CLINICAL SPOTLIGHT - CORNEA
INTRAOPERATIVE OCT IN ANTERIOR SEGMENT
IMAGING– PRESENT AND FUTURE
Rebika Dhiman, Radhika Tandon
With the recent advancements in technology of microscope-integrated technology,
ϐ
operation theatre. Although primarily this technology was focused on improving
the intraoperative retinal imaging, recently it has proved to be a valuable tool in
Ǥ
ϐ
the usefulness of this technology in anterior segment and ocular surface surgical
manipulations
Optical coherence tomography (OCT) has
emerged as an important clinical tool in the through a handheld, externally mounted, or microscope-
perioperative diagnosis and management mounted systems5,6. Although these systems provide excellent
of ophthalmic diseases. There has been a visualization of the anatomical structures, there are certain
continuously expanding clinical application of limitations. A pause is required to bring the system into
alignment that interrupts the surgery and prolongs the surgical
OCT in diagnostic imaging of the posterior and time. Secondly, a real-time visualization of surgical maneuvers
anterior segment since its introduction almost two decades is not feasible with these systems. In order to address these
ago1. OCT provides a rapid, non-invasive, non-contact, and limitations, microscope-integrated OCT (MI-OCT) system has
high-resolution cross sectional imaging2. With the rapidly been developed7.
ϐǡ The MI-OCT system available at our Centre is RESCAN™
procedure anymore. Seamless integration of this technology 700 (Carl Zeiss Meditec, Germany), which is a real-time
into ophthalmic surgery has laid the foundation for a new future spectral-domain OCT integrated into the OPMI Lumera 700
in the surgical management of ophthalmic disease. Although microscope. The OCT has an imaging rate of 27,000 scans per
much of the development of intraoperative OCT has focused second with the axial and transverse resolution of 5um and 15
on retinal imaging, investigations have recently been directed um respectively. The OCT camera is attached to the microscope
toward intraoperative OCT imaging of the anterior segment. In and connected to an assistance system (ZEISS CALLISTO eye)
this article we describe our experience of various applications (Figure 1). The control of the OCT camera is available hands-
of microscope integrated OCT (MI-OCT) technology in anterior free via the foot control panel of the surgical microscope or via
segment surgeries. the touch panel of the assistance system. So, the surgeon can
take videos, snap-shots and 3-D OCT images without affecting
INTRODUCTION ϐǤ
The OCT technology has rapidly evolved over the past few for instant information or during review mode for observing
decades, from a time-domain Stratus OCT (Carl Zeiss Meditec, images already taken at a previous point in time during surgery.
ǡ Ȍ ͳͲ Ɋ The OCT images are provided to the surgeon within the ocular
rate of approximately 400 A-scans per second, to a spectral- of the surgical microscope by data injection. In addition the OCT
domain OCT yielding an improved resolution of lower than 5 images can be displayed on the screen of the assistance system.
Ɋ ʹͲǡͲͲͲ Ǧ
Ǥ The imaging data of each surgery can be stored, analyzed or
retrieved from the assistance system.
OCT was initially designed for the imaging of posterior
segment using an 830-nm wavelength light source. Anterior Clinical scenarios of use of Microscope-integrated OCT
ϐ ͳͻͻͶ3 using in anterior segment and ocular surface imaging
an 830-nm wavelength light source. Use of a longer wavelength
laser of 1,310 nm was found to result in improved penetration There is a wide range of application of MI-OCT technology
through highly scattering structures, including the sclera in anterior segment and ocular surface surgeries.
and limbus4 and has been adopted in commercially available – MI-OCT helps to image the anterior segment
anterior segment OCT systems. Since then, the use of OCT in in dense corneal opacity or paediatric corneal opacity. It
anterior segment imaging has become the standard of care. gives surgeon some idea about the underlying structures like
ǡ ϐ
lens status, anterior or posterior synechias, angle structure,
attempted to provide intraoperative visualization either dysgenesis of anterior segment, and thus guide the surgical
www. dos-times.org 61
CLINICAL SPOTLIGHT - CORNEA
of host stromal bed, areas of descemet
scarring, detection of irregularities in
the stromal bed, selection of appropriate
graft size, the graft orientation, centration
and apposition after insertion, any
ϐ ǡ
graft. A recent report on intraoperative-
OCT assisted DMEK showed that live
intraoperative OCT is useful to visualize
and assess graft orientation after
surgery. Even in complicated cases
associated with major corneal edema
in which direct visualization of the graft
was compromised, the OCT images
facilitated the graft evaluation, thus
avoiding additional graft manipulation8.
Ǧ ϐ
in managing certain post-operative
complications like graft fold or graft
displacement by imaging the graft
position before and after the rebubbling
Figure 1: 4GUECP KPVGITCVGF KP VJG .WOGTC OKETQUEQRG YKVJ VJG FKURNC[ QH VJG 1%6 KOCIGU QP procedure.
VJG CUUKUVCPEG U[UVGO
%CNNKUVQ '[G Cataract surgery – MI-OCT with its
real time imaging gives a good assistance
planning of keratoplasty. With the rapidly keratoplasty, the graft-host junction to the surgeon in several steps of
evolving keratplasty techniques, most cataract surgery – wound construction,
surgeons err on side of performing disparity etc (Figure 3). capsulorrhexis, chopping or trenching
lamellar instead of penetrating of nucleus, posterior capsular status
keratoplasty. But lamellar procedures Similarly, in posterior lamellar in doubtful cases, intraocular lens
need great deal of expertise and have a position after placement, to identify
slow learning curve. The role of MI-OCT keratoplasty like descemet stripping certain intraoperative complications like
has been found to be very promising descemet membrane detachment (DMD)
in lamellar keratoplasty that provides automated endothelial keratoplasty and adequacy of wound closure at the end
surgeon with a vivid picture of surgical of surgery. In a study by Das et al this OCT
alterations occurring in the tissue. (DSAEK), descemet membrane technology has shown promising results
in decision making as well as training
Anterior lamellar keratoplasty that endothelial keratoplasty (DMEK) and pre-
descemet endothelial keratoplsty (PDEK),
MI-OCT is helpful in various surgical
steps. It allows the direct visualization of
the tissue during the preparation of donor
in DMEK or pDEK (Figure 4), preparation
include automated lamellar keratoplasty
ȋ Ȍǡ ϐ
keratoplasty (SALK), hemi-automated
ȋ Ȍǡ ϐ
hemi-automated lamellar keratoplasty
(SHALK) and deep anterior lamellar
keratoplasty (DALK) are certain ideal
surgical scenarios where MI-OCT
has emerged as a very valuable tool.
The surgeon can visualize the depth
of dissection in corneal stroma, the
thickness of the residual stromal bed, the
smoothness of recipient bed (Figure2),
any site of perforation, the graft-bed
apposition especially in cases of glue-
assisted sutureless anterior lamellar Figure 2: 6JG KPVTCQRGTCVKXG 1%6 FKURNC[ IKXGU C XKXKF KOCIG QH VJG KTTGIWNCTKVKGU QH VJG TGEKRKGPV
DGF KP CPVGTKQT NCOGNNCT MGTCVQRNCUV[
Dr. Rajendra Prasad Centre for Ophthalmic Sciences,All India Institute of Medical Sciences, New Delhi, India
Dr. Rebika Dhiman MD Dr. Radhika Tandon MD, DNB, FRCSEd
62 DOS TIMES - NOVEMBER-DECEMBER 2015
CLINICAL SPOTLIGHT - CORNEA
Figure 3: 5WVWTGNGUU JGOK CWVQOCVGF NCOGNNCT MGTCVQRNCUV[ Ō 6JG 1%6 KOCIG UJQYU VJG VJKEMPGUU
QH TGUKFWCN UVTQOCN DGF YKVJ C ſPG NC[GT QH ſDTKP INWG QXGT VJG TGEKRKGPV DGF DGHQTG VJG RNCEGOGPV (MSGT) – This procedure is undertaken in
QH VJG ITCHV cases of severe dry eye commonly seen
after Steven Johnson syndrome (SJS)
Figure 4: 2TGRCTCVKQP QH VJG FQPQT EQTPGC HQT &/'- 2&'- D[ CKT KPLGEVKQP KP VJG RTG FGUEGOGVŏU and ocular cicatricial pemphigoid (OCP).
NC[GT 6JG 1%6 KOCIGU ENGCTN[ UJQY VJG UGRCTCVKQP QH RTG FGUEGOGV NC[GT HTQO VJG TGUV QH VJG The disease pathology in SJS and OCP is
UVTQOC D[ CKT also known to involve mucosal surfaces
like labial and buccal mucosa. Since, the
source of minor salivary glands in MSGT
is labial mucosa, a diseased mucosa will
lead to a surgical failure. In such cases,
MI-OCT guides the surgical planning by
the assessment of status and number of
minor salivary glands.
– The management
of limbal dermoid with dermoid excision
and lamellar patch graft is aided by the
intraoperative OCT images of depth of
dermoid, extent of stromal involvement,
positioning and apposition of lamellar
patch graft etc.
– MI-OCT has
the capability to image the underlying
structures at the area of scleral melt thus
aiding in the preparation of recipient bed,
placement of scleral patch graft and graft-
host junction apposition
Apart from this there are certain
other surgeries where the use of MI-
OCT is validated. In the placement of
Intracorneal ring segments (INTACS) a
live visualization of instrument-tissue
interaction adds to the safety of the
procedure. A recent study has evaluated
ϐ
microscope-integrated real time spectral
domain optical coherence tomography
in keratoconus patients undergoing
accelerated collagen crosslinking (ACXL)
between epithelium on (epi-on) and
epithelium off (epi-off). The depth of
penetrance was measured using a zone
ϐ
Ǥ
ϐ
ϐ Ǧ Ǧ
ACXL10.
purpose in microincision cataract surgery Figure 5: # ECUG QH C RQUV ECVCTCEV UWTIGT[ FGUEGOGV OGODTCPG FGVCEJOGPV YJGTG VJG 1%6 KOCIG
(MICS) and femtolaser assisted cataract UJQYU VJG WPEWTNKPI QH FGUEGOGV OGODTCPG HQNNQYKPI ICU KPLGEVKQP YKVJ UQOG KTTGIWNCTKV[
surgery (FLACS)9. The management
of post-operative complications like a
gas injection in case of DMD is aided by
the intraoperative visualization of any
descemet curls and descemet membrane
status pre and post management (Figure
5).
– MI-OCT gives
a good understanding of underlying
ϐ
keratoprosthesis insertion like osteo-
odonto keratoprosthesis (OOKP), Boston
KPro etc. It also aids in correct assembly
and positioning of the device (Figure 6).
www. dos-times.org 63
CLINICAL SPOTLIGHT - CORNEA
Figure 6: /+ 1%6 UJQYKPI VJG RQUKVKQP QH QRVKECN E[NKPFGT KP ECUG QH 1UVGQ QFQPVQ -GTCVQRTQUVJGUKU REFERENCES
11-2
1. Huang D, Swanson EA, Lin CP, et al.
In terms of potential downside cost clinical outcomes, and enable novel Optical coherence tomography. Science.
is a major issue. Also with the currently surgical techniques requiring precision 1991; 254:1178– 81.
available metallic surgical instruments,
ϐ
shadowing occurs that obscures microstructures. This technology is yet to 2. Chen TC, Cense B, Pierce MC, Nassif N,
visualization. The intraoperative evolve further with greater research in the Park BH, et al. (2005) Spectral domain
measurement of structures like tissue ϐ Ǧ
optical coherence tomography: ultra-
thickness etc is not possible yet. and acquisition of intraoperative tissue high speed, ultra-high resolution
Nonetheless, MI-OCT technology has measurements. It would be interesting to ophthalmic imaging. Arch Ophthalmol
added new dimensions to surgical see what this technology unfolds for us in 123: 1715–20.
visualization. This may help guide future.
surgery decision- making, enhance 3. Izatt JA, Hee MR, Swanson EA, et al.
Micrometer-scale resolution imaging
of the anterior eye in vivo with
optical coherence tomography. Arch
Ophthalmol. 1994; 112:1584–89.
4. Hoerauf H, Gordes RS, Scholz C, et al.
First experimental and clinical results
with transscleral optical coherence
tomography. Ophthalmic Surg Lasers.
2000; 31:218–22.
5. Ehlers JP, Ohr MP, Kaiser PK, Srivastava
SK Novel microarchitectural dynamics
in rhegmatogenous retinal detachments
ϐ
coherence tomography. Retina
2013;33:1428–34.
6. Knecht PB, Kaufmann C, Menke
MN, Watson SL, Bosch MM. Use of
intraoperative fourier-domain anterior
segment optical coherence tomography
during descemet stripping endothelial
keratoplasty. Am J Ophthalmol
2010;150:360– 365 e362.
7. Ehlers JP, Tao YK, Farsiu S, Maldonado
R, Izatt JA, et al. Integration of a spectral
domain optical coherence tomography
system into a surgical microscope
for intraoperative imaging. Invest
Ophthalmol Vis Sci 2011;52: 3153– 59.
8. Saad A, Guilbert E, Grise-Dulac A,
Sabatier P, Gatinel D. Intraoperative
–OCT assisted DMEK: 14 consecutive
cases. Cornea 2015;34:802-7.
9. Das S, Kummelil MK, Kharbanda V,
Arora V, Nagappa S, Shetty R, Shetty BK.
Microscope Integrated Intraoperative
Spectral Domain Optical Coherence
Tomography for Cataract Surgery: Uses
and Applications. Curr Eye Res. 201; 3:1-
10.
10. Pahuja N, Shetty R, Jayadev C, Nuijts
R, Hedge B, Arora V. Intraoperative
Optical Coherence Tomography Using
the RESCAN 700: Preliminary Results in
Collagen Crosslinking. Biomed Res Int.
2015;2015:572-698.
Clinical talk presented in DOS Monthly Clinical Meeting-1 on July 26, 2015 at Dr. R.P. Centre, Jawaharlal Auditorium,
AIIMS, New Delhi
Financial Interest: ϔ
Ȁ
Ǥ
64 DOS TIMES - NOVEMBER-DECEMBER 2015
EYE BANKING
DONOR CORNEAL TISSUE EVALUATION
Manisha Acharya, Surender Dixit, Abha Gaur, Avvaru Sairam
With Eye banking growing steadily, there is a trend towards increasing the number of
transplantable tissues. In today’s time, it is important to make a qualitative shift towards
standardization of eye banking processes. A proper tissue evaluation and documentation
is an important link between the eye bank and the surgeon as donor cornea quality is an
essential prerequisite for successful outcome of corneal transplant procedure
In the past few years eye banks in many parts of our
ϐ
Torchlight evaluation of donor eye
collection of corneal tissues. With Eye banking growing
steadily, there is a trend towards increasing the number The eyes of the donor at the time of recovery are to be
of transplantable tissues. In today’s time, it is important examined with a bright torch and preferably a portable slit
to make a qualitative shift towards standardization lamp.
of eye banking processes. A proper tissue evaluation and Ȉ The following should be documented:
documentation is an important link between the eye bank and Ȉ Adnexa: Swelling, Discharge, stye, pustules
the surgeon as donor cornea quality is an essential prerequisite Ȉ Cornea: Clarity, epithelial defects, Sloughing, Foreign body,
for successful outcome of corneal transplant procedure.
In order to reduce the subjectivity in tissue evaluation a Arcus and other scars
ϐ
Ȉ Anterior Chamber: Shallow/ Flat, Hyphema
If the examination is favorable then the technician
proceeds for recovery.
guidelines. This brings clarity and objectivity in tissue Once the donor cornea arrives at the eye bank, the cold
evaluation. In this article, we discuss the guidelines for the chain status is to be checked by examining the condition of
proper selection of donors and methods of evaluation of donor packing and the presence of ice in the transport container. The
cornea. color of the tissue storage media is important to note. Colorless
or yellowish media is an indicator of microbial contamination.
DONOR CHARACTERISTICS So the colour and the expiry date of the storage media
Donor Age
ϐǤ
A number of studies have shown that graft survival Slit Lamp Biomicroscopic Examination
is independent of Donor Age, Most eye banks and corneal
surgeons readily accept corneal tissue from donors of any age This is the single most important step in donor corneal
but some restrict donor age from 2 to 80years. Constraints to button evaluation as it assesses the viability and quality of
using infant cornea are technical because of small diameter, the tissue. The outcome of success of surgery is very much
thinness, and elasticity. dependent on the accurate bio microscopic examination. It
is now an accepted fact that an evaluation technician with
Death to excision time experience does an accurate, objective and standardized
grading of the donor corneas (Figure 1a).
Most eye banks develop their own acceptable death to
excision time limits depending on the circumstances of death
and interim means of storage of the body. Studies have now
demonstrated that post-mortem time is not a very critical
contributor to graft survival although immediate postoperative
graft swelling does vary with time. Most eye banks do accept
tissues within 6-8 hours of death to preservation time
depending on the atmosphere in which the body was preserved.
Donor Serology
In India, serological screening of donors is mandatory
by law. Currently all eye banks release corneal tissue after
serological screening for HIV, HBsAg and VDRL.
Once the above criteria have been appropriately checked
and contraindications ruled out, the donor tissue is then
evaluated and graded for surgical use.
DONOR CORNEA EVALUATION METHODS Figure 1a: 5NKV .COR $KQOKETQUEQRKE 'ZCOKPCVKQP QH FQPQT EQTPGC
Donor cornea evaluation actually begins before the eyes or
corneoscleral rims are excised from the donor.
www. dos-times.org 65
EYE BANKING
Siltlamp Illumination Techniques 30° angle between the oculars and the Specular Reflection Technique:
Donor Corneal tissue evaluation light source. This allows the smallest
change in clarity to be evaluated, as well This is a technique where a
can be accurately done by the following as pinpointing the depth of pathology small beam of light is focused on the
Illumination Techniques : (Figure 2). endothelium and by varying the angle
ϐ
Diffuse Illumination Technique Wide Slit Technique or Parallelpiped can be achieved in the central part of the
This is a wide beam illumination Technique: cornea (Figure 4). This can be used to
look for cell dropouts, and folds in that
in order to grossly examine the entire A beam as wide as the thickness of area.
corneal specimen (Figure 1b). the cornea is used so as to form a box of
illuminated tissue. A 30° angle is kept Retro Illumination Technique:
Narrow Slit or Optic Section between the optics and the light source
Technique: and the individual layers of the cornea In this technique the beam is focused
can be commented upon. This technique to illuminate behind the area of interest.
The beam can be narrowed to is used to look for Stress lines (Figure 3). This can be done by making the light
form an optical section (so thin it’s beam equal to the size of the cornea and
just discernible), with approximately a
Figure 1b: &KHHWUG +NNWOKPCVKQP 6GEJPKSWG Figure 2: 0CTTQY 5NKV QT 1RVKE 5GEVKQP 6GEJPKSWG
Figure 3: 9KFG 5NKV 6GEJPKSWG QT 2CTCNNGNRKRGF 6GEJPKSWG Figure 4: 5RGEWNCT TGƀGEVKQP 6GEJPKSWG
Cornea and Refractive Surgery Services, Dr. Shroff ’s Charity Eye Hospital, Darya Ganj, New Delhi, India
Dr. Manisha Acharya MS Mr. Surender Dixit Opt. Dr.Abha Gaur MBBS, DO Mr.Avvaru Sairam Opt.
66 DOS TIMES - NOVEMBER-DECEMBER 2015
EYE BANKING
about 2mm wide and move the light beam Donor Cornea slit lamp evaluation is Sloughing: Large areas of absence
5° off the optics (Figure 5). done in correct orientation from anterior of the epithelial layers is termed as
to posterior layer of the cornea. sloughing (Figure 8). This may be due to
This can be used to get orange trauma, edematous tissue, or infection.
illumination directly next to the beam. Epithelium Examination It is viewed on a narrow slit where the
This will illuminate epithelial defects, epithelial layer is absent
ǡ ϐǡ Exposure: Exposure in donor
lines endothelial defects and descemets corneas is generally due to the lids ϐ
peels. being all or partially open after death. It may be Pterygium and Band Keratopathy.
is visible as slight opacity or whiteness Pterygium is seen as a conjunctival growth
Location terminology of the epithelium seen in diffuse or on the cornea with scarring beyond the
retroillumination technique. limbus. Pterygium and Band Shaped
ϐ
Keratopathy are usually seen at the 3 and
Exposure is graded as: 9 O clock positions on the cornea.
for epithelium (exposure and
- The epithelial cells Examination of corneal stroma:
sloughing) and stress lines. All of these are still intact but appear white.
Arcus: Arcusis lipid or cholesterol
measurements are “on the button”, which - The epithelial deposits at/or near the limbus seen in
line is more opaque with small amounts the stroma. The central area in between
means measuring from the center of the of epithelium missing (Figure 7). It is the arcus is measured to give the clear
also accompanied with some amount of zone which then grades the arcus as mild,
cornea outwards (Figure 6). sloughing. moderate or severe
Ȉ Central = 3.0 mm – center – Small area of the Edema: Edema is collection of excess
epithelium remains intact with Large ϐ
Ȉ Paracentral = 3.0mm - 5.5mm areas of sloughing
Ȉ Mid-peripheral = 5.5 mm – 7.5 mm
Ȉ Peripheral = 7.5 mm – limbus
Ȉ Diffuse = Spread across
the entire
cornea.
Figure 5: 4GVTQ KNNWOKPCVKQP 6GEJPKSWG Figure 6: .QECVKQP 6GTOKPQNQI[
Figure 7: /QFGTCVG 'ZRQUWTG Figure 8: 5NQWIJKPI
www. dos-times.org 67
EYE BANKING
to it swelling. The zone and severity of ϐ Few: Vertical folds only, usually
edema should be noted. grading the tissue.
between one and six in number.
Mild Edema – Generally present with ϔǣ Accumulation of
mild to moderate folds ϐ Few to several: Vertical and
ϐǤ
Mild to Moderate Edema – be a response to infective material or horizontal folds, total number of folds
Associated with Moderate folds. Stromal foreign bodies on the cornea. It may be
haze extends through most of the stroma. seen along with presence of localized should be under ten (Figure 12).
edema and sloughing. In a narrow slit an
Moderate Edema– Associated with ϐ
Several: Additional folds
Moderate to severe folds. Stromal haze
ϐǤ
extends through the entire stroma. interconnect the vertical and horizontal.
Foreign Body: A foreign body may
Severe - Associated with severe folds. be located in the corneal stroma, most Numerous: Most of the endothelial
The stroma is almost completely opaque. common of them being glass or dirt
particles and is mostly seen in trauma surface is folded.
Striae: ϐ cases (Figure 10). They may or may not be
lines within the stroma caused due to
ϐ Severity of folds: The graphic gives a
ϐǤ
They are usually seen associated with the Descemet’s Membrane Examination representation of the severity of folds.
folds
Folds: Protrusion caused by localized Descemet’s detachments and Peels –
Scars: Scars are whitish areas of swelling along curved linear
abnormalities within the stroma where These may be seen as detached descemet
the corneal section appears thinner than
the surrounding (Figure 9). The location, (Figure 13).
size, density and depth of the lesion
Endothelium Examination
Stress Lines: These are linear
opacities seen at the level of endothelium.
They represent areas where folding of
the cornea has caused stretching of the
endothelium and its rupture or separation
from the descemet’s membrane. These
Figure 9: 5ECTU Figure 10: (QTGKIP $QF[
Figure 12: /KNF VQ OQFGTCVG HGY VQ UGXGTCN HQNFU Figure 13: &GUEGOGVŏU FGVCEJOGPVU
CPF 2GGNU
Figure 11: 5GXGTKV[ QH &GUEGOGVŏU HQNFU paths of the corneal stroma is seen as are usually caused at the time of recovery
folds or ridges on the Descemet’s. These due to excessive pull of the tissue. Stress
folds are rated based on their number and lines must be graded based on their
severity and determine the quality of the location and number as:
tissue. Ȉ ȋ ͳͶȌǤ
Ȉ
Ǥ
ϐ
Ȉ
and Number of Descemet’s folds (Figure
11): lines.
68 DOS TIMES - NOVEMBER-DECEMBER 2015
EYE BANKING
Figure 14: %GPVTCN UVTGUU NKPGU Figure 15: 2GTKRJGTCN UVTGUU NKPGU
Figure 16: /KNF %GNN &TQRQWVU
absent endothelial cells best seen on density between 2000- 3500 cells/mm.
ϐ
Ǥ Along with cell density, a completeanalysis
spots of missing cell pockets. Based on the of hexagonlity and polymegathism
area involved cell dropouts are graded as: should be done for accurate assessment
of endothelium. Sometimes acareful slit
Mild dropout: Approximately 5-15% lamp examination provides an overall
endothelial cell loss (Figure 16). status of the endothelium better than
specular microscopic examination as the
Mild to Moderate dropout: area examined by specular microscopy is
Approximately 15-30% cell loss (Figure very small and cannot be extrapolated to
17). the total endothelium (Figure 18).
Moderate: Approximately 30-50% After the complete evaluation
cell loss of donor tissue, the corneal tissue is
categorized as suitable for particular
Severe: 50% + cell loss. It may be
ϐ
ϐ
severe dropout.
Figure 17: /KNF VQ OQFGTCVG EGNN FTQRQWV Figure 18: 5RGEWNCT /KETQUEQR[
Ȉ Specular Microscopy corneal transplant and then released by
the eye bank to the surgeon for surgery.
lines This determines the endothelial
CONCLUSION
Ȉ ȋ cell density and the endothelial cell Donor cornea evaluation has a
15). morphology of the donor cornea. The
Ȉ crucial role in Eye banking. A dedicated
normal healthy endothelium shows
Cell Dropouts: These are areas of similar size hexagonal cells with cell
www. dos-times.org 69
EYE BANKING
Criteria for Determining Cornea Suitability for Corneas
Penetrating Endothelial Anterior Lamellar Therapeutic
Keratoplasty Keratoplasty Keratoplasty Keratoplasty
Any
Rim Width Any >2.0 mm Any Suitable
Suitable
Epithelium Exposure Suitable Suitable Suitable Suitable
Suitable
Sloughing <25% sloughing Suitable <25% sloughing Suitable
acceptable acceptable Suitable
Suitable
Debris* Suitable Suitable Suitable Suitable
Pterygium >8.00 mm clear zone Suitable >8.00 mm clear zone NOT SUITABLE
Suitable
Band Keratopathy >8.00 mm clear zone Suitable >8.00 mm clear zone NOT SUITABLE
Stroma Edema mild-moderate edema mild-moderate mild-moderate edema Suitable
acceptable edema acceptable acceptable Suitable
Suitable
Arcus/ Clear Zone >6.00 mm clear zone >6.00 mm clear >6.00 mm clear zone
zone Suitable
Scars, sub- Acceptable up to 3.0 Acceptable in Acceptable up to 3.0 mm Suitable
epithelial haze, mm on button anterior stroma but on button Suitable
opacities must not penetrate
deeper than 50% of Suitable
thickness Suitable
Not Suitable
ϐ NOT SUITABLE NOT SUITABLE NOT SUITABLE
Striae Suitable Suitable Suitable
LASIK/PRK/RK NOT SUITABLE NO RK but LASIK NOT SUITABLE
Scars and PRK are
acceptable
Cloudy dystrophy NO Suitable Suitable
or central crocodile
shagreen
Foreign bodies** >8.00 mm Any >8.00 mm
Descemet’s Folds up to few to several up to few to several no restrictions, however
membrane moderate folds
acceptable mild to moderate several or moderate folds
folds acceptable may indicate edema
Endothelium Endothelium Stress up to several diffuse up to several several/severe is suitable
diffuse or several
lines or several central central stress lines
stress lines
Defects depends on severity depends on Suitable
severity
Cell dropout <moderate <moderate Suitable
cell dropout cell dropout
(pseudoguttata) (pseudoguttata)
Polymegathism OK unless severe OK unless severe Suitable
Pleomorphism OK unless severe OK unless severe Suitable
Endopeel Up to 8.00 mm on Up to 9.5 mm on Suitable
detachments or button acceptable button acceptable
peels
evaluation technician who can adequately 2. Findings in donor cornea evaluation : A J Ophthalmol 28;6:254-258.
grade corneas along with standardization guide book .Sightlife 2015. 5. Eye banking -The Minnesota
of the technique is the need of the hour
and will go a long way in improving the 3. George O. D. Rosenwasser, William J. experience. Allarakhia L, Robin SB,
outcomes of keratoplasty dramatically. Nicholson. A Handbook and Atlas: a Rogers MS, et al Ann Ophthalmol 1990;
Guide to Eye Bank Techniques, Corneal 22:286-92.
REFERENCES Evaluation, and Grading. Ǥ ϐ
postmortem time on corneal graft
1. Donor Corneal tissue evaluation. Saini 4. Eye Bank of Canada - Procedures survival and thickness when employing
JS, Reddy MK, Sharma S, Wagh S. Indian guidelines 1994Chipman ML, Slomovic banked donor material. Andersen
J Ophthalmol 1996:44:3-13. AS, Rootman S, et al. Changing risk for J and Ehlers N. ActaOphthalmol
early transplant failure data from the 1988;66:313-17.
Ontario Corneal Recipient Registry. Can
Financial Interest: ϔ
Ȁ
Ǥ
70 DOS TIMES - NOVEMBER-DECEMBER 2015
DOS QUIZ
DOS Times Quiz 2015-16
Episode-3
ǣ
Ǧ ͷ ͵Ͳth November, 2015
Q1 (a) What is the congenital Q6. Diagnosis ?
eyelid anomaly that this boy
is having? (a) Glaucomatous optic
(b) What is the sequence in neuropathy
which the individual eyelid
abnormalities of this (b) Morning glory syndrome
syndrome are corrected by
surgery? (c) Optic nerve pit
(d) Optic disc coloboma
Q2. In a patient who has had vitreoretinal surgery, which of the following is false? Q7. Diagnosis?
(a) buckling induces astigmatism (a) Best vitelliform dystrophy
(b) cataract formation is a common complication with macular hole surgery (b) Gyrate dystrophy
(c) injection of air into the vitreal cavity of a phakic patient causes a myopic (c) Stargardts disease
shift (d) Pattern dystrophy
(d) injection of air into the vitreal cavity of an aphakic patient causes a a
hypermetropic shift
͵Ǥ ȋȌ
(b) What is the likely syndrome
anomalies can you identify that child is having?
in the photo?
(c) What other organs may be
affected in this child?
(d) At what stage of emryogenesis
did the insult occur and of
what was affected?
Q4. Give the Diagnosis? Q5. (a) This boy presented with sudden onset spontaneous proptosis of
(a) CRAO with sparing of right eye, CT scan orbit was performed, the axial cut through mid
cilioretinal artery
ϐǤ ǫ
(b) CRAO
(c) Ophthalmic artery occlusion (b) What is the management?
(d) Berlins edema
Compiled by:
Dr. Rajendra Prasad Centre for Ophthalmic Sciences,All India Institute of Medical Sciences, New Delhi, India
Dr. Rachna Meel MD Dr. Ravi Bypareddy MD Dr.Anita Ganger MS
Assistant Professor of Ophthalmology Senior Resident Senior Research Associate
Oculoplasty Services Retina Services
www. dos-times.org 71
DOS QUIZ DOS TIMES Quiz Rules
Q8. In a patient who has had vitreoretinal surgery, which of the following is false? 1. DOS TIMES QUIZ will now feature as 5 Episodes
(a) Buckling induces astigmatism (Episode 1: July-August, Episode 2: September
(b) Cataract formation is a common complication with macular hole surgery – October, Episode 3: November – December,
(c) Injection of air into the vitreal cavity of a phakic patient causes a myopic Episode 4: January – February, Episode 5: March
shift – April). Entries will have to be emailed before
(d) Injection of air into the vitreal cavity of an aphakic patient causes a a the last date mentioned in the contest questions
hypermetropic shift form. Late entries will not be entertained.
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for Ophthalmic Sciences, All India Institute of
Q10. 56 year old female presented Medical Sciences, New Delhi.
with sudden painless
diminution of vision in RE 3. Nonmembers may also send in their entries
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hypertension. Give your the contest will not be considered.
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with in such patient.
ϐǤ
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answers.
5. Please write to [email protected]/
̷Ǥ
ϐ
if any.
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72 DOS TIMES - NOVEMBER-DECEMBER 2015
ROSSWORD DOS CROSSWORD
Episode-3 34
6
Dr. Manish Mahabir MD
Senior Resident,
Dr. R.P. Centre,All India Institute of Medical Sciences,
New Delhi, India
12
5
7
89
10 11 12
13
14
15
ACROSS DOWN
2. Technique to modify individual neurons to include light-
1. Non valved polypropylene glaucoma drainage device
developed in Cape Town (7) sensitive ion channels using viral vectors (12)
3. Plot used in survival analysis (11)
5. Laser transforms tissue into plasma (15) 4. Formula to calculate the amount of tissue to be removed
7. Standard mfERG measures function of ____ (4)
8. Trophozoites form double walled cyst (12) for myopic treatment in lasik (9)
10. Refractive error in retinopathy of prematurity (6) 6. Antiepileptic drug which may cause bilateral concentric or
12. Whitish grey spot in peripheral iris,seen in Down’s
ϐ
ȋͳͲȌ
syndrome (10) 9. Gradual tapering of diffractive steps from centre to
ͳ͵Ǥ
ϐ
ȋͳͳȌ
14. Father of gonioscopy (8) periphery of a lens (11)
15. Orbital cyst with “double wall” sign on ultrasound (7) 11. Principle of stereotest used in TNO test (8)
www. dos-times.org 73
QUICK PICKS
THYROID EYE DISEASE
Dr. Gautam Lokdarshi MD progression. Therefore, maintenance of a euthyroid state
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, is important.
All India Institute of Medical Sciences,
New Delhi, India PATHOGENESIS
¾ [Lehmann GM, et al.]4,5- According to one current model,
INTRODUCTION
¾ Approximately 25–50% of patients with GD will develop TED is triggered by binding and activation of orbital
ϐ Ǥ
clinically apparent TED some time during their lifetime.
ϐ
Ȁ
Ǧͳ Ǥ
¾ Sight-threatening disease is much more infrequent and
ϐ
ǡ
IL-16, RANTES, and CXCL10, which recruit T lymphocytes
occurs in approximately 3–5% of patients. into the orbit. These lymphocytes then interact with
¾ Regardless of whether thyroid gland dysfunction or TED ϐǡ
ǡ
ȋ ɀǡ Ƚǡ
ʹǡ
ϐǡ
15d-PGJ2) and secretion of T cell-activating factors by
apparent within 18 months. ϐ ȋ Ǧͺ ͳͲȌǤ
¾ Approximately 10% of patients developing TED will never stimulated to secrete IL-6 (promoting B cell differentiation)
manifest thyroid dysfunction. and to increase autoantigen presentation, both of which
¾ Congenital GD is rare and typically occurs in infants born Ǥ
ϐ
to mothers with hyperthyroidism. with T cells result in the deposition of extracellular matrix
ǡ ϐ ǡ
Ǥ
CLASSIFICATION ¾ Autoantibodies detected are – antibody against
TED can be divided into active and inactive (stable) disease. thyrotropin receptor (TSHR). These are known as thyroid
stimulating immunoglobulin (TSI). Others are, antibodies
¾ Active disease exhibits time-dependent changes in the against thyroglobulin (TG) and thyroid peroxidase (TPO).
clinical features. Active disease can be targeted by medical TG shares physical attributes with acetylcholinesterase,
therapy and typically lasts from 6 months to 2 years. suggesting that the two might share an epitope.
Antiacetylcholinesterase antibodies were detected in 8%
¾ Stable phase follows when proptosis, eyelid retraction, of patients with TED. None of these autoantigens appear
and restrictive strabismus either remain unchanged or proximately related to TED since the levels of antibodies
improve. directed against them do not correlate with disease
activity.
Scoring systems for TED ¾ Connective tissues and not extraocular muscles represent
¾ “No signs and symptoms, Only signs, Soft tissue the primary immune targets in TED. Orbital fat expansion
Ǧͳ Ϋ
involvement, Proptosis, Extraocular muscle involvement, ϐ
Ǥ ͳ Ϊ ϐ
Corneal involvement, and Sight loss” (NOSPECS) system, ϐ
developed by Werner et al1.
Ǧ Ǥ ϐ
¾ Clinical Activity Score (CAS) was developed by Mourits ϐ
ϐǤ
et al2. Retrobulbar pain, eyelid erythema, conjunctival ¾ T/B cell interactions and immunoglobulin class switching
injection, chemosis, carunclar swelling, and eyelid edema. has been implicated in the pathogenesis of TED.
Equally weighted values are assigned to each clinical
feature and the total summed. A score of 3 was found to MANAGEMENT OPTIONS
correlate with active TED, and a score of 4 carries high ¾ Consensus on management of TED-
predictive value for response to immunosuppressive
treatment. ¾ Stable systemic thyroid status is of prime importance.
¾
Dzǡ ϐ ǡ ¾ Stop smoking
strabismus, and appearance/exposure” (VISA) ¾ Active TED (CAS>3) needs systemic steroid/
ϐ
3.
Risk/ associated factors: immunosuppression/(rarely) orbital radiotherapy.
¾ Cigarette smoking represents perhaps the strongest ¾ Sight threatening TED with poor/ no response to
association between an acquired factor and the
development and worsening of TED. Several groups have above mentioned therapies for 2 weeks or more, may
reported that smokers exhibit more severe TED, that it need orbital decompression.
is more aggressive following radioactive iodine thyroid This is a consensus statement, based on current research,
ablation, and is less likely to respond to therapy. on the management of TED by the European Group on Graves’
¾ Monozygotic twins. Orbitopathy6.
¾ While men with GD are less likely to develop TED, their
disease appears to be more severe. Steroid
¾ Hyperthyroidism runs a clinical course that is independent ¾ Rajendram and colleagues7, glucocorticosteroid response
of TED. However, radioiodine ablation of the thyroid
gland is associated with mild, transient worsening of rate ranges from 63-77%.
TED in approximately 10–15% of patients. Untreated ¾ Zoumalan and colleagues found that weekly pulse
hypothyroidism resulting from radioiodine ablation
may increase the risk of developing TED or enhance its doses of intravenous glucocorticosteroids produced
a more favorable response in more patients than oral
glucocorticosteroids given daily (74.6 vs. 55.5%)8.
ǡ ϐ
www. dos-times.org 75
QUICK PICKS are not generally utilized, and must be done under supervision
of rheumatologist.
ϐ
Ǥ
¾ Steroids as prophylaxis for Iodine Thyroid Ablation- Thyroid eye disease- Eponymous signs
Patients on radioactive iodine therapy shows rapid Ȉ ǯ ȋ Ȍ
Ȁ ϐ
Ȉ
ϐǯ ȋ Ȍ
can worsens/ precipitates TED. Oral steroid during and Ȉ ȋ
Ȍ
following course of radioactive iodine therapy should be Ȉ
ǯ ȋ Ȍ
given to prevent and treat worsening of TED. Ȉ ȋ Ȍ
¾ Use of peri-ocular steroid (triamcinolone) has been Ȉ ȋ
Ȍ
suggested by some authors to decrease size of extraocular Ȉ
ȋ
muscles and diplopia9. But, Trobe et al have reported
unfavourable outcomes in patients with compressive optic lid)
neuropathy10. Ȉ
ȋ
Non-steroidal immunosuppressant therapy gaze)
¾ Cyclosporine Ȉ ȋ
Ȍ
¾ Methotrexate (MTX) Ȉ ȋ
Ȍ
¾ Etanercept, which has an extracellular binding site for Ȉ
ǯ ȋ
Ƚǡ ϐ
ǡ
lateral rectus insertion site)
ȽǤ Ǧ
Ȉ Boston’s sign (jerky movements of upper lid on downgaze)
infections, malignancies, and the development of additional
autoimmune disorders. Paridaens and colleagues Exophthalmometry (Proptometry)
performed a pilot study using biweekly 25mg etanercept
subcutaneous injections for 12 weeks in 10 euthyroid, Ȉ αͳͲǦʹͲ ȋ α ͳǡ
recent onset TED patients with a mean pretreatment CAS female=16, children=14.5)
of 4 (range: 3-6)11. Mean CAS decreased to 2.6 at six weeks
and 1.6 at 12 weeks. No toxicity was noted. Ȉ δͳͲ εʹͲ ՜
¾ Lymphocyte Depletion Therapy, Rituximab (RTX), Ȉ Ǧ
εʹ ՜
represents a monoclonal antibody directed at the B cell Ȉ ȋ
Ȍǣ
surface antigen, CD20. RTX blocks cell proliferation and
attenuates CD20 + -dependent B cell maturation. Studies 1. Zehender- with Side view mirror
have shown that patients receiving RTX demonstrated 2. Mutch- measures through Closed eyelids
greater reduction in the CAS with fewer side effects 3. Gormaz- with Corneal cup
compared to those treated with corticosteroid. Thyroid 4. Luedde –Most Simple
function and TRAb levels were unaltered with RTX 5. Hertel– Binocular; Mirror sliding Side-to-side
treatment. Adverse effects associated with RTX include 6. Davanger- Prism sliding Anterior-Posterior
transient hypotension, cough, pruritis, transient febrile 7. Radiography – Cornea-Clinoid distance; radio-opaque
episodes, and increased risk of infection.
¾ Rapamycin is an antibiotic in the macrolide class, which dot in Contact Lens
Ǧϐ ϐ
8. Topometry (Watson) – Vertical, Horizontal and
via inhibition of cytokines and growth factor-mediated
ϐ
12. Possible Anterior-Posterior(axial) displacements
adverse reactions associated with rapamycin include 9. Perspex ruler – Vertical (scale at outer canthus)and
myelosuppression (most often thrombocytopenia) and
hyperlipidemia. Horizontal (distance of nasal limbus from nasal bidge)
displacements
Orbital irradiation 10. McCoy Trisquare- Frame measuring Non-axial
The clinical effects of irradiation are observed within 2–3 displacements
weeks of treatment, but progressive improvement can continue REFERENCES
for several months13. Progression of TED remain uncertain. the
apparent response rate to orbital radiation was approximately ͳǤ Ǥ ϐ
ǯ Ǥ
60%. Metab. 1969;29:982–4.
Orbita decompression surgery 2. Mourits MP et al. Clinical criteria for the assessment of disease activity in Graves’
Decompression surgery considered to be reserved for ophthalmopathy: a novel approach. Br J Ophthalmol. 1989;73:639–44.
patients responding poorly to steroids/ immunosuppression14. ͵Ǥ
ǡ
Ǥ
ϐ
ǯ Ǥ
Reconstr Surg. 2006;22:319–24.
CONCLUSION
Approach to management of TED is to use conservative 4. Lehmann GM et al. Immune mechanisms in thyroid eye disease. Thyroid.
2008;18:959–65.
measures for mild to moderate disease directed toward patient
Ǥ ϐ
ǡ
ǡ 5. Lehmann GM et al. Regulation of lymphocyte function by PPARgamma: relevance to
ϐ
Ǧ ϐ Ǥ Ǥ ʹͲͲͺǢʹͲͲͺǣͺͻͷͻͲͳǤ
in the active stage. Chronic soft tissue alterations are treated
surgically. Severe TED, particularly when accompanied by optic 6. Bartalena L, Baldeschi L, Dickinson A, et al. Consensus statement of the European
neuropathy, is managed using high dose oral prednisone. If full Group on Graves’ orbitopathy (EUGOGO) on management of GO. Eur J Endocrinol
taper cannot be achieved within 2 months, then bony orbital 2008;158:273–85.
decompression is performed. Orbital radiation is considered
an adjunct to steroids, decompression, or both for recalcitrant 7. Rajendram R, Lee RW, Potts MJ, et al. Protocol for the combined immunosuppression
disease. Immunosuppressive and immunomodulatory drugs & radiotherapy in thyroid eye disease (CIRTED) trial: A multi-centre, double-masked,
factorial randomized controlled trial. Trials 2008;9:6.
ͺǤ ǡ
ǡ ǡ Ǥ ϐ
beam radiation in the management of moderate to severe thyroid eye disease. J
Neuroophthalmol 2007;27:205–14.
9. R Ebner, M H Devoto, D Weil, M Bordaberry, C Mir, H Martinez, L Bonelli, H
Niepomniszcze. Treatment of thyroid associated ophthalmopathy with periocular
injections of triamcinolone. Br J Ophthalmol 2004;88:1380–86.
ͳͲǤ
ǡ
ǡ ϐ Ǥ
Ǥ
ϐ
rationale of management. Arch Ophthalmol 1978;96:1199–209.
11. Paridaens D, van den Bosch WA, van der Loos TL, et al. The effect of etanercept on
Graves’ ophthalmopathy: a pilot study. Eye 2005;19:1286–89.
12. Chang S, Perry JD, Kosmorsky GS, et al. Rapamycin for treatment of refractory
dysthyroid compressive optic neuropathy. Ophthal Plast Reconstr Surg 2007;23:225–
26.
13. Bradley EA, Gower EW, Bradley DJ, et al. Orbital radiation for graves ophthalmopathy:
a report by the American Academy of Ophthalmology. Ophthalmology 2008;115:398–
409.
ͳͶǤ
ǡ
ǡ ǡ Ǥ ϐ
treatment of thyroid-associated ophthalmopathy: long-term follow-up of 78 patients.
Clin Endocrinol (Oxf) 2007;67:101–107.
76 DOS TIMES - NOVEMBER-DECEMBER 2015
CORRESPONDENCE PORTAL
UNDESIRABLE SYSTEMIC EFFECTS OF
CYCLOPENTOLATE
Vaishali Une
Dr.Vaishali Une Figure 1: 5JQYKPI J[RGTCEVKXKV[ KTTKVCDKNKV[ PQV TGEQIPK\KPI OQVJGT
Aurangabad, Maharashtra HQNNQYKPI KPUVKNNCVKQP QH E[ENQRGPVQNCVG G[G FTQRU
Cyclopentolate, a synthetic antimuscarinic agent He was also advised fundoscopic examination and
with an action similar to that of atropine, has refraction after dilatation with 1% cyclopentolate eye drops.
been widely used in the form of eye drops to Twenty minutes after instillation of cyclopentolate eye drops
induce quick mydriasis in diagnostic procedures1. he had fever, incoherent speech, tics, tachycardia, restlessness,
As cyclopentolate has lesser systemic and CNS failure to recognize mother, disorientation and hallucinations.
side effects than atropine, it is routinely used for
ophthalmic examination in paediatric patients. CASE 3: A seven years old female child had complaints of
Cyclopentolate blocks muscarinic responses of the deviation of both eyes since birth, for which she was brought
sphincter pupillae muscle of the iris and the accommodative by her parents to our out-patient department. Her birth and
muscle of the ciliary body to cholinergic stimulation producing developmental history were normal, with no history suggestive
pupillary dilatation (mydriasis) and paralysis of accommodation of any major illness till date. She was completely immunized.
(cycloplegia) respectively. Her family history was not contributory. She was dilated with
On instillation in eyes, action starts in 15 to 20 minutes 1% cyclopentolate eye drops for fundus examination and
with peak cycloplegic action at 25 to 75 minutes and mydriasis
Ǥ ϐ
within 30 to 60 minutes. Duration of action is 6 to 24 hours. In of drops, she became irritable and thirsty following which she
some cases mydriasis remains for several days. Cyclopentolate had fever, abdominal cramps and she failed to recognize her
is a better cycloplegic than homatropine and is similar in effect parents.
to atropine but wears off more quickly2.
In the above mentioned cases, the children were admitted
Case 1: A 9 months old boy was brought by his mother to our
ϐ
out-patient department with chief complaints of deviation and were given symptomatic treatment. Administration
in eyes. Birth and developmental history were normal with of physostigmine was not required in any case. Parental
no history of birth trauma or any birth defect. There was no counselling regarding the symptoms after use of drug and
history suggestive of any major illness or hospital admission assurance was provided.
since birth. The baby had no history of seizures or paraplegia.
The child was completely immunized till date. DISCUSSION
On examination the child had bilateral alternating 30 The 1% concentration is the most commonly used among
degree esotropia (15 PD). His pupils were then dilated with
ͷͲ Ɋ ȋͲǤͷ
1% cyclopentolate eye drops for fundoscopic examination mg). Cycloplegic agents can enter the bloodstream by absorption
and refraction. Our protocol for pupil dilatation in paediatric through the cornea, conjunctiva, nasolacrimal mucosa, and
patients is to instill one drop of cyclopentolate eye drops every gastrointestinal tract3. Systemic absorption of cyclopentolate is
10 minutes for three times. After ten minutes of instillation of more through transconjunctival route or through nasolacrimal
cyclopentolate eye drops, the baby showed abnormal behavior duct4. To minimize the systemic absorption, pressure should
in the form of excessive crying, hyperactivity, irritability, not be applied over the nasolacrimal sac for 2-3 minutes and the
recognizing mother, hot and dry skin with pulse rate-110/min.
www. dos-times.org 77
CASE 2: A six years old male child had chief complaints of
ϐ
narrated by his mother.
There was no history suggestive of any major illness in
past. He was completely immunized till date with normal birth
and developmental history.
CORRESPONDENCE PORTAL
Figure 2: 5JQYKPI KPEQJGTGPV URGGEJ VKEU VCEJ[ECTFKC TGUVNGUUPGUU HQNNQYKPI KPUVKNNCVKQP QH require administration of physostigmine
E[ENQRGPVQNCVG G[G FTQRU as its action lasts only for 6-24 hours and
ϐ
Ǥ
Similar case reports were published
in the past6,8,9,. Binkhorst and co-authors
showed that the incidence of psychotic
reactions in a group of children and
ϐ
the dose administered10.
To summarise though side effects
are rare but systemic toxicity is seen with
prevalence being 1 in 100. Occurrence of
systemic toxicity can be decreased by :
1) Punctal occlusion for 2-3 minutes
2) Avoiding drops in fair skinned or
light iris
3) Avoiding use in Down’s syndrome or
cerebral palsy or brain damage
4) The use of microdrops (5 mL) as
compared to normal drops (35 mL)
could also decrease the incidence of
side effects11.
This correspondence aims at creating
awareness among the ophthalmologists
about the undesirable systemic effects of
cyclopentolate and should always keep
this at the back of mind while examining
paediatric patients.
Figure 3: &KUQTKGPVGF EJKNF HQNNQYKPI KPUVKNNCVKQP QH E[ENQRGPVQNCVG G[G FTQRU REFERENCES
child should be observed for 30 minutes5. children, increased chances of systemic 1. Camarasa JG, Pla C. Allergic contact
On systemic absorption various adverse toxicity is seen. Increased susceptibility dermatitis from cyclopentolate. Contact
effects are seen which can be minor or to cyclopentolate eye drops has been Dermatitis. 1996;35:368-9.
major. reported in infants and children with
Down’s syndrome, spastic paralysis 2. Ophthalmic Medications and Pharmacology;
Minor side effects are generally or brain damage6,7. Seizures and acute Brian Duvall, Robert Kershner; 2nd
ocular manifestations which include psychosis induced by cyclopentolate are edition;4:23-28.
stinging or irritation of eyes, blurring especially prominent in children6,7. Fair
of vision, redness of eyes, photophobia, skinned and light iris may exhibit an 3. Havener WH. Ocular pharmacology, 5th edn.
conjunctivitis, blepharoconjunctivitis, increased response, hence should be used C.v. Mosby, St Louis. 1983. p.233
increased IOP, punctate keratitis and with caution in them. Feeding intolerance
synechiae formation6. may follow its use in neonates. It is 4. Palmer EA; How safe are ocular drugs in
recommended that feeding be withheld Paediatric Ophthalmology; 1986;93:1638-
Major side effects include dry for 4 hours after examination. 40.
ǡ ϐǡ ǡ
ǡ
constipation, vomiting and dizziness. In case of severe reactions manifested 5. Drugs in Ophthalmology; Donald S. Fong,
Children may also have gastric dilatation, by hypotension with progressive Simon K. Law, Ursula Schmidt-Erfurth;
skin rashes, behavioural problems respiratory depression, parenteral 24;59:128.
including psychotic behaviour or collapse, administration of physostigmine as
ataxia, incoherent speech, restlessness, antidote may be indicated. 6. Systemic toxicity with cyclopentolate eye
hallucinations, hyperactivity, seizures drops; S.S Bhatia, C.Vidyashankar, R.K.
and failure to recognize people. Severe Cyclopentolate produces reactions Sharma, A.K. Dubey, Indian Paediatric
manifestations of toxicity include coma, similar to those of other anticholinergic Journal2000;37:329-31.
medullary paralysis and death6. All the drugs, but the CNS manifestations as
major manifestations though rare, can noted above are more common as the 7. Lahdes KK, Huupponen RK, Kaila TJ.
occur. crosses the blood brain barrier more Ocular effects and systemic absorption of
easily7. These manifestations rarely cyclopentolate eyedrops after canthal and
In view of smaller body mass of conventional application. Acta Ophthalmol
(Copenh) 1994; 72:698–702.
8. Tripathi SK, Mondal TK, Systemic toxicity
with cyclopentolate hydrochloride following
topical ocular instillation; American Journal
of Ophthalmology 1976;8:803-06.
9. Khurana AK, Ahluwalia BK, Choudhary
R, Vohra AK; Acute Psychosis associated
with topical cyclopentolate hydrochloride;
American Journal of Ophthalmology 1988;
105:9.
10. Binkhorst RD, Weinstein GW, Baretz RM,
Clahane AC Psychotic reaction induced
by cyclopentolate (cyclogyl); results of a
pilot study and a double-blind study.Am J
Ophthalmol 1963; 55:1243–45.
11. Gray LG. Avoiding adverse effects of
cycloplegics in infants and children. J Am
Optom Assoc 1979; 50: 465-70.
78 DOS TIMES - NOVEMBER-DECEMBER 2015
NEWS WATCH
DOS ENHANCED SUBSPECIALITY KORNER
DESK – I : OCULOPLASTICS
&T 0CTGUJ ,QUJK 1EWNQRNCUV[ %QPUWNVCPV HTQO &T 8KF[CUJCPMCT 1EWNQRNCUV[ %QPUWNVCPV /WODCK
7- FGNKXGTKPI JKU IWGUV NGEVWTG QP 1EWNQRNCUVKEU FGNKXGTKPI JKU IWGUV NGEVWTG QP “Use of collagen matrix
Broadening the Horizon of Functional and Aesthetic in DCR and other oculoplastics surgeries: Novel
surgery Indications”
&T #UJQM )TQXGT FGNKXGTKPI JKU VCNM QP “Future of &T 5WUJKN -WOCT RTGUGPVKPI OQOGPVQ VQ IWGUV URGCMGT
&T 8KF[CUJCPMCT
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&T 5 / $GVJCTKC RTGUGPVKPI VJG OQOGPVQ VQ )WGUV 2TQH 8 2 )WRVC RTGUGPVKPI OQOGPVQ VQ &T #UJQM
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www. dos-times.org 83
NEWS WATCH
84 DOS TIMES - NOVEMBER-DECEMBER 2015
NEWS WATCH
DOS – NEB Eye Donation Fortnight Celebrations
Eye Donation Awareness Walk, August 26, 2015, 3.00 – 4.30 p.m.
Dr. R.P. Centre, AIIMS, New Delhi
ͳʹͲ
ǡ ǡ ǡ ǡ ǡ
Ȃ
Ǥ
ǣ
Ǥ ǡ Ǥ Ǥ ǡ
Ǥ Ǥ ǡ
Ǥ ǡ Ǥ ǡ
Ǥ ǡ Ǥ ǡ
Ǥ
Ǥ
www. dos-times.org 85
NEWS WATCH
GBM Meeting and DOS Monthly Clinical Meeting-II
August 30, 2015
Ayurvigyan Auditorium, R&R, Army Hospital, New Delhi
DOS President Dr. Cyrus Shroff, General Secretary Dr. M.Vanathi, Vice President
Ǥ
͵Ͳǡ ʹͲͳͷǡ ͳͲ Ȃ ͳͳ
Ayurvigyan Auditorium at R & R, Army Hospital, New Delhi.
Dr Sanjeev Gupta, past Treasurer, DOS
RTGUGPVGF VJG CWFKVGF ſPCPEKCN TGRQTV QH
&15 HQT VJG [GCT
&T 8KRWN 0C[CT 6TGCUWTGT &15 RTGUGPVKPI
VJG ſTUV #PPWCN $WFIGV QH &15 HQT VJG [GCT
CV VJG #PPWCN )$/ QH &15
QP #WIWUV
Clinical Case Presentations
%NKPKECN %CUG 2TGUGPVCVKQP QP 810 *+22'. %NKPKECN %CUG QP 1EWNCT KPXQNXGOGPV KP FQI DKVG RTGUGPVGF D[ &T +OTCP /GJFK CPF FKUEWUUGF
.+0 &+5'#5' # 6JGTCRGWVKE EJCNNGPIG D[ .V %QN #PKTWFJ 5KPIJ
OKPWVGU
YCU FQPG D[ &T 5JCNN[ -CPFJCTK CPF
FKUEWUUGF D[ %QN 2QPKPFGT -WOCT Guest Case Presentation
MINI SYMPOSIUM on Ethics & Legality – Where we stand ?
With Brig. J.K.S. Parihar on Chair and Col. Rakesh Maggon as Co-chair
(1) (2)
%QN 5 - /KUJTC URGCMKPI
QP ő#ODKV QH .CY 1WVNCYU
CPF +PNCYUΠKP VJG OKPK
U[ORQUKWO
%QN 5CPVQUJ -WOCT )WGUV ECUG RTGUGPVCVKQP D[ &T 5KFFCTVJ /CFCP
URGCMKPI QP ő+H KVŏU PQV TKIJV QP ő$CUCN %GNN %CTEKPQOC QH G[G YKVJ .GUGT 6TGNCV
KU KV CNYC[U YTQPI!ΠKP VJG 5[PFTQOGΠCPF FKUEWUUGF D[ 2TQH 4CLKX )CTI *1&
OKPK U[ORQUKWO &GRCTVOGPV QH 1RJVJCNOQNQI[ .CF[ *CTFKPIG
/GFKECN EQNNGIG
www. dos-times.org 89
NEWS WATCH
DOS Monthly Clinical Meeting – III
Dr. Shroff’s Charity Eye Hospital, Darya Ganj, New Delhi
held on September 20, 2015
Dr. Rishi Mohan and Dr. M.Vanathi moderating the DOS
/QPVJN[ %NKPKECN /GGVKPI Ō +++ CV &T 5JTQHHŏU %JCTKV[ '[G *QURKVCN
&T 4CJWN /C[QT RTGUGPVKPI JKU ENKPKECN ECUG QP ő&QWDNG
6TQWDNGŒ
&T 0KFJK )WRVC RTGUGPVKPI JGT ENKPKECN ECUG QP ő 5VGO %GNNU
5KORNG 6GEJ HQT %QORNGZ 2CVJŒ
&T 5WPKVC &WDG[ IKXKPI JGT ENKPKECN VCNM QP ő#EJKGXKPI
'ZEGNNGPEG VJTQWIJ SWCNKV[ CUUWTCPEG U[UVGOUŒ
&T 0QUJKT 5JTQHH CPF &T 5KOC &CU OQFGTCVKPI VJG /KPK &T 4GGPC %JQWFJT[ RTGUGPVKPI VJG IWGUV ECUG ő5VWTIG 9GDGT
5[ORQUKWO QP ő1EWNCT +PHGEVKQPUŒ 5[PFTQOG %JCNNGPIGU QP )NCWEQOC /CPCIGOGPVŒ
&T #DJKUJGM &CXG GNCDQTCVKPI QP &T 5OTKVK $CPUCN URGCMKPI QP ő$WIU CPF &T 5JCNKPK 5KPIJ URGCMKPI QP ő6$ QT PQV
ő-GTCVKVKU PQV CNYC[U KPHGEVKXGŒ E[UVU CTQWPF VJG INQDGŒ VQ DGŒ
90 DOS TIMES - NOVEMBER-DECEMBER 2015
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