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Editor-in-chief Editorial Capsule Monthly Meeting Korner
3 Ring in the New 35 Double Trouble
M. Vanathi 37 Simple Limbal Epithelial
Focus Transplantation (SLET) in
Section Editors 7 Current Glaucoma Treatment Thermal Injury
Cataract & Refractive Retina & Uvea 39 Kerato-Prosthesis

Umang Mathur Pradeep Venketesh Featuring Sections Diagnostics Discussion
Saurabh Sawhney Parijat Chandra
Cataract 43 Subfoveal Foreign Body
Sanjiv Mohan Manisha Aggarwal 11 Pediatric Cataract Surgery in Masquerading as Choroiditis
S. Khokhar Shahana Majumdhar
Eyes Treated for Retinoblastoma
Cornea & Oular Surface Rohan Chawla
Uma Sridhar Ravi Bypareddy Oculoplasty Clinical Spotlight Squint
Deepa Gupta Ophthalmoplasty & 17 Primary Endoscopic 45 Dissociated Vertical Deviation:
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Umang Mathur Ocular Oncology Dacryocystorhinostomy in
Ramendra Bakshi Neelam Pushker Acute Dacryocystitis Practice Requisites
Manisha Acharya Maya Hada 51 Anterior Segment
Optical Coherence Tomography
Noopur Gupta Sangeeta Abrol
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Delhi Advisory Board A case report
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P.V. Chadha Jolly Rohtagi
Innovations
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2 DOS TIMES - JANUARY-FEBRUARY 2016

EDITORIAL CAPSULE

Dear Members

As 2015 fades into the past, we usher in the New Year with higher hopes
of happiness and prosperity. The past year paved way for the stepping in of
the new DOS executive and new angles in directions of work of DOS. DOS
Times has reached a higher zenith with its much appreciated new look and
scienti ic content. DOS library is being widely accessed by members all over
the country. DJO is also continuing its publications to add on to the scienti ic
circle of DOS.

It was indeed a pleasure to see the heightened response as never Dr. M.Vanathi
before for the WINTER DOS 2015. The new outlay, high scienti ic content
and deliberations with introductions of physical posters, ophthalmic
photography, several interactive sessions and the much acclaimed DELHI
OPHTHALMIC LEAGUE 2015 (DOL 2015: VIDEO WARS) has been embraced
with fond appreciation, raising the bars of performance of DOS to greater
heights.

As we ring out the old to ring in the new, we hope to strive to raise the
academic standards of DOS in all its endeavors to seek wider laurels from all members of the society and others as
well. We wish to thank all the members for their support to our academic activities and hope to be able to usher in
more international standards in all the activities of the society. We seek the continued patronage of all members
in their participation in all academic programmes of DOS with higher contribution and heightened scienti ic
deliberations.

DOS members need to set an example in showing higher tolerance and acceptance to changes being heralded
in to emulate international standards in all angles of conference activities. DOS members are also requested to
turn up in higher numbers to all academic deliberations and prove to the society that we are not a society that
patronizes only social circle chats and conversations.

Let us all join in to strive to take DOS on to higher standards as we ring in the new year …

HAPPY NEW YEAR!

Dr. M.Vanathi MD
Additional Prof. of Ophthalmology
Cornea, Cataract & Refractive Services
Dr R P Centre for Ophthalmic Sciences
All India Institute of Medical Sciences
New Delhi 110029, India
[email protected]

ANNUAL DOS 2016

The Annual Conference of DELHI OPHTHLAMOLOGICAL SOCIETY

April 15 – 17, 2016
NEW DELHI

REGISTRATION OPENING SHORTLY
BLOCK YOUR DATES TO BE PART OF THIS SCIENTIFIC EXTRAVAGANZA

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SEASON’S BEST EDITION of COMPREHENSIVE OPHTHALMIC TEACHING

DOST 2016

8th DOS Teaching Programme

J L Auditorium, AIIMS, New Delhi, Jan 23 – 24, 2016

Highlights

Specialty Clinics
Clinical Case Discussion on common exam cases

Examination Techniques
Demonstration on ophthalmic examination techniques

Guidance session for FRCS Examination
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Special Session on Surgical skills & specialty surgery watch

Community Ophthalmology
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Optics & Refraction and Contact Lens Essentials
All you need to know on instrument optics & principles in
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Ophthalmic Imaging, Microbiology, Pathology
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Ask the masters: interactive session addressing common
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Log on to www.dosonline.org for online registration (last date: January 18, 2016)
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For Further Details, Please contact

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Email:[email protected] Phone: 011-26588074

This edition of DOST Program is by the Editor of the popular book
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FOCUS

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8 DOS TIMES - JANUARY-FEBRUARY 2016

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10 DOS TIMES - JANUARY-FEBRUARY 2016

CATARACT

PEDIATRIC CATARACT SURGERY IN EYES TREATED
FOR RETINOBLASTOMA

Muralidhar Ramappa, Rupal H Trivedi, Swathi Kaliki, Ramesha Kekunnaya

The management of retinoblastoma has gradually eyes had anterior tumors and vitreous seeding prior to external
advanced over the past years from enucleation beam radiotherapy (EBRT) with persistent vitreous haze
to globe conservation in most cases1. Currently, present at the time of cataract surgery.
use of external beam radiotherapy (EBRT) is
restricted to the large sized tumors that are Honavar et al.13 reported recurrence of RB in 21% (5/34)
of eyes undergoing cataract surgery, 5 cases underwent

either resistant to chemoreduction or those with subsequent enucleation. None of the patients who underwent

extraocular extension2. The cataract formation is one of the cataract surgery developed metastasis. Most recurrence

frequently documented complications of EBRT, which typically occurred within the irst year, with the longest interval being

occurs 1-3 years after irradiation3,4. Rarely, cataract could be 19 months in that series. Patients needing a scleral buckling

the initial manifestation5,6. Lack of uniform guidelines, which procedure or pars plana vitrectomy (PPV) seemed to be at

includes the surgical approach, length of RB quiescence prior greater risk for RB recurrence compared with those needing

to cataract surgery, preservation of posterior capsule and cataract surgery. When looking at all of their patients in their

avoidance of anterior vitrectomy with the added concern for series, including anterior segment and posterior segment

reactivation or metastasis of the tumor2,4,7-15. Therefore, the surgeries, the patients with a favorable outcome (26 eyes) had

purpose of this editorial is to review the literature and provide a median quiescent interval of 26 months, whereas the patients

guidelines for the management of secondary cataracts in the with an unfavorable outcome (19 eyes) had a median quiescent

context of retinoblastoma. interval of 6 months. An unfavorable outcome was de ined as

the presence of tumor recurrence, need for enucleation, or

INTRODUCTION systemic metastasis.

Intraocular surgery after treatment for retinoblastoma Moshfeghi14 reported one case of RB recurrence after

(RB) poses distinctive challenges. Consequential cataract cataract surgery, ultimately requiring enucleation. While

formation (Figure 1) further confounds the management of RB no predisposing factors were identi ied in this patient, it

by precluding visualization of was noted that the quiescent

the tumor. Surgical intervention Lack of uniformguidelines in management interval was only 12 months
for cataract in these eyes of cataract in retinoblastoma (RB) prior to cataract surgery.
increases the concerns about Adequate tumor treatment

the patient’s systemic outcome includes the surgical approach, length of and a suf icient quiescent
because of the risk of viable RB quiescence prior to cataract surgery, interval appear to be critical in
tumor seeding. Nonetheless, preventing tumor recurrence

visual rehabilitation for preservation of posterior capsule and and metastasis. While the
cataracts is justi ied in certain optimal quiescent interval is not
clinical settings, especially avoidance of anterior vitrectomy with known, Miller and colleagues
if the tumor is considered to the added concern for reactivation or 2 reported that they observe

be clinically stable and or in metastasis of the tumor. The purpose for a minimum 18 month
a regression phase. Perhaps of this editorial is to review the period after the conclusion of
quiescent interval is the one of all tumor treatments before

the most key determinant of literature and suggest guidelines for the considering intraocular surgical
long-term success16. It is critical management of radiation-
to weigh the expected bene its management of secondary cataracts in induced cataract. Recurrence

of visual rehabilitation against the context of retinoblastoma rate varied from 10% for Brooks

the risk of tumor dissemination et al.8 31% for Honovar et al.13

or relapse13,17. and 0% for Miller et al.2 who

Payne et al.15 published an elegant literature review applied the longest interval, suggesting a correlation between

consists of 128 eyes that have undergone cataract extraction the longer interval and the lower rate of recurrence.

for radiation-induced cataract following RB over the past 22 In Osman’s18 series one recurrent case was operated

years. There were only 9 cases of RB recurrence and no cases 37 months after RB treatment completion and only 3 and 5

of systemic metastasis among them. Brooks et al.8 reported 3 months elapsed for the two other cases for the sake of proper

cases of tumor recurrence. In each of these eyes, surgery was monitoring of the tumor. This further suggests the importance

approached via a pars plana or pars plicata incision, and all 3 of adequate tumor control before any surgical intervention

www. dos-times.org 11

CATARACT

and the dif iculty of weighing the risk of Figure 1: A child with a bilateral retinoblastoma associated with cataract in the right eye:(a) Left eye
surgery with an undiagnosed recurrence with leucocoria due to large tumor filling the globe and touching posterior surface of crystalline
to the risk of delay of diagnosing a lens. (b) Ultrasonography of the left eye showing intraocular mass with specks of calcification.
recurrence due to an opaque lens with (c) Right eye showing total opacification of crystalline lens (d) Ultrasonography of the left eye
insuf icient tumor visualization. While the showing intraocular mass with specks of calcification, touching the posterior surface of crystalline
optimal quiescent interval is not known, a lens (e) External photograph of both eyes revealing cataract in the right eye and leucocoria due to
detailed review of literature have shown retinoblastoma in the left eye.
no tumor recurrences when the quiescent
interval was at least 16 months15. in addition to cataract extraction, and The posterior capsulotomy is
showed no evidence of tumor recurrence contentious in the background of
The risk of tumor recurrence and in their series. prior treatment for RB. Theoretically,
metastasis appears to be higher in
patients who have undergone posterior
segment surgeries such as PPV or scleral
buckling. Honovar and colleagues13
reported the largest series, and they
suspected that eyes that required a scleral
buckling procedure or PPV were more
likely to have advanced RB, and therefore,
a higher risk of recurrence. Moshfeghi
and colleagues14 concluded that
rhegmatogenous retinal detachments are
an ominous sign for both visual acuity
and eye salvage. They hypothesized
that tumor reactivation could place
mechanical stress on the retina, resulting
in stretching of an already damaged tissue
and thus allowing microscopic breaks to
form. Eyes that require posterior segment
surgery may be associated with a higher
risk of tumor reactivation.

Controversial in post RB cataract
management i.e., surgical approach,
preserving posterior capsule and or
anterior vitreous. In the setting of prior
treatment for RB, these decisions take
on even greater signi icance with the
attendant risk of tumour reactivation or
metastasis13. Both clear corneal and pars
plana approaches have been used with
good success in children undergoing
cataract surgery after treatment for
RB. Although Brooks et al.8 advised
against pars plana incisions based on
their experience of tumor recurrence,
other series have not reported tumor
recurrence with a pars plana approach.
Miller and associates2 reported a series
of 16 eyes, all of which underwent a PPV

1. Cornea and Anterior Segment Services, L.V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, India.
2. Miles Center for Pediatric Ophthalmology, Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston,

South Carolina, USA.
3. Ophthalmic Plastics Surgery And Oncology Services, L.V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, India.
4. Jasti V. Ramanamma Children’s Eye Care Center, L.V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, India.

Dr. Muralidhar Ramappa MD1 Dr. Rupal H Trivedi MD, MSCR2 Dr. Swathi Kaliki MD3 Dr. Ramesha Kekunnaya FRCS4

12 DOS TIMES - JANUARY-FEBRUARY 2016

CATARACT

Table 1: Review of literature on cataract extraction in eyes with retinoblastoma treated with EBRT

Author Year of Sample RB free Surgical Follow-up Relapses Visual Outcomes
Publication size no interval technique (range in (number of eyes)
children months)
(eyes)

Monge, et al7 1986 2 (2) 30-72 LA+PPV 78 (24) 0 6/18 in 2 eyes

Brooks, et al.8 1990 38 (42) 29 (17 LA+AV/PPL 72 (6 – 178) 3 20/20 – 20/50 in 19
-144) eyes
20/80 – CF in 12 eyes

Portellos and 1998 8 (11) 55 (16 – ECCE + PPC + 20 (6 – 39) 0 20/20 – 20/30 in 6 eyes
Buckley4 88) AV + PCIOL 20/50 – 20/250 in 5
eyes

Madreperla, 2000 3 (3) 34 (9 – 40) LA 84 (60- 189) 0 20/60 (2)**; HM**
et al.9

Bhattacharjee, 2003 1 (1) 84 ECCE + PPC + 144 0 20/30
et al.10 PCIOL

Shanmugam, 2004 5 24 LA + PPC+ AV + Not 0 > 6/9 (4) at 6 weeks
et al.11
PCIOL documented

Sinha, et al.12 2004 9 12 LA 24 – 42 0 No signi icant
improvement noted

Miller, et al.2 2005 12 (16) 18 PPL+ PPC + 66 (30 – 94) 0 20/20 – 20/40 (11)
PCIOL 20/200 – 20/400 (5)

Honovar, et 2001 34 (34) 16 (3 – ICCE (1) 72 5 > 20/200 (16)
al.13 54)* ECCE (28) (12 – 360)*
PPL (5)

Moshfeghi, et 2005 4 (4) 89 (12 – Cataract 184 1 20/30; CF; HM;
al.14 172) extraction (60 – 339) Enucleation for
recurrence

Payne, et al.15 2009 11 (12) 35 (17 – ECCE (12) 72 (13 – 148) 0 20/20 -20/60=6 eyes
240) PPC+AV (7) 20/70 -20/200=2 eyes
PCIOL (10) <20/200=4 eyes
Yag Cap (5)

Osman IM et 2010 21(20) 21.5 (3- LA=13(61%) 90 ± 69 3 ≥ 20/200 in 13 eyes
al.18 164) ECCE=8(39%) months < 20/200 in 5 eyes
IOL=19(90%)
PPC=11(52%)
AV=6(28%)

Hoehn ME et 2010 40(53) 23.4(12- LA+IOL (19) 58 (19-105) 0 20/20 to 20/60 in 3
al.19 39) LA+PPC+NO eyes (15.8%);
IOL (25) 20/70 to 20/200 in 4
(21.1%); and
20/400 or less in
10(52.6%).

Marcia beatriz 2012 6 22.3 LA+PCIOL (6) 17.2 (12-23) 0 Range: 20/400-20/30
et al.20

the posterior capsule could serve as to do posterior capsulectomy in order cataract surgery, Nd: YAG laser posterior
a protective barrier against spread of to clear the visual axis. Even in such capsulotomy may be cautiously
viable tumor cells that are present in cases, attempt should be made to do performed where required. We believe
the eye. Therefore, the posterior capsule manual posterior continuous curvilinear the risks and bene its of primary posterior
should be left intact whenever possible. capsulorhexis (PCCC) leaving intact capsulectomy and anterior vitrectomy
Yet, it is often essential to accomplish anterior vitreous face (AVF). Integrity of should be considered on a case by case
a primary posterior capsulectomy and AVF can be checked using Triamcinolone basis, taking into account the location of
anterior vitrectomy in younger children, in younger children; this can be bene icial the cataract, the age of the patient, the
even in the setting of prior treatment even in absence of posterior capsule feasibility of the Nd: Yag laser, the length
for RB. Since posterior capsule plaque plaque. of the quiescent period, and the location
is common after EBRT, it is sometimes and stage of the tumor.
necessary to do either plaque peeling or If RB regression has been deemed
stable for at least 6-12 months after We recommend avoiding opening

www. dos-times.org 13

CATARACT

the posterior capsule if the posterior that developed at the site of cataract tumor treatments before considering
capsule is not associated with plaque and incision. RB recurrence was con ined intraocular surgical management of
age limits permit. However, more often primarily to eyes with persistent vitreous radiation-induced cataract. Irrespective
these eyes are associated with posterior haze or vitreous hemorrhage at the of surgical strategy, it is important to have
capsule plaque or defect. In this case, time of surgery. There was no systemic a detailed conversation with the family
it may become necessary to perform metastasis. re lecting realistic prospects. As stated
posterior capsulectomy. However, we still hitherto, dense amblyopia or the retinal
try to achieve manual PCCC (with intact Miller’s series2 reported cystoid pathology may be so extensive that there
AVF), to avoid vitreous face disturbance macular edema in 5 of 16 eyes (31%) and may not be an improvement in the vision.
and subsequent vitrectomy. Primary the development of iridocyclitis in 3 of 16 Although rare, recurrence has been well
posterior capsulectomy with or without eyes (19%). These complications were known in the literature and should be
vitrectomy helps delaying visual axis transient and responded to topical anti- included in a proper informed consent.
opaci ication. in lammatory therapy. No local tumor
recurrence, orbital tumors, or metastatic REFERENCES
Dissemination of RB cells through disease was detected during the follow-up
the cataract surgery incision has been period. No lens displacement, persistent 1. Shields JA, Shields CL, Sivalingam V.
reported8. The clear corneal incision in lammation, radiation vasculopathy and
may reduce the risk of inadvertent optic neuropathy, or retinal detachment Decreasing frequency of enucleation
conjunctival implantation of viable tumor was seen in any of the patients.
cells and might allow for direct inspection in patients with retinoblastoma.
of the incision site for tumor recurrence Even after a successful surgical
(unlike the limbal or scleral incision, outcome, the inal visual acuity depends American journal of ophthalmology
which may be obscured by the overlying on several factors such as density
conjunctival lap)13. of amblyopia, residual refraction, 1989;108:185-8.
macular tumor, radiation complications
It is important to remember that (keratopathy and/or retinopathy), 2. Miller DM, Murray TG, Cicciarelli
these eyes are poor candidates for contact optic atrophy, retinal detachment, and
lens wear due to dry eyes associated with secondary visual axis opaci ication. NL, Capo H, Markoe AM. Pars plana
poor tear production from the irradiated Final visual acuity outcome is generally
lacrimal glands and ocular surface. Thus correlated with the extent of preoperative lensectomy and intraocular lens
in unilateral cases intraocular lens (IOL) macular involvement. Due to radiation
implantation is a reasonable option for or early enucleation, the child may implantation in pediatric radiation-
the correction of aphakia. Implantation have a fellow eye that is signi icantly
of an IOL by itself may not increase the enophthalmic in appearance. If this is induced cataracts in retinoblastoma.
risk of recurrence of RB or systemic the case, consider prescribing a +6.00
metastasis and can be considered for or +7.00 sphere for an already poorly Ophthalmology 2005;112:1620-4.
providing optimal visual rehabilitation seeing eye or an anophthalmic socket
after cataract surgery18. Portellos and with prosthesis. This will give the optical 3. Schipper J, Tan KE, van Peperzeel
Buckley 4 later reported the safety of illusion of a larger and therefore, more
extracapsular cataract extraction and symmetric appearing eye19. HA. Treatment of retinoblastoma
posterior chamber IOL implantation in
combination with pars plana posterior When proposing patching or by precision megavoltage radiation
capsulectomy and anterior vitrectomy in atropine penalization to the patient with
a series of eight patients (11 eyes) with RB, consider the overall clinical picture. therapy. Radiotherapy and oncology:
radiation-induced cataracts after RB Is the family overwhelmed? Is the retina
treatment. so distorted from residual tumor and journal of the European Society for
treatment scars that vision may not
Cytologic examination of vitrectomy improve? Remember that these are not Therapeutic Radiology and Oncology
luid can provide direct intraoperative “normal” amblyopic eyes. They often
evidence of viable RB. Prompt enucleation have extensive pathology that precludes 1985;3:117-32.
and adjuvant chemotherapy with or improvement in vision even with the most
without orbital radiotherapy may be rigorous patching regimen. Sometimes, 4. Portellos M, Buckley EG. Cataract
considered in such situations. Long-term especially in eyes that have received
follow-up is warranted, for several years, EBRT in very young children, sensitivity surgery and intraocular lens
to detect possible tumor recurrence to the patch adhesive can occur19.
and systemic metastasis. Recurrence implantation in patients with
of RB after intraocular surgery is a In conclusion, modern cataract
potentially serious problem. Tumor surgery, including clear cornea approach, retinoblastoma. Archives of
recurrence has been reported to range lens aspiration with or without posterior
from 0% to 45% after various intraocular capsulectomy and anterior vitrectomy; ophthalmology 1998;116:449-52.
procedures15. Brooks et al.8 reported where applicable with or without IOL
a recurrence of RB in three eyes (8%), implantation is a safe and effective surgical 5. Hasan SJ, Brooks M, Ambati J, Kielar
necessitating enucleation of two eyes. approach in radiation-induced cataract in
Orbital exenteration was required in one settings of well-controlled cases of RB. R, Stevens JL. Retinoblastoma with
case for subconjunctival RB recurrence We do recommend a minimum interval
of 9 months after the conclusion of all cataract and ectopia lentis. Journal of

AAPOS : the of icial publication of the

American Association for Pediatric

Ophthalmology and Strabismus /

American Association for Pediatric

Ophthalmology and Strabismus

2003;7:425-7.

6. Brown GC, Shields JA, Oglesby RB.

Anterior polar cataracts associated

with bilateral retinoblastoma.

American journal of ophthalmology

1979;87:276.

7. Monge OR, Flage T, Hatlevoll R,

Vermund H. Sightsaving therapy in

retinoblastoma. Experience with

external megavoltage radiotherapy.

Acta ophthalmologica 1986;64:414-20.

8. Brooks HL, Jr., Meyer D, Shields JA, Balas

AG, Nelson LB, Fontanesi J. Removal of

radiation-induced cataracts in patients

treated for retinoblastoma. Archives of

ophthalmology 1990;108:1701-8.

9. Madreperla SA, Hungerford JL, Cooling

RJ, Sullivan P, Gregor Z. Repair of late

retinal detachment after successful

treatment of retinoblastoma. Retina

2000;20:28-32.

10. Bhattacharjee H, Bhattacharjee K,

Chakraborty D, Talukdar M, Das D.

Cataract surgery and intraocular lens

implantation in a retinoblastoma case

treated by external-beam radiation

therapy. Journal of cataract and

14 DOS TIMES - JANUARY-FEBRUARY 2016

CATARACT

refractive surgery 2003;29:1837-41. 2005;123:1008-12. induced cataracts in retinoblastoma.
11. Shanmugam MP, Rao SK, Khetan 15. Payne JF, Hutchinson AK, Hubbard The British journal of ophthalmology
2011;95:227-30.
V, Kumar PJ. Cataract surgery and GB, 3rd, Lambert SR. Outcomes of 19. Hoehn ME, Irshad F, Kerr NC, Wilson
intraocular lens implantation in cataract surgery following radiation MW. Outcomes after cataract extraction
retinoblastoma. Journal of cataract and treatment for retinoblastoma. Journal in young children with radiation-
refractive surgery 2004;30:1825-6. of AAPOS : the of icial publication of induced cataracts and retinoblastoma.
12. Sinha R, Titiyal JS, Sharma N, Vajpayee the American Association for Pediatric Journal of AAPOS: the of icial
RB. Management of radiotherapy- Ophthalmology and Strabismus / publication of the American Association
induced cataracts in eyes with American Association for Pediatric for Pediatric Ophthalmology and
retinoblastoma. Journal of cataract and Ophthalmology and Strabismus Strabismus / American Association
refractive surgery 2004;30:1145-6. 2009;13:454-8 e3. for Pediatric Ophthalmology and
13. Honavar SG, Shields CL, Shields 16. Shields JA SCIotaaaPs. Intra Strabismus 2010;14:232-4.
JA, Demirci H, Naduvilath TJ. ocular tumours: a text and atlas. 20. Tartarella MB, Britez-Colombi GF,
Intraocular surgery after treatment Philadelphia:saunders, 1992:302-92. Motono M, Chojniak MM, Fortes Filho
of retinoblastoma. Archives of 17. Shields CL, Honavar S, Shields JA, JB, Belfort Jr R. Phacoemulsi ication
ophthalmology 2001;119:1613-21. Demirci H, Meadows AT. Vitrectomy in and foldable acrylic IOL implantation in
14. Moshfeghi DM, Wilson MW, Grizzard eyes with unsuspected retinoblastoma. children with treated retinoblastoma.
S, Haik BG. Intraocular surgery after Ophthalmology 2000;107:2250-5. Arquivos brasileiros de oftalmologia
treatment of germline retinoblastoma. 18. Osman IM, Abouzeid H, Balmer A, et al. 2012;75:348-51.
Archives of ophthalmology Modern cataract surgery for radiation-

Financial Interest: The authors do not have any ϔinancial interest in any procedure/product mentioned in this manuscript.

www. dos-times.org 15

OCULOPLASTY

PRIMARY ENDOSCOPIC ENDONASAL
DACRYOCYSTORHINOSTOMY IN ACUTE DACRYOCYSTITIS

Saurabh Kamal

formation and failure of subsequent surgery due to scarring

and granulation in sac1,4.

Dr. Saurabh Kamal MS Endoscopic endonasal DCR can be performed in acute
Consultant, Ophthalmic Plastic Surgery, dacryocystitis5-8. Advantages include decrease morbidity,
Faridabad, Haryana shortened duration of antibiotics, faster recovery with

Acute dacryocystitis is de ined as “A medical acceptable and high success rate. Other advantages compared
urgency clinically characterized by rapid onset to external DCR are avoidance of cutaneous scar, less disruption
of pain, erythema and swelling, classically of anatomy and lacrimal pump, decrease intraoperative
below the medial canthal tendon with or haemorrhage and concurrent correction of nasal and
without pre-existing epiphora mainly resulting paranasal sinuses abnormalities. With the advancement
of nasal endoscopy equipments, increase experience and
better anatomical understanding, success rate of endoscopic

from the acute infection of the lacrimal sac and endonasal DCR now compares favourably with external DCR.

perisac tissues”1. Wormald et al9 described that for complete sac exposure,

Clinical presentation includes: erythema, swelling over removal of thick bone of frontal process of maxilla and opening

lacrimal sac area, abscess formation, spontaneous rupture of of agger nasi is needed to clear the fundus of sac. This combined

abscess with istula formation or infected mucocele. Rarely it with 360 degree mucosal to mucosal approximation results in

may complicate into persistent abscess, orbital cellulitis, orbital healing with primary intention around created osteotomy7-9.

abscess, superior ophthalmic vein thrombosis and cavernous

sinus thrombosis1,2,3. PROCEDURE TIMING

Traditionally, conservative treatment of acute dacryocystitis Endoscopic endonasal DCR can be performed in stage of

consists of systemic broad spectrum antibiotics and analgesics. acute dacryocystitis with or without abscess formation. Patients

In case of abscess, percutaneous incision and drainage is done may not be started on oral antibiotics if surgery is planned

to open sac and drain pus. External dacryocystorhinostomy early. If there is associated orbital cellulitis, orbital abscess,

(DCR) is done in adults after 3-4 weeks when in lammation paranasal sinus infection then the antibiotics are needed.

subsides and for pediatric cases at 3-4 years of age. Sometimes, Fistulectomy can be done from cutaneous side if there is long

repeat incision and drainage standing istula formation

is needed in case abscess Endoscopic endonasal DCR can be performed secondary to repeated attacks of
recurs before planned surgery. in acute dacryocystitis. Advantages include acute dacryocystitis or previous
Causes of non-resolving acute incision and drainage.

dacryocystitis includes virulent decrease morbidity, shortened duration of
iaotsoop6ds(aotw9cnihwaeancrfbf%%aasarcrurgctsdslhscoeiiaautreeeiocemmmyncresaananaovbhisdnnbstamssbec,iaetmdyoeloamysdiaachsrsbfscstsr,thvaahiseatieiys,oovoyaiooasnar)toprettsscvnai,ctticcibsrp,iiehvluc1yaobe1ai.nisea.tttsstmiAdreaoetpoanteevltlidlptronitrleiecraidlaneeiccArsienespdetaac-saleslwpsatscaemlbpnomueoertlrpaooetfiylnieesisaeeiunnoonltsefsitnratsisffcinitlissescteoaoleryntiatarcearsnoinsaaomintcgntttamnr2etuiioeinoetee3niocn%itsarinnndddees%fttblp51ira%t0coanachacanall(touonnncsaai7cbaenmet-eddtsssig2alioe,amle8butpsnadlli)1lnicahi/.oaeadotsdrcMii,roarnsetgriye/ecrisnudshicucakhdtm.asnreisDvnaprn,eertiagsssasenrosifalucnesvrtcadoeoaaacpevislurnuramcnax/tus,ftneneeaeitimsotcssledradsintetnisgiruacpouseornallncass,sflearosdcalidnonetDicevcusuer.CrstiabwsnuerornueeRirrlOanyatiupsbhletetstiotartainnaewhmoamitrabhtonteteyieii.eonnttrrnNacnhoahaonotoecnivosdr.read1rnaldaomf5ddramocoiessevBnadapcavapceaalxionelaarteiiwnmndlptanitlregoia-iuttttcdePaerahcona/aeytosngs2rmbisrtakv%eeaooilsedryeesarffagilllinebegstnle(egnwwhacSctagooFpaordeydaUhiaciistmnpustegouuaiRehaeoclurifzomstlATGrhnotsr)eraatoeeeenr)oIerlnpictSCeefnworpza1hseitsdiaAercdbipiahgnriteonukrtola)hriL2eicohendelc.qetse.eeeTe7sNascu1ssdtseoxkEie:eahfmae8nipnob:Cnssle:gi0tlyiarmlAodssHafrec0leiiaoefesaaN0otick(esIdspise.af0ftsnecIeoriavmQodn4IotsuaprtithipgtitdasneUepeeymie.ieirridsnndenEs.efimumttod.stnuoaNcrLmsiianpatimdaboga(anlitdaoimdoeficsrnneevcoerslnaaidddkeeeeecrrtll,

www. dos-times.org 17

OCULOPLASTY

incision which starts about Percutaneous Incision and

10 mms above the axilla of drainage of lacrimal abscess is

middle turbinate and continued a painful procedure and may

anteriorly for 10 mms and promote intra-sac scarring and

then inferiorly till the level of granulation tissue which may

junction of upper two-thirds lead to failure of subsequent

and lower one-third of middle DCR surgery4,7.

turbinate (Figure 1b). Nasal It is known that episode

mucosal lap is then elevated of acute dacryocystitis is a risk

using either a suction elevator or factor for the failure of DCR

periosteum elevator to expose surgery10. In a prospective

the maxillary ridge and frontal randomized case series

process of maxilla (Figure 1c). comparing delayed external

Nasal mucosal lap can be either DCR with early endoscopic

removed just in front of uncinate endonasal DCR in acute

process or left over to protect dacryocystitis, success rate of

the middle turbinate and excise 90% was seen with endoscopic

later. Lacrimal bone is puncture approach compared to 66% with

inferiorly and osteotomy with external approach (p<0.05)4.

Kerrison punch is made (Figure Mean time to the resolution of

1d). The lacrimal sac is expose Figure 1 A: Endoscopy view of right nasal cavity showing the markings pain was 1 day for endoscopic

completely from nasolacrimal for local anesthesia infiltration. B: Incision of nasal mucosa carried out DCR compared to 5.5 days
duct to fundus and agger nasi is with sickle knife. C: Exposure of the frontal process of maxilla after for external DCR4. Authors
opened up (Figure 1e). Bowman mucosal flap removal. D: Initiation of osteotomy inferiorly. concluded that the endoscopic

lacrimal probe is pass and approach achieves higher

Crescent knife is use to open success rate with minimal tissue

the sac in a book like manner manipulation and trauma to the

to form anterior and posterior lacrimal system4,8. Functional

lap (Figure 1f). In cases of acute success rate achieved with

dacryocystitis and lacrimal endoscopic endonasal DCR in

abscess, purulent discharge can acute dacryocystitis ranges

be seen from within the lacrimal from 90-95% at 6 months follow

sac and wall of the sac may be up4,5,7 and is 81% with long term

in lamed and thickened (Figure follow up over one year8. With

1g). It is important to release the improved instrumentation

all the intra-sac synechiae if such as use of powered drill

present. Mitomycin-C (MMC) and diamond burr for superior

0.02% is applied for 5 minutes osteotomy, complete exposure of

and circumostial injection (0.1 sac up to the fundus is achieved

ml of 0.02% MMC at each site) and adequate clearance around

can be given as described6. internal common opening is

Silicone intubation (Figure 1h) possible. Moreover, endoscopic

and anterior nasal packing is endonasal approach helps to

done. correct nasal abnormalities

Marked resolution of Figure 1 E: Exposure of lacrimal sac after osteotomy (note the inflammed such as deviated nasal septum.
angry looking sac in a case of acute dacryocystitis). F: Crescent knife
symptoms and signs usually use to make anterior and posterior flap. G: Purulent discharge seen Use of adjunctives such
occurs within one day (Figure from lacrimal sac in a case of lacrimal abscess. H: Appearance at the as mitomycin-C and silicone
2). Postoperative systemic end of surgery, note the sac is open in book like fashion with silicone intubation in DCR is known
antibiotic and analgesics, to increase the success rate

topical antibiotic eyedrops and tube in situ. especially for cases with risk

nasal decongestants are given factor for failure7,11. There is no

Nasal endoscopy with silicone adverse effect of mitomycin-c
tube removal and ostium evaluation is DISCUSSION such as mucosal necrosis, increase

done at 4 weeks in OPD. Anatomical and Endoscopic DCR because of its infection or bleeding observed in

functional success can be demonstrated approach from nasal side has many cases of acute dacryocystitis so far7,8.

with the functional endoscopic dye test advantages when there is in lammation Similarly silicone intubation appears

(FEDT) (Figure 3). FEDT is performed by outside over the sac area. Nasal mucosa to be safe without any adverse effects

instilling luorescein dye in conjunctival and bone is never in lamed in such such as increase granulation tissue,

sac which is seen lowing through cases and lacrimal sac marsupialization nidus for infection or canalicular cheese

internal common opening and illing helps in internal drainage of abscess wiring4,5,7,8,10.

up the concavity of ostium through the and purulent discharge thus relieving Acute pediatric dacryocystitis

endoscope. the symptoms and signs of acute attack. needs special mention. Mostly acute

18 DOS TIMES - JANUARY-FEBRUARY 2016

OCULOPLASTY

Figure 2: Clinical photograph of a patient presenting with acute dacryocystitis with lacrimal
abscess in which Endoscopic DCR was performed. A: Preoperative photograph showing the
features of acute dacryocystitis. B: Photograph taken at first day postoperative showing marked
resolution of swelling and erythema.

dacryocystitis in cases of congenital REFERENCES Figure 3: Nasal endoscopy view of right nasal
nasolacrimal duct obstruction (CNLDO) cavity showing a large, well healed ostium
in young infants is managed with systemic 1. Ali MJ, Joshi SD, Naik MN, Honavar with positive functional endoscopic dye test
antibiotics and irrigation and probing SG. Clinical pro ile and management (Fluorescein seen) at 3 months follow up.
under endoscopic guidance12. DCR is outcome of acute dacryocystitis: two
indicated in cases with recurrent acute decades of experience in a tertiary Long-term outcomes of powered
attacks in which probing and adjunctive eye care center. Semin Ophthalmol
procedures such as silicone intubation 2015;30:118-23. endoscopic dacryocystorhinostomy
has failed, and for persistent cases of
CNLDO requiring early intraocular 2. Mauriello JA, Wasserman BA. Acute in acute dacryocystitis. Laryngoscope
surgery. Endoscopic DCR because of dacyrocystitis: An unusual case of life
its advantages over external approach threatening orbital intraconal abscess 2015 May 21. [Epub ahead of print].
especially in acute dacryocystitis can with frozen globe. Ophthal Plast
be done in children. Debate exists over Reconstr Surg 1996;12:294–95. 9. Wormald PJ, Kew J, Van Hasselt
minimal age when it can be performed
although it has been performed even 3. Maheshwari R, Maheshwari S, Shah CA. The intranasal anatomy of the
up to 8 months to 1 year age13,14. There T. Acute dacryocystitis causing
are certain challenges in performing orbital cellulitis and abscess. Orbit naso-lacrimal sac in endoscopic
endoscopic endonasal DCR in children 2009;28:196–99.
like narrow nasal cavity, limited working dacryocystorhinostomy. Otolaryngol
space and anatomical variations, but the 4. Wu W, Yan W, Mac Callum JK et
results of endoscopic endonasal DCR are al. Primary treatment of acute Head Neck Surg 2000;123:307–10.
comparable to external approach12,13,14. dacryocystitis by endoscopic
dacryocystorhinostomy with silicone 10. Madge SN, Chan W, Malhotra R, et al.
To conclude endoscopic endonasal intubation guided by a soft probe.
DCR is safe, effective and appear Ophthalmology 2009;116:116-22. Endoscopic dacryocystorhinostomy in
promising for the primary treatment
of acute dacryocystitis with or without 5. Lee TS, Woog JJ. Endonasal acute dacryocystitis: a multicenter case
lacrimal abscess formation. Furthermore dacryocystorhinostomy in the primary
it leads to rapid resolution of symptoms treatment of acute dacryocystitis series. Orbit 2011;30:1-6.
without any recurrence and corrects the with abscess formation. Ophthal Plast
underlying nasolacrimal duct obstruction Reconstr Surg 2001;17:180-3. 11. Nair AG, Ali MJ. Mitomycin-C in
thus relieving epiphora.
6. Kamal S, Ali MJ, Naik MN. Circumostial dacryocystorhinostomy: From
injection of mitomycin C (COS-
MMC) in external and endoscopic experimentation to implementation
dacryocystorhinostomy: ef icacy, safety
pro ile, and outcomes. Ophthal Plast and the road ahead: A review. Indian J
Reconstr Sur 2014;30:187-90.
Ophthalmol 2015;63:335-9.
7. Kamal S, Ali MJ, Pujari A, Naik MN.
Primary Powered Endoscopic 12. Ali MJ. Pediatric Acute Dacryocystitis.
Dacryocystorhinostomy in the Setting
of Acute Dacryocystitis and Lacrimal Ophthal Plast Reconstr Surg 2015;
Abscess. Ophthal Plast Reconstr Surg
2015;31:293-5. 31:341-7.

8. Chisty N, Singh M, Ali MJ, Naik MN. 13. Leibovitch I, Selva D, Tsirbas A,

Greenrod E, Pater J, Wormald PJ.

Paediatric endoscopic endonasal

dacryocystorhinostomy in congenital

nasolacrimal duct obstruction.

Graefes Arch Clin Exp Ophthalmol

2006;244:1250-4.

14. Eloy P, Leruth E, Cailliau A,

Collet S, Bertrand B, Rombaux P.

Pediatric endonasal endoscopic

dacryocystorhinostomy. Int J Pediatr

Otorhinolaryngol 2009;73:867-71.

Financial Interest: The author does not have any ϔinancial interest in any procedure/product mentioned in this manuscript.





















Best Poster Dr. Neha Pathak Misra Eye Hospital, Mansarovar, Jaipur
“One Year Cross-sectional Study of Fundal Changes in Patients Dr. Vijay Kumar Sharma Dr. R.P. Centre, AIIMS, New Delhi
with Pregnancy-Induced Hypertension” Dr. Bhagabat Nayak Dr. R.P. Centre, AIIMS, New Delhi

Best Ophthalmic Photography
Obstetric Corneal Injury with Tomographic Descemetic Microvilli

Best Video
Cionni fixation of capsular bag in pediatric lens subluxation

www. dos-times.org 19

SQUINT & NEURO-OPHTHALMOLOGY

ACCOMMODATION AND VERGENCE DISORDERS

Ramesh Murthy

Spasm of accommodation

Dr. Ramesh Murthy FRCS This can occur because of over stimulation of the
Axis Eye Clinic: Center for Oculoplasty, Squint, parasympathetic nervous system and can be associated with
Pediatric Ophthalmology and Artificial eyes fatigue. Sometimes it is part of the triad – over convergence,
Pune, Maharashtra, India over accommodation and miotic pupils known as spasm of
the near re lex. This can also occur due to cholinergic drugs,
In the present generation where one is hooked onto trauma, brain tumor or myasthenia gravis.
computers and mobiles, the incidence of accommodative
and vergence disorders is on the rise. A high percentage VERGENCE DYSFUNCTION
of computer users have binocular vision problems. The
symptoms commonly associated with these disorders Convergence insufficiency (CI)
are blurred vision, headache, ocular discomfort, The near point of convergence is receded, exophoria
ocular or systemic fatigue, diplopia, motion sickness, loss of
concentration. Children with learning disabilities or dyslexic is present for near, reduced positive fusional vergence and
children need to be evaluated for accommodation and vergence de iciency of negative relative accommodation.
problems. Good binocular skills can also contribute to better
athletic performance too. Divergence excess (DE)
Exophoria or exotropia at far greater than the near
ACCOMMODATIVE DYSFUNCTION
deviation by at least 10 prism diopters (PD). Based on occlusion
this is classi ied as true or simulated DE. In simulated DE,
occlusion increases the angle of deviation signi icantly for near
and slightly for distance. Occlusion does not affect true DE.

Accommodative insufficiency Basic exophoria

The amplitude of accommodation (AA) is lower than the The deviation of a similar magnitude for distance and near.
expected for the patient’s age and is not due to sclerosis of the

crystalline lens. There is poor Convergence excess

accommodative sustaining The incidence of accommodative and The near deviation is at
ability.
vergence disorders is on the rise. A least 3 PD more esophoric than
Ill-sustained the distance deviation. Most
high percentage of computer users commonly there is a high AC/A
accommodation ratio.
have binocular vision problems. The Divergence insufficiency
In this the accommodative symptoms commonly associated with
amplitude is normal but

fatigue occurs with repeated these disorders are blurred vision, The tonic esophoria is high
accommodative stimulation. headache, ocular discomfort, ocular when measured at distance
or systemic fatigue, diplopia, motion but less for near. There is low
Accommodative infacility AC/A ratio and low fusional

Also called as sickness, loss of concentration divergence amplitudes.
accommodative inertia, this

occurs when the accommodative Basic esophoria
system is slow in making a change or when there is a
considerable lag between the stimulus to accommodation and There is a high tonic esophoria at distance, esophoria at
the accommodative response. The distance vision is blurred near and a normal AC/A ratio.

immediately after sustained near work. Fusional vergence dysfunction

Paralysis of accommodation Normal phorias and AC/A ratios but reduced fusional
vergence amplitudes. The zone of clear single binocular vision
In this rare condition the accommodative system fails to is small.
respond to any stimulus. It can be caused by cycloplegic drugs,
trauma, ocular disease like Adie’s pupil or systemic disease like Vertical heterophorias
neuropathy and poisoning. The patient develops a ixed dilated This can be comitant and idiopathic or non comitant due
pupil.
to muscle paresis or other mechanical cause. One of the most
common cause is decompensated fourth nerve palsy where

www. dosonline.org 21

SQUINT & NEURO-OPHTHALMOLOGY

initially the hyper phoria is greatest classi ication of the motor anomalies of Paralysis of accommodation
during depression and adduction, over the eye, based on physiologic principles.
time there is contracture of the inferior Part 2. Pathology. Ann Ophthalmol A non presbyopic patient loses
oblique muscle and the deviation is Otolaryngol 1897; 6:247-60 the ability to accommodate either
greatest in adduction and elevation of the monocularly or binocularly. There is
affected eye. PREVALENCE blur due to failure to accommodate with
associated micropsia.
MODIFIED DUANE CLASSIFICATION Accommodative dysfunction has
SYSTEM* been reported to occur in 60 to 80 Spasm of accommodation
percent of patients with binocular vision
Convergence insufficiency problems. Convergence insuf iciency (CI) The accommodative system over
is the most common vergence anomaly. accommodates for a stimulus. Distance
• X < X’ The median prevalence of CI in the vision is usually impaired. This can occur
• Low AC/A ratio population is 7 percent. following LASIK, multiple sclerosis and
• Receded near point of closed head injury.
RISK FACTORS
convergence Convergence insufficiency (CI)
• Reduced fusional convergence Indiscriminate use of the computer
and mobiles and prolonged near work The most common symptoms are
Divergence excess at has emerged as leading risk factor for blurred vision, diplopia, gritty sensation
binocular vision disorders. Defects in the eyes, discomfort associated with
• X > X’ in vergence may also be the result of near work, frontal headache, heavy
• High AC/A ratio trauma and certain systemic diseases. eyelids, loss of concentration, sleepiness,
• High tonic exophoria For example, CI and fourth nerve palsy general fatigue, nausea and dull ocular
• Large exophoria/tropia are common after closed head trauma, discomfort. Children with ADHD
especially in the presence of a concussion. (attention de icit hyperactivity disorder)
distance CI is the most common vergence have CI. Most patients have reduced PFC
dysfunction found with Graves disease. (10 PD or less). Symptomatic patients
Basic exophoria Myasthenia gravis may present as a CI have poor prism adaptation and slow
or any other fusional vergence disorder. vergence ability. The NPC is receded in
• X = X’ Fusional vergence disorders are often most patients. Other indings include low
• Normal AC/A ratio associated with Parkinson disease and AC/A ratio, low NRA and failure with the
Alzheimer disease. +/-2.00 accommodative facility test.
Convergence excess
SIGNS AND SYMPTOMS The convergence insuf iciency
• E < E’ symptom survey (CISS) has 15 questions
• High AC/A ratio Accommodative insufficiency designed to quantify symptoms associated
with reading and near work. The CISS is a
Divergence insufficiency Patients complain of blurred vision, valid and reliable instrument that can be
dif iculty reading, poor concentration and used clinically and for research.
• E > E’ headaches. The AA is less than expected
• Low AC/A ratio for the patient’s age. They fail the +/-2.00 Divergence excess
• High tonic esophoria D lipper test and have positive relative
accommodation (PRA) under -1.50 D. The patient may be asymptomatic
Basic esophoria Asthenopia occurs after prolonged near especially when there is suppression or
work. anomalous correspondence. Occasionally
• E = E’ the patient may close an eye in bright
• Normal AC/A ratio Ill – sustained accommodation sunlight. Sometimes the patient
complains of distance blur when they
Vergence insufficiency The most common complaint is over accommodate to keep their eyes
blurred vision after prolonged near aligned.
• Normal AC/A ratio work. It is similar to accommodative
• Restricted fusional vergence insuf iciency except the AA is normal, the Basic exophoria
patient fails the +/-2.00 D lipper test and
amplitudes has decreased PRA. The symptoms are due to asthenopia
• Steep ixation disparity curve or the patient is aymptomatic
Accommodative infacility
Vertical phorias Convergence excess
After prolonged near work, their
• Comitant deviations distance vision is blurred or after Symptoms include blurred vision,
• Noncomitant deviations prolonged distance viewing their reading diplopia, headaches and dif iculty
• Old decompensated 4th nerve is blurred. The patients fail the +/-2.00 D concentrating on near tasks. Symptomatic
accommodative facility test monocularly patients have low fusional divergence
palsies and binocularly. They have normal AAs, amplitudes and PRAs in relation to their
• Newly acquired 4th nerve but abnormal PRA and NRA (positive and near point demands.
negative relative accommodation).
palsies
X = exophoria at distance; E =
esophoria at distance;
X’ = exophoria at near; E’ = esophoria
at near.
*Modi ied from Duane A. A new

22 DOS TIMES - JANUARY-FEBRUARY 2016

SQUINT & NEURO-OPHTHALMOLOGY

Divergence insufficiency Expected Values for Accommodation and Vergence Testing*

These patients have reduced fusional Measurement Mean S.D. Range
divergence amplitudes at distance and
low AC/A ratios. They report diplopia or Distance
blur for distance.
Phoria 1X 2X 0-2X
Basic esophoria
Base-in blur — — —
These patients are symptomatic
only when their fusional divergence Base-in break 7 3 5–9
amplitudes are not large enough to
compensate for the esophoria. Symptoms Base-in recovery 4 2 3–5
are not present in the patient who
suppresses. Base-out blur 9 4 7−11

Fusional vergence dysfunction Base-out break 19 8 15−23

Some of the patients present with Base-out recovery 10 4 8−12
asthenopia. They have reduced fusional
vergence for convergence and divergence. Near

Vertical heterophoria Phoria 3X' 5X' 0−6X

Diplopia is usually the presenting Base-in blur 13 4 11−15
symptom. Patient may also have a head
tilt or asthenopia trying to maintain Base-in break 21 4 19−23
single binocular vision.
Base-in recovery 13 5 10−16
EVALUATION
Base-out blur 17 5 14−20
History
Base-out break 21 6 18−24
Common questions which need to be
asked include Base-out recovery 11 7 7−15
1. Do your eyes bother you? If yes, how
PRA -2.25 0.50 -1.75 – +2.25
often and under what circumstances?
2. How do your eyes bother you? NRA +2.00 1.1 +1.75 − 2.25

Do you experience eyestrain, Gradient AC/A 4/1 2 3−5
fatigue, headaches, sleepiness, etc.,
associated with near tasks? AA 16 − (0.25 × age) ±2.00 ±1.00
3. Do you ever get headaches? If yes,
explore further (e.g., frequency, *Modiϔied from Morgan MW. Analysis of clinical data. Am J Optom 1944; 21:477-91.
location, type, and associated AA = amplitude of accommodation; AC/A = accommodative convergence/ accommodation
activities). ratio; NRA = negative relative accommodation; PRA = positive relative accommodation; X =
4. How long can you read comfortably? exophoria at distance; X' = exophoria at near.
Have the patient specify an actual
time. After the patient’s distance correction facility- Accommodative Amplitude
5. When you read, does the print ever (AA) may be measured monocularly,
blur, double, or move around? is established, he or she is instructed using either the push-up or the
6. Do you experience car or motion minus lens method. Generally, the
sickness? to view small letters on a card 40 optometrist uses a 20/20 to 20/30
target and notes the irst sustained
Examination cm from the eyes. The examiner blur. Accommodative facility testing
can be performed using a +/−2.00
1) Visual acuity – check for near and adds lenses in +0.25 increments D lens lipper or a phoropter. The
distance. If monocular is better patient should be able to clear
suspect binocular vision disorder. until the patient irst reports that these lenses monocularly within
11 cycles per minute without
2) Refraction – look for latent they become blurry. Heterophoria evidence of fatigue. Some clinicians
hyperopia; if accommodation more advocate using a+/−1.50 D lens test,
consider cycloplegia. should be measured irst followed because it can be done easily in the
phoropter and normal patients are
3) Ocular motility and alignment by divergence amplitudes and less likely to fail it. Patients with
4) Near point of convergence – break accommodative infacility frequently
convergence amplitudes. report intermittent blurred vision
and recovery should be recorded. and asthenopia after near work.
Can use a red lens over one eye and 6) Relative accommodation Symptomatic patients demonstrate
testing repeated several times. reduced accommodative facility on
5) Near fusional vergence amplitudes- measurements- Positive relative

accommodation (PRA) A measure

of the maximum ability to stimulate

accommodation while maintaining

clear, single binocular vision.

Negative relative accommodation

(NRA) A measure of the maximum

ability to relax accommodation while

maintaining clear, single binocular

vision.

7) Accommodative amplitude and

www. dosonline.org 23

SQUINT & NEURO-OPHTHALMOLOGY

the +/−2.00 D lipper test. removed before an accommodative blurred vision, headaches, asthenopia,
8) Stereopsis response occurs. For most patients, diplopia, loss of concentration, motion
9) Fundus examination and systemic the lag is between approximately sickness, and fatigue. Such symptoms
+0.25 D and +0.75 D. A lag of may interfere with school or work
health screening greater than +1.00 D is often found performance and thus decrease a patient’s
10) Accommodative convergence to in individuals with accommodative quality of life. Most accommodative and
insuf iciency or infacility, suggesting vergence dysfunctions respond to the
accommodation ratio ( AC/A ratio) the use of plus lenses at near. A lag appropriate use of lenses, prisms, or
Distance Near method: AC/A ratio = of −0.25 D or more usually indicates vision therapy. It is medically necessary
convergence demand of near target − Hd accommodative excess. to diagnose the condition accurately,
+ Hn stimulus to accommodation of near to discuss the diagnosis and the risks
target Management and potential bene its of existing
Where Hd = distance heterophoria, treatment options with the patient, and
Hn = near heterophoria. With this formula, • Convergence insuf iciency: Vision to initiate treatment when appropriate.
an esophoria is a plus value, while an therapy; prisms Management, including lenses, prisms,
exophoria is a minus value. Convergence and vision therapy, is not age restricted.
demand is calculated by dividing the IPD • Divergence excess: Vision therapy; Vision therapy can be given at any age. In
by 4 (e.g., 60/4 = 15). prism; minus lenses some cases, the best treatment includes
Alternatively, AC/A ratio = IPD (cm) a combination of lenses, prisms, and/or
+ N (Hn-Hd); Where N is the near ixation • Basic exophoria: Prism; vision vision therapy. Proper treatment usually
distance in meters. therapy results in rapid, cost-effective, and
Gradient method: AC/A ratio = permanent improvement in visual skills.
heterophoria 1 - heterophoria 2 / lens • Convergence excess: Plus lenses;
power (D) vision therapy REFERENCES
11) Distance fusional vergence
amplitudes-to be performed when • Divergence insuf iciency: Vision 1. Eye based upon physiologic principles.
there is signi icant heterophoria for therapy; prism Part 2. Pathology. Ann Ophthalmol
distance. 1897; 6:247-60.
12) Vergence facility - Prism lippers • Basic esophoria: Prism; vision
may be used to test vergence therapy 2. Cooper J, Duckman R. Convergence
facility. Normative values have been insuf iciency: incidence, diagnosis, and
established for 16 PD BO and 8 PD BI • Fusional vergence dysfunction: treatment. J Am Optom Assoc 1978;
prisms. The normal values for adults Vision therapy 49:673-80.
is 7 cpm. Mean values are 8 cycles
per minute (cpm) for children ages • Vertical phorias: Prism; vision 3. Cooper J, Medow N. Major review:
5-8 years and 13 cpm for children therapy intermittent exotropia; basic and
ages 7-14 years. divergence excess type. Binocul
13) Accommodative lag - The lag of • Accommodative insuf iciency: Vision Vis Eye Muscle Surg Q 1993; 8(3
accommodation is the difference therapy; plus lenses suppl):187-216.
between the stimulus of
accommodation and the response. • Ill-sustained accommodation: Vision 4. Von Noorden G. Binocular vision and
MEM retinoscopy is performed therapy; plus lenses ocular motility, 5th ed. St. Louis: CV
while having patients read grade- Mosby, 1996:129.
level words at their habitual near • Accommodative infacility: Plus
working distance. The clinician lenses; vision therapy 5. Scheiman M, Wick B. Clinical
rapidly interposes a lens in front management of binocular vision:
of the eye being evaluated and • Paralysis of accommodation: Optical heterophoric, accommodative, and eye
estimates the motion of the light correction movement disorders. Philadelphia: JB
re lex. Lenses of various power are Lippincott, 1994:310.
brie ly interposed in this manner • Spasm of accommodation: Plus
until neutrality is found. Each lens is lenses; vision therapy; cycloplegic 6. Raskind R. Problems at the reading
drug distance. Am Orthopt J 1976; 26:53-9.

CONCLUSION 7. Brown B. The convergence insuf iciency
masquerade. Am Orthopt J 1990;
Accommodative and vergence 40:94-7.
dysfunction comprises a group of
neuromuscular disorders that may occur 8. Care of the patient with accommodative
at any time after the normal development and convergence dysfunction.
of binocular vision (6 months of age). American Optometric Association
These anomalies may cause a host of guidelines. 2011.
symptoms, including, but not limited to,

Financial Interest: The author does not have any ϔinancial interest in any procedure/product mentioned in this manuscript.

24 DOS TIMES - JANUARY-FEBRUARY 2016

SNAPSHOT

MYCOTIC KERATITIS CAUSED BY SCEDOSPORIUM
APIOSPERMUM: A CASE REPORT

Anil Kumar Verma, Anuradha Sood, Rajeev Tuli, Anil Chauhan

Fungal corneal ulcer is an important ophthalmic Scedosporium apiospermum is a
problem in the developing world. The most ubiquitous ilamentous fungus and is
common ilamentous fungi that cause keratitis found in soil, polluted water and decaying
are Aspergillus and Fusarium. Newer and rare vegetable matter. Scedosporium
fungi are being reported all over the world. We apiospermum is a rare pathogen, but
report a rare case of fungal corneal ulcer caused it should be considered as a potential
by Scedosporium apiospermum which worsened on empirical pathogen in patients presenting with
treatment but was successfully treated with 1% of topical corneal ulcer with no improvement
voriconazole. despite conventional antifungal agents
like natamycin. It is a well known fact that
INTRODUCTION Scedosporium apiospermum keratitis
is dif icult to treat and has high level of
Fungal infections of the eye are recognized as an important antifungal resistance.
cause of morbidity and blindness world wide. Newer and rare
fungi are being reported all over the globe. Fungal keratitis forti ied tobramycin 1.3%, atropine 1% and pressure lowering
represent one of the most dif icult forms of microbial eye oral acetazolamide 250 mg tid. After 7-10 days incubation
infections to diagnose and treat successfully. It shows greater growth was obtained on plain SDA (without cycloheximide). It
morbidity than bacterial keratitis because of delayed diagnosis was spreading white, cottony growth initially which eventually
and available drugs may not be effective. Scedosporium turned to a brownish colour. Microscopic morphology on LCB
apiospermum is a ubiquitous ilamentous fungus and is mount showed septate Hyphae (2-4μm) with conidiophores
found in soil, polluted water and decaying vegetable matter. bearing oval conidia (5-10μm) at the apex (lollipop like
Scedosporium apiospermum is a signi icant opportunistic agent conidiophores) (Figure 2). Conjunctival swab of left eye did not
with very high levels of antifungal resistance. Scedosporium show any signi icance. After culture report topical natamycin
apiospermum and its sexual form, Pseudallescheria buydii
have been identi ied as emerging opportunistic pathogen
responsible for mould infection in immuno-compromised
and occasionally immuno-competent patients. In our case the
patient was an immuno-competent person1,2,3.

CASE REPORT

A 64 year old male, driver by profession presented with Figure 1
red ness, watering and foreign body sensation in his right
eye for last 6 days. There was no history of trauma, diabetes
mellitus or immuno-compromise state. He gave history of use
of eye drops for last 6 days for acute red eye. On examining
the eye drops which he was using was antibiotic and steroid
combination. On slit-lamp examination it was seen that ulcer
had irregular and feathery margins with satellite lesions
(Figure 1). On day of presentation, after taking all aseptic
precautions corneal scrapings were collected from right eye
and conjunctival swab from left eye. The corneal scrapings were
immediately inoculated on 5% sheep blood agar, chocolate agar
and two sets of Sabouraud’s dextrose agar with and without
antibiotics. Plates of 5% sheep blood agar and chocolate agar
were kept at 37o C for 48 hours for any bacterial growth. One
set of SDA tubes was kept at 37o and the other at 25o for 3
weeks. Direct microscopic examination with 10% potassium
hydroxide mount (KOH 10%) and Gram stain was also done.
No fungal hyphae were seen on direct microscopy. Patient was
put on empirical treatment with topical forti ied cefazoline 5%,

www. dos-times.org 25

SNAPSHOT

Figure 2 Figure 3

5% was added to the above treatment. turnover and ocular toxicity. Patients with reports of treatment with voriconazole
But the corneal ulcer did not improve and corneal ulcer may continue to lose vision suggest that it may be used safely and
oral itraconazole 100 mg bid was added and suffer ocular pain and discomfort. effectively against a broad range of fungal
to the above treatment after obtaining Correct identi ication of infectious agent pathogens. Topical voriconazole 1% has
liver function test. Even with this regime supports a more effective treatment. A to be freshly prepared using injection
corneal ulcer neither improved nor did range of treatments have been suggested voriconazole and water for injection. This
it show signs of progression. Patient was for use in fungal keratitis including preparation has to be stored between
discharged on request. He continued natamycin, azoles such as luconazole 2-80 C. It is also available in the market
with the treatment at home. But when and voriconazole. The molecular weight as a dry lyophilized powder 30 mg in a
he reported back after about 10 days the of natamycin is relatively high (665.73g. vial (Vozole by Aurolab) which is used
cornea had perforated but it was a sealed mol-1) and as a consequence it has low as eye drops after adding 3ml water for
perforation with hypopyon of height penetration into corneal tissue. This injection. It has the advantage that it does
1mm. Patient was re-admitted in the may explain the reduced effectiveness. not require refrigeration4,5,6,7,8.
hospital as indoor patient and he was put All though natamycin is widely used as
on topical voriconazole 1% in addition to irst line therapy for ilamentous fungal Based on recent case reports
above treatment and topical natamycin keratitis, primary treatment failure has voriconazole appears to have a
was discontinued. Corneal ulcer started been reported in 31.3% of cases in a remarkably broad spectrum of activity,
showing signs of improvement and study of 115 patients by Lalitha P etal. which includes against Candida, Fusarium,
it healed within next 4-6 weeks with Namperumalsamy V. Pranja et al in their Aspergillus, Curvularia, Paecilomyces
remaining squeal of dense vascularized study compared the clinical outcome of and Scedosporium apiospermum.
corneal opacity (Figure 3). treatment with topical natamycin and Scedosporium apiospermum is a rare
topical voriconazole for fungal keratitis pathogen, but it should be considered as a
DISCUSSION in 120 patients and concluded that potential pathogen in patients presenting
there was no signi icant differences in with corneal ulcer with no improvement
Worldwide the incidence of fungal visual acuity, scar size and perforations despite conventional antifungal agents
keratitis is rising and current therapies between voriconazole and natamycin like natamycin. It is a well known fact that
are often ineffective. Initial management treated patients. We suggest that if Scedosporium apiospermum keratitis
of corneal ulcer is empiric with broad- clinically patient is not improving with is dif icult to treat and has high level of
spectrum topical antimicrobials, as with the natamycin, the treatment should be antifungal resistance. And we suggest
current microbial investigations it can take immediately switched over to topical that topical application of voriconazole
even days or weeks to identify a causative voriconazle (1%). S M Hariprasad et 1%, may be a good alternative for these
organism. The topical therapy has its al reviewed the current literature and patients9,10,11,12.
limitations, including the rapid loss of the concluded that over 40 clinical case
drug caused by drainage and high tear

Department of Ophthalmology DRPGMC Kangra at Tanda ( H.P.)

Dr.Anil Kumar Verma Dr.Anuradha Sood Dr. Rajeev Tuli Dr.Anil Chauhan

26 DOS TIMES - JANUARY-FEBRUARY 2016

SNAPSHOT

REFERENCES 5. Karsten E, Watson SL, Foster LJR. Edition. Saunders Elsevier Canada
Diversity of Microbial Species 2008. Chapter 51 Fungal Keratitis. 715-
1. Ozkan A, Susever S, Erturan Z, Uzun M, Implicated in Keratitis: A Review. 21.
Alparslan N, Oz Yasemin et al. A case The Open Ophthalmology Journal 10. Lee S, Lee DW, Lee HS, and You Ic. A
of keratitis caused by Scedosporium 2012;6:110-24. case of fungal keratitis Scedosporium
apiospermum. Journal of Microbiology apiospermum. J Korean Ophthalmol
and Infectious Diseases 2013;3:45-48. 6. Lalitha P, Prajna NV, Kabra A, Soc. 2014; 54: 675-79.
Mahadevan K, Srinivasan M. Risk 11. Guarro J, Kantarcioglu AS, Horre R,
2. Sun Q, Xu X, Zhang Q, Wang H, and Liu Y. factors for treatment outcome in Rodriguez-Tudela JL, Cuenca Estrella
Diagnostic direct DNA sequencing and fungal keratitis. Ophthalmology M, Berenguer J etal. Scedosporium
systemic treatment with voriconazole 2006;113:526-30. apiospermum: changing clinical
in Scedosporium apiospermum spectrum of a therapy-refractory
keratitis ? A case report. Clinical and 7. Prajna NV, Mascarenhas J, Krishnan opportunist. Med Mycol 2006; 44: 295-
Experimental Ophthalmology 2013; 4. T, Reddy R, Prajna L, Srinivasan M, 327.
etal. Comparision of natamycin and 12. Espinel-Ingroff A, Boyle K, Sheehan
3. Fadzillah MT, Ishak SR and Ibrahim voriconazole for the treatment of DJ. In vitro antifungal activities of
M. Refractory Scedosporium fungal keratitis. Arch Ophthalmol voriconazole and reference agents
apiospermum keratitis successfully 2010;128:672-678. as determined by NCCLS mehods:
treated with combination of review of literature. Mycopathologia
Amphotericin B and Voriconazole. Case 8. Hariprasad SM, Mieler WF, Lin TK, 2001;150:101-15.
reports in Ophthalmological Medicine Sponsel WE, Graybill JR. Voricanzole
2013. in treatment of fungal eye infections:
a review of current literature. Br J
4. Kakhandaki A, Mukthayakka G, Nithisha Ophthalmol 2008;92:871-78.
TM, Nanda S. Fungal keratitis caused by
Scedosporium apiospermum. Medica 9. Denis O’Day. Albert Jakobiec’s Principles
Innovatica 2013;2:105-107. and Practice of Ophthalmology. Third

Financial Interest: The authors do not have any ϔinancial interest in any procedure/product mentioned in this manuscript.

www. dos-times.org 27

INNOVATIONS

A NOVEL TECHNIQUE FOR WOUND LEAK AFTER
PHACOEMULSIFICATION

Rashmi Saraff, Keshab Haldar

Wound burn is a serious complication However many cataract surgeons occasionally encounter this
that occurs not so frequently during potentially devastating complication. Various methods have
phacoemulsi ication surgery. A large been described to manage such leaky wounds. Conventionally
cross-sectional study conducted in USA the wound is closed with interrupted radial suture. But
and Canada documented an incidence multiple tight sutures may be needed. That can cause very high

of 0.037 percent1. Another study in USA astigmatism. Sometimes even multiple sutures may not achieve

reported an incidence of 0.098 percent2. It may be rare but a watertight closure. The patient may have leaky wound with

when it occurs it can be dif icult to manage and the end results positive Siedel’s test on irst postoperative visit. If the leak is

can be less than satisfactory due to residual high astigmatism3. small it can be managed by a bandage contact lens or tissue

Wound burn is caused by overheated phaco tip. The low of adhesives. Aqueous suppressants and frequent antibiotic drops

luid around the tip due to irrigation and aspiration helps to may be needed. Daily follow ups may be required. If the wound

maintain the tip temperature at a safe level. But if the tip is continues to leak, a wound revision may be necessary. Instead

heated beyond 60°C burn can occur1. of radial suture gape suture has been tried5. These are mattress

Various factors can cause rise in tip temperature. Proper sutures which are parallel to the limbus and passed through the

setting up of the phacomachine and the tubings are important anterior and posterior lips to appose them. Gape sutures may

as a kink in a tube can reduce the low and make the tip heated cause less astigmatism compared to radial sutures however,

up. If the wound construction In this article a novel technique for patients may subsequently
is not proper, the tight opening require treatment for high
can force the tip to be in close management of wound leak is elaborated. residual astigmatism. In severe
contact with the corneal tissue cases wound may not close with
with a reduced low around it. This technique predictably achieves a any suture and corneal patch
The same situation can arise if sealed wound on table. Frequent follow graft may be needed5.

the operating angle is awkward up visits, repeated procedure in OT, delay In short, managing such a

as in case of a deep set eye. If in visual recovery can make a patient case can be dif icult. Patients
the phaco tip is fully occluded may require frequent post- op
the out low stops. Consequently worried. All of those dif iculties can be visits and may need further
the in low also stops. Continued procedures in the operation
phaco with an occluded tip can avoided with the use of this technique theatre. Extra medicines may be

cause severe burn very quickly. required. Visual recovery may

OVDs with higher viscosity are take longer time and end result

known to obstruct the tip and reduce the low of luid through may not be very satisfactory. In this article we will describe a

the tubings. new technique which we have effectively used to treat such

It is important to maintain a proper low through the cases.

system. Keeping a vigil at the drip chamber ensures that

the low remains continuous. The Surgeon needs to stop DESCRIPTION OF THE TECHNIQUE

phaco whenever there is occlusion of the tip and remove the Step I (Conjunctival flap)
obstruction before proceeding. Eye should not be over illed
with OVD before phaco and part of OVD should be aspirated, When the wound burn is diagnosed care is taken to
before emulsifying the nucleus. During surgery one should prevent any further damage. After insertion of the IOL, chamber
remember that appearance of milky luid around the tip is an is formed with BSS or viscoelastic substance. The wound is
important indicator of rising tip temperature4. Subsequent assessed. A horizontal mattress suture is planned across the
tissue damage causes ish mouthing of the wound which is wound (Figure 1). A fornix based rectangular conjunctival
dif icult to close. Fluid continues to leak through the wound lap is raised (Figure 2). Sideways, it should extend 1 to 2 mm
with shallowing of anterior chamber and it becomes impossible extra on either side of the wound. The lap should comprise of
to achieve a watertight closure. The condition may worsen over conjunctiva and tenon. It is separated from underlying sclera. It
next few days when tissue contracture causes the wound to is pulled down to see if it adequately covers the wound.

gape even further. Step II (Passing the suture)
With improvements in technology and better The suture can be passed using either a double armed or

understanding of the luidics wound burn has become very rare.

www. dos-times.org 29

INNOVATIONS

Figure 1: Planning of the suture. The extent of the flap is marked. Figure 2: The conjunctival flap is raised.

a single armed 10-0 mono ilament nylon
suture. Two points are marked on the
epithelial side of the conjunctival lap
(Figure 3 a-f). They should be at the middle
of the lap, at the same level and a few mm
apart. They should be at least 2 mm away
from the free limbal margin. A double
ended 10-0 mono ilament nylon suture
is taken. Each needle is passed through
each conjunctival point from epithelial
side coming out through the stromal side.
Next a corneoscleral bite through the
wound is passed with one of the needles,
from corneal to scleral side. Then the
second corneoscleral bite is passed in
the same direction with the other needle.
The 2 bites should be parallel to form a
mattress suture across the wound. The
suture can also be placed with a single
arm suture. Here, one sclerocorneal bite
is taken irst from limbal to corneal side.
After that the suture is passed through
the two points in the conjunctiva. Then
the second corneoscleral bite is taken
from corneal to limbal side.

Step III (Tying the suture) Figure 3: The double ended 10-0 monofillament nylon suture is passed. Conjunctival bites (a-b),
first corneoscleral bite (c-e) and second corneoscleral bite (d-f) are shown. The ends e and f are
The suture ends are then pulled to tied to complete the suture. Alternatively a single arm suture is passed e-c, a-b, d-f, then e and f
cover the wound with conjunctiva. The are tied.
lap should cover the wound completely.
Then the ends are tied keeping the lap in

Currae Eye Care Hospital, 1A Acharya Jagadish Chandra Bose Road, Kolkata

Dr. Rashmi Saraff MD, FRCSEd Dr. Keshab Haldar MD, FRCSEd

30 DOS TIMES - JANUARY-FEBRUARY 2016

INNOVATIONS

place. The knot is automatically utilised to close the wound
covered by the conjunctiva with optimum tension. We
(Figure 4). have followed up two patients
for over four years. We have
RESULTS not found any untoward
incidences.
From March 2011 to Dec
We would like to
2012, we encountered ive eyes highlight here that in all our
cases, sutures were applied in
in ive patients, with wound burn superior wounds. In temporal
wounds the effect of gravity
during phacoemulsi ication, or the effect of lid movement
may be different compared
where we applied this suture. to the superior wounds.
Consequently the suture
Patients were examined next may not work effectively on
temporal wounds.
day when the bandage was
With this technique, it
removed. Subsequently they is possible to get predictable
results in all cases. The size
were followed up after one of the lap may need to be
modi ied according to the
week, two weeks, four weeks size and severity of the burn.
By changing the width of the
and six weeks post-op. Slit lamp lap a larger wound can be covered. By
modifying the length and hinging points
examination including Siedel’s of the lap, the tension on the wound can
be modi ied. To conclude we feel that
test was done in all post- unless there is extensive tissue damage,
this suture can successfully manage any
operative visits. The sutures wound burn and wound leak patient with
comfortable post-operative recovery and
were removed between 2 to satisfactory visual outcome.

4 weeks. Final refraction was Figure 4: The suture after completion. REFERENCE

done at 6weeks. 1. Sorensen T, Chan CC, Bradley M, Braga-Mele
R, Olson R J. Ultrasound-induced corneal
Since the cataracts were incision contracture survey in the United
States and Canada. Journal of Cataract &
advanced in all the cases pre-operative during phacoemulsi ication. Apart from Refractive Surgery. 2012; 38:227-33.
refractive data were not available. All wound burns, this suture can also be used
5 cases had age related cataract. 2 to treat leaking wounds due to any other 2. Bradley MJ, Olson RJ. A Survey about
cases had grade III and 3 had Grade IV cause. Phacoemulsi ication Incision Thermal
cataracts. 4 patients were male and one Contraction Incidence and Causal
patient was female. Average Age was 67. Two factors help to seal the wound. Relationships. American Journal of
All cases had clear corneal incision. At the Firstly the conjunctival lap covers the Ophthalmology. 2006; 141:222-24.
end of the procedure watertight wound external opening of the wound directly
was achieved in all cases. Subsequently and seals it. Secondly it maintains an 3. Sugar A, Schertzer RM. Clinical course of
Siedel’s test was negative in all cases in optimum pull to appose the wound which phacoemulsi ication wound burns. J Cataract
subsequent visits. Post-operatively best is neither too tight nor too loose. As the Refract Surg. 1999; 25:688-92.
corrected visual acuities were 6/6 in all healing takes place post- operatively,
cases. In the inal refraction at 6 weeks, conjunctiva tends to go back to its original 4. Kohnen T, Wang L, Friedman NJ, Koch
one case had no residual astigmatism. position at the limbus, the loop of the DD. Complications of cataract surgery.
Three patients had 0.5 D and one patient suture hinged to the conjunctiva is pulled In: Yanoff M, Duker JS, Augsburger JJ, eds,
had 1D residual astigmatism. Post- up. The conjunctiva provides a spring-like Ophthalmology, 3rd Edition. Mosby Elsevier.
operative recovery was uneventful in all suspension and exerts constant apposing 2009; 484-92.
cases. tension to keep the wound closed. For
this reason the suture does not need to 5. Sippel KC, Pineda R. 2002.
Phacoemulsi ication and thermal wound
DISCUSSION be very tight. As a result the astigmatism injury. Semin Ophthalmol. 2002; 17:102-109.

remains low from the early post-operative 6. Khodabakhsh AJ, Zaidman G, and
Tabin G. Corneal surgery for severe
In this article we have shared period. We recommend suture removal phacoemulsi ication burns. Ophthalmology.
2004; 111:332-34.
our experience of a novel technique after one month. The conjunctiva does
7. Haldar K, Saraff R. Closure technique for
developed by us7. This technique not permanently remain hanging over the leaking wound resulting from thermal
injury during phacoemulsi ication. Journal
predictably achieves a sealed wound superior cornea. After suture removal, of Cataract & Refractive Surgery. 2015;
40:1412-4.
on table. Frequent follow up visits, the conjunctiva gradually retracts back to

repeated procedure in OT, delay in visual the limbus.

recovery can make a patient worried. One apprehension was that covering

All of those dif iculties can be avoided the gaping wound with conjunctiva may

with the use of this technique. Patient’s cause epithelial or ibrous down growth.

vision remains clear from early post- However I think ibrous down growth

op period. Refraction stabilises within is unlikely to occur as the technique

six weeks of surgery with relatively low achieves a watertight closure on table.

astigmatism. Considering all these factors This not achieved by plugging a gaping

we feel this is better than other available wound with conjunctival tissue. Instead

techniques for treating wound burns the tensile strength of the conjunctiva is

Financial Interest: The authors do not have any ϔinancial interest in any procedure/product mentioned in this manuscript.
www. dos-times.org 31

INNOVATIONS

SMARTPHONES AND DIAGNOSTIC MICROBIOLOGY: SIMPLE
INNOVATIONS IN OPHTHALMIC BASIC SCIENCE

Pooja Bandivadekar, Tushar Agarwal

Use of smartphones in ophthalmology has grown The pocket magni ier is a battery operated device with
exponentially in past 5 years. As a single hand- a plastic body measuring 8.2 x 3.0 x 1.8 cm in size 10. It has
held device, it can be used for diagnostic imaging an ‘eye piece’ where the smartphone camera aperture can
and documentation of corneal as well as retinal be placed. Opposite the aperture is the ‘objective complex’
pathologies1,2,3. Smartphone cameras coupled with a central lens surrounded by LED (light emitting diodes)
with slit-lamp are increasingly being used for encased in a transparent plastic box. This plastic box lies in
anterior segment imaging. Similarly, coupling with aspheric contact with the glass slide. The pocket camera has two spin
20 or 28 diopters lenses allows retinal imaging including wheels, one for adjusting the optical zoom (100 x ) and other
peripheral retina1. Relaying of images by trained technician for adjusting illumination. Serial photographs with autofocus
using a smartphone has revolutionized telemedicine and public are obtained from different areas of the slide in a contiguous
health care delivery3. Patient education and maintenance of manner. The images (Figure 2&3) are concurrently reviewed
administrative records can be facilitated by smartphone usage. on the smartphone screen, and digital magni ication using the
Smartphone based apps allow calculation of intraocular lens smartphone pinch-to-zoom function is obtained in an area
(IOL) power in both adult and pediatric patients, marking for suspicious of fungal hyphae.
toric IOL, near and distance visual acuity assessment as well as
colour and contrast assessment. APPLICATION

The use of smartphone for clinical and administrative Suppurative keratitis is commonly caused by bacterial
uses is well described. However, its application in para-clinical or fungal infection, rarely parasitic. Anti-bacterial therapy
and basic sciences is yet to be explored as point-of-care
diagnostics. Previously, smartphone use has been extensively
used in assessing malarial parasites in blood ilms4,5,6. Its use
for assessing reagent reactions in ield of biochemistry is also
well known. We describe a technique using combination of
pocket magni ier and a smartphone camera to directly detect
fungal hyphae in smear prepared from corneal scraping.
This prototype system uses an economical pocket magni ier
with smartphone, without any additional micro-sensors or
luorescent-tagging.

TECHNIQUE OF OBTAINING DIGITAL IMAGE

Smear prepared from corneal scraping is stained with
Gram’s stain and a 10% KOH mount is also prepared. Cover
slips are placed on both the slides. Digital photographs of the
slides are acquired using a smartphone camera through the
pocket magni ier (Figure 1).

The use of smartphone for clinical and Figure 1: Pocket magnifier used to capture images from the slide
administrative uses is well described. www. dos-times.org 33
However, its application in para-clinical
and basic sciences is yet to be explored
as point-of-care diagnostics. Previously,
smartphone use has been extensively
used in assessing malarial parasites in
blood ilms

INNOVATIONS

Figure 2: Aspergillus fumigatus from a culture
sample stained with Lactophenol Cottonblue
and captured using smartphone-pocket
magnifier assembly (Pilot Case).

is often initiated empirically. However, Figure 3(a-c): are photographs of smear stained with Gram’s stain and captured using the
it is essential to make a diagnosis of smartphone-pocket magnifier assembly. Figure 3a: has been captured with the optical
keratomycoses based on light microscopy, magnification set at 100 x in the pocket magnifier. Figure 3b: represents digital magnification of
confocal microscopy or culture to initiate Figure 3a: by 50% and Figure 3c: represents digital magnification by 100%. Figure 3d: (optical
speci ic therapy. The average size of a magnification 100x), Figure 3e: (digital magnification by 50%), Figure 3f: (digital magnification by
ilamentary fungus varies from 2-10 μ in 100%) are photographs obtained from corneal scraping of another patient using the lactophenol
width. Using the optical magni ication of cotton blue stain.
the pocket- magni ier (100-160 x), fungal
hyphae can be identi ied with relative a tertiary health care center. Image REFERENCES
ease on the smartphone display. The cost acquisition and relay at microscopic level
of the pocket-magni ier is around Rs.700. has been a major lacuna for telemedicine. 1. Yen, M. et al. Telemedicine Diagnosis
Our technique uses Gram’s staining, 10% This technology helps us bridge the same. of Cytomegalovirus Retinitis by
KOH, glass slide and cover slip which Nonophthalmologists. JAMA Ophthalmol.
are inexpensive, readily available and This is a preliminary step in digital (2014).
used abundantly during routine light imaging of infectious organisms using
microscopy. There is no requirement readily available and handy equipment. 2. Peeler, C. E. et al. Telemedicine for corneal
for special dyes or immune-labeling as Re inement in technology, equating to disease in rural Nepal. J. Telemed. Telecare
described in previous studies, keeping better lens quality, improved shutter (2014).
the recurring costs minimal. speeds and sensors would eventually
translate into images with better 3. Morse, A. R. Telemedicine in ophthalmology:
This system has the advantage of resolution. Light-microscopy and culture promise and pitfalls. Ophthalmology
not just viewing the fungal hyphae but based diagnosis continues to be the gold 2014;121: 809–11.
also of saving the image. The digital standard in con irmation of infective
magni ication of the smartphone adds to agent. The imaging based technology is 4. Liu, X., Lin, T.-Y. & Lillehoj, P. B. Smartphones
the optical magni ication of the pocket not a substitute for the same and the inal for Cell and Biomolecular Detection. Ann.
microscope, aiding better identi ication. treatment should be in accordance with Biomed. Eng. (2014).
The same images can be relayed with now the microbiological report.
ubiquitous wireless internet technology, 5. Zhu, H., Sikora, U. & Ozcan, A. Quantum dot
to an experienced microbiologist at enabled detection of Escherichia coli using a
cell-phone. The Analyst 2012;137,:2541–44.

6. Frean, J. A. Reliable enumeration of malaria
parasites in thick blood ilms using digital
image analysis. Malar. J. 2009;8: 218.

7. Woodward, B., Istepanian, R. S. & Richards,
C. I. Design of a telemedicine system using a
mobile telephone. IEEE Trans. Inf. Technol.
Biomed. Publ. IEEE Eng. Med. Biol. Soc.
2001;5: 13–15.

Cornea, Cataract and Refractive Surgery Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences,All India Institute of Medical Sciences,
New Delhi, India.

Dr. Pooja Bandivadekar MD Dr.Tushar Agarwal MD

Financial Interest: The authors do not have any ϔinancial interest in any procedure/product mentioned in this manuscript.

34 DOS TIMES - JANUARY-FEBRUARY 2016

MONTHLY MEETING KORNER

DOUBLE TROUBLE

Rahul Mayor, Manisha Agarwal, Shalini Singh, Ramesh Venkatesh

A24 year female presented to us in april 2013
with complaints of diminution of vision in the
right eye for one week. Best corrected Visual
acuity was 6/6p in both the eyes. Anterior
segment was unremarkable. On fundus
examination retinal edema was seen along the

inferotemporal arcade, sparing the fovea with hemorrhages all

over the fundus (Figure 1). Fundus Fluorescein Angiography

(FFA) was done (Figure 2 and 3) which showed delayed arm

to retina time and delayed illing of the inferotemporal artery.

A diagnosis of combined retinal Central retinal vein occlusion

(CRVO) with branch retinal artery occlusion (BRAO) was made.

Patient was advised blood investigations including blood

sugar (fasting and post prandial), complete blood count (CBC),

peripheral blood smear, Montoux test, Coagulation pro ile

including PT, APTT, INR and platelets, advanced coagulation

pro ile including Serum homocysteine, Protein C and Protein S, Figure 1: Area of retinal edema seen along the inferotemporal arcade
lipid pro ile and RA factor. Other tests included carotid Doppler. sparing fovea with dilated veins and retinal hemorrhages.
Patient was reviewed with reports and was found to have

increased Erythrocyte Sedimentation rate (ESR) and C reactive Other case reports show patients with combined
protein (CRP) and decreased Haemoglobin (Hb) and decreased occlusion may have history of smoking, migraine, previous
protein C activity. Rest all investigations were within normal cardiovascular lesions, connective tissue diseases (Systemic
limits. Physician opinion was taken and after clearance patient Lupus Erythmatosis, Anti phospholipid syndrome)3, other
was started on oral steroids 1mg/kg body weight on weekly systemic in lammatory disease, use of agents, such as oral
tapering doses along with medications for anemia .Patient was contraceptives and illicit intravenous drugs, that promote vaso-

reviewed after 2 weeks. Best corrected Visual acuity was 6/6p occlusion and females on hormone replacement therepy1.

in both the eyes Retinal edema and retinal hemorrhages had Associations with raised Serum homocysteine2, def iciency

decreased (Figure 4). Weekly tapering of oral steroids was done of folate and vitamin B12 (promote increase in serum

.Patient has been following up with us for 2 years and is stable. homocysteine), Protein C and S abnormality, Antithrombin 3

Till date we have a rare case series of 6 young females (16- abnormality, Antiphospholipid antibody abnormaility have also

36 years), diagnosed as Combined central retinal vein occlusion been described.

with associated branch retinal artery occlusion. All cases have Most of the case reports describe a combined central

right eye involvement. All Combined central retinal vein and retinal vein occlusion with
females underwent thorough branch retinal artery occlusion is a very cilioretinal artery occlusion4.
systemic evaluation. This series rare presentation Though the exact
is rare as there are no case pathophysiology is not known it may The pathogenesis is not
series of combined CRVO and vary from hematological causes like clearly understood. Blood low
BRAO in young patients. Major anemia to in lammatory conditions like in general depends upon the
indings of our cases are listed vasculitis and rare coagulation cascade intraluminal perfusion pressure
in (Table 1). disorders like protein C de iciency and (perfusion pressure = arterial
pressure- venous pressure).
DISCUSSION Therefore, factors that either
reduce the arterial pressure or
Combined central retinal increase the venous pressure, or
vein and branch retinal a combination of both, result in
reduced perfusion pressure and,
artery occlusion is a very rare
presentation. No case series hyperhomocysteinemia consequently, decreased blood
low or even no circulation4. The

in young patients have been pathogenesis of CLRAO in CRVO

published. is due to transient hemodynamic blockage of the cilioretinal

The pathophysiology may vary from an emboli causing artery caused by a sudden sharp rise in intraluminal pressure

a combined central retinal artery and vein occlusion, intra in the retinal capillary bed (due to CRVO) above the level of

luminal thrombosis, In lammatory causes like vasculitis, that in the cilioretinal artery. On the contrary CRVO may occur
arterial spasm and circulatory collapse1. Though the exact secondary to Artery occlusion in case of a thrombus which may
pathophysiology is not known it may vary from hematological cause decrease blood low and hence CRVO4.
causes like anemia to in lammatory conditions like vasculitis
and rare coagulation cascade disorders like protein C de iciency Our case series is different as all patients in our series have
and hyperhomocysteinemia2. combined CRVO with BRAO, are young females and right eye
involvement.

www. dos-times.org 35

MONTHLY MEETING KORNER

Figure 2: Early phase of FFA showing delayed arm to retina time of 26 Figure 3: (Mid phase of FFA showing delayed filling of the infero
seconds. temporal artery.

Table 1

Affected BCVA Near Pupil IOP Abnormal
eye Distant vision reaction 20 Systemic Findings
16
Case 1 RE FC 1/2mt <6/60 RAPD Hypertension
Case 2 @30cm
HB-10.2,raised CRP
RE 6/6p N6 Brisk De icient protein C
activity
Case 3 RE 6/6p N6 Brisk 20 Figure 4: Fundus photo after 2 weeks of
Case 4 RE FC 2mt N36 Brisk 14 De icient protein C starting oral steroids.
activity
Case 5 RE 6/9 N6 Brisk 16 REFERENCES
Case 6 RE 6/12 N6 Brisk 12 Non-speci ic
in lammation 1. Jagdeep Singh Gandhi “Assessment
Raised ESR, of Risk Factor Pro iles in Acute
polymorphs Retinovascular Occlusion”, Retinal
Physician 2009.
Raised serum
homocysteine 2. S¸ O¨ zdek, F Yu¨ lek, G Gu¨ relik, B Aydın
and B Hasanreisog˘ lu “Case report-
Non speci ic Association of Serum homocysteine
in lammation / with combined occlusions” Eye
protein C not done 2004;18:942–45.

In our case series all patients In younger patients in lammation 3. Greven CM, Slusher MM, Weaver RG
were started on oral steroids on seems to be the main cause of vascular “Retinal artery occlusions in young
weekly tapering doses and all showed occlusions. Pathophysiology may vary adults.” Am J Ophthalmol 1995; 120:
improvement in signs and symptoms. from hematological causes like anemia 776–83.
to in lammatory conditions like vasculitis
CONCLUSION and rare coagulation cascade disorders 4. Hayreh SS, Fraterrigo L, Jonas J . ”Central
Vascular occlusions in patients like protein C de iciency. Though there is retinal vein occlusion associated with
no published literature, oral steroids may cilioretinal artery occlusion.Retina”.
requires complete systemic work up. be bene icial in young patients. 2008;28:581-94.

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

Dr. Rahul Mayor MS Dr. Manisha Agarwal MS Dr. Shalini Singh MS Dr. Ramesh Venkatesh MS

Financial Interest: The authors do not have any ϔinancial interest in any procedure/product mentioned in this manuscript.
Case presented in the DOS Monthly Clinical Meeting III held in Conference Hall, at Dr. Shroff Charity Eye Hospital, New Delhi on September 20, 2015.

36 DOS TIMES - JANUARY-FEBRUARY 2016

MONTHLY MEETING KORNER

SIMPLE LIMBAL EPITHELIAL TRANSPLANTATION
(SLET) IN THERMAL INJURY

Nidhi Gupta, Tseej Zurag-Indra, Umang Mathur

Simple limbal epithelial transplantation (SLET) is a the bared ocular surface and secured with ibrin glue (TISSEEL
novel technique of limbal stem cell transplantation Kit from Baxter AG, Vienna, Austria).
(LSCT) which is becoming popular amongst
ophthalmologist. It combines the bene it of existing From the donor eye, a 2x2 mm area was marked centered
techniques of limbal stem cell transplant for on the superior limbus, the conjunctiva was incised, and a
unilateral ocular burn and obviates the need for sub-conjunctival dissection was carried out until the limbus
laboratory processing and utilizes minimal donor tissue. was reached. A dissection was carried out 1 mm into the clear
cornea, and the limbal tissue was excised. The donor tissue was
CASE PRESENTATION then gently held with Lim’s forceps and cut into eight to ten
small pieces with a No 15 surgical blade.
We report a case of 25 year old gentleman who had thermal
injury in right eye. The patient presented in our clinic after 2 The small limbal transplants were placed on the hAM
hours of fall of hot aluminum sheet. On ocular examination and distributed in a circular fashion around the center of the
BCVA was 6/60 in right eye and 6/6 in left eye. The right eye cornea, avoiding the visual axis. The transplants were also ixed
had grade V1 ocular burn with presence of scleral ischemia in place with ibrin glue.
(Figure 1). Left eye was unaffected. He was prescribed topical
steroids, antibiotic and lubricating eye drop.

Tenoplasty and amniotic membrane grafting was done
at 2 weeks. Patient was advised steroid`s on a tapering doses,
antibiotic, oral doxycycline and followed up weekly for 2
months.

Sectorial conjunctival epitheliectomy2 and amniotic
membrane grafting was performed at 6 months. However
the symblepharon recurred covering the visual axis (Figure
2,3). At 8 months patient was advised simple limbal epithelial
transplantation.

SURGICAL TREATMENT

In the recipient eye, a 360 degree peritomy was performed.
The human amniotic membrane (hAM) graft was placed over

Figure 2: Clinical photograph showing Partial Limbal Stem Cell
Deficiency

Figure 1: Clinical photo on showing Day 1 Thermal Burn Grade V with Figure 3: Failure of Sectoral Sequential Conjunctival Epitheliectomy
Scleral Ischemia www. dos-times.org 37

MONTHLY MEETING KORNER

Figure 5: Clinical photograph on showing post of limbal stem cell transplant which
penetrating keratoplasty at 3 months effectively restores the corneal surface
without harming the donor eye. The
Figure 4: Clinical photograph on showing removed. At 4 months postoperatively his outcome of SLET depends on the severity
postoperative Day 1 of SLET visual acuity was 3/60 in the right eye of limbal stem cell de iciency and grade
with stable ocular surface. During follow- of symblepharon, immediate medical
A soft bandage contact lens was up cornea continued to maintain a stable management and amniotic membrane
placed on the recipient eye followed by avascular, epithelized surface. grafting within 2 weeks of ocular burn.
overnight patching (Figure 4). Also, the adequate interval of several
Penetrating keratoplasty was done months to allow for ocular surface
OUTCOME AND FOLLOW-UP in right eye at 6 months (Figure 5) and in lammation to subside is important for
BCVA was 6/18 at follow-up. a good outcome.
Post operatively topical prednisolone
acetate 1% in tapering doses along with DISCUSSION REFERENCE
antibiotic and lubricating drops were
prescribed. At 2 weeks the ocular surface 1. A new classi ication of ocular surface
epithelized and bandage contact lens was burns. Dua HS, King AJ, Joseph A. Br J
Ophthalmol. 2001;85:1379-83.

2. Sectorial conjunctival epitheliectomy
and amniotic membrane
transplantation for partial limbal stem
cells de iciency. Díaz-Valle D, Santos-
Bueso E, Benítez-Del-Castillo JM,
Méndez-Fernández R et al. Arch Soc
Esp Oftalmol. 2007;82:769-72.

Simple limbal epithelial

transplantation is a simple technique

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

Dr. Nidhi Gupta DNB Dr.Tseej Zurag-Indra MBBS Dr. Umang Mathur MS

Financial Interest: The authors do not have any ϔinancial interest in any procedure/product mentioned in this manuscript.

Case presented in the DOS Monthly Clinical Meeting III held in Conference Hall, at Dr. Shroff Charity Eye Hospital, New Delhi on September 20, 2015.

38 DOS TIMES - JANUARY-FEBRUARY 2016

MONTHLY MEETING KORNER

KERATO-PROSTHESIS

Pallavi Sugandhi

AURO-KERATOPROSTHESIS -ASSEMBLY & PROCEDURE

Dr Pallavi Sugandhi1,2 MS, FMRF The donor cornea was trephined wth 8 mm disposable
Cornea & Refractive Surgeon trephine (Figure 2a) and then was centrally trephined by 3
1. Eye 7 Chaudhary Eye Centre, Daryaganj, New Delhi; mm punch (Figure 2b) provided by manufacturer. The front
plate was kept with the stem side up and the graft was put
A2. Complete Eye Care Centre, Mayur Vihar-2, New Delhi. over it with concave side up (Figure 2c). Back plate was then
68 years old male presented with Decrease put over the graft and the locking ring was pushed into place
with a pusher till a snap sound was heard (Figure 2-f). The host
of vision in right eye for 6 months and in left cornea was trephined with 7.5 mm trephine and membranes
over the IOL were removed, so that the central zone remained
eye for 2 years. The patient had a long Ocular clear (Figure 2g). The bag was found to be stable and no
anterior vitrectomy was required. The assembled device was
History with multiple surgeries. He had been then put over the host bed and sutured with interrupted 10-0
nylon (Figure 2h). A large diameter BCL (18 mm) was put over
treated for Corneal Ulcer in the right eye in the kerato-prosthesis.

1996 followed by a Penetrating keratoplasty

in March 1997. He then underwent Cataract Surgery right eye

in November 1997 and three years later he had to undergo a

second Penetrating keratoplasty with trabeculectomy in the

same eye in the year 2000. He maintained good vision for the

next six years in this eye when he again had an episode of graft POST-OPERATIVE
rejection. Subsequently, A third PK with AGV shunt was done in
2007 in the right eye and the patient was maintaining a vision Post Operative Day one the, patient was comfortable
of 6/36 till about six months back. This right eye became the with visual acuity of 6/36 with minimal in lammation (Figure
only seeing eye of the patient after the patient underwent a 3a&b). Patient was started on topical steroids six times a day
cataract surgery in the Left Eye in 2013 and unfortulately lost along with a fourth generation luroquinolone like Gati loxacin
the left eye to endophthalmitis. 0.3% 4/d and vancomycin (1.4%) and Lubricants.

On Examination, Right Eye visual acuity was PL+ PR At one year follow up the Unaided Visual acuity was 6/24
Accurate and anterior segment showed Corneal Scar (failed P. The retinoscopy revealed a refractive error of +4.0 DS/-
Graft), Sup Bleb with 360 vascularized Cornea (Figure 1a & 3.0DC X 120 degrees but the patient did not show any further
1b). The anterior chamber details were
not visible. The Ocular Surface appeared improvement in vision.The ocular surface
to be Stable and Schirmer in Right eye was stable with no in lammation. The
was 22mm & Left eye was 20 mm at ive keratoprosthesis was well secured with
minutes. Digital Tension appeared normal. sutures; the central area was clear although
Tonopen IOP in RE was 10 & LE 38 mmHg. a retro prosthetic membrane was seen in
Left Eye had no light perception with raised the inferior part (Figure 4a). The BCL was
digital tension suggestive of absolute eye. well centered. The central fundus as seen
through the K-Pro, showed a tessellated
Right eye USG B Scan was suggestive fundus with cupping of 0.6-0.7 with a few
of IOL reverberations, Retina was attached RPE changes at the macula (Figure 4b).
throughout, but showed ONH Cupping.
Axial length was 18 mm. Right eye VEP Patient was continued on tapering
showed delayed latency 140 ms (N-97) and doses of topical steroid to be continued
decreases Amplitude 5.3 micro V ( N-9.9) . twice a day inde initely along with
Vancomycin (14mg/ml) twice a day (life
Multiple adverse prognostic factors long prophylaxis). Anti-fungal prophylaxis
were associated with this case like multiple (Vozole 1% eye drops) was given once a
failed graft, vascularized cornea, associated month. Change of Contact Lens is required
glaucoma S/P AGV and pre-phthisical eye every 3 months.

(AXL 18 mm). So the patient had limited Figure 1a: Preoperative - Failed graft with INDICATIONS
options – doing Regraft for the fourth time superficial vascularisation.
would have very high chances of graft failure, Figure 1b: Preoperative – AGV Shunt Kerato prosthesis are indicated in
either to leave the eye without any surgical bilateral ocular problems, Stevens johnson
intervention or put a Keratoprosthesis syndrome, Ocular cicatricial phemphigoid,
(arti icial cornea). The best option Chemical injury, Multiple graft failures/
available was the keratoprosthesis. So, high risk grafts (Figure 5) with poor
the patient underwent uneventful Auro- prognosis for further transplants, LSCD
Keratoprosthesis after proper counselling. with severly vascularized cornea1.

www. dos-times.org 39

MONTHLY MEETING KORNER

Figure 2a: Donor tissue trephination; b: Central 3 mm trephination; c: Trephine tissue placement over front plate stem ; d: Back plate placement
with concave side up; e& f: Locking ring put over the assembly and pushed with pusher ; g: Membranectomy to clear visual axis; h: Suturing with
10-0 nylon.

Figure 3 a&b: Post Operative Day 1

TYPES OF K-PRO Prerequisites for Boston/ Auro-K- Figure 4a: One year post op – Keratoprosthesis;
Pro are moist eye with Good blink Figure 4b: One year post op –Fundus photo
Most commonly used kerato- mechanism and no exposure. Lid through K-Pro
prosthesis are Boston K- Pro (Figure 6), abnormalities should be corrected irst
Osteo-odonto-kerato-prosthesis (OOKP), and should rule out immune etiology. are described in literature. However, we
Tibial K-Pro and Pintuccio K-Pro. OOKP is did not encounter any vision threatening
suitable for patients with severe dry eye PREOPERATIVE CONSIDERATIONS complication till the last follow up.
like SJS.
Fleiringa Ring should be pre placed POST-OP COMPLICATIONS:
BOSTON (Dohlman) Kerato- with the anchoring sutures. Graft tissue
prosthesis are made of PMMA and are of should be trephined centrally with Retro Prosthetic Membrane (RPM)
2 types (Figure 7); TYPE I (Collor Button stand by Tissue should be kept in case
Type) for Wet Eyes and TYPE II – Nut of de-centration. Locking ring problems RPM2 is the most common post
and Bolt Type for Dry Eyes. Various low (Breaking and Slipping) were common op complication (25-64 %) at 1 year
cost modi ications of Boston K Pro are with older designs. In the recipient follow up. It usually originates from host
available in India like Auro-K Pro, LVP eye bleeding should be controlled with stromal cells. It’s an indicator of chronic
K Pro. Auro-K-Pro (manufactured by the help of gentle cautery. Line of sight in lammation. Also common with aniridia
aurolab) is available in 2 types –aphakic behind optical element must be free of
and Pseudophakic. In aphakic eyes any obstruction. Anterior vitrectomy
power of the K-Pro is decided on basis of must be performed in aphakic cases.
axial length while pseudophakic type is VR Procedures can be combined with
available in ixed power. Temporary K-Pro or through Auro-K Pro
itself. Silicon Oil ill in Pre-Phthisical Eye
Consists of 3 parts (Figure 8): The helps to maintain the shape of the globe.
Front part (Front plate with stem), Back
Plate (with holes) made of PMMA and DISCUSSION
titanium Locking ring. Corneal graft is
placed between the front & back plate Various post operative complications
and then locked with the ring.

40 DOS TIMES - JANUARY-FEBRUARY 2016

MONTHLY MEETING KORNER

and persistent Epithelial defect are the
commonest risk Factors. This may later
lead to endophthalmitis if not intervened
early.

Figure 5: Indication for K-Pro- Multiple failed Figure 8: Parts of Boston K-Pro Glaucoma
graft with LSCD
Glaucoma causes severe and
irreversible visual loss. Pre operatively
it co-exists in 36 -75% cases. It can
develops in 2-28% cases post operatively.
It should be managed surgically with GDD
before K-Pro Surgery. IOP measurements
are dif icult in post operative period and
digital monitoring is the best indicator.
Regular HVF & GDX are a must to assess
the progression.

Figure 6: Boston (Dohlman) Keratoprosthesis Figure 9: Retro-Prosthetic Membrane Posterior Segment Complications

Incidence of Endophthalmitis varies
from 1.2-11.4 % and usually sequelae
of infectious keratitis3. Sterile vitritis
(1.6-14.5%) presents as sudden painless
loss of vision which responds to topical
steroids. Other posterior segment
complications are choroidal Detachment
(3.5-16.9 %), retinal Detachment (16%)
and vitreous Hemorrhage.

Figure 7: Type I (Dry) and Type II (Wet) Boston Figure 10: Sterile Keratolysis SUMMARY
K-Pro
Figure 11: Fungal Infiltrate Keratoprosthesis is a ray of hope for
and Infectious keratitis. Incidence of RPM
is reduced with Titanium back up plate Infectious Keratitis patients with multiple graft failures/high
at 6 months (41.8 t0 13 %). It can easily Reported Incidence at 1 year follow
be diagnosed clinically and on anterior risk grafts in B/L affected patients. This
segment OCT. Nd yag laser can be done up is 7-17 %5. Most commonly cause
while thcker membranes may require by gram-positive bacteria (Staph and patient had improved vision post surgery
surgical capsulotomy. Strep). Lately fungal in iltrates have also
been reported.Prolonged Steroid use which was restricted to the central ield.
Sterile Keratolysis
However, monthly regular follow
Incidence of sterile keratolysis is 10-
18 % at 1 year follow up4. Most common up is required. Further complications
cause is Dellen Formation followed by
PED and Stromal Thining. Irregular may arise later in post op period which
suturing may cause tissue Recession from
edge leading to keratolysis. It is 3 times may require multiple interventions.
more common with RPM. Use of large
diameter BCL prevents ocular surface Hence, careful case selection with
dessication and has largely reduced the
incidence of sterile keratolysis. proper counseling regarding anti biotic

prophylaxis is a must.

REFERENCES

1. Sejpal K, Yu F, Aldave A. The Boston
keratoprosthesis in the management of
corneal limbal stem cell de iciency. Cornea.
2011;30:1187–94.

2. Rudnisky CJ, Belin MW, Todani A, Al-Arfaj K,
Ament JD, Zerbe BJ, Ciolino JB. Risk factors
for the development of retroprosthetic
membranes with Boston keratoprosthesis type
I. Ophthalmology.2012; 119:951–5.

3. Goldman DR, Hubschman JP, Aldave AJ, Chiang A,
Huang JS, Bourges JL, Schwartz SD. Postoperative
posterior segment complications in eyes treated
with the Boston type I keratoprosthesis. Retina.
2013;33:532–41.

4. Greiner MA, Li JY, Mannis MJ. Longer-term
vision outcomes and complications with
the Boston type 1 keratoprosthesis at the
University of California, Davis. Ophthalmology.
2011;118:1543–50.

5. Aldave AJ, Kamal KM, Vo RC, et al. The Boston
type 1 keratoprosthesis: improving outcomes
and expanding indications. Ophthalmology.
2009; 116:640–51.

Financial Interest: The author does not have any ϔinancial interest in any procedure/product mentioned in this manuscript.
Guest Case presented in the DOS Monthly Clinical Meeting IV held in PGIMER, at Ram Manohar Lohia Hospital, New Delhi on October 25, 2015.

www. dos-times.org 41

DIAGNOSTICS DISCUSSION

SUBFOVEAL FOREIGN BODY MASQUERADING AS CHOROIDITIS

Shahana Mazumdar, Ashish Kakkar

A20 yrs old healthy male factory worker pin point leaks at the macula (Figure 2) and highlighted the
presented with blurred vision in the left eye scar and few window defects. OCT macula (Figure 3) showed
since six months. No history of trauma, redness, subfoveal elevation of the choroid with subretinal luid (SRF)
pain. He was treated elsewhere and diagnosed and a small sub RPE hyperer lective lesion. B scan showed
as a case of choroiditis and treated with steroids localized choroidal thickening at posterior pole and a highly
which improved his condition but recurred on re lective lesion in the coats with attenuation suggestive of
tapering the steroids. a foreign body. Plain CT scan orbit (Figure 4) showed a large
foreign body in the coats posteriorly.
BCVA was 6/6 and 6/18. Anterior segment examination
showed no abnormality. Posterior vitreous showed a few cells. On further questioning he said that he worked in a factory
Optic nerve head was healthy. The macula showed an elevated making copper wire and had suffered multiple episodes of
lesion with orange pigmentation, internal limiting membrane the ine copper particles entering his skin with granuloma
(ILM) folds running across the macula originating from a gliotic formation and eventual extrusion of the particle. On detailed
pigmented scar temporally (Figure 1). FFA revealed multiple reexamination of the cornea and sclera, no entry wound could
be found. We gave him oral steroids following which his vision
has improved to 6/9, the SRF has subsided and the foreign body
is now visible (Figure 5).

Though the foreign body is not so small on the CT scan it
must be a sharp and thin as it has entered the globe without

Figure 1: Fundus photo showing an elevated orange coloured lesion Figure 3: OCT macula showing nodular subfoveal elevation of the
at the macula and a gliotic scar temporal to the macula with ILM folds choroid with subretinal fluid and a small hyperreflective lesion in the
running across the posterior pole anterior choroid sub RPE space.

Figure 2: FFA showing pinpoint leaks at the macula Figure 4: CT scan orbits showing a foreign body in the posterior ocular
coat

www. dos-times.org 43

DIAGNOSTICS DISCUSSION

leaving a detectable entry wound and has
gained access to the sub RPE, anterior
choroidal space, through the temporal
macula scar coming to rest under the
fovea.

De initive treatment will require
removal of the foreign body which will
be challenging as the foreign body is
subfoveal, vision is 6/9 and it is likely to be
non magnetic copper particle. An external
route of removal with detachment of
muscles maybe required.

The objective of writing this
discussion is to consider a retained IOFB
in cases of elevated lesion of the choroid
especially when a retinal scar is present
even in the absence of history of injury or
a detectable entry wound.

Figure 5: fundus photo showing the orange colored foreign body visible subfoveally
Retina Services, Icare Eye Hospital, NOIDA, U.P.

Dr. Shahana Mazumdar Dr.Ashish Kakkar

Financial Interest: The author does not have any ϔinancial interest in any procedure/product mentioned in this manuscript.

DOS Enhanced Subspecialty Korner: DESK-II
Glaucoma Programme

March 6, 2016, 8:30 AM - 5 PM
India Habitat Centre, New Delhi

44 DOS TIMES - JANUARY-FEBRUARY 2016

CLINICAL SPOTLIGHT - SQUINT

DISSOCIATED VERTICAL DEVIATION: AN OVERVIEW

Shweta Chaurasia, Pradeep Sharma

Dissociated deviations in strabismus have 5. Unlike in paralytic vertical strabismus, the degree
been observed and reported for more than a of elevation of the dissociated eye is often the same,
century. Dissociated deviation manifests as an regardless of whether the eye elevates from adduction,
intermittent anomaly with variable vertical primary position, or abduction
(DVD), horizontal (DHD) and torsional (DTD)
6. Latent or manifest nystagmus (often present).

movement often included under dissociated 7. Associated strabismus, usually an esodeviation, but may

strabismus complex (DSC) (Figure 1a,b). DVD is usually the most be with exodeviation too.

clinically signi icant component of DSC mostly accompanied 8. Excyclotorsion with sursumduction during occlusion and

with less noticeable DHD and DTD. incyclotorsion with deorsumduction after the occlusion is

DVD is de ined as an intermittent or constant tropia or removed.

as a phoria that manifests as a slow upward drift of the non 9. De icient fusion.

ixing eye that occurs only when ixation is disrupted1. This 10. Anomalous head posture is a frequent correlate of DVD.

entity uniquely violates Hering’s law of ocular motility2. The The deviation is irst measured in the preferred posture

ocular movements associated with DVD are slow and variable and again with forced head tilt in the opposite direction.

compared with non-dissociated deviation. No movement is If DVD is increased or control breaks down with the better

seen in the ixing eye when the deviated eye re ixates. maneuver, it is contributing to the anomalous posture.

George Stevens in 1895 attributed “alternating vertical 11. Bielschowsky phenomenon

strabismus” to an error in torsion of the ixing eye. The most When the ixing eye is presented with light of deceasing

often quoted early descriptions are from Bielschowsky who intensity, the eye with DVD falls. Conversely, increasing

postulated that aberrant impulses from a vertical divergence light in the eye with DVD will cause an increase in upward

centre in the brain stem are responsible for DVD. According vertical drift. Light intensity may be varied by using

to Helveston DVD results from supranuclear disturbance of graduated neutral density ilters or the Bagolini red ilter

a vertical vergence centre. Others have postulated vertical bar. It is found in at least 50% of patients with DVD as well

rectus muscle imbalance, oblique muscle imbalance, primitive as DHD. It signi ies DVD as a sensory anomaly because

vestibular re lexes, or abnormal altering the sensory input to
vertical motion processing Dissociated deviation manifests as an the ixing eye produces the
as the cause of this strange characteristic indings.
vertical strabismus. According intermittent anomaly with variable 12. Red glass test
to Brodsky DSC may represent vertical (DVD), horizontal (DHD)
Regardless of whether

an atavistic resurgence of the and torsional (DTD) movement often the red ilter is placed before
dorsal light re lex that emerges included under dissociated strabismus the right or left eye, the patient
when bi ixation and high-grade complex (DSC). DVD is usually the most describes a red image below a
binocularity are absent. white image. This contrasts to

CLINICAL clinically signi icant component of DSC the indings in patients with a
CHARACTERISTICS true vertical deviation where
mostly accompanied with less noticeable second (red) image is seen
above or below the primary
1. Slow upward deviation of DHD and DTD image depending on whether
an eye when occluded or the red ilter is placed in front of
spontaneously during periods of inattention, and slow the hyperdeviated or hypodeviated eye.
downward movement of an eye when the occlusion is 13. DVD may be associated with A and V patterns and oblique
removed or when ixation stimulus occurs. muscle overaction that may be true or simulated.
2. The vertical re ixation movements of either eye are of 14. Classi ication
It may remain latent (compensated) or manifest
equal amplitude after removal of the cover. (decompensated). The deviation may be symmetrical
3. With bilateral DVD either eye moves down to re ixate after or asymmetrical between two eyes and small or very
large, measuring more than 20 prism diopters. DVD
removal of the cover. The condition is bilateral in most that measures roughly the same (i.e within ±7 pd) in
instances but most often asymmetric in magnitude all horizontal gazes i.e abduction primary position and
4. Dissociated vertical and horizontal deviations may occur adduction is called comitant DVD. Incomitant DVD refers to
in a manifest or latent form. The latent form can only be measurable disparity in the magnitude of DVD in different
observed by covering either eye; the manifest form occurs gazes.
spontaneously, often with inattention or when the patient
is tired

www. dos-times.org 45

CLINICAL SPOTLIGHT - SQUINT

(a) (b) DVD grading
0-9pd Small DVD;
10-19 moderate DVD;
>20pd large DVD

Figure 1a: Showing patient in examination room while fixating on target. Figure 1b: same patient DIFFERENTIAL DIAGNOSIS
with decreasedconcentration and manifesting OS DVD& DHD Inferior oblique overaction (IOOA)

The entity most frequently confused

CLINICAL EVALUATION (a) with DVD is overaction of the
(b) inferior oblique muscle. It is
Despite adequate critical to differentiate IOOA
from DVD because either may
descriptions in the literature cause elevation in primary
position or adduction (Figure
of the clinical picture of DVD, 2a,b&3).
1. The dissociated
this condition is frequently eye not only elevates but
excycloducts. When the fellow
misdiagnosed and may even eye is covered, the dissociated
eye returns to primary position
be over- looked and remain with a corrective incycloduction
movement.
undiagnosed. Although, for the 2. Unlike the brisk
saccadic re ixation movement
careful, experienced observer that occurs during the cover-
uncover test in patients
DVD should be easy to recognize, with horizontal and vertical
heterotopias or heterophorias,
it is dif icult and challenging the re ixation movement
in dissociated vertical and
o quantify for the following horizontal deviations is slow
and tonic.
reasons.

1. DVD is in luenced by

patients’ attention span

and concentration. It is

even more marked at home

when patient is fatigued

daydreaming than during

looking at ixation target at

examination room.

2. The deviation tends to be

variable and without clear

end- points, making prism

and cover measurements Points to remember while

dif icult and unreliable. Figure 2a: DVD showing elevation of LE in. Figure 2b: LE IOOA doing measurements

3. Nystagmus, both horizontal showing elevation only in adduction adduction well as abduction DVD alone-DVD is
and rotary, is frequently
present, although it may the eye in question and the size of DVD measured with PBUCT. It is
be dif icult to appreciate because under cover is estimated. Prism bar comitant with same measurements in all
amplitudes maybe small and the (with base down) and cover are placed in positions of gaze.
frequency rapid. front of dissociated eye and as the cover
is switched to the ixing eye, only the IOOA-In IOOA the true vertical
4. Dissociation and redress movements movement of the deviated eye (DVD) is deviation may be measured in adduction
are slow and variable in speed. observed and neutralized by increasing using the prism cover test. The up drift in
the strength of the base down prism. IOOA is rapid compared with DVD gaze.
5. Other strabismus is usually present. The point of neutralization is reached The hypertropia may not be present in
when no further downward movement is primary position. Hypertropia in primary
DVD MEASUREMENT observed and measurement is recorded position is present if IOOA +3.
in terms of prism dioptre. A translucent
Although Hirschberg’s corneal occluder is a better way of disrupting DVD with IOOA- This is a dif icult
re lex test can give an estimate of the fusion while simultaneously measuring situation. True hypertropia may
amount of deviation, but the prism bar DVD using prism bar over the occluder. occur when both DVD and IOOA occur
under cover test (PBUCT) is a precise simultaneously. DVD with hypertropia
way of measuring DVD in co-operative may occur from secondary SR
patients. A cover is placed to dissociate

Squint & Neuro-Ophthal Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences,All India Institute of Medical Sciences, New Delhi, India

Dr. Shweta Chaurasia MS Dr. Pradeep Sharma MD, FAMS

46 DOS TIMES - JANUARY-FEBRUARY 2016

CLINICAL SPOTLIGHT - SQUINT

Figure 3: DVD with IOOA Figure 4: Comitant and symmetric DVD

Main differentiating features between DVD and IOOA surgical treatment should be considered.
Planning and performing the effective
DVD IOOA surgery is extremely dif icult in DVD.

Upward drift or elevation From primary position, Maximal in adduction, It represents a challenge for
adduction and abduction never in abduction diagnosis and surgical treatment. DVD
neither disappears nor improves over
SOOA May overact Usually underaction time; the aim of treatment is to obtain a
latent deviation.
V pattern absent Often present
Non-surgical management
Pseudoparesis of absent present
contralateral superior Observation- preferable for DVD that
rectus is controlled as a phoria and for smaller
deviations that occur.
Incycloduction on present absent
re ixation Strengthen fusion mechanism-
optimal spectacle correction should
Saccadic velocity of 10-200 deg/sec 200-400 deg/sec be provided to encourage fusion or
re ixation movement bi ixation. Also correcting an associated
horizontal deviation with prism or
Latent nystagmus Often present Absent surgically may help.

Bielschowsky Often present absent Switch ixation- occlusion of the
phenomenon ixing or dominant eye either as a means
of treating amblyopia or encouraging
contracture. Measuring the hypertropic Skew deviation ixation may be tried in an attempt to
re ixation movement in the contralateral improve DVD.
eye by prism cover test reveals the It is a descriptive term used to
true hypertropic component. The total denote an acquired, supranuclear, Indications for surgery
upward drift is then measured by the vertical misalignment of the eyes that
PBUCT. The measurement between the fails to conform to known innervational • Increasing frequency of Manifest
two constitutes the component that is patterns of the extraocular muscles. It is DVD in a patient with peripheral
caused by DVD. Re ixation movements seen primarily in patients with unilateral fusion
observed in the contralateral eye in true brainstem lesions, particularly those
vertical deviation is not observed in DVD. involving the brainstem tegmentum in • Patient who adopt an anomalous
the mesodiencephalon or the medulla, head posture to control the
The less experienced clinician may although injury to the peripheral magnitude of DVD
easily mistake a dissociated horizontal vestibular system or the cerebellum can
deviation (DHD) for exotropia or also cause it. This utricular ocular tilt • Large DVD occurring frequently.
exophoria or a dissociated vertical reaction produces a tonic or paroxysmal Different surgical procedures have
deviation (DVD) for vertical strabismus. vertical divergence of the eyes (ie, skew
DHD may be associated with DVD or deviation), which differs from DVD. been advocated for DVD. The sum of
occur in isolated form. DHD (mostly forces in any DVD surgery should favour
an exodeviation) only one eye abducts MANAGEMENT depression.
under cover and re ixates with a slow, • Comitant and Symmetric DVD with
tonic adduction movement. In contrast, Primary goal of DVD management is
in exophoria the just uncovered eye to improve patients’ physical looks so that good bilateral visual acuity (VA),
re ixates with a brisk adduction saccade. the upward turning of the eye is hardly without oblique muscle dysfunction:
noticeable. Both conservative as well as surgical alternatives (Figure 4):
(1) Bilateral large superior rectus

(SR) recession upto 10mm
(hang back if required)3,4

www. dos-times.org 47

CLINICAL SPOTLIGHT - SQUINT

(a)

(b)

Figure 5: DVD with SOOA OS>OD Figure 6: Asymmetric DVD

(2) Bilateral retroequatorial Differences between DVD and acquired skew deviation

myopexy (posterior ixation) DVD Acquired skew deviation

of the SR combined with or

without recession of these Age at onset 2-4 Any age

muscles5,6,7. Tempo of onset Gradual Acute

(3) Bilateral inferior rectus (IR) Variability Intermittent Usually constant

resection can be added if there Ocular torsion Extorsion of higher eye, Intorsion of higher eye,
intorsion of lower eye extorsion of lower eye
is still residual signi icant DVD.

Pattern of incomitance and Pathophysiology Binocular visual Utricular imbalance
imbalance (central or peripheral)
recommended surgical procedures
Neurologic lesion None Unilateral utricular,
• Bilateral DVD with deep unilateral brainstem or cerebellar
amblyopia: three available lesion
procedures:
(1) Unilateral SR recession, Subjective awareness of Undetermined Variable
(2) Unilateral inferior oblique visual tilt
anterior transposition (IOAT),
and Head tilt Variable Toward side of lower eye
(3) Unilateral IR resection or
tucking. Perceived visual vertical Undetermined Rotated in direction of
(4) Combined monocular IOAT with ocular torsion
SR recession or IR resection8
Lorenz et al in 1992 retrospectively Diplopia None Vertical

studied 42 patients who had surgery Nystagmus Latent nystagmus See saw or hemi-see saw
between 1982 and 1990, the immediate
as well as the long-term effect of three effect of the Faden operation was clearly anteriorly at inferior rectus
different surgical procedures on the superior to the large recessions. insertion.
dissociated vertical deviation (DVD) was 2. DVD greatest in the ield of
studied12. The procedures were: Faden Diab et al in 2013 concluded that non- ixing eye with signi icant
operation of Cüppers of the superior Inferior rectus tucking is as effective DVD in abduction- Bilateral SR
rectus muscle 12 to 14 mm posterior to its as superior rectus recession with recession added to bilateral
insertion (10 patients); Faden operation posterior ixation sutures for the primary inferior oblique (IO) recession.
of the superior rectus muscle 12 to 14 mm treatment of DVD without inferior oblique 3. DVD greatest in the ield of IO of
posterior to its initial insertion combined overaction. Inferior rectus tucking can the non- ixing eye after bilateral
with a 3-millimeter recession of the also be used effectively for the treatment SR recession - moderate IO
muscle (7 patients); and large recession of residual and recurrent DVD; further recession 8-10mm.
of the superior rectus muscle of 10 mm studies are recommended in this ield13. Akar et al in 2014 retrospectively
in a hang-loose technique (25 patients). • DVD with inferior oblique overaction reviewed 94 eyes and concluded Only IO
The initial effect on the DVD was similar anterior transposition or SR weakening
in the Faden group and in the group of the (IOOA) and V pattern: surgery appear to be a successful surgical
large recession. However, the long-term 1. DVD greatest in the ield of approaches in the management of
patients with mild and moderate angle
IO of the non ixing eye- IO
Anteroposition (IOAT)9,10 where
whole width of IO is positioned

48 DOS TIMES - JANUARY-FEBRUARY 2016

CLINICAL SPOTLIGHT - SQUINT

(≤15pd) DVD. Weakening both the SR and large recession and resections. Palpebral the treatment of dissociated vertical
IO muscles yield a greater success in the issure changes may accompany vertical deviation. Am J Ophthalmol. 1992;113:
management of patients with large angle rectus muscle surgery. SR recessions may 287-90.
(>15pd) DVD14. produce a widened palpebral issure as 7. Kii T , Ogasawara K, Ohba M, Hotsubo
• DVD greatest in abduction with well as ptosis whereas large IR resections M, Sakai N, Nakagawa T. Nihon Ganka
are accompanied by a narrowed lid Gakkai Zasshi [Article in Japanese] The
superior oblique overaction (SOOA) issure. effectiveness of the Faden operation on
and A pattern (Figure 5): the superior rectus muscle combined
Bilateral SR recession + superior A vertical imbalance may follow with recession of the muscle for the
oblique (SO) posterior tenectomy surgery on any of the cyclovertical treatment of dissociated vertical
(PTSO 1 or 2 mm sparing) muscles especially if done unilaterally or deviation]. 1994;98: 98-102.
Bilateral superior rectus muscle asymmetrically. 8. Mary M. Varn, MD, Richard A.
recession corrects small amounts Saunders, MD, M. Edward Wilson,
of A pattern. Larger amounts of A CONCLUSION Combined bilateral superior rectus
pattern require additional superior muscle recession and inferior oblique
oblique weakening11 Obtaining long-term control of the muscle weakening for dissociated
• Symmetric vs. Asymmetric surgeries deviation in patient with DVD is dif icult; vertical deviation. Journal of
for DVD: Bilateral symmetric a successful outcome in the postoperative American Association for Pediatric
procedures are performed for cases period does not guarantee the inal Ophthalmology and Strabismus.1997;
with bilaterally symmetric DVD. alignment. In treated patients with 1:134–37.
Cases with asymmetric DVD are DVD, some kind of movement is always 9. Farvardin M, Attarzadeh A. Combined
more common. These cases require detected when performing the cover test. resection and anterior transposition
asymmetrical techniques (Figure 6). DVD never disappears completely and the of the inferior oblique muscle
• Currently bilateral surgery is done dissociated behavior in DHD also persists for the treatment of moderate to
for DVD reserving unilateral surgery when testing under slow cover test. large dissociated vertical deviation
for the patient with such deep associated with inferior oblique muscle
amblyopia that he will never ix with REFERENCES overaction. J Pediatr Ophthalmol
the operated eye. Strabismus. 2002; 39: 268-72.
1. Von Noorden GK, Campos EC. 10. Burke JP, Scott WE, Kutschke PJ.
COMPLICATIONS Cyclovertical deviations. In: Binocular Anterior transposition of the inferior
vision and ocular motility theory and oblique muscle for dissociated vertical
DVD are known to recur or persist management of strabismus: Mosby- deviation. Ophthalmology. 1993;100:
after surgery as we are trying to solve year book Inc.; 2002: 6th ed. 378-84. 245-50.
cortical imbalance problem with extra- 11. Velez FG , Ela-Dalman N, Velez G.
ocular muscle surgery. Freeman in 1989 2. Santiago AP, Rosenbuam AL. Dissociated Surgical management of dissociated
reported a series of seven patients who Vertical Deviation. In: Rosenbuam AL, vertical deviation associated with A
exhibited a persistent DVD following large Santiago AP eds. Clinical Strabismus pattern strabismus. J AAPOS. 2009;
superior rectus recession15. DVD was management principles and surgical 13:31-5.
markedly incomitant, much greater in techniques: WB Saunders Co; 1999: 12. Lorenz B, Raab I, Boergen KP.
adduction than in abduction. This residual 237-48. Dissociated vertical deviation: what is
DVD mimiced inferior oblique overaction the most effective surgical approach? J
on version testing, although proving to 3. Scott WE, Sutton VJ, Thalacker Pediatr Ophthalmol Strabismus. 1992;
be purely DVD on critical observation. JA. Superior rectus recessions for 29: 21-9.
This “overaction” is apparently due to dissociated vertical deviation. 13. Serpil Akar, Şenol Sabancı, Birsen
the marked weakening of the superior Ophthalmology. 1982; 89:317-22. Gökyiğit, Çiğdem Altan, Pelin Kaynak,
rectus and was not always predictive of Ali Eren, Ahmet Demirok Outcomes
the location and amount of persistent 4. Magoon E, Cruciger M, Jampolsky of surgical treatment in dissociated
DVD. They emphasized that previously A. Dissociated vertical deviation: vertical deviation cases. TJO. 2014; 44:
unreported complication of large an asymmetric condition treated 132-37.
superior rectus recession is important with large bilateral superior rectus 14. Diab MMK. Inferior rectus tucking
to recognize so that alternative surgical recession. J Pediatr Ophthalmol versus combined superior rectus
approaches may be contemplated. Strabismus. 1982;19:152-6. recession with posterior ixation
suture (Faden) for the treatment of
One has to be carefull while doing 5. Yu G, Zhonghua Yan Ke Za Zhi. Article dissociated vertical deviation without
in Chinese Treatment of dissociated inferior oblique overaction. Journal of
vertical deviation (DVD) with superior the Egyptian Ophthalmological Society.
rectus recession and posterior ixation 2013;106: 239-44.
suture.1992; 28:296-7. 15. Freeman RS , Rosenbaum AL. Residual
incomitant DVD following large
6. Esswein MB , von Noorden GK, Coburn bilateral superior rectus recession
A. Comparison of surgical methods in J Pediatr Ophthalmol Strabismus.
1989;26: 76-80.

Financial Interest: The author does not have any ϔinancial interest in any procedure/product mentioned in this manuscript.

www. dos-times.org 49

PRACTICE REQUISITES

ANTERIOR SEGMENT
OPTICAL COHERENCE TOMOGRAPHY

Uma Sridhar, Geetika Khurana, Jyoti Batra, Vivek Sharma

Optical coherence tomography (OCT) is an marketing clearance from the FDA in 2010. Although indicated
important new tool which has revolutionized for posterior segment imaging, a lens is available to allow
corneal imaging. Every day, improvements imaging of the anterior segment.
are taking place in this ield which will make
corneal imaging and corneal surgery more Three available laser systems, the LenSx (Alcon), Catalys
(Optimedica), and VICTUS (Technolas Perfect Vision), include

technologically advanced. OCT to provide image guidance for laser cataract surgery.

This is a high resolution cross-sectional imaging modality

which was developed for retinal imaging. Huang et al1 irst ANTERIOR SEGMENT OCT IN CLINICAL PRACTICE

described optical coherence tomography of the eye in 1991, 1. Cornea
and Izatt et al described Anterior segment OCT (ASOCT) 2. Cataract
imaging using the same wavelength of light as in retinal OCT i.e. 3. Refractive procedures
830nm2. A longer wavelength of 1310 nm is now used for better 4. Glaucoma
penetration through the sclera.

The question that needs to be asked is , when the anterior Cornea
segment is so easily visualized with slit lamp biomicroscopy,
what is the need for a tool like anterior segment OCT? Pachymetry - various devices are currently used for
Also, in what way is it an added advantage over ultrasonic measuring corneal thickness reliably
biomicroscopy? • Ultrasonic pachymeter
• Specular microscope
This article seeks to answer these questions, review the • Orbscan II
current systems available and the future of this technology. • Oculus pentacam

The current systems available are AS OCT compares very favourably with the above systems
1. Visante—Carl Zeis meditec in measuring corneal thickness.
2. Optovue – RT -Vue
3. Slit lamp OCT –Heidelberg Engineering , Germany Pachymetric maps are useful in
• Diagnosis of keratoconus ( Figure 1A&1B)
The Visante™ OCTwas approved by the US FDA in 2005.
• Depth of lesions when planning phototherapeutic
The Visante OCT is described as a non-contact, high resolution
keratectomy
tomographic and biomicroscopic device indicated for the in
• Depth of foreign body in the corneal stroma

vivo imaging and measurement of ocular structures in the • Thickness of LASIK lap

anterior segment, such as corneal and LASIK lap thickness. • Corneal thickness after LASIK

The Slit-Lamp OCT (SL- Anterior segment OCT is a useful tool • Depth of demarcation
OCT, Heidelberg Engineering, line after collagen crosslinking

Heidelberg, Germany) was in the armamentarium of the anterior
approved for commercial use Diagnosis of Descemet’s
by the US FDA in 2006. The segment surgeon. The depth of a lesion membrane detachment in

SL-OCT is intended as an aid can be clearly visulaised even through cases of bullous keratopathy
for the quantitative analysis of
structures and the diagnosis an edematous cornea. Intraoperative Post cataract surgery, in
and assessment of structural AS OCT helps the corneal surgeon in cases of dense corneal edema
(Figure 2), a diagnosis of

changes in the anterior lamellar keratoplasty. AS OCT is also Descemet’s detachment may be
segment of the eye. The SL- an integral part of femtolaser cataract missed. AS OCT helps to visualise
OCT examination system is not systems. The glaucoma surgeon can the Descemet’s membrane
intended for the analysis of the visualise structures in the angle of detachment and can be used to
cross -sectional images to obtain anterior chamber fairly accurately visualise the reattachment after
quantitative measured values. air or gas injection (Figure 3&4).
Neither the obtained measured

values nor the qualitative Lamellar keratoplasty

evaluation of the images should Attachment of endothelial graft, whether DSEK/ DMEK /
be used as the sole basis for therapy-related decisions. DSAEK after endothelial keratoplasty especially in edematous
corneas is possible with ASOCT. In cases of anterior lamellar
The RTVue (Optovue) is a commercially available Fourier- grafts, the depth of dissection can be seen. Double anterior
domain OCT system with a resolution of 5 microns that received

www. dos-times.org 51

PRACTICE REQUISITES

Figure 1A: Pachymetry map in a case of keratoconus. Note the area of Figure 2: Pachymetric map in a case of corneal edema after cataract
thinning highlighted in blue color surgery. Thick cornea is highlighted in orange color

Figure 1B: Keratoconus. Area of thinning of cornea seen clearly Figure 3: Descemet’s detachment after cataract surgery. Dense cornel
edema prevented the detachment from being seen on slit lamp

chambers also can be diagnosed (Figure stromal opacities (Figure 7). Epithelial cell nests, interface luid
5& 6). Depth of corneal foreign body, depth syndrome, irregular laps can also be seen
clearly with AS OCT (Figure 13).
Intraoperative AS OCT is increasingly of deposits in various corneal dystrophies,
used in cases of lamellar corneal iris adherence in adherent leucomas, Radial keratotomy Depth of radial
surgeries. descemetoceles can be visualized very keratotomy scars is seen beautifully with
well with AS-OCT (Figure 8-11). AS OCT (Figure 14).
Band Shaped keratopathy
Refractive procedures Cataract Surgery
Hyperre lective opacity at the level
of Bowman’s layer is seen in cases of band AS OCT helps to visualize depth of Many laser systems such as Lensex
shaped keratopathies. placement of intracorneal ring segments for Femto laser cataract surgery have
and corneal inlays (Figure 12). intraoperative OCT which helps the
Climatic droplet keratopathy- surgeon do the procedure accurately.
irregular surface of cornea, opacities Thickness of LASIK laps can be The entire procedure is done by an image
at various depths in stroma with measured and laps can be visualized guided system which helps to perform
hypore lective shadows behind the even years after LASIK procedures. capsulorrhexis, nuclear fragmentation,

Cornea Department ICARE Eye Hospital, NOIDA, U.P. India.

Dr. Uma Sridhar MS, DNB, FRCS Dr. Geetika Khurana MS Dr. Jyoti Batra MD, DNB, Dr.Vivek Sharma

52 DOS TIMES - JANUARY-FEBRUARY 2016

PRACTICE REQUISITES

Figure 4: Descemet’s reattachment after c3f8 ga injection in the
previous case

Figure 7: Climatic droplet keratopathy. Raster scan showing the
irregular corneal surface and shadowing beyond the deposits in the
area of the deposits

Figure 5: DSEK showing attachment of the endothelial graft

Figure 8: Adherent leucoma showing area of iris adherence to the
cornea

Figure 6: First week post op after manual DALK. The graft is still
edematous and the level of presecemetic dissection is seen

corneal incisions and astigmatic corrections by arcuate Figure 9: Thin and ectatic cornea in the area of descemetocele
incisions (Figure 15-17).

Glaucoma imaging
Anterior segment OCT is not considered as accurate as

UBM for visualising angle of anterior chamber (Figure 18).
In a study by Narayanswamy et al in phakic eyes3, angle of
anterior chamber was compared by AS-OCT and gonioscopy
was compared. An eye was considered to have narrow angles if

www. dos-times.org 53

PRACTICE REQUISITES

Figure 10: Level of granular deposits in a case of granular dystrophy

Figure 14: Radial keratotomy scar extending almost full thickness

Figure 11: Location of corneal foreign body in the stroma Figure 15: Intraoperative OCT scan with the lensex system showing
level of anterior and posterior capsule
Figure 12: Intacs – intracorneal ring segments
the posterior pigmented trabecular meshwork was not visible
Figure 13: Interface fluid after LASIK for at least 180° on gonioscopy. Horizontal AS-OCT images were
54 DOS TIMES - JANUARY-FEBRUARY 2016 analysed for the following measurements using customized
software: angle opening distance (AOD) at 250, 500, and 750
μm from the scleral spur; trabecular-iris space area (TISA) at
500 and 750 μm; and angle recess area (ARA) at 750 μm. Areas
under the receiver operating characteristic curves (AUCs) were
generated for AOD, TISA, and ARA to assess the performance
of these measurements in detecting eyes with narrow angles.
Of the 2047 individuals examined, 582 were excluded mostly
because of poor image quality or inability to locate the scleral
spur. Of the remaining 1465 participants, 315 (21.5%) had
narrow angles on gonioscopy. Mean (SD) age was 62.7 (7.7)
years, 54.1% were women, and 90.0% were Chinese. The AUCs
were highest for AOD750 in the nasal (0.90 [95% con idence
interval, 0.89-0.92]) and temporal (0.91 [0.90-0.93]) quadrants.
The AOD750 is the most useful angle measurementfor
identifying individuals with gonioscopic narrow angles in
gradable AS-OCT images. Poor de inition of the scleral spur
precludes quantitative analysis in approximately 25% of AS-
OCT images3.

PRACTICE REQUISITES

Figure 18: Angle of anterior chamber

Figure 19: Imaging with visante OCT

Figure 16: Intraoperative OCT image with lensx system showing
nucleus fragmentation

Figure 20: DSEK button seen with Visante OCT

Figure 17: Introperative OCT showing corneal incisions Figure 21: Angle of anterior chamber seen with Visante OCT
www. dos-times.org 55
ASOCT versus UBM

Besides ASOCT, ultrasound biomicroscopy (UBM) may also
be used for cross-sectional imaging of the anterior segment and
the AC angle. When compared to ASOCT, UBM has the unique
advantage of enabling visualization of structures posterior to
the iris such as the ciliary body, zonules and the peripheral
lens. However UBM is relatively more uncomfortable, requires
a highly skilled operator in order to obtain good quality images
and has a limited scan width (5 x 5 mm with the traditional
UBM devices). For these reasons, UBM is typically used as a
second line imaging device.

PRACTICE REQUISITES

THE FUTURE OF AS-OCT Figure 22: Narrow angles as seen with visante OCT

AS-OCT is currently being utilized in dry eye studies.
Measuring tear meniscus height (TMH) and conjunctivochalasis
are among some of the newer elements being studied utilizing
AS-OCT capabilities during diagnosis and management. Using OCT
imaging to determine effectiveness in dry eye treatment during
clinical trials looks to be promising and encompasses another
capability of this technology.

As post-LASIK patients age, determining proper corneal
power for cataract surgery can be an issue.

AS-OCT measures both the anterior and posterior corneal
curvature-the relationship affected by LASIK. Speci ic software
for this measurement is being studied and released in some of
the SD-OCT systems. SD-OCT has dramatically increased speed
acquisition and improved anatomical detail in both the posterior

ASOCT versus UBM Technical Speciϐications of Visante

ASOCT UBM OCT

Technology Optical Ultrasound Illumination laser source

Long wavelength 1,310 nm

Resolution 15 μm 50μm superluminescent LED

Longest scan dimensions 16 x 6 mm 5 x 5 mm Scan types

Contact with eye No Ultrasound probe does not contact the ____________________________________________
eye directly but requires immersion bath
Anterior segment Single, dual and

quad line scans

Real-time imaging Yes Yes (16 mm x 6 mm) Adjustable in

Imaging posterior to iris No Yes 1-degree increments

256 A scans per line sampling

Quantitative measurement Yes Yes 0.125 second per line acquisition time

____________________________________________

Speciϐications of RTVue Pachymetry map Adjustable 8-line

RTVue Premier Scanner scan pattern

(10 mm x 3 mm) Regional map with

OCT Image: 26,000 A-Scan/second maximum, minimum and average

Frame Rate: 256 to 1024 A-scan/Frame values

128 A scans per line sampling

Depth Resolution (in tissue): 5.0μm 0.5 second total acquisition time

Transverse Resolution: 8μm (nominal) ____________________________________________

Scan Range: High-resolution corneal scans

Adjustable in 1-degree increments

Depth: 2 - 2.3mm (retina) (10 mm x 3 mm) 512 A scans per line

Scan Beam Wavelength: λ=840 +/- 10nm sampling

0.25 seconds per line acquisition time

Exposure Power at pupil: 750μm ____________________________________________

External Image (Live IR) FOV: 13mm x 9mm Optical resolution Axial: 18 μm

Patient Interface: Transverse (center): 60 μm

____________________________________________

Working Distance: 22mm Ametropia correction -35 to +20

Motorized Focus Range: -15D to +20D diopters

____________________________________________

Fixation target Internal or external

and anterior segment. Use of AS-OCT has Achieving this result can someday REFERENCES
allowed for better and more ef icient result in biopsy-like images of corneal
diagnosis, improved disease monitoring, pathogens including protozoa and fungi. 1. Huang D, Swanson EA, Lin CP, et al.
enhanced surgical planning and superior Future swept-source models with a longer Optical coherence tomography. Science.
monitoring of response to treatment. wavelength allowing better penetrance of 1991;254:1178-81.
anterior segment tissue morphology may
Future OCT technology includes also enhance the role of OCT imaging on 2. Izatt JA, Hee MR, Swanson MS, et al. Micrometer
imaging of microscopic structures the eye-care profession. scale resolution imaging of the anterior eye in
and those located posterior to the iris. vivo with optical coherence tomography. Arch
Ophthalmol. 1994;112:1584-89.

3. Diagnostic Performance of Anterior Chamber
Angle Measurements for Detecting Eyes
with Narrow Angles An Anterior Segment
OCT Study; Narayanaswamy A, Sakata LM,
He, Friedman DS et al Arch Ophthalmol.
2010;128:1321-27.

Financial Interest: The authors do not have any ϔinancial interest in any procedure/product mentioned in this manuscript.

56 DOS TIMES - JANUARY-FEBRUARY 2016

DOS QUIZ

Episode-4

Last date: completed responses to reach the DOS OFFICE by e-mail or mail before 5 pm on 25th February, 2016

Q1. The following image shows: Q3. WHO Trachoma management does not include:
a. Bartonella a. Use of SAFE strategy
b. Neurocysticercus b. Examination of children less than 9 years for presence
c. Pellets in brain of follicles and in iltrate
d. Tuberculoma c. Examination of children less than 18 years for
presence of follicles and in iltrate
d. Examination of adults for presence of trichiatic lashes
and or corneal opacities

Q4. The most common cause of pediatric visual impairment
in India is:
a. Refractive error
b. Retinopathy of prematurity
c. Cataract
d. Glaucoma

Q5. RAAB stands for
a. Rapid assessment of avoidable blindness
b. Rapid assessment of association for blind
c. Regional association for alignment of blind
d. None of the above

Q6. The following ϐigure depicts
a. Macular corneal dystrophy
b. Gelationous corneal dystrophy
c. Lattice dystrophy
d. Microsporodial keratitis

Q2. WHO deϐinition of blindness:
a. Vision less than 6/60 in better eye with available
correction
b. Vision less than 3/60 in better eye with available
correction
c. Vision less than 1/60 in better eye with available
correction
d. All of the above

Compiled by:

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

Dr. Meenakshi Wadhwani MS1 Dr. Dewang Angmo MD, DNB, FRCS, FICO2
Research Associate Senior Research Associate

www. dos-times.org 59

DOS QUIZ

Q7. What percentage of patients on medium to high dosages of topical DOS TIMES Quiz Rules

dexamethasone for 6 weeks develop elevated IOP?

(a) 20% (b) 42% (c) 66% (d) 83% 1. DOS TIMES QUIZ will now feature as 5

Episodes (Episode 1: July-August, Episode 2:

Q8. (a) Identify the following September – October, Episode 3: November
instrument?
– December, Episode 4: January – February,
(b) What is it used for?
(c) What is its magniϐication? Episode 5: March – April). Entries will have to

be emailed before the last date mentioned in

the contest questions form. Late entries will

not be entertained.

2. Please email (as scanned PDF ONLY)

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Times Quiz, Dr. M. Vanathi, Room No. 479, 4th

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Q9. (a) Identify the clinical picture. Sciences, All India Institute of Medical
(b) Where is the implant
placed? Sciences, New Delhi.
(c) What is the size?
3. Nonmembers may also send in their entries

but will be required to send along with

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documents) to enroll as member. Failing

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No entries will be entertained after the last

date. The scores of each contestant for all

10. This is the clinical picture of a 5 episodes together will be compiled at
5 year old child operated for
congenital glaucoma. the end of episode 5 and the winner will be

Grade the bleb seen announced in the DOS Annual Conference

in April 2016. In the event of more than one

winning contestants, a draw of lots will decide

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be published in the next episode along with

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5. Please write to dostimes10@gmail.

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60 DOS TIMES - JANUARY-FEBRUARY 2016