DOS_feb_2009

Figure 2: Combination OCT ICG Pro-re-nata (PRN) basis with visual acuity, OCT and FA criteria.
In the 'treat and extend' strategy it is recommended to treat till the
macula is dry and continue to treat with extended time span
between injections, even when dry.

"Combination treatment" combining PDT, and anti-VEGF agents,
with or without intra-vitreal steroids, also has made the treatment
more finite. Reduced fluence PDT has improved the safety profile.
The results of two multicenter trials, SUMMIT trial and PDEX II
trial comparing combination therapy to ranibizumab monotherapy
are eagerly awaited. The SUMMIT trial has 3 arms; Standard
fluence PDT with intra-vitreal ranibizumab, reduced fluence PDT
with intra-vitreal ranibizumab and monthly intra-vitreal
ranibizumab. In the PDEX II trial another effective modality, intra-
vitreal steroids has been added. It compares reduced fluence PDT
with 0.5 mg ranibizumab and 500mg dexamethasone to monthly
ranibizumab.

Two agents of promise in phase III trials are VEGF trap and
Epiretinal Brachytherapy with Lucentis. VEGF trap is a recombinant
protein which binds and inactivates circulating VEGF. Phase II
studies with VEGF trap showed mean best corrected visual acuity
improvement of 5.7 letters and reduction in CMT in all groups at
12 weeks compared to baseline.

Figure 3: Pascal laser Figure 4: Neovista

bruch's membrane. The laser thus triggers what is described as Figure 5: Neurotech NT 501
photoregeneration of the retinal pigment epithelium and Bruch's DOS Times - Vol. 14, No. 8, February 2009
membrane.

With 2RT, there is potential to have a laser treatment that affects
only the RPE without damaging the photoreceptor cells, meaning
that we can get closer to the fovea without damaging central vision.
For the first time, there is the possibility of very early intervention
in patients with diabetic macular edema to preserve a greater
degree of functional vision for a longer time.

Drugs and their Applications

Age related macular degeneration

In AMD management we have entered a 'consolidation phase".
The two major challenges are early detection and dosing regimes.
Early detection of AMD progression is the single most important
factor for minimising the risk of permanent vision loss. Educating
at risk population and general practitioners, good referral network
and use of telemedicine should help towards this goal.

The challenge of reducing the number of intra-vitreal anti-VEGF
agents while striving to maintain the benchmark visual gain in
trials with monthly injections (MARINA & ANCHOR) is a daunting
one. The most commonly used strategy is to give a 'loading dose'
of three, 4-6 weekly injections followed by further treatment on a

70

Phase III study (View 2) is recruiting approx. 1200 subjects in over Figure 6: Bionic Eye
200 centres worldwide. Primary objective is to assess the efficacy
of intra-vitreal VEGF Trap compared to Ranibizumab in preventing Important limitations of this study are that focal and diffuse edema
vision loss in subjects with all subtypes of neovascular AMD. have not been separated in terms of treatment requirement and
metabolic status of the patient has also not been a criteria.
Epiretinal Brachytherapy (NEOVISTA) Beta radiation is applied
to the macula after a vitrectomy, using a strontium 90 isotope The fact that the 4-mg intravitreal triamcinolone group had a
source (Figure 4). A multicenter feasibility study enrolled 34 greater positive treatment response on visual acuity and retinal
participants with any CNV type. These patients received a single thickening at 4 months, whereas the photocoagulation group had
24 Gy treatment of epiretinal brachytherapy with two injections of a greater positive response later, raises the possibility that
intra-vitreal Avastin - one dose prior to or at the time of radiation combining focal/grid photocoagulation with intravitreal
delivery and another, one month later. Analysis of 18 month follow triamcinolone may produce greater benefit for DME than either
up on 25 patients showed mean improvement in visual acuity of focal/grid photocoagulation or intravitreal triamcinolone alone. A
10.7 letters. 44% gained 15 or more letters and 8 % gained 30 or DRCR.net study currently is evaluating a combination of
more letters. This is better than the visual results with current intravitreal triamcinolone and focal/grid photocoagulation, a
standard of care. CABARNET (CNV secondary to AMD treated combination of ranibizumab and photocoagulation, and
with Beta Radiation Epiretinal Therapy) is a large phase 3 ranibizumab alone in eyes with characteristics similar to those
multicentre ongoing trial comparing combination treatment included in the current study (protocol available at www.drcr.net).
(Radiation plus Ranibizumab) to Ranibizumab monotherapy.
Pushing the frontiers
The future therefore definitely lies in a combined attack on multiple
sites of the angiogenesis cycle. Gene Therapy: According to Paul A. Silving , MD, Phd, director of
NEI, the eye is an especially good target for gene therapy. It is a
Bevasiranib (CAND5) is a siRNA which switches off VEGF "wonderful place to test therapy ideas", since the eye is a "Separate
production, but clinical effect is not seen till the preexisting VEGF Compartment", we only need to administer a microscopic quantity
is cleared. It has a potentially longer duration of effect than currently of gene vector (instead of circulating it in the body) and the results
available anti-VEGF agents. It is well tolerated at multiple doses. are obviously measurable.
Phase 3 trial comparing initial neutralization of VEGF - 3 doses of
Ranibizumab followed by Bevasiranib every 8 or 12 weeks Michael Redmond's pioneering work showed that the gene RPE65
(maintenance) versus Ranibizumab alone is currently underway. was critical for metabolism of Vitamin A for proper photoreceptor
functioning. A mutation in RPE 65 accounts for 10% of all Leber's
Fenretinide is a Retinoic acid derivative It is an orally administered Congenital Amaurosis ( LCA) patients.
drug being studied for use in geographic atrophy associated with
dry AMD and it acts by reducing accumulation of lipofuscin in Recent Phase I Studies of gene therapy for young adults with a
RPE cells. mutation in the RPE65 genes and a severe form of recessive retinitis
pigmentosa have used adeno-virus mediated delivery to introduce
The Lucentis Vs Avastin debate rages on. The retinal world eagerly a human RPE 65 gene construct to the RPE. Results from two trials
awaits the results of the Comparison of AMD Treatments, Lucentis for LCA have suggested moderate visual improvement in some
Vs Avastin Trial (CATT). This is a phase III trial currently recruiting adults as monitored by psychophysical tests and studies are in
patients (target 1200 patients) at 57 locations. Objective is to evaluate progress to see if greater visual improvement can be achieved
relative efficacy and safety of treatment of neovascular AMD with safely in younger patients. A Canadian & American research group
Lucentis and Avastin with fixed and variable dosing schedules. from Montreal Children's hospital hopes to begin a human gene
Preliminary results are expected in 2010 and study would be therapy trial in Canada within 5 years for LCA, Stargardt macular
completed by 2011. However Avastin continues to be used dystrophy & retinitis pigmentosa.
vigorously all over the world. Available data suggests good efficacy
and safety profile though it lacks the level of evidence of a
randomized, controlled clinical trial. The sheer economics of it
makes it available to almost any patient who requires it.

Diabetic Retinopathy

The publication that grabbed headlines this year was" A
Randomised Trial Comparing intra-vitreal Triamcinolone
Acetonide and Focal/Grid Photocoagulation for Diabetic Macular
Edema - a trial conducted by the Diabetic Retinopathy Clinical
Research Network" - DRCR. net.

Their conclusions were that over a 2 year period, focal/grid
photocoagulation is more effective and has fewer side effects than
1 mg or 4 mg doses of preservative free triamcinolone for most
patients with DME who have characteristics similar to the cohort
in this trial. They recommended that focal/grid photocoagulation
should currently be the benchmark against which other treatments
are compared in clinical trials for DME.

www.dosonline.org 71

Nano Medicine: This is a highly specific medical intervention at RTE: Replacement of damaged retinal cells using retinal progenitor
nano scale (1-100nm) for curing diseases or repairing damaged cells delivered on bioresorbable polymer scaffold and transplanted
tissues. Applications in Retinal Diseases include: into sub-retinal space is a promising therapeutic strategy. Likewise,
using tissue engineering strategies, sheets of retinal pigment
• Drugs & Delivery (Neurotech NT-150) epithelium (RPE) are grown on synthetic biodegradable polymers
for subsequent transplantation.
• Retinal Tissue Engineering (RTE)
Optoelectric retinal prosthesis "Bionic Eye":
Neurotech (Figure 5) NT- 501 intra-vitreal implant is a Ciliary
Neurotrophic Factor (CNTF) secreting encapsulated cell device. Argus II, 60 electrode epiretinal prosthesis has been developed by
CNTF is a cytokine, which is a survival factor for various neuronal researchers at.
cells and seems to prevent neurodegeneration. A semi-permeable
membrane encapsulates genetically engineered human RPE cells Doheny Eye Institute, Los Angeles. 16 subjects with advanced
that secrete CNTF. It prevents host antibodies and immune cells retinitis pigmentosa.
from entering the device but allows nutrients to diffuse in, to
nourish the cells within and CNTF to diffuse out. The purpose is have been implanted with this device at 8 centres. Orientation and
to support and rescue degenerating retinal tissue using neurotophic mobility with device 'on' were better than with device 'off ' with
factors. This holds promise for retinitis pigmentosa and dry age door and line tests.
related macular degeneration. Phase I trial is completed. Phase II
& III patients have been recruited and results are expected by
2009/2010.

Author
Cyrus M. Shroff MD

S.B. Eye Hospital

Mainpuri (UP) – 205001

Applications are invited for the following posts:-

(a) Eye Surgeon:- MS/DNB/DOMS having experience in
phaco/S.I.C.S./IOL.

(b) O.T. Assistant:- Trained with experience Contact with
full Bio-Data Immediately to:-

Director
Dr. J.K. Purang (Eye Surgeon)

Mob.: 09811021192, 011-25446622, 25163444
Email: [email protected]

72 DOS Times - Vol. 14, No. 8, February 2009

Concordance between Common Dry Eye Diagnostic Tests Abstracts

J E Moore1,2, J E Graham1, E A Goodall1, D A Dartt3, A Leccisotti1,4, V E McGilligan1, T C B Moore1

British Journal of Ophthalmology 2009;93:66-72

1 Centre for Molecular Biosciences, University of Ulster, Northern Ireland, UK, 2 Royal Group Hospitals, Belfast, Northern Ireland, UK
3 Schepens Eye Research Institute, Boston, Massachusetts, USA, 4 Casa di Cura Rugani, Siena, Italy

AIM

Large variations in results of diagnostic tests for mild tomoderate dry eye are widely recognised. The purpose of thisstudy was to assess
if there was concordance between common dry eye diagnostic tests.

METHODS

A total of 91 subjects were recruited to the study. The tearfilm and ocular surface were evaluated using the phenol redthread test (PRT),
tear film break-up time (TBUT), biomicroscopicexamination and impression cytological assessment of conjunctivalgoblet cells. Dry
eye symptoms were assessed using McMonnies’ dry eye questionnaire (MQ) and statistical correlations betweenall tests were assessed.

RESULTS

This study cohort did not include severe aqueous deficient dry eye patients as determined by the PRT. A statistically significant
difference was noted between PRT results and all other tests (p<0.001). Only Meibomian gland pathology, MQ, reduced goblet cell
density and TBUT (<7s) demonstrated correlation determined by McNemar’s test.

CONCLUSION

A correlation was found only between tests assessing lipid/mucous deficiency (Meibomian gland evaluation, goblet cell density,TBUT
and MQ).

Prevalence of Dry Eye at High Altitude: A Case Controlled
Comparative Study

Gupta N, Prasad I, Himashree G, D'Souza P.

High Alt Med Biol. 2008 Winter;9(4):327-34

Department of Ophthalmology, Lady Hardinge Medical College and Associated Smt. Sucheta Kriplani Hospital and Kalawati Saran
Children Hospital, New Delhi, India.

High altitude is associated with physiological as well as pathological changes in the eye related to adverse environmental conditions that
result in increased tear evaporation and contribute to a higher incidence of dry eye in these regions. We aimed to study the difference
in prevalence of dry eye at high altitude and at low altitude. The prevalence of dry eye among the natives and the army soldiers who
were recently posted at high altitude was also studied and compared. 200 adults above 20 years of age were enrolled. 100 subjects were
recruited at a high altitude region (study group), of which 50 were native Ladakhis and 50 were soldiers recently posted at Leh, Ladakh,
India (height; 3300 m above sea level; temperature: 18 degrees C to 24 degrees C). 100 subjects, age and sex matched, were screened at
a low altitude region, New Delhi, India (218 m above sea level; temperature: 19 degrees C to 24 degrees C) to serve as the control group.
Prevalence of dry eye was assessed through standard questionnaires (McMonnies' Questionnaire (MMI), Ocular Surface Disease
Index Questionnaire (OSDI), and Schirmer's basic secretion test. On the basis of the parameters studied (symptoms, MMI, OSDI and
Schirmer's test), dry eye was diagnosed in 20% of subjects screened at high altitude and in 9% of subjects in the control group screened
at low altitude. In the study group, the prevalence of dry eye was significantly higher amongst the native population (54%) than in the
army soldiers who were recently posted at that region (26%). The difference was statistically significant (p < 0.005). In conclusion, dry
eye is more common at high altitude, particularly in the native population. Awareness among people residing at high altitude and the
treating medical personnel needs to be created for early detection and treatment of dry eye to prevent vision-threatening complications.

www.dosonline.org 77

Plasmin enzyme-assisted Antiangiogenic therapy with
vitrectomy for primary and intravitreal bevacizumab for
reoperated eyes with stage 5
retinopathy of prematurity
retinopathy of prematurity
Retina. 2008 Mar;28(3 Suppl):S19-25

Wu WC, Drenser KA, Lai M, Capone A, Trese MT Quiroz-Mercado H, Martinez-Castellanos MA, Hernandez-
Retina. 2008 Mar;28(3 Suppl):S75-80 Rojas ML, Salazar-Teran N, Chan RV

Associated Retinal Consultants, PC, Royal Oak, Michigan, USA.

Retina Service, Asociacion Para Evitar La Ceguera en México

PURPOSE (APEC), Mexico City, Mexico. [email protected]

To review the surgical outcome of plasmin enzyme-assisted PURPOSE
vitreoretinal surgery in managing stage 5 retinopathy of
prematurity (ROP). To evaluate the role of antiangiogenic therapy with intravitreal
bevacizumab for retinopathy of prematurity (ROP).
METHODS
METHODS
A retrospective, consecutive interventional cases series of 80 eyes
(68 patients) with stage 5 ROP, treated with autologous or maternal In this noncomparative, prospective, interventional case series,
plasmin enzyme-assisted vitreoretinal surgery, were reviewed. All bevacizumab was injected into the vitreous of patients with ROP
study patients underwent surgery between 1995 and 2004 with in three different groups: group I, patients with stage IVa or IVb
plasmin enzyme-assisted vitreoretinal surgery. Thirty-eight eyes ROP who had no response to conventional treatment; group II,
had previous vitreous surgery without retinal breaks (Group 1). patients with threshold ROP who were difficult to treat with
Fifteen eyes had previous vitreous surgery with retinal breaks conventional therapy because of poor visualization of the retina;
(Group 2). Twenty eyes received previous laser, and/or cryotherapy, and group III, patients with high-risk prethreshold or threshold
and/or scleral buckling, but no vitrectomy (Group 3). Seven eyes ROP.
did not receive any treatment previously (Group 4).
RESULTS
RESULTS
Thirteen patients (18 eyes; mean age +/- SD, 4 +/- 3 months; mean
Postoperative anatomic outcome, functional results, and surgical follow-up, 6 months) were included in the study. We found
complications in each group of eyes at an average follow-up of 49 neovascular regression in 17 eyes. One patient with stage IVa ROP
months were recorded. Following surgery of all 80 eyes, anatomic had spontaneous retinal reattachment after an intravitreal
success was achieved in 68.8%. Six eyes (7.5%) achieved 20/60 to injection of bevacizumab. There were no serious ocular or systemic
20/600 vision. Fifty-nine eyes (73.8%) achieved vision worse than adverse events.
20/600 to light perception. Eleven eyes (13.8%) achieved no light
perception. Visual results were uncertain in 4 eyes (5%) because of CONCLUSION
the inability to measure reliably.
The use of bevacizumab may be promising in the treatment of
CONCLUSION patients with ROP. Further studies need to be performed to
determine the safety and long-term efficacy of intravitreal injection
Plasmin enzyme-assisted vitrectomy in eyes with and without of bevacizumab, either as first-line therapy or after failure of
previous vitrectomy surgery can achieve visual improvement in conventional therapy.
stage 5 ROP. Early intervention with vitreous surgery for stage 4A
ROP will achieve better anatomic and visual results and reduce
the number of children with stage 5 ROP.

DOS Correspondent
Noopur Gupta MS, DNB

78 DOS Times - Vol. 14, No. 8, February 2009

Forthcoming Events : National

February 2009 July 2009

25-26 CHENNAI 20-22 CHENNAI

Neuro-Ophthalmology Update 2009 Indian Intraocular Implant & Refractive
Sankara Nethralaya, 18, College Road, Surgery Convention
Chennai, Tamil Nadu Hotel Taj Coromandel, Chennai
Contact Person & Address Tel : +91-44-2811 2811 Fax : +91-44-2811 5871
S. Ambika, Conference Secretariat Email : [email protected]
E-mail: [email protected], [email protected] Website : http://www.iirsi.com

March 2009 October 2009

20-22 NEW DELHI 2-4 BHAVNAGAR, GUJARAT

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

Forthcoming Events : International

February, 2009 May, 2009
6-8 ROME, ITALY
3-7 FLORIDA
13th ESCRS Winter Refractive Surgery Meeting
Rome, Italy Greater Fort Lauderdale/Broward County
Phone: +3535 1209 1100 / Fax: +353 1209 1112 Convention Center
Email: [email protected] 1950, Eisenhower Blvd.,
Web Site: http://www.escrs.org Fort Lauderdale, Florida - 33316
Phone: 1.240.221.2900, Email: [email protected]
March, 2009
17-22 CHICAGO 16-19 INDONESIA

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

April, 2009 June, 2009

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

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

www.dosonline.org 79

Delhi Ophthalmological Society

(LIFE MEMBERSHIP FORM)

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

Clinic/Hospital/Practice ______________________________________________________________________
_______________________________________________________________ Phone __________________
Residence ________________________________________________________________________________
_______________________________________________________________ Phone __________________
Correspondence ___________________________________________________________________________
_______________________________________________________________ Phone __________________
Email ___________________________________________________________ Fax No. ________________
Proposed by
Dr. ____________________________________ Membership No. _________ Signature __________________
Seconded by
Dr. ____________________________________ Membership No. _________ Signature __________________
[Must submit a photocopy of the MBBS/MD/DO & State Medical Council / MCI Certificate for our records.]

I agree to become a life member of the Delhi Ophthalmological Society and shall abide by the Rules and
Regulations of the Society.
(Please Note : Life membership fee Rs. 3100/- payable by DD for outstation members. Local Cheques acceptable, payable
to Delhi Ophthalmological Society)
Please find enclosed Rs.___________in words ____________________________________________________ by Cash
Cheque/DD No.____________________ Dated_____________ Drawn on______________________________________

Three specimen signatures for I.D. Card. Signature of Applicant
with Date

FOR OFFICIAL USE ONLY

Dr._______________________________________________________________has been admitted as Life Member of

the Delhi Ophthalmological Society by the General Body in their meeting held on________________________________

His/her membership No. is _______________. Fee received by Cash/Cheque/DD No._______________ dated_________

drawn on __________________________________________________________________.

(Secretary DOS)

www.dosonline.org 81

INSTRUCTIONS

1. The Society reserve all rights to accepts or reject the application.
2. No reasons shall be given for any application rejected by the Society.
3. No application for membership will be accepted unless it is complete in all respects and accompanied by a Demand Draft of Rs.

3100/- in favour of “Delhi Ophthalmological Society” payable at New Delhi.
4. Every new member is entitled to receive Society’s Bulletin (DOS Times) and Annual proceedings of the Society free.
5. Every new member will initially be admitted provisionally and shall be deemed to have become a full member only after formal

ratification by the General Body and issue of Ratification order by the Society. Only then he or she will be eligible to vote, or apply
for any Fellowship/Award, propose or contest for any election of the Society.
6. Application for the membership along with the Bank Draft for the membership fee should be addressed to Dr. Namrata Sharma,
Secretary, Delhi Ophthalmological Society, R.No. 474, 4th Floor, Dr. R.P. Centre for Ophthalmic Sciences, AIIMS, Ansari Nagar,
New Delhi - 110 029.
7. Licence Size Coloured Photograph is to be pasted on the form in the space provided and two Stamp/ Licence Size Coloured
photographs are required to be sent along with this form for issue of Laminated Photo Identity Card (to be issued only after the
Membership ratification).
8. Applications for ‘Delhi Life Member’ should either reside or practice in Delhi. The proof of residence may be in the form Passport/
Licence/Voters Identity Card/Ration Card/Electyricity Bill/MTNL (Landline) Telephone Bill.

82 DOS Times - Vol. 14, No. 8, February 2009

DOS Quiz Columns

Anagram Time

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

So get cracking.

1. UNAMED ___ ___ ___ ___ ___ ____

2. NOWROB ___ ___ ___ ___ ___ ____

3. SHORREN ___ ___ ___ ___ ___ ___ ____

4. RETURNY ___ ___ ___ ___ ___ ___ ____

5. RETERNI ___ ___ ___ ___ ___ ___ ____

6. BIRSUMO ___ ___ ___ ___ ___ ___ ____

7. CURENETION ___ ___ ___ ___ ___ ___ ___ ___ ___ ____

8. BARWUDGARDEN ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ____

Answers on page number 43 Saurabh Sawhney DO, DNB Ashima Aggarwal MS, DNB
Insight Eye Clinic, New Delhi

Missed DOS Times Copy Sharma Eye Hospital

If you have missed your copy of DOS Times. Arya Chowk, Ambala City
Please Contact:
Requires
Secretary DOS : Dr. Namrata Sharma
Room No. 474, 4th Floor, 1. ONE Oculoplasty (Part Time)
2. ONE Squint Surgeon (Part Time)
Dr. Rajendra Prasad Centre for Ophthalmic Sciences , 3. ONE Ophthalmic Surgeon proficient in SICS/
All India Institute of Medical Sciences,
Ansari Nagar, New Delhi – 110029 Phaco surgeries (Fulltime)
4. TWO Optometrists (preferably from AIIMS)
Ph.: 91-11-65705229, Fax: 91-11-26588919,
E-mail: [email protected], Raj Eye Hospital
Website: www.dosonline.org
Naseerabad, Gorakhpur
www.dosonline.org
Requires ONE Fulltime Retina Surgeon
with preferably fellowship experience

Contact: Dr. J.S. Guja

Sai Retina Foundation
Ph.: 2673688, 26279867, 9350102339

83

Target IOP Tearsheet

Determinants of Target IOP Glaucoma Suspect at Moderate Risk for Visual Loss

• IOP level at which optic nerve damage occurred • Fellow of eye with established GON (excluding secondary
• Extent and rate of progression of glaucomatous damage, if unilateral glaucoma). OHT with multiple risk factors (thin
CCT, high lOP, suspicious disc)
known
• Presence of other risk factors • GLC gene mutations associated with severe glaucoma
• Patient’s age
• Expected life span • Recurrent optic disc hemorrhages
• Medical history
Emperical Formula for Target IOP • PXF syndrome

• Younger age

Glaucoma Suspect or Other Condition with Low Risk for
Glaucomatous Visual Loss

Target IOP = “Maximum IOP – Maximum IOP% - Z” More important
• Z is an optic nerve damage severity factor. • OHT(Ocular hypertension)
• Z Optic Nerve damage • Older age
• 0→Normal disc and Normal visual field • PACS (anatomically narrow angle with no PAC signs or
• 1→Abnormal Disc and Normal visual field
• 2→Visual field loss not threatening fixation raised lOP)
• 3→Visual field loss threatening or involving fixation • Pigment dispersion syndrome with normal lOP
Risk Categories • Glaucoma suspect disc, including disc asymmetry
• Family history of glaucoma
Glaucoma with High 5-year Risk for Progressive Visual Loss or Less important
High 5-year Risk for Visual Disability • Steroid responder, steroid user
Moderate to advanced Glaucomatous optic neuropathy (GON) • Myopia
with correlating visual field(VF) loss and • Zone β peripapillary atrophy
• Demonstrated progression over a short time • Diabetes mellitus
• Higher lOPs • Uveitis
• Bilateral VF loss • Systemic hypertension
• Pigmentary and (Pseudoexfoliative)PXF glaucoma American Academy of Ophthalmology Guidelines
• Very advanced VF loss, fixation threat, or glaucoma-related • Glaucoma patients with mild damage (optic disc cupping

visual disability but no visual field loss)
• Young age with advanced disease → Reduction of 20-30% from baseline
• Secondary glaucoma • Glaucoma patients with advance damage
• ACG (angle closure glaucoma) → Reduction of 40% or more from baseline
Glaucoma with Moderate 5-year Risk for Visual Loss or • Normal pressure glaucoma
Glaucoma Suspect with High Risk for Visual Loss → Reduction of 30% from baseline

• Mild GON with correlating early VF loss and higher lOP • Ocular hypertension

• Mild-to-moderate glaucoma with low IOP2 → Reduction of 20% from baseline

• PAC with high lOP and PAS • Open angle glaucoma with IOP in the mid to high 20s →
• Younger age Target IOP range 14-18 mmHg

www.dosonline.org 85

• Advanced Glaucoma → Target IOP < 15 mmHg Glaucoma Suspect at Moderate Risk for Visual Loss:

• OHT whose IOP > 30 mmHg with no sign of optic • Monitor closely for change or treat depending on risk
nerve damage → Target IOP < 20 mmHg and patient preferences

Asia Pacific Glaucoma Guidelines • Treat if risk(s) increase(s) with pressure reduction of
20% or 1 SD above the population mean, whichever is
Glaucoma with High Risk for Progressive Visual Loss or Visual lower
Disability: Pressure reduction of 40% or 1 to 2 SD below the
population mean (9 to 12 mmHg), if achievable safely. • The fellow eye of unilateral glaucoma may require the
same target as the affected eye depending on risk and
Glaucoma with Moderate Risk for Visual Loss or Glaucoma state.
Suspect with High Risk for Visual Loss: Pressure reduction of
>30% or population mean, whichever is lower. Glaucoma Suspect with Low Risk for VisualLoss

Monitor, no treatment.

Shibal Bhartiya MS, Shubha Bansal DNB

Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi-110029

86 DOS Times - Vol. 14, No. 8, February 2009