dos-mar-2011

ISSN 0972-0723
VOLUME 16 - No. 9/MARCH 2011

Cover Feature NaStpioencaiallIssue

Glaucoma Surgery-page 9
Diabetic Macular Edema-page 41
Genetics of Retinoblastoma-page 51
Newer Tonometers-page 57

Contents

E5 ditorial Glaucoma

Focus 57 Newer Tonometers

9 Glaucoma Surgery Manav Deep Singh

A17 nnual DOS detailed programme Miscellaneous

Retina 65 Endoscopic Endonasal DCR, the need of the day for treating the

41 Diabetic Macular Edema lacrimal sac disorder
Nishi Gupta, Suma Ganesh, Neeraj Chawla, Manish Sharma, Vishal Nigam
Shashank Rai Gupta, Parul Dwivedi, Abhishek Dagar
Clinical Monthly Meeting
51 Genetics of Retinoblastoma – An Overview
75 Clinical Talk: Neuro-Ophthalmological Manifestations in Trauma
Abhishek Jain
j.L .Goyal

F83 orthcoming Events

www.dosonline.org 3

4 DOS Times - Vol. 16, No. 9, March, 2011

Editorial

Dear Colleagues and Friends,

India has won the World Cup and all is well with the world. It is time to be happy and feel that patriotic arrogance! In the
darkness of scams-a brilliant ray of sunshine.

Here at DOS , it is time to start packing our bags. The annual conference our final Hurrah!

Welcome to the DOS Annual Conference at Hotel Ashok from 15 to 17 April. We’ll make it large!!

Curtain Raiser

Oration on Femtosecond Cataract Surgery.

Is it the next big revolution in Cataract surgery? A special oration on this cutting edge tech; by the famous Dr Michael
Knorz. Come and find out!

Special Q and A session With Dr Michael Knorz on Lasers and Lasik: Dr Michael Knorz is the Pioneer in Lasik and is widely respected as having
introduced Lasik in India. You are welcome to attend this session and learn from the master.

How to Publish Scientific Articles- members from the editorial board of the prestigious BJO , headed by the chief editor Dr Arun D Singh; will conduct
this special session for the benefit of our members. Another first for the annual conference!

Instruction Courses and live workshops. Live contact lens fitting workshop on actual and real patients. come and learn the specialized fittings in
Keratoconus and Fitting Scleral Contact Lenses etc.

Live Gonioscopy workshop on patients. Gonioscopy is a crucial part of glaucoma work up and we are conducting a live demo on patients-fully interactive.

Do come and attend these two special trainings.

The Annual DOS Quiz-always a winner! has this time been spiced up with extraspecial prizes to entice you even more. There are Prizes for everyone-
from the participants to the audience!! Enjoy the Quiz and also win great prizes.

Cultural Evening-A very grand and sumptuous cultural evening awaits all the delegates on saturday. So come prepared to be thoroughly entertained.

Dear Friends,

I have fully enjoyed my tenure as the secretary of this great association and i thank all DOS members for their help and contribution. I wish the new
team a great success and ensure them of all my assistance.

Jiyo Khiladi Wahe Wahe -
Ayede Peyde (De Ghumake)
Aare Paare (De De Ghumake)
Uttiguttam (De Ghumake)
Adchan Khadchan (De De Ghumake)

Yours Truly.
Thanking you,

Dr Amit Khosla
Secretary,
Delhi Ophthalmological Society

Glaucoma Surgery Focus

Dr. Madhu Bhadauria Dr. Gowri Jaydev Murthy Dr. Rengaraj Venkatesh Dr. Subodh Sinha
MS, FMRF MBBS, DO, DNB, FRCS DO, DNB DO, MSc

Dr. Sunil Gupta Dr. Manish Shah

Trabeculectomy has been the main stay for surgical management of glaucoma. When full medical therapy does not arrest the
progression of the disease, a filtering surgery is required. The basic technique of this surgery has remained whatsoever the same over
many a decades, with few additions/alterations like: Moorfields safe surgery system, Use of antimetabolites, a shift towards fornix
based flaps and use of adjustable/releasable sutures. Even after the advent and popularity of NPGS, Trabeculectomy is the surgery of
choice in average hands.

Dr. Madhu Bhadauria (MB): MS, FMRF Professor, Professor and Medical Superintendent, Regional Institute Of Ophthalmology Chief
Medical Officer, Eye Hospital, Sitapur

Dr. Gowri Jaydev Murthy (GJM): MBBS, DO, DNB, FRCS (Edin), FRCOphth (Lon), Consultant, Glaucoma Service, Prabha Eye Clinic
and Research Centre , 504, 40th Cross, BSK 2 Stg, Bangalore, Karnataka

Dr. Rengaraj Venkatesh (RV): DO, DNB, Chief Medical Officer and Consultant Glaucoma Services, Aravind Eye Hospital, Pondicherry

Dr. Subodh Sinha (SS): MS, MSc (CEH), Consultant, Glaucoma & Cataract Services, Venu Eye Institute & Research Centre

1/31, Sheikh Sarai Institutional Area, New Delhi

Dr. Sunil Gupta (SG): Ram Avtar Eye Hospital & Glaucoma Pavilion, Tilak Nagar, Jaipur (Rajasthan)

Dr. Manish Shah (MS): 13, Kailash Niketan, L.D. Ruparel Marg, Mumbai, Maharashtra

Dr. Yogesh C. Gupta (YCG): Gupta Eye Centre, B4/156, Lowrence Road, Delhi

YCG: In which type of glaucoma you encounter more incidence GJM: Post operative hypotony after trabeculectomy occurs
of Post operative hypotony and flat A/C’s, and what usually due to overfiltration, or bleb leakage.
preoperative precautions should be taken to avoid these?
The precautions one should take, on the table is to
MB: Hypermetropics with angle closure glaucoma, children, ensure that the AC remains formed and does not shallow
and young adults are more prone to shallow AC and immediately after infusion of saline through the side port.
hypotony. Inappropriate use of antimetabolites and poor
surgical technique makes all the trabeculectomies more The desirable end point after trab, is that when BSS is
prone to hypotony and shallow AC. For prevention of this infused through the side port, the bleb should form, and
complication two important steps are meticulous dissection the AC should remain formed and deep.
of conjunctiva (No button holing) and to apply sufficient
no of sutures to scleral flap using titration of AC depth The use of releasable sutures allows for tight closure and one
through a side port. To have good control of IOP post can avoid overfiltration in the immediate post op period,
operatively these sutures can be cut by laser suturolysis while releasing them later, to allow filtration as needed.
if laser is available. It is good to use releasable sutures
routinely to prevent hypotony. In a patient with advanced glaucoma, early post op
hypotony with shallow AC can occur sometimes due to

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ciliary shut down. MS: No, only in select cases generally use Laser suture release
whenever required
In addition, late post operative hypotony more commonly
occurs after Trab in young myopes with POAG. YCG: Is the use of antimetabolites a routine or case to case?

RV: I encounter this problem in cases with chronic angle closure MB: In my practice antimetabolites are used on case to case
glaucoma. The various pre-operative precautions employed basis. When I need a large drop in pressure or if there are
in our institute are; maximum possible medical control of high risk characteristics like retrab, previous intraocular
intra ocular pressure (IOP), pre-operative YAG peripheral surgery, pediatric glaucoma and other difficult glaucomas,I
iridectomy (P.I), pre-operative intravenous mannitol, and use antimetabolites.
adequate massage after peribulbar block.
GJM: I do not use antimetabolites for all cases. I use it where risk
SS: Hypotony with a flat anterior chamber after filtration factors for aggressive healing are present, and where the
surgery most commonly results from over filtration or aimed post op target IOP is very low.
bleb leaks. Incidence of post-operative hypotony depends
on several factors such as tightness of sclera flap sutures, I would for example not use it in a patient with mild
use of antimetabolites at the time of surgery and use of to moderate glaucoma who has not been on long term
intracameral viscoelastics. Use of pressure patch also can medications, topically, and has not undergone any previous
affect the incidence of post operative hypotony. Eyes with surgery.
angle closure (CACG) are more likely to have flat anterior
chamber post-operatively. I would consider the following risk factors for aggressive
wound healing- previous intraocular surgery, long term use
Gentle handling of conjunctiva, use of round tapered of topical medication for many years, secondary glaucomas
noncutting needle for conjunctival suturing and meticulous such as uveitic glaucoma, post traumatic glaucoma etc.
closure of conjunctiva along with adequately sutured scleral
flap can help in prevention of post-operative hypotony. RV: Usually I use antimetabolite as a routine. I avoid using in
cases of high myopia, thin sclera, normal pressure glaucoma
SG: It is encountered more in ACG, with persistently high IOP, and elderly or debilitated patients with low presenting IOP.
Also in Pseudoexfoliation Syndrome
SS: Antimetabolites reduce the risk of failure of trabeculectomy
MS: More often experience hypotony in high myopes and in both in eyes at high risk of failure and those undergoing
these cases I try to use minimal MMC or am considering surgery for the first time. I use antimetabolites (intra
ologen. Also releasable sutures with tighter closure in the operative Mitomycin C) routinely in all cases undergoing
early post operative period which may be released at 14 to trabeculectomy. Only in patients with thin conjunctiva and
21 days scleral diseases I don’t apply antimetabolites.

YCG: Do you routinely use releasable sutures and why? SG: I use it routinely.

MB: I use releasable sutures routinely as they give me option MS: Use MMC in most cases only some cases I have started
to lower the IOP at desired time to a reasonably desired using ologen on trial basis.
level and prevent post operative hypotony and shallow AC.
Some times in old patients with POAG with a very stable YCG: What is the antimetabolite you use: conc., duration and
AC, I may not use. For younger people it is advisable to use site of application?
releasable routinely.
MB: My preferred antimetabolite is mitomycin C 200
GJM: I use releasables, in selected patients, not as a routine. microgram/ ml with duration of 1to 3 minutes. In
young adults and myopes I use 5 FU intraoperative in
Generally I use them in all eyes with angle closure concentration of 50 mg/ml for 3 minutes as there are less
glaucoma, young myopes, and in patients with advanced chances of hypotony.
field loss, to avoid immediate post op hypotony.
RV: Routinely I use Mitomycin C, 0.2 mg/ml for 2 minutes and
RV: No, I don’t routinely use releasable sutures as I have an I follow Dr. Peng Khaw’s method of placing the sponges
access to YAG laser. If the need arises I perform a YAG away from the flap site.
suturolysis. The minimum window period is 3 weeks after
the surgery. SS: I use Mitomycin C on cellulose sponges in the concentration
of 0.2mg/dl for duration of 2 minutes over sclera bed before
SS: I routinely do laser suture lysis postoperatively to titrate the making sclera flap. In cases of postuveitic glaucoma,
outflow and IOP. Releasable sutures are used in situations neovascular glaucoma, aphakic glaucoma and failed
where we anticipate difficulty in laser suture lysis such as previous trabeculectomy, I use MMC for 4 minutes.
trabeculectomy with collagen implants and patient with
thick tenon’s capsule. SG: MMC(0.02%)usually 30 secs to 1mt.I put it after the Scleral
Flap is made.
SG: No .Being in private practice, it gives the patient a feel that
something went wrong in the surgery, hence it is being MS: My default use is MMC 0.2 mg/ml for 3 mins in the
corrected. subtenons region prior to dissection of the scleral flap

10 DOS Times - Vol. 16, No. 9, March, 2011

YCG: What should be the indication for the use of a drainage sutures and their tightness is inversely proportional to
tube. each other. The good way is to titrate AC depth and keep
on placing sutures till such time AC becomes stable on
MB: Two fundamental set of patients who are benefitted by the table. There is no magic number for sutures and the
tubes are the people with scarred conjunctiva and threat number depends on the size of inner ostium, iridectomy
for closure of inner ostium. Scarred conjunctiva is typically and tightness of sutures. More sutures are needed in big
seen after multiple surgeries like trabeculectomy, SICS, ostium trabeculectomy in young patients.
RD, steven Johnson syndrome, chemical burns and ocular
surface diseases. Inner ostium can be closed by new vessels GJM: The scleral flap should be sutured such that, as BSS is
(NVG), fibrin pigment in uveitic glaucoma or endothelium injected through the paracentesis, egress of aqueous can
in ICE. Tubes are also a good option in myopes and PK still take place at the edges of the flap, but is not so brisk
associated glaucoma as primary procedure. Contact lens that the AC shallows.
patients are also benefitted by tubes.
I generally use three sutures in case of a triangular flap, one
GJM: The indication for use of a GDD, would be where previously at the apex and one on each side, and four sutures in case
trabeculectomy has failed, and a repeat trab is not possible of a rectangular flap.
or has a high chance of failure due to extensive conjunctival
scarring. RV: I use a single apical suture in a triangular flap and it is
sutured snugly, following which the chamber is reformed
I do not consider GDDs as primary surgical technique for and fluid leakage through the flap is checked. If there is
routine glaucomas. excessive leakage or the chamber is not forming well then
additional suture are placed to the sides of the flap.
Certain types of secondary glaucomas- e.g. NVG, silicone
oil induced glaucoma, might do better with a tube SS: Scleral flap should be sutured snugly especially after
compared to trab. application of antimetabolites as it prevents many
complications related to hyperfilteration and wound leak. I
I use mitomycin C 2mg%, for 2 mins, subconjunctivally, use 3-4 sutures and titrate the outflow at the end of surgery.
over a large area of application.
SG: Yes, it should be. I use 3-1 apical & 2 lat
RV: Neovascular glaucoma
MS: Usually take 2 sutures on the flap. I verify the flow but
• Post PKP with glaucoma injecting saline from a side port with temporary knots
which may be loosened of tightened if necessary. Also check
• Retinal detachment surgery with glaucoma that the eye is not too soft by digital palpation. If the eye is
soft I take additional sutures or tighten the initial ones.
• ICE syndrome
YCG: In an advanced glaucoma case with very poor vision,
• Uveitic glaucoma what is your choice: cyclodestructive procedure or
surgery?
• Traumatic glaucoma
MB: My preferred ideal choice for advanced glaucoma with
• Open-angle glaucoma with failed trabeculectomy poor vision is a tube. In case a patient can’t afford I will
do a cyclodestructive procedure .First option will be a
• Epithelial downgrowth diode laser cyclophotocoagulation followed by cyclocryo.
In cyclocryo mini cyclocryo offers reasonable amount of
• Refractory infantile glaucoma safety from hypotony.

• Contact Lens users requiring glaucoma surgery GJM: If the eye has visual potential, undoubtedly I would prefer
a Trabeculectomy first.
Sturge Weber syndrome
RV: In advanced glaucoma with poor vision normally I prefer
SS: My indication for the use of a drainage tube is failed to do a diode ciliary photocoagulation (CPC).
previous glaucoma surgery, aphakic glaucoma and patients
with extensive scarring of the conjunctiva. SS: In primary advanced glaucoma with very poor vision,
I prefer trabeculectomy with MMC, while some of the
SG: Neovascular Glaucoma, Pseudophakic Glaucoma in my refractory advanced glaucoma with poor vision such as post
practice. PK glaucoma; I prefer Diode laser cyclophotocoagulation
(DLCP). I also prefer DLCP in patients unwilling for or
MS: Drainage implants are used in cases where the conjunctiva not fit for incisional surgery.
is scarred due to previous surgery or the AC is very shallow
with extensive PAS. In the latter situation I prefer a Pars SG: Always, always surgery. Cyclodestructive is the last resort.
Plana insertion of the tube.
MS: If it is NLP then cyclodestruction but with remaining vision
YCG: Should the scleral flap be sutured snugly and how many definitely surgery either Trab or tube shunt.
sutures?

MB: The sclera flap should be sutured snugly enough that
aqueous is able to flow out through this. The number of

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YCG: What is the management protocol in an old failed filter? hypotony are autologous serum injection, and compression
sutures on the bleb
MB: Long term filters may fail from obstruction of inner ostium
by iris, fibrosis, NVAs or endothelium in ICE. Or there may RV: It is managed conservatively with topical steroids, aqueous
be intra sclera fibrosis or the conjunctiva it self may get suppressants, atropine and pressure bandage, all the while
scarred and adhere tightly with sclera. First thing to do is looking out for choroidal detachment. Post-operative
do a gonioscopy and confirm patency of inner ostium. If hypotony usually resolves with conservative management.
inner ostium is patent the likely cause is with conjunctival In case there is a massive choroidal detachment or a
fibrosis. In case the ostium is blocked by fibrin or iris, an yag hypotonous maculopathy, then surgical resuturing of the
laser opening can be made using the settings of PI for iris flap is done.
and lesser energy for fibrin. In case of NVA or endothelium
this does not help. For detection of intrascleral block UBM SS: Overfilteration without an obvious hole in the conjunctival
or ASOCT may be used. The most common cause for late flap or leak at the wound edge can be managed with
bleb failure is conjunctival scarring. Needle revision of bleb observation with cycloplegic agent and/or use of “torpedo”
with injection 5 FU can be done and is effective. When patch. Obvious large defect in conjunctiva is treated with
needle revision fails a second filter is the only good solution. resuturing/free conjunctival graft. I also use bandage
contact lens for management of postoperative hypotony.
GJM: Rather than trying bleb revision, in a failed filter (> 6mths Persistent hypotony sometimes requires wound revision
post op), I would opt for repeat trab with antimetabolite with injection of viscoelastics and effusion drainage
in another site. particularly in cases with corneal-lens touch or appositional
choroidal effusion (kissing choroidal).
RV: In our institution, a failed bleb 3-4 months post-operative
period is managed with needling of the bleb with 5-FU SG: A good, full dilatation in the OPD along with a cycloplegic
injection in the opposite fornix, if this fails then the other & CAIs & lots of prayers!!
options are; a repeat trabeculectomy, shunt procedure or
a diode CPC. MS: Initially cycloplegic and steroids which if it does not work
and specially in late hypotony seen with MMC require a
SS: I manage early bleb failure with topical corticosteroids, bleb revision which usually does well
digital ocular compression and laser suture lysis. I do laser
suture lysis between 2-6 weeks post surgery. YCG: How do you manage postoperative shalow/flat A/C?

For late bleb failure, I start with laser suture lysis. MB: First step towards management of over filtration related
However, most of the failed bleb requires needling with hypotony is critical evaluation of anterior chamber depth,
subconjunctival 5-Fluorouracil injection. If the IOP still Bleb characteristics, leakage and choroidal detachment
remains high I consider medical management or repeat due to cyclodialysis cleft. Clinical grading of shallow
surgery. AC is important from treatment point of view. Grade I
peripheral iris cornea touch, Grade II papillary border
SG: Conservative initially, If uncontrolled, a repeat surgery. cornea touch and Grade III lenticular corneal touch. Large
blebs are usually non leaky and leaking blebs are usually
MS: In case of early failure I verify that the internal ostium flat. Choroidal detachment should be looked for by indirect
is patent and not blocked with iris and then do a needle ophthalmoscope.
revision with antifibrotic augmentation. In late failures too
if a small bleb can still be seen and interally the ostium Hypotony caused by excessive filtration usually resolves
is patent on gonioscopy, I would try needle revision. with routine postoperative medical management.
Otherwise repeat trab with MMC, and if two trabs have Therefore, the initial management of postoperative
failed usually consider tube shunt procedure hypotony with a formed anterior chamber and elevated
bleb is conservative. Restrictions in activity (e.g., bending,
YCG: How do you manage postoperative hypotony (over weightlifting) and avoidance of Valsalva-positive conditions
filteration)? (e.g., constipation, vigorous coughing, sneezing, or nose
blowing) is good enough, especially in patients at risk for
GJM: If post operative hypotony is accompanied by a shallow suprachoroidal hemorrhage (e.g., aphakic, vitrectomized,
AC with lens cornea touch, I would reform the AC with or elderly individuals with very high preoperative IOP). The
air/ non expansile air- gas (c3f8) mixture. If a shallow AC use of pressure patching, large bandage contact lenses, the
occurs with only peripheral/ mid peripheral iris cornea Simmons shell, and symblepharon rings may be beneficial
touch, I would watch with conservative management for >5 by tamponading the filtration site, which allows gradual
days, if the AC does not form and shows no improvement, improvement in the anterior chamber depth. However, a
I would again reform the AC. flat chamber with lens-corneal touch (grade III) requires
immediate intervention with prompt anterior chamber
If post operative hypotony occurs with deep AC, in the reformation; otherwise, rapid cataract development and
immediate post op period, after ruling out bleb leak as a irreversible corneal endothelial injury may occur. For AC
cause, I would watch conservatively and usually the IOP reformation air or viscoelastic may be used. My preferred
builds up, as healing takes place. choice is Inj Sod Hyaluronate under topical anaesthesia in
operation theatre with full aseptic precautions. AC is filled
The management options for late post op persistent

12 DOS Times - Vol. 16, No. 9, March, 2011

moderately and not over filled and IOP is checked after end SS: The shallow anterior chamber in the early postoperative
of the procedure.Large contact lenses and simmon’s rings period can be associated with low or high IOP. A shallow
have been advocated but commercial avaialability is not chamber associated with a low IOP suggests either over
easy hence used sparingly. filtration and/or a bleb leak or choroidal effusion. This can
be managed as described previously.
Cryo and cautery have been used in past but are risky
procedures in terms of bleb leak. A shallow anterior chamber associated with a high IOP
in the early postoperative period can result from an
A leaking bleb can be glued if small with fibrin glue incomplete iridectomy with pupillary block, a delayed
(preferred) or cyanoacrylate glue. If cynoacrylate glue is suprachoroidal hemorrhage or aqueous misdirection
used a bandage contact lens is must. (malignant) glaucoma. It is important to rule out pupillary
block by assessing the patency of the surgical iridectomy.
Autologus blood can also be tried for sealing micro leaks Ultrasound B Scan is done to rule out suprachoroidal
and shallow AC. hemorrhage which sometimes requires drainage with the
help of retina specialist.
With all these techniques hypotony usually resolves within
7-10 days. A strict watch should be kept on maculopathy I start management of aqueous misdirection with frequent
of hypotony if that starts sclera flap/ conjunctiva may be topical corticosteroids, cycloplegic therapy and aqueous
resutured. In intermediate phase bleb reduction can be suppressants and/or hyperosmotics. Pars plana vitrectomy
done using Laser photocoagulation after painting the bleb. in phakic eyes with rupture of the vitreous face (done
by vitreo-retinal consultant) and a limbal vitrectomy in
Cyclodialysis clefts usually resolve within a few weeks. aphakic eyes is done if medical management fails.
Large choroidals may need to be drained and laser
photocoagulation directly to the cleft is my preferred SG: Injecting Air/Visco if dilation doesn’t work.
procedure which usually closed the cleft.
MS: Giving post operative cycloplegic with steroids is routine
GJM: Shallow AC with low IOP- One should first rule out and this reduces the incidence significantly. Also I believe
choroidal effusion, and bleb leak. An aggressive bleb leak in water tight water closure of the conjunctiva with separate
should be sutured in the OT. Choroidals can be managed closure of the tenons and conjunctiva. This also contributes
conservatively with topical and systemic steroids, and to reduce the incidence of early flat AC. In case of shallow
if persistent / in the presence of kissing choroidals, by AC first we must first check that there are no choroidals,
choroidal drainage. and also rule out conjunctival leak with sidel’s test. If
there are choroidals then medical treatment with frequent
If post operative hypotony is accompanied by a shallow AC steroid drops along with Atropine and systemic steroids,
with lens cornea touch, I would reform the AC with air/ non if necessary. Conjunctival bleb leaks can be managed with
expansile air – gas (c3f8) mixture. If a shallow AC occurs pad for 24-72 hours by then conjunctival usually heals.
with only peripheral/ mid peripheral iris cornea touch, I If the conjunctival leak is a wound gape that will require
would watch with conservative management for >5 days, if suturing. If there is a flat AC with corneal touch then would
the AC does not form and shows no improvement, I would like to reform the chamber and take additional sutures on
again reform the AC. the scleral flap. If no corneal touch we can wait and observe
while continuing medical treatment.
Shallow AC with high IOP- rule out choroidal hemorrhage.
check for patency of PI , rule out papillary block as a cause YCG: What is your preference: Two stage surgery: Trab.
of shallow AC. Consider aqueous misdirection as a cause followed by cataract or combined, when there is a
if all these are ruled out. significant cataract?

RV: Post-operative shallow anterior chamber be associated MB: My preferred procedure for glaucoma with significant
with either high IOP or low IOP. High IOP can be due to cataract is a combined procedure – Phacotrabeculectomy.
pupillary block, supra choroidal haemorrhage or malignant However I do two stage procedures too in patients who
glaucoma. Pupillary block can be managed with a laser have a very advanced disc damage and I do trab first.
peripheral iridotomy. Suprachoroidal haemorrhage can be
managed conservatively with steroids for a week, if there GJM: In very advanced glaucomas with split or threatened
is no resolution, then drainage can be done. Malignant fixation, I would consider a trab first allow the bleb to
glaucoma can be initially managed medically with atropine, stabilize, and later plan a clear corneal cataract extraction.
aqueous suppressants/osmotics, and intense steroid
therapy. Then laser peripheral iridotomy can be attempted. In early or moderate glaucomas with preserved fixation,
If this fails then pars plana vitrectomy with anterior and central 5 degree fields, I would consider a combined
hyaloidotomy is done. Shallow anterior chamber with low approach.
IOP can be due to a bleb leak or choroidal effusion. Bleb
leak is initially managed conservatively with pressure patch, RV: I prefer to do a combined procedure mostly. Very rarely
or by resuturing the conjunctival flap. Choroidal effusion in cases with PACG with high IOP then I initially do a
is managed conservatively initially with cycloplegics and trabeculectomy to control the IOP and then do a cataract
corticosteroids. If the effusion increases, then drainage via surgery after couple of months.
posterior sclerotomies is done.

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SS: I prefer combined cataract (preferably phacoemulsification/ of superior rectus for better exposure and prevention of
leakage from SR site.
optionally Manual Small Incision Cataract surgery) and
Conjunctival incision. The conjunctiva can be incised
trabeculectomy surgery, when there is significant cataract. c) at the limbus (fornix-based flap) or deep in the fornix
I usually prefer 2 site surgery i.e. superior trabeculectomy (limbus-based flap)- 8-10 mm from limbus with the aim
to provide large surface are without the scar ( ring of steel)
and temporal clear corneal phacoemulsification. Combined that prevents backward flow of aqueous.

surgery has the advantages of single visit to the operation Scleral flap There are several types of scleral flap. The two
most common types being rectangular and triangular in
theatre, less chances of anesthesia related complications shape.

and early visual recovery. Intraoperative antimetabolite use If intraoperative
antimetabolites are indicated. They are used after the half
SG: PhacoTrab (double Port) d) thickness scleral flap has been cut but before the eye is
entered. Antimetabolites are to be used when conjunctival
MS: If the glaucoma is well controlled medically then I usually scarring risk factors are present.

prefer only cataract surgery. If the glaucoma needs to e) Intraoperative single dose anti-scarring regimen are
undergo surgery and cataract is also significant, then continuously evolving. Lower target pressures would
suggest a stronger agent was required.
consider combined surgery.
Low risk patients (Nothing or intraoperative 5-FU 50 mg/
YCG: What is your choice: modified cairns tech. or modified ml
moorfields?
No risk factors
MB: Modified Moorfield
Topical medications (beta-blockers/pilocarpine)
GJM: I do not have a single approach to all trabs. For e.g: I •
still prefer limbal based conj flaps in a primary trab on a • Afro-Caribbean (Elderly)
previously unoperated eye. In repeat surgeries, combined •
Phaco trabs, and in presence of conjunctival scarring due • Youth <40 with no other risk factors
to previous surgeries I would prefer a fornix based flap.
Intermediate risk patients (Intraoperative 5-FU 50 mg/ml
However I incorporate certain principles of the moorefields * or MMC 0.2mg mg/ml)
safe surgery system, e.g.- wide area of application of
mitomycin C ( in any kind of flap- fornix, or limbal based), Topical medications (adrenaline)
mattress sutures and wing sutures on the conj in fornix
based flaps, and suturing of the scleral flap nearer the Previous cataract surgery without conjunctival incision
limbus to encourage more posterior filtration and more (capsule intact
diffuse blebs.
Several low risk factors
RV: I do the modified Moorfield’s technique. •
Combined glaucoma filtration surgery/cataract extraction
SS: My choice is modified moorefields safer surgical system as •
it gives consistent results. Previous conjunctival surgery e.g. squint surgery/
detachment surgery/trabeculotomy
SG: Moorfields because of my attachment to my training place •
High risk patients (Intraoperative MMC 0.5 mg/ml)
MS: My technique is using a limbus based flap with water tight •
Neovascular glaucoma
closure in two layers. I do use a wide area of application of •
anti-fibrotic agent. Chronic persistent uveitis

YCG: Could you elaborate an moorfields safe surgery system? Previous failed trabeculectomy/tubes

MB: The Moorfields Safe Surgery System • Chronic conjunctival inflammation
•
Local anaesthetic • Multiple risk factors
•
Avoid unnecessary elevation of IOP. It is advisable to use a • Aphakic glaucoma (a tube may be more appropriate in this
technique that paralyses orbicularis oculi to prevent eyelid • case)
squeezing and increased pressure on the globe. Smaller
volume of anesthetic with hyaluronidase is used with out Intraoperative beta-radiation 1000 cGy can also be used.
adrenalin and pressure. Subconjunctival anesthesia with CAT-152 (TrabioR) or humanised anti-TGFbeta2 antibody
intracameral injection may also be used. may be appropriate in the low and intermediate risk groups
in the future based on the results of current studies. These
a) Position of filtration area. Filtration surgery is most • groups account for the majority of patients undergoing
commonly performed in the superior half of the globe to glaucoma surgery.
b) protect it by upper lid. PI covered by upper lid to avoid
14 diplopia. DOS Times - Vol. 16, No. 9, March, 2011

Traction suture.- clear corneal traction suture in place

Post operative 5-fluorouracil injections can be given in limbus-based flap, a dissolving suture (e.g. vicryl) or nylon

addition to the intraoperative applications of antimetabolite. can be used to close conjunctiva using either interrupted

Possible risk factors for antimetabolite related or continuous suturing.

complications GJM: The “safety” of the moorefields safe surgery system rests

• Elderly patient on –

• wide/ diffuse application of mitomycin C,

• Primary surgery no previous medications • encouraging posteriorly directed aqueous filtration by

• Poorly supportive scleral tissue prone to collapse scleral flap sutures closer to limbus, and

• e.g. Myopia/buphthalmos/Ehlers Danlos • firm suturing of conjunctiva without leakage by wing and
mattress sutures.

• Thin conjunctiva or sclera RV: The Moorfield’s safe surgery system aims at making

• Bleb placed in interpalpebral or inferior position glaucoma surgery as safe and successful as possible. A few

A special conjunctival T clamp designed (Duckworth-and- salient features are as follows:
Kent.com No 2-686) to hold back the conjunctiva and to
prevent antimetabolite touch is used. Polyvinyl alcohol Anaesthesia - General anaesthesia can be used to
sponges are used over a large area for better and safe effect. the surgeon’s advantage as it lowers the intra ocular
Mitomycin is used 200-500 microns/ ml for 3 minutes and pressure. Peribulbar block with facial block is preferred
5 FU 50mg/ml. this is followed by wash with 20 ml ringers over retrobulbar block as the optic nerve is already
solution. compromised. Reduced volumes of anaesthetic agent with
hyaluronidase should be used. Orbital compressive devices
f) Paracentesis A paracentesis is performed to allow fine should be avoided.
control of the anterior chamber. Controlled decompression
of eye and freedom to reform AC and titration of sutures Pre and intra operative drops – Povidone-Iodine is used
are some of the advantages. pre-operatively. Pilocarpine should be discontinued to
reduce blood vessel congestion and leakage. Topical
adrenaline can be used at the beginning of the procedure

g) Infusion. An anterior segment infusion (Lewicky, Visitec) as it causes vasoconstriction and reduction in bleeding.

on a three way tap through the paracentesis can be used. NSAIDS may be useful in patients with a risk of fibrinous

This maintains the pressure and rigidity of the globe uveitis or requiring excessive iris manipulation. Beta-

throughout the surgery minimising serious complications blockers should be stopped pre-op as this will optimise

such as intraoperative choroidal effusions particularly in aqueous flow post-operatively.

high risk patients e.g. high myopes, buphthalmics. Surgical Technique – Filtration surgery in superior half

h) Block removal (sclerostomy) A punch is the method of of the globe with the peripheral iridectomy at 12 o’clock is
choice, and a variety of these are available. There is evidence preferred. Corneal traction suture is taken. Superior rectus
that a small sclerostomy (0.5mm) is easily adequate and traction suture is best avoided as it could cause a superior
may minimise astigmatism and the chance of limbal rectus hematoma, which would accelerate wound healing.
aqueous flow, and maximise the chance of controlling To minimise tissue trauma use of serrated rather than
outflow. An anterior incision is made in a similar fashion to toothed forceps is preferred. Coaxial bipolar diathermy
that previously described, slightly larger than the diameter is used for hemostasis. Scleral flap should extend into
of the punch head. The punch should then be inserted peripheral cornea. Side incisions are not cut up to the
ensuring that a full thickness of limbus is engaged. The limbus; this encourages posterior flow and prevents cystic
punch should then be aligned perpendicular to the eye to blebs. Using antimetabolite away from the site of the scleral
ensure a clean non-shelved sclerostomy. flap followed by a thorough washout. Perform as basal an
iridectomy as possible. Carefully re-approximate the wound
i) Peripheral iridectomy A peripheral iridectomy is edges using low reactive suture material and a fine needle.
performed through the sclerostomy. The reasons for
carrying out a peripheral iridectomy are to prevent iris For more details about this method please see this link
incarceration in the sclerostomy, and in some cases to http://www.ucl.ac.uk/ioo/Studentpdf/Khaw%20Safe%20
relieve any element of pupillary block. Surgery%20System.pdf

j) Scleral flap sutures - New adjustable, releaseable and fixed. SS: The essential features of moor fields safe surgery system

These sutures can be lasered tor released to control the IOP are

at desired level. • fornix-based conjunctival flap for more diffuse bleb

k) Conjunctival closure The conjunctiva can be closed with • anterior chamber maintainer to maintain intraocular
a variety of sutures. For a fornixbased flap the conjunctiva pressure and gauge opening pressure of sclerostomy, This
can either be closed just with one or two sutures at either maintains the pressure and rigidity of the globe throughout
end of the relieving incision, or more thorough closure the surgery minimizing serious complications such as
can be performed with interrupted mattress sutures or a intra - operative choroidal effusions particularly in high
continuous suture with or without corneal grooves. For a risk patients e.g. high myopes

www.dosonline.org 15

• standardized punch technique for block removal of cornea or spongy, and may differ in height, pallor, and extent of
and sclera conjunctival microcystic edema. Late successful filtering
blebs change in appearance and size over time. Filtering
• combination of adjustable and releasable sutures. blebs can be described according to morphologic features:

lateral incision of the Partial thickness scleral tunnel does a. Elevation
not extend to the limbus encouraging the posterior flow
of aqueous post operatively. b. Vascularization/redness

SG: Conj flap, scleral flap, MMC (a special clamp to avoid c. Extent in clock hours, localized or diffuse,
contact to conjunctiva), rest as per protocol
d. Presence or absence of microcysts.
MS: Moorfields safe surgery system is popularized by Dr.
P.T. Khaw. He advocates a fornix based flap with wide A thin, localized bleb, walled off at the edges, can be
area dissection and wide area application of antifibrotic classified as cystic or encysted but should not be confused
agent. This has shown results of more diffuse blebs with with an encapsulated bleb or Tenon’s cyst, which is
lower incidence of late hypotony, bleb leaks and hypotony localized, high, and tense, with vascular engorgement
maculopathy of the overlying conjunctiva and a thick Tenon’s capsule.
Elevated, large, thin, avascular filtering blebs are associated
YCG: What is your pref: triangular flap or rectangular flap? with better IOP control than are low blebs with thick,
vascularized walls.
MB: Triangular flap. Really no logic for shape, it’s surface are
that matters. GJM: I do not use any specific grading system for classifying
filtering bleb. The characteristics which would suggest good
GJM: I do not have a definite preference for either. Both types of functioning are- elevation, avascularity, and microcyst
flaps work quite well. formation. Corkscrew vessels, low/ no elevation, failure
of bleb to form on digital pressure, thick conjunctiva with
RV: I prefer to do a triangular flap. absence of microcyst formation, would all imply that the
bleb is failing or likely to fail.
SS: I prefer partial thickness rectangular flap of approximely
4 X 6 mm. In the late post op period, in addition I would categorize
them as localized or diffuse blebs.
SG: Triangular.
RV: Moorfield’s bleb grading system.
MS: Rectangular flap as I dissect the sclera with a crescent blade
and a rectangular flap is more convenient and results are SS: We grade the morphologic progression of the filtering bleb
comparable. by slit lamp examination using Indiana Bleb Appearance
Grading Scale (IBAGS). This standardized method of bleb
YCG: What is the mandate on autologous serum use in grading has specific parameters (height, extent, vascularity
persistent hypotony? and seidel test) generally represents an equal scaling
interval (H0–3, E0–3, V0–4, S0–2).
MB: Autologus blood is really a good option esp in hypotony
after use of metabolites or when there is small leak. The SG: I usually don’t grade the bleb. I concentrate more on the
coagulation factors provide sealing and fibroblasts help fuctional aspect & the effective IOP.
healing. The procedure should be done in OT under strict
asepsis as blood can be a good culture medium. MS: Blebs can be graded based on their size, elevation
vascularity and structure.
GJM: I do not have extensive experience in the use of autologous
serum in the management of hypotony. Size : in mm 1-3 mm Gr I, 3-4 mm Gr II and larger than 4
mm Gr III
RV: Certain reports have suggested the use of autologous serum
in the treatment of hypotony. I don’t have any personal Elevation from scleral surface: nil, mild moderate and large
experience in using this technique.
Vascularity: nil Gr 0, few small vessels Gr I, normal
SS: I have no experience of using autologous serum in conjunctival vascularity Gr II locally congested Gr III and
persistent hypotony. Large vessesl on bleb site Gr IV.

SG: I don’t use it. Structure: Type I localized encysted, Type II diffuse with
microcysts or Type III Loculated thin blebs
MS: I have tried it and found that it does not work in most cases
and needs to be repeated. The patient and myself both DOS Correspondent
would prefer a more reliable solution like bleb revision. Yogesh C. Gupta MS

YCG: How do you grade the Blebs and their functioning?

MB: Functional blebs contain “microcysts” or small cystic spaces
that are best seen with indirect illumination by aiming
the slit-lamp beam at the tissue and looking alongside
the beam. Histologically, the microcysts correspond to
clear spaces in the subepithelial connective tissue. A late
functioning bleb may be diffuse or localized, thin walled

16 DOS Times - Vol. 16, No. 9, March, 2011

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

Live Surgery Session Scientific Programme Session

Live Surgery (Appasamy) BASICS OF PHACO

Date: Friday 15.4.11 Time: 8:00 a.m. – 10:00 a.m. Hall: Convention Hall - A Date: Saturday 16.4.11 Time: 8:30 a.m. – 10:45 a.m.
Live Surgeons:
Chairman: Co-chairman: Convener: Co-convener: Moderator:
Absalyamov Minula, A.K. Grover, R. Vasanth Kumar,
Subodh Sinha, Amit Khosla P.V. Chadha Noshir M. Shroff Ravi Manocha V.K. Tiwari Vivek Gupta
Panelist:
Each Talk: 8 mins
Harbansh Lal, P.V. Chadha, Rajendra Khanna, Abhishek Dagar
1. Comparison of scleral versus corneal incision : Sangeeta Abrol
Live Surgery (AMO)
2. Phaco under topical aneasthesia: Patient selection matters : Neelima Mehrotra
Date: Friday 15.4.11 Time: 10:00 a.m. – 12:00 noon
Surgeons: 3. Customised nucleotomy : Suvira Jain

Noshir M. Shroff, P. Bhasin, S.P.S. Grewal, Dariel Mathur, 4. Techniques of managing a soft cataract : Saju Joseph
Saurabh Chaudhary
5. Chopping In Hard Cataract : K.P.S. Malik
Surgeons: George Beiko, Mahipal S. Sachdev, Sri Ganesh,
D. Ramamurthy, J.S. Thind 6. Safe zone phacoemulsification raising the bar : Rohit Om Prakash

Panelist: S.K. Narang, Rajendra Prasad, S. Bharti, 7. Ways to prevent posterior capsular thickening : Sharat Babu
Reena Chaudhary, Harbansh Lal, Anita Sethi
8. Pristine cornea on day 1 : Arup Chakrabarti
Live Surgery (B&L)
9. Conversion from SICS to Phaco : Vipin Sahni
Date: Friday 15.4.11 Time: 12:00 noon – 1:15 p.m.
Surgeons: 10. Technique of IOL implantation : Sanjiv Mohan

Mahipal S. Sachdev, Ajay Sharma, Amar Agarwal, 11. Where to implant the IOL in imperfect situations : Tejas Shah
Arun Kumar, Rajiv Chaudhary, V.K Tewari
Panelist: 12. Hydroimplantation- Technique of Foldable IOL : Harshul Tak
implantation without using viscoelastic
Amit Tarafdar, Kapil Vohra, J.S.Thind, Rajiv Mirchia,
D. Nath, Rajiv Bajaj, S.K. Khokhar KERATOPLASTY AND EYE BANKING:
CHANGING SCENARIO
Live Surgery (ICL)
Hall: Convention-B Date: Saturday 16.4.11 Time: 8:30 a.m. – 10:45 a.m.
Date: Friday 15.4.11 Time: 1:15 p.m. – 1:30 p.m.
Chairman: Co-chairman: Convener: Co-convener: Moderator:
Live Surgeon:
S.K. Khokhar R.B. Vajpayee Jod Mehta Radhika Tandon Neera Agarwal Rajesh Sinha

Panelist: Each Talk: 8 mins
Vivek Pal, S. Bharti, S.K. Narang
1. DSAEK – surgical technique : Mukesh Taneja
Live Surgery (Carl Zeiss) 2. DSAEK & combined procedures : Jeewan S. Titiyal
3. Collagen cross linking complications : Nikhil Gokhale
Date: Friday 15.4.11 Time: 1:30 a.m. – 2:30 a.m. 4. DALK – Getting it right : Namrata Sharma
5. Anterior Lamellar keratoplasty : Rajesh Sinha
Surgeons: 6. Intra-corneal rings……….. for Keratoconus : Anand Parthasarathy
Harbansh Lal, Subodh Sinha, R.P. Singh, Vipin Sahni 7. Femtosecond laser assisted keratoplasty : Jod Mehta
8. Past, present and future of PK : Anita Panda
Panelists: 9. Shaped Keratoplasty : R.B. Vajpayee
Ram Mirlay, Dinesh Garg, Vinay Garodia, 10. Conjunctival Grafts : Arun K. Jain
11. Keratoprosthesis : Radhika Tandon
Sanjiv Mohan, S.N. Jha, S.C. Gupta 12. How to do Multiple keratoplasty from one cornea : Vikas Mittal
13. Challenging Case – I : Manisha Acharya
Live Surgery (Alcon) 14. Challenging Case – II : Amit Gupta
15. DMAEK : Rajesh Fogla
Date: Friday 15.4.11 Time: 2:30 p.m. – 5:30 p.m.
17
Live Surgeons:
Abhay R. Vasavada, Noshir M. Shroff,
D. Ramamurthy, Sanjay Chaudhary

Panelist :
J.S. Titiyal, V.C. Mehta

www.dosonline.org

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

SICS NUCLEUS MANAGEMENT POSTERIOR SEGMENT COMPLICATIONS OF
ANTERIOR SEGMENT SURGERY
Hall: Convention Hall - C Date: Saturday 16.4.11 Time: 8:30 a.m. – 10:45 a.m.

Chairman: Co-chairman: Convener: Co-convener: Moderator: Hall: Cocktail Date: Saturday 16.4.11 Time: 8:30 a.m. – 10:45 a.m.

T.P. Lahane Debashish Bhattacharya Dharmendra Nath Ranjit Dhaliwal Ruchi Goel Chairman: Co-chairman: Convener: Co-convener: Moderator:

Dr. P.K. Jain Oration Award: Dinesh K. Chawla Neeraj Sanduja A.K. Singh Arvind Jaiswal R. Nararyanan
Witness to the evolution of cataract surgery: K.P.S. Malik (10 mins)
Keynote Address:
Each Talk: 8 mins A novel implant for micro pulsed intra-ocular drug delivery: Rohit Verma (10 mins)

1. Nucleus delivery Wire vectis + sandwich Technique : Vipin Sahni Each Talk: 8 mins
2. Nucleus delivery Irrigating vectis : Jaswant Arneja
3. Nucleus delivery Blue menthal method : Ruchi Goel 1. TASS vs Endophthalmitis : V. Aravind
4. Modified Visco expression : Anil Kothari 2. Post-operative endophthalmitis – Enemy at the door : Rupak Biswas
5. Nucleus delivery Fish Hook : Ranjit Dhaliwal 3. Post-operative endophthalmitis dilemma in diagnosis : Saurabh Sinha
6. Nucleus delivery Naths canula : Dharmendra Nath 4. Retained lens fragment management options : Vinod Kumar Agarwal
7. Nucleus delivery Snare : Debashish Bhattacharya 5. Management of dislocated lens : Dinesh K. Chawla
8. Tips and Tricks with pre-chopper in SICS : Sharad Patil 6. Closed globe refixation of dislocated IOL : Pukhraj Rishi
9. Manual phacosection : Satanshu Mathur 7. Microincisional vitreous surgery for dislocated IOL? : Ramandeep Singh
8. Do’s & Don’ts in a diabetic patient : Mallika Goyal
9. Pseudophakic RD : Deependra V. Singh
10. Prophylactic use of antibiotics in cataract
: B.K. Nayak
surgery is it needed : Prashant Bawankhule
11. Poor gain of vision in a good pseudophakos

CASE DISCUSSION IN GLAUCOMA SQUINT & NEURO OPHTHALMOLOGY I (BASIC)

Hall: Banquet Date: Saturday 16.4.11 Time: 8:30 a.m. – 10:30 a.m. Hall: Emerald Date: Saturday 16.4.11 Time: 8:30 a.m. – 10:45 a.m.

Chairman: Co-chairman: Convener: Co-convener: Moderator: Chairman: Co-chairman: Convener: Co-convener: Moderator:

Ramanjit Sihota B.K. Nayak Usha Yadava Tanuj Dada Viney Gupta B.S. Goel P.K. Pandey J.L. Goyal Gopal Das Abhishek Dagar

Keynote Address: Keynote Address:
Importance of Compliance in the management of Glaucoma: Srisha Senthil (8mins) Risk factors for amblyopia: Results from the Multiethnic and Baltimore Pediatric Eye
Disease Studies: Rohit Verma (10 mins)

1. Glaucoma; A diagnostic dilemma : Mayuri Khamar Each Talk: 8 mins
2. Occludable angles : To treat or not to treat : Parul Sony
3. Angle closure Glaucoma: An eye opener : Anuradha Chandra 1. Visual developmental milestones : Aarti Nangia
4. Structural vs Functional progression : Viney Gupta
5. Imaging Glaucoma has problems : Reena Chowdhry 2. Refraction, cycloplegia and prescribing : Munish Dhawan
6. A case of Failed trabeculectomy : Viney Gupta glasses in children
7. Silicone oil induced glaucoma post vitreo retinal surgery : Manish Shah
3. Appropriate amblyopia therapy: What is best : Subhash Dadeya

4. Oculomotor testing of a case of squint: Is it necessary? : Pradeep Agarwal

5. Sensory status: Is squint surgery more than cosmetic? : Archana Gupta Mahajan

16 mins per case inclusive Discussion 6. Non surgical management of squint: Where : Shailesh G M
does it help?

7. Evaluation of Acquired Optic Neuropathies/ : Mahesh Kumar
Unilateral visual loss

8. Esotropia in Children : Sumita Agarkar

9. Neurological examination in Ophthalmic practice : Mahesh Kumar

10. Visual rehabilitation after congenital cataract surgery : Abhishek Dagar

18 DOS Times - Vol. 16, No. 9, March, 2011

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

HOT SPOT 10. Spectral Oct Guided Treatment of Cystoid Macular

Edema in Cases of Retinitis Pigmentosa : Amandeep Singh

Hall: Sapphire Date: Saturday 16.4.11 Time: 8:30 a.m. – 10:45 a.m. 11. Argon Laser R Hyaloidotomy in Posterior Hyphema : Balbir Khan

Chairman: Co-chairman: Convener: Co-convener: Moderator: 12. Role of Ultrasonography in Evaluation of Posterior

Anita Panda B.P. Guliani Praveen Mongre Shantanu Mukherjee Bhavna Chawla Segment Lesions of the Eye : Chandra Shekhar Kain

Each Talk: 8 mins 13. A Novel Mathematical Equation to Estimate
Contrast Sensitivity From Log Mar Visual Acuity in
1. Botox related ptosis : Archana Sood Non Insulin Dependent Diabetes Mellitus : Neha Sinha
2. Intra-op corneal perforation with intacs : Ramendra Bakshi
3. All is well: Post RD surgery : Manish Tandon 14. A Study of Proliferative Vitreoretinopathy : Anurag Thakral
4. Chikungunya Panophthalmitis : B.P. Guliani
5. Pearls and pitfalls with malyugins ring : Gaurav Luthra 15. Case Series of Retinal Detachment with Vasculitis : Pankaja P.S
6. Targetting toric IOL alignment : Arun K. Jain
7. Masquerade syndrome : Vishali Gupta 16. Effect of Pioglitazone Therapy on Macular Thickness : Nitin Chaudhary
8. Managing subluxated cataract with Cionni's Ring : Arun Kshetrapal
9. Suction Loss issues with Femtosecond Lasers : Chitra R
10. DALK - DM Perforation Management : Ashish Nagpal
11. Neovascular glaucoma – management dilemma : Tanuja Kate
12. Relapsing choroidits : Vishal Dadhia

FREE PAPER-5 A (RETINA) MISDIAGNOSIS

Hall: Ruby Date: Saturday 16.4.11 Time: 08:30 a.m. – 11:00 a.m. Hall: Convention Hall - A Date: Saturday 16.4.11 Time: 10:45 a.m. – 1:00 p.m.

Chairman: Y.R. Sharma Chairman: Co-chairman: Convener: Co-convener: Moderator:
Judges: Meenakshi Thakkar, Bhuwan Chanana, Parijat Chandra, H.S. Trehan,
D.P. Vats Arun Sangal V. Rajshekhar Himanshu Gupta Jasmita Popli
Sanjay Ahuja

Each Talk: 6 mins Keynote Address:
The artist plays with our vision and befools the eye: P.N. Nagpal (10 mins)

1. Aprop: A Case Series : Sucheta Kulkarni Each Talk: 8 mins

2. Level Of Awareness of Retinopathy of Prematurity 1. Misdiagnosis in Retinoblastoma : Bhavna Chawla
Among Pediatricians in a Tier Two City of South India : Saurabh Arora
2. Intraocular Lymphomas : Vishali Gupta
3. Determinants of Normal Retinal Nerve Fiber Layer
3. Neuro-ophthalmology case scenario : Mahesh Kumar
Thickness Measured by Stratus Optical Coherence

Tomography (OCT) in Normal Human Eyes : Ranojit Basu 4. Corneal edema post cataract surgery : Rajesh Sinha

4. Aggressive Posterior Retinopathy of Prematurity 5. Persistant SPK with ptosis surgery : Archana Sood
(Aprop): Outcome of Laser Therapy
: Debanshu Bhattacharya 6. Misdiagnosis in uveitis : Shishir Narain

5. C–Scan Imaging & Automatic 3-D Segmentation: 7. Misdiagnosis in glaucoma : Shantanu Mukherjee
A Newer Dimension of Oct Analysis in Various
Vitreo-Retino-Choroidal Conditionsanalysis in 8. Oops! Misdiagnosed: Post LASIK hazy cornea : Umang Mathur
Various Vitreo-Retino-Choroidal Conditions
: Raju S. 9. Orbital cellulitis as a masqerade for various ocular tumors : Mridula Mehta

6. Case Series of Vasculitis Associated with 10. Retinal disorders of neuro-ophthalmologist interest : Neeraj Sanduja
Retinal Detachment
: Pankaja P.S 11. Common misdiagnosis in retinal disease : H.S. Trehan

7. Intravitreal Bevacizumab (Avastin) Treatment of 12. Misdiagnosed case of ectopia lentis : Madhu Bhadauria
Proliferative Diabetic Retinopathy Complicated by
Vitreous Hemorrhage. : Brijinder Singh Rana

8. Oct Guideded Management of Vitreo-Macular : Amandeep Singh
Traction with ERM

9. Preoperative Avastin as an Adjunctive Prior : Balbir Khan
to Diabetic Vitrectomy
19
www.dosonline.org

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

OCULAR ONCOLOGY VR SURGERY

Hall: Convention Hall - B Date: Saturday 16.4.11 Time: 10:45 a.m.-11:45 a.m. Hall: Banquet Date: Saturday 16.4.11 Time: 10:30 a.m. – 2:00 p.m.

Differential diagnosis of intraocular mass: Arun D. Singh Chairman: Co-chairman: Convener: Co-convener: Moderator:
Moderators:
B.P. Guliani, Mandeep Bajaj, Amit Khosla, Vikas Chadha, Vikas Menon R.V. Azad S. Natarajan Cyrus Shroff Atul Kumar J.S. Guha

DR. OM PRAKASH ORATION Dr. S.N. Mitter Oration Award:
Retinal Vascular Blocks: Changing Paradigms: Lalit Verma (10 mins)
Hall: Convention Hall - B Date: Saturday 16.4.11 Time: 11:45 a.m. - 1:00 p.m.
Chairpersons: Each Talk: 8 mins
P.V. Chadha, B.P. Guliani, Amit Khosla, A.K. Grover, Rohit Om Prakash
Prof. Michael Knorz : 1. Gas dynamics : Naresh Babu
Laser Refractive Lens Surgery using Femtosecond Lasers
2. Incision technique for MIVS & instrumentation : Puneet Gupta

3. Technological advancement in VR Surgery : Manish Nagpal

4. Problems in MIVS : Pradeep Venkatesh

5. MIVS in paediatric cases : R.V. Azad

6. Bimanual MIVS : S.K. Boral

7. IOFB with MIVS : Pukhraj Rishi

8. Diabetic vitreous heamorrhage : Lalit Verma

9. Challenges and complications in small gauge PDR surgery : Gopal S. Pillai

10. Macular Hole Surgery - Revisited : Atul Kumar

11. Perfection with Constellation : S. Natarajan

12. Primary vitrectomy for retinal detachment : Cyrus Shroff

13. MIVS complications rare and management : J.S. Guha

14. Self Stabilizing ring for lander’s lens : S.C. Gupta

15. Dyes in vitreous surgery : Prem Tanwar

GLAUCOMA SESSION INSTRUMENTS

Hall: Convention Hall - C Date: Saturday 16.4.11 Time: 10:45 a.m. – 1:00 p.m. Hall: Cocktail Date: Saturday 16.4.11 Time: 10:45 a.m. – 1:00 p.m.

Chairman: Ramanjit Sihota 2C8hairman: Co-chairman: Convener: Co-convener: Moderator:
Moderators: Harsh kumar
Y.S. Sirohi Ajay Aurora Prem Tanwar Rohit Nanda Sanjiv Lehri

1. Glaucoma practice by general ophthalmologists - Keynote Address: Scanning laser ophthalmoscope: Stela Vujosevic (30 mins)

Clinical challenges and opportunities? : Harsh Kumar (15 mins) Each Talk: 8 mins

2. Glaucoma are we doing enough as eye : Devindra Sood (12 mins) 1. USG B-scan for retinal diseases : B.P. Guliani
professionals

3. Managing glaucoma patients expectations – My 2. Performance of digital fundus stereo photography

experiences : Murali Ariga (10 mins.) for diabetic retinopathy : Sophia Pathai

3. Glaucoma a 24 hour disease – My treatment : Manish Shah (10 mins) 3. Home IOP Monitoring – The ‘I-Care’ way : Alka Pandey
approach
4. How to care of your instruments
4. PGAs which one to choose & why? : Deven Tuli (10 mins)
Phacoemulsifier & its maintenance : S. Sivagnanam (Appasamy)
5. Role of PGA combo- the evolving trends in
management of glaucoma patients : Sushmita Kaushik (10 mins) Maintenance of the ophthalmic equipments : A. Ramamoorthy

6. How to approach OSD as a consequence Electrical Safety : Mohd. Alam (Zeiss)
to glaucoma
: Suneeta Dubey (10 mins) : Sashwata Bhattacharya
(Alcon)
7. OCT Role in treating Glaucoma patients : Prateep Vyas (10 mins)

: Prashant Warade (AMO)

Question & Answer : 20 minutes : Jagon Goh, Noel Lim
(Bausch & Lomb)

20 DOS Times - Vol. 16, No. 9, March, 2011

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

ORBIT 9. Comparison of the efficacy of once-daily (QD) bimatoprost,

latanoprost, and timolol gel-forming solution in 24-hour

Hall: Emerald Date: Saturday 16.4.11 Time: 10:45 a.m. – 1:00 p.m. intraocular pressure (IOP) control : Deepak Garg

Chairman: Co-chairman: Convener: Co-convener: Moderator: 10. Evaluation of total Proteins in Aqueous Humour and in
Plasma in Cases of Primary Open Angle Glaucoma and
A.K. Grover V.M. Vachhrajani Sushil Kumar Y. Sujatha Ruchi Goel Non Glaucomatous Subjects of the Same Age Group:
A Comparative Study
Keynote Address: : Rashi Sharma
Ocular adnexal lymphoma: Arun D. Singh (10 mins)
11. Intraocular pressure lowering efficacy of topical
Each Talk: 8 mins Travoprost versus Bimatoprost in Primary open : Satish Thomas
angle glaucoma

1. Orbital Imaging: Orbit surgeons perspective : V.M. Vachhrajani 12. Phaco Trab with Foldable IOL : Shakeen Singh
2. Ultrasound in orbital diseases : Sushil Kumar
3. Surgical management of orbital tumour : V.P. Gupta 13. Role Of Lens Extraction In Management Of Primary : Kapil Barange
4. Management of blow out fracture of orbit : Priti Khetan Angle Closure Disease
5. Intra orbital Foreign Body Management : B. Vidyashankar
6. Orbital implant: a safe passage : V.M. Vachhrajani 14. Trabeculectomy Bleb Morphology Analysis Using Clinical
7. Graves disease: Update in management : E.R. Mohan
8. Contracted socket management : Ruchi Goel Grading and Anterior Segment Optical Coherence
9. Sentinel node biopsy ocular tumors : Vikas Menon
10. All about the ocular prosthesis : Sachin Gupta Tomography(As-OCT) : Deepika Khurana

15. To evaluate latanoprost therapy for children with glaucoma
: Aditya Sharma

16. Awareness Of Eye Donation In Medical Students : Priyangini Pandey

17. Cataract care services for children: Barriers encountered

in rural and backward regions. : Jayashree Baruah

18. 5 curve reverse geometry corneal reshaping-The new : Shrikant Waikar
avtar of Orthokeratology

19. Ocular Manifestations Of Intracranial Space : Soumya Sharat
Occupying Lesions

20. Cyclopentolate Induced Acute Psychosis: A Case Report : Namrata S. Kabra

FREE PAPER-4 (GLAUCOMA) FREE PAPER-5 B (RETINA)

Hall: Sapphire Date: Saturday 16.4.11 Time: 10:45 a.m. – 1:30 p.m. 32 Hall: Ruby Date: Saturday 16.4.11 Time: 11:00 a.m. - 2:00 pm

Chairman: Chairman:
Vishnu Gupta, Judges: Usha Raina, M.D. Singh, Tanuj Dada, J.S. Bhalla P.K. Sahu Rajpal, Judges: Sarita Beri, Alkesh Chaudhary, Sandhya Makhija, S.K. Mishra

Each Talk: 6 mins Each Talk: 6 mins

1. A Clinical Experience Of Co2 Laser Assisted : S.K Sah 17. Functional Outcome and Long Term Safety of Scleral-
Non-Penetrating Deep Sclerectomy Fixated Sutured Posterior Chamber Lens Implantation : Kapil Kumar Khurana

2. Anterior Chamber Depth (ACD) And Intraocular Pressure 18. Fundus Findings in Blood Dyscrasias : Soumya Sharat

(IOP)Changes Following Uneventful Phacoemulsification 19. Grading of Haemostatic Effect of Preoperative
Intravitreal Bevacizumab in Pars Plana Vitrectomy
in Non-Glaucomatous Eyes Over 1 Month : Nandini Chandak in Vascular Retinopathies

3. Combined Diode Laser Cyclophotocoagulation and : Neha Sinha
Intravitreal Bevacizumab (Avastinâ®) In Neovascular
Glaucoma : Sudipta Ghosh 20. Intraocular Cholesterolosis with Hyphema Following

4. To Compare The Correlation Between Central Corneal Intravitreal Bevacizumab : Pankaja P.S
Thickness (CCT) And Intraocular Pressure (IOP) in
Non-Glaucomatous General Indian Population Vs 21. Intravitreal Gnathostomiasis: A Case Report : Sunil Kumar Singh
Non-Glaucomatous Ethnic Tribal Population of Northeast
India and to Find Out if any Racial Variation Exists 22. Juvenile Diabetic Retinopathy:How Early To Screen : Pradeep Tekwani

: Tanie Natung 23. Multiple Subretinal Cysticercosis : A Case Report : Bhupesh Singh

5. A Study to Compare the Outcome and Complications 24. Oct Analysis of Occupational Phototoxicity To Retina : Sangita Marlecha
of BP Valve Shunts with Ahmed Glaucoma Valve (AGV)
in Neovascular Glaucomas : Prashant Bhushan 25. Post Fever Retinits – A Case Series : Srilatha T. D.

6. Accuracy of Diaton Transpalpebral Tonometer in patients 26. Prognostic Factors And Visual Outcome In Removal
of Posterior Segment Intraocular Foreign Body (IOFB) : Usha Bhargava
diagnosed with primary open-angle glaucoma and

glaucoma suspects : Alla Illarionova

7. Comparison Of Icare And Goldmann Applanation : Amit Porwal 27. Rare Case of Bilateral Central Retinal Artery : Shireen Mishra
Tonometer Occlusion Due to Essential Thrombocytosis

8. Comparison of the Anterior Chamber Angle with 28. Role of Brimonidine in the Treatment of Clinically : Parul Chawla 21
Significant Macular Edema with Ischemic Changes
aGfotenrioLsacsoeprywPaenwridpwhUeB.rMadloPIrirsdimootaonrmylyiAnnegl.eoCrlogsure Glaucoma : Gurjeet Singh in Diabetic Maculopathy

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

29. Serum Copper, Iron and Zinc Levels in Diabetic : Shashi Sharma CORNEAL DIAGNOSTICS: EVOLVING
Patients and their Comparative Analysis with TECHNIQUES
Progression of Diabetic Retinopathy

30. Spectral Domain Optical Coherence Tomography in Hall: Convention Hall - B Date: Saturday 16.4.11 Time: 1:00 p.m. – 4:00 p.m.
Group 2a Idiopathic Juxtafoveolar Retinal
Telangiectasis : Neha Goel Chairman: Co-chairman: Convener: Co-convener: Moderator:

31. Treatment of Angiomatosis Retinae with Avastin : Soniya Bhala S.P.S. Grewal Rishi Mohan Namrata Sharma Ashu Agarwal Rajib Mukherjee

32. Use of Cryopexy and Laser Photocoagulation in the Each Talk: 6 mins

Treatment of Coat S Disease : Pradeep Tekwani

33. Utility Of Automatic 3-Dimensional Segmentation : Raju S. 1. Corneal topography – Unravelling the Maze : Mukesh Taneja
Analysis in SD-OCT To Differentiate Traumatic 2. Specular Microscopy : Uma Sridhar
Submacular Hemorrhage Types- Case Series 3. Confocal microscopy in Clinical practice : Amit Gupta
4. Anterior Segment OCT – New perspective to Cornea : Rishi Swarup
34. Retained Intraocular Foreign Body Removal : : Vikram Singh Khoisnam 5. Cornea Hysterisis – Cornea Biomechanics : Rishi Mohan
Retrospective Study of 150 onsecutive Cases 6. Corneal Scraping: Old is Gold : Shilpi Diwan
7. Corneal topography Challenging Case – case discussion
35. Role of Intravitreal Methotrexate (MTX) in the : Arun Kumar Gupta
Treatment of Uveitis and Uveitic Cystoid Macular
Edema (CME)

36. Clinical Profile of Persumed Ocular Tuberculosis in Panel: S.P.S. Grewal, Ashu Agarwal, Namrata Sharma , Anand Parthasarathy,
Rajib Mukherjee
a Tertiary Care Eye Centre : Rajeev Gupta

37. Rare Case of Bilateral Disc Edema in Acute Posterior

Multifocal Placoid Pigment Epitheliopathy : Anupama Karanth

DIABETIC RETINOPATHY – CASE BASED IC: ON VISUAL FIELDS
SCENARIOS
Hall: Convention Hall-C Date: Saturday 16.4.11 Time: 1:00 p.m. – 2:00 p.m.
Hall: Convention Hall - A Date: Saturday 16.3.2011 Time: 1:00 p.m. - 2:00 p.m.
Chief Instructor: G.R. Reddy
Elaborate the role of FA, OCT, when to laser or give injection or plan surgery &
management of co-existent cataract

Faculty: Amit Khosla, Sanjeev Gupta, Puneet Gupta, Ajit Babu

22 DOS Times - Vol. 16, No. 9, March, 2011

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

UVEA CURRENT TRENDS EYES ON THE ROAD

Hall: Cocktail Date: Saturday 16.4.11 Time: 1:00 p.m. – 2:00 p.m. Hall: Convention Hall - A Date: Saturday 16.4.11 Time: 2:00 p.m. – 4:00 p.m.

Chairman: Co-chairman: Convener: Co-convener: Moderator: Chairman: Co-chairman: Convener: Co-convener: Moderator:

Jyotirmay Biswas H.S. Trehan Vishali Gupta Mallika Goyal Shishir Narain Abhay R. Vasavada Michael Knorz D. Ramamurthy Terrence P. O'Brien Jeewan S. Titiyal

Each Talk: 6 mins Each Talk: 8 mins

1. Evaluation of the uveitic patient: when to treat and : Somasheila Murthy 1. At the tollgate: Perioperative Regime for cataract surgery : Terrence P. O'Brien
when to refer? : Manohar Babu : Jeewan S. Titiyal
: Salil Mehta 2. Watch your speed: (Adjusting your Phaco settings) : D. Ramammurthy
2. Ocular toxoplasmosis: current concepts : Shishir Narain
3. Tubercular uveitis: are we over diagnosing : Amit Khosla 3. Travel Kit: Multifocal IOL : Abhay R. Vasavada
4. Current trends and emerging entities in anterior uveitis : Nanda Kumar Bhide
5. Immunosupresives in uvetis 4. The “ART” of conquering the curves’: Initial results of : Michael Knorz
6. Posterior Uveitis the Aspheric Restor Toric IOL : Arup Bhowmick
: George Beiko
Discussion: 12 minutes 5. Roadside Maneuvers: `` Presbyopia Correction – the : Ashish Nagpal
lens or the cornea ?”

6. Off Road Maneuvers: IOL Exchange

7. Comparison of Multifocal in myopes & hyperopes

8. Yield: Phacoemulsification and endothelial keratoplasty

RVO MANAGEMENT DIAGNOSIS & MANAGEMENT OF GLAUCOMA –
A STEP WISE APPROACH
Hall: Emerald Date: Saturday 16.4.11 Time: 1:00 p.m. – 2:00 p.m.

Chairperson: S.P.Garg Hall: Convention Hall - C Date: Saturday 16.4.11 Time: 2:00 a.m. – 4:00 p.m.

1. Management of ME in RVOs; an Indian perspective : Lalit Verma (10mins) Chairperson: Harsh Kumar Moderator: Devindra Sood

2. Management of RVOs-recent clinical evidence; : Ajit Babu (10mins) Each Talk: 15 mins
GENEVA trial : Albert Augustine (20mins)
1. Critical evaluation of optic disc : Harsh Kumar
3. Management of RVOs-case studies : Nishikant Borse (10mins)
2. Open angle glaucoma or Angle closure glaucoma? : Devindra Sood
4. Management of ME in RVOs using Ozurdex-Indian Role of Gonioscopy
experience : Viney Gupta
3. Relevance of Imaging in Glaucoma; how to make the : Manish Shah
Question & Answer : 10 minutes best use of Imaging techniques : Murali Ariga
: Prateep Vyas
4. Clinical evaluation of progression in glaucoma

5. IOP management in glaucoma; step wise approach

6. Beyond IOP; new clinical evidence

www.dosonline.org 23

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

PAEDIATRIC &TRAUMATIC CATARACT SQUINT & NEURO OPHTHALMOLOGY II
(ADVANCED)
Hall: Banquet Date: Saturday 16.4.11 Time: 2:00 p.m. – 4:00 p.m.

Chairman: Co-chairman: Convener: Co-convener: Moderator: Hall: Emerald Date: Saturday 16.4.11 Time: 2:00 p.m. – 4:00 p.m.

S.K. Khokhar Jagat Ram Arup Chakarbarti Partha Biswas Tushar Agarwal Chairman: Co-chairman: Convener: Co-convener: Moderator:
Vimla Menon Santhan Gopal Suma Ganesh Jaspreet Sukhija Rohit Saxena
Each Talk: 8 mins

1. Emergency /Casualty management of the anterior : Lalit Tejwani Keynote Address:
segment trauma with lens capsule rupture Optic neuritis in Indian Patients: Vimla Menon (10 mins)

2. Types of traumatic cataract : S.J. Saikumar Each Talk: 8 mins

3. Traumatic cataract with corneo-scleral Scars : Partha Biswas 1. Controversies in management of IDS : Suma Ganesh
2. Strabismus Fixus : Anurag Mishra
4. Subluxated traumatic cataracts : S.K. Khokhar 3. Accommodative Esotropia : Kanak Tyagi
4. Controversies in management of infantile esotropia : Saurabh Jain
5. Managemant and repair of traumatic iris defects and dialysis : Tushar Agarwal 5. Resurgeries- Approach : Ajay Agarwal
6. Management of pattern Squint : Jaspreet Sukhija
6. Endophthalmitis along with traumatic cataract : R.K. Sharma 7. Benign intracranial hypertension: How to approach : Sanjay Pandey
8. Neuro-Imaging in optic nerve disorders : J.L. Goyal
7. Lensectomy with SF IOL : Avnindra Gupta 9. Analyzing fields defects in Neuro-ophthalmology : Harinder Sethi

8. Combined cataract & vitreous surgery : Amit Khosla

Congenital Cataract Management : S.K. Khokhar
1. Approach to Congenital cataract and management : Jagat Ram
2. Management of complicated pediatric cases : Jaspreet Sukhija
3. Ambylopia in pediatric cataract and management

REFRACTIVE SURGERY - LASIK O.T. AND HOSPITAL MANAGEMENT

Hall: Cocktail Date: Saturday 16.4.11 Time: 2:00 p.m. – 4:00 p.m. Hall: Sapphire Date: Saturday 16.4.11 Time: 2:00 p.m. – 4:00 p.m.

Chairman: Co-chairman: Convener: Co-convener: Moderator: Chairman: Co-chairman: Convener: Co-convener: Moderator:

S. Bharti Vivek Pal Pawan Goyal Neera Agarwal Neeraj Manchanda N.S.D. Raju R.D. Thulsiraj Mathew Kurian Arun Sethi Rajiv Mohan

Each Talk: 8 mins Each Talk: 8 mins

1. E-LASEK-Surface Ablation : Sambasiva Rao 1. Quality assurance a reality in high volume set-up? : B.K. Jain
Velagapudi 2. Ergonomics in Ophthalmology : Mukesh Dholakia
3. Hospital Building : Partha Biswas
2. Importance of new generation LASIK Machine : Sri Ganesh 4. O.T. Management : Rajiv Mohan
5. O.T. Design : Mathew Kurian
3. Sphericity modification during refractive surgery : Uday Gadgil 6. NABH Accreditation : Nirmal Fredrick
7. Advantages of NABH Accreditation : NSD Raju
4. Re-enhancement excimer procedures: Considerations 8. FBS AIOS Presentation : C. Sriramamurthy
9. Next phase: Migrating from private practice to hospital : R.D. Thulsiraj
and decision algorithm : Gaurav Prakash 10. Managing an eye care project : Arun Sethi
11. Think beyond I.Q. and E.Q.:S.Q. Spirituality Quotient-it
5. Presbyopia Correction with LASIK laser - 8 months : Keiki Mehta : Namrata Kabra
results for 250 eyes pays in terms of self and patients' satisfaction

6. Refractive Surgery Options in post RK Patients : Ambarish B. Darak

7. Flap related complications in LASIK : Somasheila Murthy

8. Refractive Nightmares : Mahipal S. Sachdev

9. Managing Complications of Micro Keratome : Sonu Goel

10. Importance of Q value in LASIK surgery : Ramesh Shah

11. Treating LASIK nightmares with Topography linked LASIK : Burjor Banaji

12. Excimer based presbyopia solutions : Ajay Sharma

24 DOS Times - Vol. 16, No. 9, March, 2011

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

FREE PAPER-6 (Oculoplasty) HOW TO PUBLISH

Hall: Ruby (292) Date: Saturday 16.4.11 Time: 2:00 p.m. - 4:00 p.m. Hall: Convention Hall - B Date: Saturday 16.4.11 Time: 4:00 p.m. – 6:00 p.m.

Chairman: Vachhrajani Madhukar Virendrarai Judges: V.P. Gupta,Usha Singh, Panelists:
Anuj Mehta, Y. Sujata S. Natarajan, B.K. Nayak, Rajesh Sinha, J. Biswas, Rohit Verma, Neema Mayghugh
Each Talk: 6 mins

1. A Comparative Study Between External Dacryocystorhinostomy [EXDCR] Moderator: A.D. Singh
and Transcanalicular Diode Laser Assisted Dacryocystorhinostomy [TCLADCR]
: Joyeeta Das Each Talk: 8 mins

2. Orbital Fractures: Clinical Features & Outcome : Manju Meena 1. Overview : A.D. Singh
2. How to design a study : Rohit Verma
3. Primary Canaliculitis: Clinical features, Microbiological 3. Authorship : Rajesh Sinha
4. How to write the manuscript : S. Natarajan
Profile and Management Outcome : Manju Meena 5. How to publish an article : Jyotirmay Biswas
6. Challenges facing IJO : B.K. Nayak
4. Ocular Manifestations in the Hutchinson-Gilford : S.Lal
progeria syndrome Chandravanshi

5. Laser dacro-cystorhionostomy : Tariq Qureshi

6. A Rare Case of Moebius Syndrome : Sonam Poonam Nisar

7. A Rare Case of Orbital Haemangioma : Sonam.P. Nisar

8. Conservative management of orbital fractures: : Manju Meena Discussion: 15 minutes
indications and outcomes

9. Orbicularis Silicone Sling for Facial Palsy : Preetinder Kaur

10. Outcome of cases with evisceration and their : Suvarna Bhagde
rehabilitation

11. RARE case of multiple non-communicating co-existing

lymphangiomas with post op recurrence. : Sonam.P. Nisar

12. To elaborate a questionnaire of the psychosocial profile

of the patient with disfigured eye with indication of

readymade and custom made ocularprosthesis. : Sachin Gupta

13. Transcanalicular-Eclad-A New Surgical Technique

For Chronic Dacryocystitis : V.K. Pal

14. Eyelids and Adnexal Injuries: Management : S.L. Chandravanshi
and Outcome

15. Reposing A Extruded Eye : Shakeen Singh

PHACO IN SPECIAL SITUATIONS DIAGNOSTIC MODALITIES AND TECHNIQUES:
OLD IS NOT ALWAYS GOLD AND
Hall: Convention Hall - A Date: Saturday 16.4.11 Time: 4:00 p.m. – 6:00 p.m. NEW IS NOT ALWAYS BAD

Chairman: Co-chairman: Convener: Co-convener: Moderator:

Pawan Goyal J.S. Titiyal Jagat Ram Kapil Vohra Harinder Sethi

Hall: Convention Hall - C Date: Saturday 16.4.11 Time: 4:00 p.m. – 6:00 p.m.

Each Talk: 8 mins

Chairman: Co-chairman: Convener: Co-convener: Moderator:

1. Tips in uveitis cataract : Somasheila Murthy Vishnu Gupta B.K. Nayak Devindra Sood Tanuj Dada Suneeta Dubey

2. Phaco in subluxated cataract : Sajjad Fazili

3. Phacoemulsification in Small Pupil : Suresh K Pandey Tonometry
1. Dynamic contour Tonometry
4. New Technique for Phaco Emulsification of Soft Cataract : Narayan Bardoloi 2. Applanation tonometry : B.K. Nayak
: Rajat Maheshwari
5. Phacoemulsification with Corneal Opacity : Rajiv Chaudhary Angle evaluation
3. Gonioscopy still hold the key : Tanuj Dada
6. Cataract Surgery in Buphthalmos : Jagat Ram 4. Anterior segment OCT unzips the angle better : Prateep Vyas

7. Phacoemulsification in Deep AC (Myopia,vitrectomised eye) Disc anatomy and function : Devindra Sood
: Amit Tarafdar 5. Perimetry-Good old Humphrey / Octopus : Parul Ichhpujani
6. Three dimensional Optic disc evaluation
8. Cataract surgery in colobamatous eyes : Harinder Sethi : Viney Gupta
Pre- perimetric diagnosis : Sushmita Kaushik
9. Phacotrabeculectomy : Suresh Kumar 7. HRT
8. GDX/ FDT
10. Oval capsulorhexis in posterior polar cataract : Kiranjit Singh

11. IFIS – management options : Pradeep Swaroop

12. Hard Cataract : A.K. Grover

www.dosonline.org 25

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

LASIK QUESTION & ANSWER WITH COMMUNITY OPHTHALMOLOGY
DR. MICHAEL KNORZ
Hall: Emerald Date: Saturday 16.4.11 Time: 4:00 p.m. – 6:00 p.m.
Hall: Banquet Date: Saturday 16.4.11 Time: 4:00 p.m. – 5:00 p.m.
Chairman: Co-chairman: Convener: Co-convener: Moderator:
Panelists:
S. Bharti, Sanjay Chaudhary, Neera Agarwal, Virendra Aggarwal, D. Ramamurthy, P. Namperumalsamy G.V. Rao C.S. Dhull S.K. Goswami A.K. Jain
Ashu Agarwal, Vivek Pal, Amit Gupta
Each Talk: 8 mins

REDEFINING LASER VISION CORRECTION 1. Research Design in Community Ophthalmology : Deepak B Saxena

Hall: Banquet Date: Saturday 16.4.11 Time: 5:00 p.m. – 6:00 p.m. 2. Community eye care programs eliminating : B.K. Jain
needless blindness : P. Namperumalsamy
Chairman: Co-chairman: Convener: Co-convener: Moderator: : N.K. Agarwal
3. Diabetic retinopathy: challenges and solutions
Jod Mehta Rupal Shah Sujal Shah Virendra Aggarwal Somasheila Murthy : A.K. Sil
4. NPCB – the present status & new initiatives
1. Looking beyond Femto Flaps- The unique Visumax : Jod Mehta : G.V. Rao
Technology : Rupal Shah 5. Diabetic Retinopathy- Changing the health seeking : A.K. Jain
: Sujal Shah behaviour of the community : Lokesh Jain
2. Good bye Excimer, enter ReLEx : Virendra Aggarwal
: Somasheila Murthy 6. Children’s eye care programmes in india – ORBIS : Mohita Sharma
3. Blended Vision- Answers for my presbyopic patients perspective

4. My early experience with ReLEx 7. Disease awareness in general public

5. LVP experience with Visumax 8. Public education in diabetic retinopathy

9. Mobile unit for treatment of diabetic retinopathy: A new
concept in North India

AMD TECHNIQUES IN OCULOPLASTICS

Hall: Cocktail Date: Saturday 16.4.11 Time: 4:00 p.m. – 6:00 p.m. Hall: Sapphire Date: Saturday 16.4.11 Time: 4:00 p.m. – 6:00 p.m.

Chairman: Co-chairman: Convener: Co-convener: Moderator: Chairman: Co-chairman: Convener: Co-convener: Moderator:
S.P. Garg B.P. Guliani Lalit Verma Sanjeev Gupta Pradeep Venkatesh V.P. Gupta Neelam Pushker Anita Sethi Shaloo Bageja Mridula Mehta

Keynote Address: Keynote Address:
Present and future of SLO: Stela Vujosevic (10 mins) Facial Palsy management: Sadiq Ahmed (10 mins)

Each Talk: 8 mins Each Talk: 8 mins

1. Advancement in dry ARMD management : Gopal Verma 1. Management of lid and lacrimal trauma : Bipasha Mukherjee

2. Preferential hyperacuity perimeter in AMD : S. Natarajan 2. Lid Reconstructions – A systematic approach : Y. Sujatha

3. When to suspect and how to diagnose : Charu Gupta 3. Approach to management of entropion : Mridula Mehta

4. OCT- Merits & de-merits in AMD : Sanjeev Gupta 4. Clinical evaluation and decision making in congenital ptosis : Shaloo Bageja

5. How to tailor anti-VEGF treatment in AMD : Amit Khosla 5. Tips in ptosis management : Subhash Goswamy

6. AMD clinical trials (real life scenarios) : R. Narayanan 6. Frontalis sling surgery – made simple : A.K. Grover

7. The place of PDT in the current anti-VEGF era : Anand Rajendran 7. Complications of ptosis surgery : Anita Sethi

8. IPCV : A. Giridhar 8. Surgical management of eye lid retraction : Neelam Pushker

9. ICG – mediated photothrombosis: a cost effective alternative: B. Ghosh 9. Surgical Management of Blepharospasm : E.R. Mohan

10. Management of sub-macular heamrrhage : Rishi Singh 10.Adjustable suture LPS repair : Vikas Menon

11. Providing AMD service in a busy hospital : Manish Gupta

26 DOS Times - Vol. 16, No. 9, March, 2011

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

FREE PAPER-7 (CATARACT) PHACODYNAMICS

Hall: Ruby Date: Saturday 16.4.11 Time: 4:00 p.m. - 6:00 p.m. Hall: Convention Hall-A Date: Sunday 17.4.11 Time: 8:30 a.m. – 10:45 a.m

Chairman: Chairman: Co-chairman: Convener: Co-convener: Moderator:
V.K. Dada Judges: Rajinder Khanna, Neeraj Bhargava, Nita Guha, Om Prakash
Mahipal S.Sachdev Sri Ganesh Praveen Malik Umesh Bareja Rohit Nanda

Each Talk: 6 mins Each Talk: 8 mins

1. Posterior Claw Lens in Aphakics : Anil Kothari 1. Kitaro Cataract Surgery Training System : Junsuke Akura
: V. Rajshekhar
2. Incidence of Cystoid Macular Edema Post 2. Basics of Fluidics : Harbansh Lal
: Kamal Kapoor
Phacoemulsification and Small Incision Cataract Surgery 3. Surge Control : Amit Tarafdar
: G.L. Arun Kumar
as Measured by Oct: A Case-Comparitive Study : Nibedita Das 4. The deep analysis of phaco machine
: V.C. Mehta
3. Operating Pediatric Cataract with Anterior Vitrectomy : Ravi Vohra 5. Common errors in IOL power calculation : Sri Ganesh
: Sudhir Srivastava
4. A Comparative Study of Phacoemulsificaton in White 6. The Dual Magic : J.L. Goyal
Mature Senile Cataract and Other Senile Cataract : Ravindra Kumar Meena
7. Torsional Ultrasound - Clinical & Economical : Debashish Bhattacharya
5. Comparative Study of Secondary Scleral Sutured : Suvarna Bhagde Outcomes : Atul Singh
Sulcus-Fixated IOL (SFIOL) and Primary Anterior
Chamber IOL (ACIOL) Implantation 8. High vacuum phaco chop in different cataract

6. Comparison of Surgically Induced Astigmatism in : Nidhi Jauhari 9. Advancement in Phaco Technologies
Straight, Frown and Inverted V 'Chevron' Incision
in Manual Sics 10. Materials used in foldable IOLs

7. Floppy Iris – Its Behaviour during Phacoemulsification : Anuradha S. Rao 11. A new concept viso pump – an effective tool in
subluxated cataract, soft cataract, post
8. Hydroimplantation Of Rigid IOLS in Manual : Suvarna Bhagde polar cataract
Phaco (Sics) – A Safety and Efficacy Study.
12. Co-axial MICS new frontier

9. Management of Dropped Nucleus : Tariq Qureshi

10. On Axis and off Axis LRI for Managing Astigmatism : R.K. Bansal CORNEAL INFECTIONS: BATTLING THE BUG
in Patients Undergoing Phacoemulsification

11. Scleral Fixated Intraocular Lens (SFIOL) Implantation

in Aphakia with Inadequate Capsular Support : Usha Bhargava Hall: Convention Hall-B Date: Sunday 17.4.11 Time: 8:30 a.m. – 10:45 a.m.

5142. Study of Small Incision Cataract Surgery in Relation Chairman: Co-chairman: Convener: Co-convener: Moderator:
J.S. Titiyal Namrata Sharma Geetha Iyer Nikhil Gokhale Rajib Mukherjee
to Different Types of Wound Shape and Astigmatism
Outcome : Chandra Shekhar Kain Each Talk: 8 mins

13. Tilted Hydrodissection: For SICS in Polar Cataract. : Amisha Gupta

14. To Compare the Efficacy of Prophylactic 1. Bacterial Keratitis – Dealing with drug resistance : Rajib Mukherjee
Dorzolamide 2.0%, Brimonidine 0.15% and 2. Fungal Keratitis – Age old war………with new drugs : Amit Gupta
Timolol 0.5% Eye Drops in the Prevention of IOP 3. HSV Keratitis – There it goes again and again : Umang Mathur
Spike Following Nd:Yag Laser Posterior Capsulotomy : Neha Mohan 4. Acanthamoeba – Medical and Surgical management : Bhupesh Bagga
5. Epidemic Kerato-conjunctivitis – When to give steroids? : Pallavi Sugandhi
15. To Evaluate Frequency and Indications of Capsular : Garima Rai 6. Microbial Keratitis after refractive surgery : Neera agarwal
Tension Ring (CTR) Implant and Analyse the Visual 7. Contact Lens related Infectious keratitis : Paras Mehta
and Anatomical Outcome in Various Complicated 8. C3R in infective keratitis : Anita Panda
Cataract Surgeries 9. Herpes zoster Ophthalmicus : Jayeeta Bose
10. Techniques of management of Corneal perforations : R.B. Vajpayee
16. Vitreous “Face Off” after Nd-Yag Laser Posterior : Trapti Sharma 11. Non-healing Corneal Ulcer : J.S. Titiyal
Capsulotomy – A Rare Case Report 12. Non-Infectious Keratitis : Somasheila Murthy
13. Peripheral Ulcerative Keratitis : Ramendra Bakshi
17. Kitaro Cataract Surgery Training System : Junsuke Akura

18. Management of Spherophakia with Phacoaspiration
in Two Siblings Having Weill Marchesani Syndrome : J.S. Bhalla

19. Role of Ultrasound Biomicroscopy in Proper Operative

Planning in Traumatic Cataract Surgery. : Suraj P. Bhagde

www.dosonline.org 27

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

PREMIUM IOL PRACTICE MANAGEMENT

Hall: Convention Hall-C Date: Sunday 17.4.11 Time: 8:30 a.m. – 10:45 a.m. Hall: Cocktail Date: Sunday 17.4.11 Time: 8:30 a.m. – 10:45 a.m.

Chairman: Co-chairman: Convener: Co-convener: Moderator: Chairman: Co-chairman: Convener: Co-convener: Moderator:

A.K. Grover V.K. Dada Pawan Goyal Nitin Verma Kamal Kapoor T.P. Lahane Vivek Pal R.D. Thulsiraj Rajiv Mohan Anita Sethi

Each Talk: 8 mins Each Talk: 8 mins

1. Aspheric IOL what should be doing? : George Beiko 1. Every Ophthalmologist in Corporate World : Sharad Lakhotia
2. Clinical Effectiveness and Results of the Ultrasmart 2. Below the line Marketing : Siddharthan
: Bikbova Gusel 3. Practice down turn - what is responsible and
Aspheric IOL Implantation in Cataract Surgeries : Gaurav Luthra : Vipin Sahni
3. Premium IOLs in different situations : Abhay R. Vasavada how to turn around : Anita Sethi
4. My Experience with Blue Light Filtering IOL : Mahipal S. Sachdev 4. Group practice : R.D. Thulsiraj
5. Crystalens for premium cataract surgery : Kamal Kapoor 5. Role of Training in ophthalmic practice : Rajiv Mohan
6. My experience with ACRIOL EC hydrophobic IOLs : V. Aravind 6. Human resource management : Suvira Jain
7. Spherical aberrations what is ideal 7. Counseling - who needs it : Ramit Sethi
8. How to center, size and confirm your : Burjor Banaji 8. How I can make my money grow : Samir Sud
: Nitin Verma 9. Role of empanelment in ophthalmic practice : T.P. Lahane
Capsulorhexis - A vital step : Jacob Mathew 10. TPAs - how should we manage them : Tamilarasan Senthil
9. Clinical experience with the Acrismark IOL 11. Group buying of equipment : T.M. Sharma
10. Future of premium IOL 12. The way forward organized practice

SURGICAL INNOVATIONS GLAUCOMA: SQUINT & NEURO OPHTHALMOLOGY:
VIDEO BASED SESSION CASES AND CASES

Hall: Banquet Date: Sunday 17.4.11 Time: 8:30 a.m. – 10:45 a.m. Hall: Emerald Date: Sunday 17.4.11 Time: 8:30 a.m. – 10:45 a.m.

Chairman: Co-chairman: Convener: Co-convener: Moderator: Chairman: Co-chairman: Convener: Co-convener: Moderator:

Ramanjit Sihota J.K.S. Parihar Sirisha Senthil Subodh Sinha Devindra Sood Pradeep Sharma Venkateshwar Rao Suma Ganesh Satya Karna V. Krishna

Each Talk: 8 mins Case Presentation: 4 mins Discussion: 8 mins

1. Trabeculectomy: Time-tested stalwart : Subodh Sinha 1. A child with squint in infancy : Kanak Tyagi
2. A child who sometimes squints : Priyanka Arora
2. Surgical modifications in trabeculectomy: : Mayuri Khamar 3. A child who occasionally squints : Gaurav Kakkar
Releasable / Adjustable sutures 4. A child with wriggly eyes : Shilpa
: Sunil Jain 5. A case of optic neuropathy : V. Krishna
3. Surgical modifications in trabeculectomy: Use of : Sirisha Senthil 6. A case of optic neuropathy : Swati Phuljhele
antimetabolites : Suneeta Dubey 7. A case of abnormal pupils : Mathew James
: Anshoo Choudhary 8. Presentations can be misleading : Satya Karna
4. Management of refractory developmental glaucoma : Ritesh Narula
: Sunil Sah
5. Failing bleb: options possible : Shibal Bhartiya

6. NPDS

7. Bleb infections: Prevention is better than cure

8. CO2 laser assisted glaucoma surgery

9. Innovation in AGV implantation techniques

28 DOS Times - Vol. 16, No. 9, March, 2011

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

LACRIMAL FREE PAPER-1 (DR. A.C. AGARWAL TROPHY)

Hall: Sapphire Date: Sunday 17.4.11 Time: 8:30 a.m. – 9:45 a.m. Hall: Ruby Date: Sunday 17.4.11 Time: 8:30 a.m. - 11:00 a.m.

Chairman: Co-chairman: Convener: Co-convener: Moderator: Chairman:
R.C. Gupta Bhavna Chawla Sima Das P.V. Chadha, Judges: N.S.D. Raju, Anita Panda, Ajit Babu, Anju Rastogi
E.R. Mohan Anuj Mehta

Each Talk: 8 mins Each Talk: 6 mins

1. Evaluation of a patient with epiphora and : Rituraj 1. Visual Outcome In Camp Surgery - An Overview : Sharad Lakhotia
management of punctal stenosis : Sushil Kumar : Saurabh Sawhney
: Nishi Gupta 2. Automated Selective Astigmatism Analysis using : Garima Lakhotia
2. Basics of DCR : R.C. Gupta SIA Calculator 3.1 : Jayeeta Bose
3. Endoscopic DCR : Neelam Pushker : Nidhi Pandey
4. Conjunctivo-rhinostomy- encouraging or frustating? : Hardeep Singh 3. Ball Tip Manipulator: One For All
5. CDCR using HDPP coated tear drain tube : Deepa Gupta
6. Management of failed DCR 4. Clinical Profile And Visual Outcome In Herpes : Anshima Aggarwal
Zoster Ophthalmicus : Swapna Parekh
SUBLUXATED LENS
5. Ocular Surface Changes in Patients On Topical : Kanchan Chawhan
Hall: Sapphire Date: Sunday 17.4.11 Time: 9:45 a.m. – 10:45 a.m. Anti Glaucoma Drugs
: Bhawna Piplani
6. Photopic Negative Response (PhNR) as a Diagnostic : Gauri Bhushan
Electrophysiological Modality in Primary Open
Angle Glaucoma

7. Ocular manifestations of dengue

8. Hydroxyapatite Implants! Is Wrapping
Material Essential?

9. Outcomes Of Periocular Full Thickness Skin Graft For
Indications other than Lid Tumors at Tertiary Eye
Care Centre

10. Comparison Of Macular Structure And Function In
Retinal Detachment Treated By Scleral Buckling or
Pars Plana Vitrectomy With Silicone Oil Tamponade

11. Retinal manifestations in dengue fever

Chairman: Co-chairman: Convener: Co-convener: Moderator: 12. Spectral Domain OCT Evaluation of Retinal
Thickness In Indian Population
Abhay R. Vasavada S.K. Khokhar Kamal Kapoor Ashu Agarwal Rohit Nanda : Amit Mehtani
13. Spectral Domain Optical Coherence Tomography
Each Talk: 8 mins following Nd YAG Laser Membranotomy in : Neha Goel
premacular hemorrhage
1. Hooks & Retractors – Tips : S.K. Khokhar : Parul Dwivedi
2. Role of Capsular Hooks : Ashu Agarwal 14. Clinical characteristics and response to treatment in : Harbhajan Kaur Arora
3. Technique of surgery in subluxated lens : Abhay R. Vasavada cases presenting with uveitis secondary to TB in : Shashank Rai Gupta
4. Tips & tricks for CIONNI rings : Kamal Kapoor tertiary care setup
5. Anterior vitrectomy in subluxated lens : Amit Khosla
6. Decentered IOL : Piyush Kapur 15. Refractive outcome and patient
satisfaction in Toric IOLs

16. Intravitreal Bevacizumab for CNVM secondary
to angioid streak

www.dosonline.org 29

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

PHACO IN COMPLICATED CASES DEBATES ON MANAGEMENT ISSUED
IN GLAUCOMA
Hall: Convention Hall-A Date: Sunday 17.4.11 Time: 10:45 a.m. – 1:00 p.m.

Chairman: Co-chairman: Convener: Co-convener: Moderator: Hall: Convention Hall-C Date: Sunday 17.4.11 Time: 10:45 a.m. – 1:00 p.m.

Amar Agarwal Vivek Pal R.K. Bhandari Rohit Om Prakash Alkesh Chaudhary Chairman: Co-chairman: Convener: Co-convener: Moderator:

Keynote Address: Harsh Kumar J.C. Das Usha Yadava Prateep Vyas Deven Tuli
IOL’s are then all the same?: George Beiko (10 mins)
Keynote Address:
Each Talk: 8 mins DDLS – Its effectivity in diagnosis and management of glaucoma:
Sumit Sachdev (10 mins)

1. Anterior Capsular Opacification and Phimosis : Neelima Mehrotra Each Talk: 10 mins
2. Piggy backing a refractive surprise : Ryan D’souza
3. Post Capsule rent – why automated vitrectomy 1. Neuro-Protection: In OR Out : Manish Shah / Tutul Chakravarty
: U.S. Tiwari : Prateep Vyas/ J.C. Das
is necessary? 2. SLT: In OR out : Viney Gupta / Sushmita Kaushik
4. Options to rectify sub-optimal refractive : D. Ramamurthy
: Rohit Om Prakash 3. Corneal Thickness: In OR Out : Harsh Kumar / Sunil Jain
outcomes after phaco : Sri Ganesh
5. Preventing catastrophies in phacoemulsification : Arup Chakrabarti 4. Optic nerve head signs. No problem/ : J.K.S. Parihar / Gursatinder Singh
6. IOL implantations in PC rent : Guruprasad Ayachit Too many confounders
7. Viscoelastics & Rhexis in Awkward Situations : Amar Agarwal
8. Sclerated fixated IOL : Alkesh Chaudhary 5. Primary glaucoma tubes are good/
9. Phaconightmares Trab is fine
10. Management of Retained Lens matter

CORNEA OSD INTRA-VITREAL INJECTIONS

Hall: Convention Hall-B Date: Sunday 17.4.11 Time: 10:45 a.m. – 1:00 p.m. Hall: Banquet Date: Sunday 17.4.11 Time: 10:45 a.m. – 1:00 p.m.

Chairman: Co-chairman: Convener: Chairman: Co-chairman: Convener: Co-convener: Moderator:
Rishi Mohan H.K. Tewari B.P. Guliani M.R. Dogra Sanjeev Gupta Manisha Agarwal
Jeewan S. Titiyal Aashish Bansal
Keynote Address:
1. Management of Refractory Allergic Eye Disease : A.K. Jain (12 mins) Update on the management of retinal vein occlusive disease: Rishi Singh (15 mins)
2. Role of Osmoprotection in Dry Eye : Rishi Mohan (15 mins)
3. Ocular Surgery Dry Eye : Rajesh Fogla (12 mins) Each Talk: 8 mins
4. Surgical management of OSD : Namrata Sharma (12 mins)
5. Immune diseases & Ocular complications : Geetha Iyer (12 mins) 1. Technique of intra-vitreal injections : Sandeep Saxena
6. Empirical Vs Culture guided therapy in 2. DME – steroids versus Anti-VEGF versus laser : Meena Chakarvarti
: Rajesh Sinha 3. Steroids implant techniques & side effects : S.N. Jha
Microbial Keratitis 4. Anti-VEGF in ROP : Parijat Chandra
5. Anti-VEGF therapy in CNVM : M.R. Dogra
OSD- Clinics (case presentations) 6. Vision threatening complications of intravitreal injection : G.V. Narendra
a. Recurrent Pterygium 7. Steroids in management of macular edema : Manisha Agarwal
b. Peripheral Ulcerative Keratitis 8. Anti-VEGF in vascular occlusion : B.P. Guliani
c. Blepharitis 9. Anti-VEGF as a surgical adjunct in diabetic vitrectomy : Ajay Aurora
d. Meibomian Gland Disease
e. Acute Ocular Burns

30 DOS Times - Vol. 16, No. 9, March, 2011

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

Hall: Cocktail OPHTHALMIC QUIZ CONTACT LENS (WET LAB)

Date: Sunday 17.4.11 Time: 10:45 a.m. – 1:00 p.m. Hall: Sapphire Date: Sunday 17.4.11 Time: 10:45 a.m. – 1:00 p.m.

Quiz Masters: Chief Instructor: Monica Chaudhary
Aashish Lall, Kapil Midha
4 Live Cases Demonstration (each section for 30 mins)
Sponsored by:
Vasan Eye Care 1. Silicone hydrogels – soft lens fitting
2. Toric Soft Contact Lens
3. A case of keratoconus
4. Scleral Contact Lenses

AESTHETIC OCULOPLASTY SURGERY FREE PAPER-2 (CORNEA)
(DR. T.P. AGARWAL TROPHY)
Hall: Emerald Date: Sunday 17.4.11 Time: 10:45 a.m. – 1:00 p.m.

Chairman: Co-chairman: Convener: Co-convener: Moderator: Hall: Ruby Date: Sunday 17.4.11 Time: 11:00 a.m. – 12:00 Noon
A.K. Grover Sadiq Ahmed E.R. Mohan Poonam Jain Hardeep Singh
Judges: Madan Mohan, A.K. Jain, Neera Agarwal, Umang Mathur, Mukesh Taneja

Keynote Address: Each Talk: 6 mins
Why and how to start your own cosmetic surgery practice: Satish Chawdhary (10 mins)
1. Amniotic membrane grafting: Efficacy in Ocular : Surbhi Arora
Each Talk: 8 mins Surface Disorders

1. Ophthalmic photography : Bipasha Mukherjee 2. Indications and outcome of descemetopexy for descemet’s

2. Assessment of patient for aesthetic surgery : S.S. Saha membrane detachment after cataract surgery : Jyoti

3. Pearls and pitfalls in upper lid blepharoplasty & brow ptosis : Poonam Jain 3. Results of corneal collagen crosslinking in children : Deepa Gupta

4. Pearls and pitfalls in lower lid blepharoplasty : A.K. Grover 4. Role of subconjunctival avastin in decreasing corneal : Surbhi Arora
angiogenesis following high risk graft
5. Primary and adjunctive uses of Botox in
the periorbital Region : Sadiq Ahmed 5. Confocal Microscopy changes of corneal subbasal nerve

6. Fillers in periorbital Rejuvenation : Lalit Choudhary fibre layer in eyes with chronic glaucoma on long term

glaucoma therapy : M. Vanathi

7. Approach to periocular rejuvenation by chemical peels etc. : Rishi Parashar 6. Pseudomembraneous conjunctivitis with ischemic
conjunctiva necrosis as the presenting feature of
8. Eyebrow hair transplant : Amit Gupta Sjogren's syndrome : Naina R. Bamrolia

7. Rejection in pediatric corneal graft : Rakhi Kusumesh

www.dosonline.org 31

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

FREE PAPER-3 (CORNEA) OCT

Hall: Ruby Date: Sunday 17.4.11 Time: 12:00 Noon – 2:00 p.m. Hall: Convention Hall-A Date: Sunday 17.4.11 Time: 1:00 p.m. – 2:00 p.m.

Chairman: Chairman: Co-chairman: Convener: Co-convener: Moderator:
Anita Panda, Judges: Radhika Tandon, Uma Sridhar Amit Gupta, Sudesh Arya
Vishali Gupta Vinay Garodia Prem Tanwar Deependra V. Singh Darius Shroff

Each Talk: 6 mins Each Talk: 8 mins

1. Prognostic Parameters in Penetrating Keratoplasty : Shweta Gaur 1. Anterior segment OCT in corneal disorders : Rajib Mukherjee
2. OCT vitreo-retinal interface : Salim Zafar
2. Pterygium Extended Removal Followed by Extended : K. N. Jha 3. OCT in retinal disorders : Darius Shroff
Conjunctival Transplant (PERFECT) for Primary and : Stuti Kapur 4. OCT in glaucoma : Suneeta Dubey
recurrent Pterygium (Our experience at Manipal : Sumana Chatterjee 5. OCT in Neurophthalmology : Amit Batla
Teaching Hospital, Pokhara, Nepal) : Shubhangi Deshmukh
: Trapti Sharma GLUED IOL – ALL IS WELL
3. Post Penetrating Keratoplasty Glaucoma - : Sudipta Ghosh
A Clinical Study : Himika Gupta Hall: Convention Hall-B Date: Sunday 17.4.11 Time: 1:00 p.m. – 2:00 p.m.

4. Lamellar Keratoplasty in Paediatric Population: : Upsham Goel
Indications and Outcome : Anupama Karanth

5. Microsporidial Keratoconjunctivitis in Healthy,
Immunocompetent Individuals

6. Prevelence of Causative Micro-Organisms of
Corneal Ulcer in Central India

7. Assessment of Prevalence of Ocular Toxicity in
Glaucomatous Patients

8. Conjunctival Masses: Multiple Differentials
with Simple Solutions

9. Efficacy and Safety of a New Cyclosporine 0.05%
Ophthalmic Microemulsion for Treatment of Moderate
to Severe Dry Eyes

10. Rare Case of Conjunctival Histoplasmosis in an
Immunocom promised Patient from South IND

Chairman: Co-chairman: Convener: Co-convener: Moderator:

11. Surgically Induced Necrotizing Scleritis Following Bare Amar Agarwal Mahipal S. Sachdev Keiki Mehta Rajesh Sinha Avnindra Gupta
Sclera Excision of Pterygium in a Healthy adult male : Amit Agarwal
Each Talk: 8 mins

12. Tear Film Stability after Phaco Surgery in Long Term. : Preeti Goyal 1. Glued IOL : Mahipal S. Sachdev
2. Tips to master the glued IOL : Priya Narang
13. Epidemiology & Visual Outcome of Patients with : Seema Lele 3. Technique for glued IOL : Keiki Mehta
Ocular Trauma.-A Rural Based Study 4. Challenging cases : Amar Agarwal
5. Glued IOL with DSAEK : Rajesh Sinha
14. Fevikwik-Common Cause of Eye Injury Due to : Jaishri Murli Manoher 6. Vitreous management : S. Padhi
its Manufacturing Defect 7. Sutured scleral fixated – still relevant : Ajay Aurora

15. Pattern of Ocular Injuries in Stone Pelters : Shabana Khan
in Kashmir Valley

16. Correlation between central corneal thickness : Uma Pandey
and degree of myopia

17. Managing Anisometropia in High Myopes : Sonu Goel

18. Rotary Tooth Brush For Advance Surface Ablation- : Vinod Arora
An Indigenous Technique

19. Transepithelial PRK(T-PRK) A Safe Mode of : Uday A. Gadgi
Laser Vision Correction

32 DOS Times - Vol. 16, No. 9, March, 2011

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

BREAKTHROUGH INNOVATIONS C3R / CXL
IN EYE SURGERY
Hall: Cocktail Date: Sunday 17.4.11 Time: 1:00 p.m. – 2:00 p.m.
Hall: Convention Hall - C Date: Sunday 17.4.11 Time: 1:00 p.m. – 2:00 p.m.
Chairman: Co-chairman: Convener: Co-convener: Moderator:
G. Mukherjee Aashish Bansal S. Bharti Rajib Mukherjee Umang Mathur

Each Talk: 8 mins

1. The Culprit - Corneal thinning & ectasia – : Vinay Agrawal
Spectrum and Diagnosis : Aashish Bansal
: Rajib Mukherjee
2. Crime Scene - When to do – Indications & Pre-Op Workup : Rajesh Sinha
: S. Bharti
3. DO NOT TOUCH - When not to do –
Contraindication / Complications

4. Materials & Method –
Tools and usage / Options / Epithelium On or off

5. Rings of Oz – Corneal Implants –
When / How / Contra-indications

Discussion: 20 minutes

REFRACTIVE PROCEDURES IC: LEARN PHACO
PRE-OP EVALUATION
Hall: Emerald Date: Saturday 16.4.11 Time: 1:00 p.m. – 2:00 p.m.
Hall: Banquet Date: Sunday 17.4.11 Time: 1:00 p.m. – 2:00 p.m. T.P. Lahane, Ragini Parikh

Faculty: Amit Gupta, Sanjay Chaudhary, Arun Baweja

www.dosonline.org 33

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

WET LAB ON GONIOSCOPY OCULAR SURFACE DISORDER

Hall: Sapphire Date: Sunday 17.4.11 Time: 1:00 a.m. – 2:00 p.m. Hall: Convention Hall-B Date: Sunday 17.4.11 Time: 2:00 p.m. – 4:00 p.m.

Viney Gupta, Deven Tuli Chairman: Co-chairman: Convener: Co-convener: Moderator:

Anita Panda Aashish Bansal Vinay Agarwal Arun Jain Umang Mathur

Keynote Address:
Conjunctival squamous cell carcinoma: Arun D. Singh: (10 mins)

Each Talk: 8 mins

ASTIGMATISM MULTIFOCAL AND 1. Corneal Wound healing: Lesions in wound healing : Aashish Bansal
ACCOMMODATIVE IOL 2. Dry Eye: Diagnostic Dilemma : Sharadhini Vyas
3. Dry Eye: Which Lubricant to Choose ? : Rishi Mohan
Hall: Convention Hall-A Date: Sunday 17.4.11 Time: 2:00 p.m. – 4:00 p.m. 4. Computer vision syndrome : Jatinder Bali
5. Allergic Eye Disorders : Nikhil Gokhale
6. AMG : Its role and utility : Sudesh Arya
7. Limbal stem cell transplant : Mukesh Taneja
8. Steven Johnson Syndrome : Geeta Iyer
9. Acute Chemical Burn: First Aid : Rajesh Sinha
10. Ocular surface reconstruction after chemical injuries : M. Vanathi
11. Superficial Corneal Opacity: How to Approach ? : Pramod Kumar
12. Recurrence free pterygium surgery : Arun K. Jain
13. Phototherapeutic Keratectomy for
: Anand Parthasarathy
Recurrent Corneal Erosions

Chairman: Co-chairman: Convener: Co-convener: Moderator:

Mahipal S.Sachdev V.C. Mehta Ryan D’souza Ram Mirley Piyush Kapur SICS

Keynote Address: Hall: Convention Hall-C Date: Sunday 17.4.11 Time: 2:00 p.m. – 4:00 p.m.
Accommodating IOLs, Single and Dual Optic: Do they work?: George Beiko (10 mins)

Each Talk: 8 mins Chairman: Co-chairman: Convener: Co-convener: Moderator:
K.P.S. Malik Kamaljeet Singh C.S. Dhull Sutanshu Mathur Jaswant Arneja

1. Biometry and next gen IOLs : Rajashekar Y L Each Talk: 8 mins

2. MF IOLs - Courage to change, Wisdom to know : D. Ramamurthy 1.Transition in Cataract Surgery from ECCE to SICS : Amit Porwal
the difference 2. Learning SICS before phaco not a bad idea : Sajjad Fazili
3. Manual Small Incision Cataract Surgery under
3. AcrySof® ReSTOR® +3 - My Results : V.C. Mehta : Sanjiv Kumar Gupta
topical anesthesia. How and Why? : Ragini Parikh
4. Customized IOL way to go : Arvind Venkatraman 4. Why incisions leak & its Management : Swaraj Bhattacharjee
5. Management in incomplete rhexis : T.P. Lahane
5. Experience of Active Bifocal IOL in 100 eyes shows 6. Failure to deliver nucleus – solutions : Kamaljeet Singh
7. PCT during nucleus removal : Seema Bajaj
promising results for near and distance vision : Ramesh Shah 8. SICS & astigmatism control : Arun Kshetrapal
9. SICS with small Pupil : Ranjit Dhaliwal
6. Retrospective study of IDFF plus IOL : Namrata Sharma 10. When & how to convert to ECCE in difficult SICS : S.P. Singh
11. SICS with Hard Cataract
7. Multifocal in Small Pupil : Ram Mirley

8. Managing Corneal Astigmatism during Cataract Surgery: Anand Parthasarathy

9. Integrating toric IOL into clinical practice : Ryan D’souza

10. Astigmatism Correction with TORIC IOLs - : Noshir M. Shroff
My Experience

11. Need for Astigmatism Correction during Cataract : Sandeep Nagvekar
surgery TORIC IOL

12. Redefining Torocity in the latest Bitoric TIOL towards

enhanced patient outcome : Nitin Verma

13. Visual Performance of Acri Tec AcriLISA Multifocal IOL : Rakesh Kumar Bansal

34 DOS Times - Vol. 16, No. 9, March, 2011

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

REFRACTIVE SURGERY – FEMTOSECOND & ICL SQUINT VAST: ADVANCED

Hall: Banquet Date: Sunday 17.4.11 Time: 2:00 p.m. – 4:00 p.m. Hall: Emerald Date: Sunday 17.4.11 Time: 2:00 p.m. – 4:00 p.m.

Chairman: Co-chairman: Convener: Co-convener: Moderator: Chairman: Co-chairman: Convener: Co-convener: Moderator:
Prof Kamlesh Ajay Agarwal Gaurav Kakkar Sumita Agarkar Subash Dadeya
D. Ramamurthy S.K. Khokhar Rajinder Prasad Amit Gupta Arun Baweja

Each Talk: 8 mins Keynote Address:
Recent advances in strabismus: Santhan Gopal (10 mins)

1. Optimised patient flow with - "New refractive suite" : Rohit Shetty Each Talk: 8 mins
2. What do I want in my new refractive laser : Gaurav Luthra
3. Femtosecond laser – Revolutonizing ophthalmology : Mahipal S. Sachdev 1. Horizontal muscle surgery: Fornix Approach bilateral : Rasheena Bansal
4. Surgical Pearls with Femtosecond Lasers : Chitra R 2. Bilateral oblique palsy: Diagnosis and management : P.K. Pandey
5. Femtosecond LASIK surgery Complications : Amit Gupta 3. Inferior superior oblique weakening procedures:
6. Newer applications of femtosecond laser : K.P. Reddy : Kamlesh
7. Phakic IOLs : Partha Biswas What surgery gives how much effect? : Pradeep Sharma
8. ICL – Tips and trick : S.K. Khokhar 4. Nystagmus surgery: What to do? : Manish Sharma
9. ICL Complications : D. Ramamurthy 5. Adjustable strabismus surgery: Is it of any use? : Satish Thomas
6. Hangback Surgery: When? : Ankur Sinha
7. Management of III nerve palsy : B.S. Goel
8. Managing VI nerve palsies : Venkateshwar Rao
9. Managing Duane’s Retraction Syndrome
10. Optic nerve sheath fenestrations: : V. Krishna
: Sobi Pandey
Indications and technique
11. Posterior fixation sutures

UVEA MEDICAL RETINA

Hall: Cocktail Date: Sunday 17.4.11 Time: 2:00 p.m. – 4:00 p.m. Hall: Sapphire Date: Sunday 17.4.11 Time: 2:00 p.m. – 4:00 p.m.

Chairman: Co-chairman: Convener: Co-convener: Moderator: Chairman: Co-chairman: Convener: Co-convener: Moderator:

S.P. Garg Jyotirmay Biswas Pradeep Venkatesh Sanjeev Gupta Somasheila Murthy B. Ghosh S.N. Jha Dinesh Talwar Rajpal Deependra V. Singh

1. Role of immunologist in pediatric uveitis : Sujata Sawhney (8 mins) Keynote Address:
Pathogenesis and management of ROP: Jonathan Sears (10 mins)
2. Laboratory investigations in uveitis : Jyotirmay Biswas (15 mins)

3. Role of FFA and OCT in uveitis : Vishali Gupta (10 mins) Each Talk: 8 mins

4. Medical management in uveitis: : Padmamalini Mahendradas (8 mins) 1. Diabetic Retinopathy: Epidemiologic Initiatives : Ajit Babu
guidelines for practitioners 2. Challenging Cases : M.R. Dogra
3. Viral retinopathies : Vishali Gupta
5. Recent advances in management of : Neeraj Jain (8 mins) 4. Nd Yag Hyaloidotomy : Bhuvan Chanana
ankylosing spondylitis 5. Management of neovascular glaucoma : S.J. Saikumar
6. Diagnostic and management issues in
6. Post-op inflammation following intravitreal : Tapas Padhi
pediatric retinal diseases : Vikas Chadha
injection of anti-VEGF agents : Mallika Goyal (10 mins) 7. Choroidal melanoma : R.K. Sharma
8. Complications of untreated CSR : Ekta Rishi
7. HIV and Uveitis: an update : S. Sudarshan (8 mins) 9. Endogenous Endophthalmitis : Vinay Garodia
10. Intra-Ocular cysticercosis
8. Parasitic uveitis : Kalpana Babu Murthy (8 mins)

9. Non-infectious scleritis: tips in diagnosis

and management : Nikhil Gokhale (8 mins)

10. Infectious scleritis : Somasheila Murthy (7 mins)

11. Novel drug delivery systems in : Rajeev Reddy (8 mins)
posterior uveitis

Discussion: 15 minutes

www.dosonline.org 35

ANNUAL CONFERENCE TRENDS IN Delhi Friday, Saturday & Sunday
Ophthalmological 15th, 16th & 17th April, 2011
Society Ashok Hotel, Chanakyapuri, New Delhi

PEADIATRIC OPHTHALMOLOGY & TRAUMA 18 Role of Subconjunctival Bevacizumab in : Abhinav Agrawal
Corneal Neovascularization

Hall: Ruby Date: Sunday 17.4.11 Time: 2:00 p.m. – 4:00 p.m. 19 Specular Microscopic Evaluation of : Surbhi Arora
Penetrating Corneal Grafts

Chairman: Co-chairman: Convener: Co-convener: Moderator: 20 Surgical Management In Cases Of Refractory : Avika Kanathia
S. Ghose J.K.S. Parihar Usha Raina Mahesh Chandra Zia Chaudhari Corneal Shield Ulcer

Each Talk: 8 mins 21 The outcome of deep anterior lamellar keratoplasty {DALK}

in post herpetic vascularized corneal scarring. : Fareed Ahmad

1. Management of post-traumatic glaucoma in children : Usha Raina 22 A Comparison between Rebound and Goldmann : Ajai Agrawal
2. Pediatric Trauma - Lets Salvage their vision : Lav Kochgaway Tonometer in Screening of Patients for Glaucoma
3. Ophthalmic manifestations of craniosynostosis in children : Zia Chaudhuri
4. Retinopathy of Prematurity: Challenges in Management : Parijat Chandra 23 Clinical Profile of Various Subtypes of : Imrana Zameer
5. High Intensity Ocular Blast Injury: A Worst Case Scenario : Nitin Vichare Primary Angle Closure Glaucoma
6. Management of ocular adnexal trauma : B. Vidyashankar
7. Posterior segment trauma – open globe injury : R.P. Singh 24 Correlation between Diurnal Variation of Intraocular : Anjani
8. Secondary glaucoma following trauma : Srishti Raj Pressure and Severity of Glaucoma
9. Management of traumatic endophthalmitis : K.S. Sriprakash
10. Management of corneal lacerations : Shipra Tripathi 25 Nd: YAG Laser iridocystotomy for acute pupillary : S.L. Chandravanshi
block glaucoma secondary to iris cysts

26 Our Experience of Fibrin Sealant-Assisted Implantation

of Ahmed Glaucoma Valve : Anuj Sharma

27 Outcome of Trabeculectomy- A Retrospective Study : Samiksha Choudhary

28 Relationship of IOP and CCT in Myopes : Vivek

29 Microspherophakia - A Case Report : Soumya Sharat

30 Ophthalmic Manifestations of : Kapil Barange
Tuberous Sclerosis- Case Report

31 Spectrum of Phakomatoses : Sunil Kumar Singh

E-POSTER 32 Sturge Weber Syndrome- A Case Report : Pankaj Kataria

33 Subconjunctival Loa Loa in non endemic area : Maya Natarajan

Hall: E-Poster Area, Behind Kalinga Hall Date: 15 to 17th April, 2011 34 A Case Mimicking Orbital Apex Syndrome : Uma Pandey

Judges: Sushil Kumar, Subodh Sinha, Gopal Das, H.S. Trehan, S.K. Mishra, 35 A simple case of retrobulbar optic neuritis (RBN) or is it!!
Rohit Nanda, Deependra Vikram Singh : Saurin Gandhi

1 Bilateral Pediatric Aphakic Glaucoma with Galactosemia 36 Anisocoria In Holmes – Adie Syndrome -- A Case Report
: Rajat Maheshwari : Samiksha Choudhary

37 Pituitary Adenoma Presenting As Isolated Third Cranial

2 Automated Selective Astigmatism Analysis : Saurabh Sawhney
using SIA Calculator 3.1

3 Combined SICS-Trabeculectomy in Nerve Palsy with Ptosis : Bhavna Tiwari
Exfoliation Glaucoma
: Sheikh Sajjad Ahmed 38 CARUNCLE : Is malignancy a common occurance? : Jayashree Baruah

4 Diagnosis Of Toxic Anterior Segment 39 To Study the Efficacy and Safety of Low Dose Mitomycin –
Syndrome (TASS): A Clinical Dilemma
: Abhisek Lohia C Drops in the Treatment of Primary Pterygium. : Bithi Chowdhury

5 Computers –A Boon Or Ban For The Eyes : Soumya Sharat 40 Bilateral lacrimal gland involvement : a rare presentation

6 Eye banking : Status, problems and solutions, of Rosai Dorfman disease : Bhawna Piplani
an overview.
: Vinayak Bhatia 41 Bilateral levator Apraxia- A rare clinical entity : Vivek Kumar

7 Teacher training in vision screening: an innovative 42 Blepharophimosis - Ptosis Epicanthus inversus : Shailesh Chhajed
community based strategy to address the challenges Syndrome (BPES) – A Case Report
of childhood blindness
: Satish Thomas 43 Clinical Profile of Ocular Cysticercosis in
Paediatric Patients
8 A New Horizon in the Treatment of Keratoconus : Ravi Vohra : Wangchuk Doma

9 A Study on Topographic Changes in Corneal Collagen 44 Congenital muscle fibrosis and its
management: A case report
Cross-Linking with Riboflavin in Keratoconus : Harsimran Kaur : Nishat Bansal

10 Anterior megalophthalmos with megalocornea, central 45 Management of a case of complicated ptosis : Amit Prakash

mosaic dystrophy and cataract – Case report : Murugesan Vanathi 46 Six year old Female having Limbal Dermoid : Girjesh Kain

11 C Contact lens induced peripheral ulcer - : Navratan Rani Goel 47 A rare association of acquired myelinated nerve fibres,
A Retrospective analysis
disc drusen and papilledema in a child with

12 Climatic Proteoglycan Stromal Keratopathy of Cornea : Pawan Prasher Crouzon syndrome : Satish Thomas

13 Corneal Collagen Crosslinking in Moderate : Parul Jain 48 Absence of Retinal Vasculature - Did it Disappear : Najeeha H. Shukri
and Advanced Keratoconus or Never Appeared?

14 Corneal Tattooing : An Alternative Treatment : Jyoti 49 Childhood Obesity with Pigmentary Retinal : Priya Mangaonkar
for Unsightly Corneal Scars dystrophy : 2 Case Report

15 Cyanoacrylate Glue: An Effective Tool for 50 Community-acquired Methicillin-Resistant
Management of Corneal Perforations
: N. Linthoingambi Staphylococcus Aureus Bilateral Acute Dacryocystitis

16 Prevelence of Causative Micro-Organisms of in a Neonate : S.L. Chandravanshi
Corneal Ulcer in Central India
: Trapti Sharma 51 Prenatal Diagnosis of Congenital Cataract
at 21 & 28 Weeks
17 Pterygium Extended Removal Followed by Extended : Girjesh Kain
Conjunctival Transplant(PERFECT) for Primary and
52 Updates in the Management of ROP : Priya Mangaonkar
36 recurrent Pterygium
: K N Jha 53 A Case of CRAO - An UnusuDaOl OSutTcoimmees - Vol. 16, N:oH. 9et,aMl Ja. rPcahte,l 2011

Diabetic Macular Edema Retina

Shashank Rai Gupta MS, Parul Dwivedi MS, Abhishek Dagar MS

Diabetic macular edema (DME) is the most common cause The mechanism of the BRB breakdown is multifactorial. It
of visual impairment in patients with diabetes mellitus. The is secondary to changes in the tight junctions, pericyte loss,
pathogenesis of DME is complex and multifactorial. It occurs endothelial cell loss, retinal vessel leukostasis, up-regulation
mainly as a result of disruption of the blood-retinal barrier of vesicular transport, increased permeability of the surface
(BRB), which leads to increased accumulation of fluid within membranes of retinal vascular endothelium and RPE cells,
the intraretinal layers of the macula.1,2,3 Other factors involved in activation of the AGE receptor, downregulation of glial-cell
the progression of DME are hypoxia, altered blood flow, retinal derived neurotropic factor (GDNF),10 retinal vessel dilation, and
ischemia, and inflammation. Poor control of blood sugar, renal vitreoretinal traction.11,12,13,14,15
disease, systemic hypertension, and elevated lipid levels all increase
the risk of DME. Vasoactive Factors

Epidemiology of DME Sustained hyperglycemia affects several vasoactive factors (e.g.,
VEGF, protein kinase C [PKC], heparin, angiotensin II, PEDF,
The incidence of DME over a 10-year period was 20.1% among metalloproteases) and biochemical pathways in diabetes, which
patients diagnosed before age 30 years (younger onset) and may influence the development of structural and functional
39.3% among patients diagnosed after age 30 (older onset).4 The changes in diabetic retinopathy.15,16,17 All of these factors are
Diabetes Control and Complications Trial (DCCT) reported that interrelated, for example, hypoxia and hyperglycemia upregulate
27% of patients develop macular edema within 9 years of diabetes VEGF production in diabetic retinopathy, which in turn increases
onset.4,5,6,7 As the severity of overall retinopathy increases, the vasopermeability by activating PKC. Hyperglycemia, however,
proportion of eyes with macular edema also increases: 3% in eyes can directly increase PKC and angiotensin II, both of which
with mild nonproliferative diabetic retinopathy (NPDR), 38% with cause vasoconstriction and worsening of hypoxia by their effect
moderate to severe NPDR, and 71% with proliferative diabetic on endothelins. Increased levels of histamine seen in diabetic
retinopathy (PDR) develop DME.8 patients increases vasopermeability directly and also indirectly
by upregulating PKC.
Older onset diabetic patients have a tendency to develop macular
edema earlier in the course of their disease (prevalence: 3--8% Vitreoretinal Interface
with up to 3 years of disease duration) compared to younger onset
diabetic patients (prevalence: 0.5% with up to 10years of disease The vitreo-retinal interface structural abnormalities may play
duration). In the presence of macular edema, 50% of older onset an important role in the pathogenesis of DME.18,19,20 DME may
diabetic patients have visual acuity worse than 20/40 compared be exacerbated due to persistent vitreomacular traction by the
to 20% of younger onset diabetic patients.5 residual cortical vitreous on the macula after PVD. Thickened
and taut posterior hyaloid that may or may not be adherent to
Pathogenesis of DME ILM, macular traction due to tractional proliferative membranes,
or loculation of cytokines in the pre-macular vitreous pocket can
The pathogenesis of diabetic macular edema is multifactorial. also lead to development and exacerbation of DME. A diabetic
Several factors and mechanisms are implicated in the etiology of retina compromised due to microvascular abnormalities may be
macular edema like vasoactive factors, biochemical pathways and vulnerable to increased exudation in the presence of any macular
anatomical abnormalities. Although disrupted BRB plays a pivotal traction.
role in the pathogenesis of DME, altered vitreo-macular interface
may also contribute to the progression of macular edema. There Diagnosis of DME
are 3 important etiologies described in literature:
Diabetic macular edema is diagnosed stereoscopically as retinal
Blood-Retinal Barrier thickening in the macula using fundus contact lens biomicroscopy.
But there are various other modalities which help us to better
The common pathway that results in DME is disruption of the understand and manage this entity.
BRB.9 The BRB compartmentalizes the neurosensory retina
from the vascular component of the eye. It consists of two major Fluorescein Angiography
components: the outer barrier and the inner barrier. The inner
BRB is a biological unit formed by tight junctional complexes Fluorescein angiography is a standard method used to evaluate
between retinal vascular endothelium and a glial cells and the patients with DME that is sensitive for qualitative detection of
outer BRB is formed by tight junctions between retinal pigment fluid leakage.21,22 However, leakage on the FA does not equate to
epithelium (RPE) cells. The permeability of both components of clinical retinal thickening or edema. Once a patient is diagnosed
the BRB may be increased in diabetic patients. with CSME, an angiogram is usually performed to identify the
treatable leaking lesions and to evaluate ischemic areas.

Venu Eye Institute and Research Centre, Kang and coworkers categorized fluorescein angiographic leakage
Institutional Area, Sheikh Sarai, New Delhi in DME into three different types:

www.dosonline.org 41

(a) (b)

(c) (d)

Figure 1(a): fundus picture showing CSME. Figure 1(b): early picture of FFA showing microaneurysms.
Figure 1(c)& (d): sequential late FFA pictures showing late leakage from the aneurysms

(a) (b)

Figure 2(a): Fundus picture showing CSME. Figure 2 (b): Late FFA picture showing diffuse late leakage

• focal leakage: well-defined focal area of leakage from • diffuse leakage: presence of widespread leakage from IRMA,

microaneurysms or dilated capillaries [Figure 1(a) to (d)] retinal capillary bed.[Figure 2 (a) & (b)].

42 DOS Times - Vol. 16, No. 9, March, 2011

(a) (b)

Figure 3(a): Early FFA pictures showing early leakage. Figure 3(b): late FFA picture
showing Cystoid appearance

(a) (b)

Figure 4(a): Fundus photograph of a 48 years old gentleman with BCVA of 6/36 and
minimal CSME. Figure 4(b): FFA picture of the same revealing enlarged and distorted

FAZ indicating macular ischaemia

• diffuse cystoid leakage: diffuse leakage and pooling of dye Diabetic macular edema may present in different ways, either
in the cystic spaces of the macula in the late phase of the singly or in combinations of various patterns. The main pathology
angiogram.21[Figure 3(a) & (b)] in DME is accumulation of fluid intraretinally. This is seen as
reduced backscattering, seen most commonly in the outer retinal
Maculopathy can further be differentiated into ischaemic and non- layers.
ischaemic on the basis of angiography which help the clinician to
prognosticate the case. Ischemic maculopathy is diagnosed when Based on OCT DME can be classified into different pattern such
capillary non-perfusion is seen on the FA. [Figure 4(a) & (b)] as cystoid macular edema, spongy swelling of the retina, serous
detachment, and taut posterior hyaloid membrane.23 (Figure 1)
Optical Coherence Tomography
Sponge like Thickening [Figure 5(a)]
OCT has its role in diagnosis and quantification of retinal
thickening, macular volume, retinal morphology and vitreoretinal • most common presentation
relationship in patients with DME. It is also important in defining
the indication of surgery (in the presence of vitreo-macular • mostly in outer retinal layers while internal layers maintain
traction), determining the prognosis and quantifying the response their normal reflectivity
to therapy (laser, medication, or surgery).
• cross-sectional scans show swelling of the retina giving it a
spongy appearance with increased retinal thickness

www.dosonline.org 43

(a) (b)

(c) (d)

Figure 5: Showing OCT scans (6mm horizontal) revealing Figure 5(a): spongy thickening
Figure 5(b): cystoid macular edema Figure 5(c): serous macular detachment &
Figure 5(d): taut posterior hyaloid.

• backscattering seen from intra-retinal fluid accumulation Treatment of DME

Cystoid Spaces [Figure 5(b)] Laser photocoagulation

• second most common pattern Laser therapy has been part of our armamentarium for treating

• intra-retinal cystoid spaces diabetic macular edema (DME) since the mid-1980s. Twenty-plus
years later, the question is: Is this a procedure we still want to be

• involves variable depth of retina and has intervening septa in doing and doing regularly, or are we ready to cast it aside in favour

between of pharmacologic means for treating macular edema?

• progresses gradually to involve the whole of retinal thickness The goal of macular laser photocoagulation for DME is to
limit vascular leakage through focal laser burns of leaking
Serous Detachment [Figure 5(c)] microaneurysms or grid laser burns in areas of diffuse breakdown
of the blood-retinal barrier. The ETDRS compared outcomes in
• Seen as a hypo-reflective area between neurosensory retina eyes assigned to either deferral of macular laser photocoagulation
and RPE or immediate treatment for clinically significant DME.26

Taut Posterior Hyaloid Membrane [Figure 5(d)] From the ETDRS, we learned that performing focal/grid treatment
reduced the risk of moderate vision loss—three or more lines of
• taut, thickened, shiny, glistening hyper-reflective membrane acuity—as compared with no treatment. We also learned that,
with striations on retina over the posterior pole with when monitored for 3 years, only 15% of patients with clinically
attachment to the disc and the top of the elevated macular significant macular edema, center-involved or noncenter-involved,
surface who received focal/grid treatment experienced moderate vision
loss. This was half as frequently as the eyes assigned to observation.
• retinal thickness is greatly increased with intra-retinal That summarizes the primary outcome of the ETDRS, which has
hypo-reflective cyst like cavities (corresponding to fluid led us to do focal/grid treatment for eyes with DME for the last 20
accumulation) years. Argon green (514.4 nm) and frequency doubled Nd:YAG
lasers (532nm) are the lasers of choice in the management of DME.
• may also present as macular edema with foveal detachment
ETDRS gave the treatment strategy of laser photocoagulation for
OCT has several advantages as a retinal imaging technique: 1) it DME and this has been followed worldwide.26,27 The strategy is
is non-invasive (no injected dye involved) and well tolerated; 2) to photocoagulate all leaking microaneurysms further than 500μ
it provides quantitative information regarding retinal thickness from the centre of the macula and to place a grid of 50-100 μm
with a high degree of accuracy and reproducibility; 3) it clearly burns in areas of diffuse capillary leakage and in areas of capillary
reveals the presence and extent of vitreomacular traction; and 4) nonperfusion.
it serves as valuable teaching tool for fellows and residents and is
easily understood by most patients.24,25

44 DOS Times - Vol. 16, No. 9, March, 2011

Treatment of the macula ideally is guided by the FFA, which VEGF increases vascular permeability by relaxing endothelial cell
helps to detect areas of focal leakage, diffuse leakage from dilated junctions. Inhibition of VEGF blocks this effect to some extent,
capillary bed and areas of capillary non-perfusion. Local laser as demonstrated in several clinical trials involving the anti-VEGF
treatment for CSME consists of direct focal treatment, grid laser molecules ranibizumab, bevacizumab and pegaptanib.
treatment to diffuse leaks, or a combination (modified grid) of
direct and grid laser treatment. (Figure 2) Ranibizumab (Lucentis)- Is a humanized, antigen-binding
fragment (Fab) of a second-generation, recombinant monoclonal
Technique antibody directed against VEGF . It has high specificity and affinity
for all the soluble human isoforms of VEGF. Because of the smaller
Focal laser photocoagulation size ranibizumab has been shown to completely penetrate the
retina and enter the subretinal space after intravitreal injection.
All focal leaks located between 500μm to 3000 μm are treated
directly with 50 -100 μm spots at 0.1 second duration to produce Study conducted by Nguyen QD et al revealed that intravitreal
grayish whitening of the microaneurysm. Focal lesion located ranibizumab causes reduction in thickening in the centre of
within 300-500 μm of the FAZ be treated only if retreatment is the macula which was followed by global reduction in edema
required. throughout the entire macula. The improvement in visual acuity
correlated well with reduction in foveal thickness. Another feature
Grid laser photocoagulation that was observed was that the change in visual acuity was gradual
and steady and was not affected by the marked fluctuations in
All areas of diffuse leakage extending from arcade to arcade are foveal thickness. They did not report any intraocular or systemic
treated with 50 – 100 μm spot size placed one burn width apart, at adverse events with ranibizumab.31
0.1 second duration. The laser burns must be atleast 500 μm away
from the foveal center and 500 μm away from the disc margins. Bevacizumab (Avastin), is a US FDA approved full-length
Avascular zones, other than the normal avascular foveal zone are humanized monoclonal antibody for the treatment of metastatic
also treated. colorectal cancer. But it has been found to be very useful in treating
conditions like CNVM and macular edema secondary to DME,
A repeat flourescein angiography is to be done at 3 months. Laser CRVO, BRVO, Coats disease etc. But so far its use is still as an
photocoagulation for any persisting focal or diffuse leakage is to off-label drug.
be done. Most patients need 1 to 3 sessions. DME requiring more
than 3 treatments becomes recalcitrant and require alternative There are a number of unknown factors and concerns surrounding
treatment with pharmacological agents. intraocular use of bevacizumab like potential retinal toxicity,
longer half-life, less efficient binding to VEGF compared with
Complications can be seen with laser photocoagulation like RPE ranibizumab, potential antigenicity of the full antibody, poor
atrophy associated with the laser scars and subretinal fibrosis and retinal penetration and different manufacturing standards for
these can cause visual loss.28 intraocular vs. intravenous injections but none of them has
deterred its use in the conditions mentioned above with significant
At the end of the ETDRS, we were disappointed that, despite success and it has often been labelled as an “wonder drug” as far
successful treatment and decreased retinal thickening, only 17% as ophthalmology is concerned.
of patients recovered three or more lines of acuity relative to
their entry levels of vision. That is why we have been searching Various studies have been conducted recently to evaluate the
for better treatments. In addition to being able to stop vision loss effect of intravitreal bevacizumab injection on retinal thickness
over time, we would like to be able to restore vision in a greater and visual function in patients with diabetic macular edema and
proportion of patients. most of them has highlighted that intravitreal Avastin as a safe
and effective modality for diabetic macular edema.
Pharmacological treatment
Reasons to use bevacizumab in DME are fast onset of improved
Despite the presence of current treatment strategies of DME, retinal morphology, visual acuity and dramatic improvement in
vision loss due to DME still occurs at an alarming rate. Laser OCT appearance. Other reasons include its low cost and easy
photocoagulation is a late and destructive treatment that does availability, with no unexpected toxicity shown to date. But the
not take the etiology of disease into account. Most of the diabetes major problem with anti-VEGF are that they have to be often
related complications like macular edema and neovascularization repeated frequently as most of the therapeutic benefit wear of
occur secondary to the release of the growth factors in response within one month.32
to retinal ischemia from alterations in the structure and cellular
composition of the microvasculature.29,30 Thus inhibition of these Pegaptanib sodium (Macugen) is an anti-VEGF aptamer, a small
growth factors is an important way to treat DME which can be piece of RNA that self-folds into a shape that binds to and blocks
achieved by anti-VEGF agents or corticosteroids or combination the effects of VEGF-165, one isoform of the VEGF family of
of both. molecules. A phase II randomized multicentre controlled trial was
done with macugen (Macugen Diabetic Retinopathy Study Group)
Anti VEGF therapy which provide evidence that selective inhibition of VEGF165 may
produce a clinically meaningful and statistically significant benefit
In the pathophysiologic cascade leading to DME, chronic in the treatment of DME in terms of improvement in visual acuity
hyperglycemia leads to oxidative damage to endothelial cells as and decrease in retinal thickness.33
well as to an inflammatory response. The ensuing ischemia results
in over expression of a number of growth factors, including VEGF.

www.dosonline.org 45

Corticosteroids in the treatment of macular edema but combining intravitreal
corticosteroids or anti-VEGF with lasers has been found to give
Corticosteroids, a class of substances with anti-inflammatory better results. Also, in refractory cases intravitreal injections have
properties, have been demonstrated to inhibit the expression got a special role along with vitreous surgery. In the literature,
of the VEGF gene. A study by Nauck et al demonstrated the combination of laser photocoagulation, intravitreal steroids
that corticosteroids abolished the induction of VEGF by the or VEGF-inhibitors, or both, shows early compelling evidence
pro-inflammatory mediators PDGF and platelet-activating that some patients may benefit from less retreatment compared
factor (PAF) in a time and dose-dependent manner.34 Thus, to monotherapy. After an intravitreal injection of triamcinolone
corticosteroids downregulate VEGF production and possibly acetonide or anti VEGF, the decreased foveal thickness and
reduce breakdown of the blood-retinal barrier and reduce restoration of retinal transparency facilitate adequate laser
extravasation of fluid from leaking blood vessels. Similarly, steroids application and the presence of triamcinolone acetonide also
have antiangiogenic properties possibly due to attenuation of the might suppress the photocoagulation-induced inflammation.37,38
effects of VEGF. At the beginning of this decade, some isolated
cases and then small case series touted the benefits of intravitreal Conclusion
steroid administration. After putting steroids into the vitreous,
several researchers observed that some eyes experienced a rapid DME is a major cause of visual loss in diabetic patients. Although,
reduction in retinal thickening, as confirmed by optical coherence focal laser photocoagulation is the standard-of-care treatment for
tomography (OCT). Some of those patients also had an associated CSME, it is not a cure. Diabetic patients with macular edema who
improvement in visual acuity as their edema improved. So with the have a taut posterior hyaloid membrane may benefit from PPV
presentation and publication of those short-term, small case series, and removal of the posterior hyaloid. Intravitreal triamcinolone
the retina community began experimenting with intravitreal acetonide and anti-VEGF injections have now changed the
steroids, The most common ocular side effects attributed to management of DME which cannot be lasered directly, they are
corticosteroids are glaucoma and cataract. frequently been used either alone or in combination with lasers
for treatment of DME.
The Diabetic Retinopathy Clinical Research Network reported
2-year results of a multicenter randomized clinical trial comparing The pathogenesis of DME is complex, and a variety of factors and
preservative free intravitreal triamcinolone and focal/grid laser for biochemical pathways are involved, which provides an opportunity
DME.35 In this study, 840 study eyes with CSME were randomized for the development of a number of therapeutic modalities to treat
among 3 groups-focal/grid laser, 1 mg and 4 mg intravitreal the condition. Combined pharmacological and surgical therapy
triamcinolone groups. They found that at the end of 2 yeras focal/ may be the best approach in the future based on what is known
grid laser is still superior to IVTA but among two groups of IVTA about the pathogenesis of DME
1mg dose is equally effective as 4 mg with very few side effects.
References
Drug Delivery Insert
1. Antcliff RJ, Marshall J. The pathogenesis of edema in diabetic
With the success of corticosteroids in treating macular edema maculopathy. Semin Ophthalmol. 1999;14(4):223—32
many big pharmaceutical companies are now coming up with
sustained corticosteroid delivery implantable devices which are 2. Bringmann A, Reichenbach A, Wiedemann P. Pathomechanism of
surgically placed inside the eye and gradually releases medication cystoid macular edema. Ophthalmic Res. 2004; 36:241—9
over a long period of time and helps in maintaining macular
edema. It also saves frequent intravitreal injections.36 3. Pendergast SD. Vitrectomy for diabetic macular edema associated
with a taut premacular posterior hyaloid. Curr Opin Ophthalmol.
Many such devices are currently undergoing Phase II and Phase III 1998;9(3):71—5
trials around the world. But again the major drawback with them
is the formation of cataract and development of steroid induced 4. Anderson JM, Itallie CMV. Tight junctions and the molecular
glaucoma. Thus, we have to evaluate the risk-benefit ration before basis for regulation of paracellular permeability. Am J Physiol.
jumping on to such medications. 1995;269:G467—76

Vitreous Surgery for DME 5. Klein R, Klein BEK, Moss SE. The epidemiology of ocular problems
in diabetes mellitus. in SS F (ed): Ocular problems in diabetes
There is clinical evidence that both tractional and non-tractional mellitus. Boston, Blackwell Scientific Publications, 1991, p. 1--51
factors at the vitreoretinal interface play an important role in the
pathogenesis of macular edema. PPV with membrane peeling 6. Klein R, Klein BEK, Moss SE, Cruickshanks KJ. The Wisconsin
helps to remove traction from the macula which further leads epidemiologic study of diabetic retinopathy. XV. The long term
to resolution of macular edema. It is not clear that ILM peeling incidence of macular edema. Ophthalmology. 1995;102:7—16
is necessary for PPV to be an effective treatment for DME. Even
among patients in whom DME is not associated with clinically 7. Vitale S, Maguire MG, Murphy RP, et al. Clinically significant
evident posterior hyaloidal thickening or traction, PPV can lead macular edema in Type 1 diabetes. Incidence and risk factors.
to resolution of macular edema and improved vision. Ophthalmology. 1995;102. 117--6.

Combination Treatment 8. Klein R, Klein BEK, Moss SE. Visual impairment in diabetes.
Ophthalmology 1984; 91:1-8
This is currently the most practised modality of treatment for
resolution of DME. Although lasers are still the gold standard 9. Do Carmo A, Ramos P, Reis A, et al. Breakdown of the inner and
outer blood retinal barrier in streptozotocininduced diabetes. Exp
Eye Res. 1998;67(5):569—75

10. Nishikiori N, Osanai M, Chiba H, et al. Glial cell-derived cytokines

46 DOS Times - Vol. 16, No. 9, March, 2011

attenuate the breakdown of vascular integrity in diabetic retinopathy. 26. Early treatment diabetic retinopathy study report No. 1:
Diabetes. 2007;56(5):1333--40 Photocoagulation of diabetic macular edema. Arch Ophthalmol
1985; 103:1796-1806
11. Gillies MC, Su T, Stayt J, et al. Effect of high glucose on permeability
of retinal capillary endothelium in vitro. Invest Ophthalmol Vis Sci. 27. Lee CM, Olk RJ. Modified grid laser photocoagulation for diffuse
1997;38(3):635—42 macular edema: long term visual results. Ophthalmology 1991;
98:1594-1602
12. Grimes PA, Laties AM. Early morphological alteration of the pigment
epithelium in streptozotocin-induced diabetes: increased surface 28. Rutledge BK, Wallow IH, Poulsen GL. Sub-pigment epithelial
area of the basal cell membrane. Exp Eye Res. 1980;30(6):631—9 membranes after photocoagulation for diabetic macular edema.
Arch Ophthalmol. 1993;111(5):608-13
13. Kristinsson JK, Gottfredsdottir MS, Stefansson E. Retinal vessel
dilatation and elongation precedes diabetic macular oedema. Br J 29. Aiello L, Avery R, Arrigg P, et al. Vascular endothelial growth factor
Ophthalmol. 1997;81(4):274—8 in ocular fluid of patients with diabetic retinopathy and other retinal
disorders. N Eng J Med 1194; 331:1480-1487
14. Vinores SA, Derevjanik NL, Ozaki H, et al. Cellular mechanisms
of blood--retinal barrier dysfunction in macular edema. Doc 30. Antonelli-Orlidge A, Smith S, D’Amore P. Influence of pericytes on
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15. Vinores SA, Van Niel E, Swerdloff JL, Campochiaro PA. Electron
microscopic immunocytochemical evidence for the mechanism 31. Nguyen QD, Tatlipinar S, Shah SM, Haller JA, Quinlan E, Sung J,
of blood-retinal barrier breakdown in galactosemic rats and its Zimmer-Galler I, Do DV, Campochiaro PA. Vascular endothelial
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16. Brownlee M. Glycation and diabetic complications. Diabetes. 32. Haritoglou C, Kook D, Neubauer A, Wolf A, Priglinger S, Strauss
1994;43:836—41 R, Gandorfer A, Ulbig M, Kampik A. Intravitreal bevacizumab
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17. Frank RN. On the pathogenesis of diabetic retinopathy. Retina. 2006 Nov-Dec;26(9):999-1005.
Ophthalmology. 1984;91:626—34
33. Cunningham ET Jr et al; Macugen Diabetic Retinopathy Study
18. Harbour JW, Smiddy WE, Flynn HWJ, Rubsamen PE. Vitrectomy Group. A phase II randomized double-masked trial of pegaptanib,an
for diabetic macular edema associated with a thickened and taut anti-vascular endothelial growth factor aptamer, for diabetic macular
posterior hyaloid membrane. Am J Ophthalmol. 1996;121:405—13 edema. Ophthalmology. 2005 Oct;112(10):1747-57.

19. Lewis H, Abrams GW, Blumenkranz MS, Campo RV. Vitrectomy 34. Nauck M, Roth M, Tamm M, Eickelberg O et al. Induction of vascular
for diabetic macular traction and edema associated with posterior endothelial growth factor by platelet-activating factor and platelet-
hyaloidal traction. Ophthalmology. 1992;99(5):753—9 derived growth factor is down regulated by corticosteroids. Am J
Respir Cell Mol Biol. 1997; 16:398-406
20. Tachi N, Ogino N. Vitrectomy for diffuse macular edema in cases
of diabetic retinopathy.AmJOphthalmol. 1996;8:258--60 35. Diabetic Retinopathy Clinical Research Network. A randomized
trial comparing intravitreal triamcinolone acetonide and focal grid
21. Kang SW, Park CY, Ham DI. The correlation between fluorescein photocoagulation for diabetic macular edema. Ophthalmology.
angiographic and optical coherence tomographic features in 2008;115:1447--59
clinically significant diabetic macular edema. American Journal of
Ophthalmology. 2004;137(2): 313--22 36. Pearson P, Levy T et al. Fluocinolone Acetonide Intravitreal Implant
to Treat Diabetic Macular Edema: 3-Year Results of a Multi-Center
22. Smith RT, Lee CM, Charles HC, et al. Quantification of diabetic Clinical Trial. Invest Ophthalmol Vis Sci 2006;47:EAbstract 5442.
macular edema. Arch Ophthalmol. 1987;105(2): 218-22
37. Kang SW, Sa HS, Yoon H, et al. Macular grid photocoagulation after
23. Brian Y. Kim S, Scott D et al. Optical Coherence Tomographic Patterns intravitreal triamcinolone acetonide for diffuse diabetic maculer
of Diabetic Macular Edema .Am J Ophthalmol 2006;142:405–412. edema. Arch Ophthalmol 2006;124:653–8. Tunc M, Onder HI,
38.Kaya M. Posterior sub-Tenon’s capsule triamcinolone injection
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2000 OCT. Invest Ophthalmol Vis Sci. 2000;41:1486—91

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Humphrey OCT system. Invest Ophthalmol Vis Sci. 2002;43:490-5

First Author
Shashank Rai Gupta MS

www.dosonline.org 47

Genetics of Retinoblastoma – An Overview Retina

Abhishek Jain DO, DNB

Retinoblastoma is the most common primary intraocular gene is a recessive suppressor gene and may play a role in cell
malignancy of childhood and infancy with a cumulative growth and development.4 In order for retinoblastoma to develop;
life time incidence of 1 in 3,300 to 1 in 20,000 live births world both copies of the gene at the 13q14 locus must be lost, deleted,
wide8-10. Indian studies have shown the incidence of the tumor in mutated, or inactivated.
India as 1:15000 live births. Retinoblastoma is a highly malignant
tumor that arises from an accumulation of proliferating embryonic Even before this discovery, Alfred Knudson in 1971, proposed
retinal cells. Early diagnosis and treatment of the tumor is essential the ‘two hit’ hypothesis, which stated that two complementary
for child survival and salvaging the eye to give useful vision. chromosomal mutations are required in the same retinal cell to
develop retinoblastoma. This theory was true for both heritable
It is important for an ophthalmologist who is treating a patient with and non heritable tumors. But Knudson’s hypothesis did not gain
retinoblastoma to give a correct and adequate genetic counseling recognition for nearly a decade due to the lack of scientific method
to the parents of the child. The question which arises in the for the identification of RB1 gene. To understand the ‘two hit’
parent’s mind is the chance of their second child being affected hypothesis it is important to understand the genetic terminology
by retinoblastoma, and the chance of the tumor being inherited used in retinoblastoma.
in further generations.
The terminology can be described under 3 groups:
Genetics
• Depending upon the family history
First successful attempt to understand the genetics of retinoblastoma
was made in 1971 by Alfred Knudson1, until when the disease was • Familial
thought to follow an autosomal dominant pattern of inheritance.
It is now known that retinoblastoma can be inherited as a familial • Non Familial (sporadic)
tumor in which the affected child has a positive family history of
retinoblastoma or as a sporadic tumor. All patients with familial An affected child who has a positive family history of
retinoblastoma are at risk of passing the predisposition for retinoblastoma is termed “Familial Tumor” and a child in which
developing the tumor to their offsprings. none of the family members were affected with the tumor will be
termed as “Non-Familial” (Sporadic) tumor. The term familial is
In 1984, Murphee2 with the help of established data suggested not interchangeable with hereditary tumor.
that the gene responsible for retinoblastoma was located on
a single locus in the region 13q14. This locus represents an • Based on the chance of tumor being inherited in further
allele located on the 14th band on the long arm (q) of the 13th generations
chromosome. This allele is known as the RB1 gene. The deletion
of 13q chromosome may be associated with other dysmorphic • Heritable
features such as microcephaly, broad prominent nasal bridge,
hypertelorism, microphthalmos, epicanthus, toe abnormalities, • Non Heritable
and psychomotor and mental retardation.3
A heritable tumor implies that the mutation is such that there
The RB1 Gene is a high risk of tumor being inherited to the progeny. In a non
heritable tumor, however, the tumor does not pass on the progeny.
Retinoblastoma represents the phenotypic expression of an
abnormal tumor suppressor gene known as retinoblastoma • Based on laterality
gene RB1. This gene is the first gene in its class of human
cancer ‘suppressor’ gene, which actually prevents the abnormal • Unilateral
uncontrolled proliferation of immature retinal cells called the
retinoblasts. Normally a gene will cause expression of a cell • Bilateral
proliferation, but RB1 gene acts by suppressing the phenotypic
characteristics. About two thirds of all cases are unilateral and one third are
bilateral.
The gene is activated in hypophosphorylated state, (pRB)4, which
is responsible for the inhibition of cell proliferation. After the In the case of a familial retinoblastoma, the “first hit” is a germ
mutation, the gene is not converted to pRB form which leads line mutation that is found in all or most of the cells of the body
to uncontrolled cell growth. One normal copy of the gene is and hence inherited. The second hit occurs sometime during
adequate to prevent the tumor formation. It is believed that the development, and if it occurs in a somatic cell such as a retinal
cell then retinoblastoma develops. Also in such a case all or most
RBM Eye Institute of the cells in the body are affected by the first hit and hence are
C-2/1, Prashant Vihar, Delhi at risk of developing non-ocular tumors5, such as osteosarcoma.

Thus, the term heritable is used in context of tumors of the parents,
which are likely to be transferred to the children, while the term
familial is used in context of newly diagnosed infants who have
inherited the tumor from their affected parents.

www.dosonline.org 51

Parents

Laterality of parents Bilateral RB Unilateral RB Unaffected
Chance of offspring having RB carrier
45% affected 55% 7 - 15% 85-93% parents
Laterality of offsprings unaffected affected unaffected
<<1%

85% 15% 85% bilateral 15% 0% 33% bilateral 67%
bilateral unilateral unilateral unilateral

Chance of next siblings having RB 45% 45% 45% 45% 7-15% 5% <1%

Genetic Counselling In Summary the likely retinoblastomas which are heritable are:

The ophthalmologist who manages an infant with retinoblastoma • All familial tumors
should be responsible for adequate genetic counseling of the
parents. The parents may be reluctant to inform the child that • 15- 20 % of sporadic tumors caused by germ line mutation
he or she had cancer during infancy. The patient may grow up
and have children without realizing that there is a possibility of • Bilateral tumors
transmitting a malignant gene.
• Unilateral tumors with multi-focal lesions.
Only 6% of newly diagnosed retinoblastoma patients will
have a family history of retinoblastoma (familial) and are also References
heritable whereas 94% will have no family history (sporadic).
Approximately 15% to 20% of unilateral sporadic retinoblastomas 1. Knudson AG: Mutation and cancer: Statistical study of
are caused by germinal mutations that by chance affect only one retinoblastoma. Proc Natl Acad Sci U S A 68:820, 1971
eye. Such patients can transmit the disease to the off springs. The
remaining 80% to 85% are somatic mutations that occur only 2. Murphree AL, Benedict WF: Retinoblastoma: Clues to human
in the retina and are nonhereditary and thus this patient cannot oncogenesis. Science 223:1028, 1984
transmit the disease6.
3. Seidman DJ, Shields JA, Augsburger JJ et al: Early diagnosis
Patients who have bilateral retinoblastoma are more likely to have of retinoblastoma based on dysmorphic features and karyotype
the heritable disease i.e. the progeny can develop retinoblastoma. analysis. Ophthalmology 94:663, 1987
This is because for retinoblastoma to develop in both the eyes
simultaneously it is necessary to have a preexisting germ line 4. Chen PL, Scully P, Shew JY et al. Phosphorylation of the
mutation in all the cells of the body. Then only the somatic retinoblastoma gene product is modulated during the cell cycle and
mutation can occur in the retinal cells of both the eyes to manifest cellular differentiation. Cell 1989; 58:1193.
as bilateral tumor. Same is true for unilateral multi-focal tumors,
which are likely to be heritable. A unilateral tumor may develop 5. Roarty JD, McClean IW, Zimmerman LE: Incidence of second
by two somatic mutations in same retinal cell, hence it will be neoplasms in patients with bilateral retinoblastoma. Ophthalmology
non heritable. 95:1583, 1988

The retinoblastoma gene is about 80% penetrant so that only 6. Reese AB: Tumors of the Eye. New York, Harper and Row, 1976,
40% of their offspring will manifest the clinical findings of the p 127
gene and some offspring may only be carriers of the gene without
developing retinoblastoma.7 The term penetrance refers to the 7. Gallie BL: Gene carrier detection in retinoblastoma. Ophthalmology
frequency, with which a heritable disease manifests in offsprings 87:591, 1980
of affected individuals.
8. Tamboli A, Podgor MJ.the incidence of retinoblastoma in United
States: 1974 through 1985. Arch Ophthalmol 1990; 108(1) 128-132

9. Freedman J, Goldberg L: Incidence of retinoblastoma in the Bantu
of South Africa. Br J Ophthalmol 60:655–656, 1976

10. Suckling RD, Fitzgerald PH, Stewart J, Wells E: The incidence and
epidemiology of retinoblastoma in New Zealand: A 30-year survey.
Br J Cancer 46:729–736, 1982

Author
Abhishek Jain DO

52 DOS Times - Vol. 16, No. 9, March, 2011

Newer Tonometers Glaucoma

Manav Deep Singh MS

The more it has been understood that Glaucoma is not merely Corneal curvature
raised intraocular pressure (IOP), the more it has been realized
that there is no factor other than IOP that we can control to reduce Cornea with steeper curvature needs to be indented more
the prevalence or progression of Glaucoma. Therefore, the need requiring more force to produce standard area of contact. The
of accurate and reproducible measurement of IOP is being felt readings are affected more in DCT than in GAT.
more than ever before. The research on this subject is regularly
identifying patient and instrument related factors which affect IOP Central corneal thickness
and sources of error in the measurement of IOP. This has lead to
the development of newer devices in the hope of minimizing these All forms of tonometry, currently available, are affected by
errors over a wide range of ocular parameters and at extremes Central Corneal thickness (CCT) although the extent varies from
of IOP. Although Goldmann Applanation Tonometer (GAT) tonometer to tonometer. In general, higher CCT overestimates and
remains the gold standard for a routine ophthalmic practice, lower CCT underestimates IOP. Dynamic contour tonometer and
newer tonometers, with their specific indications, constitute a cornea compensated IOP measured by Ocular response analyzer
useful tool for any advanced glaucoma care set up. In addition to are affected the least and Non-contact and Rebound tonometer
recently developed IOP measuring devices, this article will discuss readings are affected the most by CCT. Additionally, thin central
the tonometers currently in use for specific indications. cornea is an independent risk factor for glaucoma progression.
Studies have also indicated that thicker CCT may result in reduced
Issues in the Measurement of IOP mainly include response to ocular hypotensive medication which may be related
to difficulty in drug penetration or to detecting changes in IOP
• Position of patient in thicker corneas.

• Inter & intra observer variations Bio-mechanical properties of cornea

• Corneal surface abnormalities The modulus of elasticity of cornea has been theoretically shown
to have a greater effect on IOP measurement than either CCT or
• Corneal curvature corneal curvature.3 Ocular Response Analyzer (ORA) is used to
measure corneal hysteresis (CH) which reflects viscous properties.
• Central corneal thickness Corneal response factor (CRF) is calculated (P1- kP2, where k is
a constant) and reflects elastic properties.4
• Bio-mechanical properties of cornea

• Corneal surgeries like kerato-refractive surgeries and Corneal surgeries
intracorneal devices (e.g.INTACS)
There is decline in measured IOP following most of keratorefractive
Position of patient surgeries including LASIK, LASEK, PRK and even hyperopic
LASIK and RK which cause minimal changes in CCT. There
Intraocular pressure is higher in supine than in sitting posture are further changes in recorded IOP as the wound heals post
and higher still with total inversion of body due to increased operatively. Same amount of surface ablation shows fewer declines
episcleral pressure and probably due to changed distribution in measured IOP than the same amount of ablation in LASIK. This
of body fluids (thus yogic asanas like Sheersh asana should be cannot be explained by simply decreased corneal thickness and
avoided by glaucoma patients). Thus, instruments measuring probably reflects complex changes in biomechanics and elasticity
IOP in supine position might record slightly higher readings than of cornea following these surgeries.5,6
those in sitting posture.
INTACS are mainly used to stabilize keratoconus or post LASIK
Inter & intra observer variations ectasia. Such eyes already have markedly altered bio-mechanical
properties. Therefore, IOP in such eyes is better assessed (both pre
Most instruments, in use today, have reasonably good and post operatively) by devices less sensitive to altered corneal
reproducibility. However, GAT and Pascal Dynamic Contour bio-mechanics like DCT or ORA. GAT and tonopen readings
Tonometer (DCT) have been reported to have minimum inter & directly over INTACTS have been reported to be much more
intra observer variations.1,2 unreliable than readings over central cornea.7

Corneal surface abnormalities Principles of Clinical Tonometry

Instruments which do not depend on optical systems like tonopen Manometry, using intracameral cannulation, is the only method
are more accurate for measurement of IOP in corneas with ocular that precisely measures true IOP inside the eye. However, being
surface abnormalities or contact lenses. an invasive technique, it cannot be used in clinical setting.

Ram Manohar Lohia Hospital Transpalpebral tonometry does not applanate or indent cornea.
& PGIMER, New Delhi Thus, it may circumvent inaccuracies related to scarring, edema,
curvature or biomechanical properties of cornea and sclera.8

www.dosonline.org 57

These target self tonometry groups and have not been found to Figure 4: The optical principle of Goldmann biprism
be very accurate.

Classically the IOP has been clinically measured by application of
force on cornea and its relationship with the deformation caused
as a result of this force. In indentation tonometry the shape of
deformation is truncated cone and in applanation tonometry the
shape of deformation is simple flattening.

Some new principles like contour matching and rebound have
been added for clinical tonometry.

The Current Gold Standard

Goldmann applanation tonometer, the current goldstandard, is a
fixed area type of applanation tonometer. It has five main parts viz.
measuring prism, feeler arm, control weight insert, housing and
revolving knob with measuring drum. The probe tip consists of a

Figure 1: Corneal deformation in indentation tonometry

Figure 5: Well aligned mires of Goldmann biprism

Figure 2: Corneal deformation in applanation doubling prism which is used to applanate cornea & it optically
tonometry splits the circular area of corneal contact in two horizontal semi
circles by inducing horizontal shift.
Figure 3: The Goldmann probe
The semi-circles should interlock with equal sized semi-
circles with thickness of mires equal to 1/10th the diameter of
applanation. Details of this can be seen on you tube link ‘http://
www.youtube.com/watch?v=Zx0xslEv9q0’

The Newer Tonometers

Principles of the following tonometers shall be discussed in this
article:

• Non-contact Tonometry and Ocular Response Analyser

• Tonopen

• Pneumatic tonometer

• Dynamic Contour Tonometer – Pascal

• Rebound Tonometer

• Transpalpebral Tonometers

• Continuous IOP Monitoring Systems

58 DOS Times - Vol. 16, No. 9, March, 2011

Figure 8: The Tonopen (With permission from
Reichert Corporation; USA)

Figure 6: The Ocular Response Analyser (With
permission from Reichert Corporation; USA)

Figure 9: Pneumatic tonometer (With permission from
Reichert Corporation; USA)

Figure 7: The signal plot from ORA (With permission corneal damping causes delays in inward and outward applanation
from Reichert Corporation; USA) events resulting in two different pressure values. Average of two
gives Goldmann correlated IOP (IOPg) & difference gives corneal
Non-contact Tonometry hysteresis (CH). Cornea compensated IOP (IOPcc) utilizes
information of individual corneal elasticity and viscosity. Thus,
Tonometry principle it measures not only IOP but also deformability of cornea. ORA
is used to measure corneal hysteresis (CH) which reflects viscous
Reported first by Grolman in 1972, it uses jet of air to applanate properties whereas corneal response factor (CRF) is calculated
anterior corneal surface.9 With source of air in centre, there is (P1- kP2, where k is a constant) and reflects elastic properties.4
optical system consisting of light emitter & detector on the two
sides. As air-puff flattens the cornea, reflected light increases. The Tonopen
moment of applanation is the moment of maximal light detection
by optical sensor which shuts air pulse. The computer inside This is the portable version of Mackay Marg tonometer. In Mackay
calculates IOP & displays it digitally. In the older machines, time Marg tonometer, the force that is required to keep the flat plate
from internal reference to the peak was converted to IOP whereas of plunger flush with a surrounding sleeve against the pressure
in newer machines, the IOP is measured from the actual air jet of corneal deformation is measured. The effect of corneal rigidity
pressure required to applanate cornea. The instrument is user is transmitted to sleeve. The IOP is recorded as wave front. It is
friendly, does not require anaesthesia and is reasonably accurate useful for irregular corneas as area of applanation is small (1.5 mm
except in very low or high IOPs. These qualities make it a popular diameter) and because it is not dependant on optical system. This
machine especially among optometrists. can give reasonably accurate readings over contact lenses as well.
However, in band keratopathy the surface is harder than cornea
Ocular Response Analyser (ORA -Reichert Corporation; USA) and hence, it overestimates IOP. Tonopen uses electronic gauge
to flatten cornea. The microprocessor inside averages several
Similar in principle to non-contact air puff tonometer, it measures wavefronts & gives digital display of IOP. An audible click is
the corneal response to indentation by a rapid air pulse. Precisely produced with satisfactory wavefront.
metered collimated air pulse causes cornea to move inward to
applanate and even further into slight concavity. Then air pump The IOP readings match well in the normal range. However, it
shuts off. As the pressure decreases, cornea again passes through a gives higher values in eyes with low IOP and lower values in eyes
second applanation state. Independent pressure values are derived with high IOP when compared with GAT. As each IOP reading
from inward and outward applanation effects. Due to dynamic is taken over a brief period, it does not give any indication of the
nature of air pulse and the viscoelastic properties of cornea the value around which IOP varies due to pulse & respiration and
readings are affected by cardiac cycle.

www.dosonline.org 59

Figure 10: Principle of Contour Figure 12: Pascal Dynamic Contour Tonometer
Matching and the sensor in Pascal DCT mounted on Slit- lamp (courtsey: Dr. B. K. Nayak)

Pneumatic tonometer

This tonometer is similar in principal to Mackay Marg tonometer.
This applanates cornea with a probe that is supported by column
of gas and hence, the sensing device is air pressure. Being non-
optical, it is useful for diseased corneas. Its recordings are also
similar to Mackay Marg tonometer. It can be used for continuous
monitoring of IOP. Do not confuse it with air-puff tonometer
which is another name for NCT.

Dynamic Contour Tonometer – Pascal

The Principle of Contour Matching

If eye were enclosed by a contoured, tight fitting shell, the forces
generated by IOP would act on shell wall. Replacing a part of shell
wall with a pressure sensor would enable measurement of these
forces & therefore IOP.

Developed to eliminate errors inherent in previous tonometers,
such as the influence of corneal thickness and rigidity,
this instrument was made commercially available by Swiss

Figure 11: Pascal Dynamic Contour Tonometer Figure 13: Systolic and diastolic IOP along with Ocular
60 Pulse Amplitude in Pascal Dynamic Contour Tonometer

DOS Times - Vol. 16, No. 9, March, 2011

Figure 16: Proview Phosphene as seen by Patient

Figure 14: LCD display of DCT globe while measuring the IOP. The instrument measures IOP in
both diastolic and systolic phases of cardiac cycle. The difference
in the two is called ‘Ocular Pulse Amplitude’ (OPA) which is an
indirect indicator of choroidal perfusion.

Display of DCT

The following are displayed on the LCD screen viz.

• Diastolic IOP mmHg

• OPA mmHg

• Quality score- Score of 1 & 2 are satisfactory and 4 & 5 to
be discarded. Although the manufacturers recommend the
acceptance of score 3, most of users feel it should be discarded.

Drawbacks of DCT

DCT has following drawbacks compared to other tonometers viz.

• It is more time consuming than Goldmann AT as 5 cardiac
cycles need to be recorded.

• Doesn’t seem as useful in diseased corneas or after corneal
transplant.

• It tends to read a little higher, in general, than, applanation
tonometer in people with thin or average thickness corneas.

• Recurrent cost of disposable tip.

Rebound Tonometer

Figure 15: I care Rebound Tonometer These are hand held ballistic devices that measure the return
bounce motion of an object impacting the cornea. The instrument
Microtechnology® AG, Port, Switzerland (2002). The instrument is is an electromechanical device consisting of two coils, a solenoid
mounted on slit lamp like GAT. The probe has a radius of curvature propelling and a sensing coil positioning around a central shaft
of 10.5 mm, contact surface of 7 mm diameter and sensor diameter containing a magnetized probe. Application of a transient
of 1.2 mm. The PASCAL’s probe rests on cornea with a constant electrical current to the solenoid coil propels probe to cornea.
force of one gram. Its piezoelectric sensor measures IOP 100 times This movement of magnetized probe induces voltage which
per second with resolution of 0.1mm. is monitored by the sensor. On impact with cornea, the probe
The plunger is concave and contour matched to cornea and uses decelerates and rebounds and the microprocessor analyses
low appositional force thereby not causing any deformation of deceleration of probe following the impact. This deceleration is less
at low than high IOP, consequently, the higher the IOP, the shorter
the duration of impact. With a diameter of 0.9 mm & weight of 26.5
mg, it is an easy to use instrument and no anesthesia is required,
hence, it is useful in children too. However, CCT affects readings
more than in GAT. On activation of the measurement button, it
takes 6 readings and discards highest and lowest readings on its
own before giving a digital display of average IOP.

www.dosonline.org 61

Continuous IOP monitoring (Sensimed Triggerfish®)11

Various tonometers can be used for continuous IOP monitoring.
A recent addition to this list is SENSIMED Triggerfish which can
be used for 24 hour IOP recording including sleeping hours. It
uses a sensor which is a soft hydrophilic single use contact lens,
containing passive and active strain gauges embedded in the
silicone to monitor fluctuations in diameter of the corneo-scleral
junction. The output signal sent wirelessly to the antenna is directly
correlated to fluctuations in intraocular pressure. The adhesive
antenna, worn around the eye is connected to a portable recorder
through a thin flexible Data Cable.

The patient wears the contact lens up to 24 hours and assumes
normal activities including sleep periods. When the patient returns

Figure 17: Phosphene as seen by Patient

Figure 19: SENSIMED Triggerfish
contact lens sensor

Figure 18: SENSIMED Triggerfish contact lens

Transpalpebral Tonometers Figure 20: SENSIMED Triggerfish continuous
IOP monitoring system
Theoretically, these tonometers can circumvent corneal problems
like oedema, astigmatism, variation in thickness, scleral rigidity DOS Times - Vol. 16, No. 9, March, 2011
etc. However, their doubtful accuracy has limited their use to self
tonometry by patients. Examples include TGDc-01and IGD-02
(2003) and Phosphene tonometer (1998).

Phosphene tonometry is a psychophysical test for self tonometry.
The pencil shaped instrument is pressed with its probe against
the upper lid with increasing pressure until visual phenomena
are detected.10 Phosphene appears opposite to pressure applied.
Drawbacks include, patients with field loss may not perceive
phosphenes.

62

to his doctor, the data is transferred from the recorder to the 8. Herndon LW: Measuring intraocular pressure-adjustments for
practitioner's computer via Bluetooth technology for immediate corneal thickness and new technologies. Curr Opin Optthalmol
analysis. 17:115-19.2006.

Although considered a breakthrough solution to continuously 9. Grolman B. a new tonometer system. Am J Optom 1972; 49: 646.
monitor fluctuations of intraocular pressure by the manufacturer, 10. Fresco BB: A new tonometer- the pressure phosphene tonometer:
cost is prohibitive, at least at the moment.
clinical comparison with goldmann tonometry. Ophthalmology
The list of advancements in IOP measurement and monitoring is 105:2123-6, 1998.
endless. It is not possible even to enumerate all of them. However, 11. www.sensimed.ch
in this article, I have tried to give summary of all the information
relevant to update the knowledge of general ophthalmic Author
practitioner on this topic. With varied advantages of each of them; Manav Deep Singh MS
mostly they are too expensive for routine use in our country.
Shree Gurudev Shantisuri Eye Hospital
References Mandoli Nagar, Distt. Jalore, Rajasthan

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Optometrist, DO/MS
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effects of corneal thickness and age on Goldmann applanation Contact Name: Mahender Kumar Jain
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89: 1572-5.
Email: gurudevmandoli@ymail.com
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www.dosonline.org 63

Endoscopic Endonasal DCR, the need of the day for Miscellaneous
treating the lacrimal sac disorder

Nishi Gupta MS, ENT, Suma Ganesh MS, Neeraj Chawla MS, Manish Sharma MS, Vishal Nigam MS

Lacrimal sac surgery has been revolutionized by the introduction Figure 2: Blanching of the mucosa is noted after the
of endoscopic techniques. It has become difficult to infiltration of lignocaine and adrenaline solution in
justify an external approach when the results of external and
endoscopic procedure are at par. As it stands today, there are no the left nasal cavity
contraindications of endoscopic DCR. Endoscopic surgery of the
nose goes much beyond DCR. It is possible to remove eye tumors,
brain tumors and lacrimal sac tumours through an endonasal
endoscopic approach. DCR is the simplest surgery out of all the
nasal endoscopic surgeries in the hands of a skilled surgeon. There
are many associated abnormalities in the nose; it is possible to
correct those defects during endoscopic endonasal approach to
the sac. It may be required even before an external DCR to correct
those defects in the nose for better results of external DCR.

892 cases of Endoscopic DCR were done at Dr. Shroff ’s Charity
Eye Hospital including children in last 15 years from 1996 – 2010.
There was a steep learning curve as well as improvement in results
with the passage of time. Presently our results are as good as 95%
with proper selection of the cases. Initial cases that failed were re
explored and the osteum was widened. All our initial failed cases
were managed by us and final long term results were good.

Endoscopic DCR is increasingly being done by eye surgeons
now. It is important to carefully assess the results of surgery
done by both the routes. Most of the studies compare the result
of one procedure done by an external approach in expert hands

Figure1: Endoscopic Picture of the nose showing the Figure 3: A light cable or the laser probe can be used
important structures.The key landmark for finding the to see the illumination into the right nasal cavity.
lacrimal sac is the ridge formed by the frontal process of This helps in locating the sac site in difficult cases.
maxilla and the route of the middle turbinate. This area on It is not mandatory to have this light cable as the
knowledge of the surgical landmark is enough to
the lateral wall in the left nasal cavity is infiltrated guide the surgeon about the site of sac

Dr. Shroff ’s Charity Eye Hospital, and the same DCR done endoscopically in the hands of a less
Daryaganj, New Delhi skilled surgeon and vice a versa. The results to be considered
for comparison should be in the hands of certified oculoplastic
www.dosonline.org surgeons for external DCR and skilled sinus endoscopic surgeons
for endoscopic DCR.

65

Figure 4: Bone on the lateral wall of the nose is removed using bone punch and the drill. The lacrimal sac lies in
the lacrimal fossa that lies between the anterior and the posterior lacrimal crest i.e between the lacrimal bone
and the frontal process of maxilla. Once the bone removal is complete sac is seen exposed in the right nasal cavity.
Sac is being opened with a gush of pus coming out of the sac in the right nasal cavity. Once the sac is opened
suction and cleaning is done. Stenting is generally not required accept in cases with associated canalicular block

• It preserves the normal pumping mechanism of orbicularis
muscle as there is no injury to the adjacent medial canthal
ligament.

• Endoscopic DCR avoids the complications that are likely
to spoil the results in external DCR e.g. difficulty in ostium
location, difficulty in error in bone removal, common
canalicular obstruction, scarring at the rhinostomy, a large
middle turbinate and deviated nasal septum.

Figure 5: Bilateral DCR can be done in the same sitting and Disadvantages of Endoscopic DCR
remains the most important advantage over the external DCR
• In cases with long standing lacrimal sac fistula fistulectomy
Steps of Endoscopic DCR is required with DCR resulting in a scar as big as in external
DCR.
Advantages of Endoscopoic DCR
• Endoscopic DCR is generally criticized for the inability to
• The most important advantage of endoscopic DCR over the obtain a very large window, but it has been proved beyond
external DCR is the ability to do bilateral DCR in the same doubts that even the lacrimal sac tumors can be removed
sitting. easily using an endonasal approach.Success of endoscopic
technique suggests that suturing of the flaps so much
• The second important advantage is to be able to do endoscopic emphasized in improving the success of external DCR may
DCR in the acute phase i.e lacrimal abscess unlike external be unnecessary.
DCR.
Results of Endoscopic DCR
• There is no scar on the prominent part of the face thus
cosmetically it is more accepted. Though the scar of external • Disappearance of symptoms
DCR may also disappear after sometime, but it is not
uncommon to have hypertrophy of the scar and especially if • Endoscopic documentation of the rhinostomy
it is bilateral the face appears ugly.
• Syringing and irrigation with betadine to check the patency
• Associated abnormality in the nasal anatomy can be corrected
in the same sitting. Transcanalicular Laser DCR

• No eye bandage is required after surgery thus morbidity This technique of Laser DCR is gaining popularity these days.
is very less compared to external DCR and it shortens the However it has its own limitations. If not used properly, the
hospital stay. technique can be more harmful than beneficial. Long term results
have yet to be assessed. We have done these cases on request
of ophthalmologists in collaboration with them. We do not
recommend this technique due to

66 DOS Times - Vol. 16, No. 9, March, 2011