DOS_august_2009

For Private Circulation only ISSN 0972-0723

D STimes
DOS Times - Vol. 15, No. 2, August 2009 A Bulletin of Delhi Ophthalmological Society

OCT
Ocular Prosthesis
Implantable Contact Lens
Newer Glaucoma Surgeries
Slit Lamp Photography

Contents

E5 ditorial 47 Diagnosis and Management of Conjunctival Melanoma

Retina Ramendra Bakshi

9 Optical Coherence Tomography – Practical aspects for Vitreo- 51 Internet Ophthalmology and the sites you probably missed

retinal diseases Kapil Midha
Deependra V Singh, Yog Raj Sharma
Pharmacology

55 Prostaglandins & their Analogs

Y.C. Gupta

Oculoplasty Clinical Monthly Meeting

15 Optimal Fitting of Ocular Prosthesis in Different Clinical 59 Case 1-Refractive Surgery in Refractive Accommodative

Situations Esotropia Cases in Adults
Raj Anand, Sham Sunder Gupta, Sachin Gupta Manisha Acharya, Suma Ganesh, Umang Mathur

Refractive Surgery 63 Case 2-Management of Cataract with Corneal Ectasia

21 Implantable Contact Lens Monica Gandhi, Umang Mathur, Suma Ganesh

Hemlata Gupta, Mahipal Sachdev, Charu Khurana, Archana Chafle 65 Clinical Talk - Ophthalmic Plastic Surgery: the New Horizons

Glaucoma Sima Das

27 Newer Glaucoma Surgeries F70 orthcoming Events

Sathi Devi

Cornea Columns

35 Slit Lamp Photography: Techniques 73 Membership Form

Nazneen Nazm, Julie Pegu, Umang Mathur, Suneeta Dubey, Tearsheet
Parmod Kumar
75 Management of Amblyopia
Miscellaneous
Pradeep Sharma
43 Normal MR Anatomy of the Orbits

Seema Sud

www.dosonline.org 3

Editorial

My Dear Friends and Collegues,

This is 2nd DOS Times of the season, we are trying to sort out the glitches in the distribution. Please do
inform us if any of your friends have not received the DOS Times. It is important that we are able to
update your data. Please update your form and send it by post / email.

The DOS Chariot, moves on; full steam ahead and The Mid Term Conference blinks on the horizon.
It is always successful, and extremely appreciated. “The DOS Mid Term”. Let us together revv it up
some more. The Mid Term conference will be held on 14th & 15th November, 2009 at India Habitat
Centre, New Delhi. The first day we will have live surgery & the 2nd day we will have sessions which will
address common day to day management dilemma. There will be cases where the various management solutions will be
discussed by the experts. During our residency and in our clinical practice we often face this dilemma! “What should I do now”
We wish to provide the answers during this conference. Answers to “The doctors dilemma” It is important for us to understand
the need of the end user i.e. you please do communicate to us what topics you need is to cover in DOS times & the Mid Term
Conference. Please send us your clinical & surgical dilemmas. We shall incorporate these topics and the approach to their
management in the conference.

We are organizing a series of “DOS Skill Transfer Programme” on Soft Contact Lenses for the young ophthalmologists, the
first of which is planned on 25th October, 2009, Sunday (Details in DOS Times page No. 31).

Progress occurs, when youth joins with experience and energy blends with knowledge, enthusiasm with maturity and wonder
with wisdom. My invitation to the young resident and the young practitioner. Give us the magic, only the young can. Contribute
to the DOS times. Choose your content. Feel free. Make it interesting and readable and we will print it. First time authors of
DOS Times articles will get a chance to make a presentation during the DOS annual conference in april. Get started and get
noticed!

How did you find the last issue DOS times. Hoping to see you in all the monthly DOS meets and of course during the Mid Term
conference.

Your friend,

Thanking you,

Dr Amit Khosla
Secretary,
Delhi Ophthalmological Society

www.dosonline.org 5

www.dosonline.org 7

Optical Coherence Tomography – Practical aspects Retina
for Vitreo-retinal diseases

Deependra V Singh MD*, Yog Raj Sharma MD**

Organ of vision offers excellent visibility. “Why not use light The interferometer strips off scattered light from the reflected
waves instead of sound waves for scanning ocular structures” light needed to generate an image. The time delay between the
The thought was followed by introduction of the optical coherence two reflected signals produces an interference pattern that
tomography (OCT), a technique already used in different generates an A scan of a small cross-section of the eye (Figure 1).
specialities of medicine, including ophthalmology. While imaging The intensities of the various signal returns are converted into a
of other body tissues required endoscopy to deliver light, the clear false-color rainbow scale. Each OCT image is composed of 100
media of the eye has lent itself to noncontact, non-invasive imaging individual color-coded A-scans aligned with respect to the bright
by OCT. A first two-dimensional in vivo depiction of a human eye reflection from the retinal pigment epithelium (RPE).
fundus along a horizontal meridian based on white light
interferometric depth scans was presented at the ICO-15 SAT Obtaining Optimum scans
conference in 1990.1 First in vivo, OCT images, displaying retinal
structures, were published in 1993.2 For discussion purposes the Zeiss OCT Stratus 3 will be used as
reference. The detailed registration of patient characteristics is
The basic principle of OCT is akin to ultrasound. The low coherent extremely important and the data entry should be uniform and
laser light from the source is split into a measurement beam that standardized to allow retrieval via multiple variables like physician-
scans intraocular structures and a reference beam that gets reflected wise, disease-wise, time-wise etc. Since OCT uses non visible laser
back from reference mirror. Note that most light is not reflected light, scanning can easily be done in undilated pupil for most
but, rather scatters. The scattered light has lost its original direction patients with clear media, however dilatation offers higher quality
and does not contribute to forming an image but rather contributes images with better signal strength. This is even more relevant
to glare. Using the OCT technique, scattered light can be filtered when we are obtaining quantitative data e.g. Central Foveal
out, completely removing the glare. The filtering of scattered light Thickness (CFT) or Retinal Nerve Fibre Layer (RNFL) Thickness.
is achieved via optical coherence. Only the reflected (non-scattered)
light is coherent (i.e. retains the optical phase that causes light rays Scanning activities commonly required for evaluation of Vitreo-
to propagate in one or another direction). In the OCT instrument, retinal interface are Macular Thickness Map (MTM), Fast Macular
an optical interferometer is used in such a manner as to detect Thickness Map (FMTM) and Line Scans. Both MTM and FMTM
only coherent light. use 6 consecutive macular scans, 6 mm in length, centered on the
fovea, at equally spaced angular orientations. (Figure 2A & 2B).The
6 OCT images are segmented to detect the retinal thickness, which

Figure 1: Schematic diagram showing Figure 2A: Scanning activities available for vitreo-retina,
optical principle of OCT Figure 2B: 9 sectors for macular edema and 6x6mm scans
used for macular scanning, Figure 2C: False color coded
*DRS Northex Eye Institute, Rohini, Delhi
**Dr. R.P.Centre for Ophthalmic Sciences, AIIMS New Delhi thickness maps, Figure 2D: Well centered Scan

www.dosonline.org 9

Figure 3A: Poorly centered scan misinterpreted as CSR, Figure 4A: The white layers used by Stratus
Figure 3B: Centered scan of same eye showing CME software to identify retinal layers,

Figure 4B: Superio-temporal BRVO,
Figure 4C: Note the normal Central Foveal
Thickness, but remarkably increased retinal volume

is measured as the distance from the photoreceptor inner/outer Analysis and interpretation
segment junction to the vitreo retinal interface. The retinal
thickness is displayed as a false-color topographic map, as shown We would be discussing quantitative analysis first followed by
in (Figure 2C). The thickness maps are divided into 9. Early qualitative analysis.
Treatment Diabetic Retinopathy Study (ETDRS)–type regions and
the average thickness value for each region is displayed. Because Quantitative analysis
the radial pattern of 6 OCT images samples the macular thickness
along clock hours, the retinal thickness in the wedges between Two common analysis protocols in Stratus OCT provide color
each image is interpolated. Therefore this imaging protocol of coded thickness and volume maps. Fast macular thickness protocol
stratus OCT may miss pathologies such as focal edema located in provides A-scans at a total of 768 points equally spaced along six
a span of 1 clock hour or 30°. 6-mm-long radial lines intersecting at their midpoints. The Stratus
OCT software algorithm defines the internal limiting membrane
In general quantitative results are comparable from fast (FMTM) (ILM) and the retinal pigment epithelium (RPE) (Figure 4A). The
and normal (MTM) scanning in an alert patient with clear ocular operator or eye surgeon should manually review individual line
media. In patients with hazy media MTM offers the advantage of scans to verify that the algorithm had accurately identified these
selecting high quality scans one by one for each clock hour. On the structures. Central foveal thickness (CFT), termed foveal thickness
other hand an old patient with short attention span can easily be in the software algorithm, is calculated as the mean thickness at
scanned by FMTM. the intersection of the 6 radial scan lines. Retinal sector volumes
are calculated by multiplying the mean thickness by the surface
After selecting appropriate scanning protocol, Patient is instructed area within the 9 ETDRS sectors (Figure 2C). While CFT gives us
to look at the central fixation light. A sharply focused black and a quick impression of the magnitude of macular edema, it is more
white image on the right corner serves as a guide for the operator. likely to get affected by artifacts and eccentric fixation. The eyes
After optimizing the polarization and alignment the scan is initiated. with focal diabetic macular edema (DME) and sectoral macular
A well centered and focussed scan with no missing data is saved. edema in retinal vein occlusion can have normal CFT. (Figure 4B,
The operator should ensure that the scan has signal strength of at 4C and 4D) Also the central migration of hard exudates in DME
least 4 out of 10 for MTM and FMTM and 6 out of 10 for RNFL following treatment, a phenomenon frequently observed, can
thickness map. Various alignment artifacts of OCT scans have falsely appear as increase in CFT on serial OCTs. For all these
been described in literature.3 A simple tip to avoid them is to reasons retinologists should give more importance to volume based
ensure than the scan should be horizontally and vertically centered maps from the scans of an eye with macular edema. Volume based
(Figure 2D). Figure 3 shows an example of a patient where poorly maps especially with larger radii are known to get least affected
centered scan (3A) lead to misdiagnosis of CSR while repeat from eccentric fixation and correlate well with clinically significant
scanning (3B) revealed CME. Conditions like epiretinal membrane, macular edema. A careful review of scans prior to interpretation
macular hole, solar burn, Vitreo-macular Traction, CNVM and and application of thickness results should avoid OCT image
IPCV require qualitative scanning by retina surgeon who can artifacts as described by Ray et al.3 They include (1)
directly evaluate the area of interest and make clinical judgements misidentification of the inner retina, (2) misidentification of the
based on the findings. outer retina, (3) “out-of-register” artifacts (vertically truncated A

10 DOS Times - Vol. 15, No. 2, August 2009

Figure 5: High magnification showing bilayered
hypereflective line representing RPE and IS/OS junction

images), (4) artifacts caused by a degraded scan image, (5) “cut- Figure 6: Unremarkable fundus picture of an eye
edge” artifacts (horizontally truncated images), and (6) “off-center” with welding arc injury showing isolated defect
artifacts (misalignment of foveal center). Although most of these
image artifacts can be avoided by paying careful attention during in IS/OS line (white arrow)
the scanning process, image artifacts caused by misidentification
of inner/outer retina by the OCT software are operator Patterns of diabetic and uveitic macular edema
independent (Figure 4D). To avoid the errors of misidentification
of inner/outer retina caused by the automated analysis, recent Otani and colleagues first described patterns of DME with OCT.10
studies have adopted the approach of manual measurement with They reported three patterns of clinically significant DME: sponge-
the use of the calliper function provided in the retinal thickness like retinal swelling (88%), edema with cystic spaces (47%), and
analysis protocol.4,5 Another useful method is to export the original edema with serous retinal detachment (15%). (Figure 6) Kang et
image and manually measure the retinal thickness with callipers. al included Vitreo-retinal traction to this classification11 and had
four categories:
Qualitative Scanning
• Type 1: Thickening with homogenous optical reflectivity
An OCT image from stratus OCT has a hyper-reflective (red) line
as a central reference point that represents RPE and • Type 2: Thickening with decrease optical reflectivity in the
photoreceptors. Anterior to this are heterogeneous layers of low outer retinal layer
reflectivity representing rest of the retinal layers (Figure 5). The
hyper-reflective line can be resolved into 2 distinct laminae; the • Type 3A: Foveolar detachment without traction
inner thin line and outer thicker line (Figure 5). Most researchers
now agree that the inner line represent the junction of Inner and • Type 3B: Foveolar detachment with traction.
Outer segment (IS/OS) of photoreceptors and is part of
neurosensory retina. The outer thicker red line represents RPE- Similarly Markomichelakis et al has described 3 patterns of macular
choriocapillary complex. The continuity and integrity of this IS/OS edema on OCT in patients with uveitis; Diffuse macular edema,
line has been found to correlate with the health of photoreceptors Cystoid macular edema and Serous retinal detachment.12
and visual acuity in various retinal diseases including CNVM in
age-related macular degeneration, solar retinopathy, welding arc The presence of clinically significant macular edema (CSME)
injury, CSR and macular hole.6-9 While intact IS/OS line might warrants laser treatment as per ETDRS guidelines and this requires
correlate with better visual prognosis in AMD, a successful macular slit lamp biomicroscopy. Optical coherence tomography based
hole closure is known to restore the disrupted IS/OS line. Isolated retinal volume and central foveal thickness variables have been
discontinuity in IS/OS line in welding arc injury (unpublished data found to display comparable abilities to discriminate between those
from authors) (Figure 5) or solar retinopathy explains the visual with and without CSME.
loss in presence of unremarkable OCT and fundus examination.7
Patterns in CNVM
Macular edema
OCT with its ability to detect sub retinal/intraretinal fluid, Pigment
OCT is essentially an indispensible tool for evaluating eyes with Epithelial Detachment (PED) has become the preferred mode of
macular edema of all aetiologies. OCT can not only detect investigation and following the eyes with CNVM. Although
subclinical macular edema but can also record it quantitatively fluorescence angiography (FA) has been a common diagnostic
and monitor it serially. Also different patterns of macular edema tool to consider the treatment or retreatment for exudative
have been described as to carry different prognosis.

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Figure 7: Serial scans and fundus pictures of Figure 8A: ERM with minimal edema,
an eye with CNVM treated with anti-VEGF Figure 8B: ERM with CME, Figure 8C: ERM with
neurosensory RD, Figure 8D: Serial scans of an eye with
drugs after 1 (7B) and after 3 injections ERM managed by PPV. Note the hypereflective elevations
(7C). Note minimal
persisting even 9 months after the surgery
change visible on serial fundus pictures

AMD,13,14 OCT-guided therapy with ranibizumab was evaluated In general OCT evaluation of an eye with macular hole offers
in a small case series of patients with wet AMD. The Prospective following advantages; confirmation of diagnosis, differentiation
OCT Imaging of Patients with Neovascular AMD, treated with from simulating conditions labelled as “pseudo hole”,
Intra-Ocular Lucentis (PrONTO) study used time-domain OCT demonstration of vitreous traction on edges of hole, presence of
(TD-OCT) and evaluated the central 1 mm of 6x6-mm radial line sub retinal fluid around the hole, Presence or absence of PVD/
scans to determine if a patient should receive treatment with operculum, associated ERM and retinal schisis. Comparisons
Ranibizumab. Using this OCT-guided model, patients required between pre and post operative scans offer valuable information
considerably fewer treatments than the 24 monthly injections to surgeon and patient. The restoration of the inner IS/OS line has
performed in the phase 3 studies, yet yielded comparable visual been correlated with good visual outcome after successful closure
results.15 The CNVM is visible as thickening of RPE-Choriocapillary of macular hole.
complex (the outer red line) with or without intra/subretinal fluid
(Figure 7A, B and C). The OCT not only offers both qualitative ERM on OCT can be visible as a continuous hypereflective line
and quantitative evaluation of eyes with CNVM but also can with minimal retinal thickening or a disrupted hypereflective line
differentiate sub-retinal and sub-RPE blood, serous and fibrous with multifocal points of attachments to retina with or without
PEDs and hence influence the clinical decisions. The sub RPE blood cystoid macular edema/sensory retinal detachment.
in patients with CNVM might be less visual threatening than sub- (Figure 8A, 8B & 8C). Interestingly the multiple points of
retinal blood. Above features make OCT an excellent non-invasive attachments of ERM continue to persist as tiny elevations for 2 to
tool to serially monitor a patient with CNVM after initial treatment, 4 months before flattening out, after removal of ERM by vitreous
an approach popularly known as “observe and treat”. surgery (Figure 8D).

OCT for Macular hole and ERM High resolution OCT

Hee et al first described the use of OCT in diagnosing and Recently, dramatic advances in OCT technology have enabled OCT
monitoring macular holes.16 They created an OCT-based imaging with ≈15-times to 50-times increase in imaging speed
classification of macular hole development. Gaudric et al later over standard-resolution OCT systems. These novel detection
described macular holes using OCT to follow the sequence of techniques are known as Fourier domain or spectral detection
events from antero-posterior vitreofoveal traction to fullthickness techniques, because echo time delays of light are measured by
macular hole.17 Clinically FTMH can be confused with pseudocysts, taking the Fourier transform of the interference spectrum of the
pseudoholes, and lamellar holes. OCT can distinguish these entities light signal. Different echo time delays of light produce different
and also help to confirm the relationship between these disorders. frequencies of fringes in the interference spectrum.
18 The detailed discussion of OCT based classifications,
prognostification and additional insight into the pathophysiology A Fourier transform is a mathematical procedure that extracts
of FTMH provided by OCT is beyond the scope of this the frequency spectrum of a signal. Because OCT with spectral/
communication. Fourier domain detection can measure all echoes of light from

12 DOS Times - Vol. 15, No. 2, August 2009

different delays simultaneously, it has a dramatic speed and Ophthalmology 2007;114:763–773.
sensitivity advantage compared with OCT using standard detection.
9. Matsumoto H, Kishi S, Otani T, Sato T. Elongation of photoreceptor
In SD-OCT, spectrum is measured with a spectrometer and is outer segment in central serous chorioretinopathy. Am J Ophthalmol
converted to depth information by a Fourier transformation, so 2008;145:162–168.
that SD-OCT does not need to move the mechanical reference
arm, resulting in the faster acquisition times and greater axial 10. Otani T, Kishi S, Maruyama Y: Patterns of diabetic macular edema
resolution compared with TD-OCT.19 The detailed discussion of with optical coherence tomography. Am J Ophthalmol 127:688—
advantages of three dimensional, faster and high resolution 93, 1999.
scanning with new OCTs will be dealt in subsequent issues of DOS
times. 11. Kang SW, Park CY, Ham DI: The correlation between fluorescein
angiographic and optical coherence tomographic features in clinically
To conclude OCT evaluation of Vitreo-macular interface has significant diabetic macular edema. Am J Ophthalmol 137:313—
become indispensible part of comprehensive retina examination. 22, 2004.
Management of entities such as vitreomacular traction syndrome,
macular edema, epiretinal membrane, full thickness macular hole, 12. Markomichelakis N.N, Halkiadakis. I, Pantelia E.et al. Patterns of
CNVM and AMD has been revolutionized by OCT. Macular Edema in Patients with Uveitis Qualitative and Quantitative
Assessment using Optical Coherence Tomography. Ophthalmology
References 2004; 111:946–953.

1. A. F. Fercher, “Ophthalmic interferometry,” Proceedings of the 13. Van de Moere A, Sandhu SS, Talks SJ. Correlation of optical
International Conference on Optics in Life Sciences, Garmisch- coherence tomography and fundus fluorescein angiography
Partenkirchen, Germany, 12-16 August 1990. Ed. G. von Bally and following photodynamic therapy for choroidal neovascular
S. Khanna, pp. 221-228. membrane. Br J Ophthalmol 2006;90:304–6.

2. A. F. Fercher, C. K. Hitzenberger, W. Drexler, G. Kamp, and H. 14. Eter N, Spaide RF. Comparison of fluorescein angiography and
Sattmann, “ In Vivo Optical Coherence Tomography,” Am. J. optical coherence tomography for patients with choroidal
Ophthalmol., vol. 116, no. 1, pp. 113-114. 1993. neovascularization after photodynamic therapy. Retina 2005; 25:691–
6.
3. Ray R, Stinnett SS, Jaffe GJ. Evaluation of image artifact produced
by optical coherence tomography of retinal pathology. Am J 15. Fung AE, Lalwani GA, Rosenfeld PJ, et al. An optical coherence
Ophthalmol 2005;139:18 –29. tomography-guided, variable dosing regimen with intravitreal
ranibizumab (Lucentis) for neovascular age-related macular
4. Salinas-Alaman A, Garcia-Layana A, Maldonado MJ, et al. Using degeneration. Am J Ophthalmol 2007;143:566–83.
optical coherence tomography to monitor photodynamic therapy
in age related macular degeneration. Am J Ophthalmol 2005;140:23– 16. Hee MR, Puliafito CA, Wong C, et al: Optical coherence tomography
8. of macular holes. Ophthalmology 102:748—56. 1995.

5. Larsson J, Zhu M, Sutter F, Gillies MC. Relation between reduction 17. Gaudric A, Haouchine B, Massin P, et al: Macular hole formation:
of foveal thickness and visual acuity in diabetic macular edema new data provided by optical coherence tomography. Arch
treated with intravitreal triamcinolone. Am J Ophthalmol Ophthalmol 117:744-51, 1999.
2005;139:802– 6.
18. Johnson MW: Improvements in the understanding and treatment
6. Pons M.E, Garcia E. Redefining the Limit of the Outer Retina in of macular hole. Curr Opin Ophthalmol 13:152-60, 2002.
Optical Coherence Tomography Scans. Ophthalmology
2005;112:1079–1085. 19. Chen TC, Cense B, Pierce MC, et al. Spectral domain optical
coherence tomography: ultra-high speed, ultra-high resolution
ophthalmic imaging. Arch Ophthalmol 2005;123:1715–20.

7. Stangos AN, Petropoulos IK, Pournaras JA, Zaninetti M, Borruat First Author
FX, Pournaras CJ. Optical coherence tomography and multifocal Deependra V. Singh MD
electroretinogram findings in chronic solar retinopathy. Am J
Ophthalmol. 2007 Jul;144(1):131-4.

8. Hangai M, Ojima Y, Gotoh N, et al. Three-dimensional imaging of
macular holes with high-speed optical coherence tomography.

www.dosonline.org 13

Optimal Fitting of Ocular Prosthesis in Different Oculoplasty
Clinical Situations

Raj Anand MS, Sham Sunder Gupta MS, Sachin Gupta B.Opt

Eye contact in human interactions is a universal medium of disfigured or lost eyes. Advances in the field of Ocularistry allow
social exchange, and so much more than vision is lost when an fabrication of ocular prosthesis that are life like in appearance, can
eye is lost or disfigured. Without the appearance of normal eyes, be worn continuously for months together without need of
person with a lost/disfigured eye faces social ostracism with lifelong frequent removal or cleaning and have good degree of prosthesis
consequences in personal and professional life. Even though the motility. A person with well fitted prosthesis may not be recognised
disease may appear cosmetic, the impact on patient's life is as wearing artificial eyes even at very close observation and the
equivalent to a functional disability. Right from school days the patient wearing the artificial eye has no discomfort or discharge
child may be ridiculed among his/her peers for the abnormal even with continuous wearing for months together.
appearance of the eye. At the productive age she/he may be at a
disadvantage in job and marital prospects certainly the blemish Since the Ocularist- the person trained in Ocularistry- is not an
for disfigured eye expands more than the cosmetic realms of ophthalmologist, he needs co-ordination from Ophthalmology
personal life. To render such a patient normal appearance of the colleagues for optimal outcome of the prosthesis and as
eyes and face is more of a rehabilitation work rather than cosmetic ophthalmologists we need to understand the requirements of the
fulfilment. Ocularist for best possible outcome. This article is an attempt to
bridge the gap between the two specialties so that the patients get
Present curriculum in the post graduate training of ophthalmology the maximum advantage of the expertise of both the specialists.
typically skirts around this topic for the lack of visual potential in We shall discuss in this article case scenarios for five different type
the affected eye and the rehabilitation of the patient is considered of lost/disfigured eye and role of Ophthalmologist and the Ocularist
beyond the perspective of ophthalmology. This has lead to the in the given situation.
formation and development of a new ancillary faculty of
Ophthalmology called 'Ocularistry'.

Ocularistry is the science and art of fabrication & fitting of a
customised artificial eyes or ocular prosthesis for patients with

Figure 1: A case of 25 years old boy having left Figure 2: Case of phthisis bulbi with cilliary tenderness,
phthisis bulbi following injury. This patient was who could not tolerate prosthesis even after steroid and
cycloplegics treatment, underwent evisceration with orbital
fitted with custom made ocular prosthesis
implant followed by ocular prosthesis
Chinmaya Vision
28, Bhera Enclave, Outer Ring Road, 15

Paschim Vihar, New Delhi

www.dosonline.org

Figure 3: A case of congenital microphthalmos, who presented at the age of 4 weeks. She was fitted with
progressively enlarging conformers every 4-6 weeks. Pictures shows gradual enlargement of the palpebral fissure and

the final outcome at the age of 6 months after fitting of custom made ocular prosthesis

prosthesis and good degree of prosthesis motility when the
following pre requisites are fulfilled.

• No cilliary tenderness

• Corneal vascularisation

• Diminished corneal sensation

Figure 4: Case of congenital anophthalmia with • Deep fornices
absent eye ball and rudimentary socket leading to
• Undisturbed anatomy of the orbital tissue (Figure 1).
bony orbit and facial asymmetry
In cases with cilliary tenderness, the phthisical eye may not tolerate
the prosthesis and patient may start having pain, watering, swelling
of the lids associated with redness of the eye. The prosthesis use is
discontinued; patient is prescribed strong cycloplegics (Atropine
eye drops or eye ointment) along with potent steroid eye drops
(Prednisolone or Betamethasone) 3-4 times a day and prosthesis
may be re-evaluated after 4-6 weeks. If patient does not tolerate
prosthesis even after this treatment, she/he may require
evisceration/enucleation with orbital implant followed by ocular
prosthesis (Figure 2).

Figure 5: A case of 55 years old gentleman who underwent In case of phthisis bulbi with clear cornea and intact corneal
right eye evisceration with acrylic implantation for sensations, the patient may develop recurrent corneal abrasion
due to prosthesis and she/he may not tolerate the prosthesis.
endogenous endophthalmitis followed by fitting of custom Initially the back surface of the prosthesis is modified to reduce
made ocular prosthesis corneal touch and if this fails to relieve the symptoms patient may
need to undergo surgical intervention to cover the clear cornea
Phthisis bulbi with thin conjunctival flap after epithelial debridement of the
affected cornea. Prosthesis may be fitted 2-4 weeks after the
Phthisis bulbi is a shrunken, disorganized, non-functional eye that conjunctival flap.
results from severe ocular disease, inflammation, or injury. The
condition often leads to an eye that is unsightly and/or painful. Congenital anophthalmia and microphthalmia
The patient with phthisis bulbi has optimal outcome with ocular
This is the most challenging as well as gratifying condition to treat.
Child born with anophthalmic or microphthalmic eye is a source
of great concern for the parents. The management plan for
anophthalmic/ microphthalmic eyes consist of three simple policies-
start early- be gentle- go gradual.

The crux of the management is to start early, the socket tissues are
very pliable in early life and sooner we start better we can match
the opening of the palpebral fissure of the normal eye (Figure 3).

16 DOS Times - Vol. 15, No. 2, August 2009

Figure 6: Secondary orbital implant for case of Figure 7: Dermis fat graft to reconstruct
evisceration without implant the contracted socket

Starting early also has the advantage of stimulating the growth of surgical technique of enucleation or evisceration and
bony orbit. Growth of the bony orbit in turn stimulates the growth placement of the orbital implant that decides final outcome
of facial skeleton and thereby ensuring facial symmetry. and the prosthesis motility (Figure 5).
Conversely, lack of eyeball or small eyeball does not stimulate the
growth of socket and the bony orbit to the extent normal eye • Non spherical implants like Allens implant does not help in
does. This may lead to asymmetric growth of the facial skeleton increasing prosthetic motility and its angulated edges can erode
manifesting as facial asymmetry (Figure 4). through the orbital tissue leading to exposure. They have
been abandoned in most parts of the world.
Starting early can also avoid need of surgical intervention to
accommodate the ocular prosthesis. The socket that is expanded • Exposed implant is a contraindication for prosthesis fitting.
by non-surgical treatment of serially enlarging conformer stays The exposure must be treated surgically to have healthy front
like that unlike sockets expanded by the surgical intervention that surface of the socket that will ensure trouble free wearing for
have tendency to contract with time. the patient.

Expanded sockets are more amenable to implantation of the orbital Essential points to consider in surgical technique of enucleation or
implant whenever required because the expanded surface area evisceration are
provides greater amount of surface tissue for placement and
coverage of the optimal size of orbital implant. • Preserve as much conjunctiva and tenon as possible- they
provide valuable layers to cover the implant well and also
Surgically induced anophthalmos (post Enucleation / provide deep fornices for good retention and optimal motility
Evisceration) of the prosthesis

This is the group that needs most attention for optimal • The implant size should be selected carefully to augment the
rehabilitation. Appropriate planning and execution of the surgical orbital volume in a way that prosthesis is retained well and
intervention can enable the Ocularist to deliver the best possible has good motility. The size of implant may be calculated by
outcome for the patient in terms of the prosthesis fit and motility. measuring the axial length of the contralateral eye and
The pre-requisites from Ocularist point of view for good outcome deducting 2 mm from this value.
in this category include:
• The implant should be placed posteriorly behind the posterior
• It is essential to use an orbital implant during enucleation or tenon in case of enucleation and sclera may be opened
evisceration surgery to ensure orbital anatomy is restored in posteriorly in case of evisceration to accommodate
the best possible way. Orbital implants are safe even in cases appropriate size of the orbital implant.
of endophthalmitis and retinoblastoma.
• The wound must be closed in layers with 6 -0- vicryl suture.
• The size and the type of orbital implants need careful selection Closure of tenon with thick bites is especially important
to suit patient's requirement and surgeon's comfort. For an because this is the layer with maximum vascularity to allow
adult- in general- spherical orbital implant size of 18mm or good healing and coverage of the implant.
20mm provides adequate volume replacement following
evisceration or enucleation respectively. • Conformer should be placed at end of the surgery on the
table itself to maintain the fornices and allow wound healing
• The type of implant i.e. Bio-integrated vs. Non bio-integrated without getting affected by the lid movement.
does not make great difference in the final outcome. It is the
• Intraconal inj. of Triamcinolone 1cc (40mg/ml) may be given
at end of the surgery to take care of the post op inflammation.

www.dosonline.org 17

Figure 8: Case of contracted socket secondary to chronic
irritation by stock artificial eye, socket reconstruction was

done using mucus membrane graft, amniotic
membrane graft and injection 5 FU intra operatively

Infected cases should be avoided for steroid injection. Figure 9: A case of 65 years old gentleman who underwent
left eye exenteration due to orbital OSSN and fitted with
Anophthalmia without orbital implant
glue assisted Silicon Orbital Prosthesis
Anophthalmic cases without implant have inherent disadvantage
in terms of optimal prosthesis fit. The prosthesis is heavier than Orbital prosthesis is needed following exenteration of the orbit
the usual and has limited motility. Heavy prosthesis may lead to where there are no eyelids to retain the ocular prosthesis. They
sagging of the lower lid in the long term and retention of prosthesis are of three varieties depending on their retention technique
may be compromised. To avoid these complications volume • Spectacle mounted acrylic prosthesis
augmentation may be planned either with secondary orbital • Glue assisted Silicone prosthesis (Figure 9)
implant or with dermis fat graft depending on the availability of • Magnet assisted Silicone Prosthesis.
surface area of the anophthalmic socket. Socket with adequate Performing enucleation, evisceration or exenteration is just the
surface area may undergo secondary orbital implant (Figure 6) beginning of the treatment and it ends only after the patient's
and the socket with contracted surface area and shallow fornices looks are restored to the best extent possible with a prosthesis
require dermis fat graft (Figure 7). and she/he has been explained about the protection of fellow eye
and maximum utilization of the mono ocular vision to deal with
Contracted Socket the daily routine activities like crossing road to driving a vehicle. A
book by Frank Brady - A Singular View- is a must read for
Contracted sockets are real challenges for good prosthesis fit and anophthalmic patients and physicians associated with this
prognosis is guarded in view of the suboptimal outcome that the treatment. He was a commercial pilot, who lost one of his eyes in
patients may end up with. It is best to identify the factors leading aviation accident and took the long arduous task of learning to use
to contracted sockets and avoid them rather having to treat them. the monocular vision to the extent that he got the job of commercial
Chronic use of Stock artificial eyes that do not match the socket pilot back and also made it possible for other one eyed individuals
shape and size are the most common culprit for causing contracted
sockets. Not using conformer of prosthesis after enucleation or First Author
evisceration is another important cause of contracted sockets. Raj Anand MS
Radiation therapy for retinoblastoma can lead to severe
contraction of the socket that is extremely difficult to treat owing
to poor vascular support and compromised healing of the socket
tissue. Dermis fat graft is preferred for cases of surface area and
volume loss of the socket and mucus membrane graft is used for
cases of isolated surface area contraction. Pharmacological adjunct
like inj. 5 FU and steroid injection may also complement the
treatment of contracted socket along with reconstructive surgery.
Inspite of the best efforts from ophthalmologists the outcome for
contracted socket is not as good as primary well managed cases of
enucleation or evisceration with orbital implant (Figure 8).

18 DOS Times - Vol. 15, No. 2, August 2009

Implantable Contact Lens Refractive Surgery

Hemlata Gupta MS, DNB, Mahipal Sachdev MD, Charu Khurana MS, DNB, Archana Chafle MS, DNB

Management of high refractive errors especially with thin mm) of the ICL, add 0.5 mm to the horizontal WW measurement.
cornea is a refractive challenge. Lasik for correcting high If the ICL is too short for the sulcus, the lens vault may be
refractive errors has the drawbacks of lack of predictability, insufficient to clear the crystalline lens, exposing it to the risk of an
regression, corneal ectasia, and induction of high order anterior capsular cataract. If it is too long, the lens will vault
aberrations1. The Implantable Contact lens (ICL) is a preferred excessively, crowding the angle and possibly causing closed angle
modality for correction of high myopia and for patients with thin glaucoma.
corneas. It was first developed in the late 1980’s in Russia by Dr. S.
Fyodorov and the first implant was placed in Europe in 1993. Vault
Fyodorov introduced the concept of a soft phakic lens in the space
between the iris and the anterior surface of the crystalline lens. Ideal ICL vault is approximately 500 μm, which is roughly one
Earlier, the material used was silicone; now, the material used is corneal thickness. There are concerns about high vault (1000 μm)
collamer. leading to angle crowding and resulting in angle closure or synechiae

Indications and pre-requisites:

• When residual bed after LASIK is likely to be less than 250μ

• When the initial corneal thickness is less than 480μ

• Refractive error between the ages of 21-45

• ACD greater than 2.8 mm

• Stable refraction (<0.5D change in previous 12 months)

• No ocular pathology (NSC, glaucoma, lid pathology, etc)

• Mesopic pupil <6.0mm

Implantable contact lens is indicated for placement in the posterior Figure 1: TICL calculation software
chamber of the phakic eye for correction of moderate to high
myopia ranging -3 D to -20 D and hyperopia ranging from + 3 to
+ 12D. Toric ICL (TICL) can correct upto -3 to -23 D of sphere
and + 1.0 to + 6.0 D of cyl. The toric ICL has the same overall
design as the spherical ICL with the addition of a toric optic. The
toricity is manufactured in the plus cylinder axis, within 22 degrees.
The STAAR® Visian ICL™ is made from a combination of copolymer
and collagen called Collamer®. This Collamer® implantable contact
lens reduces reflections and glare, and the collagen makes it
extremely biocompatible. It is made-up of 60% poly-HEMA, Water
(36%), Benzophenone (3.8%) and Collagen (0.2%), it attracts the
deposition of fibronectin on the lens surface, inhibits aqueous
protein binding and makes the lens invisible to the immune system.

Calculation of power

ICL/TICL calculation and implantation software (Figure 1) allows
calculation of spherical and cylindrical power, length and generates
the ICL/TICL implantation diagram (Figure 2).

Measurement of white to white diameter

In the pre-operative planning, the critical parameter in sizing the
ICL is the white-to-white (WW) measurement which can be
measured with a Pentacam, OrbScan, UBM or using calipers
(Figure 3a & b). In myopic eyes, to determine the overall length (in

Figure 2: TICL implantation diagram

Centre for Sight
Safdarjung Enclave, New Delhi

www.dosonline.org 21

formation. High vault may also increase iris chaffing and pigment on the steep meridian. The lens is introduced with angled-suture
dispersion, resulting in pigmentary glaucoma. Furthermore, low forceps or through the injector and positioned behind the iris on
vault (125 μm) may also cause ICL contact with the crystalline lens a horizontal axis with a cyclodialysis spatula (Figure 4-7). To control
and increase the risk of cataract formation over time.2,3 for potential cyclotorsion in a supine position, the zero horizontal
axis is marked preoperatively on the slitlamp. The lens is implanted
Peripheral iridotomy temporally and gently rotated to align the axis with the cylindrical
axis of the patient. Complete removal of viscoelastic material is
A peripheral iridotomy is performed 1-2 weeks before the surgery essential. Presence of residual viscoelastic material behind the
to provide an outlet for the aqueous flow around the lens. implant may cause opacification of the crystalline lens. A miotic
Alternatively it may be performed intra-operatively after ICL agent is injected and the aspiration is completed. The incision is
implantation with a Vannas scissors or a vitrectomy cutter. It should closed by hydrating the corneal incision.
be sufficiently wide (at least 500 μm), positioned superiorly (from
11 to 1 o’clock) and well away from the haptics placement. Discussion

Procedure Various studies have shown that ICL is effective in

The procedure is performed under topical anaesthesia. After 1. Mod. to High Myopia (Kamiya et al1)
making a 0.6mm side port, a 3.2-mm clear corneal incision is made

Figure 3(a): Measuring the white-to-white Figure 3(b): Measuring the
diameter with calipers white-to-white diameter with pentacam

(Schiempflug image)

Figure 4: The STAAR ICL Injection System Figure 5: Introducing the
22 injector into the eye

DOS Times - Vol. 15, No. 2, August 2009

Figure 6: ICL being slowly Figure 8: Post operative Slit lamp view of ICL
implanted in the eye

The various complications noted with ICL include:

Anterior Subcapsular opacities8 (6.7%), Cataract (1-2%), Pigment
Dispension, Lens deposits9, Acute ACG10, Late Subluxation of
ICL11, Endophthalmitis12, RD13.

Conclusion

ICL is a safe and effective modality for correction of high myopia
and for patients with thin corneas with excellent and stable post
operative results. Advancements in anterior segment imaging and
measurement technologies such as ultrasonic biomicroscopy,
optical coherence tomography and Scheimpflug imaging are now
providing valuable information about anterior segment anatomy.
This will further allow custom-designed phakic intraocular lenses
with proper sizing making ICLs invaluable for correction of
moderate to high refractive errors.

Figure 7: ICL placed behind the iris References
and in front of the lens
1. Kamiya K, Shimizu K, Igarashi A, Hikita F, Komatsu M. Arch
2. Hyperopia (Pesando et at4) Ophthalmol. Four-year follow-up of posterior chamber phakic
3. Myopia with keratoconus (Alfonso et al5) intraocular lens implantation for moderate to high myopia. Arch
4. Myopia and astigmatism after PKP (Alfonso et al6) Ophthalmol. 2009 Jul; 127(7):845-50.
Kamiya et al7 suggested that Toric ICL implantation was better
than wavefront-guided LASIK in eye with high myopic astigmatism. 2. Gonvers M, Othenin-Girard P, Bornet C, Sickenberg M. Implantable
The overall complication rate with ICL is low and most patients contact lens for moderate to high myopia: short-term follow-up of
have a good visual recovery. The incidence of glare, haloes and 2 models. J Cataract Refract Surg. 2001; 27:380-388.
night driving problems is also minimal.
Intra-operatively, it is crucial to load the ICL in the injector in a 3. Pop M, Payette Y, Mansour M. Predicting sulcus size using ocular
straight and smooth manner to implant it correctly in the posterior measurements. J Cataract Refract Surg. 2001; 27:1033-1038.
chamber. Improper loading may lead to an upside down
implantation. The visco-elastic material must also be removed 4. Pesando PM, Ghiringhello MP, Di Meglio G, Fanton G. Posterior
carefully and meticulously to prevent a post operative IOP spike. chamber phakic intraocular lens (ICL) for hyperopia: ten-year follow-
up. ( J Cataract Refract Surg 2007;33(9):1579-84.

5. Alfonso JF, Palacios A, Montés-Micó R.Myopic phakic STAAR
collamer posterior chamber intraocular lenses for keratoconus. J
Refract Surg. 2008 Nov; 24(9):867-74.

6. Alfonso JF, Lisa C, Abdelhamid A, Montés-Micó R, Poo-López A,
Ferrer-Blasco T. Posterior chamber phakic intraocular lenses after
penetrating keratoplasty. J Cataract Refract Surg. 2009 Jul;
35(7):1166-73.

www.dosonline.org 23

7. Kamiya K, Shimizu K, Igarashi A, Komatsu M. Comparison of implantable contact lens insertion unresponsive to surgical peripheral
Collamer toric implantable [corrected] contact lens implantation iridectomy. J Cataract Refract Surg. 2008 Apr; 34(4):696-9.
and wavefront-guided laser in situ keratomileusis for high myopic
astigmatism. J Cataract Refract Surg. 2008 Oct; 34(10):1687-93. 11. R. Kaufer, G. Kaufer. Late subluxation of an ICL Journal of Cataract
& Refractive Surgery, Volume 31, Issue 6, Pages 1254-1255.
8. Sanders DR. Anterior subcapsular opacities and cataracts 5 years
after surgery in the visian implantable collamer lens FDA trial. J 12. Allan BD, Argeles-Sabate I, Mamalis N. Endophthalmitis rates after
Refract Surg. 2008 Jun; 24(6):566-70. implantation of the intraocular Collamer lens: survey of users
between 1998 and 2006. J Cataract Refract Surg. 2009 Apr;
9. Chung TY, Park SC, Lee MO, Ahn K, Chung ES. Changes in 35(4):766-9.
iridocorneal angle structure and trabecular pigmentation with
STAAR implantable collamer lens during 2 years. J Refract Surg. 13. Domènech NP, Arias L, Prades S, Pujol O, Rubio M, Caminal JM.
2009 Mar; 25(3):251-8. Acute onset of retinal detachment after posterior chamber phakic
intraocular lens implantation. Clin Ophthalmol. 2008 Mar; 2(1):227-
10. Chan KC, Birchall W, Gray TB, Wells AP. Acute angle closure after

First Author
Hemlata Gupta MS, DNB

Monthly Clinical Meetings Calendar 2009-2010

Dr. R.P. Centre for Ophthalmic Sciences Midterm Conference of DOS
26th July, 2009 (Sunday) 14th & 15th November, 2009 (Saturday - Sunday)
Safdarjung Hospital
Shroff Charity Eye Hospital 27th December, 2009 (Sunday)
23rd August, 2009 (Sunday) Bharti Eye Foundation
31th January, 2010 (Sunday)
Base Hospital
4th October, 2009 (Sunday) Centre for Sight
28th February, 2010 (Sunday)
Sir Ganga Ram Hospital Guru Nanak Eye Centre
1st November, 2009 (Sunday) 28th March, 2010 (Sunday)

Venu Eye Institute & Research Centre
29th November, 2009 (Sunday)

Annual Conference of DOS 16th-18th April, 2010 (Friday, Saturday & Sunday)

24 DOS Times - Vol. 15, No. 2, August 2009

Newer Glaucoma Surgeries Glaucoma

Sathi Devi MS

Trabeculectomy continues to be the gold standard in glaucoma a 25-gauge aspiration port, and a coupling for the ablation unit at
surgery and is the most commonly performed glaucoma the tip. The tip of the instrument is bent to create a triangular
surgery across the world. Various modifications such as the use of footplate which facilitates penetration into Schlemm’s canal. The
adjunctive antifibrotic agents intraoperatively,1,2 the use of footplate is coated with a insulating material which protects the
releasable sutures3 and laser suture lysis4 have improved the canal’s outer wall and adjacent tissues from thermal or mechanical
surgical outcomes. In trabeculectomy, the anterior chamber is injury. Histologic examination of specimens treated with the
entered to shunt the aqueous humor to a subconjunctival bleb to Trabectome displayed disruption of the trabecular meshwork and
reduce intraocular pressure (IOP). However, postoperative inner wall of Schlemm’s canal without damage to surrounding
complications are not uncommon and vision threatening structures.9
complications related to the bleb, especially with use of antifibrotic
agents such as hypotony, maculopathy, late blebitis and bleb-related The surgical procedure itself is fairly simple and is performed
endophthalmitis are of particular concern. Nonpenetrating under local anesthesia. A 1.6mm temporal clear corneal incision is
glaucoma procedures (viscocanalostomy, deep sclerectomy and made using a keratome. Viscoelastic is injected into the anterior
canaloplasty with/without the collagen implant) facilitating aqueous chamber. A surgical goniolens is placed on the cornea to ensure
egress after filtration through an intact Descemet’s membrane, optimal view of angle. Tip of the trabectome is inserted into the
emerged to address these problems. Though encouraging results anterior chamber (AC) past the irrigation port. The goniolens is
have been reported with nonpenetrating glaucoma surgical then replaced on the cornea and irrigation activated. The tip of the
procedures, when lower target intraocular pressure and probability handpiece is then advanced across the AC under direct
of success over time are considered, trabeculectomy exhibits a visualization, to reach the trabecular meshwork nasally. The
better trend.5 Glaucoma drainage devices or aqueous shunts are footplate then engages and penetrates the trabecular meshwork.
generally reserved for eyes where there is a high risk for failure Once the tip is in Schlemm’s canal, the cautery unit is activated
with conventional trabeculectomy.6 However, this trend is slowly using a foot pedal. Ablation and aspiration is continued while
changing following the results of the tube versus trabeculectomy advancing the tip within Schlemm’s canal. This is done for 1-2
study.7,8. clock hours in one direction and then repeated in the opposite
direction. Viscoelastic is then aspirated and incision sutured.
The recent trend has been in evolving surgical procedures that use
Schlemm’s canal and the suprachoroidal space as routes for Minckler et al10 in their study on 37 patients with open angle
enhancing the egress of aqueous from the eye. The site of glaucoma and mean preoperative IOP of 28.2+4.4 mmHg reported
abnormality in glaucoma being the trabecular meshwork, and the a mean postoperative IOP of 17.4+3.5 mmHg (n=25) at 6 months,
site of abnormal outflow resistance within the meshwork being and 16.3+2.0 mmHg (n=15) at 12 months. The number of
the juxtacanalicular tissue adjacent to Schlemm’s canal, removal adjunctive medications decreased from 1.2+0.6 among
or bypassing this thin layer of tissue should theoretically reduce preoperative patients on medications (n=34) to 0.4+0.6 among all
the elevated IOP in glaucoma. A brief description of these novel patients at 6 months (n=25). Blood reflux occurred in all eyes
procedures follows. intraoperatively. However, the hyphaemas cleared within a week.

Trabectome

Trabectome (NeoMedix Corp., California) is a novel device for
minimally invasive surgical treatment of open angle glaucoma.
The instrument has been approved for clinical use by the US
FDA. The trabectome works by ablating and removing a 60°-120°
strip of trabecular meshwork and inner wall of Schlemm’s canal
(Ab interno trabeculectomy) using a focused electrosurgical pulse
delivered through a microelectrocautery. Continuous irrigation
and aspiration during the procedure removes debris and regulates
temperature. The procedure is thought to establish a direct access
of aqueous to the outflow channels.

The trabectome essentially consists of a hand piece (Figure 1) with
an automated aspiration port and electrosurgical ablation unit,
and a system for infusion of BSS. The intraocular portion of the
instrument consists of a handle including a 19-gauge infusion sleeve,

Glaucoma Services Figure 1: Trabectome handpiece
Narayana Nethralaya,121/C, Chord Road, 1st E-Block,
27
Rajajinagar, Bangalore

www.dosonline.org

Gonioscopy revealed focal PAS in the areas ablated through the
follow-up period in 9 eyes (24.3%). No serious vision-threatening
complications such as choroidal effusion, choroidal hemorrhage
or infection were encountered.

Interim analysis of an ongoing, prospective, multicentric study Figure 2: The Glaukos iStent in situ within
analyzed the clinical outcome of 679 consecutive patients Schlemm’s canal
undergoing ab interno trabeculectomy with the Trabectome. The
maximum follow-up was 52 months. An average reduction in
intraocular pressure of 29% was achieved at 6 months follow-up
(n=106), 34% at 12 months follow-up (n=65) and 30% at 24 months
follow-up (n=30).11 The authors conclude that Ab interno
trabeculectomy with the Trabectome appeared to be a safe
alternative to conventional filtration surgery for open-angle
glaucoma, with a clinically relevant reduction in intraocular
pressure and an excellent safety profile.

The procedure can also be combined with cataract surgery. In a were hyphema(3%) and elevated IOP(3%). No serious ocular or
study by Francis et al12, Combined phacoemulsification and ab nonocular complications were reported. The authors concluded
interno trabeculectomy using the Trabectome reduced the mean that canaloplasty effectively lowers IOP with few postsurgical
IOP from 20.0 mm Hg + 6.3 (SD) preoperatively to 14.8+3.5 mm complications.
Hg at 6 months, and 15.5 + 2.9 mm Hg at 1 year. There was a
corresponding drop in the medication use. In another study analyzing the results of eyes which underwent
canaloplasty combined with phacoemulsification cataract surgery,
Canaloplasty it was found that a significantly greater IOP reduction occurred in
combined surgical cases than in cases of canaloplasty alone.14
In viscocanalostomy, viscoelastic is injected into Schlemm’s canal
and a direct communication is created between the anterior Glaukos iStent
chamber and the lumen of the canal on either side of the dissection
site, thus treating only a segment of the distal outflow pathway. In The Glaukos iStent (Glaukos Corp., CA) is a lightweight, titanium,
canaloplasty, catheterization and viscodilation of the entire length L- shaped device. The device is placed inside Schlemm’s canal. The
of the canal is performed. The procedure restores the natural Heparin covered titanium is biocompatible, has thrombolytic
outflow process of the eye without the use of a subconjunctival activity and prevents stenosis. A small, snorkel shaped tube, about
bleb. 0.5 mm in length sits in the peripheral anterior chamber, allowing
aqueous to bypass the inner wall of Schlemm’s canal and the
The initial surgical steps for creating superficial and deep scleral juxtacanalicular trabecular meshwork. The portion of the device
flaps followed by identification and deroofing of Schlemm’s canal that sits in the canal is 1 mm in length and is shaped like a half pipe.
remain the same (as in viscocanalostomy). Following this, a It is designed to fit within the lumen of the canal, with the curved
200micron diameter flexible microcatheter (iTrack,CA) with a blunt convex side lying against the inner wall of Schlemm’s canal. This
tip is advanced 360degrees in the lumen of Schlemm’s canal, along avoids contact with the outer wall of the canal and the collector
its entire length. The tip of the catheter is illuminated with an channel orifices that enter the outer wall. The 3 barbed ridges
optical fibre enabling easy advancement of the catheter in the along this portion are designed to prevent loosening and provide
canal. As the tip is advanced, Sodium Hyaluronate 1.4% is injected a secure placement of the stent in the canal. Stents are designed as
into the lumen of the catheter to dilate the canal. The tip is advanced either right-handed or left-handed for ease of insertion into the
along the entire length of the canal till it reemerges at the surgical canal.
site. A 10/0 polypropylene suture is tied to this distal tip and the
microcatheter withdrawn, taking the suture all round the canal. A temporal clear corneal incision is made, and the anterior chamber
The suture is then cut from the catheter and its two ends tightened. is filled with viscoelastic. An applicator grasps the device, and with
This applies tension to the inner wall of Schlemm’s canal and gonioscopic guidance, traverses the anterior chamber to reach the
trabecular meshwork. A Descemetic window is formed, inner Schlemm’s canal in the nasal quadrant. The pointed tip engages
scleral flap excised and watertight suturing of the superficial flap the trabecular meshwork.
completed.
Bahler et al15 conducted in vitro studies using these trabecular
In a study by Lewis et al,13 127 eyes with open angle glaucoma bypass stents inserted into Schlemm’s canal of anterior segments
underwent canaloplasty(of whom 30 eyes underwent of 21 eyes placed in perfusion culture. Intraocular pressure was
phacocanaloplasty). At 24 months, mean postoperative IOP was lowered after placement of a single stent, from 21.4 + 3.8 mmHg
16.0mmHg + 4.2 (SD) as compared to baseline values 23.6 + 4.8 to 12.4+ 4.2 mmHg (P < .001). Thus, one stent produced the greatest
mm Hg. Mean glaucoma medication reduced to 0.5 + 0.8 from change in pressure. The sequential addition of more stents further
baseline values of 1.9 + 0.8. Using Ultrasound Biomicroscopy, it lowered pressure in seven of nine eyes. Multiple stents could be
was found that eyes which revealed at least some observable implanted, potentially achieving a lower IOP.
trabecular meshwork distension because of suture tension showed
lower postoperative IOP values. The most common adverse events

28 DOS Times - Vol. 15, No. 2, August 2009

developed XeCl excimer laser. Average period of followup was
25.3 ± 1.3 months. IOP had reduced from baseline value of 24.8 ±
2.0 mmHg to 16.9 ± 2.1 mmHg IOP at last follow-up. (p < 0.0001).
Glaucoma medications reduced from 2.2 +0.6 to 0.7 +0.8
postoperatively. The procedure failed in 2 cases (9.5%) despite
additional therapy. The authors concluded that ab interno excimer
laser trabeculotomy seemed effective in reducing IOP, served to
reduce the number of antiglaucoma medications and was relatively
safe.

In another study comparing the effectiveness and safety of excimer
laser trabeculotomy ab interno vs selective laser trabeculoplasty
(SLT)20 in 30 patients with open-angle glaucoma , complete success
rates were 53.3% for the ELT group and 40% for the SLT group.
Mean IOP decreased from 25.0 1.9 to 17.62.2 mmHg (-29.6%;
P<0.0001) in the ELT group and from 23.90.9 to 19.11.8 mmHg (-
21%;P<0.0001) in the SLT group.

Figure 3: The Glaukos iStent Wilmsmeyer et al21 studied the effectiveness of the procedure in 2
groups of patients: the first group underwent ELT alone, and the
Spiegel et al.16 have reported the results in their initial case series second group with cataract underwent phaco emulsification
of 6 patients with open angle glaucoma. The mean preoperative combined with ELT. ELT reduced the IOP from 24.1±0.7 (n=69)
IOP of 20.2 mmHg was reduced to 15.2 mmHg at 12 months. The mmHg preoperatively to 16.8±1.0 mmHg in the first group and
number of glaucoma medications fell from 2.7 preoperative to 2.2 from 22.4 mmHg±0.6 (n=57) to 12.8±1.5 (T4, n=4) mmHg in the
postoperative. No serious, implant related adverse events were group undergoing combined phacoELT(followup at 2 years after
reported. surgery). They concluded that ELT alone is less effective in IOP
reduction as compared to phacoELT.
Excimer Laser Trabeculostomy
Gold Micro-Shunt
Excimer laser trabeculostomy (ELT) uses a novel quartz fiberoptic
probe, which transmits energy from a XeCl excimer laser (AIDA, The DeepLight Glaucoma Treatment System (Solx, Boston)
Glautec AG, Germany). This relatively atraumatic, ab interno includes both a laser (titanium-sapphire) and a photo-titratable
approach creates tiny (0.5mm) holes through the anterior gold micro-shunt, which can be used separately or together. The
meshwork into the inner wall of Schlemm’s canal. This ablation DeepLight titanium-sapphire laser is a flashlamp-excited, solid-
leads to an open connection between the anterior chamber and state laser that emits near-infrared light (790 nm) in short, infrared
Schlemm’s canal, enhancing the outflow facility.17 Biochemical light pulses lasting only 5 to 10 microseconds. The laser passes
theory proposes that ELT creates microperforations through the trabecular meshwork tissues. The longer wavelength
(photoablation) of the trabecular meshwork, with minimal thermal and deeper penetration of the laser prevents thermal, coagulative
effects and lack of coagulative damage to the trabecular or biodestructive damage. It produces significant opening of the
meshwork.18 trabecular meshwork, allowing increased aqueous outflow. The
Gold Micro-Shunt is biocompatible and inert, being made of 99.5%
The XeCl excimer laser is a pulsed (80ns) laser, emitting radiation pure gold. It is a flat plate 5.2-mm long, 2-mm wide and 60-μm
in the ultraviolet range at a wavelength of 308nm. The instrument thick, containing multiple microchannels. Initially, about half of
delivers a mean energy of 1.2 mJ per pulse at a rate of 20Hz. A these microchannels are open and the remainder, which are closed
quartz probe is used to deliver the aiming beam to the trabecular by a thin film of gold, can be opened after implantation, using the
meshwork. The tip of the probe is designed to transmit energy at titanium-sapphire laser. This reactivates the shunt’s effect and
an angle of 65° to the fiber axis, enhancing contact with the additional drop in IOP can be obtained. This phototitration can be
trabecular meshwork. done at any time postoperatively, in the office.

Surgery is performed under topical anesthesia. A 1.2mm incision The shunt is implanted through a single 3mm subscleral or clear
is made in the superior limbus. Viscoelastic is injected into the corneal incision made at the limbus, into the suprachoroidal space,
anterior chamber. Probe is inserted into the eye until the tip is using a special preloaded insertion device. The channels in the
about 2 mm from the trabecular meshwork. A goniolens is placed shunt form a bridge between the anterior chamber and
on the cornea. About eight laser spots, 500 μm apart, are delivered suprachoroidal space, so no filtering bleb is created. Problems
to the anterior trabeculum, over three clock hours. Probe is associated with conjunctival entry and filtering bleb formation are
removed and visco is washed out. thus avoided.

Babighian et al19 studied 21 patients with open angle glaucoma In a pilot study by Melamed et al,22 Gold Micro Shunt (GMS)
who underwent Ab interno trabeculotomy using the recently implantation was performed in 38 patients with glaucoma. With a
mean follow-up period of 11.7 months, the IOP decreased from
27.6 (4.7) to 18.2 (4.6) mm Hg (P < .001). Eight patients had mild to
moderate transient hyphema.

www.dosonline.org 29

Conclusion 12. Francis BA, Minckler DS and the Trabectome Study Group.
Combined Cataract Extraction and Trabeculotomy by internal
The quest for the ideal glaucoma surgery continues. The newer approach for coexisting Cataract and Open-Angle Glaucoma. Journal
devices avoid external drainage and bleb formation, in the hope of Cataract and Refractive Surgery, 2008; 34(7): 1093-1103.
that the attendant problems of hypotony, bleb leakage and bleb
related infection may be avoided. These devices target the 13. Richard A. Lewis, Kurt von Wolff, Manfred Tetz, Norbert Koerber,
Schlemm’s canal or suprachoroidal space, bypassing the area of John R. Kearney, Bradford J. Shingleton, Thomas W. Samuelson.
abnormal resistance in the trabecular meshwork. Despite the Canaloplasty: Circumferential viscodilation and tensioning of
theoretical advantage and the encouraging results from the initial Schlemm canal using a flexible microcatheter for the treatment of
studies, long term followup is essential to confirm their efficacy open-angle glaucoma in adults: Two-year interim clinical study
and role in the management of patients with glaucoma. Major results. Journal of Cataract & Refractive Surgery. 2009; 35(5): 814-
limitations in their use are the additional cost involved for the 824.
device and ability to use only in eyes with open angle glaucoma.
14. Bradford Shingleton, Manfred Tetz, Norbert Korber. Circumferential
References viscodilation and tensioning of Schlemm canal (canaloplasty) with
temporal clear corneal phacoemulsification cataract surgery for open-
1. Five-year follow-up of the Fluorouracil Filtering Surgery Study. The angle glaucoma and visually significant cataract: One-year results.
Fluorouracil Filtering Surgery Study Group. Am J Ophthalmol 1996; Journal of Cataract & Refractive Surgery. 2008; 34(3):433-440.
121: 349–366.
15. Cindy K. Bahler, Gregory T. Smedley, Jianbo Zhou, Douglas H.
2. Kitazawa Y, et al. Trabeculectomy with mitomycin. A comparative Johnson. Trabecular bypass stents decrease intraocular pressure in
study with fluorouracil. Arch Ophthalmol 1991; 109: 1693–1698. cultured human anterior segments. American Journal of
Ophthalmology. 2004; 138(6): 988-994.
3. Cohen J, Osher R. Releasable scleral flap suture. Ophthalmol Clin
North Am 1988; 1: 187–197. 16. Spiegel D, Kobuch K. Trabecular meshwork bypass tube shunt: initial
case series. Br J Ophthalmol 2002; 86: 1228-1231.
4. Savage JA, Condon GP, Lytle RA, et al. Laser suture lysis after
trabeculectomy. Ophthalmology 1988; 95: 1631–1638. 17. Schumann JS, Chang W, Wang N, de Kater AW, Allingham RR:
Excimer laser effect on outflow facility and outflow pathway
5. Sharaawy T, Sherwood M, Hitchings R, Crowston J: Glaucoma morphology. Invest Ophthalmol VisSci1999; 10:1676-1680.
Surgical Management Vol. 2, Elsevier Limited. 2009; 302.
18. Walker R, Specht H: Theoretical and physical aspects of excimer
6. Assaad MH, Baerveldt G, Rockwood EJ. Glaucoma drainage devices: laser trabeculotomy (ELT) ab interno with the AIDA laser with a
pros and cons. Curr Opin Ophthalmol 1999; 10: 147–153. wave length of 308 nm. Biomed Tech 2002;47:106-110.

7. Gedde SJ, Schiffman JC, Feuer WJ, et al. Treatment outcomes in the 19. Silvia Babighian, Emilio Rapizzi, Alessandro Galan. Efficacy and
tube versus trabeculectomy study after one year of follow-up. Am J Safety of ab interno Excimer Laser Trabeculotomy in Primary Open-
Ophthalmol 2007; 143: 9–22. Angle Glaucoma: Two Years of Follow-Up. Ophthalmologica
2006;220:285-290.

8. Joshi AB, Parrish RK 2nd, Feuer WF. 2002 survey of the American 20. S Babighian, L Caretti, M Tavolato, R Cian and A Galan. Excimer
Glaucoma Society: practice preferences for glaucoma surgery and laser trabeculotomy vs 180° selective laser trabeculoplasty in primary
antifibrotic use. J Glaucoma 2005; 14: 172–174. open-angle glaucoma. A 2-year randomized, controlled trial. Eye
advance online publication July 2009; doi: 10.1038/eye.2009.172.
9. Francis BA, See RF, Rao NA, Minckler DS, Baerveldt Glaucoma Ab
interno trabeculectomy: development of a novel device 21. Sonja Wilmsmeyer, Heiko Philippin and Jens Funk. Excimer laser
(Trabectome) and surgery for open-angle glaucoma. J Glaucoma trabeculotomy: a new, minimally invasive procedure for patients
2006; 15: 68-73. with glaucoma. Graefe’s Archive for Clinical and Experimental
Ophthalmology. 2006;244(6):670-676.
10. Minckler DS, Baerveldt G, Alfaro MR, and Francis BA Clinical
results with the Trabectome for treatment of open-angle glaucoma. 22. Melamed S, Ben Simon GJ, Goldenfeld M, Simon G. Efficacy and
Ophthalmology. 2005; 112: 962-67. safety of gold micro shunt implantation to the supraciliary space in
patients with glaucoma: a pilot study. Archives of ophthalmology.
11. Filippopoulos T, and Rhee D Novel surgical procedures in glaucoma.
Advances in penetrating glaucoma surgery. Current Opinion in
Ophthalmology: 2008, 19: 149-154.

Author
Sathi Devi MS

30 DOS Times - Vol. 15, No. 2, August 2009

Slit Lamp Photography: Techniques Cornea

Nazneen Nazm MS, DNB, Julie Pegu MS, Umang Mathur MS, Suneeta Dubey MS, Parmod Kumar OD

Ophthalmic photography is a specific branch of medical the sensors not only detect the amount of light present, but also
photography which deals exclusively with the eye and related the color. The details that can be obtained from a digital camera
structures. Ophthalmic photography is a highly specialized and depend on the number of available picture elements, or pixels.
growing field, requiring knowledge of both anatomy and physiology The higher the number of pixels, greater is the resolution.
of the eye as well as knowledge of photographic techniques.
Advantages of Digital Photography

Purpose of Photography Digital photography possesses several advantages over traditional
film photography:
A slit lamp equipped with a camera for taking pictures is
indispensable for documentation of the anterior segment of the • Better storage of data: Data from digital cameras can be stored
eye. Slit lamp photographs are essential for documentation of electronically, either in portable media or on computer hard
both structural abnormalities as well as pathologic processes drive. Digital storage media can be erased and used
involving the eye. Slit lamp photographs are visual records and indefinitely.
can be incorporated in patient’s charts. This type of documentation
provides the physician with a permanent record of the patient’s • Digital photography eliminates the delay associated with film
findings. It can be used to document interesting cases or unusual processing.
findings.
• Digital photography is cost-effective.

It is also helpful for comparing ocular findings over time, to assess • Digital imaging allows us to immediately assess whether a
progress of the disease or assess the outcome of treatment. good quality image has been obtained. Technically good
images can be selected and the rest deleted.
It has a role in teaching and research purposes.
Basics of Slit Lamp Photography
Slit Lamp Photography
In this section we will discuss photographic exposure and the
A photographic slit lamp instrument is essentially same as the slit different types of illumination, knowledge of which is essential to
lamp used by us everyday for clinical examination. In addition, it obtain good quality photographs.
possesses a beam-splitter. The function of the beam-splitter is to
transmit a percentage of the light (30 or 50%) to the viewing oculars, Photographic Exposure
and reflect the remainder of the light to the camera. An additional
feature is the synchronized flash illuminator. The camera Photographic exposure is controlled by three separate adjustments:
simultaneously captures the details viewed by the photographer.
Thus, the additional parts of a photo slit lamp are: • Flash power setting on the camera power supply

• Camera body • Beam aperture

• Electronic flash • Beam width

• Background illuminator • Microscope magnification: higher the magnification, more the
light needed. Thus, for taking picture at 40X, the photographer
• Lens illuminator must either increase the flash power or open the aperture
diaphragm further.
Digital Photography
Illumination
Digital photography is today replacing the traditional film-based
slit lamp photography. Newer digital slit lamps have in-built camera A variety of illumination methods are available with photo slit
so that there is no need for a separate camera attachment. Digital lamps. Light originating from this instrument may primarily be
Single-Lens Reflex (SLR) cameras are rapidly replacing the 35mm classified as:
film cameras in slit lamp photography. They possess several
features such as excellent optics for optimal visualization of ocular • Diffuse
structures, along with digital cameras which provide high quality
easy-to-capture digital images. • Direct

Digital cameras use Charge-Coupled Devices (CCDs) to detect • Indirect
light. CCDs consist of a grid of sensors. Colored filters placed on
Each of the above illumination may be used alone or in combination.
We discuss them one by one.

Dr Shroff ’s Charity Eye Hospital, Diffuse Illumination: This can be obtained by placing a diffuser
Kedarnath Road, Daryaganj, New Delhi lens over the source of light. The diffuser helps to produce an

www.dosonline.org 35

Figure 1: Diffuse illumination showing normal Figure 2: Direct illumination - Fine slit beam
anterior segment structures demonstrating localized corneal thinning in a case of PUK

artificial source of diffuse illumination. Resultant light is of low
contrast and without shadows. This type of photograph is suitable
for showing/ documenting the overall details of the eye (Figure 1).

Direct Illumination: This is obtained by removing the diffuser
from light source. The resultant light is bright and sharply defined.
This sharply focused light is used to directly illuminate the object
of interest. If the lesion is opaque or crystalline, direct illumination
delineates the area of interest better than indirect illumination.
The internal aperture can be adjusted to vary the size and shape of
the beam.

• Narrow beam/ Fine slit beam: A very thin slit of light can be Figure 3: Broad beam showing the extent
produced to illuminate an optical section of the eye. Such a of the lesion shown in figure 2
narrow beam of light is used commonly to localize and
photograph changes in various layers of cornea. A narrow
beam is obtained by removing the diffuser filter from the
main light and reducing the beam width to a fine slit. The
beam angle may be kept at 60 degrees. (Figure 2)

• Broad beam: A wide, broad beam is used to capture the whole
extent of the lesion. (Figure 3)

• Tangential beam: Here, the source of light is placed on one components are placed at equal and opposite angles to the

side while still aiming at the structure of interest. This corneal surface and the reflection localized, the joystick is

technique helps to highlight surface details and texture and manipulated so that the endothelial cells can be focused.

thus is commonly used to photograph the iris and it’s Increase the magnification to the maximum in order to capture

abnormalities. (Figure 4) the photographs. It is difficult to photograph the endothelial

• Pinpoint Beam (Conical section): This type of illumination is layer with the photo slit lamp. Instead, a specular microscope
used to capture photographs of anterior chamber flare and with photographic ability may be used.

cells. Indirect Illumination: Transparent, refractile ocular structures are

• Specular Reflection: This type of illumination is used to better visualized and photographed with this technique. For this,
photograph corneal endothelial layer. For this, the slit lamp a beam of light is focused adjacent to the structure of interest and
microscope and illumination arms are placed 60 degrees apart. not directly at it.

This can be achieved by placing the microscope and the • Proximal: In order to highlight the structure, light is placed

illuminator 30 degrees off the axis of fixation. Once the two adjacent to the object of interest and not at it. (Figure 5)

36 DOS Times - Vol. 15, No. 2, August 2009

Figure 4: Tangential beam showing strand of Figure 6: Retro-illumination from the retina
vitreous blocking the AGV valve highlighting Lattice Corneal Dystrophy

illumination uses light reflected from patient’s retina to
highlight lesion in the lens or cornea.

• Retro-illumination from Iris: This is created by making a
moderately thin slit beam and directing the beam to the
iris at an angle of 45 degrees, while keeping the plane of
focus on the cornea. The reflected beam from the iris
helps to enhance corneal irregularities that may otherwise
be missed.

Figure 5: Indirect Illumination (Proximal) showing Figure (7a, b): Anterior segment
subluxated lens with visible zonules (Method: Diffuse illumination) showing shallow

• Sclerotic Scatter: Light is directed at the limbus on the sclera AC and Descemet's membrane folds
rather than at the cornea, in order to highlight subtle changes
in the cornea. 37

• Iris Trans-illumination: This requires an undilated pupil. Iris
trans-illumination is obtained by making an axial light beam
shine into the small pupil such that light is reflected off the
retina. The beam aperture must either match pupil size or be
smaller than it to avoid reflections from the iris. This may be
used to display iris thinning in Albinism, demonstrate iris
trans-illumination defects in pseudo-exfoliation.

• Retro-illumination: When a source of light is placed behind
the object of interest, it is seen as a silhouette. This type of

www.dosonline.org

Figure (8a, b): Conjunctiva (Method: Diffuse illumination)
showing acquired conjunctival melanosis

Figure (11a, b): Cornea (Method: Direct
illumination) showing pigments at the back of

endothelium in a patient with uveitis

Figure (9a, b): Cornea (Method: Diffuse
illumination, magnified)

Figure (12a, b): Iris (Method: Tangential
illumination) showing inflammatory membrane at the

pupillary margin and normal iris architecture

Figure (10a, b): Cornea (Method: direct illumination)
showing Fleischer Ring in a case of keratoconus

• Retro-illumination from the retina: Dilated pupil is Figure (13a, b): Lens (Method: Direct
needed. The position for the light and camera should be illumination) showing pseudo-exfoliation
close to axial. The observer then looks for a bright red-
reflex which appears due to light reflected from the material on anterior lens capsule
patient’s retina and glows from behind the lens. The
retro-illumination effect may further be enhanced by • The patient should be told that they can blink normally, unless
orienting the patient’s eye such that the reflex is brightest. specifically asked not to.
This technique can be used to highlight abnormalities of
the cornea or the lens. (Figure 6) Technique of Photography: Photographic Guidelines

Patient Instructions Anterior Segment: Anterior segment photographs are taken under
diffuse illumination. Here, magnification is kept at 10x. The beam
• Prior to slit lamp photography, the patient should be explained width is full open and the diffuser is on. The angle between the
the procedure. viewing beam and the illumination beam (beam angle) is kept at
45 degrees. Uniform illumination is obtained with the diffusion
• It is important to seat the patient comfortably. Properly lens. ( Figure 7a,b)
position the patient’s head and chin in the chin rest, with the
forehead touching the forehead band.

38 DOS Times - Vol. 15, No. 2, August 2009

Figure (14a, b): Lens (Method: Retro-illumination) Figure (16a, b): Vitreous (Method: Direct illumination)
showing lens coloboma showing synchysis scintillans

Figure (15a, b): Anterior chamber angle Figure (17a, b): Fluorescent stain Photography
(Method: using goniolens) showing normal (Diffuse illumination; under cobalt blue filter) showing

angle structures on the right RGP contact lens fitting on the right

Conjunctiva: Photographs are taken under diffuse illumination. Diffuser is kept off (Figure 13a, b).
Magnification is usually kept at 16x. Beam width is kept full open
and the diffuser is on. The beam angle is kept at 45 degrees. The • Retro-Illumination: For this technique of photography, full
flash power is kept at 0 or at 1. (Figure 8a,b) dilatation of pupil is needed. Slit light is projected at the edge
of the dilated pupil, coaxially over the microscope. The
Cornea: Slit lamp photographs may be taken under diffuse or reflected light from the fundus should be very bright. Beam
direct illumination. angle is 0-15 degrees. Beam width is kept at 12-15mm.
Magnification is kept at 16x or 25x (Figure 14a,b).
• Diffuse Illumination: Magnification is kept at 10x or 16x. Beam
width is kept full open. The diffuser is kept on. Beam angle is Anterior Chamber Angle Photography: The goniolens is placed on
kept at 45 degrees (Figure 9a,b). the eye after topical anesthesia. The angle structures are then
focused. The illumination angle and the position of the goniolens
• Direct Illumination: Here, a thin slit of light is focused on the are adjusted so as to keep unwanted reflections out of field using
cornea. Magnification is kept at 16x and beam width is kept 3- the tilt function of slit illumination. Magnification is usually kept at
4mm. The diffuser is off. The beam angle is 45 degrees. 16X. Size of the beam is kept small, to avoid light impinging the
Illumination intensity should be controlled in proportion to pupil. Beam angle is kept at 30-45 degrees. Diffuser is kept off
the slit width ( Figure 10a, b and Figure 11a, b). (Figure 15a, b).

Iris: Iris details can be well focused and photographs taken under Vitreous: Pupil dilatation is needed. The vitreous is focused by the
tangential illumination. Here, the structure of interest is focused technique of direct illumination. Thin slit of light is projected
and illuminated from the side, being careful to keep corneal directly in front of the dilated pupil. Magnification is kept at 25x.
reflection out of field. Here beam angle is kept at 60-70 degrees. Beam width is kept at 10-15mm. Beam angle is kept at 30-50
Magnification may be kept at 16x. The beam width is 12-15mm. degrees (Figure 16a, b).
Both diffuser and background illumination are off (Figure 12a,b).
Fluorescein Stain Photography: Sterile fluorescein strip is used for
Lens: Photographs may be taken under direct illumination or retro- staining and photographs are taken under cobalt blue filter. Beam
illumination. angle is kept at 45-50 degrees, beam width is kept wide open and
the magnification is kept at 16x. The diffuser is kept on (Figure
• Direct Illuminaton: Beam angle is kept at 40-50 degrees. 17a, b).
Magnification is kept at 16x. Beam width is kept at 3-5mm.

www.dosonline.org 39

Slit Lamp Photography Using a Slit Lamp and Separate 2. Singh D. Slit lamp photography of the eye. Indian Journal of
Digital Camera Ophthalmology 1976; 24(3): 33-35

Fogla and Rao3described the use of a digital camera ( Nikon Coolpix 3. Fogla R, Rao SK. Ophthalmic photography using a digital camera.
995, Nikon Corporation, Tokyo, Japan) for anterior segment Indian Journal of Ophthalmology 2003; 51(3): 269-272

photography using slit lamp biomicroscope. This camera gives an 4. Kohnen S. Light-induced damage of the retina through slit-lamp

image resolution of 2048 X 1536 pixels along with 4 X zoom facility photography. Graefe’s Arch Clin Expt Ophthalmol 2000;238: 956-
and also allows autofocus control. 959

For slit lamp photography, the camera is attached to the eyepiece 5. West SK, Rosenthal F, Newland HS, Taylor HR. Use of photographic
of slit lamp biomicroscope. By connecting the camera to the techniques to grade nuclear cataracts. Invest Ophthalmol Vis Sci
eyepiece lens, one can capture what is exactly visualized. The camera 1988; 29(1): 73-77

needs to be supported with one hand during photography. The 6. Camparini M, Macaluso C, Reggiani L, Maraini G. Retroillumination

diameter of the camera lens and slit lamp biomicroscope is versus reflected-light images in the photographic assessment of
identical. The subject can be viewed on the LCD monitor. posterior capsule opacification. Invest Ophthal Vis Sci 2000; 41:
Photographs can be taken using diffuse illumination, direct 3074-3079

illumination and retro-illumination. The camera can also be used 7. Bourne WM. Examination and photography of donor corneal

to capture images of the angle using Goldmann 3 mirror. Using endothelium. Arch Ophthalmol 1976;94: 1799-1800

the camera as an attachment to a slit lamp biomicroscope, good 8. Alward WLM, Munden PM, Verdick RE, et al. Use of infrared
quality photographs can be obtained with a little experience. videography to detect and record iris transillumination defects. Arch

References Ophthalmol 1990; 108(5): 748-750

1. Smolin G, Foster CF, Azar DT, et al. Evaluation and examination 9. Mukerji N, Vajpayee RB, Sharma N. Technique of area measurement
techniques. In Smolin and Thoft’s The Cornea: scientific foundations of epithelial defects. Cornea 2003; 22(6): 549-551

and clinical practice; 2005:156-159

First Author
Nazneen Nazm MS, DNB

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40 DOS Times - Vol. 15, No. 2, August 2009

Normal MR Anatomy of the Orbits Miscellaneous

Seema Sud DNB

MRI, is a non invasive technique that has remarkable Extra ocular extension of intraocular tumours and optic nerve
sensitivity in differentiating various normal and abnormal involvement is best diagnosed with contrast enhancement.
soft tissues.
Anatomy
With the exception of foreign bodies, detection of small calcification
(retinoblastoma), drusen and osseous lesions, it is the investigation The bony orbit consists of a roof, floor, medial and lateral wall,
of choice for evaluation of neuro-ophthalmologic disorders. base and an apex. The optic canal and optic foramen establish a
communication between the orbit and the middle cranial fossa
Sequences (Figure 1).

High quality orbital images can be obtained at field strengths The superior orbital fissure is just lateral and inferior to the optic
ranging from 1.0 to 3.0 tesla. The higher the strength of magnet, canal. The optic strut, formed by the inferior root of the lesser
the higher the resolution. wing of the spheroid, separates it from the optic canal. The superior
orbital fissure communicates with the middle cranial fossa and
Spin echo pulse sequence is essentially used for imaging the orbit. transmits the occulomotor, trochlear and abducens nerves and
Other sequences used are inversion recovery (IR), short tau the superior ophthalmic vein.
inversion recovery (STIR) and gradient echo(for identifying blood
products). The annulus of Zinn, gives origin to the superior, inferior, lateral
and medial rectus muscles and is attached to the orbital wall
The STIR sequence provides very high contrast image but poor surrounding the orbital opening of the optic canal (Figure 2). It
spatial resolution. It is used as an additional pulse sequence to extends around the inferior aspect of the superior orbital fissure.
image inflammatory and metastatic disease. Gadolinium based Along the posterior aspect of the orbit, the inferior and lateral
contrast is commonly used in evaluating orbital lesions. Post walls of the orbit are separated by the inferior orbital fissure. The
contrast T1W images with fat suppression in the axial, sagittal and maxillary nerve, infra-orbital vessels, zygomatic nerve and few
coronal planes are extremely informative in routine MRI twigs from the petrygopalative ganglion pass through the fissure.
examination of the orbit. In our institution we perform scans of The inferior ophthalmic vein also traverses the inferior orbital
the orbit using the head coil. Sequences with short echo time (TE), fissure to enter the cavernous sinus.
short repetition time (TR), 4 to 5mm slice thickness with 1 to 1.5
mm spacing are used. The images are obtained in the axial, sagittal
and coronal planes with and without fat saturation. Contrast is
used to differentiate tumors from subretinal fluid and to distinguish
choroidal melanomas from choroidal haemangiomas.

Figure 2: The common tendon of Zinn is seen
as areas T1W coronal image with fat saturation
of hypointensity between the rectus muscles (arrow)

Figure 1: Normal MR imaging anatomy. nasal cavities Figure 3: T2 W image showing intraconal(I)
(N); ethmoid air cells (E); sphenoid sinus (S); medial and extra conal (E) fat

palpaberal ligament(MPL),nasal bone(NB),lacrimal sac 43
(LS), frontal process of maxilla (FPM),optic foramen (OF)

Department of MRI
Sir Ganga Ram Hospital, New Delhi

www.dosonline.org

Figure 4: Post contrast coronal fat suppressed image of the Figure 6: fat suppressed T2W coronal image
orbit showing the normal superior oblique muscle (arrow) showing the optic nerve (arrow head) and the
and the levator palpabrae superioris muscle(curved arrow)
CSF sleeve (straight arrow)

Figure 5: T2W fat suppressed axial image at the level Figure 7: T2 W coronal image showing 3rd, 4th and 6th
of the orbits showing the optic nerve cranial nerve at the level of cavernous sinus (arrow)

(straight arrow), medial rectus(curved arrow) Figure 8: T1W axial image without fat suppression
and the lateral rectus muscle (arrow) showing the superior opthalmic vein(arrow)

The orbit is divided into the extra periosteal, sub-periosteal, Figure 9: Coronal T2W image without fat suppression
extraconal and intraconal spaces (Figure 3). showing the normal lacrimal gland(straight arrow)
And the superior, lateral, inferior and medial rectus
The four rectii muscles and their intermuscular septa separate the muscles (black arrows)
intraconal space from the other spaces(Figure 4,5). The DOS Times - Vol. 15, No. 2, August 2009
subperiosteal and tenson’s space are potential spaces. Infections
can spread into the subperiosteal spare and intraocular tumors
like uveal melanomas and retinoblastoma may spread into the
Tenon’s space.

The optic nerve connects the retina with the brain . It extends for
approximately 3.5 to 5 cm ,between the posterior globe and the
optic chiasm (Figure 6). In the orbit the optic nerve is seen
intraconally and it extends through the optic canal to enter the
middle cranial fossa, ending in the optic chiasm. The
intracanalicular part of the nerve measures approximately 4-9mm.
It enters the optic canal superior to the ophthalmic artery.

The oculomotor, after emerging from the midbrain, just medial
to the cerebral peduncle. It divides into the superior and inferior
divisions and enters the superior orbital fissure to lie within the
muscle cone of the orbit.

The trochlear nerve, arises from the dorsal aspect of the central
nervous system. It passes from the brainstem to the lateral
cavernous sinus and then traverses the superior oblique fissure
and enters the orbit extraconally to supply the superior oblique
muscle (Figure 7).

44

Figure (10a, b): T2W axial image showing the lens
(block arrow) which appears hypointense in signal as compared to the vitreous (V) and anterior
chamber (A). TIRM axial image showing the intermediate signal of the lens capsule(black arrow) and

the hypointense nucleus of the lens (n)

The abducens nerve originates at the pontomedullary junction. It The lens, measures 4-5mm in thickness. On MRI the central
also traverses the cavernous sinus and enters the orbit intraconally nucleus can be differentiated from the cortex. The lens capsule
through the superior orbital fissure. It supplies the lateral rectus appears hyperintense relative to its nucleus on TIRM images and
muscle. hypointense relative to the vitreous on T2W images, due to relative
back of water content (Figure 10a, b). The iris is a diaphragm
The ophthalmic artery is the chief artery of the orbit arising from separating the anterior and posterior chambers. The suspensory
the supraclinoid Internal carotid artery. It courses through the ligament connects the ciliary body to the lens and appears
optic canal, below the optic nerve and in the orbit divides into the hypointense in signal on T2W images. The three layers of the
supratrochlear and dorsal nasal arteries. globe namely the retina, uveal tract and the sclera cannot be
separately defined on MRI. and are seen as a hyointense ring on
The main draining veins of the orbit are the superior and inferior T2W MR images and intermediate signal on T1W fat saturated
ophthalmic veins. In the orbit the superior ophthalmic vein is seen images. The anterior and posterior chambers are filled with fluid,
lying inferior to the superior rectus muscle and above the optic hence they appear hyperintense in signal on T2W and hypointense
nerve. It measures approximately 2-3.5 mm in diameter. It courses on T1W images.
through the superior orbital fissure to drain into the cavernous
sinus (Figure 8). The inferior ophthalmic vein arises as a plexus on Conclusion
the floor of the orbit and drains into the cavernous sinus.
With the advent of higher strength magnets and high resolution
The lacrimal gland is seen lying in the postseptal extraconal space
along the superior lateral aspect of the orbit (Figure 9).

Author
Seema Sud DNB

www.dosonline.org 45

Diagnosis and Management of Miscellaneous
Conjunctival Melanoma

Ramendra Bakshi MS FRCS

Conjunctival melanoma accounts for 2% to 3% of all ocular Pathogenesis
tumors in the Caucasian population.1 In Africans and Asians,
conjunctival melanoma is rarely seen. This malignancy normally Conjunctival melanoma is a relatively rare ocular malignancy with
occurs at approximately the age of 60 years and only rarely before substantial associated morbidity. Similar to cutaneous melanomas,
the age of 40 (10%).2 Currently, local excision combined with conjunctival melanomas are malignant tumors of proliferating
cryotherapy and more recently, adjuvant topical mitomycin C is melanocytes that are derived from the neural crest.3 Conjunctival
widely accepted as a primary treatment. Little evidence exists to melanoma arises de novo without any preceding lesion in about
support any benefit from exenteration, which was the treatment 12% of patients.3 The reported incidence of development of
of choice a few decades ago.1 The mortality rate is 12% to 20% at 5 conjunctival melanoma from PAM varies from 9-57.4% and that
years and upto 30% at 10 years. Conjunctival melanomas are known from pre-existing naevi is 4-39.1%.5
to spread through the lymphatic system, although distant
metastases are also found without regional lymph node metastasis.2 When thickening of the conjunctiva is present in an area of PAM,
the development of invasive malignant melanoma is a primary
Clinical features concern, although an inflammatory reaction to the PAM also may
produce a similar clinical picture.3 While PAM without atypia does
This uncommon but potentially lethal lesion can arise in previously not progress to a malignant melanoma, almost 50% of cases of
unblemished and unpigmented regions or from a preexisting PAM with atypia result in an invasive malignant melanoma.1-4
nevus, but most cases arise from the flat spreading pigmentation Recently, Keijser S et al have described exfoliative cytology as a
of primary acquired melanosis (PAM) with atypia and affect the sensitive and non invasive technique in diagnosing pigmented
limbal conjunctiva3,4 (Figure 1). Clinically, PAM appears as conjunctival lesions.6
superficial pigmentation of the conjunctiva, and invasive malignant
melanoma develops in approximately half of patients with PAM Histopathology
with atypia1-4. Primary acquired melanosis ‘with atypia’ also be
termed ‘conjunctival melanocytic intraepithelial neoplasia’ (C-MIN) The histopathologic diagnosis of malignant melanoma of the
with atypia, with the more severe changes regarded as melanoma conjunctiva requires recognition of atypical melanocytes. The
in situ.5 Signs of malignant transformation are sudden increase in diagnosis of invasive malignant melanoma is established with
size, absence of intralesional cysts, increase in pigmentation and invasion of the underlying substantia propria of the conjunctiva
rarely mucoid or bloody discharge from the lesion. by atypical tumor cells (Figure 2).

Figure 1: Flat pigmented lesion of Figure 2: H & E stain. Cohesive spindle
Primary acquired melanosis (PAM) in cells and loosely arranged epithelioid
cells along with invasion in the
superior bulbar conjunctiva epithelium by atypical melanocytes,
scattered vascular channels
Cornea Services and focal collection of lymphocytes
Venu Eye Institute & Research Centre,
1/31, Sheikh Sarai, Phase-2, New Delhi 47

www.dosonline.org

Metastasis conjunctival lesion should undergo an excision biopsy, not only to
rule out histopathological evidence of melanoma, but also to
Clinical metastases usually occur first to the lymph nodes in prevent conversion into malignancy in future. These patients with
approximately 45% to 60% of patients with regional metastases. non-limbal malignant lesions are high risk candidates and may
Classically, the medial tumors are believed to spread to the require adjuvant treatment modalities. They also need to be
submandibular area and the lateral lesions to the preauricular reviewed at short intervals during the first few years after treatment.
region. Eventually, systemic dissemination to many body organs
may occur, although this often arises without prior clinical evidence References
of regional lymph node involvement. Tissues most commonly
affected by metastases include the lung, brain, liver, skin, bone, 1. Seppo Tuomaala, Sebastian Eskelin, Ahti Tarkkanen; Population-
and the gastrointestinal tract.2 Based Assessment of Clinical Characteristics Predicting Outcome
of Conjunctival Melanoma in Whites. Invest Ophthal Vis Sci
Management 2002;43:3399-3408

The standard treatment for primary conjunctival melanoma is 2. Guy S. Missotten, Sander Keijser, Rob J. W. De Keizer, et al.
excision with adjuvant therapy. A combination of surgical excision Conjunctival Melanoma in The Netherlands:A Nationwide Study.
with cryotherapy to the underside of the adjacent conjunctival Invest Ophthal Vis Sci. 2005;46:75-82
margins, localized alcohol corneal epitheliectomy in the areas of
corneal pigmentation, and intra or postoperative topical mitomycin 3. Seymour Brownstein. Malignant Melanoma of the Conjunctiva.
C (MMC) have been recommended for the management of Cancer Control. 2004;11:310-316
extensive cases with invasive disease.3,8,9 A complete excision (“No
touch technique”) with a 4 mm healthy margin, along with 4. Shields CL, Shields JA, Gunduz K, et al. Conjunctival Melanoma:
cryotherapy (double freeze-thaw) and intra-operative MMC risk factors for recurrence, exenteration, metastasis, and death in
would be an ideal method of removal. Amniotic membrane with 150 consecutive patients. Arch Ophthalmol 2000;118:1497-507
fibrin glue can be used to cover the large conjunctival defect created
after excision. The advantages of using the amniotic membrane 5. Bertil Damato, Sarah E Coupland. Conjunctival melanoma and
are that, in addition to the rapid wound healing effect, recurrence melanosis: a reappraisal of terminology, classification and staging.
could be detected readily as the membrane is transparent.5 Iodine- Clinical and Experimental Ophthalmology 2008; 36: 786–795
125 brachytherapy can be used as an alternative to wide excision
or exenteration of these tumors.7,10 It has been proposed that 6. J Choi, M Kim, H S Park et al. Clinical Follow-up of Conjunctival
excision of the sentinel lymph nodes allows for better staging and Malignant Melanoma. Korean J Ophthalmol 2005;19:91-95
possibly early detection of micrometastases to the regional lymph
nodes.11 7. Keijser S, van Luijk CM, Missotten GS, Veselic-Charvat M, Predictive
value of exfoliative cytology in pigmented conjunctival lesions.
Prognostic Features Acta Ophthalmol Scand. 2006;84:188-91.

Nonlimbal tumor location, thickness of the primary tumor>2mm 8. Zografos S, Uffer S, Bercher L et al. Combined surgery,
and subsequent local recurrences are statistically and clinically the cryocoagulation and radiotherapy for treatment of melanoma of
most significant independent indicators of worse prognosis.1-4 the conjunctiva. Klin Monatsbl Augenheilkd.1994;204:385-90.
Patients with multifocal tumors, orbital invasion, recurrent disease
and involvement of the caruncle, plica semilunaris, eyelid margins 9. Chalasani R, Giblin M, Conway RM. Role of topical chemotherapy
and palpebral and forniceal conjunctiva have a worse prognosis for primary acquired melanosis and malignant melanoma of the
for survival.3 Hence, nonlimbal conjunctival pigmented lesions conjunctiva and cornea: review of evidence and recommendations
should be removed early to establish a diagnosis, before they for treatment. Clin Experiment Ophthalmol. 2006;34: 708-14
grow to be thick. Survival is improved by early diagnosis of regional
metastases.1 10. Groh MJ, Holbach LM, Kuhnel B et al. Management of conjunctival
malignant melanoma associated with PAM using 0.02% mitomycin
C eyedrops. Ophthalmologe. 2003;100:708-12

11. Stannard CE, Sealy GR, Hering ER, et al. Malignant melanoma of
the eyelid and palpebral conjunctiva treated with iodine-125
brachytherapy. Ophthalmology. 2000; 107:951-8

Conclusion

Efficient diagnosis and meticulous planning of the surgery should
be carried out for the primary tumor. Any suspicious pigmented

Author
Ramendra Bakshi MS, FRCS

48 DOS Times - Vol. 15, No. 2, August 2009

Internet Ophthalmology Miscellaneous
and the sites you probably missed

Kapil Midha MS

Welcome Back, We were always taught, “Never, ever , forget Esp, when you wish to test the vision of preschoolers. It has pictures,
to put an ‘h’ after ‘Op’ when you spell Ophthalmology.” and it has single letters, and C and E and I find it very useful
How right they were! indeed.

However, if you are an Ophthalmology Book Lover, you might So would you, I am sure, and here is, where to get it. http://
wish to forget this “h” for a while, coz other wise u will miss this www.vutest.com/eyelab/apec.htm
blog, www.opthalmology.blogspot.com. And if you love eye books,
u would rather unmiss it. So take my word and forget the ‘h’ while What did the right eye say to the left eye. {will tell you later!}
u type this address.
An excellent tutorial on “Phoropter Refraction” awaits you in this
Mostly , one can easily access the above blog, as long as u are not sidelane of the ophthalmology web.
too much obsessed with the ‘h’ after ‘op’, but some times it does’nt
let you enter. “open only to members” Right here: www.medrounds.org/refract/menu.htm (Figure 1)

There is google trick to get past this blockage. Stay at medround.org a trifle longer and browse. It has some
interesting and useful stuff. Click on this link: http://
Use Google’s cache to take a peek even when the originating site’s w w w. m e d rou n d s . o rg / o p ht h a l m ol o g y - b o a rd - re v i e w / e xa m /
being blocked, with cache:example.co quiz.php (Figure 2)

Voila! Excellent questions to test yourself and others! Interesting too!
Not just dry knowledge.
If I were to tell you, that you can download a vision testing
programme on your computer, absolutely free. Similarly absorbing is the “Essential Optics Review” right here on
this site.
Well, it is a demo version. But it works.
{Music loved by Ophthalmologists? i-tunes of course!}

Optical Illusions are? Well, they are illusions, interesting to see a
few times and then they become repetitive and yawn producing.

However, this one should wake you up, or at least keep you awake.
http://www.sandlotscience.com/Guided_Tours/Tour1/Tour_4.htm

Wide awake , are you? Good.

Then you can take this test below-at the same site (Figure 3).

Figure 1 Figure 2

Midha Eye Centre 51
New Railway Road, Gurgaon, (Haryana)

[email protected]

www.dosonline.org

Figure 3 excellent quiz and see the brilliant presentations.

I did’nt know. Sorry! Eye didn’t know.

http://scrabble66.typepad.com/eyedidntknow/ Click this link and
enter the site for eye infotainement. Light, refreshing, like a cup of
Darjeeling tea. Interesting updates on the art and science of
ophthalmology and some general interesting and relevant
information, all presented in a lucid, light and highly readable
style (Figure 5).

Life beyond Phaco and Lasik.

For Hard Core Ophthalmologists, who believe that it is possible.
As a tribute to them-a couple of decent sites on the net.

www.eyepathologist.com

An Ode to the spirit of scientific curiosity. Register on this site and
educate yourself, all the while admiring the excellent graphics. You
should not need any book on eye path, once you reach this place
(Figure 6).

And

http://library.med.utah.edu/NOVEL/ (Figure 7)

Figure 4 Figure 5

Frivolous stuff and wasteful. So what. Remember, “All work and Figure 6
no play—————.” DOS Times - Vol. 15, No. 2, August 2009
Back to work.
Two good made in India websites , in the alleys and bylanes of the
wild, wild, web.
http://www.eophtha.com/index.html
Previously, a blog site and now settled down at the above address.
Very good place to visit really. Lots of good and real links and
interesting info-education with videos and trivia.
And the other:http:// www.ekalavya.org (Figure 4)
This one is from the famous Shankar Nethralaya and the visit to
this site is quite rewarding, you can register and participate in the

52

Come here to this place above, if neuro-ophthalmology fascinates
you. Meet the who’s who of neu-oph. Pictures and videos and
lectures and more. Highly educational, mind you. Not for the feeble
hearted.

That’s all folks, in this edition. After all this educational, you might
wish to unwind and go to some other, light hearted places on the
web. However, I am not allowed to talk about anything other than
ophthalmology here. So best of luck and happy browsing.

{by the way, right eye said to the left eye, “ there is something in
between us , that smells.”}

Will be back with more!

Figure 7

Author
Kapil Midha MS

Obituary 53

Dr.R Diwan passed away during the morning hours of 17th July 2009. Most of us were already
at our place of work and so was her husband and colleague, Dr.A.K. Diwan. Both of these
wonderful souls had decided to devote their energies and time for a group of charitable eye
centres run by Mahavir International.

On that day, Dr. A.K. Diwan received a call while he was at work that his wife was involved in
an accident. He reached the accident site and saw a “Blue Line Bus” and nothing else. He was
then directed to a hospital and then to the mortuary. He stood alone in his hour of grief till
late in the evening. In a city which records the highest density of ophthalmologist anywhere
in the world, it was indeed a very cold send off.

Dr. R. Diwan was a graduate from Lady Hardinge Medical College in 1964. She completed her post graduation with an
M.S. in Ophthalmology from Maulana Azad Medical College in 1968. She worked as a registrar in the same institution
from 1968 to 1971. Dr. Diwan worked as a Medical Officer with NSPB, at Dr. RP Centre, AIIMS from the years 1973 to
1978. She continued with her private practice ever since.

I came in contact with Dr. Diwan during my stay at Mahavir International sponsored eye care units. Dr. Diwan was an
extremely kind and caring person. Her caring attitude towards the patient makes a compelling story. For a paltry sum, Dr
Diwan attended to her work with a dedication which was rare to see. Ever ready to learn, she would never hesitate to
refer, for an opinion. People who run charitable organisation have an attitude of almost disdain to let Dr .Diwan’s simple
request of a regular transport be taken as an irritant. Not to miss a day of work, Dr. Diwan chose to commute by a three
wheeler auto. It cost her life.

She is survived by her husband Dr.A.C. Diwan, an Ophthalmologist and their two daughters. On behalf on the fraternity,
we convey our sincere condolence to Dr.A.C. Diwan and his family.

www.dosonline.org

Prostaglandins & their Analogs Pharmacology

Y.C. Gupta MS

The Prostaglandins belong to a family called the ‘Eicosanoids’, Mode of Action
which are all formed from the Arachidonic acid. The
Prostaglandins are present in almost every body tissue and fluids, Reduction of the IOP starts 2-4 hours after the administration
and since they act locally they are distinct from the true hormones. with peak effect reached within 8-12 hours. Maximum IOP
The early animal and human studies on the topical effects of certain lowering is often achieved in 3-5 weeks time. Except for
Prostaglandins on the eye revealed the inflammatory effects of Unoprostone which brings about an IOP fall of about 18% from
the Prostaglandins with Conjunctival hyperemia and breakdown the baseline, all others reduce the IOP by 20-35%. Wash out time
of the Blood Aqueous barrier. Later studies showed that very is 4-6 weeks.
small amount of Prostaglandins actually lowered the IOP leading
to the development of certain agents in this category, which are Dosage and Administration
known as ‘Hypotensive Lipids’.
Bimatoprost 0.03% OD
The IOP is the highest tissue pressure of any organ in the body. A OD
certain resistance to the flow is necessary to maintain the IOP at a Latanoprost 0.005% OD
level that keeps the globe rigid enough to resist the deformation OD
by the pull of the extraocular muscles. It is well established that Tafluprost 0.0015% BID
there is an increase in the resistance in the conventional outflow
pathways of the most glaucomatous eyes, but it is not yet known Travoprost 0.004%
whether uveoscleral outflow is also affected in the glaucomatous
eyes. As a treatment strategy for Glaucoma, enhancement of Unoprostone 0.12% & o.15%
uveoscleral outflow to reduce IOP is conceptually better than
reduction of aqueous formation. This is because decreased These once a day analogues are recommended for use in the
aqueous production may jeopardize the nutritional safety margin evenings. Unoprostone is used twice a day. The evening dosage
of the avascular tissues of the anterior segment including the regimen takes care of the 8-10AM IOP spikes, since the peak effects
trabecular meshwork. are observed after 12 hours. Over-administration of the analogs
may result into a fall in their efficacy. The major contraindication
The Prostaglandin analogues bring about a fall in the IOP by to the use of these drugs is known hyper-sensitivity to the molecule,
increasing the uveoscleral outflow, after binding and activating the and to be used with utmost care in pregnancy.
FP receptors in the ciliary smooth muscles. There are two
mechanisms by which this fall is brought about; a relaxation of the Individual response may vary and might require a change of the
Ciliary muscles and a bio-chemical change in the spaces between molecule. This is most frequent with Latanoprost.Travoprost has
the muscle bundles. The relaxation being an acute effect and the been observed to bring the highest IOP fall amongst all the analogs
bio-chemical change being a chronic effect. Bimatoprost also in ‘Black Races’.There has been an ongoing discussion regarding
increases trabecular outflow, and thus has been shown to have the differences between Prostaglandin derivatives and
dual mode of action. Prostamides, but recently Prostamide receptors have been
described.
The Prostaglandins have a mixed pharmacological response
because the they have affinity for more than one Prostaglandin The usual ‘Clinical Confusion’ on Concurrent administrations of
receptors. The Prostaglandin or Prostanoid receptors include four prostaglandins with Pilocarpine has been put to rest. It has been
subtypes – EP, FP, IP and TP. The Prostanoid receptors are shown that the two are not ‘Antogonistic’ but an additional IOP
distributed widely in the ocular tissues, which can account for the fall can be achieved, by using the two together.
diverse biological effects of the Prostaglandins on the eyes.
Indications
Commercially five different types of PG analogues are available in
the market, which are Latanoprost, Bimatoprost, Tafluprost, These derivatives, though originally were approved for use in
Travoprost and Unoprostone. The receptor (FP) binding affinity Ocular Hypertension and POAG. Of late many studies have shown
of these drugs is as follows: their effectiveness in Primary Angle-closure Glaucoma. IOP
lowering was more profound in PACG after an Iridectomy. In a
• Travoprost > Bimatoprost > Latanoprost > Tafluprost > study with Latanoprost it was observed that the response was
Unoprostone. more in cases of Juvenile-onset Open-angle Glaucoma than in
Pediatric Glaucoma. In NTG, the trabecular outflow is not
EP receptor activity is as follows: necessarily reduced as in case of POAG, and the extent of IOP
reduction is limited through the trabecular pathway by the
• Bimatoprost > Travoprost > Latanoprost. episcleral venous pressure (8-10mmHg) the prostaglandins do
provide a profound fall from the baseline.
Bk2/98, Shalimar Bagh,
New Delhi

www.dosonline.org 55

Side Effects drops are concurrently used as in Post-operative states and Uveitis.
These derivatives should ideally be avoided in cases of Acute
The Intraocular inflammatory effects, aqueous cell and flare and Uveitis.
miosis which results from the administration of large doses of
Prostaglandins, were not seen in animal or human eyes in the Cold chain has to be maintained in case of Latanoprost. It has
doses associated with the ocular hypotensive effect. The absorptive been suggested that unopened bottles of Latanoprost be stored
transport systems of the ciliary processes appear to prevent under refrigeration and once opened it maybe stored at room
topically applied Prostaglandins and other Eicosanoids from temperature upto 25°C for up to 6 weeks. The other agents are
causing Retinal toxicity. recommended to be stored at room temperature (15°C-25°C for
Bimatoprost and 2°C-25°C for Travoprost). These drugs have a
Conjunctival hyperemia, burning, stinging, foreign body sensation good shelf life and in long-term use are also cost effective. Various
and itching. Hyperemia has been observed to be highest with: combinations of PG analogs with Beta-blockers are also available
Bimatoprost > Travoprost > Latanoprost. making patients more compliant.

Increased pigmentation of periocular skin and eyelash changes The PG Derivatives have been approved as first line drugs; are
(increased length, thickness, pigmentation and number of lashes) being extensively used with a consistent and uniform IOP control,
are also found to be highest with Bimatoprost. Increased iris with excellent tolerance.The PG Analogues have been proved to
pigmentation is seen in light coloured irides. This effect is least been an exciting new therapeutic approach through enhancing
with Unoprostone and Travoprost. CME in aphakics / pseudo Uveoscleral outflow though the exact mechanism mediating the
phakics has been reported especially with Bimatoprost. Unusual increased Uveoscleral outflow is still under investigation. Possible
reported side effects are reactivation of herpes keratitis and anterior mechanisms proposed are: 1.Relaxation of the ciliary muscle, 2.
uveitis. All these molecules are free from systemic side effects. Remodelling of the extracellular connective tissue matrix, and 3.
CME can be prevented by concurrent use of topical/ systemic Vasodilatation causing tissue expansion by a kind of erectile
Diclofenac. Precipitation occurs when Thiomersal-containing eye response. Clarification of these mechanisms will help develop new
drops are used immediately, after the PG analogs. An interval of drugs to increase the Uveoscleral Outflow.
at least five minutes should be observed. Clinical experiences with
these drugs have shown that the efficacy falls when intensive steroid

Author
Y.C. Gupta MS

Online Journal Available

Many New Journals at DOS Library

Dear DOS Members,

We are pleased to announce that DOS has subscribed to online access of the following 22 journals. These journals can be accessed at the DOS
library situated at Room No. 2225, 2nd Floor, New Building, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi-60. The timings are from
10.00 A.M. to 5.00 P.M. on week days and 10.00 A.M. - 2.00 P.M. on Saturday. The Library will remain closed on Gazetted Holidays.
Members are requested to utilise the available facilities i.e. Computer with Video Editing & Conversion facility VHS to VCD, Journals
Viewing, Books and Journals etc. The DOS members can get the full text articles of the current issues as well as many back issues of these
subscribed journals.

E-mail ID is: [email protected]

• Acta Ophthalmologica • Acta Ophthalmologica Scandinavica
• Acta Ophthalmologica Scandinavica Supplement • Archives of Ophthalmology
• British Journal of Ophthalmology • Clinical & Experimental Ophthalmology
• Contemporary Ophthalmology • Cornea
• Current Opinion in Ophthalmology • Evidence-Based Eye Care
• Evidence-Based Ophthalmology • International Ophthalmology Clinics
• Journal of Glaucoma • Journal of Neuro-Ophthalmology
• Journal of Pediatric Ophthalmology & Strabismus • Journal of Refractive Surgery
• Ophthalmic Surgery & Lasers • Ophthalmic Surgery, Lasers & Imaging
• Ophthalmology Management • Retina
• RETINAL Cases & Brief Reports • Techniques in Ophthalmology

56 DOS Times - Vol. 15, No. 2, August 2009

Refractive Surgery in Refractive Accommodative Clinical Meeting: Case
Esotropia Cases in Adults

The classic treatment for refractive accommodative esotropia and patient was counseled that there may be undercorrections
(RAET) is to correct the hyperopic error , but the esodeviation and maybe glasses for near activities or enhancement may be
appears when the optical correction is removed. We present two required. Thus management by refractive surgery (LASIK) was
such cases where refractive surgery was chosen as the modality chosen as the modality of treatment. Topography was done for
for permanent hyperopic error correction. both eyes which was normal (Figure 2,3). Multiple point
pachymetry (Figure 4,5 )was done and was 540μ at center for both
Case 1 eyes. Standard uneventful LASIK surgery was done and full
Cycloplegic refractive error was corrected for the patient. Six weeks
A 25 year old female presented with a desire to get rid of her postoperatively the patient did not have significant residual
glasses which she had been wearing since 5 years of age. There refractive error (Table 1) and was comfortable without glasses.
was associated history of inward deviation of Left Eye since the
age of 2 years. There was no history of amblyopia treatment in
form of patching for her either eye. She had never worn contact
lenses and no surgery was done in either eye.

On Examination her best corrected visual acuity was 6/9 and 6/36
in right and left eye respectively with Dry Refraction of +6.0 D Sph
in both eyes. Cyloplegic refraction was +8.5 D Sph in right eye and
+9.5D Sph/+1.0 D @90 deg Cyl in the left eye. The vision did not
improve beyond 6/36 in her left eye. The Slit Lamp Examination
and Fundus Examination was unremarkable for both eyes. The
Orthoptic evaluation was done which revealed left Esotropia for
distance and near both with and without glasses. The prism bar
cover test (PBCT) without glasses was 45PD BO for distance and
for near. With her glasses her esotropia decreases to 20 PDBO for
distance and for near. The Sensory Evaluation revealed left eye
suppression for distance and near with absence of Stereopsis.

She was diagnosed as a case of Refractive Accomodative Esotropia. Figure 2: Case 1 Preoperative RE Topography
The patient wanted to get rid of squint without glasses for better
acceptance socially and also wanted to be rid of glasses. Option of
refractive surgery for correction of hyperopia and for correction
of RAE was discussed with patient. Informed consent was taken

Figure 1(a): Case 1 Pre-LASIK Figure 3: Preoperative Left Eye Topography
Figure 1(b): Case 1 Post-LASIK
59
Cornea and Strabismus Department
Dr Shroff’s Charity Eye Hospital,
Darya Ganj, New Delhi

www.dosonline.org

Figure 4: Case 1 Right Eye Pachymetry Figure 5: Left Eye Pachymetry

Figure 6: Case 1 right eye Postop topography Figure 7: Left eye postop topography

The post operative orthoptic evaluation revealed orthophoria Sensory Evaluation, fusion was present and she had Stereopsis of
without glasses for distance and near .However there was no 100 sec of arc.
change in her sensory status. (Table3). Postop topography was
repeated after 6 weeks (Figure 6,7). She was also a case of Refractive Accommodative Esotropia. This
patient was also not interested in wearing glasses or contact lenses.
Case 2 Thus refractive surgery was planned and consent taken for the
same. Topography (Figure 8,9) and Pachymetry was done .
Another 21 year female presented with a similar desire to get rid Standard LASIK procedure was done and full Cycloplegic refractive
of glasses which she had been wearing since 3 years of age. She error was corrected. Six months post operatively the patient was
also had history of inward deviation of her eyes since childhood. 6/6 in both eyes without any refractive correction (Table1). She
She had never worn contact lenses and had no history of surgery was orthophoric for distance and for near (Table 2). Her sensory
in either eye. status was essentially the same as preoperatively (Table 3)

On Examination her Dry Refraction was +2.50 D Sph in right eye To summarize, the correction of hyperopic error with LASIK
and +2.75 D sph in the left eye. Her vision improved to 6/6 in both resulted in correction of esodeviation angle which was previously
eyes. Her Cyloplegic refraction was +3.0 D sph in right eye and corrected with glasses. Surgical correction for squint was not
+3.75 D sph/-.50 D @90 deg Cyl in left eye. Her Slit lamp and required. The psychological impact on patients was tremendous
Fundus Examination findings were unremarkable. The Orthoptic (Figure 1a&b).
evaluation revealed right esotropia without glasses and the patient
was orthophoric with glasses. The PBCT was 25 PD BO for distance Discussion
and 30 PD BO for near without glasses The PBCT with glasses was
1-2 PDBO for near and patient was orthophoric for distance. On The classic treatment for refractive accommodative esotropia
(RAET) is the use of glasses or contact lenses to correct the

60 DOS Times - Vol. 15, No. 2, August 2009

Table 1 Pre LASIK Refraction Post LASIK Refraction (6 weeks Post Op)

Case 1 RE +8.5 D Sph -6/9 RE +0.5 DSph/ -1 D @180 cyl -6/6p LE +0.5 D @90 deg
Case 2 LE +9.5D Sph/+1.0 D @90 deg Cyl – 6/36 Cyl – 6/18
RE :+2.50 D Sph-6/6LE : +2.75 D Sph -6/6 Unaided RE : 6/6PLE : 6/6

Table 2: Post LASIK orthoptic evaluation was:

Pre-LASIKPBCT unaided Pre- LASIKPBCTwith glasses Post lasikPBCT

Case 1 45 BO -Distance 45 BO – Near 20 BO -Distance 30 BO -Near Orthophoric - Distanceand Near
Case 2
25 BO -Distance 30 BO – Near Orthophoric – Distance1-2 BO - Near Orthophoric - Distance and Near

Table 3 Pre –LASIK fusion Post LASIK fusion Pre LASIK stereopsis Post – LASIK stereopsis

Case 1 Left suppression D-Left suppressionN – Fusion Absent Absent
Case 2 Present Present 100 sec of arc 100 sec of arc

hyperopic error, but the esodeviation appears when the optical The obvious way to permanently alleviate the excess convergence
correction is removed.1 Some with accommodative esotropia is to eliminate the need for the causative excess accommodation.
develop fusional divergence amplitudes large enough to allow There are studies published on hyperopic lasik for RAET and
gradual reduction and eventual elimination of glasses or contact JairoE. Hoyos et al 3 report 9 patients over 18 years treated with
lenses while maintaining orthophoria or well controlled esophoria hyperopic LASIK achieved orthophoria without optical correction
during accommodation when they reach adulthood but it does and that it was also a safe and effective procedure.
not happen in all cases.2
Thus in the above two adult female cases of RAET we corrected
Glasses are unappealing cosmetically to these patients, in addition the hyperopia with LASIK as they were keen to get rid of glasses.
the esodeviation is present when glasses or contact lenses are Both the cases were uneventful post LASIK, one having a 2 months
removed. Refractive accommodative esotropia may have a follow up and one with a one year follow up. The preoperative
pscychological impact on adult patients when they take off their cycloplegic hyperopic spherical refraction was treated and both of
glasses as their strabismus is very evident. them had minimal residual refractive correction of 0.5 sphere

Figure 8: Case 2 Preoperative Right Eye Topography Figure 9: Case2 Preoperative Left Eye Topography

www.dosonline.org 61

only and no residual esodeviation for both distance and near. The In conclusion further studies on corneal response to treatment of
postoperative topography was stable. high hyperopia and accommodative dysfunction post LASIK on
adult patients with refractive accommodative esotropia needs to
The most important limitation of hyperopic LASIK in patients be studied.
with RAET is the degree of hyperopia. Studies show that that in
high hyperopia, predictability is reduced and there is an increased References
percentage of loss of visual acuity lines.4
1. Parks MM. Management of acquired esotropia. Br. J Ophthalmol
The factor that negatively influences the outcomes of hyperopic 1974; 58:240- 244; discussion, 244- 247.
LASIK is the degree of hyperopia corrected. Better outcomes are
expected when the magnitude of hyperopia is equal to or less than 2. Raab EL. Hypermetropia in accommodative esodeviationb. J Pediatr
+4D. Preoperative keratometry does not seem to significantly ophthalmol Strabismus 1984;21:194-197; discussion by MM. Parks,
influence the postoperative results and postoperative keratometry 197-198
(over 48 D) does not result in significant worsening of visual results
when the attempted correction is less than + 4D. 5 3. Jairo E. Hoyos,MD, Melania cigales, Jairo Hoyos – Chacon,
Hyperopic laser in situ keratomileusis for refractive accommodative
The quality of vision has also been investigated and clinical studies esotropia JCRS 2002; 28: 1522 – 1599.
show that third and higher total and corneal aberrations increase
significantly after hyperopic lasik.6 4. Ditzen K,HuschkaH, Pieger S. Laser in situ keratomileusis for
hyperopia.J Catract Refract Surg 1998; 24: 42- 47
There are no reports of corneal keratectasia consecutive to
hyperopic LASIK and this probably relates to the sparing of the 5. Cobo.Soriano R, Llovet F, Gonzalez- Opez F, et al. Factors that
central cornea by the laser ablation.7 influence outcomes of hyperopic laser in situ keratomileusis. J cataract
Refract Surg 2002; 28(9): 1530- 1538.
The other limitation maybe undercorrection which in a study done
was found to be more frequent than anticipated.8The study stated 6. Llorente L, Barbero S, Merayo J et al. Total and corneal optical
that LASIK enhancement to eliminate esotropia with diplopia was aberrations induced by laser in situ keratomileusis for hyperopia. J
required in 47% patients but with surgical enhancement all patients Refract Surg 2004; 20(3): 203- 216.
were able to discontinue spectacle or contact lens as no residual
tropia was present. 7. LinstromRL, linebarger EJ, Hardten DR, et al. Early results of
hyperopic and astigmatic laser in situ keratomileusis in eyes witgh
secondary hyperopia. Ophthalmology 2000; 107(10): 1858- 1863.

8. Christopher B. Phillips, Thomas C. Prager LASIK for high hyperopia

First Author
Manisha Acharya MS

62 DOS Times - Vol. 15, No. 2, August 2009

Management of Cataract with Corneal Ectasia Clinical Meeting: Case

Monica Gandhi MS, Umang Mathur MS, Suma Ganesh MS

A68 year old retired executive presented in Dec 2008 with 2009. His postoperative vision was 6/9, N6 with +0.75 D sph/- 1.5
progressive diminution of vision in his right eye for the past Dcyl x130, Add +2.75.
1 year. He complained of fluctuation in vision in both eyes. His
major concern was that he could not read the scrolls on television He was comfortable with the quality of his binocular vision. This
and night time driving was becoming strenuous. has remained stable in the 8 months of follow up.

He gave a history of being aware that he had keratoconus since Discussion
the age of 21. He was operated upon for cataract in the left eye 2
years ago wherein acrylic foldable IOL was inserted. He had These two cases represent the management challenge of cataract
perceived improvement in his vision but was not very happy with coexisting with corneal ectasia. The decision process in both was
the quality of vision. He was regular with spectacle use. He had dependent on the facts that there was visually significant cataract
often tried contact lenses but did not find them comfortable. which required surgery. The presence of corneal ectasia
compromised the vision quality due to associated astigmatism.
No family history of keratoconus. Systemically he had type 2 The conventional method of management of astigmatism like
Diabetes Mellitus and Parkinsonism. arcute keratectomy, limbal relaxing incisions, opposite clear corneal
incision or excimer laser keratectomy were not advocated in view
BCVA in the right eye was 6/18 (-1.25 d sph/-4.5 Dcyl x 20, N 12 of the biomechanical properties of the cornea.
with add +2.25 D sph) and in the Pseudophakic left eye 6/12 (-1.5
D cyl x 110, N9 with add + 2.25 D sph) Thus we are left with an option of selective positioning of the
incision site of the phacoemulsification and but this too will not be
Slit lamp examination showed corneal Vogt’s striae in both eyes sufficient to address the magnitude of the astigmatism.
with Fleisher’s ring. Nuclear sclerosis grade 2 in the right eye and
Pseudophakia in the left eye. Fundus examination was
unremarkable.

Topography was done and compared with that done 2 years ago
and it was found to be stable (Figure 1 and Figure 2).

In view of the high astigmatism in the right eye, stable keratoconus,
inability to use contact lenses the management plan devised after
communication with the patient was to do phacoemulsifucation
with Acrysof TORIC IOL implantation. The calculations
were done using the online toric calculator. (http://
www.acrysoftoriccalculator).

Post operatively the BCVA in the RE was 6/9 with -1.5 D cyl x 40
and N6 with add +2.50 Dsph The patient was happier with his
vision and more comfortable in his daily activities. Follow-up after
8 months showed stability in the vision.

Case 2: A 65 year old teacher presented in Jan 2009 with complaints
of decrease in distance and near vision in his left eye for the past
one year. He had undergone routine cataract surgery with acrylic
foldable IOL in 2007 and was not happy with the visual outcome.
On examination his BCVA in the Pseudophakic right eye was 6/12,
N9 (-2.00 DSsph/-3.00 Dcyl x30, Add +3.25) and in the left eye 6/
18, N12 (-1.5 Dsph/-4.00 Dcyl x160, Add +3.25 D sph)

Slit lamp examination showed presence of thinning in the inferior
cornea in both eyes which was confirmed on topography to be
consistent with the diagnosis of pellucid marginal degeneration.

Management plan of phacoemulsification with TORIC IOL
implantation was made for the left eye which was done in Jan

Figure 1: Topography of right eye 2007 and 2009

Dr. Shroff ’s Charity Eye Hospital 63
Darya Ganj, New Delhi

www.dosonline.org

Figure 2: Topography of the left eye 2007 and 2009

Toric IOLs with L shaped haptics have been shown to have better 2. Chang DF. Comparative rotational stability of single-piece openloop

rotational stability and better predictable results in correction of acrylic and plate-haptic silicone toric intraocular lenses.J Cataract
pre-existing astigmatism. There are reports of use of toric IOLs in Refract Surg 2008; 34:1842–1847

keratoconus and the use of phakic toric IOLs in bilateral corneal 3. Efekan Coskunseven, Methiye Onder, George D. Kymionis, Vasilios
marginal degenerations.
F. Diakonis Combined Intacs and Posterior Chamber Toric

Our experience with these 2 cases was good in terms of the visual Implantable Collamer Lens Implantation for Keratoconic Patients
outcome and stability of the same in the 8 month follow up. But with Extreme Myopia Am J Ophthalmol 2007; 144:387–389

we recommend that the use of toric IOLs be considered in cases of 4. Buzard K, Shearing S, Relyea R. Incidence of astigmatism. In a
cataract practice. J Refract Surg 1988; 4:173–178
corneal ectasia with cataract only if the astigmatism and ectasia

have been documented to be stable. Accurate and reproducible 5. Marjolijn C. Bartels, MD, Gabriel van Rij, MD, Gregorius P.M.
keratometry readings are a prerequisite to the proper power
Luyten, MD Implantation of a toric phakic intraocular lens to correct

calculations of the IOL. high corneal astigmatism in a patient with bilateral marginal corneal

The outcome will depend on the proper communication with the degeneration J Cataract Refract Surg 2004; 30:499–502

patient also explaining the probability of IOL repositioning and

exchange in case of postoperative refractive surprises.

References

1. Sauder G, Jonas JB. Treatment of keratoconus by toric foldable
intraocular lenses. Eur J Ophthalmol 2003; 13:577–579

First Author
Monica Gandhi MS

64 DOS Times - Vol. 15, No. 2, August 2009

Ophthalmic Plastic Surgery: The New Horizons Clinical Meeting: Clinical Talk

Sima Das MS

Ophthalmic plastic surgery is a specialized branch of chalazion and avoids the side effects associated with steroid
ophthalmology dealing with disorders of eyelid, orbit, socket injection, such as steroid deposits and steroid induced glaucoma.
and lacrimal system. Recent advances in this field combine the
well founded principles of surgical techniques with modern day The treatment of choice for cicatricial eyelid ectropion remains a
minimally invasive and aesthetically oriented approaches. With full thickness autologous skin grafting. Congenital icthyosis and
extended interest into maxillofacial surgery, a modern era other generalized cicatrizing skin disorders are very commonly
ophthalmoplastic surgeon has stepped into a new specialty of associated with sight threatening cicatricial ectropion. Harvesting
Orbito-facial Surgery, thus reorienting the way we approached a healthy skin autograft might not be possible in them due to the
various conditions, ranging from complicated orbitofacial trauma generalized skin involvement. Parental skin allografting can be a
to mid and upper facial aesthetic surgery. viable option for correction of eyelid malposition in these
conditions.
On yet another challenging front, ophthalmic plastic surgeons,
with further specialized training have now ventured into the field Upper eyelid retraction in thyroid eye disease is cosmetically
of Ocular Oncology. Today’s trained ocular oncologists not just aim disfiguring while we wait for the active phase of the disease to
for globe salvation but is making the goal of vision salvation a subside. Till such time as surgery can be performed, a small dose
reality. of botulinum toxin into the levator-muller muscle complex can
reduce the retraction, theraby providing temporary improvement.
This article aims to highlight the recent innovations in the field of
ophthalmic plastic surgery and its allied specialties of orbito-facial Upper eyelid retraction and lagophthalmos following facial palsy
surgery, facial aesthetics and ocular oncology. is now being managed with eyelid loading with gold weight.4.In
temporary cases such as Bells palsy, even Hyaluronic acid filler
Eyelid disorders injection can provide a viable non-surgical office procedure to
improve lagophthalmos5.Better understanding of the
The concept of minimally invasive approach has found its way pathophysiology of lower eyelid retraction has made its treatment
into oculoplasty in several ways. For example, conventional more individualized. Instead of classical surgeries like lateral tarsal
tarsorrhaphy involves minor surgery on the eyelids and can cause strip which induce more tissue trauma, a vertical lengthening of
eyelid scarring. Since the indication for this procedure is usually a the lower eyelid with retractor release combined with fat-pearl
temporary corneal protection, injection of botulinum toxin into grafting can correct lower eyelid retraction of varied etiologies.
the levator muscle achieves the same by inducing temporary ptosis,
the underlying mechanism being chemodenervation. The Severe congenital ptosis can cause amblyopia by obstructing the
procedure is often named as ‘chemotarsorrhaphy’. A modified visual axis or inducing astigmatism. Ptosis correction in children
anterior chemodenervation technique prevents the unwanted requires a sling surgery and the conventional procedure leaves
superior gaze palsy yet retaining the effect on levator muscle1 behind multiple forehead scars. Considering the fact that ptosis
(Figure 1).

Botulinum toxin has been the treatment of choice for benign
essential blepharospasm, a condition of involuntary spasmodic
eyelid closure, potentially blinding the patient. However, high cost
of the botulinum toxin and need for repeated injections is
prohibitive for many patients to continue with the treatment. A
surgical procedure of orbicularis myectomy can reduce the intensity
of spasm and requirement for botox considerably. Modifying the
age old procedure of total myectomy and doing a limited myectomy
has reduced the potential complications associated with this
procedure.2

Chalazion is a very common inflammatory eyelid lipogranuloma, Figure 1: Botulinum toxin ‘chemotarsorrhaphy’.
and most cases are managed with incision and curettage. More Herpetic corneal ulcer in a 10 year old girl(a).Anterior
recently, intralesional steroid injection has been found to cause
resolution of the lesion.3 Intralesional injection of 5-fluorouracil, levator chemodenervation performed with 10U
an antifibrotic agent has also been reported to cause resolution of botulinum toxin(b).Complete ptosis after 1 week of
injection(c) with preserved superior rectus function(d).
Oculoplasty and Ocular Oncology Services
Dr Shroff’s Charity Eye Hospital,
Darya Ganj, New Delhi

www.dosonline.org 65

The search for the ideal sling material for ptosis correction in
adults has been an ongoing process and until now facial lata has
been considered the gold standard for the same. However,
harvesting the facia is a time consuming procedure and is associated
with the need for a second site surgery and its associated donor
site morbidity. Silicone sling material has been used recently for
ptosis correction. The flexibility of the material reduces post
operative lagophthalmos considerably and can be used for ptosis
correction for cases with poor Bells phenomenon like chronic
progressive external ophthalmoplegia.6 The operative time is also
reduced considerably.

Orbital disorders

Figure 2: Single incision suture sling. Single stab incision Orbital decompression for thyroid eye disease is indicated in cases
given above eyebrow (a), Suture sling passed subcutaneously with compressive optic neuropathy not responding to steroids or
(b), and tightened (c), to achieve desired ptosis correction for correction of cosmetic disfigurement caused by the severe
proptosis. Classical orbital decompression procedures involved
without leaving any visible forehead scar (d) neurosurgical or inferomedial Caldwell- Luc approach, that had a
high rate of complications. Deep lateral decompression performed
through a small eyelid crease incision debulks the posterior part
of lateral wall, thus providing an adequately extended posterior
orbital volume with minimal disturbance of ocular motility and
alignment7 (Figure 3).

Figure 3: Preoperative (a) and postoperative(b) The indications for orbital decompression are expanding. More
photograph of a patient with bilateral proptosis due to patients today undergo decompression for pure cosmetic reasons,
such as to correct unilateral proptosis of thyroid etiology, or even
thyroid eye disease managed by deep lateral and non-thyroid causes of globe prominence such as unilateral high
transconjunctival medial wall orbital decompression myopia, or congenital bony orbital hypoplasia.8 Removal of little
amount of fat from the orbit through a small transconjunctival
correction for amblyopia prevention is an often a temporary incision can sufficiently reduce the orbital volume content and
procedure, a modified sling surgery (single incision suture sling) reduce the globe prominence in these cases.
whereby the suture is entirely tracked along a suborbicular plane
through small needle stabs (avoiding unsightly forehead scars) is a Conventional orbitotomy incisions like modified Stallard’s, Berke’s
desirable procedure (Figure 2). or Lynch incisions provide adequate exposure but often leave
cosmetically unacceptable scars. To reduce the post orbitotomy
scars without compromising an adequate exposure, lid crease
incisions and conjunctival approach have been reinvented.
Combination of these incisions allows access to virtually any part
of the orbit without leaving any unsightly visible scar. The focus
thus, is gradually shifting from mere “removal of tumors”, to their
“aesthetic removal”.

Figure 4: Management of congenital anophthalmos with hydrogel socket expander. Left congenital clinical
anophthalmos in a 8 month old child (a). Hemispherical hydrogel socket expander secured with sutures before

insertion into socket (b).Adequately expanded socket with a custom prosthesis in situ at 2 year follow up(c)

66 DOS Times - Vol. 15, No. 2, August 2009

Figure 5: Mini-Monoka monocanalicular
lacrimal intubations stent in situ

Socket disorders

Orbitopalpebral cysts are usually associated with a deformed globe Figure 6: Comprehensive management of orbital trauma.
with poor visual prognosis. Cosmetic rehabilitation of these Left orbital fracture in a young adult(a) with CT scan
children often requires excision or aspiration of the cyst to allow showing involvement of orbital rim with displaced bone
space for prosthesis. Aspiration of cyst is often preferred over fragments(b).Fracture reduction done along with
surgical cyst excision which often leaves behind a contracted socket repositioning of the bone fragments after securing with
as an unwanted sequel to surgery. However, simple cyst aspiration
is frequently associated with recurrences. Recurrence can be miniplates(c). Post operative photograph showing a good
avoided by using a sclerosing agent like ethanolamaine oleate.9 functional and anatomical outcome (d)

Management of congenital anopthalmic socket is often a challenge but has a higher failure rate due to occlusion of osteotomy. Use of
for both the ocularist and oculoplasty surgeon. Socket expansion hydrogel stents to maintain patency of the ostium is a recent and
attempted with graduated conformer has been the conventional promising development in this field.12
treatment. Hydrogel self expanding socket expanders have been
introduced recently for management of these difficult cases and
holds considerable promise10 (Figure 4).

Lacrimal system

Until recently, the result of canalicular injuries were unsatisfactory Orbitofacial surgery and orbital trauma
in spite of meticulous suturing as postoperative canalicular patency
was an issue. Use of self retaining silicone stents (Mini-Monoka) Management of orbital trauma needs a holistic approach and one
have reduced the surgical time and improved the post operative needs to incorporate better understanding of relevant orbital and
canalicular patency rates11 (Figure 5). facial anatomy as well acquire surgical skills to take care of
periorbital, maxillary and zygomatic regions. Such complex cases
Endonasal dacryocystorhinostomy (DCR) has evolved as an are best managed by a team approach including and ophthalmic
alternative to conventional DCR surgery. It avoids any facial scar plastic and maxillofacial surgeon (Figure 6).

Figure 7: Autologous fat injection for correction of superior sulcus deformity. Left anophthalmic socket 67
with residual deep superior with an orbital implant in situ.(a).Autologous fat harvested from abdominal

wall for injection(b).Post operative photograph showing a full superior sulcus(c).

www.dosonline.org

Figure 8: Direct browlift Figure 9: High dose chemotherapy for orbital
thorough zig-zag retinoblastoma. Massive extraocular tumor extension in

forehead incision (a,b). an untreated case of retinoblastoma(a).CT showing
Preoperative (c) and postoperative calcified mass filling left eye with extension to anterior

(d) photograph of orbit(b).Tumor shrinkage following high dose
a patient with brow ptosis managed chemoreduction.(c)Five year follow up of the patient
following enucleation and radiotherapy with no residual
by direct browlift with incision
hidden in one of the forehead crease tumor and a prosthetic eye in situ.(d)

Facial aesthetics

Concept of aging

Ageing has always been a subject of human curiosity. Recent Figure 10: Left eye sebaceous gland carcinoma with tumor
understanding has changed some age old concepts associated with extension to temporal fossa (a). Significant shrinkage of the
the process of aging. It is now believed that combination of bony tumor following 3 cycles of neoadjuvant chemotherapy (b).
changes, loss of soft tissue volume and elasticity leads to age related
effects.13 Thus newer rejuvenation therapies incorporate volume
replacement and redistribution apart from skin excision and
tightening.14 Hence, soft tissue fillers (and sometimes autologous
fat) are used extensively now for rejuvenating the aged periorbital
area and the face. Autologous fat injection has also been used as an
adjunct to orbital volume replacement for correction of superior
sulcus deformity in cases of anophthalmic socket (Figure 7).

Hyaluronic acid, a soft tissue filler have been used for non surgical complex has led to the newer concepts of fat preservation and
correction of eyelid retraction and congenital eyelid anomalies repositioning and a more conservative skin and muscle excision.
like entropion, microblepheron etc. with good results.15 Transconjunctival hidden incision is now preferred over skin
incision for lower lid blepharoplasty.
Browlift
Ocular oncology
A classical linear forehead browlift incision just above the brow
often leaves a prominent scar. A zig-zag forehead incision hidden Ocular oncology is a relatively nascent subspecialty and until
in one of the forehead crease (especially in old patients) is more recently enucleation had been the mainstay treatment for many
cosmetically acceptable. (Figure 8) In young patients, endoscopic ocular tumors. Taking a leaf out of modern oncology and applying
brow lift is the surgery of choice as all it needs is a small vertical concepts like high dose chemotherapy, brachytherapy and
incision hidden within the hairline. chemoreduction therapies, present day ocular oncology has grown
to become a complete specialty in itself. While current protocol
Blepharoplasty based management strategies have significantly reduced the
mortality and morbidity associated with ocular tumors,
Conventional blepharoplasty surgery involves excision of skin, innovations like periocular chemotherapy and transpupillary
muscle and fat. It provides unpredictable results and often leaves thermotherapy have helped us to make vision salvage a reality,
a dissatisfied patient due to unwanted eyelid retraction and especially in cases of retinoblastoma16 (Figure 9).
scarring. Better understanding of the esthetic basis of eyelid

68 DOS Times - Vol. 15, No. 2, August 2009

Concept of melanoma vaccination will revolutionize the way treat 5. Mancini, R., et al., Use of hyaluronic Acid gel in the management of
such patients. Even after adequate local tumor control, distant paralytic lagophthalmos: the hyaluronic Acid gel “gold weight”.
metastasis remains the most common cause of mortality in these Ophthal Plast Reconstr Surg, 2009. 25(1): p. 23-6.
patients. Cytogenetic studies of uveal melanoma will help us to
identify the poor prognosis cases at an early stage. Such high risk 6. Ahn, J., et al., Frontalis sling operation using silicone rod for the
cases can receive vaccination for delaying or preventing distant correction of ptosis in chronic progressive external ophthalmoplegia.
metastasis, thus saving many lives.17 Br J Ophthalmol, 2008. 92(12): p. 1685-8.

Surgical excision remains the treatment of choice for eyelid 7. Goldberg, R.A., A.J. Kim, and K.M. Kerivan, The lacrimal keyhole,
sebaceous gland carcinoma. However, advanced cases of tumor orbital door jamb, and basin of the inferior orbital fissure. Three
with regional lymph node metastasis require extensive surgery areas of deep bone in the lateral orbit. Arch Ophthalmol, 1998.
and are associated with high morbidity and mortality. Neo-adjuvant 116(12): p. 1618-24.
chemotherapy for locally advanced tumors can cause shrinkage of
the tumor and avoid extensive procedures like exenteration and 8. Goldberg, R.A., et al., Orbital decompression for non-Graves’
radical neck lymph node dissection18 (Figure 10). orbitopathy: a consideration of extended indications for
decompression. Ophthal Plast Reconstr Surg, 1995. 11(4): p. 245-
Long considered as one of the “side specialty “of ophthalmology, 52; discussion 253.
the recent innovations in the field of ophthalmic plastic surgery
has made it evolve into a complete specialty by itself. Combining 9. Naik, M.N., et al., Ethanolamine oleate sclerotherapy in the
the microsurgical skills of ophthalmology with surgical skills of management of orbito-palpebral cyst associated with congenital
plastic surgery, this scope of this specialty now encompasses much microphthalmos. Am J Ophthalmol, 2005. 139(5): p. 939-41.
beyond the eye and ventures into the exciting field of orbitofacial
surgery and facial aesthetics also. Expanding the scope of this field 10. Schittkowski, M.P., K.K. Gundlach, and R.F. Guthoff, [Treatment
is the specialty of ocular oncology which is very much the domain of congenital clinical anophthalmos with high hydrophilic hydrogel
of oculoplasty surgeon today. And nourished everyday by the expanders]. Ophthalmologe, 2003. 100(7): p. 525-34.
new innovations in all its allied fields, ophthalmic plastic surgery
definitely promises to be the ophthalmic “sub specialty of 11. Naik, M.N., et al., Management of canalicular lacerations:
tomorrow”. epidemiological aspects and experience with Mini-Monoka
monocanalicular stent. Am J Ophthalmol, 2008. 145(2): p. 375-
Acknowledgement 380.

Author acknowledges Dr Santosh G Honavar and Dr Milind Naik 12. Goldberg, R.A., et al., The hydrogel lacrimal stent for
from Orbit, Oculoplasty and Ocular Oncology Services at L V dacryocystorhinostomy: preliminary experience. Ophthal Plast
Prasad eye institute, Hyderabad for their pioneering work on many Reconstr Surg, 2008. 24(2): p. 85-9.
of the new innovations in the field of ophthalmic plastic surgery
and for allowing using some of their data and documentation in 13. Pessa, J.E., An algorithm of facial aging: verification of Lambros’s
this article. theory by three-dimensional stereolithography, with reference to the
pathogenesis of midfacial aging, scleral show, and the lateral suborbital
References trough deformity. Plast Reconstr Surg, 2000. 106(2): p. 479-88;
discussion 489-90.
1. Naik, M.N., et al., Anterior chemodenervation of levator palpebrae
superioris with botulinum toxin type-A (Botox) to induce temporary 14. Goldberg, R.A., The three periorbital hollows: a paradigm for
ptosis for corneal protection. Eye, 2008. 22(9): p. 1132-6. periorbital rejuvenation. Plast Reconstr Surg, 2005. 116(6): p. 1796-
804.
2. Patel, B.C. and R.L. Anderson, Blepharospasm and related facial
movement disorders. Curr Opin Ophthalmol, 1995. 6(5): p. 86-99. 15. Taban, M., et al., Nonsurgical management of congenital eyelid
malpositions using hyaluronic Acid gel. Ophthal Plast Reconstr Surg,
3. Goawalla, A. and V. Lee, A prospective randomized treatment study 2009. 25(4): p. 259-63. 16. Shields, C.L., et al., Retinoblastoma
comparing three treatment options for chalazia: triamcinolone regression patterns following chemoreduction and adjuvant therapy
acetonide injections, incision and curettage and treatment with hot in 557 tumors. Arch Ophthalmol, 2009. 127(3): p. 282-90.
compresses. Clin Experiment Ophthalmol, 2007. 35(8): p. 706-12.
17. Damato, B. and S.E. Coupland, Translating uveal melanoma

4. Aggarwal, E., M.N. Naik, and S.G. Honavar, Effectiveness of the
gold weight trial procedure in predicting the ideal weight for lid
loading in facial palsy: a prospective study. Am J Ophthalmol, 2007.
143(6): p. 1009-1012.

First Author
Sima Das MS

www.dosonline.org 69

Forthcoming Events : National

August 2009 Contact Person & Address
29th-30thNEW DELHI Dr. Satish Sharma, Chairman, Organising Committee
Deptt. of Ophthalmology, B.R.D. Medical College,
Annual Conference Intra Ocular Implant & Gorakhpur, U.P. Mobile : +09415313296
Refractive Society, India Email : [email protected]

Contact Person & Address November 2009
Dr. Charu Khurana & Dr. Vikas Menon
Organising Secretary 14-15 NEW DELHI
Centre For Sight
B-5/24, Safdarjung Enclave, New Delhi-29 Mid-term Conference
Tel : +91-011-41644000,41653401-07 Delhi Ophthalmological Society
Email : [email protected] Venue: India Habitat Centre, Lodhi Road, New Delhi
Contact Person & Address
August 2009 Dr. Amit Khosla, Secretary DOS
30th CHANDIGARH Room No. 2225, 2nd Floor, New Building,
Sir Ganga Ram Hospital,
XXII Annual Conference of Chandigarh Rajinder Nagar, New Delhi - 110 060
Ophthalmological Society Ph.: 011-65705229, E-mail: [email protected],
Website: www.dosonline.org
Contact Person & Address
Dr. Jaspreet Sukhija, Organising Secretary 25-28 PALAMPUR, HIMACHAL PRADESH
Advanced Eye Centre, PGI, Chandigarh
Tel : +91-0172-2756111 (M) 09876118740 XVIII Annual Conference of Vitreo Retinal
Email : [email protected] Society of India
Website : http://www.cosonline.co.in Contact Person & Address
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October 2009 VRSI 2009, Thind Eye Hospital,
2nd NEW DELHI 701-L, Mall Road, Model Town, Jalandhar, Punjab
Mobile : +09988998844
14th Dr. R.K. Seth Memorial Symposium on Email : [email protected]
Surgical Advances in Cataract Website: http://www.vrsi.in

Contact Person & Address January 2010
Dr. Gaurav Kakkar, Organising Secretary
Venu Eye Institute & Research Centre, 21-24 KOLKATA
1/31, Sheikh Sarai, Institutional Area,
Phase-II, New Delhi-17 AIOC 2010: Joint Meeting of the 68th AIOS Annual
Tel : +91-011-29251155/56 Fax: 011-29252370 Conference & 15th Afro-Asian Congress of
Email : [email protected] Ophthalmology
Contact Person & Address
October 2009 Dr. Ashis Kumar Bhattacharya Organising Secretary
2nd-4th NAINITAL, UTTARAKHAND IMA House, Room No. 8, 53,
Creek Row, Kolkata - 700014
Uttara-Eyecon-2009 Tel: 033-22371679, 033-22366350,
6th Annual Conference of Uttarakhand State Mobile : +09831019779, Email : [email protected]
Ophthalmolocial Society
April 2010
Contact Person & Address
Dr. Anurag Garg, Organising Secretary 16-18 NEW DELHI
Prakash Eye Hospital & Laser Centre
Doctor Colony, Civil Lines, Rudrapur Annaul Conference
Tel : 05944-246946, Fax: 242394 (M) 09837180286 Delhi Ophthalmological Society
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Dr. Amit Khosla, Secretary DOS
14-15 GORAKHPUR, U.P. Room No. 2225, 2nd Floor, New Building,
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44th Annual Conference of UP State Rajinder Nagar, New Delhi - 110 060
Ophthalmological Society Ph.: 011-65705229, E-mail: [email protected],
Venue: B.R.D. Medical College Campus, Website: www.dosonline.org
Gorakhpur, U.P.

70 DOS Times - Vol. 15, No. 2, August 2009

Forthcoming Events : International

September, 2009 November, 2009
12-16 BARCELONA, SPAIN
21-23 INDIA
XXVII Congress of the ESCRS
Phone: +35312091100, Fax: 35312091112 World ROP Congress 2009
Email: [email protected], Web Site: http://www.escrs.org Hotel Le Meridien,
Contact Person & Address
October, 2009 Prof. Rajvardhan Azad,
15-17 SINGAPORE Executive Chairman, Organizing Committee
World ROP Congress Secretariat
NHG Eye Institute 2nd International Ophthalmology Room No. 486, Dr. Rajendra Prasad Centre for
Congress, Advances in Glaucoma & Neuro-Ophthalmology Ophthalmic Sciences, All India Institute of Medical
Singapore International Convention & Exhibition Centre Sciences, Ansari Nagar, New Delhi
NHG Eye Institute, Level 1, TTSH Medical Centre, Phone: +91-11-26593187 / Fax: +91-11-26852919
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E-mail: [email protected]

24-27 SAN FRANCISCO, USA

Annual Meeting American Academy of Ophthalmology
Contact
American Academy of Ophthalmology,
P.O. Box 7424, San Francisco, CA 94120-7424
Phone: 415.561.8500 Fax: 415.461.8533

Delhi Ophthalmological Society
Monthly Clinical Meeting, September 2009

Venue: Nalanda Auditorium, Base Hospital, Delhi Cantt, Delhi (Map attached)
(Tea & Snacks-10:30 a.m. - 10:55 a.m.)

Date and Time : Sunday, 4th October 2009, 11:00 AM

Clinical Cases: : (Maj.) V.R.S. Reddy (8 min)
1. A rare case of Glaucoma
Discussant : (Maj.) Nitin Vichare
2. An unusual case of Retinal Vasculitis
: (Lt. Col.) Rakesh Maggon (8 min)

Clinical Talk: : (Col.) Neeraj Bhargava (15 min)
Phacoemulsification - Cutting corners or Polishing edges?

Mini Symposium: Paediatric Cataract Surgery

Chairman: (Col.) Neeraj Bhargava Co-Chairman: (Col.) A.K. Upadhyay

1. Peculiarities of Paediatric Cataract Surgery : (Maj.) K. Satyabala (10 min)
2. Surgical Treatment
3. Choice of IOL : Mahipal Sachdev (10 min)
4. Visual rehabilitation after paediatric cataract surgery
: (Col.) J.K.S. Parihar (10 min)

: (Lt. Col.) S. Bandopadhyay (10 min)

20 Surprise Early Bird Prizes

To be followed by Lunch at Base Hospital Officer’s Mess

Please see Road Map page no. 74

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