DOS_jan_2009

Figure 12: Fundus photograph of the same
patient showing disc with inferior notch
corroborating with the field defect

Figure 11: 24-2 SITA standard program
showing Double arcuate scotoma with

threatened fixation

loss. A positive number indicates that the average sensitivity is
above average normal for age, whereas a negative number points
towards a below the average normal value. If the MD is below
that found in 10% of normal population, a significance level appears.

The Pattern Standard Deviation: It is an index of roughness of the
hill of vision and indicates the degree to which the numbers in the
total deviation plot are not similar to each other. Significance limits
are displayed if PSD exceeds that found in 90% of reliable fields.

Short Term Fluctuation(SF): It is a measure of intratest variability( Figure 13: Glaucoma Hemifield
not available with SITA strategy). SF is between 1 and 2.5 dB in Test zones
reliable normal fields.

Corrected Pattern Standard Deviation (CPSD): This is calculated
by removing SF from PSD.

Zone 7: Glaucoma Hemifield Test(GHT): Five sectors in the upper

field are compared to five sectors in the lower field which are • Generalized Reduction in sensitivity: If neither of the two

mirror images. (Figure 13) Five possible messages may appear- conditions of ONL are met but General Height Calculation

• Outside Normal Limit: At least one sector pair’s score shows the best part of the field to be depressed to a degree
difference must exceed that found in 99% of the normal that occurs in 0.5% of normal population.

population or the individual zone scores in both members of • Abnormally High Senstivity: The General Height calculation

any zone pair exceed that found in 99.5% of normal shows that the best part of the field has higher sensitivity

population. than that found in 99.5% population.

• Borderline: At least one zone pair difference exceeds that • Within normal limits: If none of the preceding four conditions

found in 97% subjects. are met.

www.dosonline.org 67

Figure 14: Glaucoma Progression Figure 15: Change Analysis print out
Analysis printout.

One of the drawbacks of GHT is that it is not designed to detect a • Less than 25% of the points(18) are depressed below the 5%
temporal wedge. level and less than 10 points are depressed below the 1% level
on the pattern deviation plot.
Zone 8: Raw numeric data: This is the actual threshold score in
decibels for each of the tested points. Even if all the zones are • All points in the central 5 degrees must have a sensitivity of at
normal, but the clinical features are very suspicious, the actual least 15 dB.
threshold values in the given patient can be inspected for any
scotomata. Moderate Defect

Anderson and Patella‘s Criteria diagnostic of Glaucomatous Field • MD<-12dB
Defect in absence of retinal/neurological disease affecting the visual
field2: • Less than 50% of the points (37) are depressed below the 5%
level and less than 20 points are depressed below the 1% level
• In the Pattern Deviation Plot of 30-2 program, three on the pattern deviation plot.
contiguous non edge points having p< 5% probability of being
normal, one of which should have p<1%, all being not • No points in the central 5 degrees have a sensitivity of 0dB.
contiguous with the blind spot. These points should be
clustered in the arcuate area. In 24-2 program, there is no • Only one hemifield may have a point with sensitivity of <15
need to ignore the edge points. dB within 5 degrees of fixation

• CPSD (PSD in SITA) <5%. Severe defect(any of the following results)

• GHT outside normal limits. • MD>-12dB

Classification of defects3( Hodapp, Parrish and Anderson’s • More than 50% of the points (37) are depressed below the 5%
Classification) based on 30-2 full threshold test: level or more than 20 points are depressed below the 1% level
on the pattern deviation plot.

Early Defect • At least one point in the central 5 degrees has a sensitivity of
• MD <-6dB 0dB.

68 DOS Times - Vol. 14, No. 7, January 2009

and dots indicate points where enough data is not available to
make a comment. (Figure 14)

Change Analysis: The display includes a boxplot panel across the
top and several graphs of global indices of the series of examination
below the panel.

Figure 16: Box plots representation of The Box Plot values are derived from Total Deviation Plot of
different types of defects. single Field Analysis. The deviations are ranked according to the
amount of deviation. The vertical rectangle (box) represents the
range of deviations for 70% of the locations. The median deviation
is the flanked heavy horizontal bar in the box. The extremes of
deviation are shown with extended vertical lines above and below
this box, incorporating the additional 15% in each direction. The
ends of the vertical lines indicate the total range of deviations
from the normal values for all points. For 30-2 pattern of normal
visual field, 70% of the points range from approximately 3dB
above to 3dB below the average normal value. (Figure 15)

Based on the position, shape and tail of the box plot, the defect
can be classified into three types4: (Figure 16)

• Points within the central 5 degrees with sensitivity <15 dB in Generalized defect: the box has a lower position in the graph, but
both the hemifields. its shape is unchanged.

Follow up Examinations Localized defect: a long negative tail is present, but the box is
normal in position.

The goal of follow up is to detect the difference. For this baseline
of at least two fields is required which are to done after the
management is stable. Factors interfering in analysis are long term
fluctuations, artifacts, patient factors, pupil size, e.t.c. The statistical
packages offered by the machine are ‘Change Analysis’, ‘Overview
and Glaucoma’ ‘Change Probability’.

The Overview Program: It is the sequential series of fields
(maximum 16) of the same patient printed on a single piece of
paper containing all the data that a single field printout provides. It
provides a general idea of visual field changes. A minimum of four
field examinations(two baseline and two follow up) is required
before evidence of progression is compelling from visual
information alone.

Progression of Defect

• Deepening of the existing scotoma is suggested by the
reproducible depression of a point in an existing scotoma by
>7dB.

• Enlargement of an existing scotoma is suggested by the
reproducible depression of a point adjacent to an existing
scotoma by >9dB.

• Development of a new scotoma is suggested by the
reproducible depression of a previously normal point in the
visual field by >11dB, or of 2 adjacent previously normal points
by >5dB.

The Glaucoma Change Probability

This provides statistical help to evaluate progression. Two fields Figure 17: Lens rim artifact
are obtained as baseline and subsequent fields are compared to
the baseline, and to a set of stable glaucoma patients. In the extreme
right of the printout, the closed triangles indicate the points that
have worsened; open triangles indicate points that have improved

www.dosonline.org 69

In conclusion, the visual field testing though computer assisted,
still remains a subjective procedure, with physiological variability
component that is unavoidable5. Therefore before interpreting a
visual field print out the following points should be kept in mind:

• Treatment should not be started on the basis of a single visual
field. Any defect present should be documented on a repeat
examination. It is important to recognize artifacts if any.
(Figure 17)

• Other causes of field defect like retinal(Figure 18) and
neuroopthalmological diseases should be ruled out.

• Correlate the changes in the visual field with the optic disc.

• For follow up examinations same strategy should be used
and baseline fields are obtained after a stable management.
The baseline field strategy shall depend on the severity of
defect.

• Proceed zone wise for a systematic approach.

References

1. Thomas R, George R. Interpreting automated perimetry. Indian J
Ophthalmol 2001;49:125-40.

2. Anderson DR, Patella VM. Automated Perimetry (2nd Edition).
St. Louis: Mosby & Co; 1999.

3. Hodapp E, Parrish R K II, Anderson DR: Clinical decisions in
glaucoma. St.Louis, The Mosby Co., 1993.52-61.

Figure 18: Altitudinal defect due to 4. Heijl A, Lindgren G, Lindgren A, et al: Extended empirical statistical
inferior BRAO package for evaluation of single and multiple fields in glaucoma, in
Mills RP, Heijl A(eds): Perimetry update 1990/91. Amsterdam/ New
York, Kugler & Ghedini Publications, 1991, pp. 303-15.

5. Brusini P, Johnson CA: Staging functional damage in glaucoma:

Mixed defect: a long tail is associated with a depression of the Review of different classification methods Survey of Ophthalmology
whole symbol and/or with a depression of the lower limit of the 2007;52:156-179.

box.

First Author
Ruchi Goel MS, DNB, FICS

Obituary

With profound grief we inform the sad demise of Dr. B. Pattnaik on 17.01.2009. We pray to the almighty to give courage to his
family to face this loss and we stand by them in this difficult time.

70 DOS Times - Vol. 14, No. 7, January 2009

Tonopen: A Critical Appraisal Glaucoma

Shibal Bhartiya MS, MBBS, Sonia Bhargav MS, DNB, Sumita Sethi MS, Shalini Mohan MS, DNB, Anand Aggarwal MD, DNB

The measurement of IOP by a non invasive device , tonometry, signal. The probe tip is covered by a disposable, protective
involves applying a force against the cornea that produces a membrane, the ocufilm tip cover. Utilizing a single chip
distortion of the globe. There are two techniques, according to the microprocessor the waveform produced by each touch to the
shape of the corneal distortion - indentation tonometry and anesthetized corneal surface is analyzed and stored for a statistical
applanation tonometry. The latter may be performed with a comparison process. Leading Edge™ recognition software ensures
variable force or with a constant force. that measurements are taken only at applanation, while ScanLock™
tracking software rapidly scans the electronic measurement data
The variable force applanation tonometers are: Goldmann at a rate of 500 samples per second. This advanced microprocessor
tonometer (GAT), Draeger applanation tonometer, Perkins technology produces objective IOP measurements that are less
applanation tonometer, Mackay-Marg tonometer(MM), Tonopen influenced by operator bias than Goldmann tonometry. The
and Pneumatonometer. average of four independent readings in case of Tonopen XL
(Figure 1) and 10 independent readings in case of Tonopen Avia
This type of tonometry is based on the Imbert-Fick principle and (Figure 2), combined with a statistical confidence index, ensures
measures the IOP value based on the force necessary to flatten a accurate, repeatable, and reliable tonometry results. The Tonopen
fixed area of the cornea. Goldmann Applanation Tonometry Avia has a more ergonomic design, four times longer lasting
remains the gold standard for the measurement of IOP, however battery, larger LCD screen and does not require daily calibration,
its use is difficult or unreliable in certain situations where alternative thus simplifying the measurement process (Table 1).
methods have proven their efficacy.
Calibration
These include:

• Non sitting position of the patient —> Perkins, Draeger, The Tonopen XL unit is internally calibrated, thus the instrument
Tonopen calibration should be checked only before the first use each day or
in the event of unanticipated readings. Calibration must be
• Abnormal anatomic conditions of the cornea —> MM, routinely and successfully performed once daily prior to
Tonopen, Pneumatonometer. instrument use, whenever it is indicated by the LCD display, when
batteries are replaced, or after an unsuccessful calibration.
• Excessive lacrimation or poor fixation —> MM, Tonopen,
Pneumatonometer. The transducer end of the Tonopen is pointed straight down
towards the floor. The Operator’s Button is depressed two times
• Need to measure scleral rigidity —> Schiotz. rapidly. The time between the first and second button press must
be between 0.5 and 1.5 seconds. The Tonopen will “beep” and
• Topic anaesthetic not available; mass screening, risk of infection display [CAL]. The display will change from [CAL] to [UP].
—> NCT. Immediately (within 1 second) the instrument is inverted smoothly,
pointing the transducer end straight up. A properly functioning
Tonopen: Principle Tonopen will display [Good] followed by a “beep”. The Calibration
Procedures to be repeated if [BAD] is displayed.
Mackay Marg principle:The tonometer applanates the cornea on
contact using a plunger that moves within a sleeve. Applanation of After Good is displayed, the Operator’s Button is deperessed once
the cornea moves this tip relative to the plunger and this movement and the Tonopen will display [8.8.8.8], followed by a single row of
is recorded as a continuous tracing following detection by a
transducer. As the forces of corneal resistance are transferred to Table 1: Specifications
the sleeve, the applanation pressure concords with the IOP.1
Parameter Tonopen Avia Tonopen XL
As the area of applanation of the Tonopen is smaller than GAT
(2.36mm2 Vs 7.35 mm2 ), therefore, theoretically the difference Dimensions 6 1/4" x 3/4" x 1 3/4" 7 1/4" x 1" x 7/8"
between applanating pressure and IOP is reduced due to reduced (16 x 2 x 4.4 cm)
corneal resistance of a smaller contact area.2 Weight 2.25 oz. (64g)
Transducer 2.4 oz (71 g) Micro Strain Gauge
The Tonopen utilizes micro strain gauge technology and a 1.0 mm Measurement 5-80 mm Hg
diameter transducer tip and is specially designed to fit comfortably Range Micro Strain Gauge
in the user’s hand, facilitating fast and accurate measurements.
The stainless steel probe on the Tonopen contains a solid state 5-55 mm Hg
strain gauge which converts intraocular pressure to an electrical

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, Power Source TONO-PEN AVIA 2 OCU-CEL ™ XL
All India Institute of Medical Sciences, POWERCEL Batteries
New Delhi-110029 Battery Pack

www.dosonline.org 73

Figure 1: Tono-pen XL applanation tonometer

Table 2 Number of Days
Between Cleaning
Number of Patients
per Week 30
15
10 7
100 1
300
600

Figure 2: Tono-pen AVIA “DATA”. The higher the statistical confidence indicator, the more
reliable the measurement.
dashes, [- - - -], and then by a double row of dashes [====]
followed by a “beep” tone, indicating the instrument is ready to If at least 6 but less than 10 applanations were obtained, the IOP
measure IOP . will be displayed after a 4 second delay, along with the statistical
confidence indicator. If 15 seconds elapse prior to applanation
Taking a Measurement being initiated, the Tonopen Avia will initate the sleep mode,
indicated initially by the display of a single row of dashes [- - -],
The Tonopen probe tip should be covered with a new ocu-film followed by a blank display. The applanation mode may be initiated
tip cover for each patient. After instilling a drop of topical by pressing the operating button.
anesthetic into the eye to be examined, the patient, seated or
supine, is asked to fixate on a point of reference . The instrument Suggested Cleaning Schedule
should be held like a pencil. To initiate an IOP measurement, the
operating button is pressed and released once; and a brief display Procedure: After removing the ocufilm tip cover from the
of [88 888] will be seen as a self-test of the LCD. When the Tono- tonometer the sensor end of the tonometer is positioned against
Pen is ready to measure, the LCD will display a double row of the outlet of the canned air and air at high pressure is directed
dashes, [= = =] the green LED will light, and the device will beep. into the tip of the tonometer for approximately 3 seconds. (Table
The sensor should be tapped very lightly and briefly on the corneal 2)
surface. The Tonometer will chirp with each applanation, and the
DATA field on the LCD will increment for each valid IOP reading Review of Literature
obtained.
The inter method agreement between Tonopen and GAT has
When another beep tone is heard, (indicating that 4 and 10 been controversial ,as is true for amost all othe modalities of
applanations respectively in case of Tonopen XL and Avia have measurement of a continuous ,dynamic variable like IOP. Various
been read), the LED will turn off, and the averaged IOP authors have found the intermethod agreement between the two
measurement will appear on the LCD above “mmHg”. The techniques to be poor, with the standard deviation and the 95%
statistical confidence indicator will appear on the LCD above limits of agreement of the two instruments being high, so that the
two may not be used interchangeably.3-9

On the other hand, some studies have found measurements taken
by the Tonopen to be as accurate as GAT.10,11

Several authors have demonstrated that Tonopen tends to

74 DOS Times - Vol. 14, No. 7, January 2009

overestimate low IOPs and underestimate high IOPs. 4,7,8,9,11Others The Tonopen, however, is an important tool for screening
have concluded that there is no such variation.5,6 purposes, in scarred corneas, through bandage contact lenses and
in patients who are unable to sit up. It is an extremely portable,
Several authors have found a correlation between the tendency of hand-held instrument that provides IOP readings that correlate
the Tonopen to overestimate GAT values in thicker corneas and closely with Goldmann Tonometry. It is easy to use and operators
vice versa with a 10 micron change in central corneal thickness can take fast and accurate IOP measurement with minimal training.
(CCT) leading to a 0.10 to 0.74 mm Hg difference in IOP.12,13 ,14 Li Moreover, the disposable tip makes the chances of cross infections
et al and Tonnu et al, however, were not in agreement with these negligible.
results.15,16
References
Browman et al found that among 230 patients, IOP measurements
from the Tonopen read lowest, and Ocular Response Analyser 1. Mackay RS, Marg E: Fast, automatic electronic tonometer based on
(ORA) read highest, and GAT measurements were closest to the an exact theory. Acta Ophthalmol 1959;37:495-507
mean IOP of the 3 instruments. In a multiple regression model
adjusting for age, sex, race, and other ocular characteristics, a 10 2. Orssengo G, Pye DC: Determination of the true intraocular pressure
microm increase in CCT was associated with an increase of 0.79 and modulus of elasticity of the human corena in vivo. Bull math
mm Hg measured IOP in untreated eyes (P<0.0001). Of the 3 Biol 1999;61:551-572
tonometers, GAT was the least affected by CCT (0.66 mm Hg/10
mum, P<0.0001). They concluded that among parameters related 3. Salvetat ML, Zeppieri M, Tosoni C, Brusini P.Comparisons between
to measured IOP, features in addition to CCT, such as hysteresis Pascal Dynamic contour tonometry, the tonopen and goldmann
and corneal curvature, may also be important.17 aplanation tonometry in patients with glaucoma. Acta Ophthalmol
Scand 2007;85:272-79
Salvetat et al reported that agreement with GAT measurements
was higher for Pascal DCT than for Tonopen readings; however, 4. KaoSF, Lichter PR, Bergstrom TJ,Rowe S.Clinical comparison of the
Pascal DCT significantly overestimated IOP values compared with oculab tonopen to the goldmeann applanatin tonometer.
GAT. Measurements of IOP obtained with both Pascal DCT and Ophthalmol 1987;91:1541-44
the Tonopen appeared to be influenced by CCT, and this influence
appeared to be greater for the latter.3 5. Tonnu P-A Tonnu,1 T Ho,1 K Sharma,1 E White,1 C Bunce,2 and D
Garway-Heath1 A comparison of four methods of tonometry:
Viestenz et al concluded that the TonopenXL is useful for IOP method agreement and interobserver variability. Br J Ophthalmol.
measurement in a sitting and recumbent position. The results are 2005; 89: 847–850.
reproducible in 92% with the Goldmann-applanation tonometer.
Using the TonopenXL, the IOP was 0.8 mm Hg higher in 6. Bafa M, Lambrinakis I, Dayan M, Birch M. Clinical comparison of
recumbent position than in a sitting position.18 the measurement of the IOP with the ocular blood flow tonometer,
the Tonopen XL and the Goldmann applanation tonometer. Acta
Bandopadhyay et all found that the overall agreement between Ophthalmol Scand. 2001;79 :15-8.
the measurements of GAT and Tonopen was good but a small
percentage of large difference (> or = +/-5 mm Hg in 7.4%) may 7. Frenkel RP, Hong J, Shin DH. comparison of the tonopen to the
be of concern in a population-based survey. The time to measure Goldmann applanation tonometer. Arch Ophthalmol 1988;
IOP and the subjects’ preference were strongly in favour of the 106:750-53
Tonopen.19
8. Geyer O, Mayron Y,Loewenstien A,et al.Tonopen tonometry in
Rao et al conclude that there was no significant difference in the normal and post keratopalsty eyes. Br J Ophthalmol 1992; 76:538-
overall accuracy of the OBF tonometer over the Tonopen versus 40
the GAT in post keratoplasty eyes. 20
9. Lester M, Mermoud A, Achache F, Roy S. New Tonopen XL:
An anecdotal case report by Bergwerk et al was of latex induced comparison with the Goldmann tonometer. Eye. 2001;15(Pt 1):
allergy, bilateral conjunctival injection, eyelid erythema, and eyelid 52-8
edema following the use of a tonopen. Use of a fingertip from a
sterile nonlatex glove provided accurate intraocular pressure 10. Denis P, Nordmann JP, Bertin V, Gayraud JM et al. Evaluation of
measurements with the tono-pen, without a local or systemic the tonopen 2 and the XPert noncontact tonometers in cataract
reaction.21 surgery. Ophthalmologica 1993;207:155-61

Conclusion 11. Eisenberg DL, Sherman BG, McKeown CA, Schuman JS.
Tonometry in adults and children. A manometric evaluation of
As the Mackay Marg tonometer is not available anymore, the pneumatonometry, applanation, and TonoPen in vitro and in vivo.
Tonopen is an important method of estimation of intraocular Ophthalmology. 1998 ; 105:1173-81.
pressure,showing acceptable test–retest repeatibilty, as well as
good sensitivity and specificity in patients where GAT is not feasible. 12. Dohadwala AA, Munger R, Damji K.positive correlation between
However, it is not a subsititute for Goldmann Applanation tonopen intraocular pressure and central corneal thickness.
tonometry, whenever the latter is possible. Neither can the two Ophthalmol 1998; 105:1849-54
instruments be used interchangeably, during serial follow up.
13. Mok KH, Wong CS, Lee VW. Tonopen tonometer and corneal
thickness. Eye 1999;13:35-37

14. Bhan A, Browning AC, Shah S et al. Effect of corneal thickness
measurements on intraocular pressure measurements with the
pneumotonometer, Goldmann applanation tonometer and
tonopen. Invest Ophthalmol Vis Sci 2002;43:1389-92

www.dosonline.org 75

15. Tonnu PA, Ho T, Newson T, A El Sheikh, Sharma K, White E, applanation tonometer in a sitting and recumbent position of the
Bunce C, Garway-HeathD. The influence of central corneal thickness patients — a clinical study on 251 eyes. Klin Monatsbl Augenheilkd.
and age on intraocular pressure measured by pneumotonometry, 2002;219:785-90.
non-contact tonometry, the Tono-Pen XL, and Goldmann
applanation tonometry. Br J Ophthalmol. 2005; 89: 851–854. 19. Bandyopadhyay M, Raychaudhuri A, Lahiri SK, Schwartz EC,
Myatt M, Johnson GJ. Comparison of Goldmann applanation
16. Li J, Asrani SG, Stinnett S, Allingham R. Clinical comparison of the tonometry with the Tonopen for measuring intraocular pressure in
Proview eye pressure monitor with the Goldmann applanation a population-based glaucoma survey in rural West Bengal.
toometer and the tonopen. Arch Ophthalmol 2004;122:1117-21 Ophthalmic Epidemiol. 2002 ;9:215-24.

17. Broman AT, Congdon NG, Bandeen-Roche K, Quigley HA, 20. Rao VJ, Gnanaraj L, Mitchell KW, Figueiredo FC. Clinical
Influence of corneal structure, corneal responsiveness, and other comparison of ocular blood flow tonometer, Tonopen, and
ocular parameters on tonometric measurement of intraocular Goldmann applanation tonometer for measuring intraocular pressure
pressure. J Glaucoma. 2007;16: 581-8. in postkeratoplasty eyes. Cornea. 2001;20:834-8.

18. Viestenz A, Lausen B, Jünemann AM, Mardin CY. Comparison of 21. Bergwerk KL, Kodsi SR. Latex allergy associated with the latex cover

precision of the TonoPenXL with the Goldmann and Draeger on the TonoPen. Am J Ophthalmol. 1999;127:91.

First Author
Shibal Bhartiya MS, MBBS

Monthly Clinical Meetings Calendar 2008-2009

Dr. R.P. Centre for Ophthalmic Sciences Centre for Sight
3rd August, 2008 (Sunday) 7th December, 2008 (Sunday)

Venu Eye Institute & Research Centre Mohan Eye Institute
7th September, 2008 (Sunday) 28th December, 2008 (Sunday)

Army Hospital (R&R) DOS Picnic
28th September, 2008 (Sunday) Sunday, 4th January, 2009

World Sight Day Shroff Charity Eye Hospital
8th October, 2008 (Wednesday) 1st February, 2009 (Sunday)

Sir Ganga Ram Hospital Guru Nanak Eye Centre
2nd November, 2008 (Sunday) 22nd February, 2009 (Sunday)

Midterm Conference of DOS Bharti Eye Foundation
22nd & 23rd November, 2008 (Saturday - Sunday) 8th March, 2009 (Sunday)

Annual Conference of DOS 20th-22nd March, 2009 (Friday, Saturday & Sunday)

76 DOS Times - Vol. 14, No. 7, January 2009

Retcam Retina

Tinku Bali Razdan MS, FRCS, Amit Khosla MD

The oft repeated quote, ‘‘a picture is worth a thousand words’’ The Retcam System
certainly applies to fundus photography where panoramic
photo documentation helps in proper diagnosis and detection of The RetCam family embodies three generations of systems- the
even the most subtle clinical signs and serves as a bridge between older RetCam 120, the new generation RetCam II and the most
the past and the present. Capturing these images, however, may recent product release known as the RetCam Shuttle, a portable
not be easy in children and is virtually impossible in babies. device. All of the systems can directly image the fundus, and they
share hardware consisting of a handheld digital video camera
A good option for fundus photography in children is the RetCam connected by a fiberoptic cable to a light-emitting control unit
(Clarity Medical Systems, Inc., Pleasanton, CA). The RetCam is a and computer assembly (Figure 1). The operator controls focus,
state-of-art, high resolution, wide field, contact digital fundus illumination, and the acquisition of images with a foot switch.
camera which is being increasingly used in imaging of pediatric Images are displayed in real time on a screen and automatically
retinal diseases such as retinopathy of prematurity, retinoblastoma, captured to a DVD-RAM disc and/or to a computer. Alternatively,
and shaken baby syndrome. High resolution digital images and a short video stream can be captured with still frames saved from
videos can be captured, stored, displayed for renew, transferred the video at the end of the imaging session. The video mode helps
and/ or printed using this system. to overcome movement on the part of the patient or operator
and thus allows for the acquisition of clear, well-focused frames.

The RetCam Shuttle is one-fourth the size and weight of the full-
size RetCam II model. The Shuttle can be easily moved between
areas of the hospital or taken to different centres if needed. Another
advantage of the Shuttle is that it offers more real-time video
recording capacity than the larger model. The Shuttle also comes
at a price that is lower than the original RetCam, making it a
popular choice for hospitals.

The RetCam provides high resolution images using a 3 CCD
camera coupled to a family of lens units (Figure 2). The various
changeable lens options are (Figure 3) -

Figure 1: The RetCam Unit Figure 2: The hand-held RetCam Camera

Vitreoretina Services 79
Department of Ophthalmology
Sir Ganga Ram Hospital, New Delhi

www.dosonline.org

Figure 3: The RetCam family of Lenses computer’s monitor. Images of the posterior pole, nasal, temporal,
Figure 4: Retcam imaging superior and inferior fields are taken in order, by tilting the camera.
A retinal examination using RetCam usually takes 5 minutes for
both eyes. Pupillary dilatation, 130 degree retinal lens, ample
coupling gel and appropriate wire lid speculum are important
factors in obtaining a good retinal image. (Figure 4)

The RetCam is most commonly used for infants and children
because image quality degrades significantly with even mild degrees
of nuclear sclerosis. Optimal image quality requires wide papillary
dilatation, a clear crystalline lens and light to medium fundus
pigmentation. Extreme prematurity with narrow palpebral
aperture precludes good corneal contact with lens nosepiece.
Media opacity from corneal clouding, pseudophakia or cataract
or a stark white fundus lesion from extreme reflection of light can
reduce image quality. Poor mydriasis results in dark , round or
ring shaped artifacts and dark choroidal pigmentation can impair
visualization of retinal vascular details

Optics of Retcam

The RetCam has a large instantaneous field of view (FOV) of 1300
(Figure 5), as well access to a superb Field of regard (FOR) which
is the total field of imaging available with the camera. The FOR is
at a minimum from equator to equator. With scleral depression
the ora serrata can also be imaged.

Clinical Applications

The RetCam is most commonly used to evaluate premature infants
for retinopathy of prematurity (ROP) (Figure 5). Babies must be
examined multiple times over several weeks or months to

• 1300 lens known as Retinopathy of prematurity lens, is used Figure 5: The Field of View (FOV)
in premature babies DOS Times - Vol. 14, No. 7, January 2009

• 1200 lens known as childrens lens, is used for imaging pediatric
to young adults

• 800 lens is used for high contrast in pediatric and young adults

• 300 degree lens is used for a magnified view of the fundus

• Portrait lens is a flat lens used for external imaging.

Wide field Fluorescein angiography can also be performed with
RetCam II.

The Retcam Technique

The RetCam requires contact between the hand held camera and
the corneal surface and uses transpupillary illumination to capture
digital images of the fundus through a widely dilated pupil. After
instilling topical anesthetic drops and applying a lid speculum, an
ample amount of gel is used on the cornea or on the tip of the
camera lens (a dry eye gel is a good option) to provide an optical
coupling bridge between the camera and the eye. To maintain a
reproducible point of reference, the operator should keep the
cable connecting the camera to the RetCam’s mainframe in a 12:00-
o’clock orientation to the patient. Illumination and focus are
adjusted based on the view of the image displayed on the

80

Figure 6: Zone 2 ROP imaged using RetCam

determine how the condition of the eye is changing. The RetCam The RetCam can also be used to image and capture digital
is ideal for ROP screening because it is the only way to obtain photographs of the angle of adults and children. This method of
objective, detailed images that can be precisely compared from goniography eliminates the need for auxiliary gonio lenses and
one exam to the next to track the health of the eye over time. makes angle imaging fast, easy and comfortable for the patient.
(Figure 6)
In addition to ROP, the RetCam is used in the diagnosis and
The digital imaging of the RetCam also enables remote evaluation, documentation of Retinoblastoma, retinal haemorrhages in
so that the clinician no longer needs to be at the infant’s bedside to shaken baby syndrome and other blood dyscrasias, Coats disease,
evaluate for ROP. This has led to the introduction of telemedicine and other congenital retinal disorders.
screening networks, whereby babies are kept in their local hospitals
and images are sent to an offsite screener for expert assessment. Conclusion
Such networks are important because there is a growing number
of premature babies who require screening for ROP and a The Retcam is a unique intregrated system for bedside wide-
shrinking pool of qualified physician screeners. angle viewing. The availability of an immediate image means that
precise diagnostic comparisons can be made over time rather
The PhotoROP trial was a multicenter, prospective trial to evaluate than relying on innaccurate drawings in the patient’s chart. Because
telemedicine screening with the RetCam relative to bedside indirect the RetCam is easy to use, it has been promoted for use in ROP
ophthalmoscopy. The preliminary results indicated that remote screening by nursery staff and nurses. The digital capability also
interpretation of RetCam images had a sensistivity of 100 percent enables remote image transfer so that the clinician no longer needs
and specificity of 97 percent when compared to bedside binocular to be in the same room or even the same country as the patient.
indirect ophthamolscopy. Furthermore, the screening center The immediacy offered by the real-time view of the camera on
readers recommended treatment two weeks earlier than the the computer monitor can also serve as an excellent tool for
bedside screeners, possibly indicating the advantages of training residents, fellows, and nursery staff as well as educating
longitudinal examination with photographs. parents of infants screened.

First Author
Tinku Bali Razdan MS, FRCS

www.dosonline.org 81

Non Specific Orbital Inflammatory Clinical Meeting: Clinical Case 2
disease: Perineuritic Variant

Vikas Menon DNB, H.K.Tewari MD

A 24 year old girl presented with a 15 day old history of swelling Her hemogram and collagen vascular profile did not reveal any
around her right eye. abnormality. She was being subsequently managed on oral steroids
with continued improvement of her disc edema till she presented
She was diagnosed elsewhere as Right eye Optic Neuritis four with periocular fullness in the left eye (Figure 8a) about 6 weeks
months before her presentation to us and gave history of taking after her first presentation to us. There was no other abnormality
oral steroids at that time. At the time of presentation she was in the left eye. She was then administered a single pulse of intra
using topical steroids and Homatropine in the right eye for 2 weeks venous Methyl Prednisolone 500mg with excellent response
for anterior uveitis diagnosed elsewhere. (Figure 8b). The patient was subsequently managed with tapering
doses of oral steroids and was started on oral Azathioprine under
There was no significant systemic history supervision of an immunologist. The disease has been under
remission for about 8 months now (Figure 9).
On examination, her Best corrected visual acuity was 6/10 and 6/6
in right and left eyes respectively. Intraocular pressure was 6 and Discussion
14mm Hg. On external examination, she had an axial proptosis of
2mm in the right eye, with associated periocular fullness (Figure Non Specific Orbital Inflammation is defined as a benign, non-
1). The orbit was soft on Retropulsion. No mass could be palpated. infective clinical syndrome characterized by features of nonspecific
There was slight restriction of adduction and depression in the inflammatory conditions of the orbit without identifiable local or
right eye. (Figure 2) systemic causes. It accounts for 4.7% to 6.3% of orbital disorders1

On slit lamp examination, cells 1+ could be seen in the anterior Since the initial description in 1903 by Gleason2, many classification
chamber of right eye. Pupils were dilated pharmacologically at the schemes have been applied to idiopathic orbital inflammation
time of examination (using Homatropine). Fundus examination based on the histopathological characteristics, and the stage of
of the right eye showed disc edema with associated vascular inflammation. However, the scheme followed most commonly
tortuosity and some amount of exudation near fovea. (Figure 3) classifies the disease process based on the location of the
inflammatory process into:
Examination of the left eye did not reveal any abnormality

We reviewed her MRI done about 4 months back which showed • Anterior
increased enhancement around the right optic nerve (Figure 4). • Myositic
However, no periventricular or intracranial lesions could be • Dacryoadenitis
identified.

We got a CT scan (Figure 5) done which showed prominent fat • Perineuritic
streaking around the right optic nerve, the nerve also appeared • Apical
thickened with fuzzy margins.Slight thickening of the adjoining • Diffuse
Medial Rectus muscle and the adjoining posterior episcleral tissues
was also noted. Adjoining para nasal sinuses were however clear.

Based on the above mentioned clinico-radiologic findings, a clinical
diagnosis of Perineuritic variant of Non Specific Orbital
Inflammatory Disease (NSOID) was made. She was administered
intra venous Methyl Prednisolone 1gm daily for 3 days under
physician supervision and a complete collagen vascular profile
was ordered.

The patient showed dramatic improvement with i.v steroid therapy Figure 1: Clinical photograph of the
with vision improving to 6/6P. Proptosis and periocular fullness patient having mild axial proptosis
also resolved completely within a span of just three days. Ocular and periocular fullness in right eye
motility and disc edema also showed signs of improvement
(Figure 6). Her visual fields done at this point of time revealed few
depressed paracentral points in the right eye (Figure 7).

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www.dosonline.org 83

Figure 2: Restriction of extraocular muscle motility especially adduction,
depression and partly elevation of the right eye

Figure 3: Color fundus photograph showing disc edema and tortuosity of
vessels in the right eye. Disc appearance in the left eye being normal

Figure 4: MRI (done 4 months before presentation) showing ill
defined enhancement around right optic nerve

84 DOS Times - Vol. 14, No. 7, January 2009

Figure 5: CT showing presence of increased fat streaking around right
optic nerve, thickening of posterior episcleral tissues and slight thickening of

right medial rectus muscle

Figure 6: Clinical photograph demonstrating resolution of periocular fullness and
improvement of ocular motility after first cycle of i.v methyl prednisolone

Optic perineuritis was first described by Edmunds and Lawford in In a series of 14 cases of optic perineuritis described by Purvin,et
1883.3 who described two forms of this disease: exudative and al5, biopsy was taken in two patients, and it was seen that regardless
purulent. With the evolution of our understanding of the disease of what unknown process incites the initial inflammatory process
process, perineuritis is now considered to represent a form of in idiopathic cases, the common pathologic reaction consists of
idiopathic orbital inflammatory disease, in which the specific target marked thickening of the optic nerve sheath due to nonspecific
tissue is the optic nerve sheath4. Most cases of NSOID are isolated fibrosis with various stages of predominantly lymphocytic
and idiopathic but may occasionally occur as a manifestation of a infiltration.
specific infectious or inflammatory disorder such as Wegener
granulomatosis or giant cell arteritis. All such patients need to undergo laboratory testing to exclude
specific systemic inflammatory diseases. In all patients, the complete
The clinical and radiologic features may at times mimic optic nerve blood cell count, the erythrocyte sedimentation rate, and the levels
sheath meningioma especially if there is dense perineural fibrous of antinuclear antibodies, angiotensin-converting enzyme; a
tissue accumulation. A biopsy is definitely indicated in such a syphilis serologic test; and a chest x-ray film are recommended.
situation to reach the exact diagnosis. But most of the times the
perineural soft tissue changes may be subtle and the diagnosis is Neuroimaging in patients with OPN has been described to show
then made on the basis of the clinico-radiologic features instead. a characteristic pattern of enhancement around the optic nerve
One has to weigh the risk-benefit ratio while planning a biopsy in “tramtrack” on axial views and “doughnut” on coronal views5.
a patient with good vision. Our patient was young and had MRI scans in some cases show streaky enhancement of orbital fat.
reasonably good vision in the involved eye without evidence of In some patients, close inspection may reveal subtle enhancement
any well defined mass on imaging, hence it was decided to proceed of extraocular muscles and/or sclera in addition to the characteristic
empirically with the treatment. changes in the optic nerve sheath.

www.dosonline.org 85

Figure 7: Visual fields showing few depressed
paracentral points in the right eye

Figure 8a: Appearance of periocular fullness Figure 8b: Resolution of fullness
in the left eye about 6 weeks after the following a single pulse of i.v
first cycle of iv steroids methyl prednisolone

Based on shared clinical features, patients with OPN are likely to disease but are likely to experience a recurrence of visual loss in
be misdiagnosed initially as having Optic Neuritis. Table 1.1 lists the future.
some of the important features which can help differentiate optic
perineuritis from optic neuritis. Mild motility disturbance, due to One must also keep the possibility of hematologic malignancies
extraocular muscle inflammation, is also occasionally a helpful like leukemia and lymphoma in these cases which can be excluded
clinical feature. by various hematological laboratory tests and a biopsy of the
perineural tissues in select cases.
It is important to accurately distinguish between optic perineuritis
and optic neuritis since the prognosis is different in these disorders. Various treatment modalities like high dose oral steroids, i.v
Patients with optic neuritis are at high risk of developing multiple steroids, peribulbar steroids, azathioprine and radiation have all
sclerosis and should be counseled accordingly. Patients with been tried with variable success rates5. We prefer treatment with
perineuritis, in contrast, are not at increased risk for demyelinating high dose I.V steroids initially to be followed by pulse I.V steroid

86 DOS Times - Vol. 14, No. 7, January 2009

Table 1.15 Optic Neuritis Optic Perineuritis
Broader range (36% are >50 y)
Feature Usually young adults
Age at onset (only 15% are > 50 y) Often paracentral or arcuate
Progression over weeks
Visual loss Usually central Progressive visual loss
Time course Prompt and dramatic; common relapse
Natural history Progression over days after brief treatment
Response tocorticosteroid Perineural enhancement and “streaky” fat with
treatment Spontaneous recovery or without extraocular muscle enhancement
Magnetic resonance imaging
scan findings Variable; uncommon relapse
after stopping

Optic nerve enhancement with
or without white matter lesions

The prognosis for visual outcome in patients with OPN is generally
excellent. This is greatly influenced, however, by the interval
between the onset of visual loss and the initiation of treatment.
The other factor that influences prognosis is the frequency of
recurrent attacks. Initiating treatment with higher doses of
corticosteroids and more prolonged treatment at this level appear
to lessen the likelihood of recurrent attacks.

References

1. Rose GE, Wright JE. Exenteration for benign orbital disease. Br J
Ophthalmol. 1994;78:14-18.

2. Gleason JE. Idiopathic myositis involving the intraocular muscles.
Ophthalmol Rec. 1903;12:471-478.

Figure 9: Color fundus photograph 3. Edmunds W, Lawford JB. Examination of optic nerve from cases of
showing complete resolution of disc amblyopia in diabetes. Trans Ophthalmol Soc U K. 1883;3:160-
162.
edema in the right eye
4. Kennerdell JS, Dresner SC. The nonspecific orbital inflammatory
syndromes. Surv Ophthalmol. 1984;29:93-103.

5. Purvin V; Kawasaki A; JacobsonDM. Optic Perineuritis: Clinical

therapy or oral steroid therapy depending upon disease severity. and Radiographic Features. Arch Ophthalmol. 2001;119:1299-1306

Since these patients have a high incidence of disease recurrence,

long term immunosupression with an immunomodulatory agent

like azathioprine under care of an immunologist is also

recommended.

First Author
Vikas Menon DNB

www.dosonline.org 87

Intra-operative Floppy Iris Syndrome (IFIS): Clinical Meeting: Clinical Talk
A Phaco nightmare

Mahipal S. Sachdev MD, Charu Khurana MS, DNB, R. Ghosh MBBS

Intra-operative Floppy Iris Syndrome (IFIS), first described in The classical triad of IFIS includes:
2005, is characterized by repeated prolapse of billowing, floppy
iris, and progressive intraoperative miosis. (Figure 1) It occurs in • Fluttering & billowing of iris stroma
approximately 2-3% of cataract surgical population and has been
reported to be caused by tamsulosin prescribed for treatment of • propensity if iris to prolapse through phaco and side port
benign prostatic hypertrophy (BPH)1. incisions

Tamsulosin (Trade name Flomax/ Urimax) is an Alpha-1 antagonist • progressive constriction of pupil
which relaxes the muscles of the prostate and bladder neck and is
indicated for urinary dysfunction caused by BPH. The alpha 1A The most important aspect of successfully managing a case of IFIS
receptor subtype also mediates contraction of the iris dilator is to anticipate it and to be prepared for it. The patient should be
smooth muscle. Use of this drug causes loss of tone and muscle asked for a list of the medications he is using and a history of
atrophy of the iris and increased incidence of prolapse. Though prostatic hypertrophy should be specifically elicited. The effect of
eye surgery is listed among the known contra-indications for use alpha-1 blockers persists even after discontinuation of drugs so it
of this drug, a lot of our patients are unaware about it and may not is important to check if the patient was previously on this
report its use to the ophthalmologist. It therefore becomes the medication but has now discontinued.
responsibility of the eye surgeon to specially look for this drug
among the list of medications and to be prepared for the Check the pupillary dilation as it may provide a clue to the severity
complications that may ensue. In a retrospective study by Chang of IFIS. Though 53% of IFIS patients will have a large pupil at the
et al on 706 cataract surgery patients 64% of the patients on beginning of the surgery, about half of these will constrict and will
tamsulosin therapy had IFIS.2 need intracameral epinephrine to be re-dilated or atleast prevent
further constriction.3 Pupillary staging has been described as
The severity of IFIS ranges from a normal iris response to an follows:
atonic iris that dilates poorly and billows and prolapses during
surgery. Though many techniques have been described every case Type 1: Good mydriasis maintained throughout
needs to be evaluated individually and planned accordingly. IFIS
patients also have an increased risk of complications such as iris Type 2: Good mydriasis pre-op but pupil constricts later
trauma, posterior capsule rupture and vitreous loss.
Type 3: Mid dilated pupil that sometimes constricts later

Type 4: Poorly dilated pupil at the beginning of surgery

The various treatment strategies that maybe used for the
management of a case of IFIS include:

Figure 1: Intra-operative miosis with Figure 2: Use of iris retractor to
iridodialysis in a patient with IFIS stretch the pupil

Centre for Sight 89
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• Use small side ports, non-leaking incisions, moderate flow
and vacuum settings

• Keep the phaco tip above or below the iris plane during
removal of nuclear fragments to prevent the iris from getting
attracted to the phaco-tip

• Keep a second instrument between the phaco-tip and adjacent
iris and slowly remove the instruments from the eye keeping
the infusion discontinued

It is important to remember that stopping the tamsulosin does
not help as the effect of the drug persists even after
discontinuation. Acute urinary retention maybe precipitated if
the drug is abruptly stopped.

Figure 3: Cataract surgery with IOL References
implantation with iris repair in a
patient with IFIS 1. Chang DF, Campbell JR. Intraoperative floppy iris syndrome
associated with tamsulosin (Flomax). J Cataract Refract Surg 2005;
31: 664-673.

2. Chang DF, Braga-mele R, Mamalis N, et al. Clinical experience with

intraoperative floppy-iris syndrome. Results of the 2008 ASCRS

• Pre-op atropine: Atropine BD/ TDS 1-3 days before surgery member survey. J Cataract Refract Surg 2008; 34:1201-1209.

may help to dilate the pupil and stabilize the iris 3. Manvikar S, Allen D Cataract surgery management in patients
taking tamsulosin staged approach. J Cataract Refract Surg 2006;

• Epinephrine: Intra-cameral sulfite-free preservative-free 32(10): 1611-1614

epinephrine (dilute the 1:1000 solution to reach a concentration 4. Chang DF, Osher RH, Wang L, Koch DD. A prospective multicenter
of 1:3 to 1:5) may help to further dilate the pupil evaluation of cataract surgery in patients taking tamsulosin (Flomax).

• Visco-adaptive devices such as Healon GV maybe used to Ophthalmology 2007; 114:957-964

enlarge and maintain the pupil 5. Chadha V, Borooah S, Tey A, et al. Floppy Iris Behaviour During

• Iris hooks & pupil expanders such as the Malyugin ring, Cataract Surgery: Associations and Variations. Br J Ophthalmol.
Graether 2000 pupil expander system and Morcher pupil 2007; 91:40-42.

dilator can be used. (Figure 2)

• Manual stretching and sphincterotomies have not been found
to be effective and may actually increase the floppiness of the
iris4

First Author
Mahipal S. Sachdev MD

90 DOS Times - Vol. 14, No. 7, January 2009

Industry News Industry News

Noopur Gupta MS DNB

Small interfering RNA drug named one of most promising trends in patient’s symptoms (OSDI and patient’s worst symptom,
drugs entering phase 3 trials both trials) and in the signs of corneal staining (one trial) and blink
rate (both trials). The Company believes the lack of response to
OPKO Health, Inc. announced in a press release that bevasiranib ecabet in symptoms in the most recent trial is not of concern, in
was named one of the top five most promising drugs entering part because the OSDI responses to ecabet sodium were strong
Phase III clinical trials. Bevasiranib is a first-in-class small and predictable in the previous Phase II trials. ISTA believes that
interfering RNA (siRNA) drug designed to silence the genes that given the ability to demonstrate a positive effect on signs in the
produce vascular endothelial growth factor. environment and on symptoms in the controlled environment
chamber, there is now a clear path forward to Phase III studies
The multi-national phase 3 COBALT (Combining Bevasiranib and New Drug Application filing for this product.
And Lucentis Therapy) clinical trial of bevasiranib for the
treatment of wet AMD is currently enrolling patients at multiple The object of the study was to investigate ecabet sodium’s effects
clinical sites. on the objective signs of tear production (Anesthetized and
Unanesthetized Schirmer Tests) and tear film quality (TFBUT)
ISTA Pharmaceuticals Announces Positive Results for and subjective symptoms (OSDI, patient’s worst symptom) in
Phase IIb Study of Ecabet Sodium patients with dry eye disease when administered under normal
environmental conditions. In the analysis of responders to both
ISTA Pharmaceuticals, announced positive results from the ecabet sodium and placebo, results of the Anesthetized Schirmer
Company’s Phase IIb clinical study of ecabet sodium, which is Test in the Phase IIb study revealed a strong trend for ecabet
being developed as a treatment for dry eye disease. Patients treated sodium, which approached statistical significance versus placebo.
with ecabet sodium achieved a strong positive trend in the objective This result is important because it indicates an effect on basal tear
sign of Tear Film Break-Up Time (TFBUT) and a positive trend in secretion, which is one of the main factors in the etiology of dry
the objective sign of quantity of tears produced (Schirmer Test). eye disease. In addition, the percentage of patients who responded
In contrast, there were no trends seen in the placebo group for to ecabet sodium was greater than that seen in the trials that led
either objective sign. In addition, there were no trends seen in to the approval of the only currently approved product on the
either group in subjective symptoms as measured by the Ocular market for dry eye disease. Further, this trend in increased
Surface Disease Index (OSDI) or patient’s worst reported Schirmer Test score was seen as early as day 22 of treatment and
symptom. In Phase II tests where observations are not powered continued to trend upwards through day 43. Adverse events were
to show statistical significance, strong and positive trends are used uncommon and similar between the treatment and placebo
as indicators of potential efficacy in subsequent Phase III studies. groups, and there were no serious ocular or systemic adverse
events.
The Phase IIb results from this environmental study add further
support to our belief that ecabet sodium has the ability to treat Ecabet sodium represents a new class of molecules that increase
signs and symptoms of dry eye syndrome. Ecabet sodium may the quantity of mucin produced by conjunctival goblet cells and
provide advantages over other products used to treat dry eye and corneal epithelia. Mucin is a glycoprotein component of tear film
those that are in development, as we believe ecabet sodium not that lubricates while retarding moisture loss from tear evaporation.
only improves the quality of tears but also increases the quantity
of tears,” stated Vicente Anido Jr., Ph.D., President and Chief New Application for Ganciclovir is Accepted for Review by
Executive Officer of ISTA Pharmaceuticals. “After reviewing the the FDA for the Treatment of Ocular Herpes
guidance from and our discussions with the FDA, we believe that
by conducting two successful Phase III environmental clinical trials Sirion Therapeutics, Inc., a privately held ophthalmic-focused
for improvement in signs and two successful Phase III controlled biopharmaceutical company, today announced that ganciclovir
chamber clinical trials for the improvement of symptoms, we ophthalmic gel, 0.15%, has been accepted for review as a treatment
should receive marketing approval. In addition, we are expecting for herpetic keratitis, an ocular disease caused by the herpes
results from a Phase II clinical trial studying the potential of a simplex virus.
lower strength of Xibrom to treat the signs and symptoms of dry
eye disease in the first half of 2009. Once this lower strength “Herpes simplex keratitis remains one of the leading causes of
Xibrom trial is completed, we will make a decision on which corneal blindness and corneal transplants in the United States,”
product or products in our dry eye franchise to move into Phase explained Barry Butler, CEO of Sirion Therapeutics. “If approved
III trials, which could start as early as 2010. by the FDA, ganciclovir ophthalmic gel would become the first
topical ophthalmic antiviral treatment launched in the U.S. in
ISTA’s previous two Phase II trials of ecabet, which were conducted almost three decades. This product would provide a significant
in a controlled environment chamber, demonstrated positive new option for physicians in the treatment of patients with herpetic
keratitis.”

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, To assess the efficacy and safety of ganciclovir, four randomized,
All India Institute of Medical Sciences, multicenter trials compared ganciclovir gel, 0.15%, with acyclovir
Ansari Nagar, New Delhi ointment, 3%, both of which are used as first-line therapies outside

www.dosonline.org 93

the U.S. to treat herpetic keratitis. The studies found that ganciclovir inflammatory and anti-microbial effects of ISV-502 (a combination
is as effective as acyclovir and that the tolerability of ganciclovir of 1% azithromycin and 0.1% dexamethasone) as compared to
was superior to acyclovir, particularly with regard to blurring and either AzaSite(R) (azithromycin ophthalmic solution 1%), InSite’s
stinging or burning sensations after instillation. Additionally, since topical antibiotic eye drop currently marketed for the treatment
ganciclovir is formulated as an aqueous gel, it allows for prolonged of bacterial conjunctivitis, or dexamethasone, a commonly used
contact time with the corneal surface. corticosteroid intended to address inflammation. The primary
endpoint for the trial was the clinical resolution of all inflammatory
“Based upon its proven safety and efficacy, the introduction of a symptoms present at the time of enrollment, which could include
new topical antiviral agent with improved tolerability, such as lid margin redness or swelling, conjuctival redness or ocular
ganciclovir ophthalmic gel, would clearly be a valuable treatment discharge and lid irritation in at least one eye. The secondary
option for U.S. clinicians who treat herpetic keratitis,” noted Herb endpoint was bacterial eradication. Resolution or improvement
Kaufman, M.D., Sirion Ophthalmologist Emeritus and renowned of individual symptoms and safety were also assessed.
herpetic keratitis researcher and clinician.
Patients were randomized into one of three dose groups and
InSite Vision Announces Preliminary Results From Phase 3 received one drop in the eye and one drop on the eyelid
Clinical Trial of ISV-502 for the Treatment of Eyelid administered twice daily for fourteen days. A total of 417 patients
Inflammation and Infection with a clinical diagnosis of blepharoconjuctivitis were enrolled in
the Phase 3 trial. Of the 417 patients in the study, 27.1 percent of
Second Phase 3 Trial of ISV-502 Planned Following Discussions subjects treated with ISV-502 met the clinical criteria necessary to
With the U.S. Food and Drug AdministrationInSite Vision demonstrate a resolution of the inflammatory signs and symptoms
Incorporated (AMEX:ISV) today announced preliminary results of blepharoconjunctivitis. By comparison, 15.6 percent of subjects
from the company’s Phase 3a clinical trial of ISV-502 (AzaSite in the AzaSite study arm and 23.5 percent of subjects receiving
Plus(TM)) a topical combination antibiotic/corticosteroid product dexamethasone alone achieved a complete resolution of their eye
for the treatment of blepharoconjunctivitis. Blepharoconjunctivitis, clinical signs and symptoms.
also known as lid margin disease, is a chronic inflammatory disease
of the inside and outside of the eyelid with no approved treatment. In addition, ISV-502 successfully achieved bacterial eradication of
ISV-502 improved clinical outcomes as compared to treatment the eye as part of the secondary endpoint at a statistically significant
with a corticosteroid alone or antibiotic alone in the reduction of difference compared with dexamethasone alone. In the ISV-502
inflammatory signs and symptoms and bacterial eradication, study arm, 100 patients had positive bacterial culture confirmed in
respectively. In addition, ISV-502 was very well tolerated. However, at least one eye at the time of enrollment. Of these, 60.0 percent
an initial evaluation of the data indicates that the trial did not achieved complete eradication of their bacterial load measured at
achieve its primary endpoint as defined by the protocol. their last clinical visit. By comparison, 66.3 percent in the AzaSite
study arm and 40.2 percent in the dexamethasone arm achieved
“A safe, convenient and effective formulation of an antibiotic and eradication of bacterial load.
corticosteroid such as ISV-502 with the potential to address the
inflammation and underlying infection would have a significant ISV-502 was very well tolerated consistent with safety data
impact on the treatment of this condition. These initial data appear observed in past clinical and preclinical studies of the compound.
encouraging and I look forward to continued evaluation of this The adverse events reported were mild to moderate with no
promising product,” said Mark Abelson, M.D., a clinical associate serious adverse events related to the study drug.
professor at Harvard Medical School. “Lid margin disease is a
painful and difficult to treat condition and available treatments ISV-502 combines 1% azithromycin and 0.1% dexamethasone in
have limited success in alleviating symptoms or addressing the InSite’s patented DuraSite(R) sustained delivery vehicle to provide
underlying cause. Patients would benefit from a treatment designed simultaneous antimicrobial and anti-inflammatory treatment for
to provide both relief of the acute symptoms and to treat the the treatment of eyelid infection and inflammation in adults. InSite’s
underlying condition.” DuraSite sustained delivery vehicle is a synthetic polymer-based
formulation designed to achieve high tissue levels of drug relative
“Patients receiving ISV-502 achieved marked improvement in their to conventional topical therapies that are rapidly rinsed away by
condition. We believe that ISV-502’s performance in both tears.
addressing inflammation and eradicating bacterial infection
associated with lid margin disease make continued development This news release contains certain statements of a forward looking
of this product worthwhile,” said Louis Drapeau, InSite’s Chief nature relating to future events, including the proposed indications
Executive Officer. and clinical status of ISV-502 (AzaSite Plus), the benefits of ISV-
502, the potential benefits of ISV-502, InSite’s plans with respect to
“The study demonstrated that ISV-502 achieved a statistically future clinical trials for ISV-502 and discussions with the FDA
significant difference when compared to treatment with an regarding the same, I.
antibiotic alone for the reduction of inflammatory signs and
symptoms. A statistically significant difference was also shown DOS Correspondent
when ISV-502 is compared to treatment with a corticosteroid alone Noopur Gupta MS, DNB
for bacterial eradication. We are conducting a thorough analysis
of the promising trends observed in this trial as we finalize the
protocol for the second Phase 3 confirmatory study to be discussed
with the FDA.”

The Phase 3 multi-center study was designed to evaluate the anti-

94 DOS Times - Vol. 14, No. 7, January 2009

Clinical complications of combined phacoemulsification and Abstracts
vitrectomy for eyes with coexisting cataract and vitreoretinal diseases

L. Wensheng, R. Wu, X. Wang, M. Xu, G. Sun, C. Sun

Eur J Ophthalmol 2009; 19: 37 - 45

PURPOSE

To discuss the intraoperative and postoperative complications of combining phacoemulsification and foldable intraocular lens (IOL)
implantation with pars plana vitrectomy in eyes with significant cataract and coexisting vitreoretinal diseases.

METHODS

This retrospective study consisted of 186 eyes of 149 patients with various vitreoretinal abnormalities and visually significant cataracts.
Vitreoretinal surgery was combined with clear corneal phacoemulsification and foldable IOL implantation. Main outcome measures
were the intraoperative and postoperative complications at from 6 to 56 months.

RESULTS

The most common intraoperative complication was iatrogenic retinal hole (5.3%), transient corneal edema (3.2%), and posterior
capsule break (2.1%). The most common postoperative complication was posterior capsule opacification (21.5%) and elevated intraocular
pressure (9.7%), macular edema (8.1%), fibrinous reaction (6.9%), vitreous hemorrhage (3.7%), posterior synechiae (3.7%), and recurrent
retinal detachment (3.2%). Postoperatively, in 162 eyes (87.1%), visual acuity improved by 3 lines or more on the Snellen chart. In 14 eyes
(7.5%), vision remained within 3 lines of preoperative levels and in 10 eyes (5.3%), vision had decreased at the last follow-up.

CONCLUSIONS

Postoperative complications did not increase significantly in the combined phacoemulsification and vitreoretinal surgery. Combined
vitreoretinal surgery and phacoemulsification with foldable IOL implantation is safe and effective in treating vitreoretinal abnormalities
coexisting with cataract. Based on extensive experience with the combined procedure, the authors suggest that combined surgery is
recommended in select patients having simultaneous vitreoretinal pathologic changes and cataract.

The Effect of Topical Bevacizumab on Corneal Neovascularization

Kim SW, Ha BJ, Kim EK, Tchah H, Kim TI.
Ophthalmology. 2008 Jun;115(6):e33-8. Epub 2008 Apr 24.
Corneal Dystrophy Research Institute, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Republic of Korea.

PURPOSE RESULTS

To examine the effect of topical bevacizumab on corneal Decreased corneal NV was noted in 7 of 10 eyes, usually within 1
neovascularization (NV) over a period of 3 months. month of treatment. Epitheliopathy (epithelial defect, epithelial
erosion) was observed in 6 of 10 eyes, 1 resulting in corneal thinning.
DESIGN Adverse effects generally appeared during the second month of
treatment.
Prospective, nonrandomized, masked observational case series.

PARTICIPANTS CONCLUSIONS

Ten eyes of 7 patients with corneal NV. Topical application of bevacizumab was effective in reducing
corneal NV within the first month. However, by the second month
METHODS there was an increased risk of adverse effects.

Patients received topical bevacizumab (1.25%) twice daily.
Ophthalmic evaluations included visual acuity, slit-lamp
examination, and tonometry.

MAIN OUTCOME MEASURES DOS Correspondent
Corneal NV and changes in ophthalmic evaluations. Noopur Gupta MS, DNB

www.dosonline.org 97

Concordance between Common Dry Eye Diagnostic Tests

J E Moore1,2, J E Graham1, E A Goodall1, D A Dartt3, A Leccisotti1,4, V E McGilligan1, T C B Moore1
British Journal of Ophthalmology 2009;93:66-72

1 Centre for Molecular Biosciences, University of Ulster, Northern Ireland, UK, 2 Royal Group Hospitals, Belfast, Northern Ireland, UK
3 Schepens Eye Research Institute, Boston, Massachusetts, USA, 4 Casa di Cura Rugani, Siena, Italy

AIM

Large variations in results of diagnostic tests for mild tomoderate dry eye are widely recognised. The purpose of thisstudy was to assess
if there was concordance between common dry eye diagnostic tests.

METHODS

A total of 91 subjects were recruited to the study. The tearfilm and ocular surface were evaluated using the phenol redthread test (PRT),
tear film break-up time (TBUT), biomicroscopicexamination and impression cytological assessment of conjunctival goblet cells. Dry
eye symptoms were assessed using McMonnies’ dry eye questionnaire (MQ) and statistical correlations betweenall tests were assessed.

RESULTS

This study cohort did not include severe aqueous deficient dry eye patients as determined by the PRT. A statistically significant
difference was noted between PRT results and all other tests (p<0.001). Only Meibomian gland pathology, MQ, reduced goblet cell
density and TBUT (<7s) demonstrated correlation determined by McNemar’s test.

CONCLUSION

A correlation was found only between tests assessing lipid/mucous deficiency (Meibomian gland evaluation, goblet cell density,TBUT
and MQ).

Prevalence of Dry Eye at High Altitude: A Case Controlled
Comparative Study

Gupta N, Prasad I, Himashree G, D'Souza P.

High Alt Med Biol. 2008 Winter;9(4):327-34

Department of Ophthalmology, Lady Hardinge Medical College and Associated Smt. Sucheta Kriplani Hospital and Kalawati Saran
Children Hospital, New Delhi, India.

High altitude is associated with physiological as well as pathological changes in the eye related to adverse environmental conditions that
result in increased tear evaporation and contribute to a higher incidence of dry eye in these regions. We aimed to study the difference
in prevalence of dry eye at high altitude and at low altitude. The prevalence of dry eye among the natives and the army soldiers who
were recently posted at high altitude was also studied and compared. 200 adults above 20 years of age were enrolled. 100 subjects were
recruited at a high altitude region (study group), of which 50 were native Ladakhis and 50 were soldiers recently posted at Leh, Ladakh,
India (height; 3300 m above sea level; temperature: 18 degrees C to 24 degrees C). 100 subjects, age and sex matched, were screened at
a low altitude region, New Delhi, India (218 m above sea level; temperature: 19 degrees C to 24 degrees C) to serve as the control group.
Prevalence of dry eye was assessed through standard questionnaires (McMonnies' Questionnaire (MMI), Ocular Surface Disease
Index Questionnaire (OSDI), and Schirmer's basic secretion test. On the basis of the parameters studied (symptoms, MMI, OSDI and
Schirmer's test), dry eye was diagnosed in 20% of subjects screened at high altitude and in 9% of subjects in the control group screened
at low altitude. In the study group, the prevalence of dry eye was significantly higher amongst the native population (54%) than in the
army soldiers who were recently posted at that region (26%). The difference was statistically significant (p < 0.005). In conclusion, dry
eye is more common at high altitude, particularly in the native population. Awareness among people residing at high altitude and the
treating medical personnel needs to be created for early detection and treatment of dry eye to prevent vision-threatening complications.

DOS Correspondent
Noopur Gupta MS, DNB

98 DOS Times - Vol. 14, No. 7, January 2009

Forthcoming Events : National

February 2008 25-26 CHENNAI

5-8 JAIPUR Neuro-Ophthalmology Update 2009
Sankara Nethralaya, 18, College Road,
67th Annual Conference of AIOS Chennai, Tamil Nadu
B.M. Birla Science & Technology Research Centre, Contact Person & Address
Statue Circle, Jaipur S. Ambika, Conference Secretariat
Contact Person & Address E-mail: [email protected], [email protected]
Prof. P.K. Mathur, Organising Secretary,
C-126, Moti Nagar, Bapunagar, Jaipur-302015 March 2009
Phone: 0141-2705972, 0141-2701030,
(M) 982901592, E-mail: [email protected] 20-22 NEW DELHI

10-11 PUDUCHERRY Annual Conference of
Delhi Ophthalmological Society
International Symposium on Diabetic Retinopathy Contact Person & Address
Contact Person & Address Dr. Namrata Sharma
Dr. Umesh Chandra Bahera, Room No. 474, 4th Floor,
Venue: Aravind Eye Hospital, Puducherry Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
1, Anna Nagar, Madurai - 625 020 All India Institute of Medical Sciences,
Phone: 0452-4356100, Fax: 0452-2530984, Ansari Nagar, New Delhi – 110029
E-mail: [email protected], [email protected] Ph.: 011-65705229, Fax: 26588919,
E-mail: [email protected], Website: www.dosonline.org

Forthcoming Events : International

January, 2009 16-18 GENEVA, SWITZERLAND
15-18 HYDERABAD, INDIA
4th International Congress on Glaucoma Surgery
Asia-ARVO Organising Secretariat
Hyderabad, Andhra Pradesh, India O.I.C. Srl - Organizzazione Internazionale Congressi
Contact Name: Honavar, Santosh Viale Matteotti, 7 - 50121 Firenze, Italy
Email: [email protected] Phone: 39/055/50351, Fax: 39/055/5001912
Web Site: http://www.arvo.org/asiaarvo E-mail: [email protected]

February, 2009 May, 2009
6-8 ROME, ITALY
3-7 FLORIDA
13th ESCRS Winter Refractive Surgery Meeting
Rome, Italy Greater Fort Lauderdale/Broward County
Phone: +3535 1209 1100 / Fax: +353 1209 1112 Convention Center
Email: [email protected] 1950, Eisenhower Blvd.,
Web Site: http://www.escrs.org Fort Lauderdale, Florida - 33316
Phone: 1.240.221.2900, Email: [email protected]
March, 2009
17-22 CHICAGO 16-19 INDONESIA

Illinois Eye Review Asia Pacific Academy of Ophthalmology (APAO)
Chicago, Illinois, United States Indonesian Ophthalmologists Association (IOA)
Contact Name: Cindy Department of Ophthalmology
Phone: 312.996.6590 Fax: 312.996.7770 Faculty of Medicine, Universitas Indonesia,
Email: [email protected] Jalan Salemba Raya No. 6, Jakarta - 10430, Indonesia
Web Site: http://www.IllinoisEyeReview.org Phone : (62-21) 3190 7282, Fax : (62-21) 392 7516
E-mail : [email protected]
April, 2009
4-8 SAN FRANCISCO, CA, USA September, 2009

ASCRS/ASOA Symposium and Congress 12-16 BARCELONA, SPAIN
Francisco, USA
Phone: 701 591 2220 / Fax: 1703 591 0614 XXVII Congress of the ESCRS
Web Site: http://www.ascrs.org Phone: +35312091100, Fax: 35312091112
Email: [email protected]
www.dosonline.org Web Site: http://www.escrs.org

99

Vacancies - Ophthalmologists

Akhand Jyoti Eye Hospital (AJEH) is a 100 bed charitable rural hospital and is steadily expanding to a
250 bed tertiary eye care centre at village Mastichak, Chappra District, Bihar. The mission of AJEH
is to provide high quality, affordable eye care services in rural Bihar, and despite infrastructure and
locational constraints, in it’s very first two and a half years it has conducted over 30,000 surgeries and
is targeting a growth rate of 25% every year. Although over 70% surgeries are done at free / subsidized
rates, AJEH is self-sustainable without any institutional support. Current performance trends are 1600+
SICS and 150+ topical phacos per month with daily OPD load of 150+. AJEH is starting a 30 bed
secondary eye care centre at it’s Vision centre at Siwan town in Bihar. Geographical trends in our work
area show an existence of 40% hard/brown lens and 20% subluxation in cataract patients.AJEH expects
CCC capsulotomy in all SICS cases (for candidates applying for Sr.MO & MO) with an hourly
speed of at least 8 surgeries and the ability to deliver in a high quality, high volume setting and restrict intra-
operative complications within 2%. For candidates citing phaco experience,AJEH expects the ability to
perform phaco in all grades of cataract, mostly by topical anesthesia. Excellent OPD skills are necessary
while experience of glaucoma/strabismus/occuloplastic/pediatric surgeries will be an advantage. Learning
opportunities for SICS & Phaco exist on the campus. Posts offer good growth prospects, yearly family
holiday & loyalty bonuses and AJEH at present offers free family accommodation (with fooding at
Mastichak). AJEH reimburses 50% of the cost of the boarding school expenses of children of
ophthalmologists (at Patna 60 km from Mastichak). AJEH offers an option of part time consultancy
opportunity to Medical Officers upon completion of 3 years of service thereby ensuring income stability in
case they decide to go for private practice later on. Current postings will be alternated between Mastichak
/ Siwan. Applications are invited from ophthalmologists willing to work long term in a rural setup for the
under named posts.

SENIOR MEDICAL OFFICERS : Min. experience of 7000+ SICS & 500+ phacos post MS. Must
have excellent SICS,topical phaco, lasers, surgical complications management & OPD skills and be adept
at glaucoma & occuloplastic surgeries. Post MS long term fellowship from premier institutes and/or
experience of medical retina/pediatric/strabismus surgeries will be preferred. Strong training,
interpersonal & communication skills a must. Age limit 40 years. Starting Salary Rs 10 lacs – Rs 14
lacs per annum depending on skills / experience.

MEDICAL OFFICERS : Min. experience of 3000+ SICS post MS. Preference will be given to candidates
with an experience/fellowship in a sub speciality. Strong SICS & OPD skills a must. Age limit 35 years.
Starting salary Rs.4 lacs – Rs.7 lacs per annum depending on skills, other acquired surgical abilities and
experience.

ASST. MEDICAL OFFICERS : Min. experience of 500 ECCE-IOL and /or 200 SICS post MS. Strong
OPD skills a must.Age limit 32 years. Starting salary Rs. 2 lacs to 4 lacs per annum depending on skills and
experience.

To know more and apply for any of the above posts please send detailed C V by email to [email protected]
within 15 days. Queries can be sought from Mr M K Tiwary (Trustee) on 09934752812 / 09973550865.

AKHAND JYOTI EYE HOSPITAL

Village & Post : Mastichak, Via Pojhi Parsa, District : Saran - 841219, Bihar, India
Phones : 09934752812, 09973550865 Email : [email protected]

100 DOS Times - Vol. 14, No. 7, January 2009

Delhi Ophthalmological Society

(LIFE MEMBERSHIP FORM)

Name (In Block Letters) __________________________________________________________________________
S/D/W/o _____________________________________________________________ Date of Birth _____________
Qualifications _________________________________________________________ Registration No. __________
Sub Speciality (if any) ___________________________________________________________________________
ADDRESS

Clinic/Hospital/Practice ______________________________________________________________________
_______________________________________________________________ Phone __________________
Residence ________________________________________________________________________________
_______________________________________________________________ Phone __________________
Correspondence ___________________________________________________________________________
_______________________________________________________________ Phone __________________
Email ___________________________________________________________ Fax No. ________________
Proposed by
Dr. ____________________________________ Membership No. _________ Signature __________________
Seconded by
Dr. ____________________________________ Membership No. _________ Signature __________________
[Must submit a photocopy of the MBBS/MD/DO & State Medical Council / MCI Certificate for our records.]

I agree to become a life member of the Delhi Ophthalmological Society and shall abide by the Rules and
Regulations of the Society.
(Please Note : Life membership fee Rs. 3100/- payable by DD for outstation members. Local Cheques acceptable, payable
to Delhi Ophthalmological Society)
Please find enclosed Rs.___________in words ____________________________________________________ by Cash
Cheque/DD No.____________________ Dated_____________ Drawn on______________________________________

Three specimen signatures for I.D. Card. Signature of Applicant
with Date

FOR OFFICIAL USE ONLY

Dr._______________________________________________________________has been admitted as Life Member of

the Delhi Ophthalmological Society by the General Body in their meeting held on________________________________

His/her membership No. is _______________. Fee received by Cash/Cheque/DD No._______________ dated_________

drawn on __________________________________________________________________.

(Secretary DOS)

www.dosonline.org 101

INSTRUCTIONS

1. The Society reserve all rights to accepts or reject the application.

2. No reasons shall be given for any application rejected by the Society.

3. No application for membership will be accepted unless it is complete in all respects and accompanied by a Demand Draft of Rs.
3100/- in favour of “Delhi Ophthalmological Society” payable at New Delhi.

4. Every new member is entitled to receive Society’s Bulletin (DOS Times) and Annual proceedings of the Society free.

5. Every new member will initially be admitted provisionally and shall be deemed to have become a full member only after formal
ratification by the General Body and issue of Ratification order by the Society. Only then he or she will be eligible to vote, or apply
for any Fellowship/Award, propose or contest for any election of the Society.

6. Application for the membership along with the Bank Draft for the membership fee should be addressed to Dr. Namrata Sharma,
Secretary, Delhi Ophthalmological Society, R.No. 474, 4th Floor, Dr. R.P. Centre for Ophthalmic Sciences, AIIMS, Ansari Nagar,
New Delhi - 110 029.

7. Licence Size Coloured Photograph is to be pasted on the form in the space provided and two Stamp/ Licence Size Coloured
photographs are required to be sent along with this form for issue of Laminated Photo Identity Card (to be issued only after the
Membership ratification).

8. Applications for ‘Delhi Life Member’ should either reside or practice in Delhi. The proof of residence may be in the form Passport/
Licence/Voters Identity Card/Ration Card/Electyricity Bill/MTNL (Landline) Telephone Bill.

Delhi Ophthalmological Society
Monthly Clinical Meeting, February 2009

Venue: Guru Nanak Eye Centre Auditorium, Maharaja Ranjit Singh Marg, New Delhi - 110 002

Date and Time: 22nd February, 2009 (Sunday) 10:30 a.m. onwards

Tea & Snacks: 10:30 a.m. - 11:00 a.m.
20 Early bird Incentive

Clinical Cases : Dr. Lanalyn / 8 min
1. Iridocorneal endothelial syndrome with unusual association Dr. Usha Yadava 8 min

2. Subluxated / Ectopia Lentis – an alternative management approach : Dr. Monika /
Dr. Ritu Arora

Clinical Talk: : Dr. Meenakshi Thakar 15 min.
The choice of imaging technique in macular disorders (FA versus OCT)

Mini Symposium: Decision Making in selected Ocular Situations
Chairperson: Dr. B. Ghosh, Co-chairpersons: Dr. Kamlesh, Dr. Usha Yadava

1. Antifibrotics – future trends in glaucoma filtering surgery – : Dr. Kirti Singh 10 min
which / when / How ? : Dr. Kamlesh 10 min
: Dr. J.L. Goyal 10 min
2. Strabismus surgery – What / Which / How much. : Dr. Rtiu Arora 10 min.

3. Normal fundus , poor vision – What to do ?

4. Keratoconus – What to do when ?

To be followed by Lunch

Sponsored by: M/s. NRI Vision

102 DOS Times - Vol. 14, No. 7, January 2009

DOS Quiz Columns

Anagram Time

Each of the following words is a jumbled ophthalmic or related term. There is, however, an extra letter in every set of letters. These
extra letters will also form a eight letter ophthalmic word when unjumbled.

So get cracking.

1. MOSTACCO ___ ___ ___ ___ ___ ___ ___ ____

2. OUSEQUAL ___ ___ ___ ___ ___ ___ ___ ____

3. MEMSULCH ___ ___ ___ ___ ___ ___ ___ ____

4. LIVEGNEUJ ___ ___ ___ ___ ___ ___ ___ ___ ____

5. MIITADOORY ___ ___ ___ ___ ___ ___ ___ ___ ___ ____

6. GALATNNIMO ___ ___ ___ ___ ___ ___ ___ ___ ___ ____

7. IPSYCOMONGO ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ____

8. NEUROCLAVASA ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ____

Answers on page number 40

Saurabh Sawhney DO, DNB Ashima Aggarwal MS, DNB
Insight Eye Clinic, New Delhi

Delhi Ophthalmological Society
Monthly Clinical Meeting, March 2009

Venue: Bharti Eye Hospital, E-52, Greater Kailash-1, New Delhi - 110 048

Date and Time: 8th March, 2009 (Sunday)

Detailed Programme awaited

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