DOS Times Vol 26 No. 5 March-April 2021

Contents

Editorial Retina

05 Prof. (Dr.) Namrata Sharma 42 An Interesting Case of Recurrent Retinal
Hony. General Secretary Detachment in a Case of Fundal Coloboma with
Old Settled RD!
What’s New
46 A case of ‘Branch Retinal Artery Occlusion’
06 Varenicline Nasal Spray during Recovery Phase of a Covid Positive
07 Collagen Cross-Linking for Corneal Infections Patient
10 Rhino - Orbital-Cerebral Mucormycosis
49 OCTA Features of Diabetic Retinopathy – New
Subspecialities Era

Cataract 54 Uveal Effusion Syndrome: An Ongoing
Uncertainty
12 Capsulorhexis: Making a Perfect Circle from
History into the Future Strabismus

19 Is Cataract Surgery losing its Sheen? And are we 58 A Classic Case of Neurocysticercosis with
to be Blamed? an Unusual Involvement of Inferior Rectus
Muscle
Cornea & External Eye Disease
Systemic Disease and Eye
21 Gonococcal Keratoconjunctivitis in a
Neonate 62 An Unusual Presentation of Miliary
Tuberculosis : An Eye Opener for us!
25 The Slit Lamp to the Ocular Laboratory
Microscope: An Eye-Opener PG Corner

G laucoma 66 Pathological Myopia- Understanding it’s
Classification
27 A Case Report on Topiramate Induced Angle
Closure Glaucoma in A Young Girle Photoessay

31 Recent Advances - Microperimetry in 69 Aurolab Aqueous Drainage Implant in a Case of Late-
Glaucoma presented Primary Congenital Glaucoma

Neuro Opthalmology Review

35 Role of Intravenous Methyl Prednisolone 70 Dry Eye Diagnostics: Historical Perspectives, Current
for Management of Non-Arteritic Anterior Practices, and Future Directions
Ischemic Optic Neuropathy (NA-AION) in
Diabetic Patients at Tertiary Health Care center DOS Quiz
of Gujarat.
76

Tearsheet

77 Anti VEGF at a Glance

DOS Executive Members 2019-21

DOS Office Bearers

Dr. Subhash C Dadeya Dr. Pawan Goyal Dr. Namrata Sharma Dr. Hardeep Singh
President Vice President Secretary Joint Secretary

Dr. Jatinder S Bhalla Dr. Vinod Kumar Dr. Manav Deep Singh
Treasurer Editor Library Officer

Executive Members

Dr. Dewang Angmo Dr. Jatinder Bali Dr. Shantanu Gupta Dr. C. P. Khandelwal

Dr. Rahul Mayor Dr. Vipul Nayar Dr. Rajendra Prasad Dr. Kirti Singh

DOS Representative to AIOS Ex-Officio Members

Dr. Jeewan S. Titiyal Dr. M. Vanathi Dr. Rakesh Mahajan Dr. Arun Baweja

www.dosonline.org/dos-times DOS Times - Volume 26, Number 5, March-April 2021 03

Volume 26 No. 5, March-April 2021

DOS Times Editorial Board

Editor In Chief Editorial Board National Board
Prof. (Dr.) Namrata Sharma
Dr. Atul Kumar Dr. Parul Icchpujani
Editor Dr. Aniruddha Maiti Dr. Ronnie George
Prafulla Kumar Maharana Dr. Apporva Ayachit Dr. Sushmita Kaushik
Dr. Jitendra Jethani Dr. Gopal Pillai
Assistant Editors Dr. Mita Joshi Dr. Usha Singh
Dr. P. Dutta Majumdar Dr. Subhendu Boral
Dr. Noopur Gupta Dr. Meena Chakrabarti
Dr. Brijesh Kakkar Dr. Raksha Rao
Dr. Digvijay Singh Dr. Kumudini Verma
Dr. Ritika Sachdev Dr. Rashmin Gandhi
Dr. Dewang Angmo Dr. Siddharth Kesarwani
Dr. Rebika Dr. Chaitra Jayadev
Dr. Saurabh Sawhney Dr. Bibhuti P. Sinha
Dr. Reena Sharma Dr. Amit Porwal
Dr. Rajat Jain Dr. Prashant Bawankule
Dr. Jaya Gupta Dr. Arvind Kumar Morya
Dr. Anita Ganger
Ritu Nagpal Sahil Agarwal Dr. Umang Mathur
Dr. Neera Agarwal
Gunjan Saluja Deepali Singhal Dr. Poonam Jain
Dr. Manisha Agarwal
Dr. Hardeep Singh
Dr. Anita Sethi
Dr. Tushar Agarwal
Dr. Rohit Saxena
Dr. Swati Phuljhele
Dr. Vivek Dave
Dr. Mohita Sharma
Dr. Rajesh Sinha
Dr. Ritu Arora
Dr. P.K. Pandey
Dr. H.K. Yaduvanshi
Dr. O.P. Anand
Dr. Arpan Gandhi

Mohamed Ibrahime Asif Rahul Kumar Bafna

Sohini Mandal Prakhyat Roop

Editorial

From the
Editor Desk

Prof. (Dr.) Namrata Sharma Dear Members,

(MD, DNB, MNAMS) The field of Ophthalmology is on a fast pace of revolution, in almost every sub-
specialty. It’s important for the ophthalmologists to be well versed with the
Hony. General Secretary upcoming technologies and advancements, apart from being focused and skilled
Delhi Ophthalmological Society in their own sub-specialty. This is particularly important in order to provide
patients “the best of available care” and to refer them appropriately.
Cornea, Cataract & Refractive Surgery Services
Dr. R.P. Centre for Ophthalmic Sciences, This issue was designed to incorporate important topics in various sub-specialties
All India Institute of Medical Sciences (AIIMS) of ophthalmology. The spectrum ranges from medical and investigational
New Delhi ophthalmology to the surgical aspects. Preliminary topics such as evaluation of
techniques of slit lamp evaluation are also touched upon. Advancements in the
field of cataract surgery related to the creation of a perfectly sized and shaped
capsulorrhexis, very much important in determining the outcomes of cataract
surgery especially while implanting premium IOLs has been included, starting
from the traditional to the currently practiced methods and the upcoming future
modalities. Newer investigative modalities such as microperimetry in glaucoma
and the increasing utility of OCTA for the management of diabetic retinopathy
have also been covered. Topics of important clinical relevance such as vascular
disorders of retina, “Mucormycosis” cases of which have been on an upsurge
during the COVID-19 pandemic, newer concepts and emerging use of the widely
practiced surgical procedure of collagen cross linking for the treatment of corneal
infections, ischemic optic neuropathy and the use of aqueous drainage implants
for the management of primary congenital glaucoma have been well covered
included.

Last but not the least, the issue also contains a QUIZ page for which the winners
will be declared and prizes will be awarded.

We look forward for better understanding and learning of ophthalmology,
helping in creation of good clinicians.

Prof. (Dr.) Namrata Sharma
Hony. General Secretary

www.dosonline.org/dos-times DOS Times - Volume 26, Number 5, March-April 2021 05

What’s New

Varenicline Nasal Spray

Prafulla K. Maharana1, MD, Sohini Mondal2

1. Associate Professor, Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi
2. Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences,
New Delhi, India.

Varenicline Nasal Spray with varenicline nasal spray (called Repurposing varenicline from smoking
Varenicline nasal spray is a nicotinic OC-01) at doses of 0.6 mg/mL (n = 260) cessation to the relief of dry eye disease
acetylcholine receptor agonist recently or 1.2 mg/mL (n = 246), or the vehicle in the form of a nasal formulation
approved by FDA, that helps in re- alone (n = 252), twice daily for 28 days. proved successful in the ONSET-1 and
establishing the natural tear film, They assessed the spray’s efficacy using ONSET-2 trials, the results of which
typically disrupted in dry eye disease. anesthetized Schirmer’s test score and were presented at the annual meeting of
This is the only pharmaceutical Eye Dryness Score (EDS, 0 to 100 scale) the Association for Research in Vision
approach to treating an ocular surface at day 28. Patients treated with OC-01 and Ophthalmology, which took place
disease with a nasally delivered spray. experienced greater improvement in online from May 1 to 7.
Schirmer’s test score, with a gain of 10 Reference
Drug mm or more from baseline by day 28, • h t t p s : / / w w w . r e s e a r c h g a t e . n e t /
OC-01 Varenicline is a novel compound compared with patients who received
delivered via nasal spray in strength of placebo. publication/350042925_Varenicline_
0.6 mg/mL and 1.2 mg/mL manufactured In the 0.6 mg/mL group, 47.3% of eyes Nasal_Spray_OC-01_for_the_
by Oster Point Pharmaceuticals, Inc. showed improvement, while 49.2% of Treatment_of_Dry_Eye_Disease_The_
eyes in the 1.2 mg/mL group showed ONSET-2_Study
Mechanism of actions improvement. In the placebo group,
Varenicline nasal spray is a nicotinic 27.8% showed improvement (both P < Corresponding Author:
acetylcholine receptor agonist that has .0001). Mean change in Schirmer’s test
been shown to activate the trigeminal score in each OC-01 group was 11.3 mm Prafulla K. Maharana
parasympathetic pathway to stimulate and 11.5 mm, respectively, compared Associate Professor, Dept. of Ophthalmology,
the lacrimal functional unit, which in with 6.3 mm in the placebo group Dr. Rajendra Prasad Centre for Ophthalmic
turn re-establishes the natural tear film (both P < .0001). Both OC-01 groups also Sciences, All India Institute of Medical Sciences,
that is typically disrupted in dry eye experienced a greater reduction in EDS New Delhi-110029, India.
disease. from baseline at week 2 (0.6 mg/mL,
–16.5 mm, P < .05; 1.2 mg/mL, –17.9 mm,
Dosage P = .0078; placebo, –12.7 mm) and week
The ONSET-1 and ONSET-2 studies 4 (0.6 mg/mL, –19.8 mm, P < .05; 1.2 mg/
were conducted in which the treatment mL, –22.2 mm P = .0014; placebo, –15.4
was given twice daily for 28 days. mm).

Indication Advantages
Dry eye disease No ocular stinging or burning.

Efficacy Adverse events
In ONSET-2, Phase 3 clinical trial, There were no serious adverse events.
758 patients with dry eye disease The most common adverse event in
(Schirmer’s test score ≤ 10 mm and the 0.6 mg/mL and 1.2 mg/mL groups
Ocular Surface Disease Index (OSDI) ≤ was sneezing (95.0% and 96.7%,
23) were randomized 1:1:1 to treatment respectively).

06 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

What’s New

Collagen Cross-Linking for Corneal
Infections

Namrata Sharma1, MD (Ophth.), DNB (Ophth.), Nandyala Sushma2, MSc, Prafulla K. Maharana3, MD

1. Professor, Cornea and Refractive Surgery Services, Dr. R. P Center for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi
2. Ph.D Scholar, Dr. R. P Center for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi
3. Associate Professor, Department of Ophthalmology, Dr. R.P Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi

Infectious keratitis is a vision Currently, the most common practice such method is Collagen Cross-Linking
threatening problem accounting for to treat corneal infections is by using (CXL). Although this procedure has
significant visual loss in 50% of the broad spectrum antimicrobials. The been introduced initially to manage
cases.1 It is an acute ocular emergency probability of a good visual outcome keratoconus progression, later on
that needs to be managed on time to drops significantly, if diagnosis it was proven to be effective in
prevent complications. The common and initiation of the appropriate several other corneal conditions like
risk factors of Infectious Keratitis antimicrobials are delayed. This has keratitis, post-lasik ectasia, bullous
include ocular trauma, contact lens prompted a search for alternative keratopathy. It was renamed as
wear, dry eyes and chronic eye diseases.2 or complementary treatments. The Photoactivated Chromatophore for
Most common microorganisms causing emergence of microbial resistance Infectious Keratitis (PACK-CXL) at 9th
the infection includes bacteria, fungi, in the recent decades, the need to International Congress of Cornea Cross
virus and protozoan. introduce alternative treatments Linking, 2013; to distinguish the CXL
is becoming an issue of growing used for the treatment of Infectious
Infectious keratitis is diagnosed significance. Keratitis. It is a novel therapy proposed
following the clinical observation of for reducing the activity of pathogens
epithelial defect overlying a stromal A considerable amount of research in the eye and increase the resistance
infiltrate. A representative picture is is directed towards developing of the corneal tissue to enzymatic
shown in Figure 1. alternative methods of treatment, one degradation.3 This procedure uses
riboflavin and ultraviolet-A (UV-A) to
increase the biomechanical strength
of the cornea by photochemical cross-
linking of individual collagen fibres of
the anterior stroma.

CXL results in a marked increase
in collagen resistance to digesting
enzymes. While the exact mechanism
of stabilization of the infectious
process in the cornea has not been
fully understood, it appears that both
antimicrobial power and increased
tolerance to enzymatic digestion play
important roles in minimizing the
severity of corneal ulcers.

Figure 1 shows a Corneal ulcer with epidefect and dense infiltrate with feathery margins The antibacterial, antifungal, and
completely covering the visual axis antiamoebic efficacy of CXL have been
examined by experimental studies

www.dosonline.org/dos-times DOS Times - Volume 26, Number 5, March-April 2021 07

What’s New

performed both in vitro and in animal were randomized into medical and treat infected cornea as well. However,
models. There were few randomized PACK-CXL groups. It showed that CXL in the presence of active keratitis,
controlled trials in humans to assess adjuvant efficacy was significant in measuring corneal thickness during
the efficacy of PACK-CXL in bacterial the PACK-CXL group when compared treatment is not always possible. The
and fungal keratitis. to the medical management group.9 A presence of a corneal infiltrates or
retrospective case file analysis showed ulcer or scarring may have an effect
Bacterial Keratitis that adjuvant PACK-CXL along with on riboflavin and UVA penetration,
medical management did not have although this is yet to be determined.
In moderate bacterial keratitis, CXL any advantage in treating mycotic The amount of UV-A radiation,
accelerates epithelialization, shortens keratitis.10 In most cases, only the riboflavin concentration and duration
the course of treatment and minimizes superficial fungal ulcer show better of exposure of the Dresden protocol
or removes the need for surgery or results with the PACK-CXL than the were devised for the keratoconus.
other serious sequelae, such as corneal deep fungal infections.11 Hence understanding the effect of
perforation.4 From the literature, varying protocols on the infected
the treatment responses regarding Acanthamoeba Keratitis cornea might aid in the management.
the infectious ulcers indicated that Hyporiboflavin is used in keratoconic
photochemically activated riboflavin Acanthamoeba keratitis (AK) is a corneas thinner than 400 μm to
could lead to a future management necrotizing corneal disease caused increase the stromal thickness for
of infectious keratitis, involving by microscopic, free-living amoebae. the safety. There is no evidence about
reduction of both the frequency in It is a relatively uncommon but whether this principles can be used for
the application of topical antibiotics vision-threatening condition. There infected corneas.
and time spent in the clinic. Most were only few case series and reports
importantly, an implementation of the assessing the efficacy of PACK-CXL on Owing to the disadvantages of using
method might reduce the frequency of Acanthamoeba keratitis.12–15 Almost UV-A in CXL like keratocyte apoptosis,
complications associated with corneal all of them suggests that CXL may changes in corneal sensitivity and
infections and an increased healing rate be an option for selected patients endothelial cell loss, especially in
in the treatment of bacterial keratitis.5 with medication-resistant AK and thin corneas, new cross linking agents
In contrast there were also studies that corneal melting. It allowed patients (Genipin) and photosensitizers (Rose
proved that PACK CXL might not be to avoid emergency keratoplasty and bengal) with low corneal toxicity are
of any additional use over antibiotics.6 experience rapid symptomatic relief. currently under investigation.
The latest Cochrane review showed
that the current evidence on the Although Collagen Cross Linking References
effectiveness of PACK-CXL for protocol was originally devised for
bacterial keratitis is inconclusive and keratoconus, it was successful for 1. Jones DB. Decision-making in the
clinically heterogeneous in terms of the most of the infectious keratitis.
outcomes.7 Inspite of this success reports, there management of microbial keratitis.
were also reports, which suggest
Fungal Keratitis that there is no advantage of PACK- Ophthalmology. 1981;88(8):814-820.
CXL and sometimes it worsens the
The prognosis of a fungal ulcer is condition. The worsening effect was s0161-6420(81)34943-4
usually worse than that of a bacterial attributed to the safety concerns of
ulcer. This emphasizes the importance using the UV light on a thinned and 2. Alio JL, Abbouda A, Valle DD, Del
of an alternative treatment modality. infected cornea. But in general CXL is Castillo JMB, Fernandez JAG. Corneal
In a randomized controlled study, CXL performed in keratoconus, only when cross linking and infectious keratitis: a
proven to accelerate healing of the the corneal thickness is more than 400 systematic review with a meta-analysis
fungal ulcers, shorten the treatment μm. The threshold was established of reported cases. J Ophthalmic
duration and minimize the need for based on the endothelial toxicity and Inflamm Infect. 2013;3(1):47. 1869-
medications and surgery. It concluded stromal penetration of UV rays for a 5760-3-47
that CXL is an effective procedure normal transparent and keratoconic
and adjuvant therapy for managing cornea. We do not exactly know, if 3. Martins SAR, Combs JC, Noguera G, et
fungal keratitis.8 In another study by this threshold should be followed to al. Antimicrobial efficacy of riboflavin/
Jeyalatha Mani et al, only infections UVA combination (365 nm) in vitro
upto one third corneal involvement for bacterial and fungal isolates: a
potential new treatment for infectious
keratitis. Invest Ophthalmol Vis Sci.
2008;49(8):3402-3408. iovs.07-1592

4. Bamdad S, Malekhosseini H,

08 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

What’s New

Khosravi A. Ultraviolet A/riboflavin Padmanabhan P, et al. Therapeutic 2014;40(11):1919-1925. j.jcrs. 2014.
collagen cross-linking for treatment Effect of Corneal Crosslinking on 09.001
of moderate bacterial corneal Fungal Keratitis: Efficacy of Corneal 14. Khan YA, Kashiwabuchi RT, Martins
ulcers. Cornea. 2015;34(4):402-406. Collagen Crosslinking as an Adjuvant SA, et al. Riboflavin and ultraviolet
ICO.0000000000000375 Therapy for Fungal Keratitis in light a therapy as an adjuvant
a Tertiary Eye Hospital in South treatment for medically refractive
5. Makdoumi K, Mortensen J, Sorkhabi India. Ocul Immunol Inflamm. Acanthamoeba keratitis: report of 3
O, Malmvall B-E, Crafoord S. UVA- Published online July 9, 2020:1-8. cases. Ophthalmology. 2011;118(2):
riboflavin photochemical therapy 09273948.2020.1770296 324-331. j.ophtha.2010.06.041
of bacterial keratitis: a pilot study. 15. Garduño-Vieyra L, Gonzalez-
Graefes Arch Clin Exp Ophthalmol. 10. Vajpayee RB, Shafi SN, Maharana PK, Sanchez CR, Hernandez-Da Mota
2012;250(1):95-102. s00417-011-1754-1 Sharma N, Jhanji V. Evaluation of SE. Ultraviolet-a light and riboflavin
corneal collagen cross-linking as an therapy for acanthamoeba keratitis:
6. Prajna NV, Radhakrishnan N, Lalitha additional therapy in mycotic keratitis. a case report. Case Rep Ophthalmol.
P, et al. Cross-Linking Assisted Clin Exp Ophthalmol. 2015;43(2):103- 2011;2(2):291-295.000331707
Infection Reduction (CLAIR): A 107. ceo.12399
Randomized Clinical Trial Evaluating Corresponding Author:
the Effect of Adjuvant Cross-Linking 11. Garg P, Das S, Roy A. Collagen Cross-
on Bacterial Keratitis. Cornea. linking for Microbial Keratitis. Middle Prof. (Dr.) Namrata Sharma
Published online October 19, 2020. East Afr J Ophthalmol. 2017;24(1):18- MD,DNB, Cornea & Refractive Surgery Services
ICO.0000000000002510 23. meajo.MEAJO_305_16 Dr. Rajendra Prasad Centre for Ophthalmic
Sciences, All India Institute of Medical Sciences,
7. Davis SA, Bovelle R, Han G, Kwagyan 12. Arance-Gil Á, Gutiérrez-Ortega New Delhi-110029,India
J. Corneal collagen cross linking for ÁR, Villa-Collar C, Nieto-Bona
bacterial infectious keratitis. Cochrane A, Lopes-Ferreira D, González-
Database of Systematic Reviews. Méijome JM. Corneal cross-linking
2020;(6). 14651858.CD013001.pub2 for Acanthamoeba keratitis in
an orthokeratology patient after
8. Wei A, Wang K, Wang Y, Gong L, swimming in contaminated water.
Xu J, Shao T. Evaluation of corneal Cont Lens Anterior Eye. 2014;37(3):224-
cross-linking as adjuvant therapy for 227. j.clae.2013.11.008
the management of fungal keratitis.
Graefes Arch Clin Exp Ophthalmol. 13. Chan E, Snibson GR, Sullivan L.
2019;257(7):1443-1452. s00417 -019- Treatment of infectious keratitis
04314-1 with riboflavin and ultraviolet-A
irradiation. J Cataract Refract Surg.
9. Jeyalatha Mani V, Parthasarathy D,

www.dosonline.org/dos-times DOS Times - Volume 26, Number 5, March-April 2021 09

What’s New

Rhino - Orbital-Cerebral
Mucormycosis

Pervez Ahmed Siddiqui, MBBS MS
NSCB, Govt. Medical College, Jabalpur, MP

Introduction These patients have presented Visual Acquity
Rhino Orbital Cerebral Mucormycosis themselves initially in ophthalmology In 66% of patients visual acuity ranged
(ROCM) is a extremely debilitating dis- OPD or has been referred from ENT from 6/6 to 6/18 whereas in 39% had
ease affecting mainly immunocompro- OPD or dental OPD. NO PL unilaterally and 5% patients had
mised individual and is caused by fungi These patients who were referred from bilateral no perception of light.
mainly mucor, rhizopus and absidia ENT OPD had various complaints It was noted that few had come with
related to nose and throat like, difficulty very good acuity and with in 24 hours
There was an epidemic of Rhino in breathing, foul smelling ipsilateral developed no perception due to CRAO.
Orbital Cerebral Mucormycosis in nasal discharge or some sort of black A remarkable observation noted during
Madhya Pradesh as the cases of SARS- colour crusting along ala of nose, eschar this study.
CO-2 infection waxed and waned formation around the nasal area. One patient develop CSR on account
during this pandemic and most of the Those patients who were referred from of neurogenic and psycological stress
patient reported in our setup were Dental OPD have loosening of teeth of getting affected with Rhino Orbital
immunocompromised of varying or some sort of toothache as initial Cerebral mucormycosis.
nature due to treatment availed by presentations. These patients were routinely
these patients as a part and parcel of The age of patients ranged from 18 to 70 subjected to clinical ophthalmological
home isolation or hospital stay. years and male: female ratio was 6:4. examination ranging from visual
Those patients who presented acquity assessment, torch light
During this study patients attending themselves in ophthalmology OPD were examination, slit lamp examination,
the OPD of NSCB (Govt.) Medical either suffering from minor complaints applanation tonometery , indirect
College suffering from various stages of like conjunctival congestion and major ophthalmoscopy, B scan, OCT and MRI.
ROCM were clinically examined during complaints like loss of vision due Those patients who had ROCM of
the outbreak of ROCM. These patients to Central Retinal Artery Occlusion various grades were admitted in
had developed ROCM due to after math (CRAO). dedicated mucormycosis ward and
of COVID19 in the form of recent or subjected to routine pathological
concurrent infection. Observation examination like CBC,ESR,CRP,D-
On examination 44% had CRAO as Dimer, blood sugar(fasting and
We are presenting a short clinical initial presentation, whereas complete postprandial).
profile of initial 20 patients attending lagophthalmos was observed in These patients were subsequently
our OPD afflicted with ROCM. 5%, complete ptosis was present in subjected to nasal endoscopy, nasal
36%, conjunctival chemosis in 16%, debridment as and when required.
These patient had history of conjunctival congestion in 12% Patients were treated with injection
various form of oral or intravenous exposure keratitis in 5%, patients, Liposomal Amphotericin B 5-10mg per
corticosteroid therapy in 86%, 78% pts Circumcorneal congestion in 15% in kg body weight in 5% dextrose for 28
were suffering from raised blood sugar patients, herpes zoster in 5% diplopia days and later on tablet posaconazole
both fasting and postprandial, 44% of in 20% of patients where as partial and 300mg BD on day one and 300 mg OD
patients had a prolong ICU stay of 28 complete ophthalmoplegia was present
days,14% patients were suffering from in 24% and proptosis in 12% patients.
diabetic keto acidosis and 9 % were
using corticosteroid as a part of other
ailments.

10 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

What’s New

for 28 days as step down therapy was acyclovir, cycloplegics, antibiotic eye better after medical and surgical
provided to the patient. drops and tear substitute and intraconal intervention.
Ophthalmological problems were dealt amphotericin B 3.5mg per 1ml was Patients of CRAO were counselled as
accordingly as in the form of pad and injected, methyl cobalamin injections none of them showed signs of ROCM
bandage as and when required antiviral were given as an when accordingly, grade IV (cerebral involvement).
medications in the form oral and topical all the patients were symptomatically

Image Of Patient With Rocm Grade Grad 3 Endoscopic Nasal Debridment

Images of Patient With Rocm in Mucormycosis Ward Images of Rocm in Dental OPD

www.dosonline.org/dos-times Corresponding Author:

Dr. Prof. Pervez Ahmed Siddiqui
MBBS MS (Ophthalmology)
NSCB, Govt. Medical College Jabalpur
DOS Times - Volume 26, Number 5, March-April 2021 11

Subspeciality-Cataract

Capsulorhexis: Making a Perfect
Circle from History into the Future

Anuj Kumar Singal, Shrutika Kankariya, Vardhaman Kankariya
Asian Eye Hospital, Pune, India

Introduction later developed which used two steps and prevents drying of the cornea.
The capsulorrhexis is one of the most and anterior capsule window was not Beginners should stain the anterior
important steps in cataract surgery completed until after implantation of capsule with trypan blue before starting
and is usually the most difficult step the IOL.4 the capsulorhexis. The dye is injected
for the beginning surgeon to master. It All these techniques had increased the under air and washed after a 30 second
has several advantages over the older incidence of posterior capsule tear along interval.9
capsulotomy such as1:- with vitreous loss. Moreover such tears
prevented proper aspiration of anterior Sizing
• Easy Cortical aspiration leaving no capsule cortex and lead to decentration The ideal capsulorhexis is a centered
capsular tags of IOL due to pull on capsular tags. circle that completely covers the edge
Thus, it was in the 1980s when the of the IOL optic, thus about 5 mm
• Easy placement of the IOL invention of the continuous curvilinear to 5.5 mm in diameter. A too large
• Safe in the bag implantation capsulorhexis (CCC) by Thomas capsulorhexis allows the IOL to rest way
• Good centration of the Intraocular Neuhann of Munich, Germany, and too anteriorly, one that is irregular or off
Howard Gimbel described a technique center can lead to IOL decentration, one
lens (IOL) where a smooth, circular capsular that is too small can result in capsular
• Prevents haptics from getting opening with a sub incisional needle phimosis and interfere with vision.
puncture was made and completed with For most patients, a capsulorhexis
displaced out of the bag arcs taken both ways from this puncture. diameter measuring 0.5 mm to 1.0 mm
• Renders the capsular bag more It was coined the term capsulorhexis smaller than the IOL’s optic diameter
by Neuhann, derived from the Greek is preferred, however in eyes that
resistant to tearing during surgery suffix rhexis meaning “to tear.” He have weakened zonules or have an
• Intraoperative stress on the zonules presented his technique at the German excessively hardened nucleus, uveitic
Society of Ophthalmology meeting in cataract surgery and piggyback IOL
is minimal and is evenly distributed the fall of 1985 and published it in a implantation and where small incision
• Easy placement over the anterior German medical journal in 1987.5 Next cataract extraction (SICS) is planned,
year Calvin Fercho introduced another slightly larger capsulorhexis is required
capsulorrhexis margin in case of technique for circular capsulotomy in in as compared to phacoemulsification.
posterior capsule rupture Welsh Cataract Congress and named the
technique as “Continuous Circular Tear Surgical Techniques
History Anterior Capsulotomy”.6 Ultimately A. Manual Capsulorhexis
One of the earliest technique for Gimbel and Neuhann coined the name I. Needle Capsulorhexis
capsulotomy was Vogt’s technique continuous circular capsulorhexis It is the most commonly done procedure
where he utilized toothed forceps (CCC) to fully cover the concept.7,8 due to its low cost. A perforation is
for grasping and ripping out a part of made in the center of the anterior
anterior capsule but unfortunately Prerequisites capsule using a bent needle of 24 G to
had unpredictable and catastrophic Ideally a deep anterior chamber, a 26 G or the 2.75-3.2 mm keratome, it is
outcomes.2 In 1968 Kelman introduced flat anterior lenticular curvature, then extended as a horizontal incision.
“Christmas tree” approach in which and optimal visibility are required The tip of the needle is now used to
a dull cystitome was used to peel especially for beginners. Many surgeons redirect the tear in a clockwise or
anterior capsule cortex in triangular prefer putting methyl cellulose over anticlockwise direction (according to
morphology.3 This was soon replaced the cornea that improves visibility surgeon comfort).
by the popular “can-opener” technique
where a cystitome was used for
interconnecting perforations of anterior
capsule to create a circular window.2
The Galand “letterbox” technique was

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The circular tear is started by lifting applied perpendicular to the plane tip), Corydon (with an acute-angled tip),
and pushing or pulling the central part of tearing, usually via forceps. In this Buratto (with an acute-angled tip) and
of anterior capsule according to the technique the surgeon elevates the Buratto (with a round valve) as shown
direction in which surgeon wishes to edge of the preformed puncture or in figure 1.
start. This creates a flap that can be easily tear perpendicular to the plane of The capsulorhexis can also be performed
turned over it, engaged with the needle anterior capsule. Hence a 90° angle will with the help of microcapsulorhexis
tip and torn in a circular manner by form between the shear force and the or an intravitreal forceps. The advent
applying the tear vectors accordingly. If zonular vector force. Due to specific is that it can be introduced into the
the tear starts to extend peripherally, it organization of elastic fibers in capsule anterior chamber through the side
is usually the result of positive vitreous lens, anterior capsule shows maximum port incision and there is no leakage
pressure which can be countered by resistance in the zonular plane. of viscoelastic during the procedure.
reinflating the anterior chamber with Contrarily in the perpendicular vector, Special micro forceps have been devised
viscoelastic, especially high density fibers are most vulnerable to tear. Thus for use during micro incision cataract
viscoelastics.20 When completing the the direction of tear extension follows surgery / phakonit also.
capsulorhexis, one should overlap the direction of forceps movement. III. Bimanual Capsulorhexis
the tear in such a manner that the last Thus forceps can yield much easier and It is similar to forceps technique
part of the tear joins the first part from continuous tearing. Different types of except here, viscoelastic material is
the outside towards the centre, thus forceps are utilized for capsulorhexis continuously injected through the side
resulting in a continuous edge. If the with either sharp or blunt tips. port with one hand while the other
surgeon uses a bent 26-gauge needle II. Forceps Capsulorhexis hand performs the capsulorhexis.
mounted on a syringe, the syringe can be A Kraff-Utrata forceps can be used to IV. Two-staged Capsulorhexis
filled with viscoelastics. This is injected perform capsulorhexis.10 The initial In this procedure11 the original
into the anterior chamber while the puncture in the anterior capsule is capsulotomy is just large enough to
capsulorhexis is being performed. made with a bent 26 G needle or with admit the smaller endocapsular phaco
The best control of the tear as it the tip of the forceps itself. This creates probe and a second instrument for lens
progresses is achieved by grasping the a small flap which is folded over and manipulation. After the lens material
developing capsular flap, placing the tip then pulled by the forceps in a circular is removed, the small initial opening is
of the instrument a little peripheral to motion so that force at the point of converted into a larger one of the desired
the advancing tear, which will direct it tear is tangential to the circumference diameter, while still maintaining the
outwards. Placing it a bit central to the of the circle. Consequently, the tear is continuous tear edge.
line of the tear will direct it towards the extending by shearing rather than by The second capsulotomy is started with
centre.21 stretching. Using the forceps requires a tangential snip on one side of the
It is worthy to bear in mind that a larger opening into the anterior capsule edge with a Vannas scissors, the
surgeon’s hand is not the only source chamber as compared to a bent needle.
of extrinsic force during capsulorhexis. Other popular forceps for capsulorhexis
The zonular fiber force is augmented if include Utrata (with a straight blunt
the lens moves anteriorly as a result of
increased posterior pressure by vitreal Figure 1: A: Utrata Forceps B: Corydon Forceps C: Buratto Forceps
thrust or decreased anterior pressure http://www.katalystsurgical.com/instruments/ophthalmic/utrata-capsulorhexis-forceps-
by leakage of Ophthalmic Viscosurgical fine-sharp-tips-cystotome-teeth
Devices (OVDs) from anterior chamber. The forceps can be used to both create the initial puncture and the capsulorhexis but
The external forces applied by surgeon requires a larger opening into the anterior chamber of about 2.8mm.
can be classified as “stretching” and
“shearing”. Stretching force is applied
by a cystitome i.e. typically a double
bended 27 gauge insulin needle. Double
curve facilitates manual maneuver and
puts the tip of the needle on the anterior
capsule. “Stretching” is the application
of force in the same plane as radial
zonular force.
“Shearing” denotes ripping force

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second continuous tear is then extended, Figure 2: Capsule marker (Wallace circular corneal marker)
using Utrata forceps to complete a The capsule marker can be inserted and withdrawn through a 2.2- 2.4mm incision and the
larger circle, which is centered in the capsulorhexis can be done by using it as a guide to produce a highly precise manual CCC.
pupil and is of the desired diameter.
A two-staged capsulorhexis is effective alternative option for use in mark on the cornea surface.24 Creating
particularly useful:- cataract surgery across a wide range of a tear just inside the circular mark
In patients with small pupils, when an user experience.16 on the cornea provides a sub 5.5mm/
originally small capsulorhexis requires II. Capsulorhexis Corneal marker 6mm capsulorhexis due to corneal
subsequent conversion to a larger This is a steel or titanium instrument magnification factor of 1.15 to 1.21 as
capsulorhexis. placed over the cornea and a seen in the study by Waltz and Rubin.17.
When the original capsulorhexis is capsulorhexis margin is made over The disadvantage with them is due to the
made inadvertently small. the cornea using gentian violet. It corneal curvature and magnification,
B. Guided manual capsulorhexis comes in both 5.5 and 6mm sizes e.g. the image on the anterior capsule
A well centered, appropriate size the Wallace circular corneal marker differs from the original mark size and
capsulorhexis is very much needed for 6 that makes a 6.0 mm diameter circle location. (Figure 3).
a successful cataract surgery, successful
in the bag implantation of the IOL, and Figure 3: Morcher Silicone Ring (FCI Ophthalmics)
prevention of any complications such (http://googlescholar.medcraveonline.com/scholars/article_fulltext/214)
as posterior capsule rupture. Thus a The silicone ring can be used to stain the cornea with gentian violent which then acts as a
guided capsulorhexis became quite guide for capsulorhexis.
popular over years where the surgeon
would take the help of artificial guides
to attain an optimal capsulorhexis both
in size and centration.
I. Capsulorhexis Capsule marker
The Raviv Capsulorhexis Caliper
(Bausch + Lomb) has blunt, adjustable
marking tips that indent the anterior
capsule on two axes after they are
inserted through the main cataract
incision.
The Morcher Ring Caliper (FCI
Ophthalmics) 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. Verus Capsulorhexis
Device (Mile High Ophtalmics) is a
biocompatible silicone ring, with an
outer diameter of 6.2 mm and an inner
diameter of 5 mm. A micro patterned
surface acts as a braking system once
the device is placed on the capsule
so that the ring maintains stability
and limits side-to-side movement and
placed over the anterior capsule via
2.4 mm incision (Figure 2). These can
be useful to produce a highly precise
manual CCC and is a viable and cost-

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III. Virtual assistance I. ApertureCTC
Different Image Guided Systems (IGS) like “Verion Image guided system” (Alcon)
and “Callisto Eye Computed Assisted Cataract Surgery” (Carl Zeiss) have a rhexis The Aperture CTC (International
assistant option where a Superimposition of the exact shape and size of the Biomedical Devices, N. Charleston, SC)
capsulorhexis is made and then aligned with the optical axis of the IOL of the or continuous thermal capsulotomy is
patient eye (Figure 4). The surgeon uses this image to guide the capsulorhexis. a hand piece consists of disposable steel
rings ranging from 4.5 to 6.5 mm in
Figure 4: Callisto (http://www.gei.co.in/) diameter after being attached to the tip
The Callisto gives a virtual image over the anterior lens capsule depicting the border of the of the 1.2-mm hand piece and produces
capsulorhexis margin. The surgeon can just use the guide and create a capsulorhexis. constant, safe, low-level energy. The ring
C. Technology assisted capsulotomy delivers thermal energy to the capsular
Though guided capsulorhexis solved the problem of good centration and sizing membrane (Figure 5). It has been found
in most of the patients, still problem of optimal centration and sizing persisted to produce as strong capsulorhexis.
especially in difficult cases such as patients with weak zonules, white intumescent
cataract and pediatric cataract surgery where chances of capsule run off were high. II. Femtosecond Laser assisted
The development of multifocal lenses which required a good centration to achieve cataract surgery (FLACS)
excellent outcomes further required an optimal capsuorhexis, thus came an era of
automatic capsulorhexis technology; where the technology would make an optimal The femtosecond laser became very
central capsulorhexis. popular on its introduction because
of the claim to create precise incisions
Figure 5: The Aperture CTC continuous thermal element allows uniform contact with the with minimal collateral damage.
anterior capsule, and the incision is completed in milliseconds. As the ring is retrieved, it Femtolaser can be used not only
automatically captures and removes the circular capsulotomy button through a 2.2-mm to produce corneal incisions and
incision. capsulorhexis but also nucleotomy
(http://www.ophthalmologymanagement.com/issues/2016/september-2016/the-golden- and thus it is informally called as
mean-of-capsulotomy#ref11) FLACS (Femtosecond laser-assisted
cataract surgery). It uses neodymium:
glass 1053 nm wavelength light to
create a tiny, 3-micrometer spot with
an accuracy of 3 microns (Figure 6).22
Numerous studies have demonstrated
that femtosecond laser-assisted cataract
surgery produces a capsulorhexis of
better shape and circularity than the
manual procedure.12,25 In the beginning
more uniform capsulotomies
made by Femtosecond technology
although appealing turned out to
be associated with capsular block
syndrome (CBS). It is suggested that
sudden, uninvited movement of the
lens nucleus during hydrodissection
may block the hydrodissection fluid
leaving no exit pathway for the flow.
Furthermore the femtosecond laser
produces intracapsular gas which
might augments this phenomenon,
hence an explosive tear in the posterior
capsule thus a gentle hydrodissection
and decompression by manual pressure
on nucleus is required to balance the
intralenticular pressures. Currently,
5 systems are available for femto-
assisted surgery;23 these include the
Catalys (Optimedica), LenSx (Alcon
Laboratories, Inc), Victus (Bausch +

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Subspeciality-Cataract

Figure 6: Femtosecond laser Lomb), LensAR (Lensar, Inc.), and the
(http://www.thenakedeyebook.com/blog/latest-laser-cataract-techniques-is-zepto-the-new- Victus (Technolas). Apart from safety
femto) protocols, economic concerns (e.g. cost-
Femtosecond laser uses neodymium: glass 1053 nm wavelength light to create multiple tiny, effectiveness, health system finance, per
3-micrometer spot with an accuracy of 3 microns which then lifts off and can be removed. user charges and maintenance cost) are
Figure 7: Precision Pulse Capsulotomy (Zepto) also among important issues that lead to
Series of photos showing the Zepto Capsulotomy in a patient with Post Radial Keratotomy surgeons search for better technology.
cataract. (A) The Zepto device can be placed via 2.2-2.4 mm incision via which the squid Another interesting issue found by
like arms open (B) and are placed over the anterior capsule. After suction, energy is used to rostami et al was an increased incidence
make a nearly circular Capsulorhexis (C) which then separates. (D) The Capsulorhexis can of early-onset PCO in comparison
be seen in comparison to the IOL at the end of surgery. to Manual capsulorhexis.18 Though
accurate, the strength of rhexis made
by Femtolaser has been its limitation in
many studies.12
III. Precision Pulse Capsulotomy
(ZeptoTM Technology)
The most recent assisted technology
to provide an optimal capsulorhexis
is precision pulse capsulotomy,
informally popular as Zepto (Mynosys
Inc., Fremont, CA) cataract. It uses a
fast, focused, multiple pulse, minimal
energy discharge that produces a
round anterior capsulotomy (Figure
7). Capsulotomies are performed using
a disposable hand piece with a soft
collapsible tip and circular nitinol
cutting element.13
The non-laser device is a console having
a disposable flexible nitinol ring to cut
a capsulotomy cap about 5.2 mm in
diameter. The ring folds so as to enter
incisions are as small as 2.2 to 2.4 mm
which then spring back into shape
(Figure 8). A suction cup placed over
the capsular membrane pulls it towards
the ring, which cuts a cap in four
milliseconds. The user then discards
the disposable cutting element on
hand piece tip, along with the removed
capsular membrane slice. The Zepto
console is small, and doesn’t need to be
attached to a microscope head while
producing a maximum temperature
increase in the eye of 2.01°C. Waltx et al
in fact studied on 38 complicated cases
and observed that not only did precision
pulse capsulotomy had a short learning
curve but also resulted a round, safe
and high edge quality capsulotomy. 14
Chang et al observed a much smoother
capsulotomy edge compared to those
produced by femtosecond laser.15

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Subspeciality-Cataract

Figure 8: The Zepto consists of a disposable handpiece (A) attached to a control console techniques involved in the procedure
(B) that provides power and suction for the capsulotomy. The handpiece terminates in a have evolved drastically starting from
capsulotomy tip (C) consisting of a soft, clear silicone suction cup (SC) that houses a circular, manual capsulorhexis to those using
collapsible, superelastic nitinol capsulotomy ring (NCR) to perform the capsulotomy. An advanced aids such as thermal energy
extendable-retractable push rod (PR) helps to compress the capsulotomy tip for entry through and Femtosecond Lasers making
a 2.2-mm corneal incision. phacoemulsification safer and more
(https://crstoday.com/articles/2016-jan/precision-pulse-capsulotomy/) predictable. The role and importance
of capsulorhexis in successful cataract
Many studies have shown that the of published evidence to support it. surgery cannot be stressed upon more, it
strength of the Zepto capsulotomy The CAPSULaser attaches to a standard has not only made phacoemulsification
edge is significantly stronger than surgical microscope so it’s easily more efficacious but also allows
that produced by femtosecond laser or transportable and its use doesn’t require application of many other maneuvers
manual CCC.12 moving the patient to another location such as in-the-bag lens disassembly,
IV. CAPSU Laser for the capsulotomy. lens epithelial cell removal, posterior
It relies on continuous thermal energy to capsular plaques removal etc; thus
create capsulotomies rather than pulsed Capsule staining maintaining a clear visual axis.
in FLACS. After dilating the pupil and
making side port incisions, the surgeon Usually red reflex is sufficient to Currently as none of the capsulorhexis
stains the anterior capsule with trypan visualize the round rim of rhexis. methods can be called as ideal, with each
blue to visualize the CAPSULaser’s Staining serves as a treasured adjunct having its merits & demerits, the future
(Los Gatos, CA) anatomical target. to enhance visualization of the of capsulorhexis requires studies on the
Diameters from 4.5 to 7 mm can be anterior capsule especially in cases outcomes of available techniques along
made within a single three-second pass. with impaired red reflex. The mature with evolution of newer techniques
In the region of irradiation, the laser or white cataracts, opalescent cortical which make capsulorhexis and in turn
energy facilitates the molecular phase material, dense posterior subcapsular phacoemulsification as the choice of
change of the capsular collagen IV to opacification, vitreous hemorrhage, cataract surgery.
elastic amorphous collagen. As the or corneal clouding are the common
collagen undergoes this phase change, reasons for red reflex impairment. Of References
it creates the capsulotomy with a rim the several dyes encountered in the
that has a high degree of elasticity capsulorhexis literature (including 1. Gimbel HV, Neuhann T: Development,
and tear strength associated with the Indocyanine green (ICG), trypan blue, advantages and methods of the
amorphous collagen. fluorescein, crystal violet, gentian continuous circular capsulorhexis
It increases the temperature of iris, violet and Brilliant Blue G (BBG), technique. J Cataract Refract Surg 1990;
corneal endothelium and retina by less only trypan blue is US Food and Drug 16:31-37.
than 0.2°C. Theoretically a CAPSULaser Administration (FDA)-approved.
capsulotomy may be stronger and more 2. Steinert RF. Cataract surgery: technique,
elastic than those made by CCC or by Conclusion complications & management. 3rd.
femtosecond laser but there is a lack Philadelphia: Saunders; 2009.
Capsulorhexis is an ever evolving
technique which has been in 3. Kwitko ML, Kelman CD, editors. In:
development since past 250 years. The Kugler, editor. The history of modern
cataract surgery. The Netherlands: The
Hague; 1998.

4. Galand A. A simple method of
implantation within the capsular
bag. J. Am. Intraocul. Implant. Soc.
1983;9(3):330–2.

5. Neuhann T. Theorie und
operationstechnik der kapsulorhexis.
Klin Monatsbl Augenheilkd.
1987;190:542-545.

6. Gimbel HV. The history of the
capsulorhexis technique. Cataract
Refract Surg Today 2007;7:39–41

7. Gimbel HV, Neuhann T. Development,
advantages, and methods of the
continuous circular capsulorhexis
technique. J Cataract Refract Surg
1990;16(1):31–7.

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8. Gimbel HV, Neuhann T. Continuous Preclinical Safety and Performance technique in cataract surgery. J Cataract
curvilinear capsulorhexis. J Cataract of a New Capsulotomy Technology. Refract Surg. 2013 Sep;39(9):1297-306.
Refract Surg 1991;17(1):110–1. Ophthalmology. 2016 Feb;123(2):255-64. 24. Wallace RB (2003) Capsulotomy
diameter mark. J Cataract Refract Surg
9. Pandey SK, Werner L, Escobar-Gomez 16. Powers MA, Kahook MY.New device 29(10): 1866-1868.
et al. Dye enhanced cataract surgery. for creating a continuous curvilinear 25. Hida Wilson Takashi, Chaves Mario
Part 1: Anterior capsule staining for capsulorhexis.J Cataract Refract Surg. Augusto Pereira Dias, Gonçalves
capsulorhexis in advanced/white 2014 May;40(5):822-30. Michelle Rodrigues, Tzeliks Patrick
cataract. J Cataract Refract Surg 2000; 26 Frenzel, Nakano Celso Takashi, Motta
(10): 1052-59. 17. Waltz KL, Rubin ML. Capsulorhexis Antonio Francisco Pimenta et al .
and corneal magnification. Arch Comparison between femtosecond laser
10. Dada T, Sethi H. Forceps capsulorhexis. Ophthalmol. 1992;110(2):17. capsulotomy and manual continuous
J Cataract Refract Surg. 2002 curvilinear digital image guided
Aug;28(8):1491. 18. Rostami B, Tian J, Jackson N, Karanjia capsulorrhexis. Rev. bras.oftalmol.
R, Lu K. High Rate of Early Posterior [Internet]. 2014 Dec [cited 2017 June 30]
11. Gimbel HV: Two staged capsulorhexis ; 73( 6 ): 329-334.
for endocapsular phacoernuisi-fication. Capsule Opacification following
J Cataract Refract Surg 1990; 16:246-49. Femtosecond Laser-Assisted Corresponding Author:

12. Thompson VM, Berdahl JP, Solano Cataract Surgery. Case Reports in Dr. Anuj Kumar Singal
JM, Chang DF.Comparison of Manual, Ophthalmology. 2016;7(3):213-217. Junior Consultant
Femtosecond Laser, and Precision doi:10.1159/000449124. MBBS, MS, DNB (Ophthalmology)
Pulse Capsulotomy Edge Tear Strength Asian Eye Hospital, India
in Paired Human Cadaver Eyes. 19. Howard Larkin.FUTURE IOLS.
Ophthalmology. 2016 Feb;123(2):265-74. Eurotimes. 2013; 18(9):28.

13. David F. Chang, Nick Mamalis, Liliana 20. Polat A. Needle capsulorhexis: the
Werner,Precision Pulse Capsulotomy. importance of using an anterior chamber
Presented as a poster at: American maintainer. J Cataract Refract Surg. 2003
Academy of Ophthalmology Annual Jul;29(7):1248-9; author reply 1249.
Meeting, Las Vegas, Nevada, November
2015. Manuscript no. 2015-1481. 21. Tanuj Dada, Harinder S. Sethi, Munish
Dhawan, Vivek Dave, Kiran G. Krishnan.
14. Waltz K, Thompson VM, Quesada Capsulorhexis. DOS Times. 2007 Jul;
G. Precision pulse capsulotomy: 13(1):23-31.
Initial clinical experience in simple
and challenging cataract surgery 22. Kullman G, Pineda R II. Alternative
cases.J Cataract Refract Surg. 2017 applications of the femtosecond laser
May;43(5):606-614. in ophthalmology. Semin Ophthalmol.
2010 Sep-Nov;25(5-6):256–64.
15. Chang DF, Mamalis N, Werner
L. Precision Pulse Capsulotomy: 23. Reddy KP, Kandulla J, Auffarth GU.
Effectiveness and safety of femtosecond
laser-assisted lens fragmentation and
anterior capsulotomy versus the manual

18 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

Subspeciality-Cataract

Is Cataract Surgery losing its
Sheen? And are we to be Blamed?

I.P Singh, M.B.B.S, M.S, F.M.R.A
Dr. K.P’s Eye Hospital, SCO : 811, NAC, Sector 13, Manimajra, Chandigarh

I belong to the era when as postgraduate esteem of a good cataract surgeon takes hospitals but US DOCTORS!
students we were taught ECCE as the its first hit!
first step towards becoming an eye We have over the years propagated
surgeon . The excitement and fear right The second time they take the hit is one of the finest, sophisticated, and
from learning the washing technique to when the established eye hospitals of rewarding surgeries into an OPD
the anaesthetic block and of course the the city hold free eye surgery camps and procedure. It takes years and years of
suturing, every step was overwhelming posters for the same are put all around practice to achieve the expertise to
and has stayed in my subconscious the city. This practice impacts the become an efficient cataract surgeon,
mind till date. new surgeons badly, as now when the but the effort and all the hard work go
patient walks into their chambers, the down the drain when the procedure
We went on to learn “SICS” and then decision on how much to charge and itself loses respect and recognition. The
“PHACO”, gradually moving towards how to justify that charge is a difficult respect for this surgery is compromised
“Topical cataract surgeries” by and one to make because their senior and with us doctors eagerly agreeing to
by playing around with the various successful colleague is offering the the low-cost government schemes
intraocular lens on offer. During same for FREE. like Ayushman Bharat and accepting
residency we were taught that learning the terms and conditions of cashless
the art of refraction was very important The third hit is when the patient insurance companies which pay
as it was the bread & butter of demands “guaranteed stitchless topical peanuts for the cataract surgery!
ophthalmic practice but over the years cataract surgery” without bandage
it has been nailed that cataract surgery because the patient has seen the same The irony however is that no other
in fact is the bread & butter source of being advertised everywhere and our branch in our field of medicine offers
revenue. poor surgeon explains to the patient its main surgical procedure as FREE, so
about the chances of suturing. The why does cataract surgery face such a
After residency and fellowship, comes patient immediately starts feeling that predicament? It is time to ponder why
the period of fine-tuning ones skill, he/she is not at the right place. such an ultra-fine procedure is made to
and the search of some charitable look like a walk-in-walkout procedure;
setup starts, where a lot of “cutting” The fourth and final hit is when the that too stitchless, padless with 100%
is available, but please do not expect patient or their attendants say that results when we as surgeons are fully
much salary as they do not have a some other doctor had told them that it aware of all possible things that can go
shortage of doctors. After working for is a 5-minutes procedure and super-safe awkwardly wrong even in the best of
a year or so, becoming confident, and without anything possibly going wrong hands!
boasting a healthy CV with hardly any and also that after surgery no glasses
bank balance, the poor surgeon either will be required. This drastically raises It is a well-known fact that the majority
takes the biggest decision/risk of his the bar for our surgeon leading him/ of eye camps are organized by so-called
life to open a practice or gets absorbed her to secretly feel scared while offering religious heads, NGOs, corporate
in the multiple practices/ corporate set- their services because of the sky-high houses etc. The motives may vary
ups around. expectations!! from political to religious to personal
but why should the doctor agree for
Once into the active practice he/she Who is to be Blamed ?? performing the same for petty money
realizes that cataract surgery is being Surprisngly, it is neither the like Rs 900 per case? The additional
done more commonly than pterygium pharmacuetical companies or the IOL angle in this whole camp scenario is
excision & grafting and, then the self- companies, nor the corporate chain of that if anything goes wrong then all the

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Subspeciality-Cataract

responsibility is put on the shoulder that if we don’t give respect and they should also be duly recognized
of the performing doctor! When the importance to our work then it would and paid for their efforts. This much-
government is already having free be hard to expect that from our patients needed change will only happen
cataract surgeries under the blindness and their attendants. when everyone understands the
control program, why is there a need for The senior, well-established doctors importance, underlying difficulty, and
other organizations to jump in this pool and the extensive setup owners should expertise involved in the procedure,
and make things complicated for the always keep their journey in mind which will further only happen if we
complete ophthalmological fraternity? and not use cheap business tactics to ophthalmologists set finite standards
Coming to think about it, have the make life difficult for the upcoming to our noble profession and ensure
orthopedicians offered free joint doctors and clinics around them! It is that this expertise offered at our end
replacements; neurosurgeons offered imperative to understand that we all in comes with an expectation of suitable
free shunting or the cardiologists offered our respective journeys and everyone salaries. This is further accompanied
free CABG and stenting surgeries? If the will get their due. by an unsurmountable concern of
answer for all of them is “NO”, then The advertisement campaigns like, violence against doctors and the ever-
why, as doctors handling a very vital “Get one eye done and other Free”, “ increasing legal cases levied on the
and sensitive part of our human body No Stitch, No Bandage, No Injection doctors. The ophthalmic organizations
have brought this menace over us? surgery offered” are distressing, need to set the fundamental standards
Even when surgery packages are offered unprofessional, and demeaning for this for compliance with cataract surgery.
than the justification put forth for the humane surgical skill; hence need to be It is time to stand united and raise the
charges levied is the “quality of the lens” put a stop to. bar not only with the quality we offer
and not the expertise of the surgeon or With the increasing violence against but also for what we want and expect in
the difficulty of the procedure; because doctors and the ever-increasing return; not only from the government
how do you justify the procedure when consumer forum cases, it becomes but also the people we treat and operate.
the same is being done FREE in every critical for ophthalmic organizations This is a never-ending chain running
corner and even your senior successful to set the fundamental standards for over many years and this should END
colleague is running a so-called free compliance with cataract surgery. It is now. Like any other procedure, Cataract
NGO and offering the same (Reasons for time to stand united and raise the bar surgery should also be recognized as a
him/her are debatable ) not only with the quality we offer but highly sophisticated surgery requiring
It is high time that we as also for what we want and expect in high expertise and not led by the
ophthalmologists stop offering the return; not only from the government IOL companies, PHACO machine
discounted cataract surgery, and but also the people we treat and operate. companies, NGO or the corporate giants
together put an end to the practice of This discussion will lead to the surface an but by the experience, training, and
“Free” cataract surgery and thereby otherwise simmering humane concern qualification of the surgeon.
stop giving our lifelong hard-earned of how the poor and impoverished part
expertise to these hungry business/ of the society will tackle the blindness Corresponding Author:
religious bodies, NGOs et al. The key to due to cataract! For this, let us have faith
all this is the understanding that it will in health prerogatives taken up by the Dr. I.P Singh
never stop here, and will creep over to central and state governments, eg., the M.B.B.S, M.S, F.M.R.A
other surgical practices that are done by free surgeries performed at government Chief Surgeon
ophthalmologists! hospitals. The NGO’s like “Lions” and Dr. K.P’s Eye Hospital, SCO : 811, NAC,
Cataract surgery is undoubtedly one of “Rotary” are also providing free or Sector 13, Manimajra, Chandigarh
the finest and most delicate surgeries minimal charge cataract surgery but
provided and requires arduous and the financial payback to the surgeon is
lengthy training to master. For sheer often put on the backburner by these
respect to the input involved in making organizations. We cannot ignore the
such fine surgeons in terms of years and fact that even doctors are relying on
patience, there is an ardent need to stop their education and skill set for their
propagating it as a 5-10 minutes OPD livelihood and like all other professions,
procedure. We need to acknowledge

20 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

Subspeciality-Cornea & External Eye Disease

Gonococcal Keratoconjunctivitis in
a Neonate

Siddharth Madan1, M.S, D.N.B, F.I.C.O, FAICO (Retina and vitreous)
Sarita Beri2, M.D.,
Himani Pal3, M.B.B.S,
1. Assistant Professor, Department of Ophthalmology, UCMS and GTB Hospital, University of Delhi, New Delhi
2. Director Professor, Department of Ophthalmology, UCMS and GTB Hospital, University of Delhi, New Delhi
3. Department of Ophthalmology, Lady Hardinge Medical College and Associated Hospitals, University of Delhi, New Delhi, India

Introduction Case History Left eye demonstrated a non center
Neisseria gonorrhoeae infection is one A 22-days-old neonate presented involving corneal ulcer measuring
of the most common sexually with redness, watering from her 4 x 4 mm along-with surrounding
transmitted disease (STD) caused left eye accompanied with eyelid conjunctivitis (Fig. 1A). Fundus details
by bacteria. Various risk factors are swelling since three days after birth. were unclear on ophthalmoscopy.
associated with increased risk of She was born at term following an Conjunctival swab sent from the
infection with Neisseria gonorrhoeae uncomplicated vaginal delivery. There infant’s eye for culture studies
during pregnancy. Also a delay in was no accompanying history of ocular demonstrated polymorphonuclear
treatment is attributed to the lack of trauma. The child received some topical cells. Right eye was apparently normal
clinician recognition in upto 65% medication elsewhere but no relief was (Fig.1B). Retrospective history from the
of cases.1 Undetected infections can observed. The mother was married for mother revealed the presence of a foul
have serious implications both for two years and had one previous live smelling whitish vaginal discharge
the mother and the newborn.1 A birth but no abortions. On examination, for four years but no treatment was
rapid, severe, ulcerative keratitis may the neonate could respond to light taken. Culture from this discharge
follow an infection with Neisseria with eye closure from both eyes (BE). demonstrated a growth of gram negative
gonorrhoeae that may be potentially
sight-threatening. The therapeutic Figure 1a-1c: Left eye developed conjunctivitis with corneal ulcer at presentation (Fig. 1a).
decision making process is modified by Right eye was minimally congested yet cornea was normal (Fig. 1b). Follow up at three
frequent co-infection with other STD’s. months with normally fixating both eyes (Fig. 1c)
Emergence of antibiotic resistance to
available treatment options is another
matter of concern. Ocular infection in
an infant can result is life-long visual
compromise and development of
amblyopia, also called the lazy eye. This
also poses a management challenge
for the attending ophthalmologist.
Screening protocols must be established
in all centers to screen antenatal patients
for Neisseria gonorrhoeae, Chalmydia
trachomatis and syphilis apart from
Human immunodeficiency virus (HIV)
and other potential infections that can
have deleterious effects on the newborn.
One such infant presented to us with
sight threatening sequel of gonococcal
infection as the mother could not be
screened in the antenatal period.

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Subspeciality-Cornea & External Eye Disease

diplococci present intracellularly in be performed in patients suffering from Infants with GC should be hospitalized
polymorphonuclear cells suggesting gonococcal conjunctivitis.9 Clinicians and prompt treatment initiated. A
Gonococcal cervicitis. Further, testing should be aware of current screening meticulous history, including sexual
for Human immunodeficiency virus recommendations and methodology and social histories, should be obtained
and syphilis was negative in parents. for diagnosis for detection of gonorrhea from the parents for establishing a
Treatment with topical moxifloxacin and chlamydia in genital as well as diagnosis of GC. Eliciting this history
0.5% eye drops instilled on one hourly extra-genital sites in an attempt to may pose a tremendous challenge
basis (BE), cycloplegics (1% atropine address this prevailing epidemic to the health care provider as most
ointment instilled thrice daily), which is mostly seen in young women patients may not be receptive and may
lubricants, oral vitamin A prophylaxis in the reproductive age group.9 If the not disclose the history pertaining to
as per age along-with oral azithromycin infection with Neisseria gonorrhoeae these issues. A convenient environment
(10mg/kg/day) for three days resulted goes unnoticed and is practically for the patient, a doctor who shows
in the resolution of clinical signs and missed by the attending obstetrician empathy with good communication
development of a faint corneal scar in the antenatal period, the same skills may help the patient open-up
in three weeks.2-5 Examination of the may come to light with potentially to such facts and make the approach
retina at this stage was normal. Both blinding manifestations in the to diagnosis easy. The mother of the
mother and father were treated for newborn in the form of gonococcal infant disclosed this history of vaginal
gonorrhea. The child is on follow-up keratoconjunctivitis(GC). discharge after much effort that gave
and doing well (Fig.1C). a clue to the diagnosis and prompt
Gonococcal keratoconjunctivitis management.16, 17, 18
Discussion (GC) is a potentially devastating The current standard FDA approved
blinding disease.1,10,11,12,13 If adequate laboratory test for detection of
Gonococcal infections in women are prophylaxis is not administered to urogenital chlamydia and gonorrhea
frequently asymptomatic in as high the newborn, 30% to 42% of infants is a nucleic acid amplification test
as upto 50% of the females infected born by vaginal delivery to infected (NAAT).19 These tests are highly
with this microorganism.2 Infection mothers will develop gonococcal ON.14 sensitive and specific for detecting both
with Neisseria gonorrhoeae in females The transmission rate to the neonate these common pathogens and can be
most commonly involves the cervix. is higher in mothers with co-infection performed using urine sample of the
Classical symptoms of the infection with chlamydia.15 The neonate may infected patients without the need
include a mucopurulent discharge, present with extensive chemosis, for pelvic examination or obtaining
and the examination may reveal a edema of the eyelids, and abundant a urethral sample. As per the current
friable cervical mucosa. Abdominal purulent discharge that might be blood- recommendations, all women age 25
pain, dysuria, dyspareunia, pruritus, tinged. These manifestations can start years or younger must be tested for
Pelvic inflammatory disease (PID) within two to five days of birth however chlamydia and gonorrhea infections, as
or perihepatitis are other presenting it can have a late presentation up to well as women older than 25 years who
features. PID may occur in upto 40% of two to three weeks after delivery. The have a history of STDs, new or multiple
women with cervical infection with N. presentation may be late as well but sex partners, or the ones who exchange
gonorrhoeae which can culminate in such cases need to be comprehensively sex for drugs or money. Pregnant women
tubal scarring/infertility or an ectopic investigated as the source may should invariably be screened for all
pregnancy.3 If gonococcal cervicitis possibly be the attending parents STDs.20 Culture requires endocervical
goes undetected in pregnancy and no who are ignorant of an underlying swab specimen in women and a urethral
treatment is administered, it can have infection. The same was the scenario swab specimen in men for isolating
serious clinical manifestations ranging in our patient wherein the mother was Neisseria gonorrhoeae. However, the
from miscarriage, premature labor diagnosed with gonococcal cervicitis sensitivity of NAAT for the detection
associated with chorioamnionitis, after clinical manifestations of GC of N. gonorrhoeae in urogenital and
ocular or pharyngeal infections in were obvious in the infant. Untreated nongenital anatomic sites is superior to
the neonate or an acute illness which infection with N. Gonorrhoeae can lead that of culture studies. But the results
includes ophthalmia neonatorum (ON) to corneal scarring, corneal ulceration, vary depending on the product insert
and sepsis leading to arthritis and/or panophthalmitis and perforation of the from various manufacturers.20 A Gram
meningitis that may develop two to five globe within 24 hours.7 Keratomalacia stain performed on the endocervical
days after delivery.4,5,6,7,8 Screening for should always be ruled out in neonates secretions or urtheral secretions has a
STDs must be performed for all pregnant and infants who develop corneal specificity as high as over 99% with a
women for the presence of chlamydia ulcers.10,11,12 In older age, GC can present sensitivity of over 95%. The staining
cervicitis, syphilis, and HIV. Diagnostic with a red eye without evidence demonstrates polymorphonuclear
testing for chlamydia and syphilis must of concomitant genital infection.13

22 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

Subspeciality-Cornea & External Eye Disease

leukocytes with intracellular Gram- infection. Chlamydial testing should efficacy in fighting the infection with
negative diplococcic. In young patients be done simultaneously in neonates Neisseria gonorrhoeae, yet a pregnant
a NAAT may be easier than obtaining who are infected with Neisseria patient with a red eye or vaginal
endocervical samples as a screening gonorrhoeae. The infant’s mother and discharge needs to be investigated
modality. her sexual partners should be treated for gonorrhea even in the current
The prophylaxis either with 1% silver for gonorrhea.22 To avoid reinfection times before the neonate develops
nitrate, 0.5% erythromycin ointment or and break the circle of transmission serious manifestations in the form of
azithromycin, gentamicin, tobramycin, of infection, partners should be GC or significantly life-threatening
chloramphenicol, 1% tetracycline instructed to abstain from unprotected meningitis.10,11,12,13,14
hydrochloride or fluoroquinolones sexual intercourse for seven days
topically may be administered to all after they and their sexual partner(s) References
newborns, including those born to have completed treatment and after
mothers who underwent cesarean resolution of symptoms, if present. 1. Goggins ER, Chamberlain AT, Kim TG,
section, in the first hour after birth.21 Antimicrobial resistance against many Young MR, Jamieson DJ, Haddad LB.
Prophylaxis is warranted because drugs has been observed in Neisseria Patterns of Screening, Infection, and
it can prevent potentially sight- gonorrhoeae.25 Penicillin, tetracycline, Treatment of Chlamydia trachomatis
threatening gonococcal ophthalmia. and fluoroquinolones that had been and Neisseria gonorrhea in Pregnancy.
The safety, ease of administration, and used against Neisseria gonorrhoeae Obstet Gynecol. 2020;135(4):799-807.
inexpensive treatment regimen go a infection have now been shown to be
long way in preventing complications. ineffective due to rapid development 2. Conejero C, Cannoni G, Merino PM, et
The efficacy for prevention of of resistance to this bacterium.26 Oral al. [Screening of Neisseria gonorrhoeae
chlamydial ophthalmia is unclear treatment regimens for the treatment and Chlamydia trachomatis using
as this treatment does not prevent of infection with N. Gonorrheae are few techniques of self collected vaginal
colonization of the nasopharynx by C. in number. Azithromycin is an azalide sample in young women]. Rev Chilena
trachomatis. All neonates regardless of antibiotic that works in multiple Infectol. 2013;30(5):489-493.
whether they are delivered vaginally clinical situations including gram-
or by cesarean section should receive positive upper respiratory infections, 3. Chan PA, Janvier M, Alexander NE, Kojic
prophylaxis. Infants with GC need premature rupture of membranes. As EM, Chapin K. Recommendations for
frequent irrigation of the conjunctiva the drug is highly effective against the diagnosis of Neisseria gonorrhoeae
and intravenous or intramuscular urogenital infections due to Chlamydia and Chlamydia trachomatis, including
administration of ceftriaxone (25 to and gonorrhea when administered as extra-genital sites. Med Health R I.
50 mg/kg, to a maximum dose of 125 a single one-gram dose, it has gained 2012;95(8):252-254.
mg), and evaluation for disseminated importance.27 Macrolide antibiotics
gonococcal disease (eg, arthritis, including Azithromycin are generally 4. Maxwell GL, Watson WJ. Preterm
sepsis, meningitis).22 The emergence safe in pregnancy and also do not premature rupture of membranes:
of ceftriaxone and azithromycin increase the risk of any major fetal results of expectant management in
resistance in N. gonorrhoeae represents malformations above the baseline patients with cervical cultures positive
an important global concern that has risk of one to three percent.27 Further for group B streptococcus or Neisseria
serious implications pertaining to clinically meaningful increased risk to gonorrhoeae. Am J Obstet Gynecol.
the public health.23 Currently many the infant/fetus in the form of pyloric 1992;166(3):945-949.
countries in the world recommend stenosis/ intussusception was highly
combination therapy using the unlikely as suggested by the conclusions 5. Liu B, Roberts CL, Clarke M, Jorm L, Hunt
extended spectrum cephalosporin from the study by Anat Bahat Dinur et J, Ward J. Chlamydia and gonorrhoea
ceftriaxone and azithromycin.23 al.28 A limited transplacental transfer infections and the risk of adverse
However, as observed by the WHO to the extent of upto 2.6% of the obstetric outcomes: a retrospective
report Antimicrobial resistance: drug has been observed to cross the cohort study. Sex Transm Infect.
global report on surveillance 2014, placenta when it reaches the maternal 2013;89(8):672-678.
there are significant loopholes in N. arterial side.29 The drug is of particular
gonorrhoeae antimicrobial resistance benefit in adolescent patients and 6. Heumann CL, Quilter LAS, Eastment
surveillance, particularly where the asymptomatic infections, where many MC, Heffron R, Hawes SE. Adverse
rates of occurrence of this disease are individuals suffering from the infection Birth Outcomes and Maternal Neisseria
highest.24 No data exist on the use of are unlikely to be compliant with multi- gonorrhoeae Infection: A Population-
dual therapy to treat neonates born dosage regimens.30 Based Cohort Study in Washington
to mothers who have gonococcal Although the drugs have a good clinical State. Sex Transm Dis. 2017;44(5):266-
271.

7. Woods CR. Gonococcal infections in
neonates and young children. Semin
Pediatr Infect Dis. 2005;16(4):258-270.

8. Rothenberg R. Ophthalmia neonatorum
due to neisseria gonorrhoeae: prevention
and treatment. Sex Transm Dis. 1979;6(2
Suppl):187-191.

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Subspeciality-Cornea & External Eye Disease

9. Pamel GJ, Feldman ST. Chlamydial patient-physician interaction. Maturitas. 2010;184(3):851-858; quiz 1235.
conjunctivitis and genital gonorrhea 2009;63(2):124-127. 27. Sarkar M, Woodland C, Koren G,
in pregnancy. Arch Ophthalmol.
1990;108(3):327. 19. Johnson RE, Newhall WJ, Papp JR, et Einarson ARN. Pregnancy outcome
al. Screening tests to detect Chlamydia following gestational exposure
10. Lessing JN, Slingsby TJ, Betz trachomatis and Neisseria gonorrhoeae to azithromycin. BMC Pregnancy
M. Hyperacute Gonococcal infections--2002. MMWR Recomm Rep. Childbirth. 2006;6:18.
Keratoconjunctivitis. J Gen Intern Med. 2002;51(RR-15):1-38; quiz CE1-4. 28. Bahat Dinur A, Koren G, Matok I, et al.
2019;34(3):477-478. Fetal safety of macrolides. Antimicrob
20. Workowski KA, Berman S, Centers for Agents Chemother. 2013;57(7):3307-
11. Tan A-K. Ophthalmia Neonatorum. N Disease Control and Prevention (CDC). 3311.
Engl J Med. 2019;380(2):e2. Sexually transmitted diseases treatment 29. Heikkinen T, Laine K, Neuvonen PJ,
guidelines, 2010. MMWR Recomm Rep. Ekblad U. The transplacental transfer of
12. Fiorito TM, Noor A, Silletti R, Krilov 2010;59(RR-12):1-110. the macrolide antibiotics erythromycin,
LR. Neonatal Conjunctivitis Caused by roxithromycin and azithromycin. BJOG.
Neisseria cinerea: A Case of Mistaken 21. Matejcek A, Goldman RD. Treatment and 2000;107(6):770-775.
Identity. J Pediatric Infect Dis Soc. prevention of ophthalmia neonatorum. 30. Marra CA, Patrick DM, Reynolds R, Marra
2019;8(5):478-480. Can Fam Physician. 2013;59(11):1187- F. Chlamydia trachomatis in adolescents
1190. and adults. Clinical and economic
13. Barbeito G, Rivadulla I, Regueiro- implications. Pharmacoeconomics.
García BJ, Pardo F. [Gonococcal 22. Thanathanee O, O’Brien TP. 1998;13(2):191-222.
keratoconjunctivitis in adults: an Conjunctivitis: systematic approach to
emerging entity]. Rev Esp Quimioter. diagnosis and therapy. Curr Infect Dis Corresponding Author:
2014;27(3):213-214. Rep. 2011;13(2):141-148.
Dr. Siddharth Madan
14. Zuppa AA, D’Andrea V, Catenazzi P, 23. George CRR, Enriquez RP, Gatus BJ, M.S, D.N.B, F.I.C.O, FAICO ( Retina and vitreous)
Scorrano A, Romagnoli C. Ophthalmia et al. Systematic review and survey of Assistant professor, Department of
neonatorum: what kind of prophylaxis? Neisseria gonorrhoeae ceftriaxone and Ophthalmology , UCMS and GTB Hospital,
J Matern Fetal Neonatal Med. azithromycin susceptibility data in the University of Delhi, New Delhi-110095, India
2011;24(6):769-773. Asia Pacific, 2011 to 2016. PLoS ONE.
2019;14(4):e0213312.
15. Laga M, Plummer FA, Nzanze H,
et al. Epidemiology of ophthalmia 24. World Health Organization.
neonatorum in Kenya. Lancet. Antimicrobial resistance: global report
1986;2(8516):1145-1149. on surveillance Geneva, Switzerland:
Antimicrobial resistance: global report
16. Andrews WC. Approaches to taking a on surveillance, 2014.
sexual history. J Womens Health Gend
Based Med. 2000;9 Suppl 1:S21-24. 25. Donà V, Low N, Golparian D, Unemo
M. Recent advances in the development
17. Politi MC, Clark MA, Armstrong G, and use of molecular tests to predict
McGarry KA, Sciamanna CN. Patient- antimicrobial resistance in Neisseria
provider communication about sexual gonorrhoeae. Expert Rev Mol Diagn.
health among unmarried middle-aged 2017;17(9):845-859.
and older women. J Gen Intern Med.
2009;24(4):511-516. 26. Deguchi T, Nakane K, Yasuda M,
Maeda S. Emergence and spread of drug
18. Brandenburg U, Bitzer J. The challenge resistant Neisseria gonorrhoeae. J Urol.
of talking about sex: the importance of

24 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

Subspeciality-Cornea & External Eye Disease

The Slit Lamp to the Ocular
Laboratory Microscope: An
Eye-Opener

Isha Chaudhari1, Arpan Gandhi2, MD

1. Adjunct Consultant Cornea Department, Shroff’s Charity Eye Hospital 5027 Kedar Nath Road Daryaganj, New Delhi
2. Associate Medical Director, Head Laboratory Services Department,
Shroff’s Charity Eye Hospital 5027 Kedar Nath Road Daryaganj, New Delhi

As a first-year ophthalmology resident, has been a game changer in ulcer the heart of Uttar Pradesh. We see at
it is recommended we memorize management. least 4-5 new or previously treated ulcers
clinical features of all types of corneal everyday at the center, and most if not
ulcers for better diagnosis. As per the Figure 1: Mixed Fungal and Bacterial all patients believe it’s due to sugarcane
textbook, there are specific features finding on a Grams Stain leaf injury while walking through the
that differentiate a bacterial from Fungal Hyphae and Gram Positive Cocci field. If going by the classical history of
fungal, a fungal from parasitic, and viral a clinical diagnosis based on the vegetative trauma, all of these patients
from the rest. Despite knowing all the history and slit lamp features is of will be diagnosed as fungal and started
differentiating features by heart, why course the pillar of ulcer management, on antifungal treatment, which is clear
then the etiology of the ulcer confuses but microbiology helps in cases of by the fact that all the referred cases are
us at times and why it always remains a superadded infections, like bacterial most definitely using natamycin drops.
mystery in some? on viral, diagnosis of pythium keratitis, However, having a facility of KOH
For starters, the textbook description which is not so familiar clinically to mount and gram’s staining, at least
is of a naïve corneal ulcer, and seldom many practitioners, viral keratitis by helps us rule out fungal keratitis.
do we see a naïve corneal ulcer in our looking for viral cytopathic changes Our experience in the last three months
tertiary care referral practice. The in Giemsa stain, atypical organisms has been that
patient has already been treated with or no cardia, not suspected clinically.
cocktail therapy and now the picture is Also the importance of seeing the Figure 2: Corneal ulcer
nowhere close to the classical textbook slides and discuss the cases with the
description. Also, drug resistance has microbiologist and their team has
now emerged, where despite a correct always been rewarding and helped in
diagnosis the treatment may not work. patient Management.
Treating ulcers based just on the clinical We have experienced the real
features can sometimes be extremely importance of the diagnostic value that
confusing and also a nightmare. A ocular microbiology adds at a peripheral
box full of medications, a patient not center of our hospital. Sugarcane fields
responding to treatment and a blame surround one of our centers located in
game between the doctor’s expertise
and the patient’s compliance. This
may be the reason why after months
of treatment, the private practitioners
refer their ulcer patients else where.
It is safe to say, that using ocular
microbiology to diagnose the organism
and its sensitivity to various drugs,

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Subspeciality-Cornea & External Eye Disease

out of 154 corneal scrapings we say use that to manage patients with a 5. Whitcher JP, Srinivasan M. Corneal
a mismatch in the clinical diagnosis more holistic approach. ulceration in the developing world: A
and the microbiology findings in 46 silent killer epidemic. Br J Ophthalmol
samples – about 30 percent of the References 1997; 81(8): 622–3
cases. The maximum missed were
fungal Keratitis-55 percent followed 1. Pascolini D, Mariotti SP. Global estimates 6 M, Gonzales CA, George C, George
by Bacterial Keratitis – 34 percent. The of visual impairment 2010. British C, Cevallos V, Mascarenhas JM, et
clinical review was done in all these Journal of Ophthalmology 2012; al. Epidemiology and aetiological
46 cases and additional findings were 96:614-8 diagnosis
of corneal ulceration in
found in 27 /46 cases. Madurai, south India. Br J Ophthalmol
A detailed clinical and microbiological 2. Dandona R, Dandona L. Corneal blindness 1997; 81(11):965-71
discussion has resulted from this in a southern Indian population: Need
observation and sometimes even taking for health promotion strategies. British Corresponding Author:
a relook or a second opinion for the Journal of Ophthalmololgy 2003; 87:133-
cases has been a result. 41 Dr Arpan Gandhi
In this letter, we don’t mean to thwart MD, Associate Medical Director,
the importance of clinical features and 3. Oliva MS, Schottman T, Gulati M. Chairperson and Head Laboratory Services
detailed history taking is diagnosis and Turning the tide of Corneal blindness. Department. Delhi
management of a corneal ulcer, but Indian Journal of Ophthalmology 2012;
highlight how an ocular microbiology 60:423-7
facility aides and in some instances
leads the management. The letter 4. National Programme for the control
would like to highlight the need to of blindness. Report of National
have more clinical lab interacts and Programme for Control of Blindness,
India and World Health Organisation;
1986-89National Program for Control
of Blindness and Visual Impairment.
Available at https://npcbvi.gov.in/
writeReadData/mainlinkFile/File341.
pdf [Accessed June 4, 2020]

26 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

Subspeciality-Glaucoma

A Case Report on Topiramate
Induced Angle Closure Glaucoma
in A Young Girl

Sarkar Shreyasi1, MBBS, DO, Anuradha Chandra2, MBBS, MS,
1. Post-Diploma DNB trainee, Susrut Eye Foundation and Research Centre
2. Consultant - Glaucoma and Pediatic Ophthalmology, Susrut Eye Foundation and Research Centre

Introduction We report this case of topiramate Case History
Topiramate, a sulfamate-substituted induced secondary angle closure, who A 15-year old girl, resident of west
monosaccharide, is mainly used for had a headache with an undiagnosed Bengal came to our OPD on 1/9/2020
seizures and prevention of migraines. cause, and was under treatment with complaints of swelling of both
It also forms a part of the management with multiple drug regimens, and upper and lower eyelids of both the
for conditions like depression, topiramate was also one of them. We eyes, which started 1 day before , and
neuropathic pain, obesity, idiopathic report this case where, the side effect aggravated overnight. It was associated
intracranial hypertension, and bipolar the drug was much more severe than with blurring of vision, acute pain,
disorder.1 Topiramate-induced acute the original complaint of headache, and redness and chemosis of both the eyes.
bilateral angle closure (TABAC) and also a simple diagnosis of convergence Her visual acuity was 2/60 in both the
myopia with ciliochoroidal effusion is insufficiency, was missed previously, eyes, which improved to 6/18 with
a recognized side effect of topiramate whose treatment was the key solution pinhole. No history of similar episode
with a relatively low prevalence2-9. to the problem.
TABAC is important because of the Figure 1: bilateral eyelid oedema
following reasons: firstly, topiramate
is increasingly prescribed; secondly,
features of this disease are unusual and
its pathogenesis not clearly understood
as-well; and thirdly, its treatment is
different than that for primary acute
angle closure.2 In July 2001, Banta et
al[4] first reported a case of secondary
angle-closure glaucoma associated with
topiramate use, since then, several cases
of ocular side effects associated with
topiramate have been published. The
presenting symptom in the majority of
patients was blurring of vision.3

AS-OCT (anterior segment optical
coherence tomography) is a good
diagnostic modality for ciliochoroidal
effusion along with ciliary body
rotation, in topiramate induced
secondary angle closure, and the first
case was reported by Christopher van
Issum in 2010.

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Subspeciality-Glaucoma

Figure 2: angle closure on AS OCT the eyes. She was advised a topical usually manifests in 2 weeks after
combination of eyedrop gatifloxacin starting the medication, and is
in the past. No history of any ocular or (0.3%) and dexamethasone (0.1%) on associated with myopia, choroidal
systemic comorbidities. a QDS basis for 5 days with a tapering effusion is also noted in many a case. 5,8,
She had a history of recurrent headache, dose, eyedrop atropine 1% BD for both .10,11
for which her treatment included eyes, was suggested a discontinuation of
multiple medications. On detailed topiramate after a neurological opinion Pathophysiology: Topiramate causes
history taking, she mentioned, that and asked for a review after 2 days. modulation of Na channels, GABAA
topiramate was one of the medications. receptors and AMPA/kainite and
On follow-up, examination after 1 may bind to AMPA/kainite receptor
General Examination week, her IOP was 15 and 18 mm of membrane channel complexes, thus
BP- 90/60 mm of Hg, Pulse- 72 beats/min. Hg measured on Tonopen, her BCVA modulating the ionic conduction.12
No signs of pallor, icterus, clubbing, was 6/6 (+1.25 DS with -1.75 Dcyl at In one case report, topiramate has
cyanosis or lymphadenopathy. 180 degree) in RE and 6/6 (+1.50 Ds also shown effects of disruption of the
with +1.25 at 180 degree) in LE. Her blood–brain barrier, thus increasing
Ocular Examination colour vision was within normal limit, the protein content of cerebrospinal
- she had bilateral lid oedema with her checked individually for each eye. Her fluid, also damaging the blood–
chemosis of both the eyes. She had topiramate has been discontinued eye barrier, causing ciliochoroidal
shallow anterior chamber depth in both without any significant side effects. effusion, which is a localized oedema13
the eyes, with regular reactive, pupillary Her NPA was 90 for both eyes and NPC Idiosyncratic hypersensitivity reaction
reactions and IOP of 30 mm of Hg in RE was 9 cm, accommodative flippers has also been reported in a previous
and 28 mm of Hg in LE (measured at 11 were 4 cycles within 1 min. She was case, and we can identify some similar
am). Her vertical cup-disc ratio was 0.2:1 further diagnosed with convergence features in our case.14 This increases the
in both the eyes with healthy neuro- insufficiency and was advised permeability of choroidal capillaries,
retinal rim and macula. Gonioscopy for convergence exercises and an thus causing the effusion. At times, this
could not be performed on that day due automated perimetry (24-2), and was choroidal effusion is due to eicosanoid
to increased chemosis. asked for a follow-up after 2 weeks. metabolism mediated by leukotrienes
On recent follow-up, she achieved 6/6 and prostaglandins.15
Investigations unaided vision in both the eyes, after
Systemic-CT scan brain was within following the convergence exercise The other probable mechanisms
normal limit. regimen properly, and her headache include- a) ciliary detachment and
Ocular-ASOCT revealed acute angle has also reduced to a great extent. So, anterior ciliary body rotation causing
closure bilaterally due to forward was advised regular follow-up with ciliary oedema, thus displacing the
pushing of the lens-iris diaphragm convergence exercises. lens–iris diaphragm anteriorly, relaxing
bilaterally. the zonule, that causes anterior
Discussions displacement of the lens.3,8 These are
Provisional Diagnosis Topiramate, a sulfamate drug, is well detected in UBM and ASOCT Ciliary
Topiramate induced acute angle closure associated with a prevalence of angle detachment and anterior rotation4,8,16
of both the eyes. closure and myopia of 3/100,000 b) Choroidal elevation pushes the
according to a food and Drug vitreous forward, thus displacing the
Treatment Administration report (http://www. lens–iris diaphragm anteriorly, but this
She was treated with intravenous fda.gov/downloads /safety/MedWatch/ mechanism is unlikely.17 c) Congestion
injection of 300ml mannitol stat. Her Safety Information/Safety Alert for of the iris and ciliary body increases the
IOP was rechecked after 90 minutes, Human Medical Products /UCM173936. iris volume and diminish the normal
it came down to 16 mm of Hg in both pdf), probably an underestimation. loss of iris volume which occurs on
Topiramate induced angle closure pupillary dilation, contributing to
angle closure18. Distinguishing features
of topiramate induced angle closure
is that a) it is not associated with very
high IOP, often below 40 mm of Hg4,8
b) mild to moderate pain and c) mild
corneal oedema in spite of having
complete angle closure. It can be due to
partial ciliary shut down, and partially
because topiramate also have carbonic

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Subspeciality-Glaucoma

Figure 3: angle closure on AS OCT 2. to prescribe IOP reducing agents thus opening the angle to some
like beta-blocker and alpha extent.
anhydrase activity which reduces the agonists. Prostaglandin analogues
aqueous production. preferably avoided, and carbonic 7. pilocarpine is contraindicated as it
Anterior segment OCT which is a anhydrase inhibitors avoided too, causes ciliary muscle spasm, and
non-contact, high-resolution, in vivo owing to its chemical structure additional pupillary block
cross-sectional, anterior segment similarity to topiramate
imaging with a spatial resolution of 10 8. peripheral iridotomy is not much
to 20 µm, and can detect topiramate 3. acetazolamide might cause useful since the angle block is not
induced angle closure well, along with secondary angle in the same due to pupillary block mechanism.
USG B scan. It can detect better, than mechanism as topiramate.
direct visualization as these effusions Conclusions
are shallow. It has limited ability to 4. intravenous mannitol helps,
visualize completely the normally though IOP doesn’t remain very As we have seen in the above case
heavily pigmented ciliary body17, but it high. reports, it can be concluded that
can demonstrate ciliary body effusion topiramate cause bilateral secondary
and has the advantage of being non- 5. topical cortico-steroids might help angle closure, which is reversible on
contact, in contrast to UBM. in reducing cilio-choroidal effusion, withdrawal of the specific medication.
Treatment and related controversies- so can be prescribed. they reduce Here, the IOP is not very high, often
1. To discontinue the causative drug- the capillary permeability by below 40mm of Hg, with mild to
tightening the capillary junctions. moderate pain. It is often accompanied
topiramate with physician`s opinion by a hypersensitivity reaction, and
6. cycloplegics help in pulling the associated with ciliary body effusion.
lens-iris diaphragm posteriorly, It’s a rare case, with a low incidence,
which is often misdiagnosed. Here,
we report this case of the young girl,
who underwent various investigations
and treatment for her non- remitting
headache, was also prescribed
topiramate as a part of the treatment.
She developed secondary acute angle
closure, as a result of the topiramate,
and presented with severe diminution
of vision, when her symptoms were
treated and actual cause was diagnosed.
The main pathology was lying with
her convergence insufficiency, which
was detected in the follow-up. She is
undergoing orthoptic exercises and is
symptomatically better at present. Also,
AS-OCT had been a very good imaging
modality in diagnosing the angle
closure and visibly thickened iris, with
its increased resolution. This case also
hints towards the importance of correct
diagnosis, at earliest, which can revive
the vision from 2/60 to 6/6 unaided in
both the eyes.

References

1. Topamax. In: Physicians’ Desk Reference,
62nd ed. Montvale, NJ: Thomson; 2008:
2378-88

2. Christopher van Issum, et al. Topiramate-
induced acute bilateral angle closure and
myopia: pathophysiology and treatment
controversies. Eur J Ophthalmol 2011;

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Subspeciality-Glaucoma

21 (4): 404-409 Topiramate-induced bilateral angle- 16. Medeiros fA, Zhang XY, Bernd AS,
closure glaucoma. Can J Ophthalmol Weinreb RN. Angle closure glaucoma
3. Fraunfelder fW, fraunfelder fT, Keates 2006 associated with ciliary body detachment
EU. Topiramate associated acute, in patients using topiramate. Arch
bilateral, secondary angle-closure 10. Medeiros fA, Zhang XY, Bernd AS, Ophthalmol 2003; 121: 282-5
glaucoma. Ophthalmology 2004; 111: Weinreb RN. Angle closure glaucoma
109-11. associated with ciliary body detachment 17. Quigley HA, friedman DS, Congdon
in patients using topiramate. Arch NG. Possible mechanisms of primary
4. Banta JT, Hoffman K, Budenz DL, et al. Ophthalmol 2003; 121: 282-5 angle-closure and malignant glaucoma.
Presumed topiramate-induced bilateral J Glaucoma 2003;12:167-80
acute angle-closure glaucoma. Am J 11. Low S, Nolan W. Anterior segment
Ophthalmol 2001; 132: 112-4. imaging for glaucoma: where are we and 18. Quigley HA. What’s the choroid got to
what next. Clin Experiment Ophthalmol do with angle closure? Arch Ophthalmol
5. Leung DY, Leung H, Baig N, et al. 2009; 37: 431-3 2009; 127: 693-4.
Topiramate and asymptomatic ocular
angle narrowing: a prospective pilot 12. Shank RP, Gardocki Jf, Streeter AJ, Corresponding Author:
study. Eye 2009; 23: 2079-81. et al. An overview of the preclinical
aspects of topiramate: pharmacology, Dr. Sarkar Shreyasi
6. Thambi L, Kapcala LP, Chambers W, pharmacokinetics, and mechanism of MBBS, DO
et al. Topiramate-associated secondary action. Epilepsia 2000; 41(Suppl): S3-9 Post- Diploma DNB trainee in Ophthalmology
angle-closure glaucoma: a case series. Susrut Eye Foundation and Research Centre,
Arch Ophthalmol 2002; 120: 1108. 13. Viet Tran H, Ravinet E, Schnyder C, Kolkata
et al. Blood-brain barrier disruption
7. Palomares P, Anselem L, Diaz-Llopis associated with topiramate-induced
M. Optical coherence tomography angle-closure glaucoma of acute onset.
for diagnosis and monitoring of Klin Monatsbl Augenheilkd 2006; 223:
angle-closure glaucoma induced by 425-7
topiramate. Can J Ophthalmol 2007; 42:
633-4. 14. Schiavino D, Nucera E, Buonomo A, et
al. A case of type IV hypersensitivity to
8. Craig JE, Ong TJ, Louis DL, Wells JM. topiramate and carbamazepine. Contact
Mechanism of topiramate-induced Dermat 2005; 52: 161-2.
acute-onset myopia and angle closure
glaucoma. Am J Ophthalmol 2004; 137: 15. Krieg PH, Schipper I. Drug-induced
193-5. ciliary body oedema: a new theory. Eye
1996; 10: 121-126
9. Levy J, Yagev R, Petrova A, Lifshitz T.

30 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

Subspeciality-Glaucoma

Recent Advances - Microperimetry
in Glaucoma

Anirudh Kapoor1, MBBS, Dewang Angmo2, MD,DNB,FRCS,FICO
1. Dr. RP Centre of Ophthalmic Sciences, AIIMS, New Delhi, India
2. Assistant Professor of Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi

Introduction possible with any static standard SLO. They differ in their dynamic range
Standard automated perimetry (SAP) is perimetry1,3. Therefore, the VF of the stimulus which is 0 to 34 dB, 0 to
a form of visual- function testing which sensitivity measured by MP is supposed 20 dB and 0 to 36 dB in MP-3, Optos OCT/
looks for visual field (VF) changes and to have better spatial localization. Also, SLO and MAIA, respectively. The MP-3
has been used in the diagnosis and MP can detect more subtle glaucoma has a wider range of stimulus intensity
to monitor progression of glaucoma functional damage than standard when compared to the previously used
and many other retinal disorders1. automated perimetry4 and can detect MP-1 model. Also, they have different
However, the detection of the site and early loss of retinal sensitivity where a background luminance, maximum
stability of retinal fixation and the standard VF examination is normal 5,6. stimulus luminance and stimuli
quantification of retinal threshold over Simultaneously,theeyetrackeranalyses projection system. In a recent study
small, discrete areas of retinal lesion are the retinal movement during fixation comparing the Nidek MP-3 and MAIA
beyond the possibility of conventional attempt to detect the fixation stability in healthy subjects, retinal sensitivity
perimetry. Microperimetry (MP) or and tries to localize the preferred retinal measurements were higher with
fundus perimetry is a novel functional locus in eccentric viewers. MAIA than with the MP-37. The MAIA
method which assesses retinal offers three different testing modes;
sensitivity to light stimulation while Types of Devices ‘Fast Test’, ‘Expert Test’ and ‘Follow-
directly examining the fundus 1, 2. Currently, three popular available Up Test’. The ‘Fast Test’ can perform a
This enables exact correlation between microperimeter devices are: macular assessment in less than three
macular pathology and corresponding minutes per eye, which is helpful for
functional losses2 and has been used as I. Nidek MP3 ( Nidek technologIES, non cooperative patients. The standard
an important tool to detect and describe Japan) (Figure 1a) MAIA examination covers a 10°
pathologies affecting the macular areas. diameter area with 37 measurement
II. Optos OCT/SLO (Optos) ( Figure 1b) points (Figure 2). Additionally, the
Principle III. MAIA microperimeter (Centervue, examination can be customized with
Microperimetry combines fundus different numbers of stimuli covering
imaging using an infrared fundus Padova, Italy ) (Figure 1c) a variable field of central vision and
camera, retinal sensitivity mapping personalized measurement points can
and fixation analysis in one exam. The These devices have similar function be added to the selected grid if needed.
fundus is imaged in real time and a light with the added optical coherence
stimulus is targeted directly on specific tomography component in Optos OCT/
points on the retina rather than a screen
(as in Humphrey Field Analyzer) and Figure 1: Different microperimeter devices (a) Nidek MP3 ( Nidek technologies,Japan)
the visual field data is directly mapped (b) Optos OCT/SLO (Optos) (c) Macular Integrity Assessment (MAIA) microperimeter
on the fundus image. An eye tracker (Centervue, Padova, Italy)
detects eye movements during stimulus
projection, allowing accurate matching
between expected and projected
stimulus on the retina. This ensures
perimetry data that is independent of
eye movements and exactly related
to the stimulated area, which is not

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Subspeciality-Glaucoma

Role of Microperimetry in inner plexiform layer (GCIPL) thickness compared to SAP and paramacular
glaucoma measured using the Cirrus HD-OCT absolute defects were seen at 6–10° from
have shown statistically significant fixation20. In the study by Kita et al21,
Primary open angle glaucoma (POAG) structure- function relationship with the evaluation of circumpapillary MP
is a progressive optic neuropathy in the central visual field sensitivity sensitivity showed similar diagnostic
which there is loss of retinal ganglion of MP in glaucoma 17,18. Orzalesi power to cp RNFL thickness in diagnosis
cells and corresponding nerve fiber et al19 had also found reduction in of early and moderate POAG. Also, more
layer loss leading to visual field losses. visual sensitivities with MP in areas of significant changes were found in the
Since it is an irreversible and potentially localized RNFL defects but with normal inferotemporal and superotemporal
blinding disorder, early detection and SAP results. In a study conducted at our circumpapillary sectors which are
subsequent management is important. centre, we evaluated early glaucoma typical for early glaucomatous damage
It has been shown that structural patients having a single nasal step or in early POAG and normal tension
changes at the optic nerve head and a single arcuate scotoma on standard glaucoma 22,23. Also , the test - retest
retinal nerve fiber layer (RNFL) loss automated perimetry (SAP), with reproducibility of MP-3 has been found
can occur well before any detectable central 10° being normal. A significant to be similar and even better to that of
functional visual loss8,9. Other studies loss of central retinal sensitivity was conventional perimeter in POAG eyes,
have shown the opposite may also recorded on MP in these patients as with a significantly stronger structure-
be true, that in some cases functional
losses can precede detectable structural Figure 2: A Standard Expert Test (37 points covering central 10°) of a 39- year old normal
loss10,11,12,13. Traditionally, glaucoma adult showing central fixation with normal macular index and normal retinal sensitivity
was considered to affect the peripheral at the macula with an average threshold value of 28.5 dB.
visual function in the early stages and
involving the central macular region
only in the advanced stages. However,
retinal image studies of the nerve fiber
layer suggest that the macular ganglion
cells are reduced, even in the early
stages of the disease 14,15. Yamazaki
et al.16 found that the mean values for
macular sensitivity of blue -on- yellow
and white-on- white perimetry in
early POAG were significantly lower
than for normal subjects and ocular
hypertension. The main application of
microperimetry has been to assess the
retinal sensitivity in patients suffering
from macular disease. However, there is
also rationale to use microperimetry in
patients with glaucoma (Figure 3) , since
light stimulation with MP is precise and
small eye movements are corrected via
motion tracking. Also, patients having
localized areas of retinal nerve fiber
layer loss with normal visual field
testing can be tested via MP to evaluate
the loss of retinal sensitivity at these
areas.

It has been reported that
microperimetry has the potential to
detect visual field losses earlier than
SAP, and these findings were consistent
with corresponding reduction in
macular thickness on time domain
OCT4. Also, macular ganglion cell and

32 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

Subspeciality-Glaucoma

functional relationship with GCC
thickness compared to HFA24,25.
However, few studies have shown
that structural changes occur prior to
functional changes in preperimetric
glaucoma 8,9. Microperimetry did
not show any benefit in predicting
preperimetric glaucoma versus
RNFL thickness on OCT, but a good
correlation with RNFL thickness was
found25. Similarly Rao et al. showed
GCIPL thickness measurement with
HD-OCT performed significantly better
than visual sensitivity by SAP and
MP27.

Advantages
Microperimetry offers a fast, easy to
perform, reproducible and reliable
method in evaluation of visual fields
which can be used in the diagnosis of
early glaucomatous changes and also
to monitor progression in glaucoma
patients. Various studies have supported
the usefulness of this technique in
early diagnosis of glaucoma, especially
for evaluation of retinal sensitivity in
patients having localized areas of retinal
nerve fiber layer defects or reduced
GCC thickness with normal standard
visual field testing.

Limitations Figure 3: A 10-2 Expert Test (68 points covering central 20°)in a 76-year old patient of
However, in patients having diffuse low tension glaucoma showing a total scotoma inferior to the fovea surrounded by reduced
RNFL defects or established visual sensitivity. Superior of the fovea reduced sensitivity was also present. The pattern is typical
field defects on SAP, MP does not add for glaucomatous optic nerve damage. The scotoma follows the distribution of the optic nerve
to the standard diagnostic techniques. fibers in the retina.(Courtesy of: Dr. Mr Markus Groppe MRCOphth, PhD Oxford Eye
Also, the reduced angle of visual field Hospital and Nuffield Laboratory of Ophthalmology, Oxford University)
(central 40 degrees) in MP, limits its
application only to patients having References 3. Midena E, Radin PP, Convento E,
central glaucomatous field damage. Cavarzeran F. Macular automatic fundus
1. Rohrschneider K, Bultmann S, perimetry threshold versus standard
Future Recommendations/ Springer C. Use of fundus perimetry perimetry threshold. Eur J Ophthalmol.
Directions (microperimetry) to quantify macular 2007;17:63–8.
Development of custom automatic sensitivity. Prog Retin Eye Res.
grid strategies, introduction of an 2008;27:536–48. 4. Lima VC, Prata TS, De Moraes CG, Kim J,
increased angle of visual fields as well Seiple W, Rosen RB, et al. A comparison
as implementation of a normative 2. Ratra V, Ratra D, Gupta M, between microperimetry and standard
database for microperimetry would Vaitheeswaran K. Comparison achromatic perimetry of the central
allow us to further increase the between humphrey field analyser visual field in eyes with glaucomatous
application of this novel technique and microperimeter 1 in normal and paracentral visual-field defects. Br J
as an adjunct in the diagnosis of early glaucoma subjects. Oman Journal of Ophthalmol. 2010;94:64–7.
detection of glaucoma. Ophthalmology. 2012;5(2):97–102.

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Subspeciality-Glaucoma

5. Miglior S: Microperimetry and 15. Stamper RL. The effect of glaucoma tomography and its correlation with
glaucoma. Acta Ophthalmol Scand 2002; on central visual function. Trans Am visual field defects in early glaucoma. J
236: 19. Ophthalmol Soc. 1984;82:792–826. Formos Med Assoc 2005;104:927–934
24. Matsuura M, Murata H, Fujino Y,
6. Midena E: Microperimetry. Arch Soc Esp 16. Yamazaki Y, Mizuki K, Hayamizu F, Hirasawa K, Yanagisawa M, Asaoka
Oftalmol 2006; Tanaka C. Correlation of blue chromatic R. Evaluating the usefulness of MP-3
macular sensitivity with optic disc microperimetry in glaucoma patients,
7. Balasubramanian S, Uji A, Lei J, Velaga change in early glaucoma patients. Jpn J American Journal of Ophthalmology
S, Nittala M, Sadda S. Interdevice Ophthalmol. 2002;46:89–94. (2018), doi: 10.1016/j.ajo.2017.12.002.
comparison of retinal sensitivity 25. Leisser C, Palkovits S, Hirnschall N,
assessments in a healthy population: 17. Hirooka K, Misaki K, Nitta E, Ukegawa Georgiev S, Findl O: Reproducibility
the CenterVue MAIA and the Nidek K, Sato S, Tsujikawa A. Comparison of Microperimeter 3 (MP-3)
MP-3 microperimeters. Br J Ophthalmol. of macular integrity assessment Microperimetry in Open-Angle
2018;102:109-113. (MAIATM), MP-3, and Humphrey Glaucoma Patients. Ophthalmic Res
field analyzer in the evaluation of the 2020;63:302-308.
8. Sommer A, Katz J, Quigley HA, et al: relationship between the structure 26. Klamann MK, Grünert A, Maier AK,
Clinically detectable nerve fiber atrophy and function of the macula. PLoS ONE Gonnermann J, Joussen AM, Huber
precedes the onset of glaucomatous (2016). https://doi.org/10.1371/ journal. KK. Comparison of functional and
field loss. Arch Ophthalmol 1991; 109: pone.0151000 morphological diagnostics in glaucoma
77–83. patients and healthy subjects.
18. Sato S, Hirooka K, Baba T, Tenkumo K, Ophthalmic Res. 2013;49(4):192-198.
9. Quigley HA, Addicks EM, Green Nitta E, Shiraga F. Correlation between 27. Rao HL, Hussain RS, Januwada M, et al.
WR: Optic nerve damage in human the ganglion cell-inner plexiform layer Structural and functional assessment
glaucoma. III. Quantitative correlation thickness measured with cirrus HD- of macula to diagnose glaucoma. Eye
of nerve fiber loss and visual field defect OCT and macular visual field sensitivity (Lond). 2017;31(4):593-600.
in glaucoma, ischemic neuropathy, measured with microperimetry. Investig
papilledema, and toxic neuropathy. Ophthalmol Vis Sci. 2013 54:3046–3051 Corresponding Author:
Arch Ophthalmol 1982;100: 1 35–146.
19. Orzalesi N, Miglior S, Lonati C, Rosetti Dr Dewang Angmo
10. Harwerth RS, Vilupuru AS, Rangaswamy L. Microperimetry of localized retinal MD,DNB,FRCS,FICO,MNAMS
NV, et al: The relationship between nerve nerve fiber layer defects. Vision Res. Assistant Professor of Ophthalmology
fiber layer and perimetry measurements. 1998 Mar; 38(5): 763–71. Dr Rajendra Prasad Centre for
Invest Ophthalmol Vis Sci 2007;48: 7 Ophthalmic Sciences
63–773. 20. Phuljhele S, Angmo D, Aalok L, Parwal All India Institute of Medical Sciences
S, Azad RV, Gupta V, et al. Functional New Delhi, India
11. Artes PH, Chauhan BC: Longitudinal evaluation of the macular area in early
changes in the visual field and optic glaucoma using microperimetry. Indian
disc in glaucoma. Prog Retinal Eye Res J Ophthalmol 2020;XX:XX-XX ( in-press
2005;24: 333–354. article)

12. Strouthidis NG, Scott A, Peter NM, et al: 21. Kita Y, Holl G, Saito T, Murai A,
Optic disc and visual field progression in Kita R, Hirakata A. Circumpapillary
ocular hypertensive subjects: detection microperimetry to detect glaucoma: a
rates, specificity, and agreement. Invest pilot study for sector-based comparison
Ophthalmol Vis Sci 2006;4 7:2904–2910. to circumpapillary retinal nerve fiber
layer measurement. Int Ophthalmol.
13. Crabb DP, Owen VMF, Garway-Heath DF: 2019;39(1):127-136.
Poor agreement between current tests of
structural and functional progression 22. Lee WJ, Na KI, Kim YK, Jeoung
in glaucoma can be explained by JW, Park KH. Diagnostic ability of
measurement noise. Invest Ophthalmol wide-field retinal nerve fiber layer
Vis Sci 2007;48: Eabstract 1615. maps using swept-source optical
coherence tomography for detection
14. Kim NR, Lee ES, Seong GJ, Kim JH, of preperimetric and early perimetric
An HG, Kim CY. Structure–function glaucoma. J Glaucoma 2007; 26:577–585
relationship and diagnostic value
of macular ganglion cell complex 23. Chen HY, Wang TH, Lee YM, Hung
measurement using Fourier-domain TJ. Retinal nerve fiber layer thickness
OCT in glaucoma. Invest Ophthalmol measured by optical coherence
Vis Sci. 2010;51:4646–51.

34 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

Subspeciality-Neuro Ophthalmology

Role of Intravenous Methyl

Prednisolone for Management of

Non-Arteritic Anterior Ischemic

Optic Neuropathy (NA-AION)

in Diabetic Patients at Tertiary

Health Care center of Gujarat.

Saxena Devendra, MS, Kshatriya Esha, MBBS, Goswami Nisarg, MBBS,
Chudasma Avani, MBBS, Hingorani Priya, MBBS

Shri Krishna Hospital , Karamsad, Anand, Gujarat.

Abstract : Objective: To evaluate the outcomes of intravenous Methyl Prednisolone for treatment of NA-AION in Diabetic
Patients Presenting to a Tertiary Care Hospital at Anand. Methods: Diabetic Patients presenting and diagnosed as NA-AION,
were conservatively managed with intravenous 1-gram methyl prednisolone (in 100 ml N.S) for up to 3 consecutive days.
The outcomes were evaluated mainly on basis of visual acuity, color vision, contrast sensitivity improvements and fundus
changes compared to their initial day of presentation at outpatient department. Results: 8 Diabetic patients, with mean age as
56.5 years were included for this study. Out of patients presenting from 5-14 days from onset of symptoms, after intravenous
methyl prednisolone, 25% showed 1-line improvement, 12.5% showed 2,3,4 line improvement each on Snellen’s chart on
Day 3.Patients presenting on 20-30 days from onset of symptoms didn’t showed significant improvement of visual acuity
post methyl prednisolone on day 3. 50% showed Contrast Sensitivity (upto 1 line) and color vision improvement (2-3 plates)
along with considerable disc edema reduction on examination by day 3. Conclusion: As per our study, intravenous high dose
methyl prednisolone provides a faster resolution of the compartment syndrome along with visual acuity improvement in the
treatment of NA-AION and is a good option with no major adverse effects seen in diabetic patients who approach timely before
optic disc atrophy sets in.

Introduction may aid in diagnosis. 97% specificity neuropathy (NAION) is most common
Anterior ischemic optic neuropathy for temporal arteritis has been seen acute optic neuropathy in people aged
(AION) results from ischemic damage to in cases of AAION in which both ESR 57-65 years.
the anterior portion of the optic nerve, a and CRP were elevated. Patients with
region primarily supplied by the short NA-AION do not show these types of 95% cases of AION are non arteritic.
posterior ciliary artery circulation. abnormalities. [1] Annual incidence is 2.3-10.2/1,00,000 in
Anterior ischemic optic neuropathy is USA
divided into two types: Optical Coherence Tomography
(OCT) is useful in assessing sectoral It presents with sudden painless
Arteritic AION (AAION) which is disc edema, retinal nerve fiber layer unilateral visual loss which may be
secondary to vasculitis (especially thickness. Fluorescein Angiography static with little or no fluctuation
giant cell arteritis). Optic disc edema shows delayed optic disc and choroidal or progressive (20-31% cases of NA-
resolution is seen in 4-8 weeks with filling may be present and can serve AION) with either episodic, stepwise
resultant optic atrophy and generalised as a diagnostic tool for AAION, given decrements or steady decline after weeks
attenuation of retinal arterioles. An that the test is performed soon after the prior to eventual stabilization, typical
elevated erythrocyte sedimentation onset of vision loss. visual field defects, relative afferent
rate (ESR) (up to 70-120mm/min) and/ papillary defect and characteristic
or serum C reactive protein (CRP) Nonarteritic AION (NA-AION): fundus changes disc edema which may
Nonarteritic anterior ischemic optic be diffuse or sectoral with hyperemic/

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Subspeciality-Neuro Ophthalmology

pale disc and may have presence of Normally there are about 1,200,000 hemangioma or Neovascularization of
peripapillary hemorrhages (seen in axons that constitute the optic nerve Disc (NVD).[7]
72% cases). to exit the eye; however, in patients
Recent data suggests that vasculopathy with structurally small optic discs any Vasculopathic risk factors:
within the paraaortic branches of short inflammatory swelling within the Diabetes, hypertension, and
posterior ciliary artery may play an confines of a tight disc might produce hypercholesterolemia are well known
important role with resultant infarction a “compartment syndrome “resulting risk factors for ischemic small vessel
predominantly located in retrolaminar in a vicious cycle of disc edema and disease according to the Ischemic Optic
region of optic nerve head. peripapillary hemorrhages.[4] The Neuropathy Decompression Trial
Pathogenesis of NAION: The exact crowded axons swell in the restricted (IONDT). [8]
pathophysiology is not known but space, and capillaries and other small
the etiology of NAION is believed to vessels among the nerve fibers are There is no independent effect of
be multifactorial and many medical compressed, resulting in cytotoxic and any of the systemic disease as a
and surgical interventions aim to vasogenic edema that causes infarction risk factor (diabetes, hypertension,
shorten the duration of disc edema and tissue loss .[5] hyperlipidemia).
yet no effective treatment has been Optic nerve head ischemia/hypoxia
established.[2] can result in secondary axoplasmic OPTIC DISC DRUSSEN: optic disc
Proposed risk factors include: The flow stasis within the optic nerve. drusen (ODD) are calcified deposits
anatomic predisposition of a “crowded” [6] However, the mechanism remains located in the optic nerve head
optic disc, systematic conditions, unclear whether ischemia results anterior to the lamina cribrosa and
such as hypertension, diabetes from local arteriolar sclerosis with or are common congenital disc anomaly
mellitus (DM), hyperlipidemia, sleep without thrombus formation, venous found in 2% population. They may
apnea syndrome, and nocturnal congestion, generalised hypoperfusion, appear as refractile bodies on disc
hypotension, side effects of some vasospasm, failure of autoregulation or surface or may be buried under disc
medical or surgical interventions, other unknown mechanisms. producing disc elevation may resemble
such as erectile dysfunction drugs, Focal hyperemic telengectic vessels like true papilledema. ODD might
amiodarone, instance liposuction and may appear on optic disc within days increase the risk of developing NAION
hemodialysis, genetic factors.[3], Optic to weeks after onset of symptoms by theoretically contributing to the
disc drusen,Hypermetropic disc known as “Luxury Perfusion” i.e “crowded” optic nerve in discs with
Cup to disc ratio: Patients with a small vascular autoregulatory response to small cup to disc ratios.[9]
cup to disc ratio are predisposed to ischemia characterized by dilatation of
NAION and are said to have a “disc at blood vessels and increased perfusion Hypermetropic disc: In 1974, Hayreh
risk”. [Figure 1] to tissue in region surrounding an reported that 7 of 10 eyes with
infarct. On FFA it appears as focal early nonarteritic anterior ischemic optic
hyperfluorescent and corresponds to neuropathy (NA-AION) had no optic
spared region of visual field. It mimics disc cup, and the remainder had only a
small cup. Absence of an optic disc cup
or only a small cup in NA-AION has
already been confirmed by several large
studies. Another study by Tomlinson
and Phillips also showed that the more
hypermetropic the eye the smaller
the cup in relation to the whole disc,
making it another risk factor for NA-
AION.[10]

Other factors: Sleep apnea, generalized
hypoperfusion, vasospasm, failure of
autoregulation, severe anemia, and
nocturnal hypotension are all potential
yet unproven pathogenetic factors for
NA-AION.[11]

Figure 1: Fundus photographs of patient with RE Na-AION showing temporal disc pallor An underlying mitochondrial
and LE NA-AION having generalised optic disc pallor abnormality has also been suggested[12]
There is no gender predisposition for
NA-AION. The mean age of onset is

36 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

Subspeciality-Neuro Ophthalmology

between 57 and 67 years, but NAION capillary blood supply of the optic controlling modifiable risk factors
may occur at any age nerve head, resulting in ischemia and like hypertension, diabetes, high
Drugs associated with the development axonal damage, leading to release of cholesterol, smoking cessation, and
of NA-AION include amiodarone[13] cytotoxic factors; therefore, worsening discontinuing amiodarone usage.
and erectile dysfunction agents,[14] the clinical course.[16] A faster resolution
but no definite relationship has been of the compartment syndrome by Laboratory tests: If Giant cell
established. rationale for the use of systemic steroids arteritis(GCA) is suspected then
Clinical course of NA-AION: for the treatment of NAION was based laboratory tests including ESR, CRP and
According to ischemic optic neuropathy on the hypothesis that steroids possibly platelets should be obtained along with
decompression trail research group decrease capillary permeability thereby a temporal artery biopsy to exclude
most of the untreated patients reduces the compression of capillaries GCA. If patient has typical presentation
remains stable with no significant in the optic nerve head reducing the of NA-AION with signs and symptoms
improvements or detoriation of visual edema and improves blood flow, which similar to Giant cell arteritis with
acuity over time. Recovery of at least 3 restores visual function.[17] normal ESR and CRP no additional
Snellen lines is found in 42.7% who had investigation is required.
initial visual acuity of <20/64. Visual Aspirin in NA-AION was thought to
acuity was 20/200 or worse in 52% at 6 act as anti-thromboembolic. However, Additional laboratory tests like Serum
months. stabilization of vision usually two large studies, one in 431 patients[18] Homocysteine for hypercoagulable
occurs within 2 months in affected eye, and another one in 173 patients,[19] have states can be considered in patients
recurrent or progressive vision loss is shown that aspirin has no long-term under 50 with personal or family history
unlikely in affected eye. benefit of reducing the risk of NA-AION of early or unexplained thrombosis.
Contralateral eye involvement is seen or improving the visual acuity in these
in 52% at 6 months. Mostly seen in patients. Neuroimaging is not necessary in
patients who are known case of diabetes all cases but MRI of the brain and
and baseline visual acuity of 20/200 or Another method includes orbits should be obtained in cases
worse.[15] Triamcinolone acetonide which is a with significant pain, to exclude
Treatment options of NAION: So crystalline steroid has also been used optic neuritis and multiple sclerosis.
far, no particular treatment has been in the treatment of various posterior Neuroimaging should also be obtained
identified for non-arteritic anterior segment disorders, its advantage in patient exhibiting an atypical course
ischemic optic neuropathy (NA-AION) is that it eliminates the adverse including those with prolonged disc
that can be shown to be effective in an systemic effects of steroids and high edema or progressive and/or recurrent
adequate clinical trial in recovering concentration of cortisone at the site visual loss more than two months after
visual loss, despite various claims. of action can be achieved for optic their initial presentation to exclude
Few treatments options available till disc edema resolution and thereby inflammatory or compressive lesions.
date are antithrombotic agents, oral/ improves the reversible component
IV steroids, optic nerve decompression of ischemic insult in NAION[20]. Carotid imaging can be done if there is
surgery, and intravitreal triamcinolone However, intraocular pressure rise, prominent pain or signs of orbital or
acetate, though they remain cataract formation and increased risk ocular ischemia are present.[22]
controversial. of endopthalmitis in uncontrolled
Medical therapy for NAION hasincluded diabetics are the adverse effects of the Differential Diagnosis of NA-
vasodilators, diphenylhydantoin (for intravitreal steroid therapy. AION: Differential diagnosis(DD’s)
its effect in improving conduction may include idiopathic, syphilitic,
in hypoxic neurons), intraocular Surgical methods of treatment include tuberculosis, sarcoid,lymes disease
pressure lowering agents and pressor optic nerve decompression surgery. cause as they are related to anterior
agents (norepinephrine) to improve In this surgery two slits or a window optic neuritis.
the gradient of nerve head perfusion are made in the swollen eye tissue
pressure to intraocular pressure, surrounding the optic nerve which Other DD’s may include infiltrative
systemic corticosteroids, anticoagulants allow fluid building up around the optic optic neuropathy, anterior orbital
and antiplatelet agents. nerve to escape thereby reducing the lesions producing optic nerve
Optic disc swelling compresses the pressure on the optic nerve, however compression, idiopathic optic disc
49% had initial visual acuity of at edema , diabetic pappilopathy.[22]
least 20/64,66% had better than 20/200
visual acuity improvements for optic Methodology
decompression surgery in literature. [21]
Our Retrospective study included 8
Preventative treatment includes Diabetic Patients diagnosed as NA-
AION who presented to our out-

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Subspeciality-Neuro Ophthalmology

patient department (no evidence for coomorbidies were noted out of which They who presented within a range of
an alternative diagnosis.). A detailed Diabetes was the most common. They 5-14 days from onset of symptoms after
history of various risk factors associated were all given intravenous 1-gram high dose methyl prednisolone 25%
with this disease was taken .They were methyl prednisolone reconstituted in showed 1-line improvement, 12.5%
serially evaluated for their vision using 100 ml normal saline daily for up to 3 patients had improvement of 2 line,3
Snellen’s chart for distance vision and consecutive days, under supervision of line 4 line each on Snellen’s chart on
Romans chart for near vision, which a physician. Day 3.
showed reduced or sudden loss of
visual acuity in affected eye, decreased Table-1: Distant Visual Acuity before and after intravenous Methyl prednisolone.
color vision with Ishihara chart,
reduced contrast sensitivity with Pelli Patient visual Distant Visual Distant Visual Distant Visual
Robson chart , pupil status assessment Number acuity on acuity on day acuity on day acuity on day
showing presence of relative afferent presentation 1 of methyl 2 of methyl 3 of methyl
pupillary defect(RAPD) of affected eye (day 0) prednisolone prednisolone prednisolone
, reduced visual field by Confrontation
test and dilated fundus examination Patient 1 6/36;6/18(PH) 6/36;6/18(PH) 6/36;6/18(PH) 6/24;6/12(PH)
with indirect ophthalmoscope showing Patient 2 Cf 2 mt;NIF Cf 3 mt;NIF 6/60;6/36(PH) 6/60;6/24(PH)
hyperemic disc or having sectoral/
diffuse optic disc pallor. Patient 3 6/24;NIF 6/18;NIF 6/18;NIF 6/12;NIF
Patients’ blood pressure and random Patient 4 6/60;NIF 6/60, NIF 6/36, NIF 6/36, NIF
blood sugars were checked before
administration of methyl prednisolone Patient 5 Cf 2 mt;NIF Cf 3mt, NIF. 6/60;6/36(ph) 6/36;6/24(PH)
injections. Patients were given methyl
prednisolone under supervision of Patient 6 Cf 2 mt;NIF CF 2mt;NIF CF 3mt;NIF CF 3mt;NIF
physician. Patient 7 Cf 1 mt;NIF Cf1.5mt, NIF Cf1.5mt, NIF Cf 3 mt, NIF
Patients were conservatively managed
with intravenous 1-gram methyl Patient 8 PL+PR FULL PL+, PR CF 1mt CF 1mt
prednisolone reconstituted in 100 HM+;NIF FULL,HM+ CFCF
ml normal saline daily for up to 3
consecutive days. The outcomes were Table 2: onset of symptoms and Distant visual acuity improvements in
evaluated daily mainly on basis of terms of Snellen’s line and in meters
visual acuity for distance and near
vision improvement at Day 3 along with Patient Number Duration of onset of Distant visual acuity improvement
their color vision, contrast sensitivity symptoms (in days) of Snellen’s line.
improvements and reduction in disc
edema seen clinically during fundus Patient 1 14 1
evaluation via indirect ophthalmoscope
compared to their day of presentation Patient 2 7 3
at outpatient department. Their Optical
Coherence Tomography(OCT) scans Patient 3 10 2
along with Fundus Photographs, pre
and post methyl prednisolone were also Patient 4 20 1
taken. After completing course of High
dose intravenous methyl prednisolone Patient 5 5 4
all patients were shifted to Oral systemic
steroid tablets according to their weight Distant visual acuity improvements
which were tapered off on weekly basis. in meter

Results Patient 6 20 3/60
There were 8 Diabetic patients were
included for this study out which 4 Patient 7 25 3/60
were male and 4 were female. Their
mean age was 56.5 years. Their Patient 8 30 1/60

Table-3 shows colour vision & contrast sensitivity of affected eye pre & post
injection methylprednisolone, improvements highlighted in Red.

Patient Pre Methyl Prednisolone Post Methyl Prednisolone
No Colour vision Contrast sensitivity Colour vision Contrast sensitivity

1 0/17 0.5 0/17 0.5

2 6/17 0.9 6/17 0.9

3 0/17 0.3 2/17 0.45

4 10/17 0.9 12/17 1.2

5 0/17 0.3 2/17 0.3

6 2/17 0.3 2/17 0.3

7 0/17 0.15 3/17 0.3

8 0/17 0 0/17 0.15

38 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

Subspeciality-Neuro Ophthalmology

Patients presenting on 20-30 days from peripapillary nerve fiber layer thickness Ganglion cell complex loss is also
onset of symptoms didn’t showed due to edema in acute stage of disease observed as one consistent finding on
significant improvement of visual which reduced subsequently after OCT.
acuity post methyl prednisolone on day methyl prednisolone and later scans
3. [TABLE 1 and 2] reduced edema of peripapillary nerve Discussion
50% showed Contrast Sensitivity (upto fiver layer along with reduced Retinal 8 patients diagnosed as having NAION
1 line) and color vision improvement nerve fiber layer (RNFL) thickness. were included in study. the mean age of
(2-3 plates), along with considerable [Figure 2] presentation was 56.6 years similar to
disc edema reduction by clinical subsequent OCT scans of follow up other studies.[23] [24] [25]
examination by day 3 as compared to shows some improvement in RNFL due Systemic risk factors noted in this study
initial day of presentation. [TABLE 3] to reduction of edema(may not be seen were diabetes like other studies.[26] [27]
OCT scans initially showed increased always in all cases). [Figure 3] Majority of diabetic patients had
uncontrolled diseases reflected by their
Figure 2: Both Eye RNFL loss due to bilateral NA-AION sugar reports.
Figure 3: RNFL thickness in subsequent followup visit Post I V methyl prednisolone In our study majority of patients had
presenting vision of <6/60 on Snellen’s
chart. After giving them high dose
intravenous methyl prednisolone for
3 days daily following results were
obtained:
They who presented within a range of
5-14 days from onset of symptoms after
high dose methyl prednisolone 25%
showed 1-line improvement, 12.5%
patients had improvement of 2 line,
12.5% patients had improvement of
3-line, 12.5% patients had improvement
of 4 line on Snellen’s chart on Day 3.
3 Patients presented on 20-30 days
from onset of symptoms didn’t showed
significant improvement of visual
acuity post methyl prednisolone on day
3.
The rationale for the use of steroids in
NA-AION comes from a study from the
late 1960’s In that study, improvement
in visual acuity occurred in 11 of 13
(85%) patients treated with systemic
steroids (60 mg prednisone daily),
compared to 5 of 11 patients (45%) not
treated. [28]
Impaired color perception is a sensitive
sign for optic nerve dysfunction and
is always present in nearly all patients
with optic nerve disease. When
compared to other categories of disease
(e.g. maculopathies, amblyopia, etc.),
optic neuropathies affect color vision to
a more significant degree at any given
level of acuity.

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Subspeciality-Neuro Ophthalmology

In our study defective color vision, less follow-up visits to conclude the Group,1995 Feb 22.
contrast sensitivity and confrontation outcomes for further period of time.
tests were seen on initial day of 9. Rueløkke, Lea L. MD; Malmqvist, Lasse
presentation. 4 patients’ i.e. 50% showed Conclusion MD, PhD; Wegener, Marianne MD;
Contrast Sensitivity improvement by 1 Thus we can conclude , intravenous Hamann, Steffen MD, PhD Optic Disc
line on Pelli Robson chart ,4 patients’ i.e. high dose Methyl Prednisolone provide Drusen Associated Anterior Ischemic
50% showed color vision improvement a faster resolution of the compartment Optic Neuropathy: Prevalence of
of 2-3 plates on Ishihara chart, 7 syndrome for the treatment of NA- Comorbidities and Vascular Risk Factors,
patients’ 87.5% patients confrontation AION by possibly decreasing capillary Journal of Neuro-Ophthalmology:
test improved along with considerable permeability and thereby reduces the September 2020 - Volume 40.
disc edema reduction in all by day edema and compression of capillaries in
3 as compared to their initial day of the optic nerve head and improves blood 10. Sohan Singh Hayreh, Nonarteritic
presentation. flow, which restores visual function and Anterior Ischemic Optic Neuropathy:
Stephen C. Pollock, Raymond E. Hubbe it proves to be a good option with no Refractive Error and Its Relationship to
in their study Records of forty-five significant major adverse effects seen Cup/Disc Ratio, 2008 by the American
patients with non-arteritic AION who in patients who approach timely before Academy of Ophthalmology.
had been evaluated at Duke University the stage of optic disc atrophy sets in.
over a consecutive four-year period were Control of Vasculopathic risk factors 11. Arnold AC;Pathogenesis of nonarteritic
reviewed retrospectively concluded may be important to avoid fellow eye anterior ischemic optic neuropathy,J
that patients with non-arteritic AION involvement. Neuroophthalmol. 2003.
have color vision correlating with
visual acuity. [29] References 12. Bosley TM, Abu-Amero KK, Ozand
OCT allows a detailed analysis of the PT, Mitochondrial DNA nucleotide
optic disc and its adjacent nerve fiber 1. Sohan Singh Hayreh, Ischemic optic changes in non-arteritic ischemic optic
layer, RNFL measurements may be used neuropathy, In Progress in Retinal and neuropathy,Neurology. 2004.
to monitor the progression of NA-AION Eye Research 2009; Volume 28.
and usefulness of measurement of GCC 13. Murphy MA, Murphy JF,Amiodarone
thickness in NA-AION. Akbari et al. 2. Tzu-Lun Huang, Kung-Hung Lin, and optic neuropathy: the heart of the
reported that thinning of the GCC is first Rong-Kung Tsai;Treatment strategy matter,J Neuroophthalmol. 2005.
detectable at 1 month after NA-AION, for non-arteritic anterior ischemic
persists for 3 months, and occurs before optic neuropathy;Tzu Chi Medical 14. Lee AG, Newman NJ,Erectile dysfunction
RNFL thinning. Larrea et al. reported Journal;Volume 25. drugs and nonarteritic anterior ischemic
that GCC thickness measurement by optic neuropathy,Am J Ophthalmol.
OCT is capable of detecting early axonal 3. Lee MS, Grossman D, Arnold AC, 2005.
damage in NA-AION eyes in the acute Sloan FA. Incidence of nonarteritic
state prior to RNFL loss. [30] anterior ischemic optic neuropathy: 15. Walsh., miller, n., subramanian, p.
These findings are similar to that seen in increased risk among diabetic patients. and patel, v., 2016. clinical neuro-
our study where progressive RNFL and Ophthalmology. 2011. ophthalmology. 3rd ed. wolters kluwer,
GCC loss corelate with above studies. pp.277-278.
Theoretically, the effect of steroid 4. Arnold AC., Pathogenesis of nonarteritic
therapy could be attributed to anterior ischemic optic neuropathy 16. Biousse V, Newman NJ, Ischemic Optic
decreased compression of capillaries Neuroophthalmol. 2003. Neuropathies,N Engl J Med. 2015.
in the optic nerve head as a result of
decreased edema and increased blood 5. Hayreh SS, Zimmerman MB,Optic disc 17. Rebolleda G, Pérez-López M, Casas-LLera
flow to the optic nerve head. Based on edema in non-arteritic anterior ischemic P, Contreras I, Muñoz-Negrete FJ,Graefes
these results, steroids are selected as a optic neuropathy. Graefes Arch Clin Exp Arch ,Visual and anatomical outcomes
treatment option for NA-AION by many Ophthalmol. 2007 of non-arteritic anterior ischemic optic
physicians, although conflicting results neuropathy with high-dose systemic
regarding its benefit have been reported 6. Purvin V, King R, Kawasaki A, Yee corticosteroids, Clin Exp Ophthalmol.
over the past 2 to 3 decades. R,Anterior ischemic optic neuropathy 2013.
Drawback of this study is limited in eyes with optic disc drusen,Arch
number of participants along with Ophthalmol. 2004. 18. Kay Dickersin, Tianjing Li, Surgery for
nonarteritic anterior ischemic optic
7. Walsh., miller, n., subramanian, p. neuropathy, Cochrane Eyes and Vision
and patel, v., 2016. clinical neuro- Group,Cochrane Database Syst Rev.
ophthalmology. 3rd ed. wolters kluwer, 2015.
pp.274.
19. Beck RW, Hayreh SS, Podhajsky PA, Tan
8. JAMA, Optic nerve decompression E-S, Moke PS (1997) Aspirin therapy
surgery for nonarteritic anterior in nonarteritic anterior ischemic optic
ischemic optic neuropathy (NAION) neuropathy. Am J Ophthalmol 123:212–
is not effective and may be harmful. 217 .
The Ischemic Optic Neuropathy
Decompression Trial Research 20. Kaderli B, Avci R, Yucel A, Guler K,
Gelisken O. Intravitreal triamcinolone
improves recovery of visual acuity in
nonarteritic anterior ischaemic optic
neuropathy. J Neuro-Ophthalmol 2007.

40 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

Subspeciality-Neuro Ophthalmology

21. Newman NJ, Scherer R, Langenberg 25. Miller NR. Walsh and Hoyt’s Clinical 30. Clinical Usefulness of Spectral-Domain
P, Kelman S, Feldon S, Kaufman D, Neuro-Ophthalmology. 4th ed. Vol. 1. Optical Coherence Tomography in
Dickersin K; Ischemic Optic Neuropathy Baltimore: Williams and Wilkins; 1982. Glaucoma and NAION,Tae Hee Lee,
Decompression Trial Research Group p. 219-21. Hwan Heo, Sang Woo Park,Chonnam
(2002) The fellow eye in NAION: report Med J.
from the Ischemic Optic Neuropathy 26. Sawle GV, James CB, Russell RW. The
Decompression Trial Follow-Up Study. natural history of non-arteritic anterior Corresponding Author:
Am J Ophthalmol. ischaemic optic neuropathy. J Neurol
Neurosurg Psychiatry 1990. Dr. Saxena Devendra
22. Walsh., miller, n., subramanian, p. Vitreo Retinal Surgeon and Proffesor of
and patel, v., 2016. clinical neuro- 27. Jacobson DM, Vierkant RA, Belongia Ophthalmology,
ophthalmology. 3rd ed. wolters kluwer, EA. Nonarteritic anterior ischemic optic Pramukh Swami Medical College, Karamsad.
pp.278-279. neuropathy. A case-control study of
potential risk factors. Arch Ophthalmol
23. Repka MX, Savino PJ, Schatz NJ, Sergott 1997.
RC. Clinical profile and long-term
implications of anterior ischemic optic 28. Foulds WS. Visual disturbances in
neuropathy. Am J Ophthalmol 1983. systemic disorders: optic neuropathy
and systemic disease. Trans Ophthalmol
24. Johnson LN, Arnold AC. Incidence Soc UK. 1970;89:125–146.
of nonarteritic and arteritic anterior
ischemic optic neuropathy. Population- 29. Stephen C. Pollock, Raymond E.
based study in the state of Missouri Hubbe,Color vision in anterior ischemic
and Los Angeles county, California. J optic neuropathy,American Journal of
Neuroophthalmol 1994. Ophthalmology Case Reports,Volume
19,2020.

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Subspeciality-Retina

An Interesting Case of Recurrent
Retinal Detachment in a Case of
Fundal Coloboma with Old Settled
RD!

Devendra Saxena, M.S, Saloni Desai, M.S
Department of Ophthalmology, Shree Krishna Hospital , Gujarat

Keywords: Keywords: Retinal detachment, fundal coloboma, old settled retinal detachment
Abstract: Ocular coloboma is a rare ocular malformation which occurs due to defective closure of the embryonic fissure, which
normally occurs in the sixth and seventh week of gestation. It may involve the iris, ciliary body, lens, choroid, retina, and optic
nerve. Congenital absence of part of the retinal pigment epithelium and choroid is coloboma of the choroid.
In the case below, the patient had old settled retinal detachment on the upper and lower nasal part along with recurrent retinal
detachment on supero-temporal part due to proliferative vitreo-retinopathy (PVR) changes with retinal break and sub retinal
fluid. Retinal detachments were recurrent due to PVR changes.
The overall anatomic success rate of retina reattachment surgery in eyes with coloboma is good, and the visual outcome
following surgery can improve in the majority of the cases or may remain the same in a few cases. Hence, timely surgery is
advocated. But careful follow-up is required as the risk of postoperative complications is also high.

Introduction terminates as a distinct pigmented cases of retinal detachment associated
layer peripheral to this point of with choroidal coloboma the preferred
A congenital defect caused by the reversal. The split in the retinal layer technique for retinal detachment is
faulty closure of embryonal fissure occurs at the level of the inner nuclear viterectomy with either long-acting
is known as fundal coloboma. or outer plexiform layer or both. Locus gas or oil tamponade.
Choroidal coloboma occurs in 0.14% minoris resistentiae is the junction The use of silicone oil has the advantage
of the general population and is where this reversal occurs. of being a long-term tamponade of the
characterized by congenital absence of As the intercalary membrane is traced entire colobomatous border. Breaks
part of the retinal pigment epithelium centrally, it progressively becomes in the intercalary membrane can be
and choroid. Chances of retinal thinner. identified pre or intraoperatively,
detachment are about 40% in these At the junction and in the intercalary whereas the breaks at the locus minoris
patients, typically in the second decade membrane, breaks can occur. Also, resistentiae are not identifiable but can
of life. peripheral retinal breaks can occur. be expected to be located along the
When the retinal breaks are located: (A) coloboma border. The placement of
The retina splits into two layers near outside the area of coloboma, (B) inside an encircling band is performed on a
the margin of the coloboma. The outer the anomalous retinal tissue within the purely empirical basis.
layer turns back, becomes disorganized coloboma, or (C) both, these patients The retinal breaks can overlie bare
and fuses with retinal pigment with posterior segment colobomas are sclera, and achieving chorioretinal
epithelium, while the inner layer at a risk for retinal detachment (RD). In adhesion is not possible simply
continues as an intercalary membrane
on the coloboma. The choroid

42 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

Subspeciality-Retina

Figure 1: Fundus photograph of left eye shows inferior fundal Figure 4: Fundus photograph of left eye shows supero-temporal
coloboma settled retina and indentation of the scleral buckle.

Figure 2: Fundus photograph of left eye shows superotemporal Figure 5: Fundus photograph of left eye shows settled retina post
settled retina and indentation of the scleral buckle. operatively

Figure 3: Fundus photograph of left eye showing supero-temporal Figure 6: Fundus photograph of left eye showing inferior coloboma
settled retina and indentation of the scleral buckle with a small with subretinal bands and supero-temporal laser marks.
horse-shoe tear with vitreous traction.

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Subspeciality-Retina

because there are no choroids for the Immediate post-operative distant nerve. Congenital absence of part of
retina to adhere to. Therefore, the vision in left eye was counting finger the retinal pigment epithelium and
retinal breaks overlying the coloboma 3MT on snellen’s distant visual acuity choroid is coloboma of the choroid.
stay open. Some surgeons attempt to chart and improved upto 6/36 with
form a barrier by lasering the edge -3.00DSph/- 4.00DCyl x 90 after 2days. • In the above case, the patient had
of the coloboma. This laser needs The near vision was N36. Dilated old settled retinal detachment
to be applied to the whole extent of fundus examination showed settled on the upper and lower nasal
the coloboma and may or may not retina and retinal break with vitreous part along with recurrent retinal
be effective due to lack of developed traction over the buckle. The patient detachment on supero-temporal
RPE. was started on topical antibiotics, part due to PVR changes with
steroids, cycloplegics and anti- retinal break and sub retinal fluid.
Case glaucoma drugs in the left eye. Retinal detachment were recurrent
due to PVR changes.
A 28 year old male presented to the eye On follow up laser barrage around the
OPD at SKH on 23th September 2019 break was done due to insufficient • Iris coloboma and inferior fundal
with chief complaint of gradual painless cryoreaction. coloboma were present and
loss of vision in his left eye since 3 secondary breaks were identified.
months. The patient had phthisis bulbi Subsequent fundus examination after
on the right side as a result of corneal a few days showed persistent supero • Since, there is poor contrast due
ulcer 2 years ago. temporal retinal detachment and to absence of retinal pigment
hence patient underwent (LE) Intra- epithelium and choroid and there
On examination vitereal injection SF6 of expansile is associated nystagmus, there
concentration of 0.5cc on 12/12/19 if often difficulty in identifying
Distant visual acuity for (RE) was no and paracentesis was done at 9 o clock the breaks. Other factors include
perception of light and in (LE) on position. presence of atrophic holes without
snellen’s visual acuity chart was 6/60 the presence of flaps or opercula
improving upto 6/24 with -4.00Dcyl Immediate post-operative distant in the thin rudimentary retina
x 80. Near vision in LE was N18 and vision in left eye was counting finger and hidden breaks in overhanging
improved upto N12 with correction. 1MT on snellen’s distant visual acuity edge of coloboma or in areas of
chart and improved upto 6/24p with haemorrhage.
(LE) pupillary reaction was present. -3.50DSph/- 4.00DCyl x 80. The near
Inferiorly iris coloboma was present in vision was <N36. The patient continued • Scleral buckling and cryopexy was
(LE). the topical antibiotics, steroids, done followed by laser barrage and
cycloplegics and Anti-glaucoma drugs intra-vitreal SF6 gas injection and
Dilated fundus examination revealed in the left eye on tapering dosage. the retina was settled.
superotemporal retinal detachment
with horse-shoe tear and old settled The distant vision after 2months was The overall anatomic success rate
retinal detachment over the nasal and 6/60p improving upto 6/18p with of retina reattachment surgery in
inferior retina, sparing fovea along -2.50DSph/-5.50DCyl x 90 and the near colobomatous eyes is good, and the
with inferior coloboma 5 clock hours vision was N12 improving to N10 with visual outcome following surgery can
sparing optic disc. +3.00DSph. The fundus examination improve in majority of the cases or
revealed flat retina with macula on and may remain same in few cases. Hence,
The patient was diagnosed with sub-retinal fibrosis at macula. timely surgery is advocated. But careful
(RE) Phthisical eye and (LE) supero- follow-up is required as the risk of
temporal retinal detachment with Discussion postoperative complications is also
iris coloboma with old spontaneously high.
settled retinal detachment over nasal Ocular coloboma is a rare ocular
and inferior retina and PVR changes malformation which occurs due to Conclusion
with subretinal bands at macula. defective closure of the embryonic
fissure, which normally occurs in the Patients with posterior segment
The patient was advised surgery and sixth and seventh week of gestation. colobomas are at risk of rhegmatogenous
underwent (LE) cryopexy + 360 degree retinal detachment (RRD) occurring as a
scleral buckling with 42 band with SRF • It may involve the iris, ciliary body, consequence of retinal breaks. Although
drainage at 1 o clock on 25/11/19. lens, choroid, retina, and optic spontaneous retinal reattachment has

44 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

Subspeciality-Retina

been reported in the literature, most Thapa, Sanyam Bajimaya, Sanjita Corresponding Author:
retinal detachments associated with Sharma, Eli Pradhan, “A Study on Pattern
chorioretinal coloboma require surgery of Retinal Detachment in Patients with Dr. Saxena Devendra
and often have good visual outcomes. Choroidal Coloboma and Its Outcome Vitreo Retinal Surgeon and Professor of
after Surgery at a Tertiary Eye Hospital in Ophthalmology,
Scleral buckling with cryotherapy can Nepal”, Journal of Ophthalmology, vol. Pramukh Swami Medical College, Karamsad.
be a good alternative with satisfactory 2019, Article ID 7390852, 5 pages, 2019.
visual outcome to PPV with silicone https://doi.org/10.1155/2019/7390852
oil injection as seen in this case with
recurrent retinal detachment along 2. Hussain RM, Abbey AM, Shah AR,
with PVR changes. Drenser KA, Trese MT, Capone
A Jr. Chorioretinal Coloboma
References Complications: Retinal Detachment
and Choroidal Neovascular Membrane.
1. Barsha Suwal, Govinda Paudyal, Raba J Ophthalmic Vis Res. 2017;12(1):3-10.
doi:10.4103/2008-322X.200163

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Subspeciality-Retina

A case of ‘Branch Retinal Artery
Occlusion’ during Recovery Phase
of a Covid Positive Patient

Bharti Shivnani, MBBS, DNB
Department of Ophthalmology, Bhopal Memorial Hospital and Research Centre, Bhopal Madhya Pradesh.

Abstract: In the ongoing era of COVID-19 where the disease is manifesting in various forms, the clinical signs and symptoms
in the eye could not be ignored and can be attributed to the underlying disease. This also leads to further diagnosis of the disease
and the systems affected by it which is essential for appropriate intervention.
Here I am reporting a case of Branch Retinal Artery Occlusion secondary to COVID-19 in a patient 15 days after he tested positive
for SARS-CoV-2.

Introduction

Amidst COVID-19 Pandemic, we
came across several reports of ocular
manifestation in patients with covid-191
.Wu et al. described a case series
involving 38 patients with covid-19
where 12 patients had ocular signs of
conjunctivitis and epiphora2.

Here I report a patient who presented
with peripheral loss of vision in one eye
during recovery phase of covid-19.

Case Figure 1: Fundus Photograph of Left eye of patient showing retinal edema in inferotemporal
quadrant along with emboli lodged at different levels and characteristic boxcarring of vessels
A 72 year old male patient presented suggestive of Branch Retinal Artery Occlusion.
in Eye OPD with complaint of sudden
onset of diminution of vision in left
eye since one day. It was painless and
progressive in nature, not associated
with flashes, floaters or headache. His
both eyes were operated for cataract one
year back.

Patient is a known case of hypertension
since 20 years, controlled on
medications. He was found to be COVID
POSITIVE by RT-PCR test 15 days back
for which he was admitted in hospital
for one week with complaint of mild
fever and treated symptomatically.

46 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

Subspeciality-Retina

On clinical examination the Best examination rule out Non Arteritic virus and its effects. This case report
Corrected Visual Acuity in Left eye was Ischaemic Optic Neuropathy. CRVO will allow us to increase our knowledge
6/9p with Grade I RAPD and loss of visual was unlikely due to absence of retinal about the various ocular manifestations
field in superior and nasal quadrant on haemorrhages and cotton wool spots on and be vigilant about the vision
confrontation test. On dilated fundus fundus examination4. threatening ocular disease(s)10.
examination, retina was found to be
edematous in inferotemporal quadrant Given history of peripheral vision Declaration Of Patient
in left eye with boxcarring of vessels loss in one eye along with normal Consent:
and emboli lodged at various levels neurological examination and as per
(fig.1) the ophthalmic findings – Branch The author certifies about the
Retinal Artery Occlusion was the most appropriate patient consent form
The right eye of patient appeared to be likely diagnosis in our patient. where the patient has given his consent
normal on examination. Patient was for his images (retina) and other clinical
diagnosed with Branch Retinal Artery BRAO stems from occlusion of a information to be reported in the
Occlusion in Left eye status post covid branch of the central retinal artery and publication. The patient understands
recovery. Thereby patient was referred accounts for approximately 38% of all that due efforts will be made to conceal
for urgent cardiology opinion in view acute retinal artery occlusions5. More his identity, but anonymity cannot be
of carotid and left ventricle thrombus than 90% of patients with BRAO are guaranteed.
which was later ruled out. The systemic above the age of 40 and have vascular
investigations advised i.e. Hemogram, risk factors such as hyperlipidemia and Financial Support And
CRP, ESR, Serum Homocysteine levels hypertension. Most patients with BRAO Sponsorship
and Blood Sugar levels were within recover normal vision gradually6.
normal limits. However patient’s Lipid Nil
Profile was slightly deranged with LDL The pathophysiology associated in this
levels on higher side. The D Dimer level case could be inflammation associated Conflicts of Interest:
was found to be border line ( 495ng/ with covid-19 but his ESR and CRP
ml ). The neurological examination of were normal7. Another mechanism There are no conflicts of interest.
patient was found to be normal. Thereby could be related to the thromboembolic
patient was started with anticoagulants phenomenon seen in covid-19 patients References
and atorvastatins and asked for regular although our patient’s D-dimer level
follow-up3. was normal8. 1. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou
CQ, He JX, et al. Clinical characteristics
Discussion Magro et al. showed that there might of coronavirus disease 2019 in China. N
be a microvascular injury syndrome Engl J Med 2020;382:1708-20.
The clinical spectrum of illness due to mediated by action of complement
COVID-19 continues to evolve. Sudden pathways and an associated 2. Wu P, Duan F, Luo C, et al. Characteristics
loss of vision is a medical emergency procoagulant state that may be at play of Ocular Findings of Patients With
and can occur over a period of a few in these patients9. Coronavirus Disease 2019 (COVID-19)
seconds or minutes to a few days. Vision in Hubei Province, China. JAMA
may become blurry, cloudy, completely Our patient’s symptoms were early in Ophthalmol. 2020;138(5):575–578.
or partially absent or affected by flashes the course of his illness. A thorough
and floaters. cardiovascular and neurological 3. Tang N, Bai H, Chen X, Gong J, Li D,
examination is essential in all Sun Z. Anticoagulant treatment is
Common causes of sudden vision patients diagnosed with covid-19. This associated with decreased mortality in
loss include Central Retinal Artery case illuminates wide spectrum of severe coronavirus disease 2019 patients
Occlusion, Central Retinal Vein covid-19 related symptomatology and with coagulopathy. J Thromb Haemost
Occlusion, Retinal Detachment, emphasizes the need for clinicians 2020;18:1094-9.
Optic Neuropathy, or inflammatory to be aware of the various clinical
conditions like Giant Cell Arteritis. manifestations associated with this 4. Marinho PM, Marcos AAA, Romano AC,
Since ESR and CRP were within infection. Nascimento H, Belfort R Jr. Retinal
normal limits and no complaint of findings in patients with COVID-19.
scalp tenderness, GCA was less likely. Conclusion Lancet 2020;395:1610.
No signs of disc edema on fundus
With the prevailing information 5. Olsen TW, Pulido JS, Folk JC, Hyman
regarding the ocular manifestations, L, Flaxel CJ, Adelman RA. Retinal and
much is still unknown regarding the Ophthalmic Artery Occlusions Preferred
Practice Pattern(R). Ophthalmology
2017;124(2):P120-p143.

6. Hayreh SS, Podhajsky PA, Zimmerman
MB. Branch retinal artery occlusion:
natural history of visual outcome.

www.dosonline.org/dos-times DOS Times - Volume 26, Number 5, March-April 2021 47

Subspeciality-Retina

Ophthalmology 2009;116(6):1188-1194. 2016; vol. 6, no. 1, pp. 69–80. Corresponding Author:

7. Casagrande M, Fitzek A, Püschel 9. Magro C, Mulvey JJ, Berlin D, et al. Dr. Bharti Shivnani
K, Aleshcheva G, Schultheiss HP, Complement associated micro MBBS,DNB Ophthalmology
Berneking L, et al. Detection of SARS- vascular injury and thrombosis in 10, Nirmal Nursery, Opposite Sanskar School,
CoV-2 in human retinal biopsies of the pathogenesis of severe COVID-19 Bairagarh Bhopal, M.P. (462030)
deceased COVID-19 patients. Ocul infection: a report of five cases Transl
Immunol Inflamm 2020;28:721-5. Res. 2020;S1931-5244(20)30070-0.

8. E. Giannitsis, J. Mair, C. Christersson 10. Sheth JU, Narayanan R, Goyal J, Goyal
et al., “How to use D-dimer in acute V. Retinal vein occlusion in COVID-19:
cardiovascular care,” European Heart A novel entity. Indian J Ophthalmol
Journal Acute Cardiovascular Care, 2020;68:2291-3.

48 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times

Subspeciality-Retina

OCTA Features of Diabetic
Retinopathy – New Era

Shalin Shah, MS, Rahul Mayor, DNB
Vitreoretina Services, Dr. Shroff’s Charity Eye Hospital, New Delhi

Diabetic retinopathy (DR) is leading Figure 1: (A) Microaneurysms surrounded Microaneurysms seen on superficial
cause of blindness in the working-age by capillary nonperfusion area (1, 2), capillary plexus (SCP) as round,
population worldwide.[1] DR affects punched out foveal avascular zone (FAZ) saccular or fusiform focal hypersignal.
30% of patient of diabetes mellitus and outline (3), capillary loops surrounded [6] [Fig1A(1,2)]
proliferative diabetic retinopathy (PDR) by capillary nonperfusion area (4, 5),
affect 9% of these.[2] blind-end capillaries (6, 7), and capillary FAZ is specialized region of retina that
Fluorescein angiography (FFA) is nonperfusion area (8, 9). (B) OCTA scan of is entirely devoid of retinal vessels,
useful for identifying morphological healthy individual in SCP the FAZ outline including capillaries. FAZ on superficial
and functional changes in retinal is clear and uninterrupted and the capillary capillary plexus (SCP) called superficial
vasculature in DR. FFA is invasive plexus is regular, without nonperfusion FAZ and on deep capillary plexus (DCP)
procedure with various side effects and area. (C) In DCP the FAZ outline is less called deep FAZ. OCTA detect irregular
complications of dye. clear but still uniform and symmetrical, and outline, dropout of the anastomotic
Optical coherence tomography no capillary loss appears (D) OCTA image vascular arcade and also enlargement of
angiography (OCTA) is a promising of SCP in patient with NPDR showing an FAZ area.
noninvasive emerging tool capable of enlarged FAZ, multiple microaneurysms
imaging retinal vasculature without dye (arrows) and capillary nonperfusion areas. Also OCTA in NPDR detect venous
injection. It is a method of visualizing (E) OCTA image of DCP in same patient tortuosity, capillary loss which is defined
the movement of red blood cells by showing remodeling of the FAZ, which look as non perfusion areas characterized by
analyzing the change in the intensity even more enlarged compared to the SCP. a dark zone without any flow signal,
and/or phase signal arises from repeated with loss of speckled hyperreflectance
B scan performed in the same location.[3] homogeneity, capillary loops and blind
OCTA it probably represents the future ended capillaries which are dilated
in the early detection and management interrupted terminal vessel surrounded
of this disease.[4] by an area of capillary loss.[5]
Following are OCTA features of non-
proliferative and proliferative diabetic The clinical utility of these finding has
retinopathy. yet to be determined but it is likely that
OCTA will allow clinician to detect
OCTA features in NPDR subtle microvascular change earlier
Following abnormalities commonly than conventional clinical examination
concordant in NPDR in literature using and FFA.
OCTA.[5,6]
Microaneurysms, venous tortuosity, OCTA feature of intraretinal
enlarge foveal avascular zone (FAZ), microvascular abnormalities
capillary loss, capillary loops, blind (IRMA)
end capillaries are early signs of NPDR
which can picked up on OCTA. IRMA are arteriolar–venular shunts that
run from retinal arterioles to venules,
thus bypassing the capillary bed. All
IRMAs originated from the venous
side at the edge of the capillary non

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Subspeciality-Retina

Figure 2: (A,B): Fundus Photograph and fluorescein angiography (FFA) showed tortuous 1. Type 1 NVE
and dilated vessels arising from the venous side. The hairpin-like looping vessel (arrow)
originate from and drain into a retinal venule without dye leakage and is shown to be an 2. Type 2 NVE
IRMA. The bowknot-shaped vessel (arrowhead) was shielded by dye diffusion and is shown
to be an NVE. (C,D) The hairpin-like looping vessel is in the retina (arrow): there is no 3. Type 3 NVE
breach of the internal limiting membrane (ILM), and it is confirm as IRMA. The IRMA have
a pruned-tree appearance, it is confine to a single nonperfused area and never exceeded it. Type 1 NVE

Type 1 originate from the venous side
and the NVEs are located at the margin
of CNP, arising from the ganglion
cell layer and nerve fiber layer, that
represent the layers of major retinal
vessels. It is least common subtype.

Arising from the venous side at the
margin of CNP, the NVEs breach the
ILM, then extended into the vitreous
cavity and remain as the one main
vessel until it attached to the outer
aspect of the posterior hyaloid surface;
then many branches formed rapidly,
with a tree-like appearance. [Fig 3]

perfusion (CNP). All IRMA originated
from and drained into a retinal venule
at the margin of CNP, and extended into
the retina.[7]

On OCTA IRMA has appearance of a
pruned tree. They were usually confined
to a single CNP and never exceeded it.
On OCT B scan it never breach internal
limiting membrane (ILM). [Fig 2]

OCTA features in early Figure 3: A type 1 neovascularization elsewhere (NVE) (A) Patient with PDR, The
proliferative diabetic neovascularization is inconspicuous in the photograph (arrow). (B) Neovascularity is
retinopathy (PDR) confirm by FFA. (C) The new vessel (NV) arise from the nerve fiber layer (arrow), and
then breach the internal limiting membrane (ILM) (D) After breaching the ILM, the NV
On biomicroscopy and fundus extended into the vitreous cavity and remain as the only main vessel (arrow).
photography were not sufficient to
detect early neovascularization of
disc (NVD) and neovascularization
elsewhere (NVE). FFA is useful tool
for detecting NVD and NVE. But due
to noninvasive nature OCTA is new
emerging tool for detecting early
neovascularization in PDR.

• OCTA feature of NVE

Pan J et al classify neovascular elsewhere
(NVE) into 3 type based on OCTA.[7]

50 DOS Times - Volume 26, Number 5, March-April 2021 www.dosonline.org/dos-times