dos_jan_2016

DOS CROSSWORD

Episode-4

Dr. Manish Mahabir MD
Senior Resident,
Dr. R.P. Centre,All India Institute of Medical Sciences,
New Delhi, India

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ACROSS DOWN

1. Right optic tract damage would lead to _____ RAPD (4) 2. Anticonvulsant which can cause acute angle closure
6. Persistence or recurrence of a visual image after the stimulus glaucoma(10)

has been removed (10) 3. String of pearls is characteristic of endophthalmitis caused
8. Suprachoroidal drainage device made of polyimide placed by(7)

through ab-interno approach (6) 4. Procedure to tighten lower lid retractors often used in the
9. Pursuit originates in this lobe (8) setting of spastic entropion or early involutional entropion(8)
10. Corneal epithelial iron line at the edge of iltering blebs (5)
11. Overnight use of RGP contact lens to temporarily reduce 5. Congenital contractural arachnodactyly with autosomal
dominant mutation in FBN2 gene(5)
myopia (15)
12. Pathway utilized by Short-wavelength automated perimetry 7. Surgical incarceration of a slip of the iris within a limbal
incision to act as a wick for aqueous drainage(13)
(13)
14. Declaration of ________ is a set of ethical principles regarding 13. Age and pachymetry adjusted nomogram for calculating
LRIs(8)
human experimentation by World Medical Association (8)
15. Plot used in analyzing the agreement between two different www. dos-times.org 61

assays (11)

QUICK PICKS

MACULAR HOLE CLASSIFICATION

INTERNATIONAL VITREOMACULAR TRACTION STUDY GROUP (IVTS) SYSTEM

Suresh Babu N., Ravishankar H. N.
Afull thickness macular hole is a defect in retina
involving the fovea associated with interruption vitreomacular interface (VMI) diseases.
of all neural layers from internal limiting Vitreomacular adhesion as de ined by the IVTS group is
membrane to the retinal pigment epithelium.
Historically, macular holes were ascribed characterized by an elevation of the cortical vitreous above the
retinal surface, with the vitreous remaining attached within a
3-mm radius (de ined arbitrarily) of the fovea (Figure 2). The

to trauma and were observed in young retina shows no change in contour or morphological features

individuals. The irst known case report of macular hole was on OCT and patients are asymptomatic. Eyes with VMA were

in 1869 by Knapp in a patient with ocular trauma. Knapp and subclassiϔied by the size of adhesion into either:

other authors attributed macular holes to trauma in the 19th (1) Focal (≤ 1500 microns) or (2) Broad (>1500 microns).

century. Traumatic macular holes occur in men but majority of The 1500 microns diameter was selected as it is a known area of

age related macular holes occur in women1. increased vitreous adhesion to fovea. Eyes with VMA associated

Coats described histopathologic features of full thickness with macular abnormalities like ARMD, diabetic macular edema

and lamellar macular holes and observed cystic intraretinal and retinal vein occlusions are de ined as concurrent, and the

changes adjacent to macular holes, cysts coalesce to form a full term isolated designated for cases where no ocular disease is

thickness macular hole. present.

Gass2 described the concept of tangential vitreous

traction and attributed it to macular hole

formation and provided a biomicroscopic

classiϔication of macular holes (Figure

1).

Stage 0- Premacular hole, perifoveal

vitreous detachment and subtle changes

in macular topography such as loss of

foveal depression

Stage 1- Impending hole- Loss of

foveal depression with a central yellow

spot(stage 1a), yellow ring(stage 1b), no

vitreofoveolar separation.

Stage 2- Eccentric or centrally

located,<400 micron diameter, oval,

crescent or horse shoe shaped retinal

defect inside edge of yellow ring.

Stage 3- central, round > 400 micron

diameter retinal defect, no weiss ring.

Stage 4- central, round retinal defect,

rim of elevated retina, weiss ring with

prefoveolar opacity.

However, the advent of OCT has

changed the concepts and understanding

of macular hole formation. OCT has

revolutionalised vitreoretinal diagnosis

by helping ophthalmologists to visualize

and study the vitreoretinal interface

(VMI) and decipher the pathogenesis of

macular holes.

The International Vitreomacular

Traction Study (IVTS, 2013) group

classi ication of vitreomacular Adhesion,

Traction and Macular hole3 has provided a

new OCT based anatomic classi ication of
Figure 1: Gass biomicroscopic classification of macular hole

www. dos-times.org 63

QUICK PICKS

Figure 2: Vitreomacular Adhesion Figure 4: FTMH: Aperture size measured at the narrowest hole width in
mid retina as a line parallel to RPE.
Figure 3: Vitreomacular Traction
on inner retina. The macular hole mimickers are epiretinal
The vitreous constitutes of 98% water and 2% structural membrane with pseudomacular hole, lamellar macular hole,
macromolecules. The vitreous is attached to all contiguous chronic cystoid edema, impending holes.
structures of the eye including the ILM. The posterior vitreous
cortex and the retinal ILM are bound at their interface by Full thickness macular holes were classiϔied by IVTS
ibronectin, laminin and other extracellular components that group as:
form a glue like matrix. PVD occurs due to gel liquefaction
and weakening of vitreoretinal adhesion. The process of PVD (1) Small FTMH (≤250 microns diameter aperture size)
occurs from multiple sites and proceeds for decades before as these macular holes are associated with a small
detaching from macula and optic nerve, resulting in complete rate of spontaneous closure, very high rate of closure
PVD. Inadequate separation of vitreous from retina leads to with vitrectomy (nearly 100%)
anomalous PVD.
(2) Medium FTMH is de ined as aperture size from 250 to
With the progression of PVD, traction is exerted on macula 400 microns. These holes have a high rate of anatomic
resulting in anatomic changes such as loss of foveal contour, closure (>90%) with complete removal of hyaloid
intraretinal pseudocyst formation, elevation of fovea from with or without ILM peeling.
RPE or a combination that results in reduced or distorted
vision. Such detectable OCT changes with perifoveolar PVD are (3) Large macular holes (>400 microns diameter
characterized by IVTS as aperture size), associated with 90-95% success rate
with vitrectomy combined with ILM peel.
Vitreomacular tration (VMT)(Figure 3). Like VMA, VMT
is subclassiϔied as International Vitreomacular traction study group
classiϔication system of macular holes3
(1) Focal (≤1500 microns) or
(2) Broad (>1500 microns). Stage 0- vitreomacular adhesion
Full thickess macular hole may arise from several reasons Stage 1- vitreomacular traction
like traction on inner retina, tractional foveal cystoid space, Stage 2- Small (≤250 microns diameter aperture size) or
breakdown and elevation of central photoreceptors, traction medium (aperture size from 250 to 400 microns) FTMH with
VMT
Stage 3- Medium or large FTMH (>400 microns diameter
aperture size) with VMT
Stage 4- Small, medium or large FTMH without VMT
The IVTS group has provided a classi ication based on
OCT for consistent reporting, classi ication and evaluation of
potential therapies to treat these conditions.

REFERENCES

1. Ho C Allen etal: Macular hole, Surv Ophthalmol , 1998;42:393-
416

2. Gass JD: Idiopathic senile macular hole: Its early stages and
pathogenesis. Arch Ophthalmol 1988;106:629-39

3. Ducker et al: The International Vitreomacular Traction Study
group classi ication of vitreomacular Adhesion, Traction and
Macular hole. Ophthalmology 2013;120:12.

1.Vitreo Retina Services, Sankara Eye Hospital, Harakere,Thirthahalli Road, Shimoga
2. Chief - Vitreo Retina Services, Sankara Eye Hospital, Harakere,Thirthahalli Road, Shimoga

Dr. Suresh Babu N. MS, DOMS, Fellow1 Dr. Ravishankar H. N MS, DNB, FRF2
64 DOS TIMES - JANUARY-FEBRUARY 2016

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Best Video Dr. Bhagabat Nayak Dr. R.P. Centre, AIIMS, New Delhi
Cionni fixation of capsular bag in pediatric lens subluxation Dr. Bhagabat Nayak Dr. R.P. Centre, AIIMwS,wNwe.wdoDs-etlihmies.org 65
Getting out of a Sticky situation

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Best Ophthalmic Photography Dr. Vijay Kumar Sharma Dr. R.P. Centre, AIIMS, New Delhi
Obstetric Corneal Injury with Tomographic Descemetic Microvilli

66 DOS TIMES - JANUARY-FEBRUARY 2016

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Best Poster Dr. Neha Pathak Misra Eye Hospital, Mansarovar, Jaipur
“One Year Cross-sectional Study of Fundal Changes in Patients www. dos-times.org 67
with Pregnancy-Induced Hypertension”

NEWS WATCH Log on to www.dosonline.org for more photos





















DOL 2015: Winner EASTERN EARLS
Best Cataract Round Video: Dr. Namrata Sharma; Best Glaucoma Round Video: Dr. Kirti Singh; Best Cornea Round Video: Dr. Uma Sridhar;
Best Retina Round Video: Dr. Charu Gupta

68 DOS TIMES - JANUARY-FEBRUARY 2016

NEWS WATCH
October 25, 2015
Dr. Ram Manohar Lohia Hospital, New Delhi
DOS President Dr. Cyrus Shroff, General Secretary Dr. M.Vanathi RML HOD Dr. Praveen Malik and
Dr Govekar in DOS monthly meeting in PGIMER Auditorium on October 25, 2015, 11 AM – 1 PM
at Dr. Ram Manohar Lohia Hospital, New Delhi

Clinical Case Presentations, Clinical talk and Mini Symposium presentation

Guest Case Presentation

Guest case presentation Aurokeratoprosthesis by
Dr Pallavi Sugandhi Cornea & Refractive Surgeon
Eye 7 Chaudhary Eye Centre, Daryaganj, New Delhi

www. dos-times.org 75

NEWS WATCH

New Delhi, 8th October, 2015

Free Eye Screening Camp organised at Shroff Eye Centre, Connaught Place, New Delhi on the occasion of WORLD SIGHT DAY
DOS-World Sight Day free eye screening camp at Shroff Eye Centre, New Delhi with Dr. Amit Prashant Gupta, Dr. Soma Talukdar

and Dr. Shraddha Gupta of the screening team at work during the camp.

DOS expresses its sincere appreciation to SUNWAYS, ENTOD, FDC, MANKIND, CIPLA, SUNPHARMA – AVESTA, SYNTHO for
providing free medicines for the world sight day camp.

www. dos-times.org 77

NEWS WATCH

Free Eye Screening Camp organised at MM Eye Tech Hospital, New Delhi on the occasion of WORLD SIGHT DAY

Free Eye screening camp of DOS – Dr R P Centre at AIIMS Rotary Hospital at Trilokpuri, New Delhi. WHO Programme Director
Dr Suvajee Good with Dr M.Vanathi, Prof Praveen Vashist, Dr Suraj Senjam, Dr Vivek,

the screening team of doctors – Dr. Meenakshi Wadhwani, Dr Hemant, Dr Lakshmi & Dr Priyanka and the rest of the camp team.

Free Eye Screening Camp organised at Chadha Eye Centre, Connaught Place,
New Delhi on the occasion of WORLD SIGHT DAY

78 DOS TIMES - JANUARY-FEBRUARY 2016