 right eye and
20/60 left eye for distance and N6 right and N8 left for near.
He had bluish LE grey pigmentation of temple, periorbital
skin and around external auditory meatus (Figure 1,2).
Ocular examination revealed similar pigmentation of bulbar
conjunctiva, episclera and sclera of left side (Figure 3). Fundus
revealed cup disc ratio of 0.4 & 0.6 RE & LE respectively and
dense pigment clumps in posterior in pole and peripapillary
area with extensive chorioretinal atrophy of left eye (Figure
4). Gonioscopy revealed opened angle on both the sides with
heavily pigmented trabecular meshwork on the left side. IOP of
16 mmHg in both eyes was recorded in applanation tonometery.
Patient was asked to attend glaucoma clinic for evaluation but
he never turned up.
CASE 2 Figure 2: 2KIOGPVCVKQP QH NGHV UKFGF GZVGTPCN CEQWUVKE OGCVWU
Thirty eight year old female presented with dimness of
near vision for 6 month. BCVA was 20/20 in both the eyes. She
had speckled bluish pigmentation of face. The pigmentation was
typically along 1st and 2nd division of ophthalmic nerve (Figure
5). Apart from the bluish discoloration of conjunctiva, episclera
and sclera of right eye, anterior and posterior segments were
www. dos-times.org 41
SNAPSHOT
Figure 3: 2KIOGPVCVKQP QH NGHV EQPLWPEVKXC GRKUENGTC CPF UENGTC
%CUG Figure 4: (WPFWU RKEVWTG QH DQVJ G[GU 4KIJV HWPFWU KU PQTOCN .GHV
HWPFWU UJQYU EWRRKPI YKVJ UWRGTKQT VJKPPKPI YKVJ RGTKRCRKNNCT[
CVTQRJ[ UECVVGTGF GZVGPUKXG EJQTKQTGVKPCN CVTQRJ[
%CUG
Figure 5: 7PKNCVGTCN RKIOGPVCVKQP QH TKIJV EJGGM CPF HQTGJGCF YKVJ Figure 6: 2KIOGPVCVKQP QP JCTF RCNCVG
%CUG
EQPLWPEVKXC GRKUENGTC CPF UENGTCN KPXQNXGOGPV
%CUG
ϐ
Ǧ Table 1: Chronological listing of intraoral nevus of Ota (Documented cases).
pituitary-ovarian axis5. It is present in
only 0.5% of the Asian population. Though Case Author Gender/age Location
the prevalence of oculodermal melanosis
(ODM) is less among white population 1 Dorsey and Montgomery M/16 Buccal mucosa
(0.04%), the chance of malignancy is 30-
35 times higher than general population6. 2 Mishima and Mevorah F/35 Hard palate
Unilateral presentation of Ota’s naevus is
seen in 90% of the cases2. 3 Mishima and Mevorah M/45 Hard palate
Episclera and choroidal involvement 4 Decosta and Carneiro M/23 Buccal mucosa
is seen in all the cases and iris is affected
in 80% cases. The two most important 5 Reed and Sugarman F/43 Hard palate
complication of ODM are choroidal
melanomas and glaucoma. Choroidal 6 Yeschua F/27 Buccal mucosa
melanomas are known to occur in less
than 4% of cases and glaucoma has been 7 Page F/59 Hard palate
noticed in less than 10% of cases7. Recent
studies have documented the role of G 8 Rathi F/30 Hard palate
9 Karthiga F/32 Hard palate
10, 11 Parihar F/32, M/33 Hard palate
12 Gaurav and Rathi M/22 Hard palate
13 Present authors F/38 Hard palate
Department of Ophthalmology, Calcutta National Medical College and Hospital, Kolkata,West Bengal, India
Dr. Chandana Chakraborti MD Dr. Nabanita Barua DNB
42 DOS TIMES - NOVEMBER-DECEMBER 2015
SNAPSHOT
ȽǦ ȋ
Ȍ malignant transformation is still a risk12. 5. Fitzpatrick TB, Kitamura H, Kukita A,
in primary ciliochoroidal and central ϐ
nervous system melanomas. Glaucoma lesion but less for deep lesion13. For et al. Ocular and dermal melanocytosis.
may present at any age and is usually larger skin lesion, surgical excision with
open angle. The probable mechanism or without graft is needed14. AMA Arch Ophthalmol. 1956;56:830-
of glaucoma could be melanocytes
deposition in trabecular meshwork Malignant transformation of nevus 832.
and iridocorneal angle impairing the of Ota is reported in structures like skin,
drainage8,9. In case 1, though the disc less commonly with CNS and uveal tract. 6. Kopf AW, Weidman AI. Nevus of Ota.
ϐ
ǡ Mucosal pigmentations should also be
diagnosis could not be established as the screened biannually for features like Arch Dermatol. 1962;85:195-208.
patient was lost to follow up. sudden increase in size of discoloration,
ulceration and paresthesia. Patient 7. Roy PE, Schaeffer EM. Nevus of Ota and
Nevus of Ota can also be associated must be informed about the potential
with other cutaneous disorders and complication of malignancy and choroidal melanoma. Surv Ophthalmol
ocular diseases like phakomatosis glaucoma, its early symptomatology and
ǡ ϐǡ need for yearly follow-up. An integrated 1967;12:130–40.
Sturge-Weber syndrome, Takayasu multidisciplinary approach involving
disease, Klippel-Trenaunay syndrome dentistry, ophthalmology, dermatology, 8. Teekhasaenee C, Ritch R, Rutmin
ϐ10. neurology and pathology is required
to look for early case detection and U, et al. Glaucoma in oculodermal
Hard palate involvement in nevus management11.
of Ota is a rare presentation. Till date melanocytosis. Ophthalmology.
there have been only 12 cases reported
in literature. Our case is the 13th. Palatal 1990;97:562-570.
Ǧϐ
with irregular border that merges with 9. Khawly JA, Imani N, Shields MB.
oral mucosa.
Glaucoma associated with the nevus of
The diagnosis of ODM is essentially
clinical. Biopsy is indicated only to Ota. Arch Ophthalmol. 1995;113:1208-
ϐ
spreading lesion or nodular lesion 1209.
suggesting malignancy11. Treatment
option includes laser and cryotherapy. 10. C.C. A´ lvarez-Cuesta, C. Raya-Aguado,
Recent advent of Q-switched laser with
ruby, alexandrite or Nd:YAG laser is Ǥ ƲǦ Ʋǡ Ǥ Ǥ
ƲÇǡ Ǥ
successful in treating lesion completely
without scarring, though chance of P´erez-Oliva. Nevus of Ota associated
with ipsilateral deafness. Journal of the
American Academy of Dermatology.
2002;47: S257–9.
11. Patel BC, Egan CA, Lucius RW, et al.
Cutaneous malignant melanoma and
oculodermal melanocytosis (nevus
of Ota): report of a case and review
REFERENCES of the literature. J Am Acad Dermatol.
1. Ota M: Nevus fusco-caeruleus 1998;38:862-65.
ophthalmomaxillaris. Tokyo Med J 12. Noordzij MJ, van den Broecke DG,
1939;63:1243-5. Alting MC, et al. Ruby laser treatment of
2. Hidano A, Kajima H, Ikeda S, et al. congenital melanocytic nevi: a review
Natural history of nevus of Ota. Arch of the literature and report of our
Dermatol 1967;95:187–95. own experience. Plast Reconstr Surg.
3. Gonder JR, Shields JA, Albert DM, et al. 2004;114:660-67.
Uveal malignant melanoma associated 13. Chan HHL, Kono T. The use of lasers
with ocular and oculodermal and intense pulsed light sources for the
melanocytosis. Ophthalmology treatment of pigmentary lesions. Skin
1982;89:953–60. Therapy Lett. 2004;9:5-7.
4. Shields JA, Iris melanoma arising from 14. Hata Y, Matsuka K, Ito O, et al. Treatment
sector congenital ocular melanocytosis of nevus of Ota: combined skin abrasion
in a child. Cornea 2009;28:1191–3. and carbon dioxide snow method. Plast
Reconstr Surg. 1996;97:544-54.
Financial Interest: ϔ
Ȁ
Ǥ
www. dos-times.org 43
INNOVATIONS
INNOVATIVE SURGICAL TECHNIQUE
FORNIX FORMATION USING A FLEXI SYMBLEPHARON RING
Shweta Agarwal, Bhaskar Srinivasan, Geetha Iyer
The main aim of treatment in the acute stage is to facilitate rapid epithelisation,
ϐ
complications in the chronic phase. Amniotic membrane transplant with sutures or
ϐ
and chronic stage management
Chemical injuries are potentially blinding injuries Ȉ
and are considered as a true ophthalmic or not possible amniotic membrane can be secured insitu
emergency. They affect all age groups mainly the with the tube under topical anaesthesia.
young and can occur at work or at home. Chemical
injuries result in extensive damage to the ocular Figure 1: +PFKIGPQWUN[ FGUKIPGF UKNKEQPG U[ODNGRJCTQP TKPI
surface epithelium, cornea and limbal stem
cells.Long term outcome depends not only on the severity of inserted deep into the fonices in a circular fashion and the exact
the injury but mainly on the management in the acute stage. size needed to keep the fornices formed is determined. The
Persistent non-healing epithelial defects and prolonged surface excess tube is cut. The free edges of the tube are approximated
ϐ
ǡ ǡ
using a 8-0 nylon suture and the circular ring is placed in
perforation, conjunctival scarring, symblepharon formation the fornix (Figure 2). Both the upper and lower lids are then
ϐ
Ǥ
ϐ
The main aim of treatment in the acute stage is to facilitate over the tarsal surface and continuous 10-0 vicryl sutures along
ǡ
ϐ the lid margin.
corneal melts in the acute stage and cicatrical complications in ADVANTAGES
the chronic phase. Amniotic membrane transplant with sutures Ȉ Ǧ
ǡ ϐǡ
ϐ
Ȉ
disorders both in the acute and chronic stage management1,2. Ȉ
In the acute stage of ocular surface disorders with extensive
epithelial injury, amniotic membrane is draped over the entire retracted
ocular surface from lash line to lash line using various techniques Ȉ
like suturing with 10-0 vicryl and taking fornix forming sutures Ȉ
(John T et al)3 ϐ ȋ Ȉ ǡ
et al)4 or Prokera (Tseng et al)5. Prokera has a cryopreserved
membrane clamped to a 15 or 16mm symblepharon ring and membrane
thus it not just helps better apposition of the membrane to the
surface but also helps to keep the fornices better formed.
In adults Prokera might not be able to effectively cover the
entire bulbar surface and has economic constraints to consider.
ϐ
ring using an intravenous (IV) tubing was designed to keep the
fornices formed.IV tube is made of synthetic material which is
ǡ ϐǡ
available in the operating room. Based on this concept a
symblepharon ring was designed indigenously (with Appasamy
Associates) using a silicone tube with an inner diameter of
20mm and thickness of 2mm (Figure 1).
SURGICAL TECHNIQUE
The amniotic membrane is draped over the entire bulbar
ϐ Ǥ
www. dos-times.org 45
INNOVATIONS
REFERENCES
1. Bouchard CS, John T.Amniotic
membrane transplantation in the
management of severe ocular surface
disease: indications and outcomes.
Ocul Surf 2004;2:201-11.
2. Shimmura S, Shimazaki J, Ohasi
ǡ Ǥ ϐ
effects of amniotic membrane
transplantation in ocular surface
disorders. Cornea 2001;20:408-13.
3. John T,FoulksGN,JohnME,etal.
Amniotic membrane in the surgical
management of acute toxic
epidermal necrolysis.Ophthalmology
2002;109:351-60.
4. BQ Liu,ZC Wang, LM Liu,et al.
ϐ
membrane patch as a therapeutic
contact lens by using a polymethyl
ϐ
sealant in a rabbit model. Cornea
2008;27:74-79.
5. Shay, Elizabeth, Tseng Scheffer, et al.
ϐ
Figure 2(a): #OPKQVKE /GODTCPG
#/ Ō CRRTQZ OO KP FKCOGVGT (b): #/ KU FTCRGF QP VJG amniotic membrane transplantation
DWNDCT UWTHCEG WUKPI ſDTKP INWG (c): +8 VWDG KU KPUGTVGF KP VJG HQTPKEGU (d): 'ZCEV FKOGPUKQP QH VJG
+8 VWDG KU FGVGTOKPGF GZEGUU VWDG KU EWV CPF HTGG GFIGU CTG CRRTQZKOCVGF WUKPI P[NQP UWVWTG for acute toxic epidermal necrolysis.
CPF VJG VWDG KU RWUJGF DCEM KP VJG HQTPKEGU
Cornea 2010;29:359-61.
CONCLUSION also prevents forniceal shortening. It is
a sutureless technique thus making it
In this technique the IV tubing less intrusive, technically easier, with
not just helps keep the amnion better no added cost, faster to perform and
opposed to the bulbar surface but it cosmetically exceptable.
Cornea and Ocular Services, Surface Disorders, Sankara Nethralaya, Chennai, India.
Dr. Shweta Agarwal MS Dr. Bhaskar Srinivasan MS Dr. Geetha Iyer DNB, FRCS
Financial Interest: ϔ
Ȁ
Ǥ
46 DOS TIMES - NOVEMBER-DECEMBER 2015
PRACTICE REQUISITES
INTRAOPERATIVE WAVEFRONT ABERROMETRY - NEW PARADIGM
TOWARDS ACHIEVING NEAR PERFECTION IN CATARACT SURGERY
Sudipto Pakrasi, Srilathaa Gunasekaran, Carreen Pakrasi, Digvijay Singh, Maya Hada, Varun Gogia
Intraoperative aberrometry (IWA) - better acronym of intraoperative wavefront
aberrometry is intended to reduce residual refractive error by estimating aphakic
ϐ
using preoperative biometry tools. Also it helps in managing astigmatism by assisting
ϐ
of arcuate corneal incisions either as primary procedure or as an enhancement
Cataract surgery has increasingly become a
refractive surgery in itself. Regardless of the age of system1. The shape of the wavefront is analysed by expanding
the patient or type of cataract and irrespective of it into a set of polynomials called as Zernike polynomials which
previous ocular history, the patients’ expectations is a combination of independent trigonometric functions
of having an emmetropic vision postoperatively Ǥ ϐ
ǡ
the second order includes defocus and astigmatism, third
cannot be underestimated. Technology has also order has coma and trefoil while the fourth is represented by
evolved hand in hand to match this requirement. In the last tetrafoil, secondary astigmatism and spherical aberration. The
decade alone, so many newer devices have been launched to common errors of refraction are placed in the second order
ϐ ǡ and spectacles can correct only these and not the higher order
based IOL power calculation, planning softwares that guide aberrations.
in toric IOL placement to the development of femtosecond Wavefront analysis done using an aberrometer measures
laser for assisting the most crucial steps in cataract surgery. the optical aberrations and hence evaluates the optical quality
And to this is the recent addition of intraoperative wavefront in an eye. The unit for wavefront aberrations is microns or
aberrometer to ascertain refraction status of the eye for better fractions of wavelength and is expressed as the root mean
prediction of IOL power. ȋ ȌǤ
ϐ ǣ
1. Outgoing wavefront aberrometer as in the Hartmann–
WAVEFRONT ABERROMETRY Shack sensor
ϐ
2. Ingoing retinal imaging aberrometer as in the cross-
optics. In geometrical optics, the rays from a point source of cylinder aberrometer, Tscherning aberrometer and the
Ǥ
ϐ sequential retinal ray tracing method
is considered to be linear bundles of light rays. In physical
optics, on the other hand, light is expressed as a wave, and the 3. Ingoing feedback aberrometer as used in the spatially
light waves spread in all directions as a spherical wave. The resolved refractometer and the optical path difference
wavefront is the shape of the light waves that are all in-phase. method
ϐ
The higher order aberrations (HOA) measured from an
wavefront.
optical system are represented as total and cornea HOAs and
ϐ
ϐ
CLINICAL APPLICATIONS OF WAVEFRONT
that refracts the light rays, it can also be considered as the one ABERROMETRY
that transforms the shape of the wavefront. The refractive status
of the eye, for example emmetropia, myopia, hyperopia and Wavefront data has been extensively employed in the
eyes with HOAs (irregular astigmatism), can be displayed using wavefront guided refractive surgery also called as customised
wavefronts. The wavefront from an emmetropic eye is a perfect ablation. Here the excimer laser corrects not only the spherical
plane that is perpendicular to the line of sight. Wavefront from and cylindrical errors but also the HOAs and is known to reduce
myopic eye has a bowl shape with the peripheral wavefront the surgically induced aberrations. Various studies have proven
more advanced from the central wavefront while the wavefront that the technique is safe and effective for the treatment of
from hyperopic eye has a hill shape with the central wavefront myopic astigmatism.
more advanced than the peripheral wavefront. Other clinical applications include measurement of
ϐ aberrations in keratoconus, pellucid marginal degeneration,
wavefront that originates from the measured optical system
ǡ ϐ ǡ
from reference wavefront that comes from an ideal optic and in cataracts.
www. dos-times.org 47
PRACTICE REQUISITES
INTRAOPERATIVE WAVEFRONT guidance system. It was designed by ORA SYSTEM DESCRIPTION
Wavetec Vision and has been recently
ABERROMETRY acquired by Alcon (Fortworth, Texas). The ORA System is composed of:
The ORA System provides streaming 1. Optical head with the aberrometer
Wavefront aberrometry has also refractive information to help the
made its inroads into intraoperative surgeon determine IOL power, cylindrical mounted to the surgical microscope
estimation of refractive status of the eye ϐ 2. A freestanding cart – It is OR based
for better IOL prediction and emmetropic calculations in post refractive procedure
Ǥ ϐ
eyes. It also improves astigmatic system housing the touchscreen
particularly in post refractive surgery outcomes by accounting for both anterior monitor and processor. The monitor
eyes undergoing cataract surgery as and posterior corneal astigmatism and displays a three-camera view of the
estimation of accurate IOL power in these by calculation of surgically induces eye during the measurement process
eyes has only been eluding the surgeons. astigmatism (SIA) thus decreasing the and the refractive information. It
Intraoperative aberrometry (IWA) is percentage of patients falling outside provides control to ORA System
intended to reduce residual refractive 0.5D aberrometer and also receives and
error by estimating aphakic refraction processes data from ORA System
ϐ Evolution in technology aberrometer.
revise the IOL power choice made using 3. The three cameras housed in the
preoperative biometry tools. Also it helps ORA ϐ ϐ
in managing astigmatism by assisting wavefront aberrometer designed by camera, focus camera and refraction
in toric IOL alignment with real time Wavetec in 2009 which was replaced by camera (fringe pattern) which
ϐ
the ORA system in 2011. The ORA system actually displays the aberrometry
placement of arcuate corneal incisions with Verifeye was later released in 2013 through the generated fringe pattern
either as primary procedure or as an and the latest upgrade “VerifEye+” was (Figure 2).
enhancement. recently launched in 2015. Globally 4. AnalyzOR secure web based
over 440 systems have been installed, data system which provides data
OPTIWAVE REFRACTIVE ANALYSIS tested and optimised with 10 upgrades analysis and stores the pre and post-
over three years and over 3 lac cataract operative patient data.
Optiwave refractive analysis (ORA) procedures performed. The ORA System is designed to
ȋ ͳȌ ϐ
function with a 200 mm focal length
available FDA approved intraoperative microscope objective lens. The light
source used in the system is from Super
Figure 1: /KETQUEQRG OQWPVGF CDGTTQOGVGT YKVJ VJG 14 ECTV Figure 2: &KURNC[ UJQYKPI VJG VJTGG ECOGTC XKGY YKFG ſGNF QH XKGY
TGHTCEVKQP ECOGTC CPF HQEWU ECOGTC
Medanta the Medicity, Gurgaon and Medanta Mediclinic, New Delhi, India
Dr. Sudipto Pakrasi MD Dr. Srilathaa Gunasekaran MD Dr. Carreen Pakrasi MS
Dr. Digvijay Singh MD Dr. Maya Hada MD Dr.Varun Gogia MD
48 DOS TIMES - NOVEMBER-DECEMBER 2015
PRACTICE REQUISITES
Figure 3: $GCO RCVJ FWTKPI YCXGHTQPV CPCN[UKU Figure 4: 2GTHGEVN[ CNKIPGF G[G YKVJ VJG VTCEM DCNN KP VJG EGPVTCN ITGGP \QPG
luminescent diode (SLED) which provides (a) (b)
sharper fringe pattern and improved
measurement accuracy. Beam from (c) (d)
ȋ Ȍ ϐ
off of dichroic mirror and into eye where Figure 5: (TKPIG RCVVGTP FKURNC[ CU ECRVWTGF D[ TGHTCEVKXG ECOGTC (a): 1RVKOCN RCVVGTP (b): #KT
it scatters off of the retina. Scattered light DWDDNG KP CPVGTKQT EJCODGT (c): 4GUKFWCN EQTVKECN OCVVGT (d): %QTPGCN GFGOC FWG VQ GZEGUUKXG
then returns through lens and cornea and YQWPF J[FTCVKQP YJKEJ OC[ KPVGTHGTG YKVJ VJG OGCUWTGOGPV QH CUVKIOCVKUO
the wavefront returns to aberrometer for
analysis (Figure 3). ORA calculates ELP as lens constant is done after cataract extraction and
plus wavetec factor (WTF). Wavetec factor
The aberrometer in ORA houses is derived from 3rd order polynomial thorough cortical cleanup. The anterior
the Talbot Moiré interferometer which equation based on aphakic SE. It is
ϐ ϐ
ϐ
chamber must be devoid of any air
the operating microscope. The diffraction based on anatomical characteristics of
of the wavefront as it passes through the the eye being measured. ϐ
grating pair produces a fringe pattern
and it is analyzed using proprietary Measurement using ORA system salt solution or any cohesive viscoelastic
algorithms. Aberrations of the eye alter
the wavefront which cause distortions The wavefront analysis of the eye but never both. The incisions must be
in the fringe pattern that is captured by
the refraction camera and displayed on sealed taking care not to create excessive
the monitor as the refractive status of the
subject eye. stromal edema. The lid speculum and
IOL power calculation using ORA drape must be out of the way and
cornea well moistened. Before capture,
ORA uses aphakic Spherical
ϐ
Equivalent (SE), average K and ORA anterior corneal surface, then its light
calculated Effective Lens Position (ELP) turned off and the patient instructed to
in the refractive vergence formula for the ϐ Ǥ
ǡ
calculation of IOL power. ORA takes into all three camera images on the monitor
account the posterior K value as well and are centered in their respective screens
hence keratometry readings captured (Figure 4). Within a few seconds 40
by ORA may be different from pre-op K images are captured and the IOL power
values. The refractive vergence formula recommendation is displayed. In short
being for a successful measurement the eye
must be well aligned, widely opened, well
hydrated, and well pressurized (Figure
5,6).
www. dos-times.org 49
PRACTICE REQUISITES
surgery. The dynamic reticle provides
refractive data, toric placement data,
toric alignment data and data on LRI
placement and enhancement (Figure 8).
Ȉ
provides the measured sphere,
cylinder, axis, lens prediction, degree
gauge, capture zone and centroid
focus bar, measured axis location
and magnitude gauge.
Ȉ
provides cylinder and axis, base axis
location and focus bar
Ȉ
dynamic reticle provides cylinder
and axis, base axis location, rotation
arrow (in alignment mode),
measured cylinder and magnitude
gauge, focus bar.
Ȉ
dynamic reticle provides cylinder
Figure 6: 14# OGCUWTGOGPV FKURNC[ HQT C OWNVKHQECN +1.
VQR NGHV VQTKE +1. YKVJ VJG FKURNC[ QH and axis, LRI template, base axis
CNKIPOGPV CZKU
VQR TKIJV VQTKE +1. TQVCVKQP TGEQOOGPFCVKQP
DQVVQO NGHV .4+ RNCEGOGPV CPF location.
CNKIPOGPV
DQVVQO TKIJV
Table 1: ORAs measuring capabilities LRI cases
The laser-created LRIs that are
CAPABILITIES SPECIFICATION based on pre¬operative topography and
Measurement range -5D to +20D ϐ
Accuracy (sphere) ±0.25D before the ORA readings are taken, the
Repeatability (sphere) ±0.13D aphakic refraction guides in deciding
whether or not to dissect open the laser-
Accuracy (cylinder) ±0.2D from 0.5-5.0D created LRI. When the aphakic refraction
Accuracy (cylinder axis) ±4° if >0.5D (axis less relevant <0.5D) shows a reduction of cylinder to less than
Capture time <2 sec average 0.50 D, one may not have to open the LRI.
ϐ
axis of the LRI, one may dissect open the
CLINICAL APPLICATIONS OF ORA surgeon’s right ocular, providing real- laser LRI and repeat the ORA reading.
ORA provides information that time data and guidance on cylinder, axis, Thus we can titrate down the remaining
amount of rotation required and the lens cylinder in this fashion, and can even add
ϐ power recommendation (Figure 7). a manual LRI to extend the laser LRI with
plan using intraoperative refractive a diamond blade when required.
information for IOL power calculation, VERIFEYE+
axis of astigmatism and magnitude of Analyz Or data
astigmatism (Table 1). This latest advancement in the
ORA technology projects all the salient The ORA analyzor (Figure 9)
Post refractive surgery eyes intraoperative data in the surgeon’s stores and displays surgeon’s data (18
This was the indication which ocular to improve precision during months) and global data (12 months).
ϐ
intraoperatively. Though multitude of (a) (b)
historical and non - historical formulae
are available for IOL power calculation,
the accuracy of IOL power prediction
available with ORA is unmatched.
Toric IOLs Figure 7: &[PCOKE TGVKENG (a): UJQYKPI VJG E[NKPFTKECN RQYGT CPF CZKU CU FKURNC[GF QP VJG 14#
ECTV OQPKVQT (b)
The Verifeye upgrade has enabled
ϐ
IOL power but also the cylindrical
power, axis and guides in perfect IOL
orientation. With VerifEye+ Technology,
the information available on the system
monitor is now sent directly into the
50 DOS TIMES - NOVEMBER-DECEMBER 2015
PRACTICE REQUISITES
6. In addition, utilization of iris hooks
during an ORA System image capture
(a) (a) is contraindicated, because the use
of iris hooks will yield inaccurate
measurements.
Limitations
ͳǤ ϐ
irregularities resulting in higher
order aberrations might yield
inaccurate refractive measurements.
2. Post refractive keratectomy eyes
might yield inaccurate refractive
measurement.
3. The safety and effectiveness of using
(c) (d) the data from the ORA System have
not been established for determining
treatments involving higher order
aberrations of the eye such as coma
and spherical aberrations.
Figure 8(a): 6JG FKHHGTGPV F[PCOKE TGVKENGU KP VJG 8GTKHG[G
VGEJPQNQI[ FKURNC[KPI VJG TGHTCEVKXG Conditions that impact ORA
FCVC (b): VQTKE RNCEGOGPV (c): VQTKE CNKIPOGPV (d): .4+ RNCEGOGPV CPF GPJCPEGOGPV
measurement
1. Dilated pupil should range between
4.5 to 10 mm
2. Over sedation and peribulbar blocks
will impede the patient’s ability to
ϐ
3. Patient’s whose aphakic refraction
ʹǣ ϐ
Ȃ
Ǥ2
Refractive IRB using ORA Conventional pre Haigis L method Shammas method P value
outcomes (246 op methodology
eyes)
Med AE, D (95% CI) 0.35 (0.35 – 0.43) 0.60 (0.58 – 0.73) 0.53( 0.52 – 0.65) 0.51 (0.50 – 0.60) <0.0001
MAE ± SD (D) 0.42 ± 0.39 0.71 ± 0.56 0.65 ± 0.58 0.59 ± 0.52 <0.0001
% within ± 0.5 D 67 46 48 50 <0.0001
% within ± 0.75 D 85 63 66 72 <0.0001
% within ± 1.00 D 94 76 80 87 <0.0001
α
ϐ
ǡ D = dioptres, MAE = Mean absolute error, Med AE = Median absolute error SD = standard deviation
It gives analysis of surgical outcomes 2. Corneal pathology such as Fuchs’ falls outside of ORA’s dynamic range
as absolute prediction error and actual dystrophy, EBMD, keratoconus, (-5 D to + 20 D and > 5 D astigmatism)
prediction error. It also helps manage advanced pterygium, and ocular The Fringe pattern display and focus
astigmatism reports through cumulative surface disease such as dry eyes. camera display in unusual situations is
post op cylinder distribution and double depicted in (Figure 10).
angle vector plots displaying pre op 3. In patients whose preoperative
keratometric astigmatism and post op regimen includes residual viscous REVIEW OF LITERATURE
refractive cylinder. substances left on the corneal surface
such as lidocaine gel or viscoelastics. Ianchulev et al2 have by far done the
CONTRAINDICATIONS largest study of IOL power prediction in
ͶǤ ϐ
the post refractive surgery eyes and have
The ORA System is contraindicated media opacity (such as prominent compared the IOL predictability using
for patients with following clinical ϐ Ȍ Intraoperative Refractive Biometry (IRB)
conditions: will either limit or prohibit the with the other methods of IOL power
1. Progressive retinal pathology such measurement process. calculation in these patients. The IRB was
performed using the IWA – ORA and the
as diabetic retinopathy, age related 5. Patients who have received retro IOL power derived was compared against
macular degeneration, retinal or peribulbar block, nystagmus and Surgeon’s choice, Haigis – L, Shammas
detachment,, macular hole. ocular motility disturbances that formulae sourced from the ASCRS online
impairs their ability to visualize the
ϐ Ǥ
www. dos-times.org 51
PRACTICE REQUISITES
time of cataract surgery or refractive lens
exchange. In the aberrometry group, an
ORange wavefront aberrometer was used
intraoperatively to measure total ocular
refractive cylinder after intraocular
lens implantation and to guide LRI
enhancement. A group in which the
aberrometer was not used served as the
control. The excimer laser enhancement
rate was 3.3% in the aberrometry group
and 16.2% in the control group. He
concluded that the use of intraoperative
wavefront aberrometry to measure and
enhance the effect of LRIs produced a
ϐ
ͷǤǦ
reduction in the odds ratio of subsequent
excimer laser enhancement.
In their study, Huelle et al5 have
ϐ
feasibility, quality and reproducibility
of aberrometry-based intraoperative
refraction during cataract surgery.
IWA refraction was recorded at 7
ϐ
standardised cataract surgery in 74 eyes
of 74 consecutive patients. Out of 814
IWA measurement attempts, 462 WFMs
could be obtained. The most successful
readings were achieved in aphakia with
Figure 9: #PCN[\QT TGRQTVU FKURNC[KPI VJG CDUQNWVG CPF CEVWCN RTGFKEVKQP GTTQT QH VJG UWTIGQP viscoelastic. The highest and lowest
CICKPUV VJG INQDCN FCVC
quality of WFMs across all measurement
points were found after clear corneal
calculator. The study included 246 post methods (intraoperative aberrometry incision and in pseudophakia with
refractive surgery eyes undergoing and a Fourier-domain OCT based IOL
cataract surgery. The ORA was a formula) for IOL power determination at viscoelastic, respectively. High
ϐ
ǯ cataract surgery in a group of patients who
IOL selection and decision making. Of the have received LVC. 39 eyes were included consistency across repeated measures
total 246 eyes, in 68% of the time, ORA in the study. The differences among the
ϐ
ȋ͵ͺΨȌ
tested methods were not statistically were found for mean spherical equivalent
(30%) over the preoperative IOL power ϐ
ǡ
calculation. In the additional 13% of for more accurate results with the Masket ȋ Ȍ
ΫͲǤͲͳ
ǡ
ϐ method in the group with historical data
IOL power calculation. For the main in whom all formulae were analyzed. In ΫͲǤͲͳ ǡ
outcome of median absolute error, IRB the group without historical data mean
using absolute error values were comparable ranges were high.
between the groups. This study shows
ORA achieved the lowest error of promising results for newer methods, They noted that IWA refraction in
0.35 D. All other methods demonstrated such as intraoperative aberrometry and
at least a 45% higher error than IRB, Fourier-domain OCTebased IOL formula, aphakia was reliable once stable and
which in the case of surgeon best choice in postrefractive IOL calculations in eyes
was 70% higher at 0.60 D. Additionally, undergoing cataract surgery particularly pressurised anterior chamber conditions
67% of eyes were within 0.5 D of target in patients for whom prior data is not
with the IRB method almost 45% more available. were achieved. They concluded that more
than the surgeon best choice (46%) and
34% more than the Shammas method, Packer4 had studied the effect of efforts were required to improve the
which came in second at 50% within intraoperative aberrometry on the
0.5 D. These outcomes were consistent rate of postoperative enhancement precision and quality of measurements
across all endpoints for 0.75- and 1.0-D for astigmatism correction. It was a
postoperative refractive thresholds. retrospective case-control chart review before IWA can be used to guide the
In the case series by Fram et al3 they had of patients who chose to have correction
compared the accuracy of 2 established of pre-existing corneal astigmatism by surgical refractive plan in cataract
methods (Haigis-L and Masket) and 2 new limbal relaxing incisions (LRIs) at the
surgery.
The quest for emmetropic vision
after cataract surgery continues.
Management of astigmatism in cataract
ϐ
evolving new techniques. However no
tool has been available for the surgeon to
ϐ
the cylindrical power and the alignment
Ǥ ϐ
ϐ
to bring down the astigmatism to zero.
Thus ORA is essential for all surgeons
who want to do everything they can to
achieve LASIK-like outcomes for their
refractive cataract patients
52 DOS TIMES - NOVEMBER-DECEMBER 2015
PRACTICE REQUISITES
REFERENCES
1. Maeda N. Clinical applications of
wavefront aberrometry – a review. Clin
Experiment Ophthalmol. 2009;37:118-
29.
2. Ianchulev T, Hoffer KJ, Yoo SH et al.
Intraoperative Refractive Biometry
for Predicting Intraocular Lens
Power Calculation after Prior Myopic
Refractive Surgery. Ophthalmology
2014;121:56-60.
3. Fram NR, Masket S, Wang L.
Comparison of Intraoperative
Aberrometry, OCT-Based IOL Formula,
Haigis-L, and Masket Formulae for
IOL Power Calculation after Laser
14# +1. &GEGPVGTGF Vision Correction. Ophthalmology
14# +1. 7PHQNFKPI
14# 2QQT RCVKGPV ſZCVKQP 2015;122:1096-1101.
4. Packer M. Effect of intraoperative
aberrometry on the rate of
postoperative enhancement:
Retrospective study. J Cataract Refract
Surg 2010;36:747–755.
5. Huelle JO, Katz T, Druchkiv V et al. First
clinical results on the feasibility, quality
and reproducibility of aberrometry-
based intraoperative refraction during
cataract surgery Br J Ophthalmol
2014;98:1484–1491.
14# 6KNV (KZCVKQP 5RGEWNWO
Figure 10: (TKPIG RCVVGTP FKURNC[ CPF HQEWU ECOGTC FKURNC[ KP WPWUWCN UKVWCVKQPU
Financial Interest: ϔ
Ȁ
Ǥ
www. dos-times.org 53
MONTHLY MEETING KORNER
OCULAR RECONSTRUCTION IN A SEVERE DOG BITE
Imran Mehdi, Anirudh Singh, J.K.S. Parihar
Paediatric dog bite cases commonly involve face and periocular region. We had a
case of severe and multiple dog bites in a 6 year old girl child where a pack of dogs
mauled the girl with injuries on scalp, face, eyelids, conjunctiva, sclera and cornea
D besides injuries on arm, buttocks and legs
og bites are a growing but preventable epidemic approximated and repaired. There were multiple conjunctival
that mostly involves children. While the western and tenon’s tears with torn scleral and corneal tissue. The
literature suggests that the dog bites are mostly choroidal tissue was exposed over the area where 5 mm x
from pet dogs, the incidence of stray dog 10 mm scleral tissue had been peeled off, however there was
bites are more in Indian subcontinent with an no globe perforation. The anterior chamber was intact and
increasing incidence noted around the summer pupil was round and dilated (pharmacologically). Fundus
months. These paediatric dog bite cases involve mostly face examination was normal.
and periocular region. We had a case of severe and multiple dog The mid stromal thickness defect in perilimbal cornea from
bites in a 6 year old girl child where a pack of dogs mauled the 09 o clock to 12 o clock was repaired with four interrupted 10 -0
girl with injuries on scalp, face, eyelids, conjunctiva, sclera and polyamide suture. The scleral patch was repaired and sutured
cornea besides injuries on arm, buttocks and legs. with 7-0 non absorbable nylon. The facial wounds were also
repaired and dressing done (Figure 2). Postoperative the child
CASE was continued on intravenous antibiotics along with antibiotic
A 6 year old girl child presented with multiple and severe eyedrop and cycloplegic.
dog bites injury in an unprovoked attack by a pack of stray
dogs when the child was walking alone upto the park near a
residential area. She was rescued by a passerby and brought
to the emergency. The child was bitten over her face, right
eye, scalp, arm, forearm, abdomen, thigh and buttock regions.
The child on arrival at emergency was administered 0.5ml of
tetanus toxoid intramuscularly as booster dose. She further
received post exposure prophylaxis (Category III as per
Ȍ ͳ
ϐ
Ǧ
vaccine (RABIPUR) of potency > 2.5 IU per dose in schedule of
0,3,7,14 and 28 days along with 40 IU per kg body weight of
heterologous (equine) immunoglobulin .after test dosage. The
ϐ
and the rest was administered in gluteal area. All the wounds
were extensively cleaned with saline and betadine.. On initial
ophthalmic examination, the child had blepharospasm of both Figure 1: 1EWNQHCEKCN TGEQPUVTWEVKQP #XWNUKQP QH TKIJV NQYGT NKF YKVJ
eyes and was in extreme pain. Further examination under mild KPXQNXGOGPV QH WRRGT NCETKOCN ECPCNKEWNWU
sedation revealed a full thickness lower lid avulsion of right
lower lid measuring 4 cm in length and gaping wound over right
lacrimal sac region measuring 3 cm X 3.5 cm. On separating the
lids a mangled mass of tissue comprising of conjunctiva, tenon’s
and sclera was seen. Only the lower half of cornea could be seen
ǡ ϐ
integrity was doubtful (Figure 1).
The child was placed on intravenous antibiotics cover
in form of Inj Cefotaxime 100 mg/kg/day, Inj. Metronidazole
7.5mg/kg/day and Inj. Gentamycin 2.5 mg/kg/day each in three
divided dosage as well as antibiotic eye drop and cycloplegic
.She was immediately planned for a detailed examination and
primary repair under GA. The right eye which had complete
avulsion of the lower lid from the medial canthal was repaired
in three layers after approximating the grey line. There was a
deep puncture wound over the lacrimal region with complete
avulsion of both the canaliculi, there was also loss of muscle Figure 2: 2QUV 5WTIKECN %QTTGEVKQP
tissue with overhanging skin, hence only the skin was partially
www. dos-times.org 55
MONTHLY MEETING KORNER
The child has recovered with a large population of stray
well with primary healing of dogs. The mean age of children
wounds. Her visual acuity was with eye injuries was 3.9, which
6/6 with -1.00DCYL @90 degree ϐ
in both eyes with the right eye lid than in patients without
movements intact. Conjunctiva eye involvement. In cases of
had healed normally, cornea periocular injury, the eyeball
showed a nebulomacular is usually spared4,5. These
opacity in superior half not incidences show an increase
involving the visual axis. Her in the summer months when
canaliculi were both diagnosed the aggressiveness of the dogs
to be torn, hence she had slight may be at the peak. This case
watering in her right eye, which is unique because all the levels
was considered acceptable at of ocular tissue were involved
the present circumstance by including the cornea and sclera
parents (Figure 3). On further Figure 3: %NKPKECN RKEVWTG QH VJG TKIJV G[G QP ſTUV 2QUV QRGTCVKXG FC[ but there was no perforation.
follow up, by 08 weeks post It also involved a multiple level
operatively, she had developed repair where the completely
right convergent squint with torn lower lid was sutured back
right face turn due to intense as well as the peeled of sclera
ϐǤ Ͳ and the corneal lamellar defect
with limitation of abduction were repaired.
hence a re-surgery was planned
ϐ CONCLUSION
Rectus restriction and 5mm of Multidisciplinary care by
MR recession was done (Figure Figure 4: %NKPKECN RKEVWTG QH VJG TKIJV G[G QP VJ YGGM HQNNQYKPI TGRCKT ophthalmologists, physicians,
4). Post-surgery there was paedia-tricians, neurologists
a residual Right convergent Canine tooth syndrome is an ocular and plastic surgeons is often
motility disorder comprising ipsilateral needed. Unlike studies in the west
squint of 40 PDBO along with the issue Brown’s syndrome and superior oblique where dog bites due to pet dogs may be
muscle dysfunction. Ocular motility common in India dog bites due to stray
of epiphora due to lacrimal drainage ϐ
dogs is more common. There is a major
depression, maximum in an adducted role of civic administration in control of
system injury which shall be addressed in position. Typically this follows a dog stray dogs to prevent severe dog bites in
bite (hence the name) that damages the children.
a subsequent surgical session.
DISCUSSION trochlea and superior oblique muscle REFERENCES
concurrently.
Primary wound repair is not 1. Simao NR, Borba AM, da Silva AL, Vieira
advocated in cases of dog bite but injuries The incidence of dog bite in children EM, Carvalhosa AA, Bandeca MC, Borges
involving the globe and adjacent adnexa
need to be addressed without delay as decreases with increasing age3. However, AH. Animal bite injuries to the face: A Case
the threat of complications and loss of in our experience the peak is in those Report. J Int Oral Health. 2013;5:68-72.
ϐ
Ǥ
aged 6–10. Eye injuries were a marker 2. Schalamon J, Ainoedhofer H, Singer G.
dog attacks are a preventable public of the severity of injury overall. Children Analysis of dog bites in children who
health issue1. Animal bite injuries in the ϐ
are younger than 17 years. Paediatrics
region around the eye require a thorough more facial zones involved and a higher 2006;117:374-79.
examination to assess the presence and total number of lacerations which calls 3. Mcheik JN, Vergnes P, Bondonny JM.
extent of lid laceration, conjunctival and Treatment of facial dog bite injuries in
corneal damage and even globe rupture. children: a retrospective study. J Pediatr Surg
Special consideration is given to risk of
infection and anti-rabies immunisation for urgent and systematic management 2000;35:580-3.
should be administered immediately if of such injuries which could be life 4. Gonnering RS. Ocular adnexal injury and and
the rabies status of the dog is positive or threatening.
unknown2. complications in orbital dog bite. Ophthalmic
Plastic Recontructive Surgery 1987;3:231-5.
Severe mauling of children under 5. Shannon GM. The treatment of dog bite
10 years has been reported in countries injuries of the eyelids and adnexa.Ophthalmic
Surg 1975;6:41-4.
Army Hospital, R&R, Delhi Cantt, New Delhi, India.
Dr. Imran Mehdi MS Dr.Anirudh Singh MS, DNB, MNAMS, FAICO Brig. J.K.S. Parihar MS, DNB, DOMS, MAMS
Financial Interest: ϔ
Ȁ
Ǥ
Case presented in the DOS Monthly Clinical Meeting II held at Ayurvigyan Auditorium, R & R, Army Hospital, Delhi Cantt, New
͵Ͳǡ ʹͲͳͷǤ
56 DOS TIMES - NOVEMBER-DECEMBER 2015
MONTHLY MEETING KORNER
EYELID MARGIN BASAL CELL CARCINOMA MANAGEMENT IN A
BACKGROUND OF LESER TRELAT SYNDROME
Siddharth Madan, Rajiv Garg
Eruptive appearance of multiple seborrheic
keratoses in association with underlying malignant
disease characterises Leser-Trélat syndrome,
related most commonly to underlying visceral
malignancies but rarely with adenocarcinoma of
the breast1-3.
OBSERVATION
Figure1: 0QFWNQ WNEGTCVKXG ITQYVJ KPXQNXKPI VJG TKIJV NQYGT G[GNKF
A 75 years old male presented with gradually enlarging
blackish coloured painless growth over the lateral aspect of extent of 5 mm having overlying blackish discolouration of the
right lower eyelid for 6 years duration (Figure 1) and multiple ϐ
hyperpigmented black coloured raised lesions over face, ǡ ϐ
ǡ
trunk, scalp and abdomen over 9 years (Figure 2a, Figure 2b) upto the posterior lid margin, not involving the inferior fornix
.The eyelid growth was pea sized to start with and gradually ϐ
increased to its present size, more horizontally than vertically. of lid margin and loss of cilia, clinically suggestive of BCC (T2b
ϐ
N0 M0, Stage IC). There was posterior chamber pseudophakia
ͳǡ ʹǡ ͵
ϐ in both eyes and fundus showed myopic chorioretinopathy
ductal carcinoma breast (Stage III b, T4b N1M0) 11 years involving macula in the left eye accounting for low vision.
back followed by 6 cycles of neoadjuvant chemotherapy
(Cyclophosphamide, Adriamycin, 5- Fluorouracil) with Full thickness resection of the lid tumor including
radiotherapy (45 Gy over 25 days) with hormone therapy. The additional 2 mm circumferential tissue was excised and
patients elder brother developed carcinoma breast, did not subjected to intraoperative frozen section. Involvement of the
undergo treatment and he succumbed to the illness. medial resected margin with the tumor was reported. The
involved margin alongwith additional 2 mm of the lid tissue,
General physical examination revealed healed scar marks sparing the puncta and lacrimal drainage apparatus, was excised
over anterior and posterior aspect of arm (previous fracture and was reported negative of the tumor tissue intraoperatively.
repair) and a linear scar around 5 cms present over left chest ǯ
ϐ
extending to the axilla with absent nipple areola complex(post lateral canthoplasty was performed and the lid reconstruction
mastectomy) respectively. Dermatological opinion was sought
ϐ
wherein a scalp biopsy from amongst multiple lesions revealed Ǥ ϐ
seborrheic keratoses histopathologically (Figure 3) for which followed revealed BCC of the nodulo-ulcerative type with free
no active intervention was advised. medial, inferior and lateral margins (Figure 4,5).
Best corrected visual acuity was 6/9 in the right eye and DISCUSSION
ϐ ʹ
pin hole, with accurate projection of rays in all quadrants in Sudden acute eruption of multiple seborrheic keratoses
both eyes. A single sessile growth measuring 15 mm in inner associated with pruritis or acanthosis nigricans (or both) is
horizontal extent, 18mm outer horizontal extent and vertical suggestive of the “sign of Leser Trelat” which may be present
with or without occult malignancy. A paraneoplastic “syndrome
Leser Trelat syndrome consists of of Leser Trelat” characterises concomitant presence of the sign
appearance of a solid tumor like
carcinoma breast, colon or stomach
following eruption of multiple seborrheic
keratoses (S.K.) of skin. The sign of Leser
Trelat followed by a BCC of eyelid is
ϐ Ǥ
www. dos-times.org 57
MONTHLY MEETING KORNER
Figure 2(a): /WNVKRNG UGDQTTJGKE MGTCVQUGU QXGT DCEM Figure 2(b): 5GDQTTJGKE MGTCVQUGU QXGT HCEG
Figure 3: 5ECNR DKQRU[ 5VTCVKſGF USWCOQWU MGTCVKPK\GF GRKVJGNKWO YKVJ Figure 4: 'ZEKUGF G[GNKF VKUUWG UJQYKPI $CUCN EGNN ECTEKPQOC 0QFWNCT
CECPVJQUKU RCTCMGTCVQUKU RCRKNNQOCVQUKU RTQNKHGTCVKPI DCUCNQKF EGNNU KP V[RG
FGTOKU YKVJ V[RKECN JQTP E[UVU
in patients in whom occult malignancy multiple seborrheic keratoses in patients known Leser-Trélat syndrome who
ϐ
with underlying malignancies.and has
ϐ
sign, which should be distinguished been documented histopathologically of their seborrheic keratoses6.
from isolated presence of the sign4. using immunohistochemistry5. A
Various growth factors including the comprehensive diagnostic screening In our patient, sign of Leser Trelat
epidermal growth factor (EGF) have programme for a malignant pathology can be considered to be an indicator
ϐ
should be targeted in patients with of underlying BCC as it appeared
concomitantly 3 years before when the
Department of Ophthalmology, Lady Hardings Medical College, New Delhi, India.
Dr. Siddharth Madan MS Dr. Rajiv Garg MD
58 DOS TIMES - NOVEMBER-DECEMBER 2015
MONTHLY MEETING KORNER
Figure 5: *KIJ RQYGT XKGY QH RTQNKHGTCVKPI OCNKIPCPV DCUCNQKF EGNNU Figure 6: 9GNN OCKPVCKPGF NKF OCTIKP YKVJQWV CP[ TGEWTTGPV ITQYVJ
YKVJ RGTKRJGTCN RCNKUCFKPI CPF CDWPFCPV OKVQVKE ſIWTGU OQPVJU RQUV QRGTCVKXGN[
patient developed a grossly visible eyelid REFERENCES ͷǤ ǡ ϐ ǡ
ǡ ǣ
lesion which was subsequently evaluated Melanoma, growth factors, acanthosis
and managed. Having the syndrome of 1. Schwengle LE, Rampen FH, Wobbes nigricans, the sign of Leser-Trelat, and
Leser Trelat, a second malignancy in the T: Seborrhoeic keratoses and internal multiple acrochordons. A possible role
form of BCC of lower eyelid appeared in the malignancies. A case control study. Clin for alpha-transforming growth factor in
patient. In our case, as tissue mobilisation Exp Dermatol 1988, 13:177-79. cutaneous paraneoplastic syndromes.
ǡ ϐ
N Engl J Med 1987;317:1582-87.
vertical tension and almost no lower lid 2. Grob JJ, Rava MC, Gouvernet J, et al: The
retraction or ectropion and additional relation between seborrheic keratoses 6. Ponti G1, Luppi G, Losi L, Giannetti A,
horizontal lower eyelid laxity contributed and malignant solid tumours. A case- Seidenari S. Leser-Trélat syndrome
ϐ control study. Acta Derm Venereol in patients affected by six multiple
(Figure 6). The present case highlights a 1991;71:166-69. metachronous primitive cancers. J
rare association of Leser Trelat syndrome Hematol Oncol. 2010;3:2.
with an anamnestic oncologic history 3. Lindelöf B, Sigurgeirsson B, Melander
developing a second carcinoma in the S: Seborrheic keratoses and cancer. J
form of BCC of lower eyelid Am Acad Dermatol 1992;26:947-50.
4. Heaphy MR Jr, Millns JL, Schroeter AL:
The sign of Leser-Trelat in a case of
adenocarcinoma of the lung.J Am Acad
Dermatol 2000;43:386-90
Financial Interest: ϔ
Ȁ
Ǥ
Guest case presented in the DOS Monthly Clinical Meeting II held at Ayurvigyan Auditorium, R & R, Army Hospital, Delhi
ǡ ͵Ͳǡ ʹͲͳͷǤ
www. dos-times.org 59
The words you are searching are inside this book. To get more targeted content, please make full-text search by clicking here.
dos_dec_2015
Discover the best professional documents and content resources in AnyFlip Document Base.
Search