July 2003

July, 2003 1 DOS Times - Vol.9, No.1

July, 2003 2 DOS Times - Vol.9, No.1

EDITORIAL

Dear friends, monthly meetings and also DOS to confuse our patients or our col-
As the Times. I think it is the duty of each league as we strive for what we
premonsoon and every one of us to contribute envision as ultimate goals. We must
showers offer us a as much as possible to our society be careful not to raise expectations
welcome change and I am confident of your support. beyond realistic outcomes. Most
from the hot and DOS Times will have a multis- importantly we must carefully con-
scorchy climate of peciality approach with major em- sider proper guidelines and assess
the capital, my phasis on practical management as- all safety issues before the clinical
new team mem- pects, which will be supported by application of new technology to
bers of DOS Times are ready to invite leading Ophthalmologist of our avoid undue controversies.
you to another new innings of the most country, if possible some interna-
popular ophthalmology bulletins of tional faculty. Some of the articles A new trend has been observed
recent times. will also be based on review of lit- in recent years where many oph-
DOS had a very good beginning erature. I take this opportunity to thalmic companies are promoting
early this year when all the office invite suggestions, advice, and let- individual sponsorship rather than
bearers were chosen unanimously. ters to the editor from all our mem- supporting academic activities of the
I hope this healthy trend continues bers so that we improve on our ef- society. This trend is observed not
in future too. Our society is a scien- fort to maintain the standards of only for DOS but it is true for other
tific society, it is not a political fo- DOS Times. state societies as well as for AIOS.I
rum. Why can’t we choose or select really don’t know where this trend
a member who is suitable and is We are going to include new sec- is going to lead us. There should be
willing to accept the responsibility. tions on institutional profiles, which an effort to increase participation of
Accepted, that it is always better to will reveal the contributions of in- traders not only for conference
have healthy competition and if stitutions to eyecare, information sponsorship and putting up stalls but
there is more than one member suit- regarding facilities and training pro- also support for other scientific ac-
able for a given post than solution grams for young ophthalmologists. tivities of society like publication of
should be found with mutual under- The very popular DOS quiz will be journals, proceedings and commu-
standing. presented in a new format. nity programmes. The symbiotic re-
A lot of effort has been made in lationship should be increased so
the past few years to improve DOS I shall also make efforts to de- that both flourish.
Times. My predecessors have car- velop good and healthy relationship
ried out a lot of innovations and I among DOS Members. Our society We require good wishes and sup-
shall strive to continue for the same. has taken initiative in various fo- port from each and everyone to
It will be my endeavour to involve rums to disseminate knowledge and carry out DOS Times to a new hori-
as may people as possible in DOS educate ophthalmologists about zon so that our society continues to
activities, for which I look forward various aspects of clinical practice remain at the forefront of all oph-
for your support, especially for or- and newer advancement. I think we thalmological societies in India.
ganizing DOS conferences, our have been very successful in Phaco,
SICS, and LASIK. We must continue – Dr. Jeewan S. Titiyal
to progress, we must be careful not Secretary, DOS

!!Attention DOS Members!!

The registration fees for life membership of

Delhi Ophthalmological Society

is now being increased to Rs. 3,100 from

1st August 2003 – Secretary DOS

July, 2003 3 DOS Times - Vol.9, No.1

CURRENT PRACTICE

High Risk Penetrating Keratoplasty ods have been advocated:
1. Making the donor tis-
Rajesh Sinha MD, Jeewan S Titiyal MD, Namrata Sharma MD,
Rasik B. Vajpayee MBBS, MS sue less antigenic.
2. Suppressing the host

immune response.

Corneal transplantation Figure 1 Apart from these fac- Reducing Donor Antigenicity
is currently the most frequent tors, there are additional The use of a central cor-
and successful type of tissue much more readily thus lead- risk factors which make
transplantation performed ing to a higher rate of rejec- the corneal graft high neal graft is perhaps the most
worldwide. With the advent tion and a higher failure rate. risk for failure (Table 1). common strategy for reduc-
of operating microscopes, Corneal grafting is con- ing donor antigenicity.
better suture material and the The ‘Collaborative Cor- sidered as high risk for Langerhans’ cells that ex-
use of improved techniques, neal Transplantation Stud- failure in healed herpes press class II antigens are
the failure of corneal trans- ies’ has defined ‘High Risk’ simplex keratitis (Figure primarily located in the pe-
plant on a technical basis has as presence of two or more 2) not only because of ripheral cornea, and thus
become less common. The quadrants of corneal stromal high chance of recur- excluding the peripheral cor-
remarkable survival of cor- vascularization (Figure 1), rence of the disease but nea from the donor tissue
neal transplants can be extending at least 2mm into also because of the high can significantly prolong
largely attributed to their the cornea, or a previous risk of graft rejection due to graft survival.Removal of the
unique avascular structure. graft rejection in the affected stromal vascularization that donor epithelium was also
This feature allows the graft eye (Regraft – Figure 2). The is associated with it. At one believed to decrease the risk
to remain somewhat isolated degree of vascularization time, corneal transplantation of rejection because the epi-
from the immune system and was defined as the number in children was considered thelium is a source of class I
effectively gives it an immu- of quadrants of vasculariza- doomed to failure and even and class II antigens. Cor-
nologically privileged status. tion rather than the total contraindicated. More re- neal grafts exposed to ultra-
However, the survival of cor- number of vessels, therefore cently, some success has violet light in vitro were
neal graft still remains less a cornea is high risk when been reported, however prog- shown to have a lower inci-
than desired. Although there only two vessels are present, nosis for pediatric kerato- dence of rejection presum-
are various causes for poor provided they are in differ- plasty is clearly not as good ably because of selective
graft survival, immune me- ent quadrants. In high risk as that for an adult. It is depletion of Langerhans’
diated rejection remains the corneas, the incidence of re- suspected that some of cells. Likewise, pretreatment
foremost cause. jection is reported to be 50% these failures might
to 70%. Hill has recently pro- have been attributable Figure 2
Upto 30% of penetrating posed a new classification of to immunologic graft
keratoplasty patients have at high- risk corneas, based on rejection that was un- Figure 3
least one episode of rejection, the degree of vasculariza- recognized because of
with 5% to 7% of all grafts tion. In this classification difficulty in examina-
eventually failing because of low, medium and high risk tion and communicat-
rejection. Several host factors corneas correspond to avas- ing with these patients.
have been shown to increase cular, 1-2 quadrants, and 3 Therefore, all paediatric
the risk of immune-mediated or more quadrants of vascu- keratoplasty should be
rejection. The most important larization, respectively. considered as “High
factors appear to be the de- Risk”.
gree of corneal neovascu- The management of
larization. In vascularized high-risk keratoplasty
corneas, the recipient’s im- and prevention of rejec-
mune system can recognize tion continues to be a
and attack the donor tissue significant challenge.
To prevent immune me-
Cornea & Refractive Surgery diated rejection in high-
Services, Dr. Rajendra Prasad risk corneal transplan-
Centre for Ophthalmic Sciences, tation, following meth-
AIIMS, New Delhi.

July, 2003 4 DOS Times - Vol.9, No.1

CURRENT PRACTICE

of the graft with hy- Table 1: High risk factors for Pen- high-risk patients, hibits the expression of high-
perbaric oxygen or etrating Keratoplasty topical steroids are affinity IL-2 receptors.
heterologous anti- ———————————————— started early in the
bodies were found to High Risk Factors (CCTS) preoperative period Topical cyclosporin A
prolong its survival and applied fre- Topical cyclosporin A

in experimental cor- Ø Deep Stromal Vascularization > 2 quently. when used alone can be ef-
fective both for the preven-
neal transplantation. quadrants Intensive Postopera- tion and the treatment of cor-
neal graft rejection. It is pre-
Corneas stored in or- Ø Regrafts tive Corticosteroid re- scribed 4 - 5 times a day in
gan culture have also gime in high risk high risk keratoplasty along
been shown to have a Additional Risk Factors keratoplasty with other postoperative
reduced number of Ø Young recipient : 2 hourly x 3 days treatment. A randomized
trial found that 2% cyclos-
Langerhans’ cells. Ø Limbal position of the transplant : 4 hourly upto Day porin A drops applied five
times a day in patient’s re-
However, none of Ø Eccentric, large grafts 15 ceiving 1% dexamethasone
these techniques Ø Dry Eye syndrome : QID upto 2 months four times a day significantly
have been shown to Ø Lid Abnormalities : TDS for 2 more prolonged graft survival
be clinically signifi- months compared with 1% dexam-
ethasone alone (88% clear
cant and thus have Ø Intractable lagophthalmos : BD for 3 more grafts at 12 months versus
35%). It is prepared either in
not been adopted as Ø Defective blink-reflex months olive/ castor oil as 2% solu-
a management strat- Ø Limbal stem cell deficiency : OD for 4 more tion or in artificial tears as
egy for high-risk Ø Herpetic Corneal Scar months 1% solution.
keratoplasty.
It has been found that
Tissue matching Ø Uncontrolled Glaucoma Cyclosporin A whole blood cyclosporin A
level after topical therapy is
has been studied ex- Ø Poor Socioeconomic Status Cyclosporin A repre- undetectable or well below
tensively as another Ø Pediatric Keratoplasty sents a new generation systemic therapeutic levels.
strategy for reducing Ø One eyed patient of specific immuno- Based on these results, it
donor antigenicity in suppressive agents does not seem necessary to
monitor blood cyclosporin A
high-risk corneal that selectively inter- levels in patients receiving
topical cyclosporin A; how-
transplantation. Although Corticosteroids feres with immunocompetent ever, to be on safer side, the
renal and liver function
some reports have suggested Corticosteriods are the cells without causing gener- should be monitored before
and during instituting topi-
that HLA and ABO match- drugs of choice for both the alized cytotoxic effects. cal therapy and random
samples should be sent to
ing could reduce the inci- prevention and treatment of Structurally, cyclosporin is a detect blood cyclosporin A
levels.
dence of rejection, most tri- corneal graft rejection. They hydrophobic, cyclic
Systemic Cyclosporin
als have found no significant have been shown to block the decapeptide derived from the Although systemic cyclos-

benefit from histocompatibil- synthesis of prostaglandin fungus Tolypocladium porin has profound effect on
the success of many solid or-
ity matching in high-risk pa- by inhibiting phospholipase inflatum gans. It is an gan transplants, its applica-
tion to corneal transplanta-
tients. A2, decreasing cellular and immunomodulator and tion is limited because of its
significant associated side
fibrinous exudation, inhibit- works mainly on T cells by effects. The use of systemic

Suppressing the host's Im- ing chemotaxis and phago- binding to an intracellular

mune Response cytosis, restoring capillary peptide known as

Currently, suppression of permeability, stabilizing the cyclophilin. Cyclophilin is a

the host immune response lysozomal membranes of type of regulatory protein

using pharmacologic agents polymorphonuclear leuko- known as immunophilin

remains the mainstay of pre- cytes, and inhibiting graft that seems to control the syn-

venting corneal allograft re- vascularization. On sys- thesis of proteins involved in

jection. Although corticoster- temic administration, ste- T cell activation. By inhibit-

oids continue to be the gold roids also reduce the num- ing cyclophilin activity,

standard of ocular immuno- ber of circulating T cells and cyclosporin blocks the tran-

suppressants, promising inhibit their proliferation. scription and production of

newer agents may soon pro- Corticosteriods IL-2, thus limiting the activa-

vide a safe and effective ad- are most commonly admin- tion of CD4+ and CD8+ T

junct for immunosuppres- istrated by topical applica- cells. In addition, cyclos-

sive therapy in high-risk cor- tion, which provides good porin blockers the produc-

neal transplantation. ocular penetration and effec- tion of other lymphokines

tive immunosuppression. In such as interferon-g and in-

July, 2003 5 DOS Times - Vol.9, No.1

CURRENT PRACTICE

cyclosporin A (dose: 4 mg/ transplant blood level as currence of herpes simplex cere and regular follow up
kg/ day) has been associated high as 200ng/ml is re- keratitis in corneal graft. This should be done in all these
with a number of complica- quired. Patients need peri- not only reduces the chance cases and patient should be
tions including nephrotoxic- odic monitoring of their blood of graft infection but also de- encouraged for good compli-
ity, hepatotoxicity and hy- pressure, serum creatinine, creases the risk of initiation ance to achieve a good struc-
pertension. To minimize the liver enzymes and blood of rejection episode. tural and functional out-
serious side effects, blood counts while taking oral come of corneal grafting in
cyclosporin A level should cyclosporin. Hence systemic Inspite of all the precau- high risk cases.
be monitored carefully and cyclosporin has not found a tions and prophylactic
kept at the lower end of the place in routine management therapy, development of Suggested Reading
therapeutic range. A target of high risk keratoplasty. graft rejection cannot be to-
level is between 130ng/ml tally prevented. Hence the 1. Corneal Surgery: Theory, Tech-
and 170ng/ml using whole Oral acyclovir in a dose of patient and the treating phy- nique & Tissue. Brightbill FS;
blood method (monoclonal 400 mg twice daily is pre- sician should be well aware Mosby, St Louis.
antibody). But in corneal scribed for 6 months to 1 year of the early symptoms and
for prophylaxis against re- signs of graft rejection. A sin- 2. Corneal Transplantation.
Vajpayee RB; JAYPEE Broth-
ers.

Monthly Meetings Calendar New DOS Members
For teh Year 2003-2004
S-1669 J-1670
27th July, 2003 (Sunday) Sapovadia Vasantbhai V. Jhaveri Pravesh
Army Hospital 302, Rameshwar Appartments 7, West View
University Road, Jalaram-1 1st Pasta Lane, Colaba,
30th August, 2003 (Saturday) Rajkot-360005 Mumbai-400005
Sir Ganga Ram Hospital
N-1023 G-1024
27th September, 2003 (Saturday) Narayanan R. Garg Pankaj
New Institute/Hospital A-3/1, M.S. Flats, Sector-13, House No.1190
R.K. Puram, New Delhi-110066 Sector 43-B
19 October, 2003 (Sunday) Chandigarh
DOS Midterm Conference L-1681
Lal Sanjiv M-1671
2nd November, 2003 (Saturday) Kanpur Retina Centre Mehta Gaurav Jayendrabhai
R.P. Centre for Ophthalmic Sciences 112/2(I), Benajhabar Road “Gauravdeep”
Kanpur-208002 12, Saurashtra Bank Society
29th November, 2003 (Saturday) Vasna Barrage Road, Paldi
Dr. Shroff’s Charity Eye Hospital S-1682 Ahmedabad-380007
Srivastava Krishna Kumar
27th December, 2003 (Saturday) D-8a, Defence Colony B-1672
New Institute/Hospital Jajmau, Kanpur Bhojwani Krishna
Sahai Hospital & Research Centre
31st January, 2004 (Saturday) A-1026 Sp-15, Bhabha Marg
Safdarjung Hospital Agrawal Anshuman Moti Dungri, Jaipur
Department of Ophthalmology
28th February, 2004 (Saturday) Sir Ganga Ram Hospital G-1673
M.A.M.C. (GNEC) Old Rajinder Nagar Goyal Sanjiv
New Delhi-110060 Street No.1
28th March, 2004 (Saturday) Bhan Singh Colony
Mohan Eye Institute K-1027 Faridkot-151203
Kumar Narendra
3-4th April, 2004 (Saturday & Sunday) C/O Shri Mahavir Singh Berwal B-1674
Annual DOS Conference A-78, Kewal Park Extn. Bhagat Dinesh Kumar
Azadpur Road, Subzi Mandi Bungalow No.T-7/B
July, 2003 Delhi-110033 Sahebpara, Katihar

K-1683 S-1675
Kumar Ajay Swarup Pradeep
S/O Shri Balbir Singh Swarup Eye Centre
House No.222, Tibri 145, Dwarkapuri Colony
B.H.E.L., Ranipur(Hardwar) Hyderabad-500082

K-1684 A-1676
Kumar Rajesh Ranjan Arora Sehdev Kumar
C/O Sri Durga Pd. Bhagat Gagan Hospital, ADWA Road,
P.P. Path, West Of Hospital Shahabad-Markanda
Rajendra Nagar, Patna-16 Dist. Kurukshetra

Continued in Page 30

6 DOS Times - Vol.9, No.1

CURRENT PRACTICE

Whenever cataract sur- Cataract Surgery in Uveitis Patients
gery is performed in patients
with age related cataract, the Pradeep Venketash, MD
surgeon is usually certain of
achieving a good visual out- cide whether lensectomy is the posterior pole of the fun- induced cataract, cataract in
come. This certainty regard- feasible or not and also the dus (for disc pallor, cupping, patients with intermediate
ing the visual prognosis is of- possibility of just an age re- macular degeneration, macu- uveitis and Fuch’s hetero-
ten lacking when a patient lated cataract occurring con- lar edema, scarring). It is also chromic iridocyclitis. Poor
with uveitis is taken up for currently in an eye with a of utmost importance to mea- outcome is seen in patients
cataract surgery. Although history of uveitis in the past. sure the intraocular pressure with juvenile rheumatoid ar-
the visual results are better Treatment history would act and evaluate for glaucoma thritis and rubella cataract.
than about two decades ago as an indirect indicator to- as well as excessive hy- Well established (prerequi-
this is not consistently so. wards the type, severity and potony. sites for cataract surgery ) in
duration of uveitis; suggest uveitic eyes are:
The visual outcome in pa- the possibility of a steroid Since it is very often diffi- l inflammation must be un-
tients with uveitis following induced cataract and also cult to visualize structures
cataract surgery depends on reveal whether the inflam- behind the pupillary plane der control (with no or
three important factors, mation has been inactive for as well as the posterior seg- minimal medication) for
namely, preoperative, intra- the preceding three months ment in an eye with uveitis atleast the preceding three
operative and postoperative atleast. one may have to assess these months (cells must be ab-
variables. A thorough preop- regions using specialized sent from the anterior
erative evaluation is a must Ocular examination must modalities like laser interfer- chamber)
for proper planning of the pay attention to determine ometry, conventional ultra- l perioperative steroid
surgical approach and its ex- visual acuity of the eye (in- sonography, and ultrasound cover is a must (oral and
ecution. The postoperative cluding projection of rays); biomicroscopy. The useful- topical corticosteroids for
outcome in turn is dependent clarity of the cornea (if band ness of these diagnostic tools atleast three to four days
on both the preoperative and shaped keratopathy is found is discussed in the section on before surgery and for 7-
intraoperative variables. to be significant it should be clinical investigations in 10 days after)
treated before cataract sur- uveitis patients. l obtain the best pupillary
At the very beginning it is gery) including its endothe- dilation before surgery as
prudent to understand that lial status; contents of the Having assessed the vi- this would help in decreas-
not all cataracts in a patient anterior chamber (should sual potential of the eye, the ing trauma to the iris during
with uveitis is related per se have no cells but may have surgeon must define the ob- surgery and hence in mini-
to the inflammation alone. persisting mild degree of jectives of performing cata- mizing postoperative inflam-
Uveitis associated cataracts flare); severity of disorgani- ract surgery. These objectives mation.
may be of three categories: zation of the pupil (study usually revolve around the The surgical options for
inflammation induced, ste- details of pupillary fibrosis, following: visual rehabilita- cataract extraction in uveitic
roid induced and age related synechiae, membrane forma- tion, visualization of the pos- eyes remains phacoemulsifi-
and the prognosis is better in tion and the response to maxi- terior segment and to alter the cation, conventional extra-
the latter two categories than mal efforts at achieving dila- deleterious course of a dis- capsular extraction and
in inflammation induced tion); look for iris neovascula- ease (e.g. to decrease the risk lensectomy. Intracapsular
cataracts. rization and the severity of of phthisis by lensectomy, cataract surgery has no role
iris bombe’ (determine the anterior vitrectomy and re- because it is difficult to un-
Important preoperative peripheral iridocorneal rela- moval of any cyclitic mem- dertake in eyes with a com-
considerations would in- tionship superiorly by the brane causing traction on the promised iris architecture
clude patient age, type of van Harrick method of grad- ciliary body). These objec- and is also associated with
uveitis, type of cataract (see ing peripheral anterior tives and the visual progno- greater tissue trauma. It how-
later), treatment history and chamber depth; this is impor- sis have to be discussed with ever may be useful in some
the presence of related com- tant to know while making the patient and an informed eyes with lens associated
plications such as glaucoma, the incision and formation of consent has to be obtained. uveitis. Issues that need to be
macular edema, vitreous the anterior chamber during The immediate, early and addressed are, whether an
opacification and band surgery); determine charac- late visual outcome as indi- IOL would be tolerated well
shaped keratopathy. The age teristics of the angle by go- cated earlier is quite variable by the eye and if an anterior
of the patient undergoing nioscopy, evaluate density of in uveitic patients undergo- vitrectomy is likely to im-
cataract surgery would de- cataract if possible and make ing cataract extraction. Cases prove the visual outcome.
all efforts to visualize at least in which the prognosis is re- Poor candidates for IOL im-
Dr. R.P.Centre for Ophthalmic ported to be good are steroid
Sciences, AIIMS,
New Delhi.

July, 2003 7 DOS Times - Vol.9, No.1

CURRENT PRACTICE

anterior chamber implants and im- a pupillary membrane mak- for assessing the risk of de-
plants with polypropyelene haptics are ing it difficult to achieve a veloping later complica-
proper capsulotomy and tions and the visual progno-
strongly contraindicated there may be associated sis.
zonular weakness. To ob-
plantation are said to those tion (emphasis on tain an adequate pupillary Important postoperative
viscosurgery as much as aperture one may resort to necessities in all patients un-
with cataract in association possible), minimizing the following procedures dergoing cataract surgery
trauma to the iris (by avoid- during surgery: iris retrac- with associated uveitis is to
with juvenile rheumatoid ing blunt dissection of tors, multiple sphincteroto- continue topical steroids for
densely adherent synechiae mies, complete iridectomy a more prolonged period (3-6
arthritis, VKH syndrome, and achieving maximal pu- (resutured at the end of sur- months) despite a relatively
pillary dilation before sur- gery), synechiolysis and quite eye, use oral steroids (in
sympathetic ophthalmia, gery), complete cortical re- viscodilation or by ‘sphinc- full doses) for the first 7-10
moval, placement of IOL terectomy’. days after surgery and to have
recurrent granulomatous within the capsular bag and a more thorough and closer
not disturbing the vitreous Despite all precautions a followup. In patients who
uveitis of any cause and si- whenever this is not indi- uveitic eye in which cata- develop significant pigment
cated. In addition, anterior ract extraction has been un- dispersion on the IOL,
derosis bulbi. chamber implants and im- dertaking is at an increased iridolenticular synechiae and
plants with polypropyelene risk of developing several after cataract one could con-
Lensectomy may be con- haptics are strongly con- early and late postoperative sider laser procedures such
traindicated. The useful- complications. Early com- as YAG sweeping, synech-
sidered in children and ness of heparin in the irri- plications include unusu- iolysis and YAG capsulo-
gation fluid and the role of ally severe anterior cham- tomy once the eye is quite.
young adults (particularly heparin surface modified ber inflammation, increase After these procedures it is
IOLs is controversial. in intraocular pressure, cor- again important to treat such
with extensive anterior syn- neal edema, hyphema, pig- eyes with an intensive and
During the surgery itself, ment dispersion on the IOL, extended course of topical ste-
echiae) and also in those the surgeon may encounter macular edema and pupil- roids and prevent elevation
the following difficulties. lary capture. Late complica- of the intraocular pressure.
with concurrent lesions like There may be excessive tions encountered with
bleeding from the conjunc- greater frequency are, for- The greatest challenges
vitreous membranes / vit- tiva; entry into the anterior mation of iridolenticular for a surgeon involved in op-
chamber may be difficult synechiae with pupillary erating cataracts in an eye
reous opacification or (due to iris bombe’/periph- distortion, displacement of with uveitis continue to be an
eral synechiae) increasing the IOL, early and severe ability to achieve an ad-
cyclitic membrane. the risk of detachment of after cataract formation, equate atraumatic dilation of
the descemet’s membrane, glaucoma and decompen- the pupil, minimizing post-
Lensectomy may have the iridodialysis and iris hole sation of the cornea and operative inflammation and
formation; there may be macula. Usually, the sever- its sequelae, decreasing the
advantages of less damage bleeding from the iris; it ity of inflammation during risk of after cataract forma-
may be difficult to distin- the early postoperative tion and restoring a clear vi-
to the corneal endothelium guish anterior capsule from course acts as a predictor sual axis.

and trabecular meshwork,

decreased risk of after cata-

ract formation and enabling

management of posterior

segment lesions. Disadvan-

tages of this procedure in-

cludes loss of compartmen-

talization with increased

possibility of macular

edema, inability to insert an

IOL and a risk of retinal de-

tachment (when the parsp-

lana route is used).

The surgical principles of

extreme importance while

undertaking cataract sur-

gery in patients with uvei-

tis are, endothelial protec-

July, 2003 8 DOS Times - Vol.9, No.1

ART OF REFRACTION

Subjective Refraction 18 that gives the spherical power
value or divide visual acuity 2. Modify the spherical

by 9 for cylinder amount . correction by adding + 1.0 D

Ms. Monica Chaudhry, Jeewan S. Titiyal MD Suppose the visual acuity sphere or higher lens which
is 6/18.then the spherical is reduces the visual acuity

6/18 divided by 18 = 1D or from 6/6 to 6/18 or less.

It is the technique in ing cylinder amount and the cylinder is 18 divided by 3. Plus power is reduced

which the examiner is axis wherever the cornea is 9 = 2Diopters. and minus power is added

guided by the patients re- the main refracting media , in 0.25 steps till the patient

sponse to the changes in the like in aphakia and The first step can just read 6/6, or the best

appearance of observed tar- psedophakia. Controlling accommodation corrected visual acuity is

gets as the power of the lenses – The fogging technique achieved.

before the patients eye is al- Relationship between vi- The objective is to relax ac- The second step;

tered. sual acuity and refractive commodation which causes Astigmatic component of re-

Since the conclusion de- error acceptance of over minus or fractive error cylindrical

pends on the subject, the re- Clue to estimate correction false cylinder amounts. power and axis is deter-

sultant power may not be al- – Divide the visual acuity by Fogging technique: mined uniocularly by two

ways the pure refractive sta- 1. Achieve the spherical methods

tus of the eye under test. Some

patients may be sensitive to 12 90
small changes of even 0.12 D 11 1 60 120

and some may not respond

to even 1D change. 10 30 150
Subjective refraction may 4
3
be performed by use of trial 2

frame or by use of phoropters. 8
9
To establish a starting point 0 180

either or all may be useful guide:

1. Auto refraction find-

ing – good AR helps a lot to 330 210
have an idea about the refrac-

tive status. A7 5 300 240 B
2. Retinoscopy – there is

no substitute of this and the 6 270

objective findings can be Diagram 1 : A The clock dial - Astigmatic FAN, B Sunburst dial - Lancaster Regan astigmatic fan
matched with the subjective

response.

3. Previous power of POSITION FD JCC TO VERIFY AXIS POSITION OF JCC TO VERIFY POW ER
glasses – The visual acuity

measured with present AXC
glasses will help in estimat-
AXC

ing the variation in the power

from the previous prescrip-

tion. The old cylinder axis is

also important. It also helps

in judging the adjustments

needed based on previous

complaints. A B
4. Keratometry – this

may be useful in approximat-

Dr. R.P.Centre for Ophthalmic Diagram 2: AXC - axis of the cylinder in the trial frame, Black dot - indicate minus cylinder
Sciences, AIIMS, White dot - indicate plus cylinder
New Delhi.
9 DOS Times - Vol.9, No.1
July, 2003

ART OF REFRACTION AXC AXC l Again unfog and deter-
mine the sphere.
1. Jackson cross cylinder
2. Astigmatic fan

Astigmatic fan Monocular spherical end
point
Testing is done under fog-
The rule is to prescribe the
ging and it always results in maximum plus and the least
minus power that permits the
neutralization of cylindrical CC AFTER CC AFTER maximum acuity possible.

error with cylinder lens of Several techniques are
used but the most common
minus power. and practical is the Duoch-
rome test
Fixed Astigmatic dials Diagram 3 : To Verify Power Flip over JCC, once white dot
have lines spaced angles 10 corresponding with axis of cyl, then red dot corresponding hence Duochrome or the bich-
to 30 Degrees from each adding plus or minus alternately rome Method
other, hence called the clock
It is the most usedand tra-
dials also. ditional method to determine
the final spherical power.It
1. the patient is fogged tion the red dots indicate mi- grees to the side preferred. utilizes the principle of the
chromatic aberration as
2. Unfog gradually and nus cylinder power and the l Repeat this till on flipping shown in the figure.

ask to compare the sharp- white dots indicate the plus over both the positions are 1. Patient reds the chart
with letters on red and green
ness and darkness of various cylindrical power. The equally clear or blurred. background.

lines in various directions. power and the axis can be 2. The eye to be tested id
slightly fogged.
3. Discontinue unfo- accurately determined by this Verify cylinder power
3. On fogging the alpha-
gging at the point of greatest as it uses the principle of l Place the axis of the cylin- bets on the red background
will be clearer to read.
contrast. sturms conoid. der and the JCC axis coin-
4. Unfog in 0.25 steps till
4. Localize the axis of mi- ciding with each other. both the colours have equally
distinct colours.
nus cylinder Procedure l Ask patient again by flip-
5. So if the patient reads
5. simply multiply the 1. The retinoscopy find- ping over position 1. once the red background letters
clearer that means it requires
lesser hour of the most ing or the autorefraction can the red coinciding ( means plus to be reduced or minus
to be increased.
prominent line by 30 be used as the starting point. increasing the minus cyl-
This method may have
6. eg – if the set of 2 and 8 2. Target patient at one inder value) position 2. some reliability problems if
the coloured filters used are
O’ clock is clear multiply 2 line above which it can read. the white dot coinciding not standardized or room il-
lumination is inadequate or
by 30 so the axis of the mi- (means the minus power the patient has colour vision
defect.
nus cylinder is 60 Degrees. Verify axis is now reduced)
Binocular equalization
7. Final power of the cyl- l Place the handle of the l Keep on increasing or de- This has to be done after

inder is determined by in- cross cylinder as shown creasing till the patient in- the best corrected lens is veri-
fied uniocularly. The binocu-
creasing its power until the coinciding with the axis dicates no difference in lar status of accommodation
then needs to be balanced.
most prominent set of line marking of the cylinder both positions or reverses
The two common meth-
and the set of line perpen- l In case of minus cylinder back. ods used are

dicular to it are equally clear. in the trial frame look at The next step after power

Jackson cross Cylinder – the red marks. and axis finalization is fog-

technique for astigmatism l Flip over the JCC once po- ging repeated again.

without fog. sition 1 , red dot to right of JCC is very useful and

JCC is a combination of the axis and then position faster than astigmatic dials

plus sphere combined with 2 with red dot to left of the as it does not require accom-

minus cylinder where cylin- axis.( diagram no - ) modation to be kept inactive.

der is twice the spherical, re- l Patient is asked to differ- The dial is likely to success-

sulting in a lens which has entiate between the two ful in patients with amblyo-

one meridian of convex positions an indicate pia or corneal opacity where

power and the other merid- which position is better to the retinoscopic findings are

ian perpendicular to it with read. not possible.

concave power. By conven- l Rotate the axis by 10 de-

So summarizing the steps for

Retinoscopy – there is no substitute of JCC
l Achieve sharp acuity
this and the objective findings can be l Determine axis

matched with the subjective response l Determine the power

July, 2003 10 DOS Times - Vol.9, No.1

Douchrone Test

gy r

Diagram 4 : Diagram of chromatic aberration of the eye. The yellow wavelength focuss on the retina.

1. Alternate cover details of giving near correc- l Determine the sphere gence problems
2. Borish Technique tion will follow in next issue. l Binocularly equalize
l Check binocular visual Dizziness
Equalization by Alternate Binocular Vision status l If strong cylinder is pre-
occlusion After finalizing the power status
l Give near addition if re- scribed for the first time
1. Alternate occlude the it is mandatory to check the l Cylinder axis is changed
eyes while the patient looks binocular visual status and quired. l Change in cylinder
at the acuity chart rule out phorias , tropias Patient Complaints and
diplopia or suppression. the possible subjective tests amount in large step.
2. Compare the clarity to be done if the problem is
and sharpness of each eye by Frame and face measure- associated with incorrect Near blurred vision
rapidly occluding and also ments subjective refraction. l Check distance power
giving enough time to the pa- l Amplitude of accommo-
tient to pick up the difference. Before finally prescribing Blurred distance vision
note down the following: l Determine the final dation
3. Adjust the sphere till 1. IPD , or monocular PD’S l Do duochrome for near to
both the charts are equally 2. Back vertex distance of sphere by fogging
sharp by increasing or de- l Duochrome test to rule out rule out over or under cor-
creasing sphere. trial frame. rection for near.
3. Segment height for bifo- under or over correction of l Vergence problems.
Borish technique myopia Subjective test is totally
This technique is more re- cals l Unequal accommodation patient dependant and ma-
in two eyes – Use boorish lingerers or slow responses
liable than the above as ac- To summarise technique or poor observers can mis-
commodation can still be er- l Starting point – objective l Verify axis and power of lead in estimating the refrac-
ratic on alternate occlusion the cylinder – by JCC tive status. So there lies the
tests like retinoscopy importance of objective tests
1. Base In prisms are put l Accomodation control by Asthenopia which should be correlated
in the trial frame to dissoci- l Verify correction with the subjective tests.
ate each eye. fogging l Rule out fusional and ver-
l Uniocularly determine the
2. The patient now sees
2 vision drums. astigmatism

3. Isolate 6/12 visual High Lights for August Issue of DOS Times
acuity line and compare the
sharpness of the two charts. Ø Sutureless Vitrectomy : Dr. S. Natarajan
Ø Surgical Management of Pediatric Cataract : Dr. Abhay Vasavada
4. Reduce or increase Ø Surgical Approach for Orbitotomy : Prof. S.M. Betheria
power to make both charts Ø Visual Rehabilitation After Keratoplasty : Dr. J.S. Titiyal
equally clear. Ø Glaucoma Surgery with Fugo Blade : Dr. Daljeet Singh
Ø Eye Banking in India : Dr. Ramani
Near addition Ø Transpupillary Thermo Therapy : Dr. Lalit Verma
After finalizing the dis-

tance power the near addi-
tion is given over the distance
to prebyopic patients. The

July, 2003 11 DOS Times - Vol.9, No.1

OPHTHALMIC APPLIANCES

IOL Master pia, with a type 1 peripapil-
lary posterior staphyloma,
Balasubramanya R. MD, Jeewan S. Titiyal MD, being able to measure to the
Rasik B. Vajpayee, MBBS, MS fovea is an enormous advan-
tage over conventional A-
The IOL Master is : A com- ment is based on a patented scan ultrasonography. Ø Strong ametropia
bined biometry instrument. It interference optical method ØDense media opacity along
measures parameters of the known as Partial Coherence Valid Signal Curves
human eye needed for in- Interferometry (PCI). This ØVery good signals (signal-to- the visual axis
traocular lens calculation. technique relies on a laser Ø Repeat the measurement
It measures quickly and pre- Doppler technique to mea- noise ratio > 10)
cisely sure the echo delay and in- ØSeveral secondary maxima and ask the patient to fix-
1. Axial length tensity of infrared light re- ate steadily.
2. Corneal curvature. flected back from tissue in- visible (system-specific) l To measure aphakic
3. Anterior chamber depth terfaces-cornea and Retinal Ø Clear media, correctly fix- eyes, Pseudophakic Eyes, or
4. "White-To-White" (op- Pigment Epithelium. eyes filled with Silicone Oil,
tional ating patient select the corresponding
Ø non-contact optical device At least four of the mea- Ø Weak ametropia mode from the ALSettings
Ø measures distance from surements should be within Ø Clear signal (SNR >2.0) menu.
0.02 mm of one another, and Ø Secondary maxima visible l The instrument will
cornea to RPE should exhibit the character- Ø Relatively clear media automatically be reset to the
Principle : based on partial istics of an Ideal Display. An "phakic" mode by changing
coherence interferometry ideal axial length display is Non Valid Signal Curves the side (moving to other
within ±0.02 mm or better (A- more important than a high ØLow signal (signal-to-noise eye), or by measuring a new
scan ultrasonography 0.10- signal-to-noise ratio (SNR). patient.
0.12mm) Ø IOL master accurately de- ratio < 1.6)
ØError message is displayed.
Advantages termines the axial length Ø The measuring signal can-
Ø Learned very quickly of eyes ranging from 14.0
mm to 40.0 mm. not be clearly distin-
(User Friendly) This technique is espe- guished from the noise.
Ø Extensive integrated cially useful for eyes
with Possible reasons
safety features Ø small corneal scars Ø Unsteady (non fixating)
Ø The LC display functions Ø anterior cortical
spokes patient
both in patient eye align- Ø posterior subcapsu-
ment as well as results lar plaques
and calculating interface. Ø other localized me-
Ø Non-contact measure- dia opacities.
ments.(Patient comfort) l Instruct patient
Ø Five formulae are inte- to look directly at the
grated. small red fixation light.
Data of the desired lenses l gives refractive
must be entered into the da- axial length, rather
tabase. than the anatomic axial
On the basis of postopera- length.
tive refraction results, the lens l In high refractive
constants that are entered in error (more than ±6.00
the calculation formulas may D), measurement to be
be individually optimized taken with the patient's
(personalized) for every user. glasses in place to en-
The axial length measure- sure adequate fixation.
l For eyes with
Cataract & Refractive Surgery high to extreme myo-
Service, Dr. R.P. Centre for
Ophthalmic Sciences,
AIIMS, New Delhi - 29

July, 2003 12 DOS Times - Vol.9, No.1

OPHTHALMIC APPLIANCES

l Measurements thro- symmetrical, you choose the "one Ø Any erroneous measure-
ugh contact lenses will lead Ø The central point usually measure" option, ments should be deleted.
to measurement errors only one measure- The anterior chamber
and therefore should not be not focused and not ana- ment result will be
performed. lyzed displayed (the result depth is determined as the
Ø all six peripheral points of five internal single distance between the optical
l Measurements of eyes should be visible, and lo- measurements) sections of the crystalline lens
with retinal detachment will cated in the field between Ø If on the Options and the cornea produced by
lead to measurement errors the two auxiliary circles - Setup / Program lateral slit illumination.
and therefore should not be on the display. Settings you choose Ø automatically activate the
performed. The measuring points the "list of measures"
should be circular, or ellip- option, three mea- lateral slit illumination
The corneal curvature is soid . surements results Ø the lateral slit illumina-
determined by measuring the Ø Five measurements within will be displayed, ob-
distance between reflected a period of 0.5 seconds, av- tained each through tion bright and mentioned
light images as in conven- erage value displayed five internal single prior to measuring the
tional keratometry. ØThe completion of the mea- measurements. ACD.
surement indicated by a Ø If the results of Ø patient to look straight
Procedure short acoustic signal the last three measurements ahead and directly at the
Ø a drop of artificial tears is Ø The corneal curvature (in differ by an average value of small, yellow fixation
mm, or diopters) of the greater than 0.5 D, or 0.08 light and not into the lat-
instilled in each eye, principal meridians dis- mm to 0.1 mm (depending on eral slit which is flicker-
Ø have the patient blink sev- played with the corre- n) has been exceeded, the dis- ing during the measure-
sponding axis. play shows the message ment
eral times, Ø If the cornea is "Evaluation", which indi- Ø Fine-align the instrument so
Øall measurements with both spherical, only one radius, or cates that you need to check that:
one refractive power value for accuracy The image of the fixation
eyes open as WIDE as pos- will be displayed. Ø check the pre-corneal tear point appears to be opti-
sible. Ø If several mea- film of the eye to be exam- mally sharp within the
Ø blink between each mea- surements of the corneal cur- ined square on the display,
surement. vature are in "one measure" Ø If needed, add artificial The image of the cornea is
Ø as many measurements as mode, the previously mea- tears, have the patient not disturbed by reflections,
needed sured values will be over- blink, open their eyes The anterior crystalline lens
Ø good automated kerato- written in the display. wide, and then repeat the is optimally visible.
metry measurements will Ø Simply press measurement. Ø As a rule, the image of the
all be within 0.25 D in shortcut key CTRL +Z fixation point lies between
each meridian. Ø If on the Options the images of the cornea
Ø Tell the patient to fixate on - Setup / Program Settings and the crystalline lens. It
the yellow light.
Ø Align the instrument so
that the six peripheral
measuring points are

July, 2003 13 DOS Times - Vol.9, No.1

OPHTHALMIC APPLIANCES

should be near (but not IOLMaster is more accurate and repro- the 2 techniques were highly
within) the optical section ducible than contact ultrasound in pro- correlated.
of the crystalline lens.
Advantage viding accurate AL measurements Packer M. Fine IH.
Ø Non-contact measure- Hoffman RS. Immersion A-
ments.(Patient comfort)
Ø No risk of cross infection scan compared with partial
Ø Single instrument per-
forming AL,Km &ACD and coauthors compares Olson RJ. Accuracy and re- coherence interferometry:
Ø Learned very quickly. contact ultrasonography producibility of biometry us- outcomes analysis. J Cataract
(User Friendly) and partial coherence inter- ing partial coherence inter- Refract Surg 2002; 28:239-242
Ø Observer independent re-
liability ferometry using the ferometry. In our own experience of
Ø More accurate than con-
ventional A-scan(approx IOLMaster (Zeiss Humph- J Cataract Refract Surg >150 eyes at present the IOL
five times)
Limitations rey Systems) in 111 eyes. The Feb2002; 28:235-8 Master measurement were
Ø Dense media opacity
along the visual axis laser interferometer provided A study by Packer et al. successful in more than 85%
Ø Unsteady (non fixating) significantly better results, compares partial coherence of cases with respect to AL
patient
Ø Strong ametropia with a decreased mean ab- interferometry and immer- (axiallength), anterior cham-
Ø Patients with nystagmus
Ø Retinal detachment solute refractive error postop- sion ultrasound in 50 eyes. ber depth (ACD), and

Literature Review eratively and an increase in The AL measurements with keratometry measurement.
A recent study by Connors
the percentage of eyes within

±0.5 diopters (D) (61.2% ver- Where is my copy of DOS Times?
sus 42.3%) and ±1.0 D (87.4%

versus 77.5%) of the pre- Dear DOS members, anyone who could not receive

dicted refraction. The au- DOS Times from the month of July, 2003 onwards.

thors conclude that the Please Contact:
IOLMaster is more accurate
and reproducible than con- MR. SUPROTIK BANERJI
tact ultrasound in providing M/s. Syntho Pharmaceuticals Pvt. Ltd.
accurate AL measurements. 31/16, 2nd Floor, Old Rajinder Nagar, New Delhi-60

Connors R. Boseman P, E-mail: [email protected]

July, 2003 14 DOS Times - Vol.9, No.1

MANAGEMENT PEARLS

Management of Cataract in ract surgery. Complications
Glaucoma Patients following ALT include hem-
orrhage from trabecular
Tanuj Dada MD, Harminder K Rai MD, Harinder S Sethi MD meshwork during treatment,
formation of peripheral an-
The prevalence of glau- rise of IOP can threaten the Glaucoma patients who terior synechiae, uveitis and
coma and cataract both in- remaining field of vision. undergo cataract surgery elevation of IOP. Laser
crease with each decade of alone should be followed up trabeculoplasty tends to re-
life and thus often coexist. On the other hand cataract regularly they may develop duce IOP by about 20% and
The decision for manage- extraction in a patient of poor control of glaucoma any there is a loss of the effect over
ment of such cases depends chronic angle closure glau- time, requiring modification time. Thus one has to moni-
upon the visual disability coma may be curative for the of therapy or surgery. tor these patients over a pro-
caused by the cataract, the glaucomatous process and longed period of time.
level of IOP control and the result in a lowering of IOP. Laser trabeculoplasty fol-
extent of glaucomatous dam- This may allow the ophthal- lowed by cataract extrac- Filtering surgery with sub-
age. The ophthalmologist is mologist to withdraw even tion
faced with following options the single anti glaucoma Indications : cataract not vi- sequent cataract extrac-
when dealing with a case drug. sually disabling, mild/moder-
with coexistent cataract and ate glaucomatous damage, IOP tion
glaucoma: - With the current tech- well controlled on two/more Indications: Severe uncon-
1. Cataract surgery alone nique of phacoemusification topical medications trolled glaucoma, advanced
2. Laser trabeculoplasty fol- and the use of chondroitin glaucomatous visual field de-
sulfate and sodium hyalur- Argon laser/Diode laser/ fects requiring IOP in “low
lowed by cataract extrac- onate as viscosurgical de- NdYAG laser trabeculo- teens”, presence of risk factors
tion vices it is important to com- plasty followed 3 months for filtration failure
3. Filtering procedure fol- pletely aspirate the vis- later by cataract extraction is
lowed by cataract extrac- coelastic at the end of sur- another alternative in eyes When IOP is uncontrolled
tion at a later date gery as any residual vis- with primary open angle despite of maximal tolerable
4. Simultaneous cataract coelastic can lead to a very glaucoma, pseudoexfolia- medical therapy and laser
and glaucoma surgery – large IOP spike. One should tion syndrome and pigmen- trabeculoplasty, a trabeculec-
Combined extraction digitally measure the IOP af- tary glaucoma. It decreases tomy should be performed
ter sealing the main wound the risk of immediate eleva- alone. This is also the case in
Cataract extraction alone and the side ports to ensure tion of IOP in the postopera- eyes with advanced glau-
Indications : Visually signifi- that an excessively high IOP tive period. This may also re- coma that require a very low
cant cataract, early glaucoma- is not obtained. Post opera- duce the requirement of anti target pressure. Doing a
tous damage, IOP well con- tively tab acetazolamide 250 glaucoma medications both trabeculectomy alone pro-
trolled on single topical medi- mg should be given to the prior to and following cata- vides a better IOP control
cation patients. then a combined procedure.
Eyes with conjunctival scar-
It is the treatment of choice ring, neovascularization,
in patients who are well con- healed uveitis, and young
trolled on a single drug medi- patients who are at a higher
cal regimen and with little or risk of filtration failure
no glaucomatous optic nerve should always be subjected
damage. However there is a to a two staged procedure.
possibility of a postoperative In patients who are on pilo-
IOP spike which is danger- carpine therapy, eliminating
ous in patients with moder- the need to use miotic
ate/advanced glaucomatous therapy may improve vision
visual field damage because enough to delay cataract sur-
even a slight post-operative gery.

Dr. Rajendra Prasad Centre for Cataract extraction can be
Ophthalmic Sciences, New Delhi performed through a tempo-
ral clear corneal incision at a
later date ( preferably after 3
months of the trabeculec-
tomy).

July, 2003 15 DOS Times - Vol.9, No.1

OPHTHALMIC APPLIANCES

Surgical approach Drop in IOP 1-4 surgery without any modifi- time and the relatively faster
cation, a limbus based flap improvement in vision post-
Trabeculectomy alone 48% is used which gives a good operatively. The main disad-
Combined Phacoemulsi- 31% postoperative bleb with a vantage is bleb leakage.
fication and trabeculectomy decreased chance of bleb
Using MMC Additional 2-4 mm of leaks and against the rule Phacoemulsification in the
Hg drop astigmatism which may be Presence of a Filtering
Combined Phacoemulsi- 1-3 mm of Hg less than induced by the superior trab Bleb
fication and ECCE Phacoemulsification is neutralized by the tempo-
Two site surgery 1-3 mm of Hg more drop ral phaco incision. The only Eyes which have under-
than single site disadvantage is that it takes gone a trabeculectomy and
a longer time to do. Various have a filtering bleb need
The inherent disadvan- a delayed presentation af- studies have been conducted special consideration in ref-
tages of this approach are ter 72 hours, a combined on the efficacy of these two erence to the location of the
that it requires two hospital extraction should be done techniques and there is no incision, poor pupillary di-
admissions with two surger- after controlling the in- significant difference in the latation, low corneal endot-
ies and their associated com- flammation. final outcome although in helial counts and the preop-
plications, there is a longer When combining glau- our experience the chances erative hypotony. There is
cumulative recovery period coma surgery with cataract of bleb failure are much more also a risk of post operative
and there is always a possi- extraction, the surgery be- in a single site surgery. bleb failure due to the inflam-
bility of failure of the filtra- comes technically more dif- mation produced by the sec-
tion bleb after the cataract ficult than either surgery The surgery of choice is a ond surgery. The surgeon
surgery. alone, there is more post op- two site phaco trabeculec- should keep the following
erative inflammation, the tomy with a superior trabe- points in mind when operat-
Simultaneous cataract bleb formation is less reliable culectomy and a temporal ing on eyes which have un-
and glaucoma surgery - and the lowering of IOP may phacoemulsification. dergone a previous filtering
not be adequate to the surgery.
Combined Extraction amount of glaucomatous The preponderance of evi-
Indications damage (i.e may not achieve dence from the literature sug- 1. The time interval be-
Ø IOP not well controlled on target pressure). gests a small (2-4 mm of Hg) tween the trabeculectomy
There are two choices benefit from the use of mito- and the second stage cata-
single topical medication with the phaco surgeon: mycin-C (MMC), but not 5- ract surgery should be atleast
in a patient with mild/ 1. Single site phaco trabe- fluorouracil (5-FU), in com- 3 months and preferably 6
moderate glaucoma. culectomy. bined cataract and glaucoma months.
Ø Intolerable drug induced 2. Two site phaco trab- surgery. Two-site surgery
side effects eculectomy (superior trab & provides slightly lower (1-3 2. Superpinky should be
Ø When the patient is not temporal phaco). mm of Hg) intraocular pres- avoided as it can result in a
compliant Single site surgery takes sure (IOP) than one-site sur- gross hypotony with shallo-
Ø Medical disability not al- less time, induces against the gery although there are con- wing of the anterior chamber.
lowing patient to instill rule astigmatism, may pro- flicting reports in literature.
eye drops vide difficulty in cutting the IOP is lowered more (1-3 mm 3. Since the site of the fil-
Ø Non availability of medi- trabecular block if a punch of Hg) by phacoemulsi- tering bleb is usually supe-
cation in patients native is not available, likely to in- fication than by conven- rior, a 3 mm temporal clear
area duce more inflammation and tional extracapsular cataract corneal incision should be
Ø Uncontrolled glaucoma, fibrosis and is usually done extraction in combined pro- made for performing
but an urgent need to re- with a fornix based flap with cedures. Trabeculectomy phacoemulsification.
store vision or when two more chances of postopera- alone produces a much
separate surgeries are not tive wound leak (especially lower IOP as compared to a 4. The corneal endothe-
feasible (eg patient not if Mitomycin C is used). Two combined phacotrabecule- lium should be coated with
likely to come for follow site surgery offers the benefits ctomy. The type of conjuncti- a dispersive viscoelastic
up). of a standard trabeculectomy val flap in a 2-site phacotra- such as chondroitin sulfate
Ø In eyes with phacomor- beculectomy did not seem to to provide maximal protec-
phic glaucoma who have influence the final outcome. tion..
The main advantage of the
fornix-based conjunctival 5. The pupil should be
flap is the shorter surgical dilated by use of iris hooks
or other mechanical means.

6. These eyes tend to
have a shallow chamber and
the height of the infusion

July, 2003 16 DOS Times - Vol.9, No.1

OPHTHALMIC APPLIANCES

bottle should be increased to References NOTICE
prevent collapse of the ante-
rior chamber. The vacuum 1. Jampel HD, Friedman DS, ANNUAL GENERAL BODY MEETING
settings should also be kept Lubomski LH, Kempen JH,
on the lower side. Quigley H, Congdon N, The Annual General Body Meeting of Delhi
Levkovitch-Verbin H, Ophthalmological Society will be held on
7. If there is a tendency Robinson KA, Bass EB Effect Sunday the 27th July 2003 at 9.00 A.M. at
for bleb failure and one needs of technique on intraocular Ayurvigyan Auditorium, Army Hospital
to give postoperative mas- pressure after combined (Research & Referral), Near Dhaula Kuan (on
sage, atleast one suture cataract and glaucoma sur- NH-8) Delhi Cantt – 110010.
should be applied even to a gery: An evidence-based re- All members are kindly requested to make it
3 mm incision. view Ophthalmology. 2002 convenient to attend.
Dec;109(12): 2215-24.
8. Early postoperative Dr. Jeewan S. Titiyal
intraocular pressure spikes 2. Friedman DS, Jampel HD, Secretary, DOS
are frequently observed after Lubomski LH, Kempen JH,
cataract surgery in glauco- Quigley H, Congdon N, Attention DOS Members!
matous eyes, and consider- Levkovitch-Verbin H,
able fluctuations in pressure Robinson KA, Bass EB. Sur- Contents of our website
can occur during the first gical strategies for coexisting www.dosonline.org
postoperative month. There- glaucoma and cataract: an
fore one should keep a close evidence-based update. w Important notices
watch on the IOP and give Ophthalmology. 2002 w Monthly Clinical Meeting
antiglaucoma medications in Oct;109(10):1902-13. w Mid Term Conference
the post operative period. w Annual Conference
Vigorous use of topical ste- 3. Samuelson TW. Manage- w List of Executives with Address
roids is also indicated to de- ment of coincident glaucoma w List of Editorial Board
crease post operative inflam- and cataract. Curr Opin w Life Membership Form
mation which may subse- Ophthalmol. 1999 Feb;10(1): w Constitution
quently lead to bleb failure. 66-72. w Forthcoming Events
Subconjunctival injection of
5-FU or mitomycin drops 4. Hsu CH, Obstbaum
may be considered if there is SATechnique and outcome
a tendency for bleb failure. of combined phacoemulsi-
fication & trabeculectomy.
Curr Opin Ophthalmol. 1998
Apr;9(2):9-14.

July, 2003 17 DOS Times - Vol.9, No.1

MANAGEMENT PEARLS

Posterior Capsular Tear oriented, anxious patient. common in eyes with poste-
12. Inexperienced surgeon. rior polar cataract as in these
Tishu Saxena MS, Rasik B. Vajpayee MBBS, MS, 13. Deep set eyes cases the posterior capsule
Namrata Sharma MD, Jeewan S. Titiyal MD, 14. Short and obese stature, may either be abnormally
thin and fragile or there may
Any breach in the conti- of the surgeon or the surgi- thick neck patient be a pre existing central open-
nuity of the posterior capsu- cal technique employed. 15. History of vitreous loss ing. The first tell–tale sign of
lar is defined as posterior There are various types of PCT occurring during
capsular tear (PCT)1. It has cataract which have higher in other eye hydrodissection is “Pupil
various nomenclatures, such association with PCT with Intrasurgical posterior snap sign”. PCT occurring
as posterior capsular rent or vitreous loss. Pseudoexfo- capsular tears are the most during nuclear manipula-
posterior capsular rupture. liation, posterior polar cata- common type of PCT. During tion is often not very obvious.
Posterior capsular tear is a ract, traumatic cataracts, ECCE it can occur due to The following signs should
potentially serious intraop- posterior lenticonus, dia- small incision, trauma dur- alert the surgeon that a prob-
erative complication of cata- betic cataracts, cataracts ing capsulotomy, injury to lem is likely to exist –deep-
ract surgery. It may be asso- with persistent primary hy- posterior capsule, irrigation- ening of anterior chamber,
ciated with vitreous loss, cys- perplastic vitreous and cata- aspiration, small pupil in the loss of lens followability and
toid macular edema, uveitis, racts following vitroretinal course of cortex aspiration lens tilt or deepening of pos-
glaucoma, retinal detach- surgery have increased inci- and high pressure from the terior chamber. If a PCT oc-
ment, vitreous touch syn- dence of posterior capsular posterior chamber 9. 10. These curs during irrigation and
drome, vitreous wick syn- tear. PCT are irregular in shape aspiration, posterior capsu-
drome, and expulsive haem- and may be located any- lar vacuuming or during
orrhage. It is a common com- Factors, Etiology and where and have the ten- IOL implantation, the dis-
plication that occurs during Features. dency to enlarge rapidly. The covery is quick and evident
cataract surgery. The differ- clinical signs of occurrence and it can be managed im-
ent types of posterior capsu- Predisposing factors for a of intrasurgical PCT are sud- mediately. Four cardinal
lar tear are intrasurgical, pre- posterior capsular tear are. den deepening of anterior signs of torn posterior cap-
existing (congenital or trau- 1. Poor visibility due to sec- chamber and shift of the lens sular during Phacoemulsi-
matic) and spontaneous 2, 3, 4. ondary problems. iris diaphragm back wards, fication are (1) sudden deep-
(1) intrasurgical PCT- are the Ø Unstable Hand position, dyscoria and incarceration ening of anterior chamber (2)
most common and can be of vitreous strands in the suc- momentary papillary dilata-
accidental or planned, as in fluid pooling. tion port of the cannula. Pos- tion (3) nuclear does not fol-
primary posterior capsulor- 2. Poor visibility secondary terior capsular tear can oc- lowed towards the Phaco-
hexis (2) pre existing PCT are to pathology. cur during any stage of emulsification tip (4) nucleus
usually detected at the time phacoemulsification surgery falls away from the phaco tip.
of the surgery in cases of con- Ø Arcus senilis. like hydrodissection, nuclear
genital or traumatic cataracts Ø Pterygium. emulsification, capsulor- Management
(3) spontaneous PCT-are Ø Band shaped kerato- hexis, cortical removal, irri- The rupture of the poste-
rare and are associated with gation aspiration, posterior
hypermaturity, posterior len- pathy capsular polishing and IOL rior capsule with its attend-
ticonus intra ocular tumors Ø Corneal scars. implantation. Intra –opera- ing complication is one of
and posterior polar cataract Ø Dense asteroid hylosis tive posterior capsular tear the most feared complica-
The incidence of PCT follow- 3. Hypermature cataracts. during hydrodissection is
ing extracapsular cataract 4. Posterior polar tions of cataract sur-
extraction varies from 0.2% cataracts. gery. The manage-
to 10.3%5, 6 while that during 5. Pseudoexfolia- ment PCT is depen-
phacoemulsification ranges tion. dent on its immedi-
from 0.7% to 16%7, 8. Occur- 6. Black cataracts ate recognition, size
rence of PCT is not only de- 7. Traumatic cata- of the tear, whether
pendent upon surgical skill racts. the hyloid face is in-
8. Long and short tact, the stage at
Dr. Rajendra Prasad Centre for axial length which the surgical
Ophthalmic Sciences, 9. Cataracts follow- procedure has
New Delhi ing previous reached and the
vitreo retinal sur- complication which
gery. have ensued prior to
10. Small pupil recognition of the
11. Demented, dis- PCT. Timely recogni-

July, 2003 18 DOS Times - Vol.9, No.1

MANAGEMENT PEARLS

tion and planned manage- tended larger than the frag- bag may be performed. References
ment is required to ensure an ment and the nuclear frag- If PCT >6mm / margins
optimal visual outcome. ment is extracted out with the 1. Vajpayee RB, Sharma N, Dada
Once a problem is suspected, using Sheet’s glide or loop. are not clearly visible– T, et al: Management of poste-
a surgeon must have the dis- ACIOL should be implanted. rior capsular tears. Survey
cipline to immediately stop Post capsular tear with rup- In the presence of PCT, an ophthalmol 45: 473-488, 2001
working. This however does tured hyloid face without lux- IOL may be placed in the sul-
not mean abrupt removal of ation of nuclear material into cus if the capsular rim 2. Angra SK, Vajpayee RB,
instrument from the eyes. vitreous. In case of small re- (anterior or posterior) is Titiyal JS, et al: Types of pos-
sidual nuclear material: high available or the bag if the tear terior capsular breaks and their
Intra surgical posterior viscosity viscoelastic is in- is small. surgical implications. Oph-
capsular tear jected under the nuclear ma- thalmic surg 22: 388-391, 1991
terial and dry anterior vitrec- Visual outcome in eyes
If PCT is identified during tomy is performed followed with PCT 3. Vajpayee RB, Angra SK,
early stages of ECCE-it by phacoemulsification us- Honavar SG, et al: Pre-exist-
should be plugged with vis- ing high vacuum. PCT is a common and sig- ing posterior capsule breaks
coelastic substance followed nificant complication of cata- from perforating ocular inju-
by dry aspiration of the re- In case of large residual ract surgery that can affect ries. J cataract refract surg 20:
maining cortical lens matter. nuclear material: it is advis- visual outcome12. When PCT 291-294, 1994
Meticulous control of infu- able to convert to routine is without vitreous loss and
sion, establishment of semi ECCE. a PCIOL is implanted in the 4. Vajpayee RB, Sandramouli S:
closed system and avoidance bag or ciliary sulcus, there is bilateral congenital posterior
of over hydration prevents Post capsular tear with rup- still an increased risk of capsular defects: A case report.
enlargement of tear and an- tured hyloid face with luxation CME, vitreous prolapse in Ophthalmic surg 23: 295-296,
terior displacement of vitre- of nuclear material into vitre- the anterior chamber and 1992
ous. If the PCT > 6mm, or ous – it is a serious complica- pseudophakic retinal de-
there is failure to visualize tion and ranges from 0-18% tachment. Vitreous loss ap- 5. Chambless WS: Incidence of
margins of PCT, or there are in various reports11 . The nu- pears to be the crucial factor anterior and posterior segment
extensive vitreous distur- clei can get dislocated into influencing visual outcome. complications in over 3000
bance, a partial anterior vit- the vitreous during grooving Once vitreous is lost, the cases of extracapsular cataract
rectomy followed by implan- (33%), cracking (33%), emul- post-operative course is com- extraction; intact and open
tation of AC IOL is advo- sification (23.8%) and plicated in 30% of patients capsules. J Am Intraocul Im-
cated. Hydrodissection (2%). An due to retained cortex, cor- plant Soc 11: 146-148, 1985
anterior segment surgeon neal edema, hyphema,
If PCT occurs during early with no training in vitreo- blurred vision, vitreous 6. Courtney P: The National cata-
stages of Phacoemulsifi- retinal surgery should not try strands and secondary glau- ract surgery survey: I. Meth-
cation i.e. during capsulo- to retrieve the lost nuclear coma. Long term retinal prob- ods and descriptive features.
rhexis or early sculpting, fragment as it may lead to lems include chronic CME, Eye 6: 487-492, 1992
then the procedure should be serious posterior segment macular holes and retinal
converted to an ECCE. In the complications. In such cases detachment. 7. Allinson RW, Metrikin DC,
late stages of Phacoemu- good anterior vitrectomy Fante RG: Incidence of vitre-
lsification PCT can occur should be done, wound Conclusion ous loss among third year resi-
with or without intact hyloid should be properly closed Recognition and appro- dents performing phacoemuls-
face with or without the lux- and the patient should be ification. Ophthalmology 99:
ation of nuclear material. refered early to a vitreoretinal priate adjustment of the sur- 726-730, 1992
surgeon. gical plan in the presence of
PCT with intact hyloid face predisposing factors for a 8. Corey RP, Olson RJ: Surgical
with nuclear material present:- Intraocular lens implanta- PCT help to decrease the in- outcomes of cataract extrac-
In cases of small nuclear ma- tion in PCT cidence of this problem. tion performed by residents
terial viscoelastic is injected Prompt recognition and using phacoemulsification. J
to plug the PCT and nuclear The desired location, ori- treatment of PCT and vitre- Cataract refract surg 24: 66-
material is moved into the entation, type and size of the ous loss, methodical analy- 72, 1998
anterior chamber with IOL depends upon the size sis and nuclear and cortical
spatula and emulsified with of the PCT, visibility of re- removal, preservation of as 9. Gao Y, Chen T, Zhao S: An
short bursts. In case of large maining capsular margin much posterior capsule and analysis of posterior capsular
nuclear material – high vis- and capsulo-zonular anat- appropriate IOL selection rupture in cataract surgery.
cosity viscoelastic is injected omy. If PCT <6mm / margins and insertion help to prevent Chung Hua Yen Ko tsa Chih
above and below the nuclear are clearly visible with no surgical complications and 32: 200-202, 1996
material. The incision is ex- vitreous prolapse – PCIOL improve usual outcome.
implantation in the capsular 10.Hao YS, Hui YN, Li JG: Pri-
mary implantation of poste-
rior chamber intraocular lenses
eyes with defective posterior
capsule. Chung Hua Yen Ko
tsa Chih 30: 25-27, 1994

11.De Groot V, Jonckheere
P,Tassignon Mj : Centration of
intraocular lenses with circu-
lar haptics. J Cataract Refract
Surg 23: 1247-1253, 1997

12.Osher RH, Cionni RJ.The torn
posterior capsule : its intraop-
erative behaviour, surgical
management, and long term
consequences: J Cataract Re-
fract Surg !6: 490-494, 1990

July, 2003 19 DOS Times - Vol.9, No.1

REVIEW

Pediatric Cataract the parents is
useful to under-

stand whether

Jagat Ram & Sushmita Kaushik the cataract is
congenital, de-

velopmental or

There are 1.5 million blind cataract as one the most traumatic in ori-

children (corrected visual common type. Common gin. One must

acuity <20/400 in the better types of zonular cataract ascertain if

eye) in the world1-3 and one seen are nuclear, lamellar, there is any his-

million of these live in Asia. sutural or capsular (Fig- tory of maternal Fig. 1. Bilateral total infantile cataract. An early
The prevalence of childhood ure 2, 3). drug use, infec- surgical intervention and prompt visual reha-
cataract has been reported to b) Total or diffuse cataract: tion or exposure bilitation is mandatory to prevent irreversible
be 1 to 15 cases in 10,000 chil- These are usually bilat- during preg- amblyopia.
dren. It is estimated that there eral. Most of the children nancy. Each

are 200,000 children blind from rural areas may child should be examined by both for surgery and for as-

from bilateral cataract glo- present with total diffuse a pediatrician for thorough sessment of possible raised

bally.3 (Figure 1). cataract. systemic work up to rule out intraocular pressure. Condi-

c) Polar cataract: This type of systemic associations, tions like Peter's anomaly,

Etiology cataract usually occurs in anomalies or congenital ru- juvenile rheumatoid arthri-

The main causes of infan- the anterior or posterior bella. tis, or post-traumatic corneal

tile cataract are genetic, meta- polar region. Posterior scars may compromise the

bolic, prematurity and in- lentiglobus is also a type Ocular examination quality of cataract surgery in

trauterine infections.4-6 Other of posterior polar cataract. A thorough ocular exami- these children.

causes of childhood cataract d) Membranous cataract: This nation is a must in every c. Laterality and type of

include trauma, drug-in- type is usually associated child. All children must un- cataract: We should docu-

duced cataract, radiation with congenital anoma- dergo complete ocular evalu- ment whether the cataract is

therapy and cryo-applica- lies such as microphthal- ation and wherever neces- unilateral or bilateral. We

tion or laser therapy for ret- mos or congenital rubella sary, examination under an- should carry out biomicro-

inopathy of prematurity. syndrome. Membranous esthesia. scopic examination in coop-

Trauma is one of the com- cataracts may occur in as- a. Visual acuity: Light erative children after dilata-

monest cause of unilateral sociation with mi- fixation should be recorded tion of pupil with topical

cataract in the developing crophthalmos, congenital in each child. It is important cyclopentolate 1% and phe-

countries.5,6 Bilateral cata- rubella, Lowe syndrome to note whether fixation is nyl ephrine 2.5% to evaluate

racts occur commonly due to and Hallermann-Streiff- central steady and main- the size, density and location

the long-term use of topical Francois syndrome. tained or not. Pupillary re- of cataract to plan the surgi-

or systemic steroid therapy. actions are carefully noted. cal procedure. Any sublux-

In industrialized countries, Pre-operative evaluation b. Corneal clarity: The cor- ation of cataract is to be re-

in approximately 50% of bi- A thorough history from neal clarity is of importance corded.

lateral cases and virtually all d.

of the unilateral cases, the Fundus ex-

underlying cause can not be amination

determined.1,3 must be car-

ried out after

Morphology pupillary dila-

The morphologic types of tation. In chil-

childhood cataracts are dren with

broadly classified as: dense or dif-

a) Zonular cataract: In clinical fuse cataract,

practice we find zonular B-scan ultra-

sonography

Department of Ophthalmology, Fig. 2. Zonular cataract is the most com- Fig. 3. This is sutural (Y- Suture) cata- should be
Postgraduate Institute of Medical mon type of infantile or developmental cata- ract, which may increase in density and done to rule
Education & Research, ract. may require surgical intervention. out retinal pa-
Chandigarh

July, 2003 20 DOS Times - Vol.9, No.1

CURRENT PRACTICE

thology i.e retinal detach- The basic idea of the lUnilateral partial or

ment or vitreous hemorrhage. laboratory work-up is complete cataract

e. Intraocular pressure to detect associated needs early surgery to

should be recorded with ap- medical problems in prevent amblyopia.

planation tonometry in co- addition to the cata- lPoor retinoscopic re-

operative children. In others, ract, which may need flex:. If during retinos-

it should ideally be recorded specialized treatment. copy through dilated

under anesthesia at the time Cataract types that pupil reflex is poor

of surgery. need no workup: Uni- due to cataract, it is an

f. We should also note lateral, posterior len- indication for surgery.

presence of associated ocu- ticonus, traumatic, fa- lCongenital or devel-

lar pathology such as mi- milial. opmental cataract

crophthalmos, associated Cataract types that with strabismus

strabismus and nystagmus. need to be worked up: In- lCongenital or devel-

Presence of any of these fac- flammatory, oil drop- Fig. 4. Anterior lenticonus associated with high opmental cataract
tors is likely to adversely af- let, sporadic com- myopia. Cataract gradually develops which further with nystagmus / un-
fect the prognosis and the plete, associated impair vision. steady fixation
parents ought to be coun- physical abnormal- lChildren with bilat-

seled appropriately. ity. eral cataract where

g. A-scan biometry is de- average adult K-reading that one eye has been operated

sirable to measure the axial IOL Power Calculation is 44.00D. Dahan, et al8 have second eye with cataract

length for calculating IOL Intraocular lens power suggested to aim for under- should be operated pref-

power and monitoring the calculation for the growing correction in children be- erably with in one to two

globe elongation postopera- pediatric eye poses several tween two to 8 years perform weeks to prevent amblyo-

tively. Wherever possible, problems. Most reports have biometry and under-correct pia

keratometry should be done recommended under-correc- by 10%. For children younger

and the IOL power calcu- tion of the IOL power for pe- than 2 years, perform biom- When to operate pediatric

lated using the SRK-II for- diatric cataract, anticipating etry and under-correct by cataract?

mula. In younger/uncoop- the myopic shift following 20% or use the axial length Timings of cataract sur-

erative children, globe length IOL implantation. The axial only. IOL power suggested gery depend on the indica-

can be assessed using B-scan length and keratometry read- for 21mm is (22.00D), 20mm tions and factors influencing

ultrasonography. ings should be measured for (24.00D), 19mm (26.00D), visual outcome. Once indi-

In younger and non-coop- IOL power calculation in 18mm (27.00D) and for 17mm cated, the child may be oper-

erative children detailed children. Dahan, et al8 sug- axial length 28.00D. BenEzra ated as early as 2 weeks of

ocular examination after pu- gested a very practical ap- suggested implanting 21.0D age considering the safety of

pillary dilatation is done to proach for younger children. of adult IOLs in all pediatric general anesthesia. Unilat-

document type of cataract, He stated that IOL power cal- cases.9 This may be accept- eral cataract needs early sur-

IOP and fundus evaluation, culations may be performed able for most of the children gery and in bilateral cataract,

axial length, keratometry un- using axial length in chil- over 2 years but will not be after operating first eye, sec-

der general anesthesia. dren under one years of age suitable for eyes with mi- ond eye may be operated

and keratometry readings crophthalmos and infantile with in a week or two to pre-

Laboratory Work-up are not as crucial since these cataract. vent amblyopia.

It is not a must to carry out readings change rapidly

all the laboratory investiga- from 52.00 ±4.00D to Indications for cataract sur- Why early surgery for

tions in each case. The tai- 44.00±4.0D in the first 6 gery for pediatric cataract younger children with cata-

lored approach keeping in months of life. The K-read- Indications for surgery in ract?

mind the specific case is a ings in the newborn are ig- pediatric cataract include: Early surgery is indicated

more appropriate strategy. nored and replaced by the l Child with visually sig- for visually significant infan-

nificant cataract. Cata- tile cataract to prevent am-

Detailed ocular examination is done to ract, which occupy visual blyopia, as this is a critical

document type of cataract, IOP fundus axis and occupy 3mm or period of visual develop-
evaluation, axial length and more of the pupil is an in- ment. Simultaneous macular
dication for cataract sur- perception and fusion de-

keratometry gery. velop in the first 3months af-

July, 2003 21 DOS Times - Vol.9, No.1

CURRENT PRACTICE

ter birth and stereopsis in the Table 1: Tailored approach for laboratory work-up in children with cataract*
first six-months of life. Early
cataract surgery in the very Cataract type Associated medical Workup
young children is recom- problem
mended to ensure adequate
visual input in this critical Nuclear (sporadic) Rubella Varicella TORCH, IgM & IgG in baby and
period of development. mother
Lamellar (sporadic) Neonatal tetany
Prognostication Oil droplet Galactosemia Ca, phosphorus, PTH
Various factors affect the
Complete (sporadic) G-1-P uridyl trans def. Urine reducing substance +, urine
ultimate visual outcome in a Galactokinase def. glucose -
child with cataract. Visually Rubella CMV Galactose-1-phosphate transferase
significant cataracts not only RBC galactokinase
produce blurred images on PSC Diabetes
the retina but also affect the Subluxed Corticosteroid use TORCH, IgM & IgG in baby and
development of visual path- Radiation mother Urine culture for CMV
ways. In the 1970s, it was JRA
customary to defer infantile Refsum disease Blood glucose, HgA1C
cataract surgery until at least Mannosidase
6 months of age. In sharp deficiency ANA, RF, HLA B27
contrast, presently more and Phytanic acid
more surgeons recommend Marfan
that visually significant cata- Examine relatives;
ract should be removed at the Homocystinuria Echocardiography
earliest possible time to pre- Plasma homocystine, urine
vent sensory deprivation as Anterior subcapsular Sulfite oxidase nitroprusside
the first few months of life is Hyperlysinemia Test urine sulfocysteine & thiosulfate
critical. Unilateral cataracts Weill Marchesani Plasma lysine
are by far more dangerous None
from the point of view of de- Conradi syndrome
velopment of dense amblyo- X-ray of long bones
pia. Unilateral cataract Spoke-like Fabry disease (stippled epiphyses)
should be operated with in Multicolored flecks Myotonic dystrophy
first few weeks to months of Punctate Down syndrome Alpha-galactosidase A in fibroblasts
life to prevent development
of sensory deprivation am- Sunflower Wilson disease Serum CPK
blyopia.10,11
Physical exam, chromosome
The fixation grade should analysis if needed
be noted, and unsteady fixa-
tion after surgery usually in- Serum Cu, ceruloplasmin, 24-hour
dicates a poorer prognosis. urine Cu
Similarly, children with cata-
racts associated with strabis- * Albert Biglan7
mus may have a more com-
pound problem than in those Choosing the correct op- satisfactory for rehabilitation lateral aphakia is of no use,
in which the ocular align- tion in visual rehabilitation because of several problems since the anisokenia would
ment is maintained. Associ- will also affect the final out- associated with their use preclude fusion of the two
ated ocular diseases such as come. The rehabilitation of such as induced magnifica- retinal images, and the larger
corneal opacities, glaucoma, pediatric aphakia is a must tion, visual field restriction image in the spectacle-cor-
intraocular inflammation, to prevent further amblyopia and prismatic effect beside rected aphakic eye would be
microphthalmos, aniridia, and changes in the visual poor compliance.4,10 How- suppressed anyway.
etc. are also associated with pathways. The options in ever, the use of aphakic
a poorer visual prognosis af- management of pediatric glasses is a viable option in The major goal of visual
ter surgery. aphakia include aphakic several developing countries rehabilitation is to bypass the
glasses, contact lenses and for the management bilateral use of spectacles and strive
intraocular lens implanta- aphakia. However, the use of for an effective means of cor-
tion. Aphakic glasses are un- aphakic spectacles for uni- rection - the intraocular lens
(IOL). Although contact

July, 2003 22 DOS Times - Vol.9, No.1

CURRENT PRACTICE

lenses offer several advan- is better option than part 1997;23:601-604 Nelson LB, et al: Extended-
tages over aphakic spec- time occlusion at least in the 2. Thylefors B: A global initia-
tacles, such as full visual initial phase of treatment wear contact lenses for the
field and stereopsis, there are and its compliance is utmost tive for the elimination of
several problems associated important for better visual avoidable blindness Am J treatment of pediatric aph-
with their use such as risk of outcome. Ophthalmol 1998;125:90-93
infection, loss of the contact 3. World Health Organization. akia. Ophthalmology 1988;
lens, higher cost and diffi- Preoperative Counseling Global Initiative for the
culty with compliance. Re- 1. Preoperative counseling Elimination of Avoidable 95: 1107-13
peated insertion and re- is most important. Parents Blindness (WHO/PBL/
moval of a contact lens may must understand that sur- 97.61), 1997 14.BenEzra D, Cohen E, Rose L:
also be psychologically trau- gery is only the first step of 4. Lambert SR, Drack AV: In-
matic to the child.11,12 management. The child fantile cataracts. Surv Traumatic cataract in chil-
Epikeratophakia for surgical needs follow up for a long Ophthalmol 1996;40:427-458
rehabilitation of pediatric period for repeated correction 5. Jain IS, Bansal SL, Dhir SP, dren. Correction of aphakia
aphakia has been aban- of residual and changing re- et.al: Prognosis in traumatic
doned at present. Presently, fractive error and occlusion cataract surgery. J Pediatr by contact lens or intraocu-
refined microsurgical tech- therapy. Possibility of post- Ophthalmol Strabismus
niques have made lens im- operative complications and 1979;16:301-305 lar lens. Am J Ophthalmol
plantation one of the most need of secondary interven- 6. JainIS,PillaiP,GangwarDN,
successful surgical tech- tion must be emphasized. In et al: Congenital cataract: Eti- 1997;123: 773-82,
niques for management of pe- Summary: ology and morphology. J
diatric cataract. There is a l Pediatric cataract is a Pediatr Ophthalmol Strabis- 15.Apple DJ, Ram J, Foster A,
swing towards implantation mus 1983;20:238-242
of IOLs over contact lenses common cause of child- 7. BiglanAW,ChengKP,Davis Peng Q. Elimination of cata-
for management of cataracts hood blindness JS, Gerontis CC. Secondary
among children.12-21 Younger l Early surgery is indicated intraocular lens implanta- ract blindness: A global per-
children under 8 years of age for visually significant tion after cataract surgery in
are undercorrected with re- cataract to prevent am- children. Am J Ophthalmol. spective entering new Mil-
spect to their IOL power, and blyopia. 1997; 123 :224-34.
they require additional l Only a trained and expe- 8. Dahan E, Drusedau MU: lennium. Survey
glasses following surgery. rienced ophthalmologist Choice of lens and dioptric
Spectacles may be prescribed in this field should per- power in pediatric pseudo- Ophthalmol (A special
as soon as the initial inflam- form pediatric cataract phakia. J Cataract Refract
mation has subsided and the surgery. Surg 1997; 23 (Suppl): 618- Suppl) 2000; 45 (1): 1-196
media has cleared. The child l Choosing an appropriate 623
is initially prescribed near modality of visual reha- 9. BenEzra D. Cataract surgery 16.Pandey S, Ram J, Werner L,
correction in the preverbal bilitation of pediatric aph- and intraocular lens implan-
age. As the child grows older akia is important. tation in children, intraocu- Brar GS, Jain A, Gupta A,
and starts going to school, l Preoperative counseling lar lens implantation in chil-
shift to bifocals or two pairs of parents is most impor- dren. Am J Ophthalmol Apple DJ. Visual results and
of spectacles-one for distance tant as the surgery is only 1996;121: 224-226
and one for near. The power the first step in manage- 10. Birch EE, Stager DR: The criti- postoperative complica-
of spectacles needs to be ment and child needs cal period for surgical treat-
checked on every follow up long-term follow up for ment of dense congenital tions of capsular bag and
visit and any change of 0.5D repeated correction of re- unilateral cataract. Invest
or more needs to be incorpo- sidual/changing refrac- Ophthalmol Vis Sci 1996;37: ciliary sulcus fixation of pos-
rated. The parents should be tive error and occlusion 1532-38
told that the spectacle power therapy is required. 11.Birch EE, Swanson WH, terior chamber intraocular
would gradually decrease Stager DR, et al: Outcome
with the growth of the eye. References after very early treatment of lenses in children with trau-
Amblyopia needs to be rec- 1. Foster A, Gilbert C, Rahi J: dense congenital unilateral
ognized early and treated cataract. Invest Ophthalmol matic cataract. J Cataract
carefully. Full time occlusion Epidemiology of cataract in Vis Sci 1993; 34:3687-99
childhood. A global perspec- 12.Kaufman HE: The correction Refract Surg 1999; 25:1576-
tive. J Cataract Refract Surg of aphakia. XXXVI Edward
Jackson Memorial Lecture. 84
Am J Ophthalmol 1980; 89:
110 17.Brar GS, Ram J, Pandav SS,
13.Levin AV, Edmonds SA,
Reddy GS, Singh U, Gupta A.

Postoperative complica-

tions and visual results in

uniocular traumatic cata-

ract. Ophthalmic Surg Laser

2001;32: 233-38

18.Rosenbaum AL, Masket S:

Cataract surgery and in-

traocular lens implantation

in children, intraocular lens.

Am J Ophthalmol 1996; 121:

225-26

19.Sinskey RM, Amin PA, Lin-

gua R: Cataract extraction

and intraocular lens implan-

tation in an infant with a

monocular cataract. J Cata-

ract Refract Surg 1994;20:647-

51

20.Vasavada A, Chauhan H: In-

traocular lens implantation

in infants with congenital

cataract. J Cataract Refract

Surg 1994;20:592-98

21.Wilson ME, Bluestein EC,

Wang XH: Current trends in

the use of intraocular lenses

in children. J Cataract Re-

fract Surg 1994;20:579-83

July, 2003 23 DOS Times - Vol.9, No.1

REVIEW

Eales’ disease is an inter- Eales’ Disease or Retinal Phlebitis
esting clinical entity, classi-
cally presenting with re- Bijayananda Patnaik, Rajinder Kalsi
peated vitreous hemorrhages
in a young adult male. How- The New Concept phlebitis, the use of the term feature of Eales’ disease is re-
ever, many cases may be di- There is considerable con- ‘vasculitis’ for phlebitis is peated vitreous hemorrhages
agnosed on the basis of other both improper and imprecise. in a young adult male. The
classical features of the dis- fusion, even today, in the Retinal vein inflammation patient would complain of
ease, but no hemorrhages in western literature on the un- can be, on one hand very se- sudden blurring of the vi-
to the vitreous. The underly- derstanding of the disease. vere with massive infiltration sion, or appearance of float-
ing pathology is retinal phlebi- This is to an extent under- or nodule formation with ing spots or cobwebs or sim-
tis1,2,3, typically involving the standable, for these authors complete obliteration of the ply cloudy vision – all these
peripheral retinal veins. The have little experience of lumen and on the other, mild symptoms are that of vitre-
clinical manifestations are es- studying Eales 'disease in cuffing of a vein segment. To ous hemorrhage. The vision
sentially that of inflammatory recent years, with modern describe both these as ‘pe- some times may get com-
branch retinal vein occlusions means, for the disease is now riphlebitis’ would be inap- pletely lost. Very often, with
(BRVO), usually multiple a rarity in their own coun- propriate. Without blunder- rest and time vision may tend
and bilateral. Some times tries. For instance, a recent ing in the realm of pathology, to improve. There could be
there may be inflammatory (2001)4 definition of Eales it would be proper to simply repeated such episodes. On
central vein occlusion Disease is “an idiopathic describe these as cases of examination the anterior seg-
(CRVO) also. Phlebitis may obliterative vasculopathy..” is ‘phlebitis’. ment may show some signs
or may not be associated with totally inconsistent with the of inflammation in some
choroiditis, iridocyclitis, ar- available contemporary kno- The disease was de- cases. Fundus examination
teritis or papillitis.These as- wledge on the subject. On the scribed and was apparently of the same eye, if the media
sociated features are only in- other hand, since our de- common in Europe in late is clear or some times the fel-
cidental and not relevant to scription of the pathophysi- 19th and early 20th century. low eye would show many
the clinical features of Eales ology of the disease in 19791 With affluence and improved of the following abnormali-
disease. The only pathology the concept is now univer- standard of living, all infec- ties:
relevant to the development sally accepted by all those tious diseases, including tu-
of the clinical features of who have among them- berculosis have disappeared. 1. During the stage of ac-
Eales’ disease is phlebitis. selves, had the occasion to So also Eales’ disease. It is tive phlebitis one may find
The nature of phlebitis can study several hundred of the now seen in Indian subcon- yellowish white infiltration
be extremely variable. It may cases of Eales disease in this tinent, Afganistan, Turkey of vein segments. The inten-
be very acute with massive country2 .The proper defini- and Greece that Eales dis- sity of infiltration vary. So
vitreous hemorrhage or very tion would be : It is “an idio- ease is being reported today. also the degree of venous in-
mild so as to go unnoticed. pathic inflammatory venous sufficiency or occlusion.
These extreme variations in occlusion..”2 Since it is now Pathophysiology of Clinical There may be massive infil-
the presentation and the clear that the only relevant Presentations tration, nodule formation or
course of the disease prob- pathology in Eales disease is may be mild cuffing. The site
ably indicate, that it is a con- The classical presenting
dition of multiple etiologies
and etiopathological pro-
cesses. One of these is tuber-
culosis. Once the pathophysi-
ology of Eales disease is un-
derstood, the management of
the condition becomes both
rational and highly satisfac-
tory.

Retina Associates Eye Institute, Fig. 1 Fig. 2
E-584, Greater Kailash, II 24 DOS Times - Vol.9, No.1
New Delhi -110048
www:patnaikb.com

July, 2003

REVIEW

Figure 3

of inflammation is the site of venous circulation. The in- men. A serial Fluorescein chaemia, would lead to reti-
venous occlusion. The retinal flamed segments of the veins study would demonstrate nal neovscularisation – the
vein peripheral to the site of stain and even leak the dye this process. The process is proliferative retinopathy.The
inflammation would be en- (Fig 5), indicating break helped by effective anti in- most dramatic demonstrable
gorged, tortuous. The blood down of the blood retinal flammatory treatment. The sign of retinal ischaemia are
column may be dark blue be- barrier of the retinal blood second process of circulatory areas of retinal capillary clo-
cause of stagnation. The vessels, caused by inflamma- compensation is the develop- sures (Fig 7). The ischamic
acuteness of the venous clo- tion. ment of veno-venous capil- retina is believed to release a
sure also vary. In cases with lary shunts. The blood from vaso-proliferative substance,
very acute closure, there may 2. Sooner or later, with or the territory of affected vein which stimulates neovas-
be subhyaloid or even vitre- without treatment, the is shunted through the cap- cular growth from surround-
ous hemorrhages (Fig1). In venous inflammation sub- illary bed to the adjoining ter- ing vascular system with
subacute cases the retinal sides. The site of segmental ritory. These lesions are seen good circulation. When one
territory distal to the site of inflammation of the veins typically in the retinal pe- branch retinal vein is in-
the inflammation would may be seen narrowed or riphery or temporal to the volved, the new vessels
show signs of venous insuf- kinked and may show par- macula across the horizon- would be seen growing from
ficiency or occlusion and of allel sheathing. On FA the tal raphe, as dilated tortuous the frontier blood vessels of
retinal circulatory decom- dye no longer stains or leaks. blood vessels (Fig.6). Rarely, the area with good circula-
pensation (Fig2). There Very often, there may be a lo- one may find larger vascualr tion proximal to the affected
would be flame shaped reti- calized patch of healed chor- shunts(Fig 9). However, vari- territory in the state of is-
nal hemorrhages, retinal (in- oiditis under the vein seg- able degree of state of decom- chaemia (NVE). The new
cluding macular) edema. ment which was inflamed. pensation could persist, spe- vessels may grow flat on the
The capillary system may be We feel, the choroiditis is sec- cially in acute and subacute surface of the retina or grow
engorged and some time leak ondary to phlebitis, for clas- cases. in the vitreous gel. When
blood, causing repeated vit- sically these leasions are there are involvement of mul-
reous hemorrhage (RVH). seen only along the veins 3. Persistent state of dec- tiple retinal veins, with wide
There may be areas of capil- and under the inflamed seg- ompensation and retinal is-
lary closure, indicating per- ments. Occasion- spread peripheral is-
sistent retinal ischaemia. In ally, the inflamma- Fig. 4 chaemia, one would ex-
some cases with mild phle- tion causes perma- pect neovascularisation
bitis, one may find segmen- nent closure or de- of the disc (NVD) also,
tal inflammations with some struction of vein besides the NVEs. Thus
engorgement and tortuosity segments (Fig 3). NVD indicates wide
of the distal veins but no ob- The process of cir- spread retinal is-
vious evidence of retinal cir- culatory stabiliza- chaemia. When retinal
culatory decompensation tion (compensation) ischaemia is even more
(Fig 3). These may be de- gets going. To start severe and persistent,
scribed as nonacute variety with, there is al- there may be in addi-
(Fig 4). Fluorescein angiog- ways an attempt at tion, anterior segment
raphy would show the de- opening up of the neovascularization (e.g.
gree of insufficiency in narrowed or ob- rubiosis iridis), some
structed venous lu- times leading up to the

July, 2003 25 DOS Times - Vol.9, No.1

REVIEW

Figure 5 Figure 6

dreaded neovascular glau- would explain all the (fol- ated uveitis, arteritis or papil- obliteration of venous seg-
coma. The new vessels with lowing) features of Eales Dis- litis. ments are probably due to
fragile walls are prone to re- ease: actual tubercular infestation
peated vitreous hemorrhages Etiology and do well with ATT. There
(RVH), accounting for these 1. Segmental infiltration It is not clear what causes may be many more, where
events in the majority of of various types and severity the phlebitis is because of
cases. in and around venous the retinal phlebitis. Consid- immune reaction to tubercu-
branches, indicating active ering the wide variation in lar proteins.
4. With time the retinal phlebitis, the basic the nature and severity of the
ischaemic retina dies. Alter- Pathology of Eales Disease. phlebitis, it may be logical to Management
natively, the ischaemic assume that there are prob- Once the pathophysiol-
retina is selectively de- 2. Engorged tortuous ably multiple etiological fac-
stroyed by either scatter pho- veins distal to the site of tors involved. Even there ogy of the disease is under-
tocoagulation or cryopexy. venous inflammation and could be multiple etiopa- stood, the management be-
Once the ischaemic retina occlusion thological or immunopatho- comes both rational and ef-
dies, the stimulus for vascu- logical processes involved. fective. In fact, the modern
lar growth disappear and the 3. Retinal, sub hyaloid management of Eales disease
new formed blood vessels re- and vitreous hemorrhage, Suspicion of tuberculosis is highly satisfactory. Since
gress. The regressing new the direct result of BRVO. being a etiological factor has recurrence of phlebitis is very
vessels are replaced with existed for decades. Eales rare and macular circulation
glial (scar) tissue. The glial 4. Retinal and macular disease was common in Eu- is usually not affected, the
tissue on contraction may edema as signs of venous in- rope at a time when tubercu- long term visual results can
cause several sight threaten- sufficiency losis was rampant there. be surprisingly good.
ing complications: 1) there With dramatic improvement
may be traction retinal de- 5. Dilated tortuous of standard of living in these Stage of Active Phlebitis
tachment (TRD). When and blood vessels, the veno industrialized countries, tu- During the state of active
if the macula is detached, venous capillary shunts berculosis has all but disap-
there is a catastrophic loss of peared. So also, Eales dis- phlebitis, the treatment is
central vision (Fig 8). 2) there 6. Sheathing, kinking of ease. The disease is now seen bases on energetic anti in-
may be a traction tear, usu- veins at the old site of seg- in countries like ours where flammatory drugs. The most
ally at the point where the mental vein inflammation, tuberculosis is a major pub- commonly used drug is oral
vein draining the new vessel the result of post inflamma- lic health problem. Recent corticosteroids (Prednisolon,
grown in to the vitreous, tory gliosis PCR studies for tubercular 1mg/kg body weight or
touches the flat retina. This DNA in aquous and vitreous equivalent). Sub tenons in-
would lead to traction initi- 7. Patches of choroiditis samples from Eales disease jection of depo steroids have
ated rhegmatogenous RD under and along the affected cases have provided strong been used. We doubt whether
(Fig.9). 3) there may be a thick veins, secondary to phlebitis evidence of the actual in- this method of administra-
scar tissue covering the volvement of tubercle bacilli tion is at all helpful. In cases
macula causing serious vi- 8. New blood vessels in in this disease. It is now be- showing ocular hyperten-
sual loss. the retinal periphery (NVE) lieved that at least some cases sive response, one may have
and on the disc (NVD) of retinal phlebitis showing to use non steroidal anti in-
Thus the understanding massive infiltration, nodular flammatory drugs, as an al-
of the pathophysiology 9. Gliosis of proliferative formations and complete ternative.
retinopathy with traction RD
or traction related Rheg.RD

10. Anterior segment
neovascularization (iris,
angle) and neovascular glau-
coma

11. Occasionally associ-

July, 2003 26 DOS Times - Vol.9, No.1

REVIEW

Figure 7 Figure 8 Figure 9

Where phlebitis is sus- be confined only to the terri- special indications. 1) When Ø The basic pathology is
pected or established to be tory of the affected vein. pupil is small and undila- Phlebitis
tubercular (by PCR) we ting. Laser can not reach the
strongly recommend 3 drug The Stage of Vascular Pro- periphery 2) When vitreous Ø It has multiple etiologies
combination of drugs for tu- liferation hemorrhage has settled over and pathological pro-
berculosis, over and above the lower periphery and la- cesses.
oral steroids. Our favourites Once there is significant ser treatment can not be com-
are : Rifampicin, Isoniazide neovascular proliferations, pleted 3) When in spite of re- Ø Tuberculosis is one of
and Pyrazinamide. indiscriminate retinal abla- peated laser new vessels do them
sion with photocoagulation not regress 4) When repeated
The Stage of Persistent Is- or cryo may lead to many of vitreous hemorrhages do not Ø Management is very sat-
chaemia the complications associated let media to clear enough for isfactory when appropri-
with the contractioning glio- successful photocoagulation ate treatment is applied at
Once the venous inflam- sis that replaces the new ves- and vitreous surgery facili- appropriate stages, with a
mation has subsided, leaving sels. Such complications can ties are not available. In all proper understanding of
an ischaemic retina, the dan- be prevented by a technique these situations, cryo helps the pathophysiology
ger is one of vascular prolif- we have described as ‘An- in facilitating or concluding
eration – proliferative retin- choring Photocoagulation’ the treatment. Cryo alone is Ø Anti inflammatory with or
opathy. Such cases must be (Fig). The vital (macula) and dangerous. Cryo can only be without ATT during the
regularly followed up with vulnerable (root of the venule used as a supplement to in- stage of active Phlebitis
serial Fluorescein Angiogra- draining a neovascular le- complete photocoagulation
phy. Evidence of persistent sion imbeded in the vitreous when sufficient photocoagu- Ø Selective retinal ablasion
state of de compensation gel) areas are first sur- lation has been put in place by photocoagulation dur-
would include: areas of cap- rounded by strong burns of around the posterior pole. ing the stage of retinal is-
illary closures, increased photocoagulation. After 3 –4 chaemia, to prevent or re-
permeability of the capillary weeks scatter photocoagula- The Stage of Complications gress new vessels
system in the affected area or tion is done to regress the In advanced cases with ei-
growth of new vessels. The new vessels. In the presence Ø Vitreous surgery in ad-
standard treatment for pro- of marked neovascular ther non absorbing vitreous vanced cases
liferative retinopathies is ‘se- growth around the posterior hemorrhage or traction re-
lective retinal ablation’ of the pole, unless the retina at the lated retinal complications Ø When managed properly
ischaemic retina, by scatter posterior pole is ‘anchored’ the only way to help matters generally the visual re-
photocoagulation and if with sufficient photocoagu- is Vitreo retinal surgery. The sults are good
needed peripheral cryo. lation, peripheral ablation ei- visual results are usually
ther by scatter photocoagu- good, for the state of macular References
It is better to prevent sig- lation or peripheral cryo circulation is generally good 1. Kalsi R, Patnaik B. The de-
nificant neovascular growth would be dangerous. The in cases of Eales diaease.
than to regress them, once risk of macular detachment veloping features of phlebi-
these have developed. We caused by contracting glial Summary tis retinae (A vertical study)
prefer relatively early photo- tissue around the posterior Ø Eales’ Disease is a mani- Indian J Ophthalmol
coagulation and deliver the pole is too great. 1979;27:87
treatment in an incremental festation of inflammatory 2. Das TP, Biswas J, Kumar A,
fashion. The treatment has to Peripheral cryo has some BRVO Nagpal PN, Namperuma-
lsamy P, Patnaik B & Tewari
HK. Eales Disease. Indian J
Ophthalmol. 1994;42:3-18
3. Gieser SC & Murphy RP.
Eales’ Disease. In Ryan SJ ed.
Retina. Vol, St Louis:Mosby;
2001: 1505-08

July, 2003 27 DOS Times - Vol.9, No.1

MANAGEMENT PEARLS

Cystoid Macular Edema (CME) Diabetes, Vascular Occlu-
sions, Hypertensive Retin-

Following Cataract Surgery opathy, Epiretinal Mem-
brane, Intraocular tumours
(melanoma, hemangioma),

Vinay Garodia MD, R.P. Singh, MD Intraocular inflammation
(like Pars Planitis), Retinitis

Pigmentosa, Drugs (Epi-

nephrine in aphakia), Radia-

The syndrome of macular mately 1% in uncomplicated some of the cases. In cases tion retinopathy etc. There-

changes and poor visual cases. Complicated cataract with chronic CME, the fore, a detailed history and

acuity, following cataract extractions like vitreous loss, intraretinal cystoid spaces examination to rule out these

surgery was first described iris or vitreous incarceration may coalesce, producing a other ocular pathologies

by Irvine in 1953 and was in wound, retained lens mat- foveal cyst. Unroofing of this must be carried out before

subsequently detailed by ter, unstable IOL etc. are as- foveal cyst may result in for- attributing the CME to post-

Gass and Norton in 1966 as sociated with increased risk mation of inner lamellar operative category. The diag-

cystoid macular edema of clinically significant CME, macular hole. This usually nosis of CME may sometimes

(CME). The syndrome of with reported incidences as results in permanent loss of be confused with other

CME following cataract sur- high as 20%. Nd-YAG visual acuity. causes of macular edema like

gery has therefore been capsulotomy in the post-op- There is also some degree Branch Retinal Vein Occlu-

termed as ‘Irvine-Gass Syn- erative period can also lead of optic nerve head swelling sion (BRVO), Diabetic Macu-

drome’. to CME in approximately with slight congestion and lar Edema, Choroidal

Cystoid Macular Edema 1.5% of patients. Fortunately decrease in the cup size. Neovascularisation (CNV),

(CME) is one of the most com- the majority of patients have These changes are best ap- Photic Maculopathy, and

mon causes of unexpected spontaneous resolution of preciated by comparing the Impending Macular Hole.

poor visual acuity following their CME with recovery of disc with that of the other eye. Looking for other associated

cataract surgery. CME has good visual acuity. However, There may also be signs of signs of the particular dis-

been classified as Angio- chronic CME (more than 6 low-grade inflammation like ease does the differentiation

graphic Macular Edema months duration) with per- ciliary injection, cells and and the diagnosis is con-

and Clinically Significant manent visual loss occurs in flare in the anterior chamber. firmed by performing Fluo-

Macular Edema. In Angio- approximately 1% of pa- Concomitant abnormalities rescein Angiography.

graphic Macular Edema, tients undergoing ECCE. from the complications of the Fluorescein Angiography

there are leakages in Fluores- The patient with CME cataract surgery such as iris (FA) is very useful in confirm-

cein Angiography but there may present with no symp- or vitreous incarceration in ing the diagnosis of CME. In

is no decrease in vision, toms at all in case of wound, posterior capsular the early frames, the capil-

whereas Clinically Signifi- Angiographic CME. The rupture, improperly place or lary dilatation and leakage

cant Macular Edema also Clinically Significant CME fixated IOL, retained lens are visible in the perifoveal

has corresponding decrease usually occurs 4 to 12 weeks matter etc. may also be vis- area. Later, pooling into the

in visual acuity. after cataract surgery, and ible. outer plexiform layer

With the earlier tech- the patient presents with (Henle’s layer) gives rise to

niques of cataract surgery poor recovery of vision fol- Differential Diagnosis classical petaloid staining

and earlier designs of In- lowing cataract surgery. Besides post-operative pattern, due to radial ar-

traocular Lens (IOL) the in- There may also be low-grade cases, Cystoid Macular rangement of the fusiform

cidence of CME was reported eye irritability with mild red- Edema may be secondary to spaces, in the perifoveal re-

to be very high. Now with ness and photophobia. Slit other ocular pathologies like gion (Fig. 1). There is also

better technique of Phacoe- lamp biomicroscopy using a Complicated cataract extractions like
mulsification and better PC contact lens or a 90/78 D

IOL designs, the incidence of lens, is the best means to vitreous loss, iris or vitreous
clinically significant CME visualise CME. There is a incarceration in wound, retained
has decreased to approxi- loss of foveal depression; the

Visitech Eye Hospital macula appears thickened lens matter, unstable IOL etc. are
Advanced Centre for Vitreo Retina with translucent intraretinal associated with increased risk of
and Lasers, Delhi. cystoid spaces. Epiretinal
membranes may be seen in clinically significant CME

July, 2003 28 DOS Times - Vol.9, No.1

MANAGEMENT PEARLS

leakage from capillaries in Fig 1. Fluorescein angiogram of an eye with CME. Fluorescein dent that this procedure be
the optic nerve head causing leakage from the capillaries and a classical petalloid appearance of performed only when defi-
a late staining of the optic macula. nitely indicated, and if re-
nerve head, which is almost quired, must be performed at
always present in cases with Slit lamp biomicroscopy using a contact least 6 months following the
CME. The amount of dye lens or a 90/78 D lens, is the best means cataract surgery and to use
leakage on FA does not cor- minimal power necessary to
relate very well with the de- to visualise CME decrease the risk of CME.
gree of visual loss. This is
possibly because the visual CME. Therefore we have to to ensure that there is no vit- We recommend a
loss is probably more depen- rely on the information from reous or iris incarcerated in stepwise therapeutic ap-
dant on the amount of thick- the past therapeutic studies the wound also helps in re- proach (Table 1) to CME. The
ening than the amount of dye and considerations of the ducing the incidence of CME. best course for a patient with
leakage. The macular thick- pathophysiology of CME. Besides a good surgical tech- CME for only a few months
ening can be better studied nique, routine topical corti- after cataract surgery is to
by newer technique of Opti- The newer techniques of costeroid for first 3-4 weeks wait, as most of these pa-
cal Coherence Tomography cataract surgery and better and topical NSAID for 2-3 tients will spontaneously re-
(OCT). IOL materials have already months may also probably solve. During this period of
helped in preventing CME in help. Since Nd-YAG waiting, topical NSAIDs,
Before discussing the pre- a long way. A good manage- capsulotomy is known to be preferably the one blocking
vention and treatment of this ment of complications of cata- a risk factor for CME, it is pru- both cyclo-oxygenase and
condition, it is prudent to dis- ract surgery like vitreous loss lipo-oxygenase pathways
cuss the pathogenesis of (e.g., diclofenac eye drops),
CME. Various theories have Table 1: Stepwise Approach for Treating CME may be used. Each of these
been proposed implicating above mentioned steps
vitreous traction at the Step 1 Wait and watch should be tried for 4-6 weeks
macula, vitreous incarcera- Topical NSAIDs period before changing the
tion in the wound, vitreous- Step 2 treatment. In case of no re-
uveal traction, inflammation, Step 3 Topical Corticosteroids sponse, add on the treatment
prostaglandins and other Step 4 from the next step, while con-
inflammatory mediators. Sub-tenon steroid injection tinuing to use the previous
Most treatment strategies are Step 5 treatments.
based on either vitreous trac- Oral Acetazolamide (Diamox)
tion or inflammation as the Oral Corticosteroid When starting the patient
primary etiology, and in- on topical steroids, one has
clude topical, subtenon and Laser Nd-YAG vitreolysis to monitor the intra-ocular
systemic corticosteroids, Vitrectomy pressure (IOP) closely to look
Non Steroidal Anti-Inflam- for steroid responders, i.e.,
matory Drugs (NSAIDs), Nd- raised IOP in response to
YAG vitreolysis, and ante- topical steroids. In cases that
rior and posterior vitrectomy. do not improve on topical ste-
Other additional treatments roids may be given the op-
like systemic Acetazolamide tion of sub-tenon steroid in-
(Diamox) have been pro- jection. Sub-tenon steroid in-
posed to reduce edema with- jection has an advantage of
out directly treating the delivering a high dose to the
cause of edema formation. macula, without the systemic
All of these proposed meth- side effects of oral steroids.
ods of treatment have been However, one has to be care-
reported to be beneficial. The ful about raised intraocular
lack of randomized thera- pressure. If during the course
peutic trials limit the objec- of topical steroids, the patient
tive information available to is found to be a steroid re-
base definitive recommenda- sponder, sub-tenon steroid
tions for the treatment of may be contraindicated.

If all the above treatment

July, 2003 29 DOS Times - Vol.9, No.1

MANAGEMENT PEARLS

options fail, then oral aceta- proach, has the potential for in cases of chronic macular following cataract surgery
zolamide and oral steroid a better repair of vitreous ad- edema. and must be performed un-
may be tried. However, one hesions to the wound or the der cover of topical steroids
has to be careful about the iris, especially in the more To sum up, improved sur- and topical NSAIDs. Even
higher incidence of systemic chronic cases. Iris incarcera- gical technique has already after taking these precau-
side effects due to these medi- tion can also be repaired dur- decreased the incidence of tions, CME is bound to oc-
cines, especially in the eld- ing the same procedure. In CME following cataract sur- cur, though in lesser number
erly population. If everything addition, pars plana vitrec- gery, and further refinements of cases. This is a disappoint-
else fails, surgical manage- tomy also offers the theoreti- will undoubtedly continue ment for both patient and the
ment may be tried. Nd-YAG cal advantage of removing this trend. To further de- ophthalmologist alike. The
vitreolysis, though described the vitreo-macular traction, crease the incidence of CME, effective prevention and
in literature, is not that removing the inflammatory it is mandatory that every treatment of CME requires
simple a procedure to do and mediators in the vitreous cataract surgeon should one to understand the pro-
it may take more than one sit- and allowing better access of have a basic functioning au- posed pathogenesis of the
ting to completely cut the vit- topical steroids to the poste- tomated vitrectomy unit to disease and to follow a
reous adhesions in the ante- rior segment. Though there manage the cases of vitreous stepwise approach for treat-
rior chamber. Moreover, it is has been no randomized loss properly and to mini- ment, as described above. A
not a very safe procedure and clinical trial to prove this, mize the chances of vitreous proper management of this
may have complications in various series have yielded incarceration in the wound. entity gives a good visual re-
form of bleeding from the iris, encouraging results for vit- Moreover, Nd-YAG capsulo- sult most of the times and re-
increased inflammation or rectomy. With greater exper- tomy whenever required for sults in a happy and satis-
even retinal detachment. Vit- tise and better results of vit- posterior capsular opacifica- fied patient and a relieved
rectomy, either through the rectomy, this may be a useful tion must use minimal power ophthalmologist.
anterior or posterior ap- mode of treatment especially necessary, and should be
delayed till at least 6 months

Programme for DOS Monthly Clinical Meeting for July 2003

Venue: Army Hospital (Research & Referral), Near Dhaula Kuan, (on NH-8), Delhi Cantt-110010
Date & Time : 27th July, 2003 (Sunday) at 10.00 A.M.

Case Presentation

1. Two unusual Cases of Eales' Disease ................................................ Dr. Lt. Col. A Banarji

2. Unusual Presentation in Two Case of Glaucoma ........................... Dr. Lt. Col. (Mrs.)
M. Bhadauria

Clinical Talk

l Dealing with the Problems in Pediatric Cataract ........................... Col. D.P. Vats,
S.M., VSM

Mini Symposium: Ocular Trauma
Chairmen: Dr. Col. D.P. Vats
Convenor: Dr. Lt. Col. A. Banarji

1. Overview of Ocular Trauma & .......................................................... Col. D.P. Vats

Anterior Segment Reconstruction S.M., VSM

2. Dealing with Lens and Uveal Injuries .............................................. Lt. Col.
(Mrs.) M. Bhaduaria

3. Dealing with RIOFB ............................................................................. Lt. Col. V.S. Gurunadh

Panel Discussions : 20 min.

July, 2003 30 DOS Times - Vol.9, No.1

REVIEW

New DOS Members Continued from Page 5

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Soni Anju Gupta Bharat Bhushan Soni Ambarish Sadatnagar, Kosli,
C/O Mr. M.C. Soni House No.332, Sector-2 Head, Dept. of Ophthalmology, Rewari
4/4, Amaltas Complex Ambala Road Maharaja Agrasen Institute of
Shahpura, Bhopal Pehowa (Dist.Kurukshetra) Medical Research & Education P-1711
Agroha (Hisar) Punia Gurpreet
N-1691 G-1701 #1505, Sector 33-D
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Kumar Mithilesh Jashpur Nagar-496331 Room No.43, P.G. Block
Karpuri Chowk S-1702 Medical Hostel, Boys
Madhepura-852113 Singh Suresh Prasad V-1717 M.G.M. Medical College, Indore
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Y-1698 39, Patel Basu Road R.P. Netra Chikitsa Kendra A-1713
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Vth Main Road S-1707 Bhopal Department of Ophthalmology
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Trichy-620003 R-15, Yamuna Colony K-1720 Kanpur
Dehradun Khuraijam Noornika
K-1705 Regional Instt. of Ophthalmology, T-1032
Meenakumari R. S-1029 Hamidia Hospital Tuteja (Mrs.)Sonia
P-34, Gnanam Colony Sahay Pallavi Bhopal 202, State Bank Nagar
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New Delhi-110060 601-A, Puja Apartments R-1033
S-1706 I.P. Extension, Patparganj Rana Vishwas
Sethia K.L. D-1708 Delhi-110092 S-2/A/121
C/O Gour Medical Store Devendra Jaya Shalimar Garden Extension-2
2nd Mile, Sevoke Road A-194, Indira Nagar V-1031 Dist. Ghaziabad,
Siliguri-734401 Lucknow-226016 Vajpeyi Abhishek Sahibabad

Congratulations! C-1034
Chaudhary Neeraj
Dr. V. Menon, Dr. S.M. Betharia, Dr. S.P. Garg and Dr. Rashmi Madan for being C-3/42, Ashok Vihar,
appointed as Professor at Dr. R.P. Centre for Ophthalmic Sciences, AIIMS, New Delhi. Phase-II, Delhi-110052

Dr. Alkesh Chaudhary for receiving ‘Dr. Prem Chander’ Best Paper Award and best M-1035
video presentation at ‘North Zone Ophthalmic Conference’, October 2002. Mongia Tripti
19-A, Pocket-A
Dr. Rakesh Ahuja for joining Galucoma Fellowship at Vancuver, Canada. Vikas Puri Extension
New Delhi
Prof. Harish Agarwal for joinig a Head of Glaucoma Services at Max Eye Care after
sucessfully completing his tenure at Dr. R.P. Centre for Ophthalmic Sciences, AIIMS, K-1036
New Delhi, DOS wishes him all the best for his future assignments. Kashfi Angabeen
167, Zakir Bagh
Dr. Lalit Verma and Dr. Dinesh Talwar, Senior Vitreo Retina Consultants, have Okhla Road
entered a new phase in their lives and have joined Centre for Sight, Green Park and New Delhi-110025
Apollo Hospital, New Delhi. We wish them good luck in their new endeavour.
S-1037
Sinha (Major) Rajneesh
Bf-72, Janakpuri
New Delhi-110058

July, 2003 31 DOS Times - Vol.9, No.1

DOS QUIZ

DOS QUIZ NO. 1

1. Eclipse sign is seen in …………………………..............................................................................................
2. Normal foveal thickness by OCT is …………………………..............................………………………….......
3. Concentration of Bimatoprost is …………………………..............................………………………….......
4. Most common systemic association of Retinitis Pigmentosa is ………………………………………............
5. Most common organism causing Acute painful dacryoadenitis …………………………............................
6. Treatment of choice of Tolosa Hunt syndrome …………………………....................................................
7. Most common cause of secondary lipid keratopathy is…………..…………………………........................
8. Essential blepharospasm is due to dysfunction of ………………..………………………….........................
9. Chrysiasis is due to deposition of ……………..…………………………........................................................
10. Most common lacrimal gland carcinoma is …………..…………………………..........................................

Jugglery

1. E E O O R T M N ___ ___ ___ ___ ___ ___ ___ ___

2. R V E D P N E E I ___ ___ ___ ___ ___ ___ ___ ___ ___

3. R T P T R B M A S O ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

4. S S P P T A O O I ___ ___ ___ ___ ___ ___ ___ ___ ___

5. C I R E R N I F E B G E N ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

6. A M M G K A R Y C ___ ___ ___ ___ ___ ___ ___ ___

7. D I I A A R N ___ ___ ___ ___ ___ ___ ___

8. U P T L A A E ___ ___ ___ ___ ___ ___ ___

9. UITNSOVONACERSALU ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

10. O E D T N P F L L S E U O O X ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Rules:
l Among the above intermingled alphabets, ophthalmic terms are hidden.

l No abbreviations are used. Let us see who can find the most number of words. Good luck.

l Please send your entries to the DOS office latest by 25th August, 2003.

l Prize Rs.500/- Courtesy: Syntho Pharmaceuticals

l Quiz Trophy will be given to the member who answers maximum number quizes in a year
during the Annual GBM of DOS.

July, 2003 32 DOS Times - Vol.9, No.1

JOURNAL ABSTRACTS

Surgical management of postoperative LASIK. The mean contrast sensitivity values preoperatively
endophthalmitis: comparison of 2 in group 1 and 2 eyes were 161.3 (8.7) and 172 (68.2) respec-
techniques tively. There was a significant decrease in-group 1 at 6
months (102(60.5) (p<0.01)) compared to group 2. The deci-
Kaynak S, Oner FH, Kocak N, Cingil G. J Cataract Refract mal glare acuity preoperatively in group 1 and 2 eyes was
Surg. 2003 May;29(5):966-9. 0.95 (0.11) and 0.89 (0.12), respectively. It decreased signifi-
cantly in-group 1 (0.7) (0.1 (p<0.01)) compared to group 2 at
The aim of the study was to evaluate the results of 2 surgical the 6-month follow up. The authors concludes that occur-
techniques in eyes with postoperative endophthalmitis. rence of intraoperative interface hemorrhage may affect the
Twenty-four eyes with endophthalmitis after cataract sur- visual performance following LASIK surgery.
gery had vitrectomy as an initial procedure according to the
Endophthalmitis Vitrectomy Study (EVS) criteria (Group 1, Keratoplasty for keratomalacia in
n = 24). These eyes were compared with 28 eyes that had preschool children
total pars plana vitrectomy with an encircling band, sili-
cone tamponade, and endolaser (Group 2, n = 28). The vi- Vajpayee RB, Vanathi M, Tandon R, Sharma N, Titiyal JS.
sual and anatomical outcomes and the need for additional Br J Ophthalmol. 2003 May;87(5):538-42.
procedures (repeat vitrectomy) were evaluated in the 2
groups. The study found that in Group 1, 6 eyes (25.0%) had This paper describes the results of surgical management of
an additional procedure, 3 eyes (12.5%) had phthisis, and keratomalacia in children. In this study clinical case series
21 eyes (87.5%) had successful surgery. In Group 2, no eye of all children with keratomalacia, admitted to an Indian
had an additional procedure, 1 eye (3.5%) had phthisis, and Center during the period from June 2000 to June 2001 is
27 eyes (96.4%) had successful surgery. The number of addi- presented. The parameters evaluated were demographic data,
tional procedures was significantly less and the rate of sur- systemic associations, and results of medical and surgical
gical success was significantly higher in Group 2 than in intervention. The study founds that 29 children with
Group 1 (P<.01). The author concludes that despite the poor keratomalacia ranging from 2 months to 5 years of age (mean
visual prognosis of endophthalmitis surgery, more radical 1.8 (SD 1.4) years) were included in the study. All children
intervention can increase the chance of surgical success and belonged to families of lower socioeconomic status. 27 pa-
decrease the number of additional procedures in eyes with tients (93.1%) had not been immunized at all. The systemic
postoperative endophthalmitis. diseases precipitating the onset of keratomalacia included
measles (41.37%), pneumonia (31.03%), and acute diarrhoea
Visual performance after interface (37.93%). 36 eyes (66.7%) had total corneal melting and 11
haemorrhage during laser in situ (20.3%) eyes had paracentral corneal melting. In 15 eyes
keratomileusis (27.8%) an emergency tectonic penetrating keratoplasty was
performed of which only five grafts (33.3%) remained clear
Vajpayee RB, Balasubramanya R, Rani A, Sharma N, at a mean follow up of 7.3 (6.8) months (range 3-24 months).
Titiyal JS, Pandey RM. Br J Ophthalmol. 2003 Seven eyes underwent optical penetrating keratoplasty; of
Jun;87(6):717-9. which four grafts (57.14%) remained clear at a mean follow
up of 6.4 (3.6) months (range 3-12 months). None of these
The study aimed to report the visual performance in eyes could achieve a visual acuity better than 6/60.The study
with interface haemorrhage during laser assisted in situ concludes that corneal grafting surgery in keratomalacia is
keratomileusis (LASIK). Authors evaluated the case records associated with poor visual outcome.
of 20 patients, who had bleeding from the limbal vessels in
one eye during LASIK (group 1) and uncomplicated surgery Macular image changes of optical
in the fellow eye (group 2) were studied. The parameters coherence tomography after
evaluated were uncorrected visual acuity (UCVA) best cor- phacoemulsification
rected visual acuity (BCVA), spherical equivalent of refrac-
tion (SEQ), contrast sensitivity, and glare acuity preopera- Cheng B, Liu Y, Liu X, Ge J, Ling Y, Zheng X. Zhonghua
tively and at 1, 3, and 6 months postoperatively. The study Yan Ke Za Zhi. 2002 May;38(5):265-7.
founds that the mean preoperative SEQ in group 1 and 2
eyes was -5.79 (2.3) D and -5.27 (1.68) D, respectively. The Authors had investigated the effects of phacoemulsifi-
mean decimal UCVA at 6 months after LASIK in group 1 cation on the macula following uncomplicated
and 2 eyes were 0.6 (0.2) and 1.0 respectively (p<0.001). The phacoemulsification by optical coherence tomography
mean decimal BCVA at 1 week after LASIK in group 1 and 2 (OCT).In this study eighty eyes of the senile cataract were
eyes were 0.89 (0.04) and 1.0 respectively (p<0.05). How- chosen randomly. The uncomplicated phacoemulsification
ever, all eyes had a BCVA of 6/6 at 1, 3, and 6 months after

July, 2003 33 DOS Times - Vol.9, No.1

JOURNAL ABSTRACTS

was performed. OCT was examined preoperatively and 1 Long-term progression of astigmatism
week after the surgery. Preoperative visual acuity, the reti- after penetrating keratoplasty for
nal thickness and phaco power were compared with those keratoconus: evidence of late
after surgery. This study founds that in 80 eyes, the preop-

erative mean foveal thickness was (142.9 +/- 16.7) microme- recurrence
ter and the postoperative (157.9 +/- 36.7) micrometer, the
difference being not significant (P > 0.05). Three eyes had De Toledo JA, De La Paz MF, Barraquer RI, Barraquer J
macular edema 1 week after surgery. In 11 eyes with Tyndall Cornea. 2003 May;22(4):317-23.
sign (+ +), the mean postoperative foveal thickness was
thicker than the mean preoperative value (P < 0.05). In lower The purpose of the study was to evaluate the changes in
phaco power group, the mean postoperative foveal thick- astigmatism throughout a 20-year period using keratometry
ness was (156.2 +/- 18.3) micrometer and the higher phaco and refraction in patients who underwent penetrating kerato-
power group was (172.6 +/- 32.9) microm (P < 0.05). The plasty (PKP) for keratoconus. Authors reviewed the charts
best corrected of patients who underwent PKP for keratoconus from 1975
to 1979 and recorded preoperative refraction, stage of kera-
toconus, laterality of surgery, graft size, suture technique,

Visual acuity after surgery had a negative correlation with time of suture removal, keratometry, subjective refraction at

the retinal thickness. The study concludes that he retinal 1, 3, 5, 7, 10, 15, 20,and 25 years after suture removal, and

thickening and macular edema can be found after uncom- slit-lamp findings. The study founds that eighty eyes with a

plicated phacoemulsification. The higher phaco power re- mean follow-up of 20 years (range, 15-25) were included in

sults in significant inflammation and thicker retina. The vi- the study. Graft size, suture technique, and time of suture

sual consequences were proportional to the degrees of macu- removal had no significant influence on the astigmatism at

lar thickening. the last examination. We observed a stabilization of

keratometric astigmatism in the first 7

Application Invited from Institutions for years (4.05 +/- 2.29 D 1 year after suture
removal, 3.90 +/- 2.28 D at year 3, 4.03

Holding the DOS Monthly Clinical Meetings +/- 2.49 D at year 5, 4.39 +/- 2.48 D at
year 7) followed by a progressive in-

As per the DCRS ratings 2 institution have been dropped from the crease from 10 years after suture removal
monthly calender (RML Hospital & Appllo Hospital). We request all the until the last follow-up visit (5.48 +/-
hospitals/institutions interested in holding the DOS monthly meeting to 3.11 D at year 10, 6.43 +/- 4.11 D at year
kindly see if they fulfill the criteria given below. They may apply to the 15; 7.28 +/- 4.21 D at year 20, and 7.25
Secretary’s Office with details latest by with 20th July 2003. (Those who +/- 4.27 D at year 25). The mean abso-
have already applied/are already holding the meeting, need not do so lute value of the difference vector (DV)
again). calculated by vector analysis was 7.17
+/- 4.35 D (0-18.33). In 70% of cases, pro-
No meeting is held in May and June. Meetings are usually held on the gression of the astigmatism was evident
last Saturday of the month. with mean absolute DV of 9.10 +/- 3.65
D. There was a significant correlation
Criteria for selection of a place:

(a) Seating capacity of 100-200 persons, preferably AC mini auditorium between the preoperative and final axis

/ hall definitely within the premises of the institutions. of astigmatism (Pearson r = 0.39, p =

(b) Audio Visual facilities to be available 0.0008). There was also a slight positive

– moving mike 1 set correlation coefficient between the DV
of the eyes in bilateral cases, but it was
– multimedia projector 1 set not significant (Spearman’s r = 0.2226,
p = 0.34). The major late slit-lamp find-
– double slide projectors 1 set ing was a peripheral crescent-shaped
thinning at the graft-host junction with
(c) Institute should send the details of the meetings/CME etc., held at absence of Bowman’s layer on histopa-
that institute in past 2 years to the DOS office thology. Authors concludes that in spite
of refractive stability obtained during the
(d) A sizeable staff in Ophthalmology who would be able to conduct the first years after PKP for keratoconus, in-
meeting themselves without any major outside participation as speak- creasing astigmatism thereafter suggests
ers/presenters.

– Before the submission of application for holding the DOS clini-
cal meeting, all the above mentioned criteria should be met.

– These may be verified by President and Secretary. that there is a progression of the disease

– Dr. Jeewan S. Titiyal, Secretary, DOS in the host cornea.

July, 2003 34 DOS Times - Vol.9, No.1

EVENTS

Forthcoming Events – NATIONAL

—————————————————————————————————————————————————————

Event Conference Date Venue Contact Person and Address

——————————————————————————————————————————————————————

Indian Contact Lens Education 20th-24th Education Centre L.V. Prasad Marg, Banjara Hills,
Program July 2003 L.V. Prasad Eye Hyderabad-500 034,
Institute, Hyderabad E-mail: <[email protected]

6th International Advanced 24th-26th Aditya Jyot Eye Contact: Dr. S. Natrajan, Aditya Jyot Eye
Vitreo Retinal Surgery Course July, 2003 Hospital, Mumbai Hospital, Aashirwad, 168, Vikas Wadi,
Chennai Dr. Ambedkar Road, Dadar T.T.,
Mumbai-400014

National Workshop on 17th-18th Dr. R.P. Centre Contact : Prof. R.B. Vajpayee, Dr. Jeewan S. Titiyal
Phacoemulsification Sept. 2003 for Ophthalmic 492, 4th Dr. R.P. Centre for Ophthalmic Sciences,
Sciences, AIIMS, AIIMS, New Delhi - 110029, India
New Delhi Ph : 26593192, 26588852-65, Ext. 3192, 3146
Fax : 011-26588919 Email : [email protected]

Ophthacon 2003 10th-11th LLRM Medical College, Contact Person : Dr. Sandeep Mithal,
(38th U.P.State Ophthalmology Oct. 2003 Meerut, (U.P.) Upgraded Department of Ophthalmology,
Conference) LLRM Medical College, Meerut, (U.P.)
Email : [email protected]
Phone : 91 - 121 - 2763133

Eye Topia 2003 19th India Habitate Centre Contact Person: Dr. Jeewan S. Titiyal,
Mid Term DOS Oct. 2003 Lodhi Road, New Delhi Secretart (DOS) R.No. 476, 4th Floor,
Dr. R.P. Centre for Opthalmic Sciences,
New Delhi - 110 029
Ph.: 26589549, Fax : 26588919,
E-mail: [email protected]
Website: dosonlin.org

Annual DOS Conference 3rd-4th India Habitate Centre — do —

April 2004 Lodhi Road, New Delhi

INTERNATIONAL

Event Conference Date Venue Contact Person and Address

———————————————————————————————————————————————————

Seventh Annual Glaucoma 2nd Aug. San Francisco, Glaucoma Research & Education Group,

Symposium 2003 CA (USA) 490 Post Street, suite 644, San Francisco,

CA 94102; Tel (415) 986-0835; Fax: 986-0876;

e-mail: [email protected].

XXI Congress of thre ESCRS 6-10 Sept. MUNICH, Contact: ESCRS Temple House, Temple Road
2003 GERMANY Blackrock, Co. Dublin, Ireland
Tel: + 353 1 209 1100, Fax: + 353 1 209 1112
e-mail: [email protected]

Joint Meeting of the European 13-16 Sept. LISZT, Contact: Ferenc Kuhn
Vitreoretinal Society & Web: www.evrs.org/meetings
International Society of 2003 HUNGARY
Ocular Trauma

United Kingdom and Ireland 18-19 Sept. CHESTER, Tel: +44 164 2854 054, Fax: +44 164 2231 154
Society of Cataract and Email: [email protected]
Refractive Surgeons 2003 UK Web: www.euroasiancongress.com

Joint European Research 8-11 Oct. ALICANTE, SPAIN Contact: EVER, Fax +32 16336785
Meeting in Ophthalmology 2003 Web: www.ever.be, Email: [email protected]

July, 2003 35 DOS Times - Vol.9, No.1

TARIFF

Dear Trader,
The Delhi Ophthalmological Society is today the premier society of our country boasting a membership of

more then 3000 Ophthalmologists from all over India, growing at the rate of at least 300 member ophthalmolo-
gists yearly.

DOS Times – The monthly magazine of around 50 pages – is its flag bearer and is a prized possession of
each ophthalmologist for which they wait with great anticipation. This position of DOS Times has been achieved
because it gives important clinical material to ophthalmologists of all walks of life. Besides it also carries all
important notices and hence form an important part of every member’s life.

The bookings are likely to be heavy, hence we request you to send in your booking at the earliest accompa-
nied by DD in the name of “Delhi Ophthalmological Society” payable at Delhi to the Dr. Jeewan S. Titiyal,
Secretary, DOS.

Advertisement Tariff for “DOS Times” Magazine

Display Advertisements Whole Year / 10 Issues Advertisement

Back Inside Cover Colour 2,00,000
2,00,000
Front Inside Cover Colour 1,25,000

Full Page Colour 75,000
2,50,000
Full Page B&W

Two Page Centre Spread Colour

Three months Advertisement is aceptable for DOS Times

In Order to Qualify for the whole year/Multiple Advertisement Rates,
All Payments should be made in Advance

Size of Journal : 8-1/4”
Frequency
Model of Printing : Monthly (10 Issues in a year)
Mode of Binding : Offset
Advt. Material
For Colour : Centre Stitched
Payment : For Black & White : Positive films (with proper density dots)

Mailing and Contact : Positive films with proofs and progressive
: All payment to be made in advance by
Email
Meeting Time Demand Draft in favour of “Delhi Ophthalmological Society”
payable at Delhi.
: Dr. Jeewan S. Titiyal, Secretary
Room No. 476, 4th Floor, Dr. R.P. Centre for Ophthalmic Sciences,
AIIMS, Ansari Nagar, New Delhi – 110029, India
Ph : 26589549(Direct), EPABX: 26588852-65 Ext. 3146
Fax: 011-26588919
: [email protected]

: 4:00-6:00 p.m.

With warm personal regards,

Dr. Jeewan S. Titiyal
Secretary, DOS

July, 2003 36 DOS Times - Vol.9, No.1

TARRIF

Advertisement Tariff for DOS Website

http://www.dosonline.org

For advertisement on top
Specification: Advertisement size 540 × 40 pixels
File format required : gif file or progressive jpg

Whole Year

Ad on Top of Home Page ................................................................ : Rs. 75, 000 /-
Ad on Top of DOS Times Section ................................................... : Rs. 25,000 /-
Ad on Top of Search Section ........................................................... : Rs. 25,000 /-
Ad on Top of Discussion Forum .................................................... : Rs. 25,000 /-
Complete website Advertisement .................................................. : Rs. 1,50,000/-
on top of all web-pages

For Advertisement on Sides : Visible in the Top Screen

Ad on Side of Home Page ............................................................... : Rs. 75, 000 /-
Ad on Side of DOS Times Section .................................................. : Rs. 25,000 /-
Ad on Side of Search Section .......................................................... : Rs. 25,000 /-
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Complete website Advertisement .................................................. : Rs. 1,50,000 /-
on side of all web-pages

For Advertisement on Bottom Part: Not Visible in the Top Screen

Ad on Home Page ............................................................................ : Rs. 25, 000 /-
Ad on DOS Times Section ............................................................... : Rs. 10,000 /-
Ad on Search Section ....................................................................... : Rs. 10,000 /-
Ad on Discussion Forum ................................................................ : Rs. 10,000 /-
Complete Website Advertisement .................................................. : Rs. 50,000 /-
on bottom of all web-pages

Sponsorship for DOS Monthly Clinical Meetings

Tariff for DOS Monthly Clinical Meeting: Rs. 50,000/-

Includes Audio Visual Advertisement during meeting and banner (as provided by the trader)
Provide for meeting : Pen, Folder with few sheets of paper / notepad / spiral pad with company
logo / product name, Tea & Snacks / Refreshments etc.

July, 2003 37 DOS Times - Vol.9, No.1

DCRS

DOS Credit Rating System (DCRS)

The rate of technological and academic obsolescence stitution was the cultivation and promotion of the Sci-
in Ophthalmology has reached astronomical levels in ence of Ophthalmology in Delhi.
recent times. What was advanced yesterday may al-
ready be obsolete today. The rapid strides in skills and In a bid to strengthen our efforts in this direction and
knowledge have created a need for an extremely inten- fulfil the vision of our society’s founders, DOS announces
sive Continuing Medical Education programme. the DOS Credit Rating System (DCRS), the details of
which are given below. Our Primary objective is to
DOS has always been in the forefront of efforts to promote value-based knowledge and skills in Ophthal-
ensure that its members remain abreast with the latest mology for our members and give recognition and credit
developments in Ophthalmology. Among the impor- for efforts made by individual members to achieve stand-
tant objectives formulated by the founders of our con- ards of academic excellence in Ophthalmic Practice.

DOS announces a new era in Continuing Medical Education
DOS CREDIT RATING SYSTEM (DCRS)
(A new chapter in CME)

Credits

1) Attending Monthly Clinical Meeting* † (For full attendence) 10

2) Making Case Presentation at Monthly Meeting** 15

3) Delivering a Clinical Talk at Monthly Meeting** 15

4) Free Paper Presentation at Annual Conference (To Presenter)** 15

5) Speaker/Instructor** in : Monthly Symposium 15

: Mid Term Symposium 15

: Annual Conference 15

6) Registered Delegate at Mid Term DOS Conference 20

7) Registered Delegate at Annual DOS Conference 30

8) Full Article publication in Delhi Journal of Ophthalmology (Visiscan) 15

9) Letter to Editor/Correspondence/Published Article in DOS Times 10

——————————————————————————————————————————————

If any of the presentations is given an Award – Institutional assessment for best performance
Additional 20 bonus Credits. will be based on the total score of members who
attend divided by number of members who at-
Member who have earned 100 Credits, are enti- tended. Institutional assessment regarding deci-
tled to: sion to retain the institute for the next year will be
based on total score by all delegates who attend
a) Certificate of Academic Excellence in Ophthal- the meeting divided by average attendence of all
mic Practice. 8 meetings.

b) 50% exemption of Registration fee at next An- Please note that the Institutions’ grading in-
nual DOS Conference. creases if the attendance at its meeting is higher
(i.e. more than the average attendence of the eight
c) Certificate of Academic Excellence in Ophthal- monthly meetings).
mic Practice (3 years in row) will entitle the mem- ——————————————————————
ber to a proposed academic grant of Rs.5,000/- only * Based on Signature in DCAC
to enable him/her to attend any international con- ** Subject to Submission of Full Text to Secretary, DOS
ference outside India to present his/her own ac- † Credits will be reduced in case attendence is only for
cepted presentation (proof required). part of the meeting.

If any member earns 200 Credits, he/she shall,
in addition to above, be awarded Certificate of Dis-
tinguished Resource-Teacher of the Society.

July, 2003 38 DOS Times - Vol.9, No.1

LIBRARY

Attention D.O.S. Members

The Hi-tech DOS Library has started functioning on Ground Floor, Dr. R.P. Centre, Delhi Ophthalmic
Sciences, AIIMS, New Delhi-110029 from 12.00 Noon to 9.00 P.M. on week days and 10.00 A.M. - 1.00
P.M. on Saturday, Sunday. The Library will remain closed on Gazetted Holidays. Members are Requested
to utilise the Facilities Available i.e. Computer, Video Journals Viewing, Latest Books and Journals. We
are planning to subscribe two journals member can give suggestion in this regard.

Dr. Lalit Verma
Library Officer, D.O.S.

List of Books and Journals Available in Library

DOS Library Book List 14. Converting to Phacoemulsification 27. Phacodynamics Mastering the
1. An Atlas of Ophthalmic Trauma (Thirgd Edition) Tools and Techniques of
Making the Transition to in-the- Phacoemulsification Surgery
Editors - Thomas C Spoor Bag Phaco (Second Edition)
2. Manual of Fundus Fluorescein Paul S. Koch. Editors Barry S. Seibal

Angiography 15. Mastering Phacoemulsification (A 28. Techniques of Phacoemulsification
Editors - Amresh Chopdar simplified Manual of Strategies Surgery Intraocular Lens Implanta-
3. Complications of Glaucoma for the Spring, Crack and Stop and tion
Therapy Chop Technique (Fourth Edition) Editors - Moshe Yalon
Editors - Mark B. Sherwood. M.D. Editors - Paul S. Koch
George L. Spaeth M.D. 29. Cataract Surgery and its Complica-
4. Corneal Topography the State of 16. Ocular Infection Investigation and tions (Sixth Edition)
the Art Treatment in Practice Editors - S. Jaffe
Editors - James P. Gills Editors - Martin Dunitz
5. Radial Keratotomy Surgical 30. A Colour Atlas of Lens Implanta-
Techniques 17. IOL and Phacoemulsification tion
Editors - Donald R. Sanders M.D. Secrets Editors - Piers Percival
PHD. Editors - V.K. Dada
6. Refractive Corneal Surgery 31. Cataract and IOL
Editors - Donald R. Sanders M.D. 18. Vitrectomy for Beginners Editors - D. Singh R. Singh J. Worst
PHD; Robert F. Hofmann-MD;James Editors - Rajvardhan Azad R. Singh
J. Salz-MD
7. Second Edition-Laser Surgery Of 19. Radial Keratotomy (Principles and DOS Library Journal List
The Posterior Segment Practice) 1. Survey of Ophthalmology
Editors - Steven M. Bloom Alexander Editors - Keiki R. Mehta
J.Brucker Vol.44 No.3 November-December-99.
8. Sixth Edition - Becker-Shafeer R.S. 20. Radial Keratotomy 2. Survey of Ophthalmology
Diagnosis and Therapy of the Editors - Donald Sanders M.D.
Glaucomas Vol.44 Supplement 1. October-99
Editors - H. Dundar Hoskins Jr.- 21. Soft Implant Lenses in Cataract 3. Survey of Ophthalmology
Michael Kass Surgery
9. Phacoemulsification New Technol- Editors - Thomas R. Mazzocco MD. Vol.44 No.2 September-October-99.
ogy and Clinical Application George M. Rajacich MD. 4. Survey of Ophthalmology
Editors - I. Howard Fine Edward Epstein M.D.
10. Textbook of Advanced Vol.43 No.6 May-June-99
Phacoemulsification Techniques 22. Computerized Perimetry A. 5. Survey of Ophthalmology
Editors - Paul S. Koch. James-A- Simplified Guide
Davison (Second Edition) Editors - Mar L.F. Vol.43 No.6 May-June-99
11. Ocular Differential Diagnosis Lieberman Michael V. Drake 6. Ophthalmology Clinics of North
Editors - Frede’rick Hampton Roy
12. Retinal Detachment A Colour 23. Fun with Phaco America
Manual of Diagnosis & Treatment Editors - V.K. Dada Ocular Infections: Update on
Editors - Jack J. Kanski Therapy
13. Current Concepts in Ophthalmic 24. Practical Atlas of Retinal Disease Editor - Terrence-P-O Brien M.D.
Lasers and Therapy 7. Ophthalmology Clinics of North
Rajvaradhan Azad, H.K. Tewari Editors - William R. Freeman America
Sports and Industrial Ophth
25. Retina and Vitreous Text Book of Editor Louis D. Pizzarello MD-Mph
Ophthalmology and Michael Easterbook MD
Editors - Steven M. Podos and Myron 8. Ophthalmology Clinics of North
Yanoff America
Ocular Oncology
26. A Practical Manual of Indirect Editor Joan M.O. Brien MD
Ophthalmoscopy
Editors - Rajvardhan Azad H.K.
Tewari

July, 2003 39 DOS Times - Vol.9, No.1

LIBRARY

List of Books and Journals (New Arrivals) in Library

DOS Library Books ond Edition) – (715-1372 Ritch, 30. Community Ophthalmology - P.K.
1. Update On General Medicine Schields, Krupin) Khosla
17. The Glaucomas, Basic Sciences
(American Academy Ophthalmol- (Sedond Edition) - (1-714 Ritch, 31. Fluorescein Angiography - A Users
ogy) Schields, Krupin) Manual - H.K. Tewari, Lalit Verma,
2. Fundamentals & Principles Of Oph- 18. The Glaucomas Glaucomas Therapy Pradeep Venkatesh
thalmology (American Academy (Second Edition) - 1373-1807 Ritch,
Ophthalmology) Schields, Krupin) 32. Text Book of Ocular Therapeutics –
3. Optics Refraction & Contact Lenses 19. Ophthalmic Plastic And Reconstruc- Ashok Garg
(American Academy Ophthalmol- tive Surgery (Second Edition) - Nesi,
ogy) Lismanlevine DOS Library Journals
4. Ophthalmic Pathology & Intraocu- 20. Practical Orthoptics In The Treat- 1. Ocular Surgery For The New Millen-
lar Tumors (American Academy ment Of Squint (Fifth Edition) - Lyle
Ophthalmology) And Jackson. S nium (Part II - March 2000. 13:1) Oph-
5. Neuro Ophthalmology (American 21. Binocular Vision And Ocular thalmology Clinics Of North America
Academy Ophthalmology) Montility (Fifth Edition) - Von. - Editor Gergel. Spaeth. Md)
6. Pediatric Ophthalmology & Strabis- Noorden 2. Information Technology In Ophthal-
mus (American Academy Ophthal- 22. Principles And Practice Of Ophthal- mology (June 2000 13:2) Ophthal-
mology) mology (Vol - 1 Second Edition) - mology Clinics Of North America -
7. Orbit Eyelids & Lacrimal System Albert, Jakobiec.Azar Editor Leonard Goldschmidt)
(American Academy Ophthalmol- 23. Principles And Practice Of Ophthal- 3. Ocular Surgery For The New Mil-
ogy) mology (Vol - 2 Second Edition) - lennium Part I (Dec 1999 12:4) Oph-
8. External Disease & Cornea (Ameri- Albert, Jakobiec.Azar thalmology Clinics Of North
can Academy Ophthalmology) 24. Principles And Practice Of Ophthal- America - Georgel Spath. Md)
9. Intraocular Inflammation And Uvei- mology (Vol - 3 Second Edition) - 4. Retinal Vascular Disorders (Dec
tis (American Academy Ophthal- Albert, Jakobiec.Azar 1998 11:4) (Ophthalmology Clinics
mology) 25. Principles And Practice Of Ophthal- Of North America (Dr. Pran N.
10. Glaucoma (American Academy mology (Vol - 4 Second Edition) - Nagpal - Donated By Dr. B. Patnaik)
Ophthalmology) Albert, Jakobiec.Azar 5. Survey Of Ophthalmology (Vol 44
11. Lens And Cataract (American Acad- 26. Principles And Practice Of Ophthal- No.4 Jan-Feb 2000)
emy Ophthalmology) mology (Vol - 5 Second Edition) - 6. Survey Of Ophthalmology (Vol 44
12. Retina And Vitreous (American Albert, Jakobiec.Azar No.5 March-April 2000)
Academy Ophthalmology) 27. Principles And Practice Of Ophthal- 7. Survey Of Ophthalmology (Vol 44
13. (1-12 Master I Ndex (American Acad- mology (Vol - 6 Second Edition) - No.6 May-Jul 2000)
emy Ophthalmology) Albert, Jakobiec.Azar 8. Survey Of Ophthalmology (Vol 45
14. The Cornea (Third Edition) – (Gilbert 28. Handbook Of Lasik Surgery - No.1 July-August 2000)
Smolin, Ricard) Vajpayee, T.Dada, R. Snibson 9. International Ophthalmology (Vol
15. Principales And Practice Of Refrac- 29. Community Ophthalmology - P.K. 23 No.1 Pp-1-60 1999)
tive Surgery- (Elander, Rich, Robin) Khosla 10. Retina The Journal Of Retinal And
16. The Glaucomas Clinical Science (Sec- Vitreous Diseases (Vol 20 No.1 2000)
11. Journal Of Cataract Refractive Sur-
gery (Vol 26 No.8 August 2000)

Methodology for Monthly Clinical Meeting:
Criteria for Selection

Formula: Institution's Marks Attendance of institution (N)
Average marks A (outside delegates) x 0.7 + ——————————————————————— x 3
maximum attendance in any monthly meeting (Nx)

Total marks by outside delegates (M) Nx = Highest attendance of all meetings
A = —————————————————— N = Total number of delegates
n = Total number of internal delegates
Total number of outside delegates (N-n)

N = Total Attendance of an instituton
(Outside + internal delegates)

July, 2003 40 DOS Times - Vol.9, No.1

July, 2003 TEAR SHEET NO. 1

Orbital Cellulit

INFLAMMATION & DISTENSION OF LIDS
(fever, periorbital pain, redness, swelling, local rise of temperature)

CHEMOSIS, PROPTOSIS, OPHTHALMOPLEGIA

ABSENT Hb, TLC, DLC
PRESEPTAL CELLULiTIS Or
Mo
Children
Hb, TLC, DLC, Culture (Pus, Blood) (vision, Pupillary rea

41 DOS Times - Vol.9, No.1 POST WITH ENDOGENOUS WITH SINUSITI
most common
TRAUMATIC DERMATOBLEPHARITIS Upper respiratory ethmoiditis
or middle ear Pansinusitis
H/o trauma, skin infection, stye, Infection. S. pneumoniae
H. influ type b S. aureus, Strep,
Lid laceration Int hordeolum, S. pneumoniae H.influ, Anaerobes
ENT consultation
Insect bite.

S. aureus S. pyogenes

Strep (B hemo)

Treatment : Mild infection/ >5yr old : T. Augmentin 40mg/kg/d Treatment : i/v a

P.O (in3divided doses ) X 10days spectrum antibio

severe infection / <5 yr old : i/v antibiotics for at least specific antibioti

3 days followed by oral antibiotics for 1 week 8hrly) or ceftriaxo

i/v cefuroxime 30-100mg/kg/d in divided doses or kg 12hrly) with T

I/v ceftriaxone 50-100mg/kg/d in 2 divided doses kg/d) ± - i/v met

depends on patie

such as Proptosis

Surgical interven

sis despite 48 hrs

worsening of ocu

Suggested Readings:

1. Jones, D. B, Steinkuller, P. G. Strategies for the initial management of acute preseptal and

2. Donahue, S. P, Schwartz, G. Preseptal and orbital cellulitis in childhood: A changing micr

tis: Management

) COMPLICATION
Ocular : Exposure keratitis,
PRESENT
ORBITAL CELLULITIS Raised IOP, CRAO, CRVO,
Optic Atrophy
Adult Orbital : Subperiosteal abscess,
C, Culture (Pus, Blood, sinus discharge ) orbital abscess, CECT,
rbital USG (B-Scan), CECT. t/t Surgical drainage
onitor optic nerve functions Cavernous sinus Thrombosis
actions, color vision, contrast senstivity, VEP) Decreased vision,
contralateral involvement
Meningitis, Brain Abscess
Bacteremia

IS ENDOGENOUS EXOGENOUS MUCORMYCOSIS

valveless ophthalmic Injury penetrating Diabetic ketoacidosis, Immunosup-

veins allow direct orbital septum, pression, rare opportunistic infn

spread of infection surgery (squint, RD, Mucor, Rhizopus invades blood

dental infection, otitis blepharoplasty) vessels causes ischemic Infarction,

dacryocystitis,SABE Animal bite foul d/s, Black eschar. Nasal & sinus

s scalp infection S.aureus endoscopy CECT INDISPENSABLE

n Treatment : i/v amphotericin B

antibiotics followed by oral antibiotics Initial broad 1mg/kg/d total dose 2-4 gm
otics effective against G+, G- ± - anaerobes, later debridement / exenteration Hyper-
ics according to culture. i/v cefuroxime(0.75-1.5g baric oxygen, correction of metabolic
one(1-2g/d) or combination of vancomycin (15mg/ acidosis

Tobramycin (1-1.5mg/kg 8hrly) or amikacin (15mg/

tronidazole Total duration of treatment (10d-3wk)

ent’s response (decrease in orbital congestive signs,

s, gaze limitation, edema)

ntion: Abscess, foreign body, worsening of propto-

s of i/v antibiotics, progression of vision loss and

ular motility Usha Yadava, Amit Bhatia,

Swarna Panigrahi

d orbital cellulitis. Trans Am Ophthalmol Soc. 1988;86:94-112. Guru Nanak Eye Centre, Maulana

robiologic spectrum. Ophthalmology. 1998;105(4):1902-1905. Azad Medical College, New Delhi.