EDITORIAL
Editorial
Dear Colleagues, at the last 2 years I have mixed feelings. I feel
happy that I have been able to carry forward
At the onset let me the responsibility given to me by you all and
congratulate all of you for also feel that I will miss the various activities
making our Annual of the secretary's office which has kept me
Conference on 2nd & 3rd April preoccupied for the last 2 years. DOS Times
a grand success.This year we the pride of our society, has been very regular
had a record participation not in last two years. When we took over I gave a
only by the members but also by the traders. new look to the cover of DOS Times, which
The scientific program was well planned and represented a mix of new emerging
executed which was appreciated by every knowledge over old existing heritage of DOS.
delegate. A total of 230 faculty which included The concept of multispeciality approach to
6 International & 80 National guest faculty various subjects & more emphasis on
covered various scientific sessions. Apart practicals topics, surgical techniques has been
from the scientific content, the hospitality was widely accepted by all members. We designed
well taken care of and the DOS Annual dinner entire two years (20 issues) of DOS Times in a
on the 2nd evening was enjoyed by all manner where we could cover almost all
including the family members. Our Annual important topics without repeatation of
Conference is one of the most popular subjects. I and my editorial team would like
conference in the country, delegates from to extend sincere thanks to all International &
different parts the India and neighbouring National authors who contributed to success
countries like Srilanka, Pakistan, Bangladesh, of DOS Times.
Nepal and Soudi Arabia have attended this
years DOS Conference. The scientific sessions On my behalf I thank my Associate
were well attended and most halls were over Editors for DOS Times and Mr. Parveen my
crowded, seeing the congestion it seems that secretary for making things possible, without
we will need bigger halls & more spacious their help it is indeed impossible to get DOS
venue to hold the Annual Conference in Times published in time. I am thankful to my
future. DOS popularity amongst the traders most understanding wife & children for
is not surprising as most traders prefer central sparing me for DOS activities and bearing with
location like Delhi and their interaction with the lost prime time for them in last two years,
delegates and business is most profitable. All I intend to make up for them this year.
this would not have been possible without
your support and the backing of the DOS Anyway all good things have to come to
Executive , the organizing committee and an end and I am sure the next team of DOS
numerous volunteers who worked very hard Times will continue from where we have left
to make this event such a success. and also improve upon this most popular
bulletin of recent times.
This is my last communication to you
through this editorial and when I look back Dr. Jeewan S. Titiyal
April, 2005 373 DOS Times - Vol.10, No. 10
Outgoing President's Address
Dear Colleagues, It is a matter of great pride and privilege for me that the
DOS Conferences (Midterm and Annual) are the best in the
I got your blessings last year on world. This has been possible due to untiring efforts of the
this floor as President of DOS in Secretary DOS, Dr. J.S. Titiyal, the Executive body,
which I promised to you that I will do conveners, co-conveners, discussants and presenters in their
my best for the academic and respective fields. The global burning topics in ophthalmology
administrative excellence of DOS. have been scientifically threshed out and discussed for all
The working of the DOS has been levels of ophthalmologists in these one and two day
overhauled on all fronts : administrative, accounting, meetings.
purchasing, for award of contract of printing of DOS Times
and DJO, Audio visual hiring, erection of stalls, lunch and Delhi Ophthalmological society also needs a DOS House
dinner. I am pleased to tell you that the revisions and for the society. It is my feeling that members would prefer to
corrections introduced by new system paid DOS a rich have a DOS House in the Central New Delhi area. However,
dividend. at present the finances of the Society are not enough to buy
a plot, hence the subsequent Executive Committees should
In accordance with the constitution new members’ explore the availability of the land with the Govt. of Delhi,
credentials were presented to the executive committee and NCT and DDA.
were duly verified and recommended for ratification to the
GBM. Adoption of this procedure in future will prevent the The DOS Members in private practice have to buy very
complaints in this regard. expensive equipments to keep themselves updated in their
specialty. However, it is seen that there is great difficulty in
Every member of DOS regularly gets 10 issues of DOS maintenance and upgrading equipments. Keeping this in
Times yearly except for the month of May and June. The mind I tried to streamline the purchasing / maintenance /
distribution of the Journal was given to M/s Syntho upgrading of equipments with major companies. I am grateful
Pharmaceuticals. Mr. S.K. Banerjee of M/s Syntho to Dr. S. Bharti who was chairman for this Committee, for
Pharmaceuticals really deserves a credit for the excellent his efforts.
job which he has performed honestly and sincerely for DOS.
To improve the quality of the DOS Secretariat response I promised the members that I would work for the
to the members grievances, the President and Secretary registration of Eye day care centre. However I must tell you
began a system of direct acceptance of the same via e- that it is not feasible at present because it needs long
mail. sustained efforts on the part of DOS, DGHS (NCT), Health
In the past year, efforts were also made to get DOS Minister and Cabinet which are difficult to muster. The DOS
registered and approved for accreditation by DMC. member are requested to get their centers registered under
Nursing home / or hospital category and name it as centre
The New DOS credit rating system has been strictly or Hospital and not nursing home as master plan NH 2001
implemented in the past year. do not allow NH in residential areas.
On the Academic front, it was decided to provide different I am thankful to entire executive and members in general
focus to the DOS Times & DJO, In the new scenario, DOS who supported my concept in bringing out the changes in
Times was used for publication of well established facts and the working of DOS. My special thanks are to Dr. J.S. Titiyal,
procedures while DJO was used to publish articles on Secretary, DOS and Dr. Rakesh Mahajan, Treasurer DOS
controversial subjects. Personally I would like to see efforts who stood by my side under turbulent crisis and helped me
started in order to index the DJO in the next few years. in successfully updating the working of DOS. I would fail in
my duty if I do not thank Dr. Satish Sabharwal, Dr. B.N.
In addition, we also instituted a new concept whereby it Khanna, Dr. D.K. Sen, Dr. Hari Mohan, Dr. B. Patnaik, Dr.
has become possible for non institutional members to present
a case during the DOS monthly meetings.
April, 2005 374 DOS Times - Vol.10, No. 10
R.B. Jain and Dr. R.B. Vajpayee for their physical and moral annihilating or compromising on the quality of scientific
support to uphold the function of DOS. I am greatly indebted deliberations presentations.
to all of them.
I wish Dr. Noshir Shroff who is taking over as the President
I feel that our paramedical companies executive heads all the best; his multifarious qualities are well known already.
need a word of thanks. I am thankful to Shri Diwakar Paul, I am aware of his great qualities from the student days when
K.L.B. for his immense help in the execution of affairs of I was in the teaching Faculty of Maulana Azad Medical
DOS who agreed to help unconditionally for various odd jobs. College. I prey for his success.
I feel he deserves a letter of appreciation from the DOS.
At the end, I feel sad and disturbed as I had to attend
I would fail in may duty if I do not thank the various the funeral of 2 great stalwarts in Ophthalmology. Dr. L.P.
companies who participated in the exposure of their products Agarwal and Dr. N.C. Singhal who left a great void by their
to DOS Members. In the end I thank Mr. Harbans Nagpal, sudden death. May Go give them peace and heavenly abode.
Director IEMS who had great attachment to DOS and agreed
to work for the erection of the stalls at 50% cost than yester In the end I again thank you again to bear with me inspite
year. I thank M/s Habitat for the food and halls arrangements. of all my shortcomings as a human being. Knowingly or
Lastly I would thank Mr. Ravi Grover for his audio visual unknowingly if my actions have hurt some souls, I humbly
support for conducting the scientific programme flawlessly. request them to forgive me as my interest was to promote
the stature of DOS on all fronts and not to take a personal
I feel satisfied that with God’s grace I could accomplish revenge.
the affairs of the DOS effectively and economically without
Dr. Gurbax Singh
President, DOS (2004-2005)
Please Note............
New Secretariat Office
This is to inform all the DOS Members that new Secretariate office is at
the following address :
Dr. HARBANSH LAL
Secretary, DOS
EYE DEPARTMENT (New Building)
SIR GANGA RAM HOSPITAL
NEW RAJENDER NAGAR, NEW DELHI - 110 060
Mobile No. : 9810239206
Email : [email protected]
Please correspond at the above address only.
April, 2005 375 DOS Times - Vol.10, No. 10
PRESIDENT'S ADDRESS
Dr. Gurbax Singh, the outgoing unnecessary requirements are done away with. We will have
President of Delhi Ophthalmological to actively pursue this with Director of Health Services and
Society, Dr. J.S. Titiyal, the outgoing other concerned authorities.
Secretary, Dr. Rakesh Mahajan, the
outgoing Treasurer, Dr. Harbans Lal the DOS members have won many key positions in the AIOS
incoming secretary, members of the and I congratulate all of them. However many lost because
executive committee, members of DOS, we had more that one candidate from DOS for the same
ladies and gentlemen. post in AIOS. In future we should consider putting up a united
front for obtaining greater representation of DOS at the all
Today the new team takes over and I welcome the India level.
incoming vice president, Dr. Mahipal S. Sachdeva, members
of the new Executive and other office bearers. I am grateful The issue of DOS house is still unresolved and needs
to you all for electing me unanimously and thankful to Dr to be actively pursued. It would be my endeavor to revive the
Kamlesh for withdrawing in my favor so that the tradition of attempt to get a headquarter for ourselves. For this I look
unanimity was maintained. forward to cooperation from all concerned.
I am happy and proud that I have been given this In today's age of Information Technology our society
opportunity to serve you as your President at a juncture should look into the possibility of online subscription to all
when the society has reached great heights. This is chiefly quality journals. We must evolve a strategy of making these
because of the academic standards it has maintained. Both conveniently accessible to our members.
our mid term and annual conferences have become
extremely popular due to the quality of the papers presented. Medical ethics have taken a back seat today. We should
The conferences have something to offer for everyone. They be more honest and transparent in our dealings with our
have the most basic courses for the beginners and the most patients. Doctors-Patient relationships should be based on
advanced ones for the experienced surgeons. Each participant mutual trust.
can take back a few useful tips that he or she can incorporate
in his/ her practice. The popularity of the annual conference Another disturbing trend seen today is to run down a
can be judged by the fact that the registration at this years fellow practitioner. This is to be avoided at all costs since it
conference has exceeded 2300 participants. creates doubts in the mind of the patient and brings a bad
name to the fraternity as a whole.
The DOS times our monthly newsletter is extremely
popular and each member looks forward to its arrival. I must Although we have had tremendous support from the India
congratulate Dr. J.S. Titiyal our outgoing secretary for Habitat Center for all our conferences, the venue is becoming
keeping up and improving its standard. small for our needs, especially for the annual conference.
There is shortage of seating space for the delegates attending
The monthly meetings of Delhi Ophthalmological Society the conference. More space is also needed to erect the
have been of a very high quality although it is a little disturbing required number of stalls for the trade delegates. We would
that the attendance has been recently dwindling a little. We require further flexibility from India Habitat Center if we are
need to find out reasons and solutions for the same. Our to continue the meetings at this venue. I understand two
endeavor this year would be to take both the conferences new halls are being constructed with a capacity of 250
and the DOS Times to even greater heights. persons in each.
The editor of the Delhi Journal of Ophthalmology has I thank Dr. Gurbax Singh, Dr. Jeewan S. Titiyal,
always found it difficult to publish the journal due to paucity Dr. Rakesh Mahajan and all members of the outgoing
of good original articles. This year I propose that we change Executive and all office bearers of the society for devoting
the format of this Journal to make it more clinically oriented such a lot of their time to the functioning of the society. I
and meaningful to our members. welcome all members of the new Executive. I look forward
to the full co-operation of the members of the Executive. I
Recognition of Ophthalmic Day-Care Centers is another am also banking on the full support of all the members of
very important issue. Many ophthalmologists find it difficult Delhi Ophthalmological Society. It is only with your help
to have large set-ups to adhere to the criteria laid down for that we can take our society forwards.
the recognition of Nursing Homes. For day care centers the
conditions will have to be appropriately modified so that Thanking you,
Dr. Noshir M. Shroff
April, 2005 376 DOS Times - Vol.10, No. 10
SECRRETARY'S REPORT
SECRETARY'S REPORT
Honourable President Dr. Gurbax complete directory of all members with their email ID,
Singh, Incoming President Dr. Noshir M. phone numbers and details of work in which they are involved.
Shroff, respected senior members of the Beside we have a discussion board and a facility that all the
society and my dear friends. meetings and notices would come on to the notice board.
Our website was visited by many people in the last year and
As Secretary of DOS it is my I am very pleased that it was active and very helpful for the
pleasure and duty to present to you the Society and its members.
report & achievement of Executive
Committee for the year 2004-2005. On line submission of abstract was on of the most
successful achievements of our annual conference.
Delhi Ophthalmological Society is growing every year
in its magnitude beyond expectation. Nine monthly meetings were held with the Army Hospital
holding the first meet as a tradition in July followed by the
The total membership at this moment is 3641 with addition Sir Ganga Ram Hospital in August, Hindu Rao Hospital in
of 227 new members (61 Delhi members and 166 outside October 1st week and Dr. R.P.Centre in last Saturday of
members) in last financial year. October, Shroff Charitable Eye Hospital in November last
week, Venu Eye Hospital & Research Centre in December
Academics have always been the watchword for the The January meeting was held at the Safdarjung Hospital
society and continuing the traditions we could successfully while the February meeting venue was at Guru Nanak Eye
achieve the excellence in the scientific contents of our Center. The last meeting was held at the Mohan Eye Institute
meetings and publications of DJO and DOS Times. We in March.
continue to be a society known for its academic excellence. All monthly clinical meetings were well attended by
members. The scientific contents and discussion were of
DOS Times the pride of the society was widely high academic standards. All meetings were held on
appreciated by the DOS members. We continued the multi Saturday except for the Army Hospital and Mohan Eye
speciality approach giving emphasis on articles with practical Institute, which were held on Sundays as per their request
tips, surgical techniques and procedures, important review and convenience.
articles, basic topics like art of refraction, LVA and Contact
lenses. This has helped us to increase the reader ship of This Year DOS travel fellow ship was awarded to two
DOS Times. We published scientific articles from reputed members for International conferences.
intelligentsia who are experienced in their respective fields
such that the common ophthalmologist (practicing In this financial year we had 5 executive meetings, 3
ophthalmologist as well as residents) gets the benefit of subcommittee meetings, one special meeting and one AGM.
their teachings. Not only the faculty from Delhi many
International and National faculty contributed to the success In the AGM treasurer read the audited accounts of DOS
of the DOS Times. The publication of all 10 issues of DOS financial year April 2003- March 2004 which was duly
Times was regular like previous year though I admit some of approved by the AGBM. In the AGM, GBM appointed the
the DOS Times printing and distribution could not be possible auditor for DOS.
in desired requisite time because of some unavoidable
difficulties. We did manage to decrease the expenditure of The Executive achieved reduction in expenses for
printing of DOS Times this year without compromising the conference management which was possible because of
standard and quality of DOS Times. policy of inviting sealed rate quotations and awarding the
job to the first lowest with good track record of the company.
The midterm conference was a resounding success with The credit goes to President Dr. Gurbax Singh and the
record participation and a rich academic feast and trade Executive. This has set an example for coming executive of
enjoyed by all. Delegates appreciated the theme “Crisis DOS.
management” and the subjects covered during the Mid Term
Conference. DOS is well known for its academic excellence and rich
trade. The Executive has been getting very good support
The DOS website now fully functional in all regards is from our traders for our conference sponsorship and for
up to date with all the activities of the society. advertisements in DOS Times and DJO. Without the support
www.dosonline.org provides all-important notices of Traders and companies the society cannot grow in this
regarding the monthly meetings, conferences and respect I am very thankful to all traders and sponsors
membership forms are all available on the net. It provides a specially Syntho Pharmaceuticals, K.L.B. Instruments, Alcon
April, 2005 377 DOS Times - Vol.10, No. 10
India, Allergan India, Bausch & Lomb, Pfizer and Appasamy Achievement of the DOS (1/04/2004 to 31/03/2005)
for their continued support.
Special achievements by the present Executive in this year:
DOS is going to be known internationally as now we are
continuously getting delegates from South East Asia and • A procedure has been laid down for giving contract for
our neighboring countries. This is because our members any major job by inviting sealed quotations from the
who are working in these countries are informed about Annual market and awarding the job to the lowest quotation to
meeting through our website as well as DOS Times. This the company with good track record. This includes Print-
year we have delegates from Sri Lanka, Saudi Arabia, Nepal, ing of DOS Times and DJO, Conference management
Pakistan and Bangla Desh. and audiovisual.
This year too many of our members received honors and • The new Executives were introduced by printing their
awards, they are as follows: photographs in July issue of the DOS Times.
• Dr. Punita K. Sodhi Specialist in Ophthalmology, Swami • Institutions were given the option of choosing Saturday
Dayanand Hospital, Shahdara received Bharat Jyoti or Sunday for holding DOS monthly clinical meeting ac-
Award cording to their conveniences. Two institutions (Army
Hospital and Mohan Eye Institute) selected Sundays.
• Dr. Ashok Garg : Medical Director of Garg Eye Institute
& Research Centre, Hisar (Haryana) received Prestigious • Non-Institutional members have been offered a chance
Gold Medal by International Academy of Ophthalmology. in each meeting to present their talk/case presentation,
which however was not fully utilized. This will initiate the
• Dr. Sanjay Ahuja & Dr. Aparna Ahuja received jointly participation from noninstitutional members and give them
a cash price of Rs. 20,000/- for their hindi book on eyes chance to compete for best presentations.
Titled “Aankhein - Rog aur Savdhanian” by Indian Council
of Medical Research (ICMR). • We have taken the initiative for DOS to be registered
and approved for accreditation by DMC for which certifi-
• Dr. Kamlesh received “Prem Prakash Award” for cates will be issued to members and delegates. This
outstanding work in the field of strabismus by AIOS for will help them subsequently for re-registration and con-
the year, 2004. sumer cases.
• Dr. D.K. Sen received “Life Time Achievement Award” • We have made registration with State Medical Council
AIOS during 63rd Annual Conference held in January, Complisary for new members. Strict application of con-
2005 at Bhubeneswar. stitutional procedure will prevent non-qualified people for
becoming member of the society.
• Dr. Dinesh Talwar has been awarded "P. Siva Reddy
Award" by AIOS - 2005. • New changed and more transparent guidelines for DOS
Travel fellowships have been formalized. In last tow years
• Dr. Tushar Agarwal, Senior Resident Cornea & we have given Travel grants to three members for Inter-
Refractive Surgery Services, Dr. R.P. Centre for national Conferences.
Ophthalmic Sciences, received INSA Medal for Young
Scientists, 2004. • DOS Time is available in the web site for members.
• Financial position of the society has become sound.
• Prof. R.B. Vajpayee, Dr. Namrata Sharma & Dr. • Library is located in the central place with significant
Tushar Agarwal received Best Scientific Video
Presentation in American Academy of Ophthalmology, increase in utilization. Internet facility and upgraded com-
New Orleans, USA, 2004. puter facility was provided. BJO (South Asia Edition)
was added to our library.
• Dr. Mohita Sharma & Dr. Angshuman Goswami, • Affiliation fees as life membership to AIOS of Rs.
Tirupati Eye Centre, Noida received Awadh Dubey Award 40,000.00 has been paid as lump sum.
for paper presentation in 39th Annual U.P. State • Scientific programmes: The scientific programmes in
Ophthalmological Society in October, 2004 at Agra. the mid terms and Annual conference has been excel-
lent. Conveners for scientific program from various spe-
• Dr. Neeraj Sanduja for received Dr. Prem Chandra award cialties have helped a lot. Many new and young mem-
for Best Free Paper Presentation in Annual Conference bers of the DOS have been given full opportunity to present
of North Zone Ophthalmological Society, 2004 & and discuss their cases.
Rashtriya Gaurav Award for Year 2004. • DOS provides floppy disc of the member’s addresses
against nominal payment.
• Dr. Harish Pathak & Dr. Vijay B. Wagh Senior • DOS Member Directory has been updated and printed
Resident R.P. Centre for Ophthalmic Sciences, won the after a gape of 5 years.
Oculoplasty Conference, OPAI-2004 Quiz at Guwahati. • DOS Executive will help members with any difficulty in
purchasing or maintenance of our equipment and in con-
sumer cases.
April, 2005 378 DOS Times - Vol.10, No. 10
Obituary DOS offers deepest condolences to the grieved family
members and pray to the almighty that their soul may rest
• Prof. L.P. Agarwal left for heavenly abode on Friday in peace.
24th September 2004, at Noida.
Thanking you,
• Dr. N.C. Singhal left for heavently abode on Saturday
20th November 2004, at New Delhi. Dr. Jeewan S. Titiyal
!! Congratulations !!
Dr. (Prof.) Hari Mohan FRCS (Edin.),
FRCOphth. (Eng), FRCS (Glasg.), DO (Lond) Hony.
Ophthalmic Surgeon to the President of India for
being honoured with Padma Bushan Award this
year for his contribution to the advancement of Oph-
thalmology.
Dr. Mohan has been bestowed with numerous
other honours. The Padma Shri in 1971, The
FRCOpth. (U.K.) in 1989, The B.C. Roy National
Award for Socioeconomic relief in 1996, The FRCS
(Glasgow) ad eundeum in 2002, was appointed In-
ternational Advisor in Ophthalmology to The Royal
College of Physicians and Surgeons of Glasgow in
2002, received the Life TimeAchievementAward from
the All India Ophthalmological Society in 2004. He
also has the rare distinction of being the Honorary
Ophthalmic Surgeon to the Honorable Presidents of
India from 1968 till date. Dr. Mohan established
Mohan Eye Institute in 1980, a state of the art Oph-
thalmic Institute located in the heart of Delhi. Edu-
cation and imparting knowledge has been Dr.
Mohan's passion, his institute is recognized by the
Medical Council of India, The National Board of Ex-
aminations, The Royal College of Physicians and
Surgeons of Glasgow for their training programs. The
Royal College of Glasgow also conducts its Fellow-
ship exams in Ophthalmology at the Institute every
year.
In this era of commercialization Dr. Mohan did not forget the poor and deprived. A charitable wing was started at the
Institute in 1980 dedicated to his mentor Dr. S.N. Mitter. Dr. Mohan has run the Charitable Wing independently and has
borne all costs for the poor himself, without any form of external funding.
Today, Dr. Mohan at the age of 77, continues to practice, operate and teach. He is also actively involved in the
organization of seminars and meets for the betterment of the Ophthalmic fraternity in India.
April, 2005 379 DOS Times - Vol.10, No. 10
APPLIANCES
The Technique of Fundus Biomicroscopy
Abhas Mehrotra MD, Gunjan Prakash MD,
Raju S. MD, Neeraj Wadhwa MD, S.P. Garg MD
Fundus biomicroscopy permits a stereoscopic, highly Non contact Lenses
magnified examination of the ocular fundus and vitreous
with a large field of view. To the accustomed user it affords • +90D
innumerable advantages like -
• +78D
• Stereoscopic view of the retina and the disc which
is of aid in cases of glaucoma and also peripheral • Hruby
retinal tear especially when associated with subtle
vitreous traction The initial eye examination should particularly include
the following before slit lamp biomicroscopy is done
• The examiner gets a magnified view of the image
as the Slit lamp magnification is also utilized • For Contact Lenses
• It gives stability to the globe to enable better – I/O so that specific areas requiring further
viewing and documentation of the posterior scrutiny can be identified.
segment pathology as contact lenses when used
give vaccum attachment to globe – Rule out active corneal disease.
• The image formed is optically of a higher quality – Rule out fresh penetrating / perforating injury.
as the optical irregularities of cornea are
neutralized by contact type lenses – Other procedures like Tonometry,
Keratometry, etc.
• The bright illumination of the slit lamp is also an
advantage especially in patients with media – Preferable to avoid immediate postoperative
opacity period
Lens selection is dependent upon personal preference and • For Non-Contact Lenses
magnification requirements, although the latter is also
dependent upon the optics of the slit lamp. The optical – No specific contraindication
system thus used-
The instruments needed are
• Replace the 45D of corneal surface refraction by an
afocal plane surface- – The specific lens
Contact type lens
– Slit lamp
• Use high power converging lens-
+90D lens – Topical anesthetic (for contact lenses)
• Neutralize refractive power of eye- – Topical mydriatic
Hruby lens – approximately -55D
– Cushioning solution (for contact lenses)
• Modern Wide-Angle Imaging System-
Ocular Mainster Wide Field The technique for Contact Lens Fundus examination is
Common Lenses: • Inform the patient about the procedure
• Maximally dilate the pupil and anesthetize the
Contact Lenses
cornea
• Goldmann Triple Mirror • Place bubble-less drops of methylcellulose into the
• Mainster
• Volk Trans Equator clean, concave surface of the lens
• Volk Super Quad 160 • Position the patient in the slit lamp
• Pull slit lamp away to allow space for lens
Dr. R. P. Centre for Ophthalmic Sciences,
AlIMS, New Delhi. placement
• Ask the patient to look upward and open eyes
widely
• Hold the lens with your thumb, index & middle
finger; tilting it slightly backward to retain the
fluid
• Tuck the inferior edge of the lens into the inferior
cul-de-sac
April, 2005 380 DOS Times - Vol.10, No. 10
• Bring the top of lens forward and ask patient to • 165° Field of View, 0.5x
look straight Magnification, 2.0x
LSMF
• Release the upper lid
• Simultaneous visual-
Further Tips ization of posterior pole
to peripheral retina,
• Keep gentle but sustained pressure on lens to keep providing a greater
it secure margin of safety during
PRP
• Watch for corneal folds or striae or induced arterial
pulsation – indicators of excessive lens pressure Area Centralis®
• Utilize an elbow rest • Excellent magnification
combined with a good field
• Start with low magnification of view
• Slowly move slit lamp forward till retina in focus • Ideal lens for focal laser
treatment of macular conditions
• If lens in focus, you have moved far too forward,
pull back the joystick • 84° Field of View, 1.06x
Magnification, 0.94x LSMF
• Make incident light slightly off-axis either
vertically or horizontally (5°) Volk Quad Pediatric
• 120° Field of View
• Pull back on the joystick slightly to examine the • 0.55x Magnification, 1.82x LSMF
overlying vitreous • Children and those with narrow palpebral fissures
• If monocular view Lens not correctly centered on Equator Plus®
cornea or Illumination column may be blocking • 129 Diopter
one ocular, using short reflecting mirror on slit • 137° Field of View, 0.44x Magnification, 2.27x LSMF
lamp can help • For small pupil examinations when traditional
• Widen the slit beam to increase fundus non-contact lenses do not provide adequate views
illumination and/or scan the entire fundus
Reichel-Mainster 2x Retina / QuadrAspheric®
• Remove the lens by asking the patient to look
upward and blink firmly; or alternatively, you can • Good for small pupil fundus examination and as a
press the globe near the inferotemporal edge of general diagnostic / laser
lens over the lower lid to remove the vacuum lens
• Always inform the patient that there would be • 144° Field of View, 0.51x
some temporary blur and mild irritation during Magnification, 1.97x LSMF
the remainder of the day. No prophylaxis /
treatment is needed Ocular Mainster Wide Field®
Complications • 127° Field of View
• Minor corneal abrasions are possible with poor • 0.68x Magnification,
technique 1.5x LSMF
• Vasovagal reflex is possible with compressive • Image binocularity
procedure of the globe across entire field
• IOP is temporarily decreased following the • Good for macular grid
procedure laser
• Cushioning solution frequently causes punctate Hruby Lens
staining or haze, affecting corneal transparency
Hruby Lens -
Wide Angle Imaging Lens-
SuperQuad® 160
• Widest field of view of any lens ever produced
• Ideal lens for treatment of proliferative diabetic retinopathy
Disadvantages:
April, 2005 381 DOS Times - Vol.10, No. 10
• Patient’s fixation needed the following pattern- Begin with optic disc- Move
• Reflections off the lens and eye’s anterior surface inferiorly with joystick to track the superior arcade- Then
look at temporal retina, reach the lens temporal limit;
produce bothersome aberrations without patient’s eye movement- Move the beam
• Small pupil can yield poor results superiorly to track the inferior arcade back to disc- Examine
• Minification nasal retina next- Finally look at the macula
• 50% reduction in size of patient’s pupil, thus
limiting the angle of view of retina
• Slit lamp movement does not enable view of
different part of retina
Non-Contact Fundus Lens
+ 90D / 78D / 60D Lens
The technique for Non
Contact Lens Fundus
examination is:
• Inform the patient about the procedure Other Non-contact lens
• SuperField NC
• Maximally dilate the pupil • Specifically designed for increased working
• Position patient in the slit lamp distance from cornea (7mm)
• Adjust beam to 2mm width • 116° Field of View, 0.76x Magnification, 1.3x LSMF
• Pull the slit lamp away SuperPupil XL
• Ask the patient to open eyes widely and fixate with • Provides the widest pan equatorial fundus view
of any non-contact lens available - over 100° field
other eye in a single view
• Optical design permits a 25 DD field area through
• Moderate illumination and 6x or 10x magnification an undilated pupil
• Aim the light source up to 10° off-axis • 124° Field of View, 0.45x Magnification, 1.75x LSMF
• Move the slit lamp to within a few inches of the Super VitreoFundus
eye to produce a large retro illuminated red • Less steep learning curve
pupillary reflex • 124° Field of View
• 0.57x Magnification, 1.75x LSMF
Once Red Pupillary Reflex is Seen
Goldmann Triple Mirror
• Hold the lens perimeter with your thumb & index Lens
finger
• Viewing from outside the biomicroscope,
introduce and center the lens directly in front of
the patient’s eye at an approximate distance of 1-2
cm
• Stabilize the lens holding your hand against the
patient’s cheek, the slit lamp upright bar or the
head strap with the remaining fingers
• View through oculars and pull back the joystick
until the narrowed red reflex beam is focused on
the retina
The method of scanning the posterior pole should follow
April, 2005 382 DOS Times - Vol.10, No. 10
• - 64D central lens power, 7.6mm radius of Cleaning
curvature, central 30° fundus • Clean the entire lens using a mild cleaning solution
• Three mirrors spaced 120° apart at an angle– – Diluted dishwashing liquid
• 59° Semicircular for Angle (Ora, Pars plana, Irido- – Mild soap water
corneal angle)
• Clean with soft lint-free cotton cloth
• 67° Square for Periphery (up to posterior ora)
Disinfection
• 73° Rectangular for Equatorial fundus
• Clean first, immerse in either of these:
• Indentation also possible – but difficult
• Glutaraldehyde 2% aqueous solution for 20-25
• Can be used for laser, with antireflective coating minutes
• View is reversed in an antero-posterior direction or
(inverted) only, not laterally as in indirect
ophthalmoscopy. • Sodium hypochlorite (10 parts water, 1 part
bleach) for 10-12 minutes
• Lens is rotated - selected mirror is opposite to
desired examination area. • Thoroughly rinse with room temperature water,
dry with a soft lint-free cloth
• Mirrors more nearly parallel to path of light allow
posterior fundus assessment. Sterilization
• Mirrors oriented closer to perpendicular reveal • Clean first
more anterior structures.
• Standard ethylene oxide hospital sterilization
• 0.9x magnification procedures with aeration up to, but not exceeding
130° F
To examine the details of the vitreous we need a dark-
adapted observer, high light intensity beam and a larger • Never autoclave or boil
angle of separation between observer unit and illumination
unit (20°). Vitreous activity may be viewed as a Tyndall
effect in the illumination beam.
Laxmi Eye Institute, Panvel Urgently Required
Offers A qualified (DOMS/MS/DNB)
young, dynamic ophthalmologist
“Small Incision Cataract having a fellowship in Vitreo-retina
Surgery with determination to excel only
in vitreo-retina.
Hands on Training”
Dr. J. S. Guha
Duration : 1 Months
(Book early to avoid Disappointment) Senior Vitreo-retinal Surgeon
For details please contact : G-1219A, Chittaranjan Park,
New Delhi – 110019
Administrator
Ph. : 011-26273688, 26279867
Laxmi Eye Institute Mobile : 9350102339,
9811011294
Uran Road, Panvel
Tel : 27453147/27452228
Fax : 27491199
Email : [email protected]
April, 2005 383 DOS Times - Vol.10, No. 10
REVIEW
Clinical Presentation of Chiasmal Disorders
Satya Karna, DO, DNB
Failure to perform or interpret visual fields properly producing a blind area of field posterior to fixation,
is a common cause of delay in the diagnosis of chiasmal leading to difficulties with near tasks, due to
disorders and has become a significant medicolegal issue. disturbance of depth perception.
A useful rule is that any patient with an unexplained
reduction in visual acuity should have visual field testing, • Hemifield slide phenomenon – loss of normal
including a search for temporal field loss indicating partial overlap of temporal field of one eye and
chiasmal compression. The major role of ophthalmologists nasal field of the other eye leads to a lack of
in the diagnosis and management of chiasmal disorders physiological linkage between the two remaining
due to sellar and suprasellar lesions is to assess visual hemifields, causing difficulty in reading because
function accurately and to interpret the results of of doubling or loss of printed letters or words.
perimetry.
Visual Field loss
Lesions
Visual field testing (Bilateral confrontation and
Some common causes of chiasmal disorders are: automated perimetry is compulsory)
• Bitemporal Hemianopia
Lesion Age
Pituitary adenoma
Craniopharyngioma any age group
1st to 2nd decade,
Meningioma any age group
Optic Glioma middle and late
Internal Carotid age group
artery aneurysm
Trauma children
middle and
late age group
any age group
Clinical features Fig 1a,1b Bitemporal Hemianopia
Some of the features common to chiasmal disorders are: • Superior scotomas in compression from below
Visual loss (pituitary adenoma, tuberculum sellae and
• Gradual or rapid Progressive loss of vision in both medial sphenoid ridge meningioma,
eyes. Relative afferent pupillary defect (RAPD) in craniopharyngioma and aneurysms)
the worse affected eye if asymmetrical loss of • Inferior scotomas in compression from above
vision occurs.
DOS Times - Vol.10, No. 10
• Loss of color vision
• Red Dyschromatopsia in temporal hemifield
• Post fixation blindness – convergence results in
crossing of the two blind temporal hemifields,
Karna Eye Clinic, 384
L-9, Lajpat Nagar III, New Delhi
Shroff Eye Centre,
New Delhi
April, 2005
Fig 1c Axial contrast T1 weighted MRI of the brain
showing a large pituitary macroadenoma
(tuberculum sellae meningioma, craniopharyngioma, Fig 1e Sagittal contrast T1 weighted MRI showing
aneurysms and optic gliomas) the anteroposterior and vertical extent of the tumor.
• Homonymous Hemianopia (lesions that damage intracranial nerves in the subarachnoid space or
the posterior aspect of the chiasm and optic tract) cavernous sinus get affected
• Traquair ’s Junctional Scotoma (lesions that • See-saw Nystagmus – is characterized by
damage the anterior aspect of the chiasm and optic synchronous alternating elevation and intorsion
nerve) of one eye and depression and extorsion of the other
eye, probably due to damage to the interstitial
Fundus evaluation nucleus of Cajal by tumors of the diencephalon
and chiasmal regions.
• Optic disc normal or atrophy or cupping. Patients
with normal appearing fundi usually have Neuroimaging is compulsory with MRI as it gives a
complete return of visual function with successful better resolution than a CT scan and Contrast enhanced
decompression of lesions. imaging gives more information than a plain image.
• Rarely papilledema when suprachiasmal lesions Some of the common lesions are discussed below.
extend into and occlude the 3rd ventricle.
Motor disorders
• Rarely ophthalmoplegia or ptosis when adjacent
Fig 1d Coronal contrast T1 weighted MRI of the brain Pituitary Adenoma
showing solid, cystic nature of the macroadenoma
Pituitary adenomas are the most common cause of
encasing the internal carotid arteries on both sides and chiasmal dysfunction in adults and form 10-15% of
extending from the third ventricle to the sphenoid sinus, intracranial tumors. These are benign epithelial neoplasms
that rarely metastasize. Tumors that are more than 10 mm
causing compression of the optic chiasm. in size are macroadenomas and these are associated with
chiasmal compression. In general, tumors that secrete
hormones such as prolactin, growth hormone or
adrenocorticotropic hormone are detected when they are
small (microadenomas), without causing any visual
symptoms. On the other hand, nonsecretory tumors are
usually detected when they become macroadenomas and
compress the visual pathway.
Nonocular symptoms include features like chronic
headache, fatigue, endocrine dysfunction like amenorrhea,
impotence, thyroid, adrenal and gonadal insufficiency.
The classical ophthalmic presentation is painless
gradual vision loss. Apart from this, cranial nerve palsies
can occur, secondary to compression of adjacent
intracranial structures. Visual field defects can vary from
classical bitemporal hemianopia (denser superiorly) to
central scotoma, to homonymous hemianopia depending
April, 2005 385 DOS Times - Vol.10, No. 10
on the size and direction of growth of the tumor. optic atrophy and bitemporal/chiasmal field defects.
Asymmetry of the field defects is the rule. Optic disc pallor
is the feature of its chronic compressive nature. Rarely Optic nerve sheath meningioma rarely extends into
asymmetric cupping with pallor of the disc occurs. the intracranial space causing junctional scotoma in the
Ophthalmoplegia or seesaw nystagmus can occur. contralateral eye.
Craniopharyngioma Optic Nerve Glioma
These are cystic calcified sellar or suprasellar tumors Optic nerve glioma, the most common lesion
that are 1.2-3 % of all intracranial tumors. These can occur infiltrating the optic nerve, represents about 17% of the
at any age but peak incidence is in 1st to 2nd decade. These orbital tumors encountered in childhood. About half of
are epithelial in origin and derived from remnants of these lesions are confined to the orbit, whereas the
Rathke’s pouch, which migrates from primitive buccal remaining half demonstrate intracranial extension.
cavity. Although benign in nature they can have aggressive Intracranial extension may be clinically suspected on the
local invasion. The solid component grows slowly and the basis of precocious puberty, somnolence, or diabetes
cystic component can expand rapidly. They commonly insipidus.
traverse one of these spaces – sellar, suprasellar or third
ventricle. They typically disrupt the anterior visual About 29% of optic pathway gliomas occur in the
pathway by external compression. setting of neurofibromatosis {NF} type 1. Any patient found
to harbor an optic pathway glioma should be assessed for
The usual manifestations are non specific headache, evidence of NF-1, and patients with cutaneous lesions
gradual decrease in vision, visual field defects - typically consistent with NF-1 should be screened for optic pathway
incomplete and asymmetric bitemporal defects or gliomas and other intracranial lesions that occur in NF.
junctional scotoma. Rarely, sixth nerve palsy and seesaw Among visually asymptomatic children with NF-1,
nystagmus can occur. neuroimaging reveals optic pathway gliomas in about 15%
of cases.
Disturbed hypothalamic–pituitary axis may lead to
hypogonadism, myxedema, weight gain, growth Diagnosis is usually made before 5 years of age. Overall
retardation, obesity and diabetes insipidus. 70% of patients present in the first decade of life and 90%
within the first two decades. The ocular findings are typical
Cognitive symptoms such as memory loss, depression of chronic optic nerve dysfunction (ipsilateral relative
or confusion may be seen. afferent papillary defect, deficient visual acuity,
achromatopsia, central scotoma). Temporal or bitemporal
Meningiomas visual field loss may occur with perichiasmal or chiasmal
glioma. Strabismus or nystagmus may result from the
Meningiomas are mostly benign tumors that originate visual loss. The optic nerve head may be edematous,
from the cells of the meninges, particularly the arachnoid infiltrated with tumor, or atrophic. Rarely, optociliary
cap cells. They form 13-18% of all primary intracranial collateral vessels may be present. Other manifestations of
tumors. They occur 2-3 times more frequently in women chiasmal gliomas are diencephalic wasting,
than men. They are most commonly detected in the middle hypopituitarism, precocious puberty, hydrocephalus and
and late decades of life. gigantism.
On histopathology, whorls of calcium salts called Traumatic Chiasmal Syndrome
psammoma bodies may be seen in the transitional type
meningioma. Meningiomas contain both estrogen and It is an optic neuropathy that is temporally related to
progesterone receptors and may become symptomatic blunt or penetrating head trauma that results following
during pregnancy. Other associations are acoustic road traffic accidents, fall from a height or from frontal
neuromas, neurofibromas, gliomas, pituitary adenomas impact by falling debris, assault, stab wounds and gunshot
and aneurysms. wounds.
Cavernous sinus meningiomas cause diplopia, Direct injury results from orbital or cerebral trauma
ophthalmoplegia, Horner’s syndrome. that transgresses normal tissue planes to disrupt the
anatomic and functional integrity of the optic nerve e.g.
Olfactory groove meningiomas cause Foster Kennedy bullet penetrating skull. Vision loss is severe, immediate
syndrome (papilledema, optic atrophy and anosmia), and recovery is unlikely.
visual field defects, seizures, and headache.
Indirect injury usually results from blunt trauma to the
Sphenoid ridge meningiomas cause headache, signs of forehead that results in transmission of force through the
raised intracranial pressure, memory loss, auditory cranium to the restrained intracanalicular portion of optic
hallucinations or orbital signs. nerve. Vision loss may be delayed and recovery is poor.
Tuberculum sellae meningiomas cause compression The vision varies from no perception of light to 6/6.
of the optic nerves and chiasm producing loss of vision, Injury to optic chiasm mostly produces a complete
bitemporal hemianopic field defect. Afferent pupillary
April, 2005 386 DOS Times - Vol.10, No. 10
defect is present in asymmetric optic nerve injury. syndrome. Am J Ophthalmol. 2004
Multisystem trauma or serious brain damage with loss of May;137(5):908-13.
consciousness may be present.
4. Cherninkova S, Tzekov H, Karakostov V.
In some cases no evidence of orbital or ocular trauma Comparative ophthalmologic studies on children
is seen. Others may have periorbital or ocular and adults with craniopharyngiomas.
haemorrhage, ecchymosis or laceration. Ophthalmologica. 1990; 201(4):201-5.
There are three possible mechanisms for the visual 5. Lee AG, Lin DJ, Kaufman M, Golnik KC, Vaphiades
loss – a tear in the chiasm, contusion necrosis or MS, Eggenberger E. Atypical features prompting
compression of the chiasm by swollen brain. neuroimaging in acute optic neuropathy in adults.
Can J Ophthalmol. 2000 Oct; 35(6):325-30.
In conclusion
6. Finn JE, Mount LA. Meningiomas of the tuberculum
Last but not the least, close follow-up of patients for sellae and planum sphenoidale. A review of 83
visual acuity, color vision and visual fields after medical cases. Arch Ophthalmol. 1974 Jul; 92(1):23-7.
or surgical treatment for at least 5 consecutive years is a
must. 7. Gayre GS, Scott IU, Feuer W, Saunders TG,
Siatkowski RM. Long-term visual outcome in
References patients with anterior visual pathway gliomas. J
Neuroophthalmol. 2001 Mar; 21(1):1-7.
1. Chamlin, M., Davidoff L.M., et al. Ophthalmologic
changes produced by pituitary tumors. Am J 8. Hassan A, Crompton JL, Sandhu A.Traumatic
Ophthalmol 1995;40: 353-368 chiasmal syndrome: a series of 19 patients. Clin
Experiment Ophthalmol. 2002 Aug;30(4):273-80.
2. Grochowicki M, Vighetto A, Berquet S, Khalfallah
Y, Sassolas G. Pituitary adenomas: automatic static 9. Chiasmal Disorders, Albert & Jacobiec’s Principles
perimetry and Goldmann perimetry. A and Practice of Ophthalmology, (Chapter 297),
comparative study of 345 visual field charts. Br J Neuro-ophthalmology, Vol. 5, 2nd Edition, Page
Ophthalmol. 1991 Apr; 75(4):219-21. 4186-4200.
3. Mejico LJ, Miller NR, Dong LM Clinical features 10. Tumors and related lesions, Walsh and Hoyt’s
associated with lesions other than pituitary Clinical Neuro-ophthalmology, Section VIII, Vol.
adenoma in patients with an optic chiasmal 2, 5th Edition, Page 1789-2223.
Eye Surgeons Invited For Immediate Requirement
As financial partner working / Non A charitable Hospital situated in Ranikhet, Distt.
working for Lasik and Phaco Almora (Uttaranchal), invite application from
Project. Eye Surgeons having MS/DNB/DO
qualifications and trained in SICS/PHACO/IOL
Junior Eye Surgeons required on with at least three years experience.
profit sharing basis.
Salary negotiable commensurate with
Space available for setting up of qualification and experience of the candidate.
retina clinic.
Interview shall be held at New Delhi. No TA/
Contact : DA shall be payable for appearing in interview.
Dr. S. K. Khanna
Posting would be at Ranikhet, Uttranchal and
Khanna Medicare Pvt. Ltd. suitable accommodation would be provided at
the Hospital Premises.
Lasik Laser Vision
W-6, Main Patel Road, Apply immediately to :
West Patel Nagar, Shree Baba Haidakhan Charitable &
New Delhi – 110008 Research Hospital
Ph : 25874954 / 55 / 56 / 57
C/o Mrs. Chandra
Arunodaey, 45, Club Drive, Opp. Vill. Ghitorni,
Mehrauli Gurgaon Road, New Delhi – 110030
Tel : 26501405/26502579 Mobile : 9811119021
April, 2005 387 DOS Times - Vol.10, No. 10
CURRENT PRACTICE
Triamcinolone-assisted Vitreous Surgery
Atul Kumar MD, Gunjan Prakash MD
Triamcinolone acetonide (TAAC) has been described of traction around iatrogenic breaks should reduce the risk
as a treatment for macular edema in a number of different of post operative RRD. Relief of macular traction may
retinal conditions, as well as a useful adjunct in vitrectomy reduce the incidence of macular edema, potentially
surgery. Recently, several studies have shown that improving visual outcomes.
intraoperative TA can assist greatly in membrane peeling.
Reports by Enaida et al, Furino et al and Fraser et al showed Use of TAAC in Proliferative Vitreoretinopathy (PVR)
that TAAC granules stain residual vitreous, epiretinal is found to be very helpful. PVR manifests as proliferative
membranes, and even the internal limiting membrane. This membrane formation resulting in retinal traction,
technique was used in a variety of retinal conditions accumulation of subretinal fluid, and redetachment.
requiring vitrectomy. It allowed for greater removal of Successful repair of complex retinal detachment requires
membranes, and no serious complications were the identification and removal of preretinal traction (and
encountered. subretinal traction in select cases) caused by these
proliferative membranes. Intravitreal Triamcinolone has
TAAC can be used in Proliferative Diabetic Retinopathy shown utility in identifying such preretinal traction,
(PDR). PDR is heralded by neovascular ingrowth into the facilitating its removal and increasing anatomic success
vitreous with common complications of vitreous rates. Pharmacologic benefits from anti-inflammatory and
hemorrhage and traction retinal detachment. Successful antiproliferative properties may help in achieving ultimate
surgical management depends upon the identification and success.
relief of mechanical vitreoretinal traction to prevent or
reduce the incidence of recurrent hemorrhage, persistent Figure 1: Triamcinolone crystals being injected into the
traction, and retinal breaks/rhegmatogenous retinal vitreous cavity (arrow)
detachment. Relief of Tractional forces contributing to
macular edema can help optimize visual outcomes. Standard 3-port pars plana vitrectomy with surgical
Pharmacologic treatment of macular edema can induction of PVD, if not already present is performed.
simultaneously occur. Inspection of retina is done with documentation of location/
extent of clinically apparent preretinal membrane or
Standard 3-port pars plana vitrectomy performed traction. Removal of clinically apparent membranes with
with dissection into subhyaloid space. Mechanical relief of forceps/pic is then carried out. Injection of intravitreal
traction from visible neovascular tufts is then performed TAAC (approx. 4 mg) to identify and facilitate removal of
and bimanual dissection with illuminated pic, forceps/hi- retained cortical vitreous. Perfluorocarbon liquid used to
speed cutter for TRD. Shaving of vitreous base is carried stabilize posterior retina during anterior dissection and
out under scleral depression and wide-field viewing. Then drain fluid though anterior break(s). 360° laser retinopexy
the injection of intravitreal Triamcinolone (approximately to vitreous base region and break(s) with perfluorocarbon-
0.1-0.2 ml) is done to identify and facilitate removal of air exchange and subsequent gas or silicone oil tamponade
retained cortical vitreous. Vitrectomy is then completed is done.
along with induction of PVD. Supplemental panretinal
photocoagulation to ora ± tamponade as indicated.
PDR is associated with a very high incidence of retained
cortical vitreous despite surgical induction of PVD.
Triamcinolone-assisted membrane peeling allows for better
visualization and more complete relief of vitreoretinal
traction in the surgical management of complications of
PDR. Potential benefits include lower incidence of recurrent
fibrin formation vitreous hemorrhage and intraoperative
breaks/need for internal tamponade. More complete relief
Glaucoma Services
Dr. R.P. Centre for Ophthalmic Sciences
AlIMS, New Delhi.
April, 2005 388 DOS Times - Vol.10, No. 10
TAAC has shown use as a surgical adjunct in
identifying transparent vitreous attachments by rendering
the hyaloid face and cortical vitreous more opaque.
Triamcinolone has also been shown to have
antipermeability and antiproliferative pharmacologic
properties that appear particularly useful in the surgical
management of diabetic eye disease and proliferative
vitreoretinopathy. TAAC is a precipitate of white particles
held in solution that became trapped in the vitreous gel.
As the TAAC solution is not a true stain but a suspension,
it does not highlight surrounding ocular tissues in the eye
as the other biostains (ICG, trypan blue) do.
Figure 2: Triamcinolone assisted vitrectomy in a case of retinal
detachment (crystals look like asteroid hyalosis, arrow)
Triamcinolone appears useful as a surgical adjunct in Figure 3: Near complete vitrectomy with only a few
the repair of complex pseudophakic retinal detachment. crystals visible (arrow)
Immature or clinically inapparent vitreous can be more
easily identified. Preretinal traction can be more Triamcinolone acetonide is a water insoluble cortical
successfully and completely relieved. Reproliferation steroid that inhibits inflammation and has been used
appears to be reduced and anatomic success rates are intraocularly as a potent anti-inflammatory agent for
enhanced. various ocular diseases such as diabetic macular edema,
cystoid macular edema, central vein occlusion, macular
Pars plana vitrectomy assisted by TAAC for refractory degeneration, and subretinal neovascularization. The
uveitis is also helpful. TAAC is inoculated into the vitreous safety of an intravitreal injection of triamcinolone
cavity to visualize the vitreous. Upto 4 mg of TA can be acetonide has been evaluated in an animal model. However,
intentionally left in the vitreous cavity to reduce the degree the preservative benzyl alcohol with TAAC has been
of postoperative inflammation, but propped-up implicated in fetal toxic syndromes when used in intravenous
positioning for 2 hours should be advised to the patient to medications. Nevertheless, the preservative can be
prevent settling of crystals on to the macula. The vitreous removed as was described by Burk and colleagues.
body is clearly seen using TAAC during surgery as in other Intravitreal TAAC is considered safe to use in human eyes.
vitrectomies, which greatly helps us to perform a posterior
hyaloid resection safely and thoroughly. As previously Suggested Readings:
described, TAAC allows us to visualize the transparent
vitreous and thus is helpful in removing the vitreous cortex 1. Enaida H, Hata Y, Ueno A, Nakamura T, Hisatomi T,
from the retina completely in uveitis. If the patient shows Miyazaki M, Fujisawa K, Sakamoto T, Ishibashi T.
an elevated intraocular pressure (IOP) after surgery, it is Possible benefits of triamcinolone-assisted pars plana
usually transient and also controllable by topical eye drops vitrectomy for retinal diseases. Retina 2003; 23(6):764-70
only. The visible TAAC diminishes day by day and almost
completely disappears within a month from operation. 2. Fraser EA, Cheema RA, Roberts MA. Triamcinolone
TAAC improves the visibility of the hyaloid and the safety acetonide-assisted peeling of retinal internal limiting
of the surgical procedures. Although the long term effects membrane for macular surgery. Retina 2003; 23(6):883-4
are still unknown, this method appears to be potentially
useful as an improved treatment for PVR associated with 3. Furino C, Micelli Ferrari T, Boscia F, Cardascia N,
refractory uveitis. Recchimurzo N, Sborgia C. Triamcinolone-assisted
pars plana vitrectomy for proliferative
Recently, TAAC is also being used during anterior vitreoretinopathy. Retina 2003; 23(6):771-6
vitrectomy procedures in a case of congenital cataract
surgery. The basis for this is: the vitreous is transparent 4. Burk SE, Da Mata AP, Snyder ME, et al. Visualizing
and difficult to visualize in the anterior chamber during vitreous using Kenalog suspension. J Cataract Refract
cataract surgery. Any vitreous remaining in the anterior Surg. 2003;29:645-51
chamber can incarcerate surgical wounds and cause
tractional retinal detachment or endophthalmitis.
Highlighting the vitreous during the surgery will facilitate
a thorough vitrectomy to ensure an anterior chamber free
from vitreous and to eliminate subsequent complications.
Similar amount (0.1 ml of 10mg/ml) is used for intracameral
injection.
April, 2005 389 DOS Times - Vol.10, No. 10
CURRENT PRACTICE
Capsulorhexis Simulator Software Application
R.S.Choudhary, MS
Aims & Objective : So this application aims to give :
Capsulorhexis Simulator Software Application, is 1. An orientation about capsulorhexis.
developed to provide resources to budding surgeons to
practice Capsulorhexis on the computer. Aim is to develop 2. Develop hand movement.
the hand movements, the way it usually happens during
real surgery. As the capsulorhexis is one of the most crucial 3. Different zone give different direction of pull. As in
steps for learning the phacoemulsification, which is the real patient peripheral lens is steeper &
most modern technique of cataract extraction. It is difficult capsulorhexis tends to go out.
to practice the step in real patient because this may
endanger their sight. 4. Chamber depth alteration which makes
capsulorhexis extend outward.
Overview of the Software Application
5. Practicing with left hand can help to develop left
hand, necessary for current technique of chopping.
This software application aims at making the budding
surgeons more conversant with rhexis before actual
practice.
This application can be useful to :
1. Surgeons who want to shift/try to
phacoemulsification.
2. Postgraduate students.
3. Surgeons who wants to develop left hand
movements.
By default simulator has metallic look and feel, but Operation Processes :
he can switch over to any of these. [Mac os, windows,
Metalic] Step 1:
[cut placement]
Note: This option will not affect the operation
anyhow; it is just for viewing purpose only.
This is the main Screen, which consist of three Click the first button on the tool menu on the left
windows panel and move the cursor, the cut will move along
with mouse.
• Tool window – The left panel
• Eye Image window – The central panel Place the cut on a position just double click to place
• Fluid meter window – The right panel this cut.
Using Tool window user can select tool for
• Defining Bound region One can change the size of this cut before the start
• Making cut of this application.One needs to go to C:\Program
• And Peeling Files\Cataract Operation simulator
Along with tool selection he can also select the
operation direction, which can be either clockwise or You will see a Parameters.txt file. When you open
anti-clockwise. this file change the fourth no. to a no. within 100.
Using the timer button user can start timer
manually, which decrease the fluid level automatically. After change save this and restart the application
again. You will see the parameter changed the cut size.
1, Shiv Vilas Palace,Rajwada,
Indore (M.P.)
April, 2005 390 DOS Times - Vol.10, No. 10
Step 2: [ marking cut] Direction of Peeling:
Select the cut tool (second button) from panel and By default operation is done in clockwise direction,
mark the cut on desired position. to change the direction of operation.
Use left mouse button to mark the cut. Select the ‘A’ option of rotation.
Use right mouse button to rotate the tool towards Direction of Peeling:
left and right
Note : The cut should always be in V shape with
two separate strokes.
Step 3: [ Peeling ]
Procedure completes
After marking the cut , user can start with peeling, Remember :
to start with it select the peeling tool from Tool panel
During the peeling process if the residue crosses
Use left mouse click to catch up the cut area and the periphery then the operation fails. One has to press
drag the mouse by holding up the layer. reset to start the operation again
Use right mouse click to rotate the tool on its axis.
Note : One can change this tool to a needle from
the forcep at any point of time during the operation
by selecting from the menu OTHERS.
April, 2005 391 DOS Times - Vol.10, No. 10
REVIEW
Ocular Prosthetics: Part I
Ramkishor Sah B. Ophth, Harish Pathak MD, DNB, FRCS
Ocular Prosthesis treatment can involve frequent, biannual or annual visits
to the prosthetic clinician to evaluate the fit, inspect for
Ocular prosthesis or artificial eyes are prosthetic signs of wear, polish & clean the ocular.
devices used to simulate a natural eye. An ocular prosthesis
does not restore lost vision. The primary purpose of an Surgery is often required to properly prepare the socket
ocular prosthesis is to maintain the volume of the eye socket for an ocular prosthesis. This involves the placement of an
and to restore appearance to that of a natural eye. A person implant to fill most of the space originally occupied by the
in need of an ocular prosthesis may have a small eye known eye. During surgery a ball implant is inserted into the eye
as microphthlmia or have a damaged eye or have lost an socket to fill the area the eye once occupied. An ocular
eye due to tumor, trauma or a congenital birth anomaly. prosthesis is then moulded to fit in front of the implant. It
occupies the space between the eyelids and the skin
Ocular prosthesis can be made to fit many different (conjunctiva) covering the implant. The ocular prosthesis
types of eye sockets and their associated conditions. It is a is generally made 4-6 weeks after surgery in order to allow
plastic prosthesis, which is made of a high optical quality the socket tissues to heal adequately. Prior to that time, a
acrylic (methacrylate resin) similar to the material used to thin plastic plate called a conformer is sometimes worn in
make dentures. Plastic eyes offer several advantages over place of the prosthesis. A conformer is inserted at the time
the glass eyes. They can be impression fit and can match of surgery to preserve the remaining space within the eye
the exact contours of the socket. After the original socket during the initial weeks of healing until an
fabrication by moulding, they can be enlarged or otherwise appropriate amount of time is needed for healing before an
modified as necessary. Plastic artificial eyes can also be ocular prosthesis can be made. This prevents shrinkage of
polished and cleaned repeatedly, when needed and are the tissue & helps to prepare the socket for ocular
practically unbreakable. The lifetime of a plastic prosthesis placement. Until the ocular prosthesis is fitted, the upper
is up to 5-6 times longer than that of a glass eye, most of eyelid can be droopy in appearance. The prosthesis will
which require replacement every year or two. Glass help support the eyelid and allow the lids to open and
artificial eyes must be blown in a flame and are extremely close normally.
fragile. When completed they cannot be polished or altered
in any way. The entire prosthesis is custom made in The process of making an ocular begins by taking an
laboratory using the patient as a model. This personalized impression of the eye socket. The impression becomes the
approach ensures symmetry and an exact color match. basis for the shape of the prosthesis and is first fashioned
Utilizing the advanced techniques in fitting & fabrication, in wax. This shape will be adapted to ensure proper fit,
we are able to offer a comfortable prosthesis with realistic correct alignment of gaze and appropriate opening of the
movement. Artificial eyes today are fabricated entirely of eyelids. After careful measurements of the iris are taken, a
plastic. The medical profession has unanimously accepted disk is patterned after and painted in the color to match
the plastic eye. the remaining eye. A mould can then be created. The final
ocular prosthesis is cast using acrylic plastic, similar to
The ocular prosthesis is inserted into the eye socket the material used to make dentures.
and removed by the patient. The lids as well as the space of
the eye socket help to keep the prosthesis in place. When An Optometrist or Ocularist is previously played a
properly fitted, the artificial eye should retain itself well large part in creating and fitting prosthetic appliances. It
within the eye socket without inadvertently rotating or is appropriate that the individuals having the knowledge
falling out. An ocular prosthesis that is well made should of the proper care and management of these devices take
feel comfortable and should be nearly undetectable even the lead in this area of specialized patient care.
upon close observation. Often the ocular prosthesis will
move in unison with the remaining eye, although certain The objective of fitting an ocular prosthesis:
circumstances such as removal of eye muscles during
surgery, radiation treatment or multiple surgeries can limit • To maintain shape and the movement of the eyelid
this movement. Ocular prostheses generally last several & for cosmetic purposes.
years if they are well maintained and monitored by an
ocular prosthetic specialist. Long-term ocular prosthetic • To retain the tone of facial muscles and to prevent
alteration of features.
Dr. R. P. Centre for Ophthalmic Sciences
AIIMS, New Delhi - 110 029 • To prevent foreign bodies from entering the ocular
cavity.
• To prevent accumulation of fluid in the cavity and
to direct secretions to proper channels.
April, 2005 392 DOS Times - Vol.10, No. 10
Basics of Ocular Prosthesis Cosmetic Shell with Cosmetic Shell with
Transparent Sclera Opaque Sclera
The types of devices used today are:
1. Artificial eye (Reform Eye):
The artificial eye (reform eye) is a curved disc of plastics
(a hollowed out half round) having a centre thickness of
2mm or greater. It replaces an eye removed either by
enucleation (removal of the eye), evisceration (removal of
the content of the globe) or exenteration (removal of the
contents of the orbit necessitating reconstructive
procedures). It is fitted to replace the lost volume of the
socket and to restore natural appearance and movement.
It is fitted after enucleation of the anterior segment or ocular
evisceration. It is made of acrylic or ant other element that
could affect the eye. It also readily adapts itself to the
temperature of the socket.
Available Size: Right & Left eye – 20mm, 22mm, 24mm &
28mm.
Prior to Reform Eye Fitting With Reform (Artificial) Eye
in place
Artificial Eye/Reform Eye after evisceration when the sclera portion is damaged along
with the iris portion.
Available Sizes: Universal – 22mm, 24mm, 26mm & 28mm.
2. Shell Eye: 4. Corneal Prosthetic Lens:
The shell eye is a curved disc of plastic having a centre The corneal prosthetic lens is a rigid contact lens the
thickness of less than 2mm. It is similar in nature and approximate size of the iris of the natural eye. This lens is
appearance to a scleral contact lens. It usually covers a colored to match the iris of the natural eye. Its purpose is
disfigured or cosmetically undesirable eye. The device is to cover a deformity of the iris, cornea or anterior segment
worn over the eye tissue and extends over the sclera as of the eye. The application can incorporate optics and a
well. The coloring and features of the natural eye are clear pupil as needed. This lens design should be removed
duplicated on the prosthetic shell. from the eye nightly and Rigid Gas Permeable solutions
should be used to maintain and store the lens. Evaluations
3. Cosmetic Shell: should be done about every 4-6 moths and replacements
considered every 18-24 months.
Cosmetic shell is case of disfigured eye only, if there is
no danger to the patient in the retention of the sightless 5. Scleral Shells:
eye. It is extensively used after evisceration. It is made of
acrylic and it is lighter and thinner than the artificial eye. A scleral shell is an ocular prosthesis that is worn over
They are moulded & hands painted and are routinely an existing eye. Typically, one who is a candidate for a
manufactured in acrylic to less than 1mm thickness. They scleral shell has a blind phthisical eye. The shell fits like a
can be made with optical corrections, clear pupils and as a large contact lens, covering the whole front surface of the
solution to ptosis (droopy eyelids). More commonly, they eye globe. It moves along with the existing eye and is fit so
are fitted to microphthalmic (small eyes) or phthisis that the eyelid openings are symmetrical. The process of
(wasted eyes). making a scleral shell is very similar to the making of an
artificial eye, with a few extra steps to ensure comfort over
There are two types of cosmetic shells: the existing cornea. Patients who wear a scleral shell are
sometimes able to wear it full time, removing it once every
1. Cosmetic Shell with transparent sclera. This is used week or two weeks for cleaning. Other patients prefer to
in the absence of iris pigmentation when the sclera portion wear them all day long and remove them at night. We can
of the eye is not damaged and only the iris is disfigured. fit a scleral shell over an existing eye even if it is nearly full
2. Cosmetic shell with opaque sclera. This is used
April, 2005 393 DOS Times - Vol.10, No. 10
sized. Scleral shells for patients who still have an eye present Hydrophilic Prosthetic Lens
in the socket. The eye is often blind. Disease or injury may
have caused this eye to become disfigured and/or painful. into the prosthesis in which lubricant is stored. It slowly
The scleral shell covers the eye protecting it & often making released on to the front surface of the prosthesis, providing
it more comfortable. moisture and comfort to the inner lining of the eyelids. Not
all prosthetic eye wearers are candidates for SLP.
Scleral shells today are fabricated entirely of plastic.
The medical & ocular profession has unanimously accepted 9. Facial Prosthesis:
the plastic prosthesis. Here are some of the reasons:
A facial prosthesis is an artificial device used to replace
• The patient is the model, not only for the size and shape a missing or malformed facial feature. A person in need of
of the shell but also for the coloration. This results in a a prosthesis may have lost a part of his or her face due to
natural keying shell with the maximum motility. cancer, trauma, or as a result of a congenital birth anomaly.
• The plastic used is tough, durable and non-allergenic. Common types of facial prostheses include:
It will provide years of comfortable wear.
Auricular : Ear
• The finished shell can be adjusted; as needed the size,
shape and color can all be modified. Nasal : Nose
6. Scleral Cover Shell Prosthesis: Orbital : Eye and Lids
It is also known as a “cover shell” is a thin, plastic Midfacial : Nose and other tissues
prosthesis used when an eye is malformed as a result of a
birth defect or becomes non-functioning due to subsequent Upper facial : Orbit and other tissues
illness or injury. In such cases, the non-functioning eye is
left within the eye socket. Prosthesis can then be molded to Hemi-facial : Nose, Orbit and other tissues
fit between the lids and the blind eye. Scleral cover shells
fit directly over the malformed eye. Sometimes a “trial They can construct of acrylic or silicon rubber & are
shell” is fashioned to allow the eye to grow accustomed to positioned by adhesives or by attachment to spectacles
the direct contact of the prosthesis. Cover shells impart a (Spectacle Prosthesis). We can also provide prosthesis that
better cosmetic appearance by closely resembling the is attached to bone implants for greater sophistication.
remaining good eye, while leaving the affected eye in the The defective orbital area is moulded and the new face
socket. area sculpted in clay and wax to restore symmetry with
the comparison orbital area. It is very distressing for the
7. Hydrophilic Prosthetic Lens: patient to find that they are left with a face, which causes
revulsion amongst their friends and relatives. The
The hydrophilic prosthetic lens is a soft contact lens construction of a facial prosthesis gives them confidence
that is fit to mask disfigurement, undesirable conditions to face the world again and is a great morale booster. The
and or handle visual issues. The cosmetic outcome is to following figure give an understanding of what can be
match or change the patient’s natural appearance. Pupil achieved.
and or iris cosmesis as well as optical prescriptions are
possible. The stock prosthetic hydrogel lenses with set This was ane eye-socket made in
parameters and colors are available and work well for latex rubber, which carried a glass
many patients. Customs design is also available. The lenses eye
should be worn on a daily schedule using the
manufacturer ’s recommended care system for the 10. Therapeutic or Socket Expansion:
disinfection cycle. Rewetting drops are recommended as
appropriate for the hydrogel polymer. The follow up should If a child is born with either anophthalmia (no eyes) or
be scheduled every 6-months and replacement about every microphthlmia (small eyes) the eye socket needs to be
12-18 months. expanded to ensure that there is no facial distortion as the
child grows up. The socket is expanded by various in house
8. Self-Lubricating Prosthesis: means over a period of days and weeks, depending on the
The self-lubricating prosthesis (SLP) is a patented
modification to a new or existing ocular prosthesis. It
provides a continual release of lubricant, eliminating dry
eye syndrome as well as burning and itching. These
conditions are more commonly associated with prosthetic
eye wearers who do not have the ability to close their
eyelids over the prosthesis. The SLP has a chamber built
April, 2005 394 DOS Times - Vol.10, No. 10
individual case to a point where a cosmetic prosthesis can
be provided. This process needs repeating frequently to
match the growth and simulate socket expansion.
11. Conformer:
Conformers are used after enucleation to conform to
the conjuctival sac formices. They should adhere closely to
the socket contour and fill the depths of the formics without
stretching them. Easy closure of the eyelids after the
conformer is slipped into place usually indicates proper
fit. Most of the conformers have 1, 3 & 5 drainage holes to
allow mucoid discharge to escape and to facilitate the
insertion of postoperative medication.
Castroveijo Implant
Conformer 14. Spherical Implant:
12. Fornices Open Conformer: Spherical implant is positioned within tenon’s capsule
without attachment to the orbital tissue. During the
Fornics open conformers are also known as version movements, the fornics of the enucleated socket
symblepharon rings. They should be immediately inserted retracts and lengthens on the side towards the direction of
to prevent adhesions and shortening of the fornices and the gaze because contraction of the muscle and tenon’s
cul-de-sacs. This conformer reduces scarring and keeps layer occur on that side.
the lids away from an irritable eye. This helps the patient
feel more comfortable. The objectives of the spherical implants are as follows:
• It provides motility to the prosthesis.
• It generally prevents cause of pressure necrosis.
Available Sizes: 13mm, 15mm, 17mm & 19mm.
13. Castroveijo Implant: Surgical Implant
Castroveijo implants motility to the prosthesis by 15. Somato Prosthesis:
acting as a smooth convex pivotal surface over which the
artificial eye or cosmetic shell glides during shortening The term somato prosthesis is used to describe a
and lengthening of the formics. Anteriorly, it has a central general category of devices distinct from facial or other
rectii muscles are accommodated in the tunnels situated types of prostheses. These types of prostheses can either
directly beneath the bridge and the end of the opposed be worn on top of the skin or surgically implanted beneath
muscles are sewn so as to overlap each other. The implant the skin. Certain somato prostheses are surgically
is completely buried under the tenon’s capsule. implanted beneath the skin surface. These types of
prostheses are made of silicone or acrylic plastic.
The advantages of casroveijo implant are as follows:
Pediatric Prosthetics
• It provides better motility and requires very little
adjustments from the ocularist. Working with children is one of the most rewarding
aspects of our profession. Their positive outlook is an
• It provides support for the artificial eye and it look less encouragement to us all. The loss of an eye is a traumatic
sulken. endeavor; no matter what age it occurs. Children are very
• It also services to prevent bony deformity of the orbital
wall.
• It also helps to maintain the normal size of the socket.
Available Sizes: 13mm, 15mm, 17mm & 19mm.
April, 2005 395 DOS Times - Vol.10, No. 10
resilient and are able to quickly learn to cope with their required the fitter to have a large selection of stock eyes on
loss and adjust to their change in vision. Prosthetic for hand to simulate the patient’s iris color and fill the shape
children demand and deserve the utmost care and requirements with the iris in the right position.
attention. We take pride in our extensive experience and
skill with children. The custom-made prosthesis as the name implies is
made from a direct model of the socket. During the first
Pediatric Prosthesis – Fitting: fitting appointment about 8 weeks following surgery, an
impression is usually taken if possible, of the socket to
At approximate 4-6 weeks following enucleation the provide maximum conformation and contact to ensure a
process being with a consultation, which provides an proper fit.
opportunity for your child to become comfortable with
optometrist or ocularist. We find it helpful to provide a 2. The Procedure:
brief and simple explanation to toddlers informing them
of what will be done during the visits since the child is The Bio-eye ocular implant is surgically placed within
usually apprehensive. It is important for the optometrist, the orbit at the time the eye is removed and the tissues are
ocularist and parents to limit their expectations of what closed over the implant. A temporary conformer is then
will be accomplished during the first visit. It is common to placed over the implant and under the eyelids to maintain
expect 3-4 visits for a well-made prosthesis. the space for the artificial eye. 6-8 weeks later, a visit is
made to an optometrist or ocularist. This highly skilled
Pediatric Prosthesis – Follow-Up Care: specialist will create a detailed artificial eye-often
astonishing in its lifelike appearance that exactly matches
Follow up visits for infants and toddlers receiving your natural eye. The artificial eye fits over the implant
prosthesis are scheduled approximately every 3-4 months. and under the eyelids and will move as the implant moves
In a case involving enucleation, enlargement or replacement or “tracks” along with the natural eye.
of the first artificial eye for an infant may be required in a
year or less. This is mainly due to growth and color change If further movement is desired, your eye care specialist
during the first two tears of line. It is often possible to can perform a simple procedure to connect the artificial
enlarge your child’s current prosthesis if only minor eye to the implant by means of a peg. In this optional
changes are required. This defers the need for a completely procedure, a hole is placed in the implant and a peg is
new prosthesis eye at least some period of time. inserted into the hole. The latest materials are used for the
pegging system and titanium is now the material of choice.
• From age 2 to 5, annual replacements are common but Once the peg is placed in the implant, a month healing
again not always necessary, mainly depending on the time is suggested before the optometrist or ocularist
amount of tissue settlement in the eye socket and modifies the back of the artificial eye to accept the head of
growth of the child. the peg, thus forming a direct link to the artificial eye. The
peg-fitting procedure can only be performed after the
• At approximate age 3, follow-up visits to the implant had time to fill with tissue from the orbit, usually
optometrist or ocularist can be reduced to every 6- about 6 months after implantation. A bone scan or
months. magnetic resonance imaging (MRI) test should be performed
to confirm whether the implant is ready to accept a peg.
• From age 6 to 12, replacements are required even less These tests as well as the peg fitting procedure are usually
frequently. In this age category it is more common to painless. Once your optometrist or ocularist has properly
keep the same prosthesis for 2-years or more, using fit the artificial eye, the full benefits of the Bio-eye ocular
the enlargement option in between. However, still implant will be available to you. Of course, the final results
continue follow-up visits every 6-months. in each case will vary depending on the condition of the
orbit, muscles, surrounding tissues and the skill of the
As a full grown adult, the average replacement time is ophthalmologist, optometrist and ocularist.
approximately 5-years. Even if there is no required change
in shape, the material eventually absorbs mucous from 3. Materials:
the eye socket and becomes less inert to the socket tissue.
Adult should continue to have their prosthesis evaluated The material used is similar to that used for taking
and polished every 6-12 months. dental impressions and the process takes only a few
minutes. This procedure is not painful although some
There are 5-area covered by Ocular Prosthetics: patients experience slight discomfort from the pressure of
the material filling the socket. Sometime during the first
1. The Fitting Theory: visits the iris is often painted that will be used in the actual
fitting and final prosthesis. The hydroxyapatite and human
There are several methods of fitting an artificial eye. bone are the main material and the natural choice.
Many years ago stock eyes or (ready-made eyes) were fit
by trying different shapes into the socket until a The goal of a more natural appearance was finally
satisfactory lid opening was achieved. This method
April, 2005 396 DOS Times - Vol.10, No. 10
achieved with the help of a natural material i.e. Ocean 7. Many eye professionals frequently recommend the use
Coral. A remarkable similarity was noticed between the of artificial tears but there are actually very few products
porous structure of certain coral species and that of human specifically made for ocular prosthesis wearers. The
bone. Soon after this discovery, a method was developed
to transform the mineral in coral to match that of human products listed below can be very beneficial:
bone known as hydroxyapatite. This is new natural derived
material has both the porous structure & the chemical Enuclene(Alcon) : Is a mild decongestant and
structure of bone. Thus, the tissues of the body will accept- lubricant that can help patients with excessive secretions?
even grow-into this naturally derived hydroxyapatite It may be obtained without a prescription at a pharmacy
implants and essentially become a “living” part of the body. from your ophthalmologist, optometrist or ocularist.
4. Processing: Sil-Ophtho : Is pure lubricating silicone oil that may
In the custom-made prosthesis, no one method is used be applied directly to the prosthesis prior to insertion or
while it is being worn. Sil-Ophtho will provide hours of
for every patient & the approach will vary with the comfort during those times when the humidity is
circumstances and the optometrist or ocularist doing the excessively low. It is also available in a light and heavy
work. From the impression of the socket, a wax model is viscosity.
made for the fitting of the final shape.
Tears Again : An exciting new product recently
5. Fabrication techniques: released called “Tears Again” is a very soothing eye drop
Impression: An impression of the socket is taken with or water based gel that works well for artificial eye
wearers. As a thicker viscosity eye drop, “Tears Again”
an alginate material to provide the posterior (back) provides longer relief for dry eye problems than regular
dimensions of the prosthesis. artificial tears, the gel is especially useful at bedtime.
Modeling: A wax model is fabricated from the Similasan : The newest drop we just recently added to
impression and is sculpted to achieve the best symmetry our selection is a Similasan eye drop. In addition we also
with lid opening and direction of the remaining eye. can provide you with eye patches and suction cups for
ocular prostheses removal and insertion.
Painting: The prosthesis is hand painted while
observing the patients companion eye. This involves Opti-Soak : Apply a few drops of Opti-Soak to your
matching the iris color, limbal blend, scleral tinting and prosthesis before inserting and it will feel much more
veining. comfortable than using plain water. Opti-Soak is Ph-
balanced and will not burn the socket upon insertion. Opti-
Polishing and Fitting: The prosthesis is polished and Soak also disinfects the prosthesis if stored overnight
fit to determine if any adjusting is necessary.
Eye Patches : We also carry Custom-made Ultra-
6. Iris and sclera tinting techniques: Suede eye patches in five colors. They are very comfortable
As the fitting proceeds, the model is shaped to form and have a Velcro attachment for easy tension adjustment
the lid opening to match the normal eye as closely as Instruction for Use : To use the gel, pull down the lower
possible. Next, the iris cornea piece is set into the model lid and apply a small amount (one eight inch) of gel to the
and moved as necessary until the position of the iris is inside of the lower eyelid. Because of the active ingredient,
centered to match the companion eye. Once the shape and Carboxymethyl Cellulose, a feeling of immediate cooling
centering requirements have been met, the model is cast in comfort is experienced upon application.
a stone mold and duplicated in white plastic. At this time,
the iris piece is also cured into the plastic piece in an oven The artificial eye fits over this buried implant and is
or curing tank. Following this procedure, some of the plastic not sutured into the socket in any way but is held in place
has to be removed to allow for the final painting and scleral by the eyelids. This allows your artificial eye to be
tinting. All the details including the small blood vessels removing for cleaning as needed and in some cases
are then painted to match the natural eye. After the final depending on the implant use, the motion of the implant
coloring process, the eye is covered with a layer of clear will transfer movement to the artificial eye. However,
plastic to seal in the artwork and give the eye prosthesis a unless the artificial eye is directly attached to the implant
rounded shape. Once finished, it is ready to be inserted by way of a motility support peg fit by the optometrist or
into the socket for a final fitting evaluation. The total time ocularist, it generally will not move as well as the normal
required to make prosthesis varies with the requirements companion eye. Integrated implants like the Bio-eye or
of each patient and the type of eye being made. Following Medpor Implants can be directly attached to artificial eye
new surgery, follow-up care is usually needed for one year by way of a motility pegging system. In addition, pegged
after delivery of the prosthesis. It often takes many months artificial eyes provide more support for the lids and reduce
of healing for the socket tissues to settle and for all of the lid lag, which often is a problem for many patients, as they
swelling to subside. Because of this, enlargements are often grow older.
necessary some months after the original fitting.
If you do not have or plan to have motility pegged
artificial eye, the following suggestions can help make the
presence of an ocular prosthesis less obvious:
April, 2005 397 DOS Times - Vol.10, No. 10
8. The world of artificial eyes Products:
Custom Artificial Eyes Surgical Conformers Maxillo-Facial (Anaplastic Prosthetics)
(Clear acrylic)
• Full replacement • Ocular splints & supports • Prosthetic noses, ears, facial parts
(Standard fitting) • Conformers for cornea • Remarks (Remarks are necessary after 3-5
years for therapeutic reasons e.g. body fluids
• Exenteration overfits Protection absorbs into prosthetic, you gain or loss
weight, which affects the socket size etc.
• High Motility (Bio- • Post surgical fenestrated Prosthesis should be cleaned and glazed every
6 months to enhance it.
matrix-hydroxyapatite) Conformers
• Ultra thin cover shell
Custom Options :
• Iris Size Pupil
• Size
• Color
• Post artificial eyes will not move up and down as well Remember when people without an artificial eye talk
as the companion eye. Therefore, avoid tilting the head to each other; it is normal for them to choose an eye to
downward while simultaneously looking up. make visual contact with. Most people will also shift their
• Many artificial eyes will have restricted motion to the gaze back and forth between the eyes while talking. If you
sides (horizontally and nasally). To compensate, feel someone is concentrating his or her gaze on your
develop a habit of turning your head, rather than just artificial eye, you should not be too concerned. This usually
the eyes in the desired direction of gaze. It also helps to means it is the eye they have selected to talk to and not
develop a habit of closing yours eyes just before you necessarily because they have noticed any difference in
turn your head and then reopening them afterward. your appearance. Most patients tell us that when they
This little trick becomes second nature after some share the fact that they wear prosthesis, the reaction from
that person is, they cannot believe it.
practice.
• Selecting eyeglasses with a rather heavy frame will For Sale
often help divert attention from your eyes and will
help cover upper any lid depression (Sulcus) if present. Excimer Laser
Tinted lenses will sometimes improve the cosmetic NIDEK EC – 5000
effect but should not be so dark as to interfere with
your night vision. Machine
• Also make sure you ask your optical professional for in excellent condition
polycarbonate lenses when ordering the glasses.
Polycarbonate lenses are extremely impact resistant Contact :
and provide the greatest degree of safety compared to
any other lens material. When you have only one eye Dr. Vivek Pal
it just makes good sense to protect it. Don’t take chances. Navjyoti Eye Centre
Protect your remaining eye with high impact
polycarbonate lenses, the safest material available. 90, Darya Ganj, New Delhi
• Using special optical power lenses in eyeglasses worn Ph : 23274495, 23272846, 23260403
over prosthesis can create an optical illusion. It is 23259167 • Mob. : 9810357871
possible to widen or reduce the lid opening or change
the apparent lid shape. Do not agree to a “non-
balanced” lens over the artificial eye because any
difference in lens style will draw attention to it. Even
though it may cost a little more money make sure the
lens style i.e. bifocal, trifocal and power are the same
as the other lens or that it is specially designed to
provide a better cosmetic appearance.
April, 2005 398 DOS Times - Vol.10, No. 10
RECENT ADVANCES
New IOL Technologies : The Light Adjustable IOL
Harinder Singh Sethi, MD, DNB, FRCS, Tanuj Dada, MD
Despite the introduction of more accurate intra-ocular within that region of the lens with an associated change in
lens (IOL) formulas and biometry instrumentation, the the radii of curvature and power. Once the desired power
ophthalmologist’s dream of perfect emmetropia in all cases change is achieved, irradiation of the entire lens to
is still a distant reality. This can be attributed to various polymerize all remaining macromer “locks-in” the
reasons like inaccuracies in keratometry and axial length adjustment so that no further power changes can occur.
measurements, an inability to accurately predict the final
position of the IOL in a fibrosing capsular bag, and the Modulating postoperative Refractive Power of Light
difficulty of completely eliminating pre-existing adjustable IOL
astigmatism.
The treatment of residual postoperative sphere and
In addition there is an increasing demand for cylinder is based on the fact that for postoperative residual
emmetropia especially in patients who have previously hyperopia, power will need to be added and for residual
undergone vision correction surgery with refractive IOLs myopia it needs to be subtracted from the LAL in order to
or with excimer laser. In patients with cataracts who have achieve emmetropia.
previously undergone corneal refractive procedures, it is
difficult to measure corneal power accurately, and hence Residual Hyperopia
the final IOL power. Such patients often have surprising
hyperopic errors despite accurate IOL power For cases with residual hyperopia, once postoperative
determination. The ability to correct hyperopic surprises refractive stability has been reached (4 weeks), irradiation
after cataract surgery in patients who have undergone of the central portion of the lens with the Light Delivery
previous refractive surgery is an urgent need for both Device ( Fig 2 ) polymerizes the macromer in this region.
patients and the operating surgeons. Over the next 12-15 hours, the macromer in the peripheral
portion of the lens will diffuse centrally down the
A new lens technology called Light Adjustable IOL ( concentration gradient in order to achieve concentration
Fig 1) offers the hope of achieving emmetropia in all cases. equilibrium with the central lens which has been depleted
The Light Adjustable IOL technology is currently being of macromers due to their polymerization. This migration
developed by Calhoun Vision (Pasadena, Ca). results in swelling of the central portion of the lens with
an increase in the radius of curvature and an associated
Principle increase in the power of the LAL ( Fig 3 ). With variation in the
duration and power of light exposure, differing amounts of hyperopia
The current design of the LAL is a foldable three-piece can be corrected. 24 hrs or more after this adjustment, the
IOL with a cross-’linked photosensitive silicone polymer entire lens is treated to lock-in the fine adjustment. Since
matrix, a homogeneously embedded photosensitive outdoor ultraviolet light can affect the LAL, patients wear
macromer, and a photoinitiator. The application of near- sunglasses to eliminate UV exposure until the final lock-
ultraviolet light to a portion of the lens optic results in in is performed. Once final polymerization and lock-in is
disassociation of the photoinitiator to form reactive executed, no further UV protection is necessary.
radicals that initiate polymerization of the photosensitive
macromers within the irradiated region of the silicone Residual Myopia
matrix. Polymerization itself does not result in changes in
lens power, however, it does create a concentration gradient In a pseudophakic patient with a myopic error,
within the lens resulting in the migration of non-irradiated power needs to be reduced from the LAL in order to achieve
macromers into the region that is now devoid of macromer emmetropia. In this case, the peripheral portion of the lens
as a result of polymerization. Equilibration from migration is irradiated to achieve a doughnut configuration, which
of the macromers into the irradiated area causes swelling results in polymerization of macromers in this region with
a resultant diffusion of central lens macromers into the
Dr. R. P. Centre for Ophthalmic Sciences, peripheral irradiated portion of the lens ( Fig 4 ). This results
AlIMS, New Delhi. in swelling of the peripheral annulus of the lens with a
concomitant decrease in central radius of curvature and a
April, 2005 399 DOS Times - Vol.10, No. 10
Fig 1: Light adjustable IOL Fig 2 : Digital light delivery device
Figure 3. Schematic illustration of the proposed mechanism of swelling. (a) Selective irradiation of the
central zone of IOL to correct hyperopic correction ( i.e adding power to LAL ). This polymerizes macromer in
central area and creats a chemical potential between the irradiated and nonirradiated regions; (b) to reestablish
equilibrium, excess macromer diffuses into the irradiated central region causing swelling; and (c) irradiation
of the entire IOL ʺlocksʺ the macromer and the shape change.
Figure 4. Schematic illustration of the proposed mechanism of swelling. (a) Selective irradiation of the
perpheral zone of IOL to correct myopic correction ( i.e Remove power from LAL ). This polymerizes macromer
in peripheral area and creats a chemical potential between the irradiated and nonirradiated regions; (b) to
reestablish equilibrium, excess macromer diffuses into the irradiated perpheral region causing perpheral
swelling; and (c) irradiation of the entire IOL ʺlocksʺ the macromer and the shape change.
April, 2005 400 DOS Times - Vol.10, No. 10
decrease in lens power . aberration-free optical system that endures as a patient
ages would be the removal of the crystalline lens and
Similarly, astigmatism can be treated by irradiating replacement with an implant that could be adjusted using
the LAL along the appropriate meridian in order to create wavefront technology to eliminate higher order optical
a toric change in the radius of curvature of the lens. This aberrations within the eye.
will increase power at a meridian 90 degress away from
the treated meridian. The early reversible nature of the LAL prior to the
final “lock-in” will allow patients the opportunity to
Proposed benefits of LAL experience monovision, multifocality, and wavefront
guided treatments and then decide if that refractive status
1. As an ideal implant for Refractive Lens Exchange is acceptable. The LAL still needs to go through
randomized controlled clinical trials till it becomes the
The concept of exchanging the human crystalline lens IOL implant of choice in the near future, however this
with a pseudophakic IOL as a form of refractive surgery is technology may hold the key to emmetropia.
gaining popularity nowadays. This is due to several
problems inherent in excimer laser corneal refractive References
surgery including the limitations of large myopic and
hyperopic corrections, the need to address presbyopia, and 1. Brandser R, Haaskjold E, Drolsum L: Accuracy of IOL
progressive lenticular changes that eventually will calculation in cataract surgery. Acta Ophthalmol Scan
interfere with any optical corrections made in the cornea. 75: 162-65, 1997.
The LAL may be an ideal implant for refractive 2. Giers V, Epple C: Comparison of A-scan device accuracy.
lens exchanges since emmetropia can be fine-tuned J Cataract Refract Surg 16: 235-42,1990.
following insertion. Calhoun Vision has demonstrated in
vitro, an ability to irradiate multifocal optics of any near 3. Watson A, Armstrong R: Contact or immersion
add onto any portion of the LAL . Theoretically, a patient technique for axial length measurements? Aust NZ J
undergoing a refractive lens exchange could have their lens Ophthalmo127: 49-51, 1999.
adjusted for emmetropia and then have multifocality
introduced to determine if they were tolerant to multifocal 4. Packer M, Fine IH, Hoffman RS et aI: Immersion A-scan
optics. If intolerant, the multifocality could be reversed compared with partial coherence interferometry.
and a trial of monovision could be induced. Once the Outcomes Analysis. J Cataract Refract Surg 28: 239-
desired refractive status is achieved, the LAL could then 42, 2002.
be locked-in permanently. This would allow patients the
option of experimenting with different refractive optics 5. Olsen T: Sources of error in intraocular lens power
and deciding in situ which was best for them. calculation. J Cataract Refract Surg 18: 125-29,1992.
2. To correct Higher Order Aberrations 6. Schwiegerling IT, Schwartz OM, Sandstedt CAet aI:
Light-adjustable intraocular lenses. Review of
The elimination of higher order optical aberrations Refractive] Surgery; Newtown Square, Jobson
would theoretically allow the possibility of achieving Publishing, LLC 2002.
vision previously unattainable through glasses, contact
lenses, or traditional excimer laser refractive. One of the 7. Packer M, Fine IH, Hoffman RS: Refractive lens exchange
major limitations of addressing higher order aberrations ith the Array multifocal lens. J Cataract Refract Surg
with corneal ablations lies in the fact that higher order 28: 421-24,2002.
aberrations such as spherical aberration tend to remain
constant within the cornea throughout life while 8. Oshika T, Klyce SO, Applegate RAet al: Changes in
aberration in the crystalline lens tends to change as a corneal wavefront aberrations with aging. Invest
patient ages. Thus, any attempt to perfect the human visual Ophthalmal Vis Sci 40: 1351-55,1999.
system with wavefront guided ablations to the cornea
will be sabatoged at a later date by increasing positive 9. Artal P, Berrio E, GuiraoAet al: Contribution of the
spherical aberration in the naturally aging crystalline lens. cornea and internal surfaces to the change of ocular
If the higher order aberrations within the cornea are indeed aberrations with age. J Opt Sac Am A Opt Image Sci
stable throughout life, a better approach for creating an Vis 19: 137-43, 2002.
10. Hoffman RS, Fine H, Packer M. Light adjustable IOL. In
Aggarwal S, Aggarwal A, Aggarwal A et al.
Phacoemulsification 3rd Edi, 714-723,2004, Jaypee
Brothers Medical Publishers, new Delhi , India
April, 2005 401 DOS Times - Vol.10, No. 10
April, 2005 DIFFERENTIAL DIAGNOSIS OF LEUCOCORIA
RETINOBLASTOMA PERSISTENT HYPERPLASTIC PRIMARY COAT’S DISEASE RETINOPATHY OF PREMATURITY TEAR SHEET
VITREOUS
+ve history of O2 therapy
HISTORY Two types : Non - familial Non - familial Birth wt. <1600 gm
Familial – 40% Gest. Age <37 wks
CLINICAL FEATURES Sporadic – 60% Unilateral ( 90% ) Unilateral
LATERALITY Bilateral
25 – 30% familial, B/ L
AGE AT 10 – 20% familial, U/ L Immediately after birth to few weeks after birth 4 – 10 yrs of age ( even in adults ) Peak towards Few weeks after birth
PRESENTATION 50 – 60% non-familial, U/L end of 1st decade
SEX 12 – 14 mths familial No sex predilection Males No sex predilection
MOST COMMON FEATURE 24 – 30 mths non-familial Leucocoria Retinal telangiectasia and exudation Leucocoria is a late presentation
Rare after 5 yrs of age
OPHTHALMOSCOPIC APPEARANCE Funnel – shaped mass of fibrovascular tissue in Yellow intraretinal or subretinal exudation that Four stages ;
Slightly more in males the retrolental space, concave anteriorly. Hyaloid forms a circinate pattern around vessels which 1. Ridge
PROPTOSIS ( India ) remnants are diagnostic ( if found ) show aneurysmal dilatation. 2. Intraretinal microvascular abnormalities
Leucocoria Exudative RD with refractile particles ( cholesterol 3. Extraretinal vasc. abnormalities
crystals) 4. Regression/ cicatrization
Three types :
1. Endophytic
2. Exophytic
3. Infiltrative
May be multifocal
402 DOS Times - Vol.10, No. 10 OTHER FEATURES IOP may be high Shallow AC Normal anterior segment Centrally displaced ciliary processes due to
COMPLICATIONS No elongation of ciliary processes Elongated ciliary processes Progressive intraretinal exudation exudative traction
Normal sized eye Adipose tissue +nt RD Tractional RD
Cataract – rare, late Microphthalmia Relative microphthalmia later ( normal size at
Early cataract birth )
Hyphema, glaucoma, spread of tumor – local, optic
nerve ( to CNS ), hematogenous, Intraocular hemorrhage, secondary angle closure Total RD, rubeosis iridis, spontaneous hyphema Extensive neovascularization, total tractional RD
Higher risk of second non-ocular malignancy glaucoma, tractional folds in retinal periphery,
rarely RD, phthisis bulbi
INVESTIGATIONS Extent of tumor No calcification No calcification No calcification
X-RAY, CT SCAN Calcification ( pathognomic ) - Telangiectasias, leakage Periph. Vasc. abnormalities
FFA
-
USG B – SCAN Cauliflower like mass filling the globe Retrolental mass, no tumor arising from retina No tumor, RD +nt Traction bands in vitreous, RD
A – SCAN V-Y pattern, highly reflective signal from calcification Shorter A-P diameter Particulate echoes of moderately high intensity
foci from refractile particles
AQUEOUS : PLASMA LDH HIGH NORMAL NORMAL NORMAL
AQUEOUS CYTOLOGY
TREATMENT Malignant cells Adipose cells Cholesterol crystals normal
Eneucleation Surgery to prevent complications – intraocular he, Early – observation, photocoagulation, Photocoagulation
Radiotherapy – eye-saving brachytherapy, for ACG, to preserve the eye ( poor visual prognosis cryotherapy Cryotherapy
recurrences ), untreated cases – phthisis bulbi Late – V-R surgery, no treatment Buckle surgery for RD with traction
Chemotherapy - metastasis
OTHER CAUSES OF LEUCOCORIA Dr. Snigdha Mahajan, Dr. Vivek Sharma,
HEREDITARY : Norrie’s disease, congenital retinoschisis, incontinentia pigmenti, familial exudative vitreoretinopathy Dr. Kirti Singh, Dr. Usha Yadav
DEVELOPMENTAL : Congenital cataract, coloboma, retinal dysplasia, congenital retinal fold, myelinated nerve fibers, morning glory syndrome, congenital corneal opacities Guru Nanak Eye Centre, New Delhi
INFLAMMATORY : Ocular toxocariasis, congenital toxoplasmosis, congenital CMV retinitis, herpes simplex retinitis, peripheral uveitis, metastatic endophthalmitis
TUMORS : Retinal astrocytic hamartoma, medulloepithelioma, glioneuroma, choroidal hemangioma, leukemia
MISCELLANOEUS : Rhegmatogenous RD, vitreous hemorrhage
APPLIANCES
Short Wavelength Automated Perimetry
Tanuj Dada, MD, Parul Sony, MD
Introduction Indications
Diagnosing glaucoma in early stages of the disease still • Glaucoma suspects with normal White-on-white
remains a major challenge for the treating perimetry in whom other risk factors are present (eg.
ophthalmologist. Till date visual field assessment has been optic nerve head changes)
the gold standard for glaucoma diagnosis, but it has been
documented that upto 40% of the retinal nerve fiber layer • Ocular hypertensives: to detect and predict their
may be lost before a defect is apparent on the standard conversion into glaucoma patients
white-on-white automated perimetry. Blue on yellow
automated perimetry or short wavelength automated • Glaucoma patient with mild to moderate Visual Field
perimetry (SWAP) was thus introduced for the early Defect for detection of glaucoma progression.
diagnosis of glaucoma. SWAP provides a high luminance
yellow background to adapt the green and red cones and Interpretation of printout
to saturate the activity of the rods, thus checking for blue
cones and may allow better detection of early Interpretation of SWAP printout is almost similar to
glaucomatous damage. the white on white standard automated perimetry. It
consists of following information
Principle
• Patients ID details
The SWAP tends to put to test a subset of retinal
ganglion cells that is lost early in glaucoma. The short • Strategy used
wavelength sensitive pathways subserved by the blue
cones, or the retinal ganglion cells responding to blue • Reliability indices: includes fixation losses, false-
stimuli in isolation, which have less redundancy in positive and negative errors
function, is specifically evaluated by the SWAP and
possibly allows earlier detection of visual loss. These cells • The numeric data and the gray scale: this is raw data
are known as Koniocellular retinal ganglion cells and are printed in numbers that express the patient’s test
sparsely distributed in the retina. Theoretically, a small responses in decibels.
diffuse loss of retinal ganglion cells should affect SWAP
thresholds. This technique uses an intense yellow • Total deviation plot
background and blue colored Goldmann size V stimulus
to isolate the blue cone system for evaluation and • Pattern deviation plot
measurement of a chromatic contrast threshold on a yellow
background. The yellow background bleaches the red and • Global indices (these are all put in a box)
green cone pigments while blue cones are minimally
affected. Therefore, SWAP isolates retinal ganglion cells o Mean deviation
responsive to short-wavelength (blue) light.
o Pattern standard deviation
Technique
o Short-term fluctuation
SWAP has now been incorporated into the Humphrey
and Octopus perimeters. It is a standard feature on o Corrected pattern standard deviation
Humphery 745 and 750 perimeters. In addition any
Humphrey field analyzer II can be upgraded to a model Clinical studies
with SWAP testing capabilities.
Short wavelength automated perimetry detected
The patients should be explained regarding the visual field loss earlier than standard threshold automated
procedure in detail. Usually 2-3 minutes are required for perimetry, with a sensitivity and specificity of about 88%
the patient to adapt to the yellow light. With 24-2 and and 92% respectively.1-8 However, it is a lengthy,
FastPac strategy the patient generally requires 7-12 demanding test, is sensitive to media opacities, and has a
minutes for the complete test, however this test usually greater magnitude of long-term fluctuation compared with
takes more time than standard achromatic perimetry and standard threshold automated perimetry, which make it
is more uncomfortable to the patients. difficult to assess disease progression accurately.
Dr. R. P. Centre for Ophthalmic Sciences Johnson et al1 in their longitudinal study of individuals
with ocular hypertension had shown of the association
AIIMS, New Delhi - 110 029 between the prevalence of localized SWAP visual field
defects and the development of glaucomatous of visual field
loss. Several investigators including Sample3 et al have
concluded from their studies that foveal blue and yellow
color vision deficits are present in individuals with ocular
hypertension and glaucoma and that these deficits appear
to be early indicators of glaucomatous damage. Drance et
al 4found that patients with ocular hypertension and blue-
yellow color deficiencies had a higher incidence of
April, 2005 405 DOS Times - Vol.10, No. 10
glaucomatous field loss five years after the initial testing be appreciated. In addition, the mean SWAP threshold values in
than those individuals with normal color vision and decibels are lower than in conventional perimetry and the gray
elevated ocular pressures. scale is darker in appearance. Grey scale in SWAP is not to be
relied on for interpretation, and the probability plots are more
Localized short wave sensitivity losses in patients useful, as in standard perimetry. The most useful application for
with ocular hypertension and glaucoma correspond to SWAP is in clinical situations where conventional tests reveal
nerve fiber bundle pattern similar to localized equivocal or contradictory results in diagnosis of glaucoma.
glaucomatous visual field defects found with conventional
white-on-white auto perimetry. Blue yellow perimetry SWAP is used in confirming or excluding diagnosis of
losses occur prior to the development of deficits for the glaucoma in individuals with significant signs and risk
conventional standard white-on-white autoperimetry factors suggestive of glaucoma, like elevated ocular
(SAP) and also tend to encompass a larger area of the visual pressures and suspicious appearance of optic discs, but
field. The initial development of visual field loss observed who reveal normal standard white fields.
with SAP occurs in visual field regions that have previously
demonstrated blue-yellow perimetry losses. The results Sita Swap
of longitudinal studies of ocular hypertensives by Johnson
and his colleagues indicate that blue yellow perimetry is The long test duration remains one of the major
predictive of impending glaucomatous visual field loss on drawbacks with full threshold SWAP tesing. Recently
SAP and that glaucomatous defects may be detected with efforts were made to develop and test a short and reliable
SWAP several years earlier than by the standard visual field threshold program for the early detection of
automated perimetry. glaucomatous visual field loss, by adapting the Swedish
interactive test algorithm (SITA) to SWAP.9,10 Studies
Abnormalities detected by SWAP in patients with comparing the computer simulations to test the accuracy
early glaucomatous loss are typically larger than and reliability of SITA SWAP, with the older Full Threshold
corresponding defects detected with the SAP5. On an SWAP and Fastpac SWAP programs in glaucoma and
average, the visual field defects with the blue yellow normal subjects showed that the average test time was 3.6
perimetry are 3 to 4 times larger than those found with minutes for SITA SWAP, 11.8 minutes for Full Threshold
white perimetry. The rate of short wavelength sensitivity SWAP, and 7.7 minutes for Fastpac SWAP. Mean threshold
loss is also greater in patients who demonstrate reproducibility, calculated as absolute difference between
progression in their visual field loss as compared to two tests, did not differ significantly between programs
individuals with stable visual fields. Progression of defects and was 2.4 dB for SITA, 2.3 dB for Full Threshold, and 2.4
found with white perimetry tends to be observed in areas dB for Fastpac SWAP. The authors concluded that SITA
having a subnormal sensitivity in the SWAP fields years SWAP is much faster than the older SWAP strategies, and
earlier. Blue yellow perimetry is thus a sensitive device to reproducibility did not differ from the earlier tests. This
monitor patients with early glaucomatous damage and to implies that SITA SWAP could become a clinically useful
detect or predict which patients are likely to have method for the detection of early glaucoma.
progressive loss of visual function as manifested by the
standard white on white perimetry. SITA SWAP test results from normal eyes also showed
higher sensitivities than results from the older Full
Johnson6 et al, in a longitudinal and a prospective Threshold SWAP. This represents an increase of the
study of individuals with ocular hypertension, also dynamic range, which implies that SWAP tests may also
observed an association between the prevalence of be applicable in larger groups of patients because of the
localized SWAP visual field defects and other risk factors increased dynamic range. The smaller intersubject
predictive of glaucomatous visual field loss. Their study variability with SITA SWAP means narrower normal
supported the previous conclusion that SWAP results were limits and may be associated with more sensitive
able to predict the development of glaucomatous visual probability maps.
field loss 3 to 5 years earlier. Age and vertical cup to disc
ratio were positively correlated with SWAP defects and Advantages
their findings suggested that combined information
derived from SWAP results, optic disc evaluation and age • Early detection of glaucomatous visual field defects
may provide the most relevant diagnostic information in than conventional white-on-white perimetry (esp. in
determining whether an ocular hypertensive patient is ocular HT).1,2
likely to develop glaucomatous visual field loss.
• Early detection of visual field defect progression
There is no agreement on the role of SWAP in clinical
perimetry. While some suggest that it should replace SWAP is almost certainly able to identify glaucomatous
conventional white on white perimetry, others suggest a limited visual field loss in advance of that by White-on-white
role for blue yellow perimetry. The test itself takes about 15% perimetry although the incidence of progressive field loss
longer than SAP and is also more difficult and tiring since the is similar between the two techniques. SWAP has increased
dim blue stimulus on yellow background renders it difficult to sensitivity in detecting glaucomatous VF loss with no loss
in the specificity. Increasing evidence suggests that
functional abnormality with SWAP is preceded by
April, 2005 406 DOS Times - Vol.10, No. 10
structural abnormality of the optic nerve head and/or the current consensus is that SWAP has higher variability
retinal nerve fibre layer. SWAP appears to be beneficial in than conventional perimetry.
the detection of diabetic macular oedema and possibly in • No clinical utility if glaucoma is in moderate/advanced
some neuro-ophthalmic disorders. stage
Limitations Conclusion
• Time consuming Long-term studies have shown that it can detect the
• Tiring for the patients presence and the progression of damage prior to
• Longer learning curve conventional perimetry. It has been shown that once SWAP
• Influence of nuclear sclerosis: occurrence and increase defects occur, they revert back to normality less frequently
in the nuclear sclerosis may lead to false appearance than with conventional perimetry. It should be noted that
or progression of visual field defects on SWAP. generally when there is moderate damage with
This is the major drawback of the test, especially in conventional perimetry, SWAP defects appear quite severe
our population with an earlier onset of age related and there is not enough dynamic range to measure further
cataractous changes in the lens. The lens acts as a blue progression. Therefore SWAP has relatively little utility in
filter and thus the field defects can occur due to the advanced visual field damage. Currently there are not as
cataractous changes and not due to glaucoma. With many statistical options for data analysis with SWAP as
the onset of nuclear sclerosis the utility of the test is there are with conventional perimetry. Furthermore, a
lost to a large extent and another diagnostic modality commercial version of SITA for SWAP is not yet available.
• should be used. References:
Higher test variability : Both the intra- and inter-test
variability characteristics have been studied and the 1. Johnson CA, Adams AJ, Casson EJ et al. Blue-on-yellow
perimetry can predict the development
Application Invited from Institutions for of glaucomatous field loss.Arch
Ophthalmol111; 645-650, 1993.
Holding the DOS Monthly Clinical Meetings 2. Sample PA, Taylor JDN, Martinez GA
et al: Short wavelength color visual fields
in glaucoma suspects at risk, Am J
As per the DCRS ratings two institutions will be dropped Ophthalmol 115: 225-233, 1993.
from the monthly calender of 2005-2006. We request all the 3. Sample PA, Weinreb RN, Boyton RM.
institutions/hospitals interested in holding the DOS monthly Acquired dyschromatopsia in glaucoma.
meeting to kindly see if they fulfill the criteria given below. They Surv Ophthalmol 31: 54-64, 1986.
may apply to the Secretary’s Office with details latest by with
20th June 2005. (Those who have already applied/are already 4. Drance SM, et al: Acquired color
holding the meeting, need not do so again). vision changes in glaucoma-use of 100 hue
test and Pickford anomaloscope as
No meeting is held in May and June. Meetings are usually predictors of glaucomatous field change.
held on the last Saturday of the month. Arch Ophthalmol 99; 829-831, 1981.
Criteria for selection of a place: 5. Johnson CA, Adams AJ, Casson EJ,
Brandt JD. Progression of early
(a) Seating capacity of 100-200 persons, preferably AC mini glaucomatous visual field loss as detected
auditorium / hall definitely within the premises of the insti- by Blue on yellow and standard white on
tutions. white perimetry. Arch Ophthalmol 111;
651-656, 1993.
(b) Audio Visual facilities to be available
6. Johnson CA, Brandt JD, Khong AM,
– moving mike 1 set Adams AJ. Short wavelength automated
perimetry in low-, medium- and high risk
ocular hypertensive eyes. Arch
Ophthalmol 113: 70-76, 1995.
– multimedia projector 1 set 7. Qi S, Jiang Y.Short-wavelength
– double slide projectors 1 set perimetry in diagnosis of early glaucoma:
(c) Institute should send the details of the meetings/CME etc., comparison with standard automated
held at that institute in past 2 years to the DOS office perimetry. Zhonghua Yan Ke Za Zhi. 2002
(d) A sizeable staff in Ophthalmology who would be able to Jan;38(1):31-5.
conduct the meeting themselves without any major out-
8. Bobeico V, Zemba M, Bratulescu M,
Ciuca C, Popescu M. Blue-yellow full
threshold automated perimetry in
glaucoma diagnosis. Oftalmologia.
2002;55(4):18-24.
April, 2005 407 DOS Times - Vol.10, No. 10
REVIEW
Avoiding Errors-with use of Goldmann-
Type Tonometers
Kamlesh M.S., Anju Rastogi M.S., Sumit Monga M.S., Ajit Kulkarni M.B.B.S.
The intraocular pressure (IOP) is a fundamental determine the absolute manometric pressure within an
parameter of ocular health and disease. Not only is IOP eye or to compare the IOPs in eyes of different individuals.
important in the diagnosis and management of
glaucomatous conditions, but its assessment is important Principal of Goldmann-type tonometers
in the postoperative management of corneal, lenticular and
vitreoretinal diseases. In its most developed form, the Imbert-Fick law states
that when a flat surface is pressed against a spherical
In recent decades the most common way to assess IOP surface of a container with a given pressure, an equilibrium
is with Goldmann-type applanation tonometry*. will be attained when the force exerted against the
Clinicians place such confidence in the accuracy of spherical surface is balanced by the internal pressure of
Goldmann-style tonometry that when the IOP as assessed the sphere exerted over the area of contact between the
by Goldmann tonometry is not consonant with the clinical sphere and flat surface. It is assumed that the sphere
findings, they assume that either the disturbance of IOP applanated by the flat surface is thin, perfectly elastic,
has not had time to manifest itself(e.g., glaucoma suspect) perfectly flexible and that only force acting against it is the
or invoke entities such as ocular hypertension or pressure of’ the applanating surface. It is further assumed
lowtension glaucoma. that the applanated area and the subsequently displaced
volume is small in relation to the total area and volume of
There are numerous sources of error that may the sphere.
significantly influence the accuracy of Goldmann-type
applanation tonometers. The magnitude of error may be Avoiding Errors while using Goldmann-Type
clinically significant in some patients. Hence, knowledge Tonometer
of the sources and magnitude of possible errors in
Goldmann-style applanation tonometry is essential for A. The proper use of goldmann-type applanation
interpretation of Goldmann or Perkins tonometer readings tonometers
and their clinical application.
l. Preparing Equipment and Materials
The act of “measuring” IOP with a Goldmann- type
tonometer consists of adjusting the force applied by a a. Regularly Check Tonometer Calibration
tonometer tip on the central cornea of the patient’s eye
until the observer is satisfied with the pattern produced Tonometer calibration should be checked at least once
by the visible fluorescence of the precorneal tear film. The a year, and preferably twice a year, following the techniques
force (in grams) is multiplied by ten and is assumed to be indicated in each tonometer’s operator’s manual.
the IOP. This estimation usually occurs over at least several
seconds with the patient in a seated position at a slitlamp. b. Proper Anaesthetic Solution
There are many sources of error in the use of In a cooperative patient corneal anesthesia is usually
Goldmann-type applanation tonometers. In clinically not necessary to perform Goldmann tonometry. Tonometry
normal corneas hypofluoresence of the precorneal film, with the Mackay-Marg to-nometer without a topical
accommodation, the valsalva maneuver and vertical gaze anesthetic yields pres-sures 1.50 mm Hg to l. 74 mm Hg
are preventable causes of large tonometric errors. Repeated higher than those found after an anesthetic is instilled*.
tonometry may induce a decline in the intraocular pressure This magnitude of pressure drop would be expected during
(IOP). Variations in the corneal resistance to indentation the course of repeated tonometry, and it can be surmised
between eyes cause significant errors. The most significant that the presence or absence of topical anesthesia probably
cause of error in clinically abnormal eyes is corneal has little or no effect on the IOP. In addition to providing a
epithelial edema, which causes a marked underestimation margin of patient comfort should inadvertent lateral
of IOP. Measurements obtained with Goldmann-type movement of the tonometer occur, the anesthetic solution
tonometers can be used with confidence to monitor changes standardizes the fluid environment of the preconeal tear
in the IOP of an individual, but should not be relied on to film. Bernoxinate 0.4% is the best studied of topical
anesthetics used in association with applanation
Guru Nanak Eye Centre, Maulana Azad Medical College, tonometry. Bechrakis* did not find any decline in the IOP
New Delhi - 110002 six minutes after the administration of a single drop of a
Benoxinate-based anesthetic, and believed that benoxinate
April, 2005 408 DOS Times - Vol.10, No. 10
did not affect the pressure. Repeated instillation does not suspected of being hypotonous then the tonometer should
appreciably affect the pressure*. Unfortunately, benoxinate be adjusted to a pressure just above zero so that the
is commercially available only as a fluorescein-anesthetic tonometer head is extended forward before contact is made
mixture. While studies have shown that proparacaine with the eye. This maneuver will prevent the tonometer
contributes to hypofluorescence of low-concentration head from abruptly tilting forward and indenting the, eye
fluorescein, it should be noted that benoxinate has similar or startling the patient. It should be kept in mind that the
properties. tonometer exerts pressure against the eye and prolonged
contact with the eye will produce a tonographic effect
c. Proper Fluorescein Solution which lowers the IOP. In addition, if the pressure is low
and the tonometer is set to a higher pressure before contact
A proper fluorescein concentration should be present is made with the eye, the tonometer prism may indent the
in the precorneal tear film. This is difficult to achieve with eye sufficiently to damage or irritate a hypotonous eye.
the paper strips impregnated with fluorescein*. This is particularly true if an intraocular lens is present
Fluorescein-proparacaine mixtures are also available, and that might be brought into contact with the endothelium
although they have been the subject of fewer studies*, seem if sufficient force is exerted against the cornea.
to provide satisfactory results. Because of the importance
of standardizing the surface tension and the topical c. Adjustment of Tonometer Head for High
fluorescein concentration in the eyes undergoing Astigmatism
applanation tonometry, it appears adrisable to use a
combination fluorescein-anesthetic solution even on If more than three diopters of corneal astigmatism are
corneas devoid of sensation. present; consideration should be given to adjusting the
tonometer head to compensate for the astigmatism. If the
2. Preparing the Patient method of Goldmann and Schmidt* is used, the tonometer
head should be set to the proper axis before the tonometer
A relaxed comfortable patient is important for contacts the eye. This method has the advantage that only
achieving an accurate IOP measurement Anxiety from the one tonometer contact with the eye is needed to get a
anticipated procedure or discomfort from awkward measurement. If the method of Holladay* is used, then two
positioning at the slit-lamp may increase the tendency of applications of the tonometer will be necessary for one
the patient to have blepharospasm or perform the Valsalva measurement of the IOP. The effect of the second application
maneuver. needed in this method should be accounted for if the
tonometry is being per-formed as part of clinical study.
The slightly extended neck position used in positioning
many patients at the slit-lamp will tend to increase the d. Achieving Maximum Illumination of Tonometer
constrictive effect of clothing around the neck. Any clothing head
restricting the venous return from the head should be
loosened. Because it is desirable to account for the effect of The slit-beam aperture should be fully opened and the
the respiratory cycle on the IOP and because the Valsalva slit-beam turned to maximum brightness. The beam
maneuver may dramatically increase the IOP, the patient should be aimed at the black line on the lateral aspect of
should be encouraged to breathe during tonometry. the tonometer prism. If a Perkins tonometer is being used
the distance between the tonometer body and the patient
3. Performing the Procedure should be adjusted to obtain the brightest fluorescent
circles.
a. Determining the order of testing of the two eyes
e. Positioning of the Eye
The order in which the eyes are tested depends
somewhat on the ease with which tonometry can be Eccentric gaze may be desired because of diagnostic
performed and the information desired from the tonometry. testing for a restrictive myopathy, or may be necessary
If prolonged effort is required to obtain a tonometer reading because of the presence of a tarsorraphy. The eye should
it is desirable to alternate the measurements between the otherwise be in the primary position of gaze during
two eyes in order to minimize the effects of tonography or tonometry, as deviations of gaze may cause the IOP to be
corneal flowing. Even if tonometer readings can be obtained inappropriately elevated. The patient should be asked to
easily it should be recognized that the IOP usually drops gaze at a distant target rather than fix on a near target
with successive measurements, and the drop is greatest such as the examiner’s ear or the slit lamp fixation target.
between the first and successive, measurements. If it is
desired to balance this artifact between the two eyes, then f. Placement of Tonometer
measurements should be alternated between the two eyes,
perhaps discarding the first measurement of the first eye. Contact with the ocular adnexa should be avoided.
Lids and lashes should be maneuvered out of the way by
A. Initial settings of tonometer pressure gentle traction with a cottontip applicator or (if necessary)
fingers. The tonometer tip should be placed on the central
It is prudent to set the tonometer to a pressure below cornea, along or near the visual axis. .
the expected range of IOPs to be tested. If ‘the eye is
April, 2005 409 DOS Times - Vol.10, No. 10
g. Minimizing Time of Tonometer Contact with Eye pressure may be very different from its present value for a
significant fraction of time should be kept in mind.
One of the advantages of Goldmann applanation
tonometry is that the fluctuations in the IOP caused by 2. Tonometry May be inaccurate
respirations and the cardiac pulse can be observed,
allowing for their effects to be considered in the pressure Based on the meager existing information, there is
assessment. Therefore, the tonometer should be in contact considerable reason to believe that tonometry will not give
with the eye for a sufficient duration of time (at least one an accurate reading in many clinically normal eyes. It
respiratory cycle) to assess the effect of Pulse and would appear that deviations in corneal thickness are a
respiration on the IOP. However, it would not appear common cause for errors in Goldmann-style tonometry.
advisable to unnecessarily prolong tonometereye contact These errors would give rise to new entities “pseudo
beyond 30 seconds to avoid corneal molding or a lowtension glaucoma” and “pseudo ocular hypertension.”
tonographic effect. The possibility that alterations in corneal thickness not
only induce an error in tonometry but may also be an
h. Proper Adjustment of the Overlap of the independent risk factor in glaucoma has not yet been
Fluorescent Rings addressed.
If no pulsation in the IOP is evident, then the tonometer 3. Reproducibility of the Tonometric Readings
pressure should be adjusted so that the inner aspects of Should Be Considered
the fluorescent hemi-circles just touch. If pulsation in the
intraocular pressure is manifested in the movement of the Because several studies have Shown that changes of2-
fluorescent hemicircles, the tonometer pressure should be 3mm Hg can be found in readings taken several minutes
adjusted so that the inner aspects of the rings oscillate apart one should not ascribe clinical significance to changes
about the position that would be correct if no pulsation in the IOP of 2-3mm Hg taken at two times.
was present. At this endpoint the edge, of the fluorescent
hemicircles will intermittently overlap, then part by equal 4. The Tonometric Findings Should Not Be Considered
distance. in Isolation
B. The Interpretation of Readings from Goldmann-Style In most situations the IOP is part of a syndrome and is
Tonometers not the only item of information necessary make a
diagnosis or perform a pro-cedure, Glaucoma should not
1. Tonometry only Samples the Intraocular Pressure be diagnosed on the, basis of elevated IOP in the absence of
anatomical or functional changes in the eye. Like-wise, if
The IOP of any patient is not fixed, but fluctuates the other components of a syndrome are present. then the
constantly from minute to minute. The possibility that the absence of an expected should not inhibit the clinician from
(cautiously) diagnosing the syndrome to be present.
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April, 2005 410 DOS Times - Vol.10, No. 10
CURRENT PRACTICE
Essential Blepharospasm & its Management
(Present Scenario)
Gurbax Singh Bhinder, MD, MS, Hanspal Singh Bhinder, MBBS
Essential blepharospasm is an idiopathic, involuntry patients with essential blepharospasm thus become
spasm of the eye lids, which is chronic and progressive socially and occupationally disabled. Such patients may
and becomes visually debilitating. This entity is well quit their jobs, shun social contacts, and become severely
recognized since past hundred of years. it is a unilateral/ depressed. Most patients who develop essential
bilateral upper facial dystonia of unknown etiology. It has blepharospasm have the condition for the rest of their lives;
been postulated that the condition is caused by either a
central monoamine overactivity or a relative cholinergic Classification: Classification of blepharospasm It has two
deficiency, but neither of these mechanisms has been types:
proven. Some physicians consider this condition to be
purely psychogenic. Although this may be the case in rare (I) Primary :a) Essential blepharospasm (b) Essential
patients, and although the condition worsens during Blepharospasm with hemifacial spasm.
periods of stress, most patients neither have overt
underlying psychiatric disease nor appear to be in need of No obvious cause is found.
psychologic counseling.
(II) Secondary : Associated with unilateral striatal
Essential blepharospasm affects both orbital and infarction, Anti Ri Para Neo-Plastic syndrome, ataxia
palpebral portions of the orbicularis oculi-muscles, Palilalia, Maysthenia gravis, Parkinson’s desease,
resulting in involuntary unilateral/bilateral closure of the multiple system atrophy. Psychogenic tremors,
eyelids. The frontalis muscle, corrugator supercilii, and encephalitis Lethargica, Ganglioma of 3rd ventricle.
procerus muscles may also be affected, producing marked
spasms of the forehead and nasal regions. Diagnosis : Do all patients have blepharospasm all the
time? No.
Age of onset: The condition usually begins in the
fourth to sixth decades of life; however, it may occur as (I) A repetitive forced closure test: To elicite the
early as the second decade or as late as the seventh or blepharospasm Gladstone and Putterman 1,2 have
eighth decades. Sex The condition blepharospasm occurs devised a test which consist of multiple times opening
more often in women than in men, with a ratio of about 3 and closing of the lids and then asking the patient to
to 1.1,2 The onset of essential blepharospasm is insidious, look straight. If involuntary blepharospasm appears
beginning as an increased frequency of blinking that often it means that test is positive and.patient has
is exacerbated by certain stimuli, such as sunlight, reading, blepharospasm
wind, or stress. It gradually progresses over months to
years until there is prolonged spasmodic eyelid closure (II) Proton magnetic resonance spectroscopy : ( Federico
that occurs without obvious external provocation. et al 1998) they noted decrease in the level of N-acetil
Although both eyes usually are affected simultaneously, aspirate (NAA). In basalganglion.
one eye may be affected weeks or months before the other.
The spasms are mild at first, but eventually they may (III)Positron emission tomography scanning : By this the
become so severe that they prevent reading, driving, and oxygen uptake by various parts of brain are measured
other normal daily activities. Indeed, essential and it has been noted that there is an increase uptake.
blepharospasm may become sufficiently severe that
affected individuals become functionally blind. In addition, Treatment of Blepharospasm
patients with severe and constant spasms become
increasingly embarrassed about their appearance. Many (1) Botulinum toxin type : A It is the current first line
therapy. There are many high quality randomized
31, Defence Enclave, Vikas Marg controlled efficacy data to support the use of BT for
New Delhi-110092 blepharospasm.
However it has been found efficacious in 90% patients
(costa et al 3, Ziak P 4, Andrade et al 1997 ). Bt. has been
given to 51patients (40 essential blepharospasm,11 facial
hemspasm) in a total dose of 10-24 units given on each
side of face. The blepharospasm disappears immediately
April, 2005 411 DOS Times - Vol.10, No. 10
and lasts on for an average of 3-22 weeks, (average for complication was high as paralysis of the upper face,
12.2 with ). The injection of drug is given subcutaneously Lagophthalmos, Exposure keratitis, and Epiphora.
at multiple sites in the involved lid and the face.
Comments: We have not attempted any such drastic
Special comments : We have noted in cases a good surgery in our cases.
response to this drug which is lasting for 3 months to 6
months. However repeated injections do not give a 100% (6) Complete Orbicularis myectomy (Anderson’s
relief of blepharospasm. procedure): This was carried out by Fox 10 and the results
of this surgery were meager with added complications
Complication: There are no serious complication of
this therapy : However few temporary complications are (7) Protractor myectomy : Chapman et al ( 1995) and
seen in these cases: (1) Ptosis .8-83% in blepharospasm (2) year et al (2003) have carried out sub total excision of the
8.16% in facial spasm , (3) The next dose had to be increased orbicularis oculi, the corrugator super cillii and the
by 10% as the effect decreases with time.. (4) Temporary procerus muscles, for treatment of essential blepharospasm
weakness of the extra ocular muscles which weans off in in 54 patients and noted that the technique provides
48 hours period. (5) Necrotising fasciitis has been reported subjective benefit to approximate 50% of the patients and
in few cases. decreases the long term need for B.T. injections.
(2) Amantadine Hydrochloride :This drug is used in Comments : Not a good modality.
parkinsism.. It relieves spasm in approximately one out of
10 patients (Putterman 5) He recommends in all patients (8) Doxorubicin Chemomyectomy : Dose= 2mg
in essential blepharospasm as a trial dose of 100 mg each injection is given into the muscles after 10 weeks. The
morning for a week. If patient has no side effects it is drug reduces the force in generation. This has been tried in
increased 100mg each morning on awakening and 100 mg 18 patients by wirtschafter and Mcloon (1998) out which
at 2 PM. If there is a favorable response to this drug, the 9 patients were cured completely for 6 years of the follow.
patient are kept on this regime indefinitely.
Comments : This seems to be cheaper modality
Side Effects: however time will tell its real utility.
(1) Depression (2) CHF (3) Orthostatic hypotension (4) (9) Spontaneous Remission: It has been suggested that
Psychosis (5) Urinary retention (6) Headache (7)Fatigue a small percentage (11.3%) experience spontaneous and
permanent relief of symptoms
Special Comments : we have seen that the drug is
efficacious in most of the cases without any side effects. References:
(3) Zolpidem & Cannaboids: 10mg tablet given at (1) Putterman, A.M. Essential blepharospasm; year book of
retiring time for 4 weeks. It induces good sleep in a short ophthalmology 1988, year book medical publisher inc.
time & release blepharospasm. It has been used by Garretto chicogo page 1-5.
et al who has reported good results in 3 patients.
(2) Gladstone, G; Putterman, A.M: A repetitive forced closure
The mechanism of action of the drug is on the outflow test. Arch. Ophthalmol. 1985; vol 103, 477-480.
structure of the basal ganglion
(3) Costa J; Esprito Santo C; Borges, A, Ferreira J; Coelho M;
Comments : We didnot get any good results with this Moore P; sampario c., Cochrane database syst Rev. 2005,
drug. Jan 25(1) CD004900
(4) Selective avulsion of the upper branches of the (4) Ziak P;Results of long term treatment of essential
facial nerve (Raynold’s procedure). Many studies were blepharospasm facial blepharospasm with botulism toxin
conducted by Raynolds et al 7, Fett et. al. 8. However, the A; cosk, S LOV. Oftalmol, 2004, jan; 60(1) 37-44.
effect of this technique was not long lasting and had a least
success rate with additional complication of brow sag. (5) Andrade LA; Borges V, Ferraz HB; Azevedo-Slva SM
Comments : Not a clinical modality.. Botulinum Toxin A; Experience in the treatment of 115
patients. Arq Nensopsiquiatr. 1997, sef,55(3B):553-7.
(5) Isolation of the main trunk of the facial nerve
Putterman and Friedman 8 have recommended the (6) Putterman, AM; Symmetrel in the treatment of essential
isolation of main trunk of facial nerve as it existed from the blepharospasm; In Bosniak (ed); Advances in ophthalmic
scalp and then snipping it for 3-4 mm in length. They plastic. reconstructive surgery; vol9, Elmsford; N.Y:
reported a success rate of 84%. However, the rate of Pergamon Press 1985, Page: 227-228.
(7) Reynolds, D,Smith, J.L; Walsh, T: Deferential section of the
facial nerve for blepha-rospasm. Trans. Am. Acad.
Ophthalmology OTO aryngol, 1976, vol71,; 656-636.
(8) Fett, D.R; Putterman A.M; Weingarten C.Z.i Facial nerve
avulsion and primary rhytidectomy in the treatment of
essential blepharospasm. In Bosniak (ed); Advances in
ophthalmic plastic. reconstructive surgery; vol9, Elmsford;
N.Y: Pergamon Press 1985, Page:349-360
April, 2005 412 DOS Times - Vol.10, No. 10
RECENT ADVANCES
Orthokeratology
Preeti Sharma, B.Sc. (Hons) Ophth. Tech., Jeewan S. Titiyal, MD
Cornea is an aspheric structure having central steeper Mainly Rigid Gas Permeable lenses are used for this
zone with gradual flattening towards periphery. purpose
Routinely fitted contact lenses follow the corneal It is very old technique of correcting refractive errors
geometry i.e. central steep and flatter periphery . (Mainly for Myopia) without using any optical aid like
spectacles during day time or any refractive surgery.
Reverse geometry lenses are lenses which have
curvatures opposite to normal lenses i.e central flat and It is a reversible procedure, on discontinuation the
steeper periphery these are speciality lenses useful for corneas regress to their natural state.
certain purpose like Orthokeratology Postrefractve
Surgery Contact Lens Fitting, IOL Power Calculation. Concept of Corneal Reforming
Lens Parameters (Reverse Geometery Lens) The normal corneal curvature gradually flattens from
centre to periphery (Prolate). During the process of corneal
• Diameter - large ,9.5mm or greater reformation, the apex becomes flatter while paracentral
area becomes steeper (Oblate).It may be a consequence of
• Optic zone- smaller ,6.0 to 6.5 mm range redistribution of corneal epithelium due to centrally flat
contact lens pressing over the control cornea.
• Secondary curve - 2.4D steeper than lens base curve
radius Reshaping The Eye With Contact Lenses
• Dk value - higher .> 100 In June 2002, the FDA granted overnight wear approval
to corneal reshaping called CORNEAL REFRACTIVE
THERAPY ( C.R.T.) and subsequently FDA approval for
one brand of ortho-k contact lenses followed in June 2004
for temporary elemination or reduction of Myopia.
How does it work?
In myopia light passing through cornea into eye gets
focused before retina due to steeper curvature of cornea.
The reverse geometry lens (Ortho-K) with flatter based
curves used over night flatten the cornea therefore the light
rays one focused on the retina.
Lenses are worn during the night time which bring
about corneal surface changes and corrects the refractive
error upto a certain extent during the daytime.
Reverse Difference between CRT & Accelerated Ortho-K
Geometery Lens
Both use special G.P lenses to reshape the cornea.
Orthokeratology - (Corneal Refractive Therapy)
Lenses for CRT are currently made by only one company ,
Literal meaning of Orthokeratology-study of straight using their own technology and fitted by companyʹs
corneas. certified practitioners .
According to KERNS - A purposeful attempt to modify the Ortho-K it is practiced with a variety of lens brands and
corneal curvature to result in reduction or elimination of a designs only one brand for Ortho-K lenses is currently
refractive error by a programmed application of contact approved by FDA for overnight wear.
lenses is Orthokeratology.
Suitable Candidates ?
Dr. R. P. Centre for Ophthalmic Sciences
AIIMS, New Delhi - 110 029 CRT and Otho-K are for people of any age who are
Myopic.
April, 2005 413 DOS Times - Vol.10, No. 10
F.D.A. approval for : It there has been considerable amount of corneal
CRT - Upto 6 D of Myopia & change, lens may need to be replaced with a flatter base
curve lens. Patients should be evaluated weekly for first
Upto -1.75 Astigmatism month and than every 2 to 3 weeks for next 3 months.
Ortho-K - Upto 5D of myopia &
At each visit, lens fit and corneal topography is taken
Upto -1.50 Astigmatism and refraction after wear is preformed.
Fitting Procedure : What Results Can Be Expected?
Corneal topography is taken first, the initial lens to be Visual acuity of 20/20 or 20/40 is acceptable. In the
fitted has base curve 1.0 to 2.50 D flatter than the flattest K FDA clinical study for approval of CRT , 93% patients
or a radius 0.4 mm longer than selected in normal RGP achieved 20/32 vision or better, and 67% achieved 20/20 or
contact lenses. better. The study included 250 patients that were followed
over a 9 month period
Large diameter is taken so that lens remains stable.
How long does it take ?
Fluorescein Pattern :
Both CRT and accelerated Ortho-K can reshape 2 to 3
Fluorescein pattern shows a 4 to 6 mm region for D of myopia in 2 weeks or less.
moderate bearing centered over entire pupil, there is a mid-
peripheral pooling a light ring of peripheral bearing. Finally During the time cornea is being reshaped certain side
another ring of fluorescein representing edge lift. In short, effects like glare and halos can be experienced that will
a target or bullʹs eye pattern this type of pattern is critical reduce with time . As with LASIK patients with large pupils
as the lens must be flat enough to induce refractive change, are especially susceptible to this.
but care should be taken for any kind of central abrasion
Once the eyes reach desired prescription, lenses can
If the lens is not well centered, base curve should be be worn while sleeping or during a part of day to maintain
slightly steepened or a steeper secondary curve may be prescription.
selected or OAD (Overall Diameter ) can be increased.
Orhto-K lenses make the patient glasses and contacts-
free during the day without any removal of tissue like
LASIK. On discontinuing the lenses, cornea will regress to
its natural shape.
Reverse Geometry Lens in Post Refractive Surgery
Eyes
Fitting a contact lens post refractive surgery is a
challenging job as clinician is faced with complex ocular
surface in which both structure & function have been
altered.
Flouroscent Pattern (3point touch)
Final Goal of Fitting Post R.K. Contact Lens Fitting
• Well centered lens
• 1 to 2 mm movement during blink Contact lenses must be fitted after corneal topography
• should show moderate apical touch and comfortable & refraction stablize, mostly, 3 months after surgery.
ʺREVERSE GEOMETRY LENSESʺ match with the post-op
midperipheral alignment. corneal surface & smoothen the irregular surface reducing
the induced astigmatism.
Dispensing and return visits
After the lenses are dispensed patients should be Fitting contact lens to a patient who has undergone
R.K. can be challenging due to oblate corneal shape created
reevaluated after 3 to 5 hours same day of lens fit.
April, 2005 414 DOS Times - Vol.10, No. 10
by surgery which will result in excessive central pooling achieved 20/20 visual acuyity demonstrated statistically
in standard Rigid Gas Permeable (R.G.P.) lens design. Post significant improvement (p<0.01). Reverse geometry lenses
R.K. patients usually have residual refractive error, over improved visual acuity in corneas with flat central &
correction, irregular astigmatism & decreased quality of peripherally steep corneas following P.K.
vision in the form of diurnal fluctuations. Corneal contour
is markedly irregular, relatively flat at centre & steeper Certain considerations that should be taken into
peripherally. Reverse geometry lenses are best option to account before fitting post P.K. patients with
cover up the negative asphericity of cornea as they have contact lenses are :
peripheral curve (P.C.) steeper than Back Optic zone Radius
(BOZR) Or Base Curve (B.C.). 1. Watch out for any broken sutures which may cause
infection.
Various post LASIK indications for contact lenses
are : 2. Fit must be topographyically guided. Initial trial base
curve to be chosen should have topographic reading
1. Residual Refractive Error - If a patient had significant of a point 4 mm from centre at temporal 180O meridian.
correction e.g. 8.0 D or higher during LASIK procedure
then the cornea may be flatter at centre in which a soft 3. Follow up at 2 weeks, 4 weeks and then every 6 months.
or semisoft (R.G.P.) tens may not provide proper lens During this time patient is monitored for early signs of
fit. In such oblate shaped corneas ʹReverse Geometry rejection. Investigate promptly if patient presents with
Lensesʹ are a better option which have a base curve redness, pain, light sensitivity or decreased/cloudy
flatter than secondary curve. They conform to the post vision.
surgical corneal topography better than conventional
R.G.P. lenses. 4. Look out for microcystic edema, mechanical irritation
and neovascularization. Differentiate graft rejection
2. Flap irregularities - Flap irregularities are masked by from graft failure.
contact lens. Reverse geometry lens provides ironing
action on the flap correcting the induced irregular Reverse Geometry Lenses - These lenses were introduced
astigmatism. in 1980s for post R.K. & other refractive surgery contact
lens fitting. Some of them are CONTEX Ortho-K lenses,
3. Astigmatism - Reverse Geometry Lens provides a RK4 lenses.
better approximation of fit in post operative regular
and irregular astigmatism. Lens should have a high DK of 60 or more so that cornea
which is already compromised after surgery gets proper
4. Optic Zone Distortion - Visual problem following oxygen supply to prevent hypoxia.
refractive surgery often occur due to distortion of optic
zone, central island or decentred optic zone. ʺReverse Fitting Procedure For Post Refractive Surgery Cornea-
Geometry Lensʺ with intentionally steepened mid - Fitting a cornea with altered topography takes into
periphery rather than centre with larger diameter (9.5 account certain features which are-
mm or more) provides more stability of vision.
1. Refraction - Proper refraction must be done. Subjective
Contact lens must be fitted 3 months after surgery so refraction more helpful as the retinoscopy reflex is not
that sufficient time is given for corneal healing and flap very clear due to disruption of corneal regularity after
adherence. For higher amount of refractive correction by surgery.
LASIK, excessive central pooling will be present in
fluorescien pattern if standard R.G.P. lenses are used so 2. Corneal Topography - Pre fit evaluation of corneal
reverse geometry lenses are lenses of choice in this case. topography is very essential to determine various
parameters of the lens. Various methods available are
PENETRATING KERATOPLASTY : Commonly a post P.K. video keratography, ORBSCAN etc. Keratometric
eye has significant amout of astigmatism due to varying readings may also be taken into consideration. Corneal
suturing techniques. The graft host interface is very topography is essential for determining the base curve
irregular area so we should try to rest the periphery of and secondary curve of the reverse geometry lens.
contact lens on host tissue and not the graft tissue with
large diameter lens. If we fit within the diameter of graft, 3. Slit Lamp Biomicroscopy - General anterior segment
its likely to bump or irritate graft - host interface, causing examination with emphasis on cornea must be done.
neovascularization of grafted tissue. Any kind of tear film abnormality or lid infections
must be ruled out prior to fitting the contact lenses. In
A study was performed with post P.K. patients fitted case of penetrating keratoplasty (PK) sutures should
with RK4 (Reverse Geometry lenses on 15 eyes in Wills be examined.
Eye Hospital, patient being monitored for 2 months 93% of
fitted eyes achieved at least 20/30 visual acuity and 53% 4. Corneal Sensation - Corneal sensation must be checked
with cotton bud or corneal a esthesiometer. In case of
LASIK & P.K., corneal sensation is lost or decreased.
April, 2005 415 DOS Times - Vol.10, No. 10
Corneal sensation should be present prior to contact better centration & stability as they follow the corneal
lens fitting so that patient can feel any kind of deposit geometry & have large diameter.
formation or break on lens which may lead to allergic
conditions. Lin et.al evaluated 67 eyes of 37 patents fitted with
R.K. 4 contact lenses after different refractive surgeries (R.K.,
5. Tear film assessment - Tear film breakup time (TBUT) LASIK & P.K.). The mean visual acuity obtained was 20/24.
& Schirmerʹs must be checked. Post refractive surgery This study showed that these lenses improved visual acuity
patients usually have marginal dry eye due to reduced & higher order abberations, measured by wave front
tear production on account of decreased corneal aberrometry decreased.
sensations. Marginal dry eye patients can be
prescribed lenses alongwith a lubricating eye drop and To summarize that eyes after refractive surgeries with
tear film status reassessed in follow up visits. residual refractive error & induced corneal surface
irregularities can be optically rehabilitated with new
6. Base curve selection - It differs from the normal base Reverse Geometry Design lenses which can be fitted to
curve selection procedure as the corneal geometry is corneas with abnormal topography using modern
significantly changed. Some methods are - topography methods.
a. Corneal topography method: It is the most accurate Reference:
method as it provides information of the whole
corneal contour. The initial base curve equals to 1. Edward S. Bennet, Michael D., Joseph P.S., Vinita A.H., Post
flattest diopteric meridian at transition zone Surgical Fitting in Clinical Manual of Contact Lenses ed,
approximately 3mm from centre. Edwards S.B. & Vinita A.H., 2000
b. Average K method: In absence of corneal 2. Lindstrom R.L., ed. Evolving trends, techniques, & pearls
topography base curve of initial trial ens can be in cataract & refractive surgery. Ocular surg News 1998;
taken as the average of preoperative and post 16( Suppl) : 18.
operative keratometry readings.
3. Aquavella J.V., Shovlin J.P., Pascucci S, De Paolʹs M. How
c. Partial reduction of corrected refractive error: Contact Lenses fit into refractive surgery. REV Ophthalmol
1994; 1:36.
d. In R.K. Subtract 1/3rd of refractive error reduction
from preoperative flat keratometry as initial trial lens base 4. Shivitz I.A., Arrowsmith P.N., Russell B.M., Contact Lenses
curve. in the treatment of patients with overcorrected radial
keratotomy. Ophthalmology 1987 Aug. 94 (8) 899-903..
Eg. Preop Km=45.0 x 180o / 46.0 x 90o
5. Lin J.C., Cohen E.J., Rapuano C.J, Laibson P.R; R.K. R.K. 4
RK Myopic Reduction= 4.50D (Reverse geometry) Contact Lens fitting after penetrating
keratoplasty. Eye Contact Lens, 2003, Jan; 29 (1) : 44-7.
Then initial base curve = 45.0 - 1/3 (4.50)=43.50D.
6. Mathur A, Jones L, Sorbara L. Use of Reverse geometry
Incase of LASIK ¼ th of myopic correction is subtracted. rigid gas permeable contact lenses in management of post
radial keratotomy patients. Int. Contact Lens Clinics. 1999
7. Peripheral (Secondary ) curve selection : Sept; 26(5) : 121-127.
Peripheral curve is steeper than base curve. Peripheral DOS Help Line
curve is determined according to difference in curvature
between flatter central & steeper midperipheral curvature DOS Members should
of cornea which can be deduced by comparing patients contact DOS President/
presurgical & post surgical refractive error. Eg. Reduction Secretary in case of
in myopia is from 10.0 D to 4.0 D as a result of R.K. indicates difficulty in Purchasing,
secondary curve 6 D steeper than base curve. Maintenance of Machine/
Equipment & Consumer
Using 0.05 mm is equivalent to 0.25 D, it would mean cases.
peripheral radius has to be 1.2 mm lesser than back optic
zone radius (BOZR). Alternatively central & peripheral
curvature difference in corneal topography can be taken.
Fluorescein Pattern Assessment :
Reverse Geometry Lenses provide better fluorescein
pattern as it reduced the central pooling obtained in post
refractive surgery corneas fitted with standard
conventional design R.G.P. lenses. These lenses provide
April, 2005 416 DOS Times - Vol.10, No. 10
BOOK REVIEW
Phacoemulsification Surgery
Editors :
Rasik B. Vajpayee, Namrata Sharma,
Suresh K. Pandey, Jeewan S. Titiyal
This latest book on Phacoemulsification surgery has been
published by Jaypee Brothers, Medical Publisher (P) Ltd, New
Delhi. Phacoemulsification is the most preferred and accepted
surgical technique for cataract world over. It has become
essential for every practicing ophthalmologist and residents
pursuing ophthalmology to know about details of
Phacoemulsification Surgery.
Editors have put up excellent well designed topics from
reputed International and National authors in this book. This
book comprehensively covers the basic and advanced aspects
of phacoemulsification techniques in a very practical manner.
The book contains a special chapter on Phacoemulsification
surgery for residents outlining the methodology to adopt while learning this surgery.
The book contains colorful pictures & illustrations of phacoemulsification steps which makes reading
of this 252 paged book very simple & interesting.
This book was recently released in Annual DOS Conference 2nd – 3rd April, 2005 and has already
climbed the list of most wanted books amongst the Ophthalmologist.
It is very appropriate to say that every ophthalmologist must have this book with them.
April, 2005 Lens Based Refractive Surgery
(Phakic IOLs)
Editors:
Ashok Garg, Jorge L Alio,
Dimitric Dementev, Antonio Marinho.
Published by : Jaypee Brothers, Medical Publisher (P) Ltd., New
Delhi.
This book on Phakic IOLs is one of its kind which covers recent
advances on Phakic IOLs. With increasing demand for correction of
high refractive errors more & more people opt for these Phakic IOL
correction.
Well known authors from all over the world have contributed with
topics of their expertise. Their experience and clinical results give
value to this book. The Editors have done excellent work on this
unique book on lens based refractive surgery. C.D. along with the
book gives excellent opportunity for readers to get acquainted to
surgical techniques.
417 DOS Times - Vol.10, No. 10
CURRENT PRACTICE
Reconstructive Materials in Oculoplastic Surgery
Madrula Mehta, Harish Pathak MD,FRCS, M.S. Bajaj, MD
Plastic surgery in orbital region often requires deformity. It has also been used as a co wrapping material
autogenous or allogenous materials for reconstructive for porous enucleation implants and to treat secondary
purpose. Commonly, such adjunctive materials are implant exposure.
required to treat orbital fractures or surgical
enophthalmos. Allograft materials along with allophasic Chondroplast (Bovine Pericardium)
materials now have an increasing role in eyelid
reconstitution for repair of anterior lamellar (skin/muscle) Bovine pericardium has been used extensively in
or posterior lamina ( tarsus/conjunctiva) along with soft cardiac and neuro-surgery as a graft material. It is
tissue recontouring and spacer grafting for eyelid generally used as a cartilage substitute. It is derived by
retraction. Various techniques with autogenous materials treatment of bovine pericardium by gluteraldelyde and B
like cartilage, eyebank sclera, fascia lata have been used irradiation, which results in removal of denaturated
till now. Alloplastic materials discussed below are recent protein and formation of a mesh of collagen fibres. It is
additions to reconstructive surgery in this area allowing available in preformed shape as a cone for enucleation
decreased surgical time, reduction of donor site mortality implants. It has also been used as spacer graft in lid surgery.
and better results It is available in both lyophilized and non-lyophilized
forms. A 3-minute saline rinse is required to wash-off
Amniotic Membrane glutaraldehyde. It is relatively non-reactive to host tissues
and there is low risk of cicatrisation, calcification and
Amniotic membrane forms the innermost layer of fetal transmission of bovine spongi . In long term no significant
membranes and has relatively thick basement membrane. resorption occurs and a vascularized capsule may form
Its nonimmunogenicity and anti microbial properties make around it rather than fibro vascular in growth.
it advantageous over other mucosal grafts. It has been used
in symblepheron repair, fornix reformation and socket Bicol (Bovine Collagen Sheets)
surgery along with posterior lamellar reconstruction in
cicatricial entropion mainly because of its anti-adhesive It is received form bovine tendons. It has been used in
property and its ability to allow lost epithelium to grow neurosurgery as a protective layer between refraction and
over it by providing a scaffold for the basement membrane brain and recently as dural patch graft. It is stiff in dry
state but malleable on rehydration with saline. It is a
Alloderm (Acellular Dermal Allograft) porous material allowing fibrovascular ingrowth and
native collagen formation. Postoperative inflammation and
Alloderm is an acellular dermal matrix (ADM) nested capsule formation is minimal with Bicol. It has been used
from human cadavers by mechanical and chemical in covering small to medium bony defects in lateral wall
treatment of cadaveric dermis. The epidermis and any or roof after osteotomy. It has also been used in
cellular dermal component is removed leaving behind smoothening the orbital rim after repair of fracture or to
minimally antigenic collagen and extra cellular protein cover microplates after reconstructive orbital surgery.
matrix. During processing antiviral treatment is also given
to it to inactivate any viral pathogens. It has a basement Polytetrafluroethylene (Ptfe, Gore-tex)
membrane on one side, which acts as a scaffold for recipient
epithelium overgrowth. It is available in freeze-dried form Polytetrafluroethylene is a cross-linked polymer that
and has to he hydrated before use. It is available is sheets has been used extensively in ocular surgery. It is strong &
and 1mm thick sheets suffice for periodical reconstruction. porous owing to cross-linking of these fibrils forming it. It
It is pliable and maintains the recipient contour thus has low immunogenicity and is extremely fragile.
advantageous ours softer tissues, sclera and cartilage, but However, it is compressible which decreases the effectivity
is unable to provide rigid vertical support in cases of lid with which fibrovascular ingrowth can occur within its
retraction. Dermal side must be placed towards host side. porous structure. Even long-term tissue integration with
Significant graft shrinkage occurs postoperatively hence this material is modest and fibrous capsule may form
over sizing is necessary. It has been used as spacer graft in around it. It is available in several shapes and forms and
lower lid retraction, placed beneath the conjunctiva with also as a suture material. It has been used as suture
basement membrane facing conjunctival side. Rolled ADM material for trans-nasal wiring to correct medial canthal
after rehydration with dermal side outwards to promote deformities, as a sling material for correction of congenital
vascularization has been used to treat superior sulcus ptosis (0.3mm strips as available as sling material). Also
custom-made PTFE spherical ortital implants are now
Dr. R. P. Centre for Ophthalmic Sciences available. Facial implants of PTFE are also available for
malar or temporal augmentation. Other uses are as a tarsal
AIIMS, New Delhi - 110 029
April, 2005 418 DOS Times - Vol.10, No. 10
substitute in posterior lamellar reconstruction and a spacer malar & nasal augmentation surgeries and for external
graft for lower lid retraction. ear reconstruction.
Hydroxyapatite (HA) Injectable Alloplastic Materials
Hydroxyapatite a complex calcium – phosphate salt Aesthetic plastic surgery with injectable substances
(Ca10 (PO4) (OH) 2), is a naturally occurring substance in has gained tremendous popularity with the beginning of
the body, the primary mineral component of the bone. It is this century. Although seems fascinating it is not free of
derived form corals. The process involves removal of the complications like inflammatory reaction, infection,
organic component of the corals, the skeletal structure is migration and difficulty in removal.
converted under high temperature and pressure to calcium
phosphate HA with a regular system of interconnecting Fat & Silicon
pores resembling harvesian system of normal lamellar
bone. Its porosity allows for fibro-vascualr ingrowth. It is Autologous fat injection prepared from the recipient’s
light weight, brittle and has natural biocompatibility i.e. body has been tried for soft-tissue augmentation and
readily accepted by the tissues of the orbit to present “ treatment in facial area including periorbital area. The
synthetic implant syndrome” i.e., pseudo capsule method of harvesting fat and preparing injection is costly
formation around the implant. It has been used as an along with unavoidable donor site morbidity. The fat may
orbital implant after evisceration and enucleation, soft- undergo unpredictable resorption and may lead to uneven
tissue augmentation and orbital floor contours. Hence it does not guarantee satisfactory results.
reconstruction . It is available in
powdered form and as granules for Injectable medical grade silicone has also been used
tissue augmentation, and also tried for the same purpose and is thought to be relatively free of
as supraorbital and malar onlay complications such as granulomatous and non
grafts and to fill any persisting orbital granulomatous inflammatory reactions. Ulcerations,
nodule formations & migration have been reported to occur
and facial bony defects. with it
Porous Polyethylene (Medpor) Hydroxyapatitie Bovine Colleagen (Zyderm& Zyplast)
Porous polyethylene has been spherical implant
Bovine collagen is prepared by partially removing
used earlier in fracture repair and socket surgeries. The antigenic peptides with enzymatic digestion and is
supplied as a collagen suspension in saline solution. It
material in made by sintering polyethylene beads into a available in three preparation as an augmentation
material: zyderm I, zyderm II and zyplast. It has been used
mesh like framework. It s porosity allows for fibrovascualr for soft tissue augmentation. Zyderm is typically injected
more superficially where as zyplase is used for deeper
ingrowth, which is responsible for better stability, dermal injections. Disadvantages are significant resorption
over time, allergic reactions and rarely skin discoloration
decreased extrusion and decreased incidence of infection. at injection site.
It properties like malleability & non-brittleness makes it Human Collagen (Autologen And Isolagen)
advantageous over hydroxyapatite. However it is Autologous collagen made from dermal tissue of
patient is another costly substitute for the above purpose
flammable and warrants caution while using cautery. It is but is non-immunogenic . Host skin excised during
blepharoplasty may be used for making the material
basically porous high-density polyethylene with an otherwise an elective skin harvest is required.
average pore size > 100 microns. It contains no additives, Isolagen is another autologous collagen preparation
derived from patient’s fibroblasts. Collagen is harvested
maintains shape and form, is biocompatible, white in color after 4-6 weeks of in-vitro culture of host fibroblasts.
Pooled human collagen is also available from healthy
and is available in sheets, spheres, and various anatomical donors.
/customized shapes. Clinically, it results in good Complications such as central retinal artery and
ophthalmic artery occlusion have been reported
stabilization, minimal or no bone resorption under the immediately after injections, due to embolization of the
material. Aspiration before injections followed by gentle
implant, minimal or absent inflammation and low injection is the proper method for injection alloplasts.
Complete ophthalmic examination including vision should
infection rate. Its use is contradicted in inferior poor he recorded before injection. It is essential to cheek for any
visual problems and visual acuity after the injection also.
vascular supply and areas with inadequate tissue coverage.
It is now being used extensively as an orbital implant in
eviscerations and enucleation, as an eyelid spacers, repair
of orbital floor, rim or
wall fractures. Apart
from its current use it
is being used for
treatment of cranial
defects, cranio- facial
augmentation in
patients with cranio-
facial anomalies, for
chin, mandibular, Medpore Implant
April, 2005 419 DOS Times - Vol.10, No. 10
Various Trophies & Awards
Presented During the Annual DOS Conference 2005
Dr. Aditya Verma Dr. Ajay Paul
Dr. H.S. Trehan Trophy Best Scientific Video Presentation
for Best Case Presentation in Monthly Meeting
Dr. Shalini Mohan
Dr. Rajesh Sinha Best Scientific Poster Presentation
Krishna Sohan Singh Trophy
for Best Clinical Talk in Monthly Clinical Meeting Dr. D.K. Mehta
Dr. P.K. Jain Oration Award
Army Hospital, R & R, New Delhi
Dr. Bodh Raj Sabharwal Trophy Dr. Anita Panda
Institution for Holding Best Monthly Meeting Dr. S.N. Mittar Oration Award
Dr. Ritu Gadia Dr. R. N. Sabharwal Gold Medals
Dr. AC Agarwal Trophy for 100% Attendance of Monthly Clinical Meetings
for Best Free Paper Presentation Session-I
Dr. Rajesh Kumar
Dr. Madhusudan & Dr. Amit Bhootra Dr. Parveen Kumar Mongre
Dr. V.K. Kalra Memorial Trophy Dr. N.K. Pattnaik
Trophy for Quiz Winners Dr. Om Prakash
Dr. Ajit Kulkarni
Certificates of Merit Dr. G.K. Das
Dr. (Prof.) Kamlesh
Dr. Jaspreet Sukhija
Best Free Paper Session -II (Cataract) Distinguished Resource Teachers of the Society
for Achieving More than 200 DCRS Credits
Dr. Ajay Banarji
Best Free Paper Session -II (Retina) Dr. Harinder Singh Sethi
Dr. Rohit Saxena
Dr. Rasna Sharma Dr. Rajvardhan Azad
Best Free Paper Session -II (Glaucoma) Dr. Namrata Sharma
Dr. Harish Pathak
Dr. Manisha C. Acharya Dr. (Prof.) Kamlesh
Best Free Paper Session -II Dr. Rasik B.Vajpayee
(Cornea & Refractive Surgery) Dr. Rajesh Sinha
Dr. Jeewan Singh Titiyal
Dr. Usha Singh
Best Free Paper Presentation Session - II
(Strabismus & Oculoplasty)
List of Members Achieving 100 or more DCRS Credits
1. Dr. Rajan Verma 12. Dr. Gunjan Praksh 23. Dr. Parveen Mongre 34. Dr. C.M. Shroff
2. Dr. Mohan Kumar 13. Dr. Nikhil Pal 24. Dr. Gopal K. Das 35. Dr. Parul Sony
3. Dr. Satya Karna 14. Dr. Shalini Mohan 25. Dr. R. Balasubramanya 36. Dr. Vijay B.Wagh
4. Dr. Aparna Gupta 15. Dr. Sanjeev Nainiwal 26. Dr. S. Bharti 37. Dr. Harbansh Lal
5. Dr. Tanuj Dada 16. Dr. Ajay Aurora 27. Dr. Tishu Saxena 38. Dr. K.P.S. Malik
6. Dr. Vinay Garodia 17. Dr. N.K.Pattnaik 28. Dr. Vimla Menon 39. Dr. Ruchi Goel
7. Dr. J.C. Das 18. Dr. Om Prakash 29. Dr. (Prof.) D.K. Sen 40. Dr. Atul Kumar
8. Dr. Satish Sabharwal 19. Dr. Sanjit K. Saha 30. Dr. N.M. Shroff 41. Dr. Yog Raj Sharma
9. Dr. Deven Tuli 20. Dr. Ramanjit Sihota 31. Dr. Deependra Singh 42. Dr. Ajit G. Kulkarni
10. Dr. Kamna Verma 21. Dr. Lalit Verma 32. Dr. Dinesh Talwar 43. Dr. Gurbax Singh
11. Dr. Anita Sethi 22. Dr. Sat Pal Garg 33. Dr. Radhika Tandon 44. Dr. Pradeep Venkatesh
45. Dr. Jaswant Arneja
April, 2005 422 DOS Times - Vol.10, No. 10
DOS QUIZ
DOS QUIZ NO. 20
1. IOL master is based on the principle of _______________________.
2. Commonest organism associated with infectious crystalline keratopathy is ___________.
3. Sclera is thickest at ______________________.
4. STYCAR means _________________________.
5. Commonest colour defects in acquired optic nerve disease are __________ and
___________.
6. Conductive keratoplasty is used in the treatment of ______________.
7. Most recent Protein kinase C inhibitor used in the treatment of diabetic retinopathy
patients is __________________.
8. Two treatable systemic disorders associated with retinitis pigmentosa are _________
and________.
9. Type of pigment present on the surface of choroidal melanoma is ____________.
10. WHO criteria for Low vision is visual acuity in the better eye between _____________.
• Please send your entries to the DOS office latest by 10th June, 2005.
• Prize Rs. 500/- Courtesy: Syntho Pharmaceuticals
ANSWERS OF DOS QUIZ NO. 18
1. Whitnals tubercle is on ______________________ bone.
2. Orbit is connected to middle cranial fossa through _________________ and superior orbital fissure.
3. Duane’s syndrome does not obey the _______________________ law.
4. Maximum limit of recession in adults are ________ for medial rectus and ______ for lateral rectus.
5. 40% loss of ganglion cells result in ________ db visual field defect.
6. Glasses used for computer vision syndrome should have __________ lens with __________ coating.
7. Most common cause of 3rd merve palsy in the pediatric population is ______________ .
8. When fitting RGP lens a 0.05 mm steeper curve produces a ___________ + ve lens.
9. Pegaptanib sodium (Macugen) is a ______________ inhibitor.
10. Muscle with the shortest tendon is _____________.
Answers :
1. zygomatic 4. 6 mm, 8 mm 7. congenital
2. optic cannel, superior oribital fissure 5. 10 db 8. 0.25 D
3. Sherrington's law 6. optical CR 39, antireflective 9. VEGF
10. Inferior Oblique
April, 2005 423 DOS Times - Vol.10, No. 10
FORTHCOMING EVENTS
NATIONAL
Annual Conference of North Zone Ophthamological 40th Annual Conference of
Society (NZOS) UP State Ophthamological Society
15th to 16th October, 2005 12th & 13th November, 2005
Contact : Dr. S.K. Sharma, Organizing Secretary Contact : Dr. Harish Gupta, Organizing Secretary
Rotary Eye Hospital Manav Hospital & Laser Eye Centre
Maranda, Palampur-176102 (HP) B-Block Market, Kavinagar,
Ghaziabad-201002 Ghaziabad-201002
Tel. : 01894-239180 Tel. : 0120-2752659, 3943310
Emal : [email protected] Emal : [email protected]
INTERNATIONAL
ESCRS 9th Winter Refractive Surgery Meeting World Cornea Congress
4th - 6th Feb.2005 ROME, ITALY 13th - 14th April, 2005
Temple House,Temple Road WASHINGTON, DC
Blackrock, Co Dublin, Ireland Contact: ASCRS
Tel: +353 1 209 1100 Tel: +1 703 591 2220
Fax: +353 1 209 1112 Fax: +1 703 591 0614
Email: [email protected] Email: [email protected]
Web: www.escrs.org Web: www.ascrs.org
20th Asia Pacific Academy of Ophthalmology Congress ASCRS/ASOA Meeting Congress
27-31st March, 2005 16-20th April, 2005
Kuala Lumpur, Malaysia Washington, DC
The 20th Asia Pacific Academy of Ophthalmology Contact : ASCRS
Congress Tel : +1-703-591-2220 Fax : +1-703-591-0614
Tel : +603-7956-3113 Fax : +603-7960-8297 Web : www.ascrs.org
Email : [email protected]
Web : www.apao2005.com.my XXIII Congress of the ESCRS
10th - 14th Sept.2005 LISBON, PORTUGAL
5th International Glaucoma Symposium Contact: ESCRS
20th March, 2005 – 2nd April, 2005 Temple House,Temple Road
Cape Town, South Africa Blackrock, Co Dublin, Ireland
Contact : Kenes International Tel: +353 1 209 1100
Tel : +41-22-908-04-88 Fax : +41-22-7322850 Fax: +353 1 209 1112
Email : [email protected] Email:[email protected]
Website : www.kenes.com/glaucoma Web: www.escrs.orgSESept.2005PTEMBER
April, 2005 424 DOS Times - Vol.10, No. 10
DOS Credit Rating System Report Card
DCRS July 2004 – Army Hospital (R&R)
Total No. of Delegates ................................................................................................................................................................. 83
Delegates from Out side (N) ........................................................................................................................................................ 75
Delegates from Army Hospital (n) ................................................................................................................................................ 8
Overall assessment by outside delegates (M) ..................................................................................................................... 610.5
Assessment of case presentation-I (Dr. Aditya Verma) by outside delegates ...................................................................... 549
Assessment of case presentation-II (Dr. Major Atul Gupta) by outside delegates ............................................................ 541.5
Assessment of clinical talk (Dr. Col. Ajay Banajee) by outside delegates .......................................................................... 572.5
Rejected Form Army Hospital (n) .................................................................................................................................................. 2
Rejected Form Out side (N) ........................................................................................................................................................... 2
DCRS August, 2004 – Sir Ganga Ram Hospital
Total no. of Delegates (Valid DCRS forms) .................................................................................................................................. 86
Delegates from Out side (N) ........................................................................................................................................................ 76
Delegates from Sir Ganga Ram Hospital (n) ............................................................................................................................... 10
Overall assessment by outside delegates (M) ........................................................................................................................ 552
Assessment of case presentation-I (Deepti Manocha) by outside delegates ...................................................................... 475
Assessment of case presentation-II (Dr. Piyush Kapoor) by outside delegates .................................................................... 498
Assessment of clinical talk (Prof. H.K. Tewari) by outside delegates ...................................................................................... 571
Total no. of invalid DCRS forms .................................................................................................................................................. NIL
DCRS September, 2004 – Hindu Rao Hospital
Total No. of Delegates ................................................................................................................................................................. 45
Delegates from Out side (N) ........................................................................................................................................................ 32
Delegates from Hindu Rao Hospital (n) ...................................................................................................................................... 13
Overall assessment by outside delegates (M) ..................................................................................................................... 225.5
Assessment of case presentation-I (Dr. Vikas Anand / Dr. Ruchi Goel) by outside delegates .......................................... 214.5
Assessment of case presentation-II (Dr. Bithi Chowdhury) by outside delegates ................................................................ 216
Assessment of clinical talk (Dr. Ruchi Goel) by outside delegates ......................................................................................... 229
Rejected Form Hindu Rao Hospital (n) ...................................................................................................................................... NIL
Rejected Form Out side (N) ............................................................................................................................................................ 1
DCRS October, 2004 – Dr. R.P. Centre for Ophthalmic Sciences
Total No. of Delegates ................................................................................................................................................................. 57
Delegates from Out side (N) ........................................................................................................................................................ 38
Delegates from Dr. R.P. Centre (n) ................................................................................................................................................ 19
Overall assessment by outside delegates (M) ..................................................................................................................... 272.5
Assessment of case presentation-I (Dr. Balasubramanya R.) by outside delegates ............................................................ 261
Assessment of case presentation-II (Dr. Arun Singhvi) by outside delegates ....................................................................... 264
Assessment of clinical talk (Dr. Rajesh Sinha) by outside delegates ..................................................................................... 300
Rejected Form Dr. R.P. Centre (n) ................................................................................................................................................... 2
Rejected Form Out side (N) ........................................................................................................................................................ NIL
DCRS November, 2004 – Shroff's Charity Eye Hospital
Total No. of Delegates ................................................................................................................................................................. 34
Delegates from Out side (N) ........................................................................................................................................................ 28
Delegates from Shroff's Charity Eye Hospital (n) .......................................................................................................................... 6
Overall assessment by outside delegates (M) ..................................................................................................................... 196.5
Assessment of case presentation-I (Dr. Umang Mathur) by outside delegates ................................................................ 180.5
Assessment of case presentation-II (Dr. Suneeta Dubey) by outside delegates ................................................................ 191.5
Assessment of clinical talk (Dr. Manisha Aggarwal) by outside delegates........................................................................... 207
Rejected Form Shroff's Charity Eye Hospital (n) ............................................................................................................................. 1
Rejected Form Out side (N) ............................................................................................................................................................ 1
April, 2005 426 DOS Times - Vol.10, No. 10
DCRS December, 2004 – Venu Eye Institute & Research Centre
Total No. of Delegates ................................................................................................................................................................. 43
Delegates from Out side (N) ........................................................................................................................................................ 29
Delegates from Venu Eye Institute & Research Centre (n) ......................................................................................................... 14
Overall assessment by outside delegates (M) ........................................................................................................................ 189
Assessment of case presentation-I (Dr. Amit Wasil) by outside delegates ........................................................................ 133.5
Assessment of case presentation-II (Dr. Ashish Ahuja) by outside delegates ................................................................... 152.5
Assessment of clinical talk (Dr. Jeena Mascarenhas) by outside delegates ......................................................................... 167
Rejected Form Venu Eye Institute & Research Centre (n) ......................................................................................................... NIL
Rejected Form Out side (N) ........................................................................................................................................................ NIL
DCRS January, 2005 – VMMC & Safdarjung Hospital
Total No. of Delegates ................................................................................................................................................................. 54
Delegates from Out side (N) ........................................................................................................................................................ 46
Delegates from Vardhman Mahavir Medical College & Safdarjung Hospital (n) ..................................................................... 8
Overall assessment by outside delegates (M) ........................................................................................................................ 312
Assessment of case presentation-I (Dr. Virender Sachdev) by outside delegates ............................................................... 305
Assessment of case presentation-II (Dr. Sulab) by outside delegates ................................................................................... 322
Assessment of clinical talk (Dr. V.S. Gupta) by outside delegates .......................................................................................... 332
Rejected Form Vardhman Mahavir Medical College & Safdarjung Hospital (n) .................................................................... NIL
Rejected Form Out side (N) ........................................................................................................................................................ NIL
DCRS February, 2005 – Maulana Azad Medical College
Total No. of Delegates ................................................................................................................................................................. 87
Delegates from Out side (N) ........................................................................................................................................................ 64
Delegates from Maulana Azad Medical College (n) ................................................................................................................ 23
Overall assessment by outside delegates (M) ..................................................................................................................... 461.5
Assessment of case presentation-I (Dr. Deepender Chauhan) by outside delegates ...................................................... 459.5
Assessment of case presentation-II (Dr. Deepali) by outside delegates ............................................................................ 447.5
Assessment of clinical talk (Dr. Ritu Arora) by outside delegates ....................................................................................... 477.5
Rejected Form Maulana Azad Medical College (n) ..................................................................................................................... 1
Rejected Form Out side (N) ........................................................................................................................................................ NIL
DCRS March, 2005 – Mohan Eye Institute
Total No. of Delegates .................................................................................................................................................................. 81
Delegates from Out side (N) ......................................................................................................................................................... 71
Delegates from Mohan Eye Institute (n) ...................................................................................................................................... 10
Overall assessment by outside delegates (M) ..................................................................................................................... 532.5
Assessment of case presentation-I (Dr. Jayshree Baruah) by outside delegates .............................................................. 480.5
Assessment of case presentation-II (Dr. Jasneet Kang) by outside delegates .................................................................. 500.5
Assessment of clinical talk (Dr. Rajiv Mohan) by outside delegates ...................................................................................... 528
Rejected Form Mohan Eye Institute (n) .......................................................................................................................................... 1
Rejected Form Out side (N) ........................................................................................................................................................... 3
Methodology for Monthly Clinical Meeting:
Criteria for Selection
Formula: Institution's Marks
AveragemarksA(outsidedelegates)x0.7+ Attendance of institution (N) x3
maximum attendance in any monthly meeting (Nx)
Total marks by outside delegates (M) Nx = Highest attendance of all meetings
A= N = Total number of delegates
n = Total number of internal delegates
Total number of outside delegates (N-n)
N = Total Attendance of an instituton
(Outside + internal delegates)
April, 2005 427 DOS Times - Vol.10, No. 10
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