March-April'19 DOS Times

Perspective

Capsulotomy for Cataract Surgery-
Evolution of A Journey

Dr. J.S. Bhalla MS,DNB, MNAMS, Dr. Nitish Kumar MS, Dr. Prathama Sarkar MS
Department of Ophthalmology, D.D.U. Hospital, New Delhi, India

HISTORY OF CAPSULOTOMY Figure 1: Can opener Capsulotomy

The art of making an anterior capsulotomy dates back Figure 2: CCC with Uttrata forceps after Trypan blue staining
to 1747 by Jacques Daviel in ECCE1. The most primitive left. Hence, lens could not be tightly sequestered into the bag.
technique used was that of Vogt2 where the anterior capsule Most common complication seen was an inferior decentration
was grasped and ripped using a toothed forceps. Later in 1968, (sunset syndrome). This was because of the lack of capsular
Kelman3 developed the “Christmas tree” approach where support at the equator.
a dull cystotome was used to peel the anterior capsule in a
Christmas tree morphology. A triangular tear starting from the ENVELOPE TECHNIQUE
6 o’clock position of the pupil was made. The torn capsular tag In 1979, Sourdilla and Baikuff in France suggested this
was pulled out of the superior incision and cut off, creating a
triangular opening. Then came the era of can-opener technique. approach. However Galand developed it to its present stage and
popularised the ‘Envelope Technique’.
CAN OPENER TECHNIQUE

The can-opener technique uses a cystitome for
interconnecting perforations of anterior capsule to create a
circular window. The sequential and stepwise can-opener
technique provides exact control of size and shape of capsule
window.

Advantage

Its easier to perform particularly if visualization is poor.
Moreover, its more convinient to make a large diameter
capsulotomy, compared to CCC. Lastly, regardless of size,
can opener technique will not trap the nucleus from delivery
anteriorly.

Disadvantage

One or more jagged residual peripheral tears were left,
leading to high likelihood that the tear(s) would extend to the
periphery toward and even around the equator. Therefore,
the diameter and shape of the capsular opening are not well
controlled. Incidences of posterior capsule ruptures and
vitreous loss are also higher. Moreover, large hinged flap of
capsule may result from incomplete capsulotomy. There may be
inadvertent aspiration which can tear into posterior capsule4.

Elschnig’s modification of can opener technique5

A very large opening was made and it also left numerous
tears extending into the equator, so that not only was the entire
anterior capsule removed, but some of the equatorial capsule
was torn away.

Disadvantage

The Ridley lenses used at that time, were intended to be
inserted into the capsular bag. In many instances, however, this
was not possible because little or no equatorial support was

Bhalla J.S. et al. Capsulotomy for Cataract Surgery- Evolution of A Journey www. dos-times.org 59

Perspective

Figure 3: Femtosecond laser assisted Capsulorrhexis bag - optimizing centration. CCC that
overlaps the edge of the optic x 360
Procedure completed curvilinear capsular tear back degrees decreases posterior capsular
in 1983 while watching Dr. James Gills opacification incidence, and may reduce
A horizontal, slightly curved linear using a combination of scissors cuts and edge dysphotopsias with subsequent
capsulotomy is aimed at the junction of tears to make his capsular openings. He anterior capsule opacification. After CCC,
upper 1/3rd to middle. The punctures started to tear the capsule continuously anterior capsule can support posterior
are directed slightly superiorly as the around the 12 o’clock area and then chamber IOL (with or without CCC-
capsulotomy approaches the right hand around the whole anterior capsule, and optic capture) if the posterior capsule is
side. This keeps the superior flap slightly called it continuous tear capsulotomy. compromised. Lastly, CCC isolates lens
more mobile and gives a better access In Europe Thomas Neuhann, developed implant from uveal and vascular tissue.
to the superior capsular fornix for the a smooth, circular capsular opening and
removal of cortical matter. This is also named this technique capsulorhexis, Disadvantage
known as antismiling capsulotomy which which appropriately uses the Greek suffix
gives an excellent entry into the capsular rhexis meaning “to tear.” He presented the During the capsulorrhexis,
bag. Therefore, placement of the implant technique to the ophthalmology society the tear may escape to periphery.
in the bag is easier. in Germany in 1985. In Asia Kimiya During phacoemulsification, the CCC
Shimizu, developed a method by opening can be torn or cut with phaco tip or
Advantages the capsule in a smooth, round fashion second hand instrument. Performing
in 1986. He was unaware of the work phacoemulsification with a single radial
The presence of anterior capsule of Gimbel and Neuhan and called this tear in the CCC may be associated with
until the IOL is implanted reduces the technique as circular capsulectomy. He a tear that “wraps around” the posterior
trauma to the tissue. The preservation proposed to give a common and complete capsule. A CCC that is too small8 may lead
of anterior capsule creates a semiclosed descriptive name to his technique to posterior capsule compromise during
system within the anterior chamber and coined from the three original names; hydrodissection in the presence of a
therefore, facilitates removal of cortical continuous tear capsulotomy by Gimbel, dense nuclear sclerotic cataract. It may
material. Scraping of the anterior capsule capsulorhexis by Neuhann, and circular also hamper the procedure of cortical
to remove epithelial cells is also possible. capsulectomy by Shimizu. The name cleanup, IOL insertion etc. Too small
In the event of a posterior capsule continuous circular capsulorhexis (CCC) CCC can also lead to excessive anterior
rupture, anterior capsule may be utilised was the most accurately descriptive name capsule fibrosis, diameter shrinkage, and
for an IOL support. and coincidentally, used one word from capsulophimosis; can reduce peripheral
each of the previous names7. fundus visualization. Whereas, too large
Disadvantages a CCC will eliminate the advantage of
Procedure overlap of the IOL edge.
It produces marked asymmetry of
the capsular flaps. This predisposes to There are many ways to fashion a Markers and devices for CCC
decentration of an IOL. The Intraocular CCC. One can begin with a cystotome to
lens tends to decentre upwards. start and then complete the CCC with a 1. The Wallace circular corneal marker
capsule forceps. Other technique uses a 6, that makes a 6.0 mm diameter
Occurrence of radial anterior cystotome alone to complete the entire circle mark on the cornea surface;
capsular tears are quite high. In-the-bag circular tear. Some may use a forceps to this marker it’s not very useful
placement becomes uncertain because puncture the capsule and then complete because of the corneal curvature and
of these tears. The free floating capsular the tear with the forceps. Some surgeons magnification and because the image
tears can get stuck to the pupillary tear in a counterclockwise direction and on the anterior capsule differs from
margin and produce a distorted pupil others a clockwise direction. The Kraff- the original mark size and location.
later on. This technique was very popular Utrata capsulorrhexis forceps is the most
in Europe and many other parts of the commonly used. 2. Semicircle markers with a internal
world for a few years. I have practiced diameter of 5.5 mm that can make a
this technique for number of years, but Advantage semicircular mark direct on the lens
because of the development of a better capsule. The Raviv Capsulorhexis
capsulotomy technique, I no longer use It increases the resistance of Caliper (Bausch + Lomb) has blunt,
this technique. the capsular bag to tearing during adjustable marking tips that indent
phacoemulsification and encases the anterior capsule on two axes
CONTINUOUS CIRCULAR intraocular lens (IOL) in the capsular after they are inserted through the
CAPSULORHEXIS main cataract incision9.

In North America, Howard Gimbel 3. The Morcher Ring Caliper (FCI
Ophthalmics)10 is a sterile,
temporary polymer ring of 0.25 mm
with an internal diameter of 5.0 mm
or 6.0 mm placed directly on top of
the anterior capsule. After aligning
the ring, the surgeon creates the
capsulotomy while staying away
from the inner margin of the ring.

4. Verus Capsulorhexis Device (Mile

60 DOS Times - March-April 2019 Bhalla J.S. et al. Capsulotomy for Cataract Surgery- Evolution of A Journey

Perspective

SC- Silicon suction ring; PR- Push rod; NCR- Nitinol cutting ring

Figure 4: Zepto Precision pulse capsulotomy

High Ophtalmics) is a biocompatible coalesce are then created, being able to capsulotomy pulling, hydro dissection,
silicone ring, with an outer diameter separate tissues. Compared to Nd:YAG or nucleus manipulations. Femtosecond
of 6.2 mm and an inner diameter of 5 laser, femtosecond is more innocuous due laser technology may be safer in some
mm. A micro patterned surface acts to smaller cavitation bubbles, in contrast surgeons’ hands, this is not necessarily
as a braking system once the device to the ones produced by longer pulses true for all surgeons and certainly
is placed on the capsule so that the used in Nd:YAG. depends on the benchmark against which
ring maintains stability and limits one is measuring. There are individual
side-to-side movement. To use this, Advantages variations in the performance of each
the anterior chamber needs to be laser platform. Deficiencies in laser output
completely filled with viscoelastic -Better centered than manual energy or disruptions to the optical path
prior to Verus ring can be injected capsulorrhexis with highly predictable of laser pulses may affect the quality
in the anterior chamber through diameters. and consistency of resultant biological
main phacoemulsification incision, photodisruption resulting from laser-
then the ring is positioned over the -The self-sealing corneal wounds, induced optical breakdown. Variations in
anterior capsule pressuring it gently the more precise and better-centered pulse energy and spot spacing between
with a lens manipulator instrument. capsulotomy and the fragmentation of the company platforms, which also are
The flap is starting by tearing the lens nucleus, all lead to a reduced number adjustable by the user, also may affect
central part of the lens anterior of complications17. Precise postoperative the architecture of the capsulotomy edge.
capsule, then lifting it up toward the IOL positioning can be achieved. Optimal laser spot spacing and power
internal edge of the Verus device settings remain to be determined. There
with a capsulorhexis forceps. The -A properly sized and centered is a significant learning curve associated
capsular flap is walked along the capsulorhexis is essential to reach with femtosecond laser technology that
inner edge of the Verus ring while demanding refractive results. A 360 may extend beyond the initial cases.
being lifted slightly over the device11. degrees overlapping capsular edge was Laser anterior capsulotomy integrity
thought to be an important feature may be compromised when compared
FEMTOSECOND LASER ASSISTED for standardizing refractive results, with phacoemulsification capsulotomy
CAPSULOTOMY preventing optic decentration, shifts because of aberrant pits creating postage-
toward myopia or hyperopia, tilt or stamp perforations during patient eye
Femtosecond laser has a wavelength capsular opacification due to symmetric movements.
of 1,053 nm and a pulse duration in the contractile forces of the capsular bag18.
femtosecond range (10-15 seconds). This PRECISON PULSE CAPSULOTOMY
short pulse duration reduces the amount -The corneal wounds can be created (PPC)
of collateral tissue damage, compared with the desired size, geometry and
to the slower excimer and neodymium- location. The corneal incisions are self- The PPC device name was chosen
doped yttrium aluminum garnet (Nd:YAG) sealing, preventing wound leakage, because, in the metric scale, Zepto is
lasers. This allows the femtosecond laser maintaining a stable anterior chamber 1 million times smaller than femto.
to be used for procedures that require and avoiding postoperative vision- Both the small size of the instrument
extreme precision. The femtosecond laser threatening endophthalmitis. and the several millisecond speed of
works on the principle of photodisruption: capsulotomy creation inspired this
converting laser energy into mechanical Disadvantages name. PPC technology mechanically
energy. This is brought about by a tightly and simultaneously cuts all 360° of the
focused beam of ultrashort pulses of light Eye movements during surgery apposed capsule without cauterizing it.
energy with enough peak power to create (that are in the range between 20
plasma. This plasma free of electrons and 100 m) have been considered to Procedure
and ionized molecules rapidly expands, contribute to increased capsulotomy
and cavitation bubbles that enlarge and edges’ irregularities, by creating A disposable handpiece and nano-
multiple, random cavitations that could engineered capsulotomy tip are powered
compromise the integrity of the capsular
edge and represent a point for a tear to
initiate with adequate force during the

Bhalla J.S. et al. Capsulotomy for Cataract Surgery- Evolution of A Journey www. dos-times.org 61

Perspective

by a small console instantaneously create There is insignificant zonular for Sight. Thorofare, NJ: Slack, Inc.;
a perfectly circular capsulotomy of a traction compared to manual CCC while 2006.
precise predesigned diameter. The tip performing PPC in paired human cadaver 6. Galand A. A simple method of
consists of a circular nitinol ring covered eyes. There is insignificant inflammation, implantation within the capsular
by a thin soft, clear silicone suction cup endothelial cell loss, or heat detection bag. J. Am. Intraocul. Implant. Soc.
(SC) shaped like a miniature inverted when compared to manual CCC in the 1983;9(3):330–332.
frying pan. Nitinol is a super elastic shape opposite eye. 7. Gimbel HV, Neuhann T (1991)
memory alloy which means that a nitinol Continuous curvilinear capsulorhexis.
ring for a 5–5.5 mm diameter capsulotomy The PPC edge was stronger in each of J Cataract Refract Surg 17(1): 110-111.
can be can be made to fit through a the eight pairs of eyes comparing PPC and 8. Little BC, Simth JH, Packer M. Little
small clear corneal incision. After filling manual CCC, and in each of the eight pairs capsulorhexis tear-out rescue. J
the anterior chamber with ophthalmic comparing PPC with femto second laser Cataract Refract Surg 2006:32:1420-2.
viscosurgical device, a retractable metal capsulotomy (FSLC). The higher strength 9. Wallace RB (2003) Capsulotomy
push rod elongates the ring and the SC of the PPC capsulotomy edge is likely due diameter mark. J Cataract Refract Surg
cup into a narrower profile that can be to its unique morphology that is very 29(10): 1866-1868.
inserted through a 2.2 mm or larger clear different from the edges produced by 10. Suzuki H, Shiwa T, Oharazawa H,
corneal incision. After retracting this PR, manual CCC and FSLC. On SEM of human Takahashi H (2012) Usefulness of a
the compressed tip resumes its native cadaver capsules, the PPC capsulotomy semicircular capsulotomy marker. J
circular shape within the AC. The surgeon edge appears to be microscopically Nippon Med Sch 79(3): 195-197.
gently positions the ring and surrounding everted to present the underside of the 11. Powers MA, Kahook MY (2014) New
suction cup onto the anterior capsular capsule as a smooth, rounded functional device for creating a continuous
surface before applying a small amount edge that circumferentially lines the curvilinear capsulorhexis. J Cataract
of suction through the external console. capsulotomy opening during surgery. Refract Surg 40: 822-830.
Only slight suction is needed to appose 12. Abell RG, Davies PE, Phelan D, Goemann
the anterior capsule against the bottom Zepto PPC only cuts the anterior K, McPherson ZE, et al. (2014)
edge of the nitinol ring, which has been capsule which is in contact with the Anterior capsulotomy integrity after
precisely engineered at the micron scale nitinol ring with no difficulties during femtosecond laser-assisted cataract
to enable uniform capsule cutting. A hydro dissection and cortical cleanup. surgery. Ophthalmology 121(1): 17-24.
rapid series of electrical pulses totalling 13. Chang DF. Zepto precision pulse
4ms in duration is used to create the Disadvantages capsulotomy: A new automated and
capsulotomy Phase transition of water disposable capsulotomy technology.
molecules trapped between the capsule Inadequate contact of the nitinol Indian J Ophthalmol 2017;65:1411-4.
and nitinol edge causes mechanical ring with anterior capsule may result in 14. Chang DF, Mamalis N, Werner
cleavage of the stretched capsular skip areas in subincisional area that led L. Precision pulse capsulotomy:
membrane circumferentially all at once. to rhexis runoff while pulling out the tip Preclinical safety and performance
of the device from the anterior chamber. of a new capsulotomy technology.
Advantages Capsular tag can be found, leading to Ophthalmology 2016;123:255‐64.
capsulorhexis extension. Iris capture may 15. Thompson VM, Berdahl JP, Solano
A perfectly sized and round happen because of inadequate contact JM, Chang DF. Comparison of manual,
capsulotomy is formed without increased of the nitinol ring with anterior capsule femtosecond laser, and precision
procedural time of FLACS (Femto second and when suction is applied the iris may pulse capsulotomy edge tear strength
laser assisted cataract surgery). The get engaged in the suction cup. It was in paired human cadaver eyes.
lower cost makes PPC available to all disengaged by releasing the suction.Steep Ophthalmology 2016;123:265‐74.
patients independent of affordability. learning curve is present. Also possible 16. Waltz K, Thompson VM, Quesada G.
Collateral ocular tissue safety is present probe malfunction should be kept in Precision pulse capsulotomy: Initial
too. Being able to centre, the capsulotomy mind and a spare probe should be readily clinical experience in simple and
on the visual axis would be advantageous available. challenging cataract surgery cases. J
when implanting refractive lens implants Cataract Refract Surg 2017;43:606‐14.
such as extended depth of focus and References 17. Kanellopoulos AJ. Laser (Bladeless)
multifocal IOLs. Cataract Surgery is Here to Stay.
1. Jaffe NS. Preface. History of cataract Cataract Refract Surg. Today. 2012
PPC can be performed after insertion surgery. In: Kwitko ML, Kelman CD, 18. Nagy ZZ. Femtosecond Laser-assisted
of iris expansion devices for small pupils. eds, The History of Modern Cataract Cataract Surgery: Facts Results. U.S.A:
The tip is designed with an angled lip in Surgery. New York, NY, Kugler Slack Incorporated; 2014. pp. 11–20.
the suction cup to allow insertion of the Publications, 1998; 3.
device under the iris margin in the event Correspondence to:
of a smaller diameter pupil. 2. Steinert RF, ed, Cataract Surgery: Dr. J.S. Bhalla
Technique, Complications, & Consultant & Head, Department of
For white cataracts or eyes with a Management. Philadelphia, PA, Ophthalmology,
poor red reflex, capsular staining is not Saunders, 1995. D.D.U. Hospital, New Delhi, India
required with PPC. If the PPC edge is
more tear resistant, this might improve 3. Kelman CD. History of
surgical safety by reducing anterior and phacoemulsification. In: Kwitko ML,
posterior capsular tears. Kelman CD, eds, The History of Modern
Cataract Surgery. New York, NY, Kugler
Publications, 1998; 126.

4. AAO, Cataract Surgery and Intraocular
Lenses, 2nd edition, 2001, p.41-42.

5. Apple, DJ. Harold Ridley and the Fight

62 DOS Times - March-April 2019 Bhalla J.S. et al. Capsulotomy for Cataract Surgery- Evolution of A Journey

Perspective

Refractive Surgery for Occupational
Reasons:The Ophthalmologist’s Role

Dr. Ritika Mukhija, Dr. Radhika Tandon
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India

Refractive surgery is one of the fastest evolving should be within normal limits.
specialties in Ophthalmology with a sharp rise For the counterparts in the United States, applicants
in the number of cases over the past one decade.
With refinement in the surgical technique and seeking an occupational career in municipal, county or state law
owing to a meticulous pre-operative work-up, the enforcement, should fulfil the following criteria. The minimum
surgical outcomes have considerably improved. acceptable uncorrected visual acuity, as on Snellen test, shall
A plethora of surgical options is now available, from LASIK be 20/30 in the better eye and 20/40 in the worse eye with
(laser-assisted in situ keratomileusis) and PRK (photorefractive total vision corrected to 20/20. For color perception, either the
keratectomy) to SMILE (small incision lenticule extraction) and Ishihara test or any other pseudo-isochromatic plates are used,
phakic intraocular lenses, thereby making a wide variety of and perception of color is deemed acceptable if the candidate
patients suitable for refractive correction. correctly reads 13 or more of the first 15 Ishihara plates. In
While many patients choose to undergo refractive addition, the candidates should be free from any chronic disease
procedures to decrease the spectacle dependency, cosmesis or possible condition that might lead to the rapid deterioration
and other lifestyle reasons, a strikingly increasing proportion of of the eyesight, such as glaucoma, cataract, chronic uveitis, etc.
cases are due to professional reasons or occupational demands.
And although a detailed and thorough pre-operative evaluation For entry into the Indian defense services, the requirements
is of extreme importance in all cases of refractive surgery, vary with the type of force and department. For the National
the ophthalmologist needs to be aware of the additional Defense Academy (NDA) Exam (Table 1), candidate should have
requirements for the latter. visual acuity of 6/6 in the better eye and 6/9 in worse eye with
In this article, we aim to review, discuss and summarize or without glasses with acceptable range of myopia upto 2.5
the various aspects of refractive surgery in regard to different D and hypermetropia upto 3.5 D including astigmatism. The
professions and occupations. limits for the same are -0.75 D and +1.5 D respectively for the
Patients applying for the police department and defense naval forces and air forces.
services constitute a majority of refractive surgery pool
as these have the most stringent requirements. There are Presence of good binocular vision (fusion and depth
several obvious and valid reasons for the same, among which perception) and colour vision are also necessary, the standard
are self-protection, ability to focus on action for both near being CPIII (Evaluated on Ishihara charts, confirmatory testing
and at a distance, as an aid in criminal investigation or as a on Martin Lantern at 1.5 m) for Army. Further, candidates are
qualified witness in court. Other occupations such as civils required to give certificates that none of their family members
services, flight attendant and personnel, etc., are also common suffer from congenital night blindness, and hence, this may be
indications; however, the need for surgery stems more from the sought after during history taking in the refractive work-up.
cumbrousness of wearing spectacles and contact lenses rather
than the medical criteria required for eligibility. Candidates who have undergone Radial Keratotomy (RK)
For entry into the Delhi Police Department, the minimum are permanently rejected for all the services, and while those
uncorrected visual acuity required is 6/12 in both eyes for who have undergone laser-based procedures (LASIK or PRK)
constables, head constables, sub-inspectors, drivers and traffic who were earlier not acceptable to Armed Forces, are now
staff. In addition, they should have a full field of vision as considered fit if they fulfil the following criteria:
tested by hand movements on confrontation test and normal (A) Candidates beyond the age of 20 years with LASIK and / or
color vision. For the clerical or technical staff, the requirement
is either 6/12 uncorrected visual acuity in both eyes or 6/6 PRK surgery can seek commission in the Army on fulfilling
in the better eye along with minimum 6/36 in the worse eye the following conditions:
correctable to 6/9 with glasses in the worse eye. For candidates (i) Uncomplicated stable LASIK / PRK done for Myopia
who have undergone refractive surgery (LASIK, PRK or SMILE),
it is now deemed necessary that additional tests like contrast or Hypermetropia with stable refraction for a period
sensitivity, dim light or mesopic vision, glare acuity and any of six months after the procedure.
other test as required on a case-to-case basis be performed and (ii) A healthy retina.
(iii) Corrected vision should be 6/6 in better eye and 6/9
in worse eye, with maximum residual refraction of
+1.50 in any meridian for myopia or hypemetropia.
(B) The LASIK and / or PRK can be permitted in Armed Force
Medical College (AFMC), Pune at entry level for candidates
above the age of 20 years. Candidates with LASIK / PRK

Tandon R. et al. Refractive Surgery for Occupational Reasons... www. dos-times.org 63

Perspective

S No. Parameter National Defense Academy at entry level are not permitted in
1 National Defence Academy (NDA),
2 Better eye Worse eye Navy and Air Force as well as at entry
3 level of Other Rank (OR) and Junior
4 Distant vision 6/6 (with or 6/9 (with or Commissioned Officers (JCOs).
without glasses) without glasses) Further, in Army, the candidates who
5 have undergone LASIK / PRK are not
6 Limits of refractive error Upto 3.5 D (including astigmatism) considered for aircrew duties.
permitted: Acceptable range of Upto 1.5 D for naval forces and air forces. For the Air Force Medical
hypermetropia Examination, the following criteria must
be satisfied prior to selecting post-PRK /
Limits of refractive error Upto 2.5 D (including astigmatism) LASIK candidates:
permitted: Acceptable range of Upto 0.75 D for naval forces and air forces. 1. LASIK surgery should not have been
myopia carried out before the age of 20
years.
Types of corrections permitted Spectacles and CL (as per above- 2. The axial length of the eye should not
be more than 25.5 mm as measured
mentioned limits) & Refractive Surgery by IOL master.
like LASIK, PRK (All cases should fulfil 3. At least 12 months should have
other criteria as mentioned below) elapsed post uncomplicated stable
LASIK with no history or evidence of
*RK not acceptable any complication.
4. The post LASIK corneal thickness as
Color vision requirements High Grade; CPIII (Evaluated on Ishihara measured by a corneal pachymeter
charts, confirmatory testing on Martin should not be less than 450 microns.
5. Individual with high refractive errors
Lantern at 1.5 m) (> 6D) prior to LASIK are excluded.
6. Candidates who have undergone
Binocular vision needed Yes (fusion and depth perception) Radial Keratotomy (RK) surgery
for correction of refractive errors
S No. Parameter Technical Services Non-Technical Services or cataract surgery with or without
intra-ocular lens (IOL) implants
Better eye Worse eye Better eye are not permitted for any Air Force
(corrected (corrected duties and are declared unfit.
vision) vision) For entry into the Indian civil
services (Table 2), all forms of refractive
Worse eye correction like spectacles, contact lenses
and refractive surgery like LASIK, PRK,
1 Distant vision 6/6 or 6/9 6/12 or 6/9 6/6 or 6/9 6/18 to Nil or Implantable Collamer Lens and even IOL
6/12 implantation are acceptable. The best
corrected vision should be at least 6/9
2 Near vision* J1 J2 J1 J3 to Nil in the better eye and 6/12 in the worse
eye for technical services and 6/18 in
J2 J2 the worse eye for non-technical services.
Also, there is no limit for the magnitude
3 Types of Spectacles, CL & Refractive Spectacles, CL & Refractive of permissible refractive errors; however,
corrections Surgery like Lasik, ICL, IOL Surgery like Lasik, ICL, IOL for candidates with myopia of more than
permitted (All cases are to be referred (All cases are to be referred 6.00 D, examination is performed to rule
to Special Ophthalmic to Special Ophthalmic out any degenerative retinal changes
Board) Board) (indirect ophthalmoscopy as well as direct
ophthalmoscopy). Only those without
4 Limits of No limit. However, No limit. However, any macular degenerative changes are
considered fit; in case of any treatable
refractive error A) there should be no A) there should be no peripheral degenerative changes, the
candidate may be considered fit after
permitted macular degenerative macular degenerative adequate treatment.

changes. changes.  

B) for myopia > 6.00D, B) for myopia > 6.00D, However, these guidelines are
candidate is fit if macular candidate is fit if macular neither universal nor permanent, and
may even vary in future. It is therefore
area is healthy and no area is healthy and no other

other treatable retinal treatable retinal changes,

changes, and temporarily and temporarily unfit if
unfit if candidate has candidate has treatable

treatable peripheral peripheral changes

changes

5 Color vision High Grade Low Grade

requirements**

6 Binocular Yes No

vision needed

7 Squint Unfit (due to absence of Fit

binocular vision)

*Near vision for Railway Services viz. IRTS, IRAS, IRPS and RPF is J1 in better eye and
J2 in worse eye.
**Colour Vision will be examined with the help of Edrige Green's Lantern technique and
Ishihara's Plates and graded as High or Low.

64 DOS Times - March-April 2019 Tandon R. et al. Refractive Surgery for Occupational Reasons...

Perspective

imperative for the refractive surgeon physical_req/requirements.html; accessed on 31/03/19)
to be aware of the specific guidelines or accessed on 31/03/19) 6. Appendix III. Regulations Relating
requirements for a particular patient in 3. National Defence Academy Examination
question, in order to be able to properly (II) – NDA & NA Exam II 2018 Physical to the Physical Examinations of
guide and counsel the patient as well as, Standards (Available at: http://www. Candidates. (Available at: https://
to protect their own self-interest, in case, upscexam.com/upsc_examinations/ persmin.gov.in/ais1/Docs/Appendix-
any question arises later. national_defence_academy_nda/nda- III.pdf; accessed on 31/03/19)
na-examination-ii-physical-standards.
References html; accessed on 31/03/19) Correspondence to:
4. Kapoor G, Vats DP, Parihar JK. Dr. Radhika Tandon
1. Letter from Office of the Commissioner Development of computerized color Dr. Rajendra Prasad Centre for Ophthalmic
of Police, New Delhi, No. 2437/Rcctt. vision testing as a replacement for Sciences, AIIMS,
Cell (AC-II)/PHQ. Dated 05/05/14. Martin Lantern. Med J Armed Forces New Delhi, India
India. 2012;69(1):11–15.
2. General Physical Requirements for 5. Disqualification of Candidates with
Applicants Seeking an Occupational Visual Defects. Press Information
Career in Municipal, County or State Bureau, Government of India, Ministry
Law Enforcement (Available at: http:// of Defence. Dated 24/02/2015.
w w w. w r i g h t . e d u / ~ j i m . a d a m i t i s / (Available at: pib.nic.in/newsite/
PrintRelease.aspx?relid=115761;

Tandon R. et al. Refractive Surgery for Occupational Reasons... www. dos-times.org 65

Recent Trends and Advances

Medicine Update for Ophthalmologists

Dr. Sonalee Mittal MS, Dr. Dinesh Mittal MD
Drishti The Vision Eye Hospital, Vijaynagar Indore, Madhya Pradesh, India

Medicine update for all doctors for prescription of drugs. Hypertension is one of the leading
causes of the global burden of disease. Hypertension doubles
Hypertension and Diabetes Mellitus are common medical the risk of cardiovascular diseases, ischemic and hemorrhagic
disorders which commonly coexist in patients with eye stroke, renal failure and peripheral arterial disease. Although
disorders. So frequently eye surgeon has to deal with these antihypertensive therapy reduces the risks of cardiovascular
conditions first before taking the patient for eye surgery. By and renal disease, large segments of the hypertensive
knowing about the treatment of diabetes and hypertension population are either untreated or inadequately treated.
ophthalmologist can help his patients to overcome the harmful
effects of these disorders and simultaneously eye treatment is Cardiac output and peripheral resistance are the two
also done expeditiously. determinants of arterial pressure. Cardiac output is determined
by stroke volume and heart rate; stroke volume is related
HYPERTENSION to myocardial contractility and to the size of the vascular
compartment. Peripheral resistance is determined by functional
Hypertension remains the most common diagnosis in and anatomic changes in small arteries and arterioles.
adult outpatient medicine and the most frequent indication

Definition and Staging1,2 TREATMENT3,4

BP Stage Systolic (MM HG) Diastolic (MM HG) Effective tools - lifestyle modifications
Normal and antihypertensive drugs - permit
<120 <80 management of hypertension.

Prehypertension (high-normal) 120-139 80-89 LIFESTYLE MODIFICATION
Stage 1 (mild) hypertension 90-99 Lifestyle choices and interventions can
Stage 2 (moderate) hypertension 140-159 100-109
Stage 3 (severe) hypertension ≥110 influence BP and furnish a foundation for
Isolated systolic hypertension 160-179 <90 prevention and treatment of hypertension.
≥180
≥140 Pharmacologic Therapy

Diet and Physical Activity Recommendations for Lowering Blood Pressure Over the past decade, the goals of
treatment have gradually shifted from
Lifestyle Modification Recommendation optimal lowering of blood pressure, which
is taken for granted, to patient’s overall
Physical Activity Recommendations In general, advise adults to engage in well being, control of associated risk
aerobic physical activity to lower BP: factors and protection from future target
3-4 sessions a week lasting on average organ damage. One should initiate therapy
40 minutes per session and involving with low doses of anti hypertensive dugs
physical activity of moderate to vigorous and achieve gradual reduction of blood
intensity. pressure.

Weight loss For overweight or obese Lose weight, ideally attaining a body Five classes of drugs can be
recommended as first line treatment for
persons mass index < 25 kg/m2 hypertension. These include:
1) Angiotensin-converting enzyme
Reduced sodium intake Lower sodium intake as much as inhibitor (ACEI),
possible 2) Angiotensin II receptor blockers
(ARB),
Dietary pattern (Dietary Approach To Consume a DASH-style dietary pattern 3) Calcium channel blockers (CCB),
Stop Hypertension (DASH)) rich in fruits and vegetables (8 to 10 4) Diuretics and
servings/day), rich in low-fat dairy 5) β-blockers.
products (2 to 3 servings/day), and
reduced in saturated fat and cholesterol. Step 1
Vegetarian diet is effective option.
First-line therapy for patients under
Increased potassium intake Increase potassium intake to 4.7 gm/day, 55 years is an ACE inhibitor, such as
which is also the level provided in the
DASH diet

Moderation of alcohol intake Alchol intake should be avoided.

66 DOS Times - March-April 2019 Mittal S. et al. Medicine Update for Ophthalmologists

Recent Trends and Advances

Effect of Lifestyle Modifications to Manage Hypertension inhibitor or ARB with a calcium-channel
blocker and a thiazide-like diuretic is
Modification Recommendation Systolic Bp recommended.
Reduction

Weight reduction Maintain normal body weight (BMI 5-20 mm Hg/10 kg Step 4

Adopt DASH eating 18.5-24.9 kg/m2 ) weight loss If BP remains > 140/90 mm Hg on
plan three agents, then the patient should be
Consume a diet rich in fruits, vegetables, 8-14 mm Hg referred for specialist advice
Dietary sodium and low fat dairy products with reduced
reduction content of saturated and total fat Which Drugs for Which
Patients
Physical activity Reduce dietary sodium intake to no 2-8 mm Hg
more than 100 mol/day (2.4 gm There is consensus that most
Moderation sodium or 6 gm sodium chloride) hypertensive patients- regardless of
of alcohol their age, race/ethnicity, and absence
consumption Limit Engage in regular aerobic physical 4-9 mm Hg or presence of target-organ damage or
activity such as brisk walking (at least comorbidities - will require double-, or
30 min/day most days of the week) more often, triple-drug combination
therapy with a calcium channel blocker
Avoid Alchol 2-4 mm Hg (CCB), an angiotensin-converting enzyme
inhibitor (ACEI) or angiotensin receptor
Hypertension treatment algorithm blocker (ARB), and a diuretic. The only
issue is which drug(s) to prescribe first.
Step Management
COMPLICATIONS OF
STEP 1A Patient <55 years old ACE inhibitor or ARB (A) HYPERTENSION

STEP 1B Patient >55 years old Calcium-channel blocker (C) Hypertension may be complicated by
branch retinal artery occlusion (BRAO),
STEP2: A+ C ACE inhibitor (or ARB) plus calcium-channel blocker branch retinal vein occlusion (BRVO),
central retinal vein occlusion (CRVO),
STEP 3: A+ C + D ACE inhibitor (or ARB) plus calcium channel blocker and retinal arterial macroaneurysms.
plus thiazide-like diuretic The coexistence of hypertension and
diabetes mellitus results in more severe
STEP4: STEP 3 plus more diuretic or betablocker. Seek retinopathy because precapillary and
specialist advice capillary insults act in combination.

Compelling Indications for Individual Drug Classes

Compelling Indication Diuretic BB ACEi ARB CCB

Heart failure ü üü ü Author way to treat
Post MI üü hypertension
High CAD risk
ü üü ü We use two combinations

Diabetes ü üü ü ü 1 Losakind H containing Losartan
üü (ARB) And Thiazide Diuretic
CKD
üü 2 Aginal at containing Amlodipine
Recurrent CVA prevention and Atenolol combination.
Step 3 If patient not child bearing we
Enalapril, or a ARB, such as Losartan. In At this point, therapy should be
young women of childbearing potential, usually start losakind H after dietary and
treatment with beta-blockers may be reviewed (including compliance and lifestyle modifications.
preferred. Patients aged 55 years and optimal dosage). Triple therapy of an ACE
above, should be treated with a calcium- Wait for some days if patient
channel blocker, such as Amlodipine (a improves. If not full correction then we
thiazide-like diuretic should be used in
patients with heart failure or those who Contraindications to Use of Specific Antihypertensive Drugs
develop troublesome ankle oedema).
Drugs Contraindication

Diuretics (thiazides) Gout

Step 2 Beta blockers Asthma, Atrioventricular block (grade 2 or 3), Athletes
and physically active patients
If BP control is inadequate, then Calcium channel blockers
the combination of an ACE-inhibitor or Tachyarrhythmia, Heart failure, Atrioventricular block
ARB with a calcium-channel blocker is Angiotensin-converting (grade 2 or 3)
recommended. enzyme inhibitors
Pregnancy, Angioedema, Hyperkalemia Bilateral renal
artery stenosis, Women with childbearing potential

Angiotensin receptor Pregnancy, Hyperkalemia, Bilateral renal artery
blockers stenosis, Women with childbearing potential

Mittal S. et al. Medicine Update for Ophthalmologists www. dos-times.org 67

Recent Trends and Advances

may have to combine use of Aginal At Diagnosis the ADA recommends a diagnosis of diabetes mellitus when 1 of the
with Losakind H. following 4 criteria are met and confirmed with retesting on a subsequent day

If pretreatment blood pressure is 140 Index Value
to 180 mm hg, patient usually respond HbA1c ≥6.5% (<5.7% = normal)
to one combination pill (Losakind H). If FPG level ≥126 mg/dL (7.0 mmol/L)
blood pressure is greater than 180 mm hg
eventually we have to start first one and 2-hour plasma glucose level ≥200 mg/dL (11.1 mmol/L) with 75-g OGTT
then add the second combination after
waiting for two weeks. These are very random plasma glucose level ≥200 mg/dL in a patient with classic symptoms of
effective combinations. Patient has to be hyperglycemia, including polyphagia, polyuria, and
stressed that medication should be taken polydipsia
preferably in the morning because it is
the morning time when maximum blood hormones are secreted as needed to have abnormal glucose metabolism
pressure is there. maintain normal serum glucose levels in long before overt symptoms develop.
the face of extremely variable degrees of Other important historical findings that
By lifestyle and dietary modification glucose intake and utilization. In the fed suggest the diagnosis of diabetes include
and starting suitable pharmacotherapy state, anabolism is initiated by increased complications during pregnancy or birth
we can prevent morbidity in our patients. secretion of insulin and growth hormone. of large babies, reactive hypoglycemia,
Here we want to emphasize that by This leads to conversion of glucose to family history, advanced vascular
just knowing two anti-hypertensive glycogen for storage in the liver and disease, impotence, leg claudication, and
combinations we usually are able to muscles, synthesis of protein from amino neuropathy symptoms.
control blood pressure in our most of acids, and combination of fatty acid
patients. and glucose in adipose tissue to form Physical findings, particularly in
triglycerides. type 2 diabetes, may include obesity,
DIABETES MELLITUS hypertension, arteriopathy, neuropathy,
In the fasting state, catabolism results genitourinary tract abnormalities
Type 2 diabetes mellitus (T2DM) from the increased secretion of hormones (especially recurrent Candida infections
is one of the most common health that are antagonistic to insulin. In this or bacterial bladder or kidney infections),
problems facing mankind and is a major setting, glycogen is reduced to glucose in periodontal disease, foot abnormalities,
public health problem. The International the liver and muscles, proteins are broken skin abnormalities, and unusual
Diabetes Federation (IDF) estimated down into amino acids in muscles and susceptibility to infections.
in 2014 that 387 million people have other tissues and transported to the liver
diabetes worldwide and that by 2035 this for conversion to glucose or ketoacids, OVERALL GOALS
number will rise to 592 million. India has and triglycerides are degraded into fatty
the world’s second largest population acids and glycerol in adipose tissue for The goals of therapy for type 1 or
of people with diabetes, affecting about transport to the liver for conversion to type 2 diabetes mellitus (DM) are to
63 million people. Obesity is a major ketoacids and glucose. (1) Eliminate symptoms related to
contributing factor. Moderate exercise
and weight loss can prevent the onset A lean adult without diabetes hyperglycemia
of type 2 diabetes in patients at risk for secretes approximately 33 units of (2) Reduce or eliminate the long-term
development of the disease. A growing insulin per day. In an obese adult, insulin
body of experience suggests that the secretion can increase almost fourfold, to complications of DM and
use of metformin as initial therapy in 120 units per day. (3) Allow the patient to achieve as
combination with diet, exercise, and
a comprehensive diabetes education Clinical Presentation of Diabetes normal a lifestyle as possible.
program can provide impressive Symptoms of diabetes usually resolve
lowering of glucose with essentially no The classic symptoms of diabetes when the plasma glucose is < 200 mg/dL
risk of hypoglycemia. If the response is mellitus are polyuria, polydipsia, and and thus most DM treatment focuses on
judged to be inadequate over 3 months, polyphagia. Type 1 diabetes tends to achieving second and third goals.
essentially any other agent can be added. present more acutely than type 2, and Type 1 diabetes was previously
There are six recommended second-line the diagnosis is usually made based on called insulin-dependent diabetes
therapies:sulfonylurea, thiazolidinedione, the presence of these classic symptoms mellitus or juvenile-onset diabetes.
dipeptidyl peptidase 4 (DPP4) inhibitor, in association with an elevated plasma Although incidence peaks around the
sodium-glucose cotransporter 2 (SGLT2) glucose level. The diagnosis of type time of puberty, approximately 25% of
inhibitor, glucagon-like peptide-1 (GLP-1) 2 diabetes often depends more on cases present after 35 years of age. This
receptor agonist, and basal insulin. laboratory testing, as patients may form of diabetes is due to a deficiency in
endogenous insulin secretion secondary
Basics of Glucose Metabolism to destruction of insulin-producing
β-cells in the pancreas.
The plasma glucose level is reduced
by a single hormone, insulin. In contrast, Treatment goals in DM treatment5,6
six hormones increase the plasma
glucose level: somatotropin, adreno Index Goal
corticotropin, cortisol, epinephrine,
glucagon, and thyroxine. All of these HbA1c Less than 7 %
FBS 80 TO 130 mg / 100 ml

PPGG (post prandial blood glucose) Less than 180 mg / 100 ml

Blood pressure Less than 140 / 90

68 DOS Times - March-April 2019 Mittal S. et al. Medicine Update for Ophthalmologists

Recent Trends and Advances

Type 2 diabetes was formerly known poiglitazone is used if patient plasma
as non–insulin-dependent or adult-onset sugar is still high. Many patients using
diabetes mellitus. Patients with type 2 this combination are candidates for
diabetes are usually, but not always, older insulin, and this should always be
than 40 years at presentation. Obesity is considered before starting a third oral
a frequent finding and is present in 80%– drug. Patients starting insulin can
90% of these patients. Other risk factors continue their oral medication, but an
for type 2 diabetes include hypertension, intensive insulin therapy regimen may be
a history of gestational diabetes, physical simpler if sulphonylurea is withdrawn,
inactivity. as the insulin is providing a similar effect
exogenously.
Choice of Initial Glucose-Lowering
Agent INSULIN7,8 Recommended technique of insulin injection

The level of hyperglycemia and Insulin treatment for T2DM is component take care of basal glucose
the patient’s individualized goal should usually started when the initial oral level. Short acting component take care of
influence the initial choice of therapy. therapy, in double or triple combination post prandial rise of blood sugar.
Assuming that maximal benefit of and at the maximum tolerated doses fails
nutritional therapy and increased physical to achieve optimal glycaemic control. The insulin dose can be titrated
activity has been realized patients with Recent guidelines recommend initiation upwards according to plasma glucose
mild to moderate hyperglycemia (FPG of insulin early in the course of disease, levels, usually in increments of 2–4 units.
< 200-250 mg/dL) often respond well especially in patients with HbA1c > 9% as
to a single, oral glucose-lowering agent. it is unlikely to achieve glycaemic targets One protocol is to start with a long-
Patients with more severe hyperglycemia with the use of oral agents alone. acting analogue such as glargine or
(FPG > 250 mg/dL) may respond detemir or NPH at 8 units in the evening,
partially but are unlikely to achieve Starting insulin in general practice titrating upwards according to fasting
normoglycemia with oral monotherapy. glucose levels. Conversion to a more
A stepwise approach that starts with a Insulin can be started in most type flexible regimen can be achieved later on,
single agent and adds a second agent to 2 patients in general practice. the usual either through the addition of short- or
achieve the glycemic target can be used. preferred regimen is a twice daily dose of rapid-acting insulins with meals to create
premixed insulin such as Mixtard 30 given a basal-bolus regimen, or by changing
First step Metformin before breakfast and before the evening over to a premixed insulin twice or three
meal. It is usual to start at 6–8 u twice a times a day.
The majority of patients and certainly day with home blood glucose monitoring.
those who are overweight should start
Metformin. This should be started at We have three types of insulin
500 mg once or twice a day and the dose available to us: Short acting, Long acting
increased to three tablets after 5–7 days. and Combination of the two. Long acting
Increasing the dose gradually may offset
the gastrointestinal side effects that many Types of insulin and there actions are as follows
patients fail to tolerate. Metformin has a
number of beneficial actions in diabetes. Types of insulin Peak Effective Duration

Non-obese patients may be insulin- Short-acting Aspart Glulisine Lispro 1 to 2 hour 2 to 6 hour
deficient and could start a sulphonylurea Regular
first rather than metformin, but
metformin has other benefits and so Long-acting Detemir Glargine NPH 4 to 10 hour 12 to 24 hour
could be co-prescribed from the starting
in this situation. Insulin MIXTARD 70/30-70%
combinations NPH, 30% regular

Second step Sulphonylurea
Glimperide

If the HbA1c is still not in target after
2–3 months, offer Glimperide. Glimperide
starting dose is 1 mg daily. Slowly it dose
can be increased up to 6 mg daily. This
increase should be very slow otherwise
patient may develop hypoglycaemia
which is a very serious complication.

Third step adding Pioglitazone to Different Insulins Onset of Action
Metformin and Glimperide

‘Triple therapy’ containing
metformin, a sulphonylurea and

Mittal S. et al. Medicine Update for Ophthalmologists www. dos-times.org 69

Recent Trends and Advances

Basal bolus regimen In general individuals with type
1 DM require 0.5 - 1 U/kg per day of
Mixtard regimen acting insulin as solid lines. The arrows insulin divided into multiple doses. one
indicate when the injections are given. commonly used regimen consisted of
Profiles of soluble insulins are shown twice-daily Injections of NPH mixed with
as dashed lines; intermediate- or long- B, breakfast; L, lunch; S, supper; Sn, a short-acting insulin before the morning
snack (bedtime). and evening meals. Premixed insulin
preparations are simple and convenient
Commonly used medications for control of diabetes regimen that provide an intermediate
acting insulin and a short- or rapid-
Salt Trade Name acting insulin within the same injection.
Initiating insulin therapy with premixed
Metformin (M) (500 mg to 1500 mg) Glycomet insulin OD opens the possibility of a step-
wise approach to intensify therapy to BID
Glimperide (G) ( 1 mg to 6 mg) Gp and even TID in patients to achieve target
HbA1c levels. These regimens, however,
Poiglitazone (P) (15 mg to 45 mg) Pozitiv , Zipio require patients to adhere to a consistent
meal schedule and carbohydrate intake to
M + G 1MG Glycomet Gp 1 avoid prandial hypo and hyperglycaemia.
Such regimens usually prescribe two-
M + G 2MG Glycomet Gp 2 thirds of the total daily insulin dose in
the morning (with about two-thirds given
M + G 1MG + P Ozomet Pg1 as long-acting insulin and one-third as
short-acting) and one-third before the
M + G 2MG + P Ozomet Pg 2 evening meal (with approximately one
half given as long-acting insulin and one-
Mixtard Insulin Mixtard insulin pen half as short-acting).

Author way of controlling blood sugar However, in younger patients in
particular, a more flexible method is the
FPG 150 TO 200 TO 250 250 MG TO 300 MG TO greater than basal-bolus regimen where a long-acting
200 mg mg 300 mg 350 mg 350 mg insulin is given at bedtime and meals are
covered by soluble insulin or a very short-
Exercise & Diet Exercise & Diet Exercise & Diet Exercise & Diet Exercise & Diet acting analogue but at the cost of more
Modification Modification Modification Modification Modification injections and more expensive. This is
convenient for those at work or at college.
Metformin Ozomet PG 1 Ozomet PG1 Ozomet Pg 2 Ozomet PG2
thrice a day OD thrice twice a day twice a day In beginning it may be appropriate
to provide once-daily insulin injection
add Ozomet PG 1 Ozomet PG 2 Increase to add Mixtard with a long-acting insulin analogue or pre
Glimperide twice Twice means thrice a day Insulin Pen mixed insulin.
1MG if reqd Glimperide
4mg Final recommendations to control
plasma glucose
1. Exercise
2. Weight Reduction
3. Metformin
4. Sulfonyl Urea
5. Poiglitazone
6. Add mixtard insulin pen.

Start bedtime dose of 8 units and
increase according to blood glucose
monitoring.

It should be noted that drugs dose
should be increased slowly and these has
to be increased from minimal dose. Above
chart is to give you a rough idea of how
much dose is required but treatment has
to be started from low doses and dose is
increased slowly.

In clinical practice, the most popular
scheme for starting insulin therapy in
T2DM is the addition of once daily (OD)
basal insulin to the oral therapy. Although
initiating basal insulin in T2DM patients

70 DOS Times - March-April 2019 Mittal S. et al. Medicine Update for Ophthalmologists

Recent Trends and Advances

Author way of using insulin the American College of Cardiology,
and the Centers for Disease Control
Lifestyle changes and and Prevention. Hypertension.
metformin 2013;63:878–885.
3. James PA, Oparil S, Carter BL, et al.
HbA1c > 7 % after 3 2014 Evidence-based guideline for the
months management of high blood pressure
in adults: report from the panel
Metformin up to 1.5 gm members appointed to the Eighth Joint
Glimperide up to 6 mg National Committee (JNC 8). JAMA.
Pioglitazone up to 45 mg 2014;311:507–520.
4. Krause T, Lovibond K, Caulfield M,
Start insulin if et al. Management of hypertension:
HbA1c > 9% summary of NICE guidance. BMJ.
2011;343:d4891.
High FPG High FPG 5. Leung AA, Nerenberg K, Daskalopoulou
Start basal insulin OD Start basal insulin OD SS, et al Hypertension Canada’s 2016
Canadian hypertension education
Titrate it upwards till Premix mixtard twice program guidelines for blood pressure
HbAic is less than 7 % daily and titrate to measurement, diagnosis, assessment
control blood sugar of risk, prevention, and treatment
& FBS < 110 mg of hypertension. Can J Cardiol.
2016;32:569–588.
Algorithm for insulin therapy in patients with type 2 diabetes mellitus 6. American Diabetes Association.
Diagnosis and classification of diabetes
mellitus. Diabetes Care. 2012;35 (Suppl
1):S64-S71.
7. International Expert Committee report
on the role of the A1C assay in the
diagnosis of diabetes. Diabetes Care.
2009;32:1327-1334.
8. American Diabetes Association.
Standards of medical care in
diabetes-2015. Diabetes Care.
2015;38:s1-s93.

Tirate there doses upward according to following table

Pre-dinner dose Pre-breakfast plasma glucose <80 80–110 111–140 141–180 >180
+4 +6
Adjustment of pre-dinner dose (U) - 2 No change +2 141–180 >180
+4 +6
Pre-breakfast dose Pre-dinner plasma glucose <80 80–110 111–140

Adjustment of pre-breakfast dose (U) -2 No change +2

results in significant improvement in and daily exercise has to be emphasized Correspondence to:
glycaemic control, therapy eventually repeatedly. Control of plasma sugar and Dr. Sonalee Mittal
needs to be intensified with the addition blood pressure ourselves is professionally Drishti The Vision Eye Hospital
of prandial insulin to achieve desired rewarding and satisfying both. Vijaynagar, Indore, Madhya Pradesh, India
glycaemic control.
References
Titration of Premixed Mixtard
- Start mixtard 12 IU before dinner 1. Gabb GM, Mangoni AA, Anderson
- Wait for 3 months. CS, et al. Guideline for the diagnosis
- If HbA1c > 7% start prebreakfast and management of hypertension in
adults-2016. Med J Aust. 2016;205:85-
Mixtard Insulin 3 IU also. 89.
So we can control plasma sugar
by using metformin, glimperide, 2. Go AS, Bauman M, King SM, et al.
pioglitazone and mixtard insulin pen. An effective approach to high blood
Lifestyle changes, decrease in weight pressure control: a science advisory
from the American Heart Association,

Mittal S. et al. Medicine Update for Ophthalmologists www. dos-times.org 71

Recent Trends and Advances

Astigmatism and Cataract Surgery:
Current Concepts

Dr. Samreen Khanam MS
Guru Nanak Eye Centre and Maulana Azad Medical College, New Delhi, India.

The recent advances in phacoemulsification Figure 1: Diagrammatic representation of incisional techniques to
techniques have made pseudophakic emmetropia correct astigmatism. The horizontal axis is the steeper one.
a refractive target for most surgeons. Precision in
biometry and technically correct uncomplicated works best for with-the-rule astigmatism as flattening due to
cataract surgery helps to achieve the refractive the incision is seen maximally in the superior incision, and least
goal in most patients. Patient expectations have in case of a temporal incision.
also increased, and postoperative spectacle independence has
become the desired outcome for patients and surgeons alike. However, practically it may not be possible to choose
steeper axis in all cases as it may lead to awkward hand
Despite the best biometry and IOL power calculation, the positioning during the surgery.
presence of preoperative astigmatism can lead to suboptimal
postoperative vision. It has been estimated that about 20 -30 A number of online calculators are available for the
% of patients who undergo cataract surgery have astigmatism estimation of SIA. The average SIA estimated for a 3.2 mm
of 1.25 D or more, and about 10% have 2.0 D or higher1. These incision is 0.5 D while a 2.2 mm incision results in a SIA of about
patients will require postoperative spectacle correction for 0.3D4. For very small incisions (~1.8 mm), SIA was not found to
both distance and near. be significantly reduced.

A number of surgical techniques for tackling astigmatism Opposite Clear Corneal Incision (OCCI)
are available in the armamentarium of a cataract surgeon these
days (Figure 1). They include: Lever and Dahan described the placement of a second
- On axis incision, opposite clear corneal incision over the steep meridian 180
- Opposite Clear Corneal Incision (OCCI), degrees away from the main incision of phacoemulsification5.
- Limbal relaxing incisions (LRI) This method is technically very simple and does not require
- Arcuate keratotomy (AK), any additional skill or instrumentation. A mean astigmatism
- Toric Intraocular Lenses correction of 2.06 D has been reported in the original paper,
- Bioptics. although a lower degree of correction (~1.6 D) has been found
in later reports. Despite being technically easy, it is associated
Coupling effect: Sato first introduced the concept of with an increased risk of leak and infections. It is, therefore,
“coupling effect”, according to which tangential incisions at advisable not to use any instruments through the second
the steep meridian induce flattening of the steep meridian and incision.
steepening of the flatter one (at 90 degrees)2. The ratio between
the induced steepening and flattening is termed as the coupling
ratio.

Surgically Induced Astigmatism (SIA) is the effect of the
surgical incision on the patient’s keratometry. SIA can vary from
surgeon to surgeon and also depends on the size and location
of the incision3.
- A larger incision will cause more flattening in that

meridian, and more steepening in the meridian at right
angles to it.
- Peripheral incisions have less effect than incisions nearer
to the centre of the cornea.
- When incisions are non-penetrating, deeper cuts induce
greater flattening.

Modification of incision site – (On axis incision)

A relatively simple method for correcting mild astigmatism
is by planning the incision on the steeper meridian. The
underlying principle is that of the coupling effect. This method

72 DOS Times - March-April 2019 Khanam S. Astigmatism and Cataract Surgery: A Review of Current Concepts

Recent Trends and Advances

Table 1: The Donnenfeld Nomogram for LRIs – “DONO” Arcuate Keratotomy

Preoperative Number of Length of incisions (in clock Arcuate astigmatic keratotomy is
astigmatism incisions hours ) another technique encompassing the
use of arcuate incisions near the mid
0.5 D 1 1.5 peripheral zone of the cornea to correct
higher degrees of astigmatism7. However,
0.75 D 21 being more central in location they need
better centration, and may more often
1.5 D 22 be associated with glare. Usually, LRIs
are preferred over arcuate keratotomy.
3.0 D 23 The use of Femtosecond laser arcuate
resection permits a more precise and
Figure 2: A toric IOL (in situ) as seen on surgical limbus. Two arcs are made 180 reproducible arcuate keratotomy.
retroillumination. degrees apart centered at the steep axis,
the arc length being determined with the Incisional techniques are less
help of nomograms. predictable, influenced by wound healing
and change with age. Also, higher degrees
LRIs are generally preferred over of astigmatism cannot be corrected by
arcuate keratotomy (see later) as there these techniques.
are less chances of inducing irregular
astigmatism and less need for precise Toric Intraocular Lenses
centration. The LRI incision is longer in
arc length as compared to an AK incision Correction of astigmatism with the
and can correct astigmatism upto 3.0 D. help of toric IOLs has become a popular
For best results, planning of the length technique in current surgical practice.
and site of incision is important. The They can correct higher degrees of
most popular nomograms used for this astigmatism with more predictable
results, and are not influenced by
Figure 3: The calculation chart of a toric IOL. wound healing over time8. Toric IOL
power is calculated with the help of
Limbal Relaxing Incisions (LRIs) purpose are the ones by Nichamin and calculation algorithms provided by the
Donnenfeld (“DONO”) (Table 1). manufacturers (Figure 2,3).
The first systematic description
of non-penetrating incisions placed LRIs are usually made at the One aspect to consider when
near the limbus was in 1898 by a Dutch beginning of the surgery. The incisions calculating a toric IOL is the (vector)
ophthalmologist L.J. Lans6. Limbal are made just about 0.5 mm inside change in corneal astigmatism induced
Relaxing Incisions (LRIs) are placed the surgical limbus with a diamond by the surgery itself. The expected
at the most peripheral extent of the or a keratotomy blade. The depth of amount of SIA must be incorporated into
clear corneal tissue, just inside the true the incision is at 90% of the thinnest the toric IOL power calculation to select
pachymetry. the most appropriate toric IOL model
and alignment axis. The effective cylinder
power of the IOL at the corneal plane is
a function of the effective lens position
and the spheroequivalent power of the
IOL. The IOL cylindrical and spherical
powers must first be converted into the
2 principal lens powers, after which both
lens powers are calculated to the corneal
plane using a standard vertex formula.
The difference between both lens powers
at the corneal plane should be used to
select the most appropriate IOL cylinder
power.

Cyclotorsion: It has been seen
that cyclotorsion of the eye occurs from
the upright to supine position and is
approximately 2 to 4 degrees on an
average, but can be up to 15 degrees in
individual patients9.

Therefore, for all the procedures
mentioned above, it is important to mark
a reference point on the eye in upright
position before surgery.

The three step ink marking
procedure: First, the horizontal axis (0

Khanam S. Astigmatism and Cataract Surgery: A Review of Current Concepts www. dos-times.org 73

Recent Trends and Advances

and 180 degrees) of the eye is marked stability when a capsular tension ring coaxial phacoemulsification incisions. J
preoperatively with the patient sitting (CTR) is co-implanted with a toric IOL. Refract Surg 2009; 25:21–24.
upright to correct for cyclotorsion. 5. Lever J, Dahan E. Opposite clear
This is usually done using a slit lamp or Bioptics corneal incisions to correct preexisting
an air bubble toric reference marker, astigmatism in cataract surgery. J Cat
or by using a gravity marker with It is a technique originally described Refract Surg. 2000; 26:803-805.
calibrated horizontal position. Next, to address residual refractive error 6. Nichamin LD. Nomogram for limbal
intraoperatively, the desired alignment following implantation of myopic phakic relaxing incisions. J Cataract Refract
axis for the IOL is marked with an angular IOLs, but is equally useful in the setting Surg. 2006;32:1408.
graduation instrument (Mendez degree of pseudophakic lens surgery11. Bioptics 7. Oshika T, Shimazaki J, Yoshitamo
gauge). Finally, the toric IOL is implanted permits one to treat both residual F, Oki K, Sakabe I, Matsuda S et al.
and rotated until the IOL markings agree spherical and cylindrical error using Arcuate keratotomy to treat corneal
with the alignment marks. excimer laser (LASIK/PRK/LASEK). astigmatism after cataract surgery.
Ophthalmology. 1998;105:2012-6.
Various other alternatives for Does all astigmatism need 8. Novis C. Astigmatism and toric
tackling cyclotorsion have now come correction? intraocular lenses. Curr Opin
into practice – the iris fingerprinting Ophthalmol. 2000; 11:47–50.
technique, the intraoperative wavefront It has been observed that a small 9. Kim H, Joo CK. Ocular cyclotorsion
aberrometry, and image guided systems amount of myopic astigmatism results in according to body position and
such as VERIONTM10. better uncorrected near visual acuity in flap creation before laser in situ
pseudophakic patients with monofocal keratomileusis. J Cataract Refract Surg.
Post operative rotation of a toric IOLs, although at the cost of distance 2008;34:557-61.
IOL has been of concern since the very acuity. Therefore, a less aggressive 10. Elhofi AH, Helaly HA. Comparison
beginning. It has been estimated that for approach is recommended for mild between digital and manual marking for
every one degree of error in a toric IOLs degrees of astigmatism. toric intraocular lenses: a randomized
rotational alignment, there is a 3.3% trial. Medicine (Baltimore). 2015;
decrease in correction of astigmatism. So, References 94:e1618.
if a toric IOL is misaligned by 10 degrees, 11. Nichamin LD. Expanding the role of
it is a 33% loss of toric correction. And 1. Ferrer-Blasco T, Montés-Micó R, bioptics to the pseudophakic patient. J
if it is misaligned by 30 degrees, it is as Peixoto-de-Matos S C, González- Cataract Refract Surg. 2001;27:1343 –
though you put in a spherical IOL; the IOL Méijome J M, Cerviño A. Prevalence of 44.
is not correcting astigmatism at all. corneal astigmatism before cataract
Surgery. J Cataract Refract Surg. 2009; Correspondence to:
The current toric IOL models have 35:70–5. Dr. Samreen Khanam
shown greater rotational stability than Guru Nanak Eye Centre and
the previous ones, and studies show that 2. Sato T. Posterior incision of cornea; Maulana Azad Medical College,
the average rotation is about 5 degrees. surgical treatment for conical cornea New Delhi, India
A centred, adequate capsulorrhexis and astigmatism. Am J Ophthalmol
and thorough removal of viscoelastic 1950; 33:943-8.
substance are important to achieve good
stability. However, greater instance and 3. Borasio E, Mehta JS, Maurino V.
magnitude of rotation has been seen Surgically induced astigmatism after
myopes (due to large size of the capsular phacoemulsification in eyes with mild
bag). Recent studies published from our to moderate corneal astigmatism;
centre have shown better rotational temporal versus on-axis clear corneal
incisions. J Cataract Refract Surg 2006;
32:565–72.

4. Masket S, Wang L, Belani S. Induced
astigmatism with 2.2- and 3.0-mm

74 DOS Times - March-April 2019 Khanam S. Astigmatism and Cataract Surgery: A Review of Current Concepts

Case Reports

An Unusual Case of Bilateral Cataract with
Anabolic Steroids

Dr. Prateeksha Sharma MS, DNB, Dr. J.L. Goyal MD, DNB, Dr. Raffat Anjum MBBS
Guru Nanak Eye Centre, Maharaja Ranjit Singh Marg, New Delhi, India.

Abstract: Purpose: To report a rare case of anabolic steroid induced bilateral cataract.
Method: A 22 years male presented with diminution of vision in both eyes for the past 4 months gradual, progressive and painless. Visual
acuity of 6/36 both eye with projection accurate not improving with pin hole. Patient was muscular in built with no significant family, past
history. Slit lamp examination showed posterior sub-capsular cataract in both eyes, intraocular pressure was 17.3mmHg with schiotz,
with normal anterior and posterior segment. Patient was on oral anabolic steroid (Stanazol) and injectable steroids (Nandrolone) along
with regular strenuous exercise for the past one year. Patient had gynecomastia along with purple striae over the abdomen and arm
region. Serum cortisol level was found to be 50 μg/dL. The twenty-four hour urine collection showed markedly elevated urinary free
cortisol. Rest of the blood investigations were normal.
Result: Diagnosis of anabolic steroid induced cataract with Cushing syndrome was made. Patient underwent uncomplicated
phacoemulsification surgery with intraocular lens in both eye and post-operative 6/6 vision was restored in both eyes. Steroids were
stopped and patient was referred to medicine department for further management.
Conclusion: Our report warns the unregulated use of anabolic steroids for muscle building and the need for awareness, education and
alertness amongst the fittest people of the society about anabolic steroids.

Anabolic steroids have anabolic as well as
androgenic effects on body. These drugs are
often abused by sports persons and others to
improve their physical appearance. Long term
use of anabolic steroids can lead to various
side effects like high blood pressure, high blood
sugar, gynecomastia, acne, male pattern baldness, male like
facial hair growth in females, menstrual disturbances. Cushing
syndrome is also known as hypercortisolism. It is caused by
excess cortisol level in body which can be endogenous or
exogenous in nature. It is mainly caused by stress hormone
which is cortisol. Its association is rarely seen with anabolic
steroids. Signs and symptoms of Cushing syndrome include
weight gain, purple stretch marks on breast, arms, abdomen,
thighs, acne, fatigue, muscle weakness, moon shape face, buffalo
hump, high blood pressure, and headache.

CASE REPORT Figure 1: Both eyes showing posterior sub capsular cataract.

A 22 year old male presented to the OPD with complaints and objective evidence, patient was provisionally diagnosed to
of diminution of vision in both eyes from past 4 months. On have Cushing’s syndrome with posterior subcapsular cataract
examination best corrected visual acuity was 6/36 in both eyes due to the chronic use of anabolic steroids. Patient underwent
which was not improving with pin hole. On slit lamp examination
patient was found to have posterior sub capsular cataract
(Figure 1) in both eyes with intraocular pressure of 17.3 mm Hg
in both eyes. Rest of anterior and posterior segment was normal.
On general physical examination patient was heavy built with
moon facies. Abdomen was distended with purple striae all
over the body. Blood pressure was 150/100 mmHg. Laboratory
investigations showed elevated fasting blood glucose level
160mg/dl, elevated serum cortisol level 50 mcg/dl, triglyceride
level was also elevated to 206 mg/dl. On history taking
patient gave history of use of oral anabolic steroid (Stanazol)
and injectable steroids (Nandrolone) along with regular
strenuous exercise for the past one year. Based on subjective

Prateeksha S. at al. An Unusual Case of Bilateral Cataract with Anabolic Steroids www. dos-times.org 75

Case Reports (b)
(a)

Figure 2(a): Signs of Cushing syndrome –large abdomen, gynaecomastia, purple Figure 3: Loss of purple straie and extra fat after 8 months of
striae. 2(b): -8 months after treatment and weight reduction. treatment.

uncomplicated phacoemulsification in cellular processes by steroid response 3. Dickerson, J.E., Jr., Dotzel, E., and Clark,
both eye cataract with a gap of one month elements (GRE) in the promoter region A.Fx, Steroid-induced cataract: new
along with implantation of foldable of specific genes5,6. Including glutathione perspective from in vitro and lens
hydrophobic intraocular posterior reductase gene. Glutathione is oxidized culture studies. Exp. Eye Res., 1997;
chamber intraocular lens. Post op vision forming GSSG as a key substrate in the 65:507-516.
was 6/6 in both eyes. Follow up done on intracellular antioxidant systems, such as
topical antibiotics and steroids. Patient glutathione peroxidase/ reductase. This 4. James, E.R., The aetiology of steroid
was referred to medicine department for system detoxifies H2O2 to water in the cataract. Journal of oculr pharmacology
Cushing’s syndrome and was motivated lens epithelial cells. When glutathione is and therapeutics. 2007; 23.
on every visit for lifestyle changes .Within decreased, this system oxidizes other cell
8 months of stopping steroids patient lost proteins which lead to cataract formation. 5. Danielian, P.S., White, R., Lees, J.A., et
20 kg of weight with reduction in waist There are several mechanisms causing al., Identification of a conserved fegion
size by 10 inches along with decrease in GSH level diminish7,8. One of them is defect required for hormone dependent
striae and gain of confidence (Figure 2,3). in glutathione reductase (GSR) activity9,10. transcriptional inactivation by steroid
GSR reduces oxidized glutathione GSSG to hormone receptors. EMBO J. 1992;
DISCUSSSION regenerate GSH. When GSR is impaired, 11:1025-33.
glutathione is reduced and glutathione
The main defining characteristics peroxidase/reductase system oxidizes 6. R., N., Molecular mechanisms of
of steroid-induced cataract include other cell proteins. glucocorticoid action: What is
an association only with steroids that important? Thorax. 2000; 55:603-13.
possess glucocorticoid activity. Anabolic CONCLUSION
steroids are derivatives of testosterone 7. Lou, M.F., Dickerson, J.E., Jr, and Garadi,
possessing only the anabolic effects of With increasing consciousness for R., The role pf protein-thiol mixed
testosterone, with minimal androgenic physical appearance in the youngsters, disulphides in cataractogenesis. Exp.
effects. They are mainly used to enhance more and more cases of anabolic steroid Eye Res. 1990; 50:819-26.
athletic performance and endurance. usage for body building are coming in
Many side effects of anabolic steroids light. Our report warns the unregulated 8. Aw, T.Y., Ookhtens, M., and Kaplowitz,
including Cushing’s syndrome have been use of anabolic steroids for muscle N., Inhibition of glutathione efflux from
seen but literature has not reported case building and the need for awareness, isolated rat hepatocytes by methionine.
of cataract caused by anabolic steroids. education and alertness amongst the J. Biol Chem. 1984; 259:9355-8.
Patients with long term exposure to fittest people of the society.
corticosteroids develop steroid induced 9. Giblin, F.J., McCready, J.P., Reddan, J.R.,
cataract which is usually posterior sub REFERENCES Detoxification of H2O2 by cultured
capsular in morphology. Susceptibility rabbit lens epithelial cells: Participation
of patients for cataract after long term 1. Liu, D., et al., A practical guide to of the glutathione redox cycle. Exp Eye
treatment with glucocorticoids is the monitoring and management Res. 1985; 40:827-40.
different. A dose of 10mg of oral steroid of the complications of systemic
for at least one year is necessary to cause corticosteroid therapy. Allergy Asthma 10. Giblin, F.J., and McCready, J.P., The effect
cataract1,2. In our case also patient was on Clin Immunol. 2013; 9(1):30. of inhibition of glutathione reductase
steroids from last one year. Oxidation of on the detoxification of H2O2 by rabbit
lens proteins is one of the mechanisms 2. Black, R.L., et al., Posterior subcapsular lens. Invest Ophthalmol Vis Sci. 1983;
which leads cataract3,4. Steroids affect cataracts induced by corticosteroids 24:113-8.
in patients with rheumatoid arthritis.
JAMA, 1960; 174:166-71. Correspondence to:
Dr. Prateeksha Sharma
Guru Nanak Eye Centre,
Maharaja Ranjit Singh Marg,
New Delhi, India

76 DOS Times - March-April 2019 Prateeksha S. at al. An Unusual Case of Bilateral Cataract with Anabolic Steroids

Case Reports

Ocular Surface Squamous Neoplasia with Superficial Fungal Colonization

Dr. Sabia Handa, Dr. Anchal Thakur, Dr. Amit Gupta
Post Graduate Institute of Medical Education and Research, Chandigarh, India

An 85-year-old man, farmer by occupation, presented with a gradually progressive, painless mass in the temporal
aspect of the left eye since 10 months. His past history and systemic history was insignificant. On ophthalmic
examination, his best corrected visual acuity was 20/80 in both the eyes. On anterior segment examination of the
right eye, a conjunctival mass was noted. The mass was measuring 6 x 4mm in greatest dimension, showed surface
keratinisation and was encroaching onto cornea. No significant inflammation or dilated feeder vessels were present.
Clinical diagnosis of leukoplakic ocular surface squamous neoplasia (OSSN) was made. The mass was surgically
excised along with 4 mm of healthy conjunctiva, with cryotherapy at the margins. Histopathology of the mass showed microabscess
formation in the conjunctival epithelium with moderate lymphonuclear infiltration and a few foci of moderate dysplasia. Scattered
fungal profiles were seen in the superficial layers of the mass on H & E, and Grocott’s methenamine silver stains confirmed the
diagnosis of conjunctival mycosis along with carcinoma in situ. This is the first report of leukoplakic OSSN with fungal colonization,
an extremely rare co-occurrence.

(a) (b)

(c) (d)

Figure 1: Slit lamp photograph showing conjunctival mass showing surface keratinisation (a). Histopathology showing microabscess formation
(black arrow) (b). Histopathology showing fungal profiles in the superficial layers (black arrow) with moderate dysplasia (black asterisk) (c). Grocott’s
methenamine silver stain confirming fungal hyphae (d).

Correspondence to:
Dr. Amit Gupta
Post Graduate Institute of Medical Education
and Research, Chandigarh, India

Gupta A. at al. Ocular Surface Squamous Neoplasia with Superficial Fungal Colonization www. dos-times.org 77

Case Reports

A Case of Pressure Induced Stromal Keratitis

Dr. Anchal Thakur MBBS, MS, FICO, Dr. Amit Gupta MBBS, MS, Dr. Sabia Handa MBBS, MS
Postgraduate Institute of Medical Education and Research, Chandigarh, India.

A28-year-old male presented to the cornea clinic segment was normal in both the eyes. ASOCT showed interface
3 weeks after LASIK surgery with complaints fluid accumulation in both eyes. (Figure 2). The patient was
of sudden onset of halos and blurring of diagnosed as having pressure induced stromal keratitis. Topical
vision since 1 day. The best-corrected visual
acuity was -0.75DS 6/9 in the right eye and steroids were stopped and patient was given 2 tablets of
-2.5DS 6/12 in the left eye. The Intraocular
pressure was 40 mm in the right eye and 36 mm in the left eye. Diamox with topical Timolol eye drops twice daily. 1 week later
The patient was diagnosed as having grade III DLK (Diffuse
lamellar keratitis) on the very 1st postoperative day and was the pressures were normal and the best-corrected visual acuity
given frequent steroids. (Prednisolone eye drops1 hourly).
Slit lamp examination revealed corneal edema limited to the was plano 6/6.
anterior stroma within the LASIK flap and fluid accumulation
at the interface in both eyes. (Figure 1a and b). The anterior First described by Belin in 2002, PISK (Pressure induced
chamber exhibited no significant inflammation and posterior stromal keratitis) presents beyond the first post-operative
week with clinical picture similar to DLK. It results from
topical steroids leading to interface fluid accumulation causing
significantly elevated intraocular pressure (IOP). The clinical
findings are caused by oedema and not due to accumulation of
inflammatory cells as with DLK.

Figure 1a: Slit lamp examination of a patient showing corneal oedema Figure 1b: Magnified view of the patient with corneal edema limited
to anterior stroma

Correspondence to:
Dr. Anchal Thakur
Postgraduate Institute of Medical Education and
Research, Chandigarh, India

Figure 2: AS-OCT (Anterior Segment OCT) showing corneal edema with fluid accumulation at
the interface.

78 DOS Times - March-April 2019 Thakur A. et al. A Case of Pressure Induced Stromal Keratitis

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DOS Times Quiz 2018-19

Episode-5

Last date: Completed responses to reach the DOS Office by e-mail or mail before 5 pm on 28th March 2019

1. The following structure 4. The following condition is
(white arrow) is seen in which associated with which of the
condition? following?
A) Streptococcus pneumoniae
A) Epithelial rejection B) Staphylococcus aureus
B) Endothelial rejection C) Mycobacterium tuberculosis
C) Stromal rejection D) Candida albicans
D) All of the above

2. Corneal ulcer shown below can 5. The following condition can be
be caused by one of the following associated with
organisms except
A) Aortic dissection
A) Curvularia B) Pneumothorax
B) Alternaria C) Vertebral anomalies
C) Fusarium D) Inguinal hernia
D) Lasidiophilia

6. Identify the condition below
A) Macular dystrophy
B) Avellino dystrophy
C) Lattice dystrophy
D) Reis Buckler dystrophy

3. What is the treatment for
underlying condition?

A) Fortified antibiotics
B) Topical steroids

C) Topical NSAIDs

D) None of the above

7. The following condition can be
associated with

A) Herpes simplex virus
B) Human Papilloma virus
C) Cytomegalovirus
D) Varicella Zoster virus

80 DOS Times - March-April 2019

8. The following condition is news watch
associated with which of the
following DOS Times Quiz Rules

A) Juvenile idiopathic uveitis 1. DOS Times Quiz will now feature as 5
B) Paget’s disease Episodes (Episode 1: July-August, Episode 2:
C) Sarcodiosis September – October, Episode 3: November
D) All of the above – December, Episode 4: January – February,
Episode 5: March – April). Entries will have to
9. All patients with Fuch’s are 10. All of the following can be used be emailed before the last date mentioned in
candidates for Descemetorhexis to treat the underlying condition the contest questions form. Late entries will
without endothelial keratoplasty except not be entertained.
(DWEK) except
A) Phototherapeutic Keratectomy 2. Please email (as scanned PDF Only)
A) Endothelial cell count > 1000/mm2 B) Nd:YAG application completed responses for the quiz along
B) Phakic C) Flap lifting and manual with details of the contestant filled in and
C) Central guttae signed to [email protected] (with cc to
D) Stromal edema removal [email protected]) or mail to DOS Times
D) None of the above Quiz, Dr. Subhash Dadeya, Room No. 114, 1st
Floor, OPD Block, Guru Nanak Eye Centre,
Compiled by: Maharaja Ranjit Singh Marg, New Delhi.

Dr. Sabia Handa 3. Nonmembers may also send in their entries
Post Graduate Institute of but will be required to send along with
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4. Contestants are requested to attempt all the
5 episodes of the Quiz contest and send in
their applications within the date specified.
No entries will be entertained after the last
date. The scores of each contestant for all
5 episodes together will be compiled at
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announced in the DOS Annual Conference
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winning contestants, a draw of lots will decide
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Contestant Details
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www. dos-times.org 81

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DOS Crossword

Episode-5

Correspondence to:
Dr. Anchal Thakur
Postgraduate Institute of Medical Education and
Research, Chandigarh, India

Fill the boxes below with the most appropriate answers by using the clues below

3

92

11 5

46

18 10

7
12

13

ACROSS Down

7. Macrostria after LASIK also known as ----thumbprint 1. Distance between ICL and crystalline lens(5).
sign(11). 2. A drug which is contraindicated in a patient

8. Myopic LASIK induces……spherical aberration(8). undergoing LASIK(10).
9. Another name for 193 Argon Flouride laser(7). 3. Law, which states that central corneal flattening, is
10. Criteria for Risk assessment of ectasia after refractive
achieved by adding tissue to the corneal periphery(8).
surgery(9). 4. Advanced topoguided LASIK(8).
11. Acute Post LASIK Glaucoma(4). 5. Technolas Femtosecond Workstation used for
12. FDA-approved presbyopia correcting IOL’s for cataract
correction of presbyopia(8).
surgery(9). 6. Most common organism causing infectious keratitis
13. DLK is also known as sands of…..(6).
post LASIK(12).

82 DOS Times - March-April 2019

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DOS TIMES 2017 – 2019 AUTHOR GUIDELINES

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84 DOS Times - March-April 2019

www. dos-times.org 85 IOLs For Presbyopia

With The Rule Astigmatism

Natural Mechanisms Pseudo-Accommodation (Pupil Size)

Mild Myopia IOLs for Presbyopia

AIM: Newer Concepts Mono-vision Refractive
“Spectacle Multifocal IOLs Diffractive
Combination
Free” Extended Range Of Vision
Vision post Changing Position: Forward Shift Passive shift
Dual Optic Active shift
cataract
surgery

Accommodating Changing Power Change in thickness
IOLs

Electronic Focusing Change in curvature

Artificial Crystalline Lens

Tear sheet

86 DOS Times - March-April 2019 Monovision Refractive type Dominant eye - emmetropic Uses Monofocal IOLs Tear sheet
Multifocal Excellent distance and Non dominant eye- slightly myopic Iolab, Pharmacia, TrueVista , AMO
intermediate, fair near vision Array, mPlus, ReZoom
3 zones Tecnis ZM900, ZA900, AcriTwin,
Diffractive type Central distance zone, intermediate zone and near zone decentered inferonasally Panoptix, Fine Vision, LISA Tri
Excellent near and very good
distance vision; less pupil AcriTwin manufactured in pairs combines multifocal and monovision principles: Lens in ReStore (+2.5D and +3D),
dependent the dominant eye: AcriLISA
70% distance and 30% near power
Combination type Second lens is reversed intensity:70% near and 30% distance power Symfony, Wichterle

DISADVANTAGES: loss of Apodized surface to provide smooth zones
contrast sensitivity, glare, haloes LISA stands for:
L: Light distribution: distance 65 % and near 35%
Extended Range of Vision I: Independent of pupil size
S: Smooth transitions between zones
A: Aberration correcting

Echelette design: elongates depth of focus zone

Accomodative Changing position Passive shift: hinged haptic; active shift: spring or magnet driven Crystalens, Tetraflex, 1-CU
IOLS Dual Optic Two optics, connected by spring like bridge through haptics Synchrony, Sarfarazi

Changing Power Change in thickness or change in curvature SmartIOL, FluidVision, Liquilens,
Fluidvision: fluid stored in haptics reservoirs, redistributed on near gaze; Liquilens: high Quest, NuLens
Electronic focussing refractive index fluid placed inferiorly
Artificial Crystalline Lens Elenza Sapphire
ISensors that detect very small changes in pupil size; and change the molecular
configuration of the liquid crystal to alter the power of the lens Tercopolymer

Injected through a small, peripheral capsulorrhexis that is later plugged
Lens epithelial cells must be removed, killed or passivated
Capsule opacification is a problem

Correspondence to:
Dr. Aditi Mehta Grewal
Postgraduate Institute of Medical
Education and Research,
Chandigarh, India