PG Corner
Figure 1: Severe dry eye showing keratopathy with filaments. Figure 2: A case of VKC with keratopathy and filaments.
dye eye with or without autoimmune Clinical features near a suture or at the graft–host
diseases, meibomian gland dysfunction Symptoms:FK presents with symptoms interface.
(MGD) and exposure keratitis. These of burning and foreign body sensation
conditions are associated with reduced with mild ocular discomfort and pain. Treatment
tear secretion or decreased tear film Other symptoms include photophobia, Theinitial step in the management of
breakup time (TFBUT) thereby, leading epiphora andblepharospasm. FK involves the management of the
to poor lubrication of epithelium underlying cause. The treatment of FK
and increased evaporation with tear Signs: On slit lamp examination, is usually chronic and challenging.
film instability. This fragile and dried filaments are seen as gelatinous strands
epithelium is often degenerated leading or protrusions attached to the corneal Topical therapy
to focal defects and filament formation. epithelium (Figure 1 and 2). These Any evidence of dry eye should be
These filaments are formed most filaments can either be translucent or treated aggressively with topical
commonly in the interpalpebral zone granular and may vary in shape from lubricants and steroids if needed.
due the shearing action of the eyelids.6 round to slender form.8 The corneal
Other ocular surface diseases associated stroma beneath these filaments Topical lubricants
with FK include superior limbic is usually normal.9 They can also Initial management includes topical
keratoconjunctivitis,recurrent corneal elongate in size with each blinking lubricants with application of
erosions, herpes simplex keratitis, and and have a high rate of recurrence even ointments at night. High viscosity
neurotrophic keratopathy.7 after debridement. These filaments tear substitutes may provide relief in
Systemic diseases seen to be associated stain positive with rose Bengal and severe cases but at the same time they
with FK include autoimmune diseases fluorescein if there is an underlying may alter the tear film composition. It
such as Sjogren syndrome, psoriasis, and epithelial defect while negative staining is always preferred to use preservative-
atopic dermatitis. Brainstem injury may is seen in cases with elevated filaments. free tear substitutes to prevent toxicity
also be associated due to the exposure to the epithelium.
keratopathy and decreased blink rate. The location of these filaments depends It has been reported that topical sodium
Seventh cranial nerve palsy leading to upon the underlying cause. In cases chloride 5% four times daily may
exposure keratopathy is also associated of dry eye and exposure they are provide some symptomatic relief but
with FK. It has been described that the commonly located at the interpalpebral the mechanism is not known clearly.
filaments seen in autoimmune diseases area while in cases of autoimmune
are located mainly at the limbus due to diseases they are located at the limbus. Mucolytic agents
the rich capillary network leading to Filaments associated with ptosis and The main stay of treatment is the
influx of lymphocytes, antibodies, and superior limbic keratoconjunctivitis use of mucolytic agents like 10%
complement factors. are often located on the superior cornea N-acetylcysteine.10 This compound acts
while those secondary to penetrating by decreasing the viscosity of the mucus
keratoplasty are located on the graft
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PG Corner
in tear film. Other options, which have been proven 11. Bloomfield SE, Gasset AR, Forstot
beneficial for FK, include ptosis surgery SL, et al. Treatment of filamentary
Topical Non steroidal anti- and botulinum injection.18,19 keratitis with the soft contact lens. Am
inflammatory drug (NSAIDS) J Ophthalmol. 1973;76(6):978–980.
Role of topical (NSAID) like diclofenac Key points
sodium, 0.1%, has been shown by • FK is most commonly associated 12. Hadassah J, Prakash D, Sehgal PK, et
Avisar et al. They have shown a greater al. Clinical evaluation of succinylated
symptomatic relief with topical with ocular surface disorder such as collagen bandage lenses for ophthalmic
diclofenac 0.1% as compared to topical dry eye. applications. Ophthalmic Res.
5% sodium chloride in cases of FK with • The underlying cause should be 2008;40(5):257–266.
secondary Sjogren syndrome.13,14 detected and managed.
• Medical therapy is the main stay. 13. Grinbaum A, Yassur I, Avni I. The
Anti-inflammatory drugs • Mechanical debridement is beneficial effect of diclofenac sodium
Topical steroids can be used in cases associated with a high recurrence in thetreatment of filamentary keratitis.
of FK with severe dry eye and ocular rat. Arch Ophthalmol. 2001;119(6):926–927.
inflammation.15 Topical cyclosporine
should be used in severe cases along References 14. Avisar R, Robinson A, Appel I, et al.
with dietary modification and punctual 1. Lv H, Liu Z, Li X, et al. Effect of lacrimal Diclofenac sodium, 0.1% (Voltaren
occlusion. Ophtha),versus sodium chloride, 5%, in
plugs combined with deproteinized calf the treatment of filamentary keratitis.
Bandaged contact lens blood extract eye gel for filamentary Cornea. 2000;19(2):145–147.
Bandage contact lenses have been used keratitis. J Ocul Biol Dis Infor
safely and effectively for FK. Complete 2010;3:134–40. 15. Marsh P, Pflugfelder SC. Topical
disappearance of filaments has been 2. Tanioka H, Yokoi N, Komuro A, et al. nonpreserved methylprednisolone
reported by Bloomfield et al. These Investigation of the corneal filament in therapy for keratoconjunctivitis sicca
lenses are always recommended along filamentary keratitis. Invest Ophthalmol in Sjögren syndrome. Ophthalmology.
with the topical treatment mentioned Vis Sci. 2009;50(8):3696–3702. 1999;106(4):811–816.
above. A regular follow up is essential 3. Wright P. Filamentary keratitis. Trans
to monitor for any contact lens related Ophthalmol Soc U K. 1975;95(2):260– 16. Ervin AM, Wojciechowski R, Schein O.
complication. Other options like 266. Punctal occlusion for dry eye syndrome.
Succinylated collagen bandage lenses 4. Zaidman GW, Geeraets R, Paylor Cochrane Database Syst Rev. 2010;(9)
(SCBL) and amniotic membrane grafts RR, et al. The histopathology of [CD006775].
have also been used successfully.12 filamentarykeratitis. Arch Ophthalmol.
1985;103(8):1178–1181. 17. Diller R, Sant S. A case report and review
Surgical management 5. Maudgal PC, Missotten L, Van Deuren H. of filamentary keratitis.Optometry. 2005
Surgical options for the management of Study of filamentary keratitis by replica Jan;76(1):30-6.
FK include mechanical debridement of technique. Albrecht Von Graefes Arch
filaments and punctal occlusion. Klin Exp Ophthalmol.1979;211(1):11–21. 18. Kakizaki H, Zako M, Mito H, et al.
6. Chen S, Ruan Y, Jin X. Investigation of the Filamentary keratitis improved by
Mechanical debridement of the clinical features in filamentarykeratitis blepharoptosis surgery: two cases. Acta
filaments is only a temporary measure in Hangzhou, east of China. Medicine Ophthalmol Scand. 2003;81(6):669–671.
with a high rate of recurrence. They can (Baltimore). 2016Aug;95(35):e4623.
be removed with a cotton tip applicator 7. Davis WG, Drewry RD, Wood 19. Gumus K, Lee S, Yen MT, et al. Botulinum
or tying forceps if large. TO. Filamentary keratitis and toxin injection for the management of
stromalneovascularization associated refractory filamentary keratitis. Arch
Punctal occlusion has been reported to with brain-stem injury. Am J Ophthalmol. 2012;130(4):446–450.
be beneficial in cases of FK with severe Ophthalmol.1980;90(4):489–491.
dry eye by inhibiting the drainage of 8. Tabery HM. Filamentary keratopathy: Corresponding Author:
tears and thus providing symptomatic a non-contact photomicrographic in
relief.16,17 vivo study in the human cornea. Eur J Dr. Prafulla Kumar Maharana
Ophthalmol. 2003;13(7):599–605. Dr. Rajendra Prasad Centre for Ophthalmic
Punctual plugs can either be temporary 9. Hamilton W, Wood TO. Filamentary Sciences, All India Institute of Medical Sciences,
which include collagen plugs or semi- keratitis. Am J Ophthalmol. New Delhi, India.
permanent including silicone plugs. 1982;93(4):466–469.
Permanent punctual occlusion can be 10. Fraunfelder FT, Wright P, Tripathi
done using thermal or laser cautery. RC. Corneal mucus plaques. Am J
Ophthalmol.1977;83(2):191–197.
52 DOS Times - Volume 25, Number 6, May-June 2020 www.dosonline.org/dos-times
Systemic Diseases and Eye
Ocular Sarcoidosis
Khushboo Chawla DNB, Aniket Rai MS
Northern Railway Central Hospital, New Delhi, India
Abstract: Sarcoidosis is a multisystem granulomatous disease which was first described by Jonathan Hutchinson in 1878. The
organs affected more often are the lungs, skin and eyes.Sarcoidosis is a multisystem, granulomatous, inflammatory disorder
with both systemic and ocular manifestations.Ocular sarcoidosis with anterior segment involvement is 80% and posterior
segment is 20% however, posterior segment disease without anterior segment involvement is unusual.Among cases of
uveitis, sarcoidosis is probably underdiagnosed depending on the extent of the work-up done for diagnosis.Treatment aims
at controlling the inflammation. Based on the severity and the extent of involvement a systematic approach towards each
individual case is required.
Sarcoidosis is a multisystem posterior uveitis or panuveitis. anterior • Optic nerve granulomas
granulomatous disease which was first uveitis being the most frequent. Vitreous lesions
described by Jonathan Hutchinson in Granulomatous inflammation-Large Complications: Ocular hypertension,
1878. Its clinical manifestations and mutton fat keratic precipitates,iris secondary glaucoma, corneal band
course can be variable in different nodules, posterior synechiae, keratopathy, cataract formation,
ethnic groups. The organs affected peripheral-angle synechiae, and epiretinal membrane, and cystoid
more often are the lungs, skin and trabecular meshwork granulomas. macular edema (CME).
eyes. Sarcoidosis is a multisystem, Conjunctival granulomas,
IOWS
granulomatous, inflammatory Cornea: Rarely involved directly but As per International workshop on
disorder with both systemic and ocular may be affected with complications ocular sarcoidosis (IWOS) criteria,
manifestations1. It occurs worldwide, such as Band shaped keratopathy taking into account clinical signs and
but it is predominant in certain ethnic lab investigation diagnosis of sarcoid
and racial groups. It is more commonly can be considered7.
seen in females. Major organs affected Lacrimal gland: 10-69% infilteration
include the lungs, skin, eyes, liver, may be seen resulting in reflex tearing, Seven signs in the diagnosis of
and lymph nodes2. Ocular sarcoidosis plapable mass, keraticonjunctivitis intraocular sarcoidosis:
with anterior segment involvement sicca and dry eye.
(1) Mutton-fat keratic precipitates
is 80% and posterior segment is 20% EOM, ON sheath Orbital spaces etc may (KPs)/small granulomatous KPs
however, posterior segment disease be involved and/or iris nodules (Koeppe/
without anterior segment involvement Busacca),
is unusual3. Among cases of uveitis, Posterior segment
sarcoidosis is probably underdiagnosed Chorioretinal lesions (2) Trabecular meshwork (TM) nodules
depending on the extent of the work- • Chorioretinitis and/or tent-shaped peripheral
up done for diagnosis. Although Chorioretinal granulomas anterior synechiae (PAS),
ocular involvement with generalized
sarcoidosis is common, systemic (3) Vitreous opacities displaying
sarcoidosis is the first mode of diagnosis • Chorioretinitis “en taches de snowballs/strings of pearls,
in a small percentage of patients with bougie”
uveitis4. (4) Multiple chorioretinal peripheral
Retinal lesions lesions (active and/or atrophic),
Ocular manifestations • Periphlebitis (5) Nodular and/or segmental peri-
Macular edema phlebitis (± candlewax drippings)
Anterior segment • Optic nerve lesions and/or retinal macro aneurysm in
Uveal tract: Most common site (30- Papilledema an inflamed eye,
70%) anterior, intermediate, and
www.dosonline.org/dos-times DOS Times - Volume 25, Number 6, May-June 2020 53
Systemic Diseases and Eye
(6) Optic disc nodule(s)/granuloma(s) of histiocytes, epithelioid cells, and 3= bilateral symmetrical lung
and/or solitary choroidal nodule, multinucleated giant cells which are infiltration (BSLF) only;
and surrounded by lymphocytes, plasma
cells, and fibroblasts. 4a= BSHL with bilateral symmetrical
(7) Bilaterality. lung infiltration indicative of
The laboratory investigations in the Alternative differentials: tuberculosis, pulmonary fibrosis
diagnosis of ocular sarcoidosis in fungal infection, vasculitis, etc.
patients having the above intraocular 4b= BSIF only.
signs included The epithelioid cells are transformed
bone marrow monocytes and have • Galium scan-
(1) Negative tuberculin skin test in marked secretory activity which
a BCG-vaccinated patient or in includes over 40 different cytokines Panda Sign – abnormal bilateral
a patient having had a positive and other mediators. Among the symmetrical GA67 uptake of the lacrimal
tuberculin skin test previously, enzymes and other chemicals secreted and parotid glands (with or without
by granulomas are ACE, lysozyme, submandibular gland GA67 uptake)
(2) Elevated serum angiotensin glucuroonidase, collagenase, and
converting enzyme (ACE) levels calcitriol. Lambda sign-GA67 uptake by parahilar
and/or elevated serum lysozyme, and infrahilar broncho-pulmonary
Management lymph nodes and (2) the right
(3) Chest x-ray revealing bilateral hilar Diagnosis paratracheal mediastinal lymph nodes
lymphadenopathy (BHL), • Kveim test
Differentials for Abnormal Gallium
(4) Abnormal liver enzyme tests, and Kveim reported the use of a suspension uptake in salivary and lacrimal glands –
(5) Chest CT scan in patients with a derived from the spleen of a patient
with sarcoidosis. Subcutaneous • Sjögren’s syndrome,
negative chest x-ray result. injection with this kveim reagent 4-6 • Tuberculosis and
Four levels of certainty for the diagnosis weeks later shows typical lesion- red or • After radiation therapy.
of ocular sarcoidosis (diagnostic brownish raised papule ranging from a Angiotensin converting enzyme present
criteria) were recommended in patients few millimeters up to 1.5 centimeters in in the vascular endothelium of many
in whom other possible causes of uveitis diameter denotes a positive test. organs elevated in 60-80% sarcoid cases
had been excluded:
• Cutaneous anergy Normal levels- less than 53IU/L
(1) Biopsy-supported diagnosis with a
compatible uveitis was labeled as • Reduced CD4+ T cells in blood: the Other differentials with elevated serum
definite ocular sarcoidosis; relative proportion of CD4+ T cells in ACE
blood is reduced
(2) If biopsy was not done but chest Gaucher’s disease,
x-ray was positive showing BHL • Normal ratio- CD4/CD8=0.8, • Leprosy,
associated with a compatible • Reverse relation is observed in Chronic pulmonary disease,
uveitis, the condition was labeled • Rheumatoid arthritis/ Spondylitis,
as presumed ocular sarcoidosis; affected tissue (e.g. CD4/CD8=1.8 in Primary biliary cirrhosis,
lung). • Tuberculosis,
(3) If biopsy was not done and the chest • This is called as compartmen- Histoplasmosis,
x-ray did not show BHL but there talization of T cells • Histiocytic medullary fibrosis,
were 3 of the above intraocular • Chest X-ray- Hyperthyroidism
signs and 2 positive laboratory • Diabetes mellitus.
tests, the condition was labeled as Garland Sign- Right and left hilar LN • Bronchoalveolar lavage (BAL)-
probable ocular sarcoidosis; and with Right paratracheal LN
Transbronchial lung biopsy (TBLB)
(4) If lung biopsy was done and the Roentgen staging of sarcoidosis: • Hypercalcemia
result was negative but at least 4 • Serum Lysozyme
of the above signs and 2 positive 0= normal chest radiograph; • Tissue Biopsy and histopathology
laboratory investigations were Treatment
present, the condition was labeled 1= bilateral symmetrical hilar Treatment aims at controlling the
as possible ocular sarcoidosis. lymphadenopathy (BSHL) only;
Histology 2= BSHL with bilateral, symmetrical
lung infiltration;
The hallmark of sarcoidosis is a non-
necrotizing granuloma.
The center of the granuloma consists
54 DOS Times - Volume 25, Number 6, May-June 2020 www.dosonline.org/dos-times
Systemic Diseases and Eye
inflammation. Based on the severity and ozurdex) 4. Ambiya V, Singh H, Mandal S,
the extent of involvement a systematic • Flucinolone acetonide 0.19mg or Radhakrishnan A. A case of systemic
approach towards each individual case sarcoidosis with ocular presentation.
is required. 0.59mg Medical Journal Armed Forces India.
2015;71:S16-S18.
Only Anterior uveitis being the most Immunosuppressive
common form can be controlled with • Methotrexate 7.5-25mg/week. 5. Stavrou P, Linton S, Young D, Murray P.
topical steroids with cycloplegics to • Azathioprine 1-4mg/kg/week. Clinical diagnosis of ocular sarcoidosis.
relieve the ciliary spasm. • Mycofenolate moefetil 1-2g/d. Eye. 1997;11(3):365-370.
• Other agents: Cyclophosmphamide
Posterior or intermediate uveitis/ 6. Matsou A, Tsaousis K. Management of
Panuveitis may require oral steroids 1-3 mg / kg / day, chlorambucil, chronic ocular sarcoidosis: challenges
or immunosuppresives. A detailed cyclosporine-A. and solutions. Clinical Ophthalmology.
systematic evaluation and treatment is 2018;Volume 12:519-532.
essential. Biological agents
• Anti TNF-Alpha agents – Infliximab, 7. Herbort C, Rao N, Mochizuki M, the
Corticosteroids members of the Scientific Commi.
• Topical- Adalimumab. International Criteria for the Diagnosis
• Prednisolone acetate 1% • Anti CD 20 agents- Rituximab. of Ocular Sarcoidosis: Results of the
• Difluprednate 0.05% First International Workshop on Ocular
References Sarcoidosis (IWOS). Ocular Immunology
• Dexamethasone 0.1% 1. Vereecken M, Hollanders K, De Bruyn D, and Inflammation. 2009;17(3):160-169.
• Loteprednol 0.2% or Ninclaus V, De Zaeytijd J, De Schryver Corresponding Author:
flurometholone 0.1%. I. An atypical case of neurosarcoidosis
presenting with neovascular glaucoma. Dr. Khushboo Chawla DNB
Oral steroids Journal of Ophthalmic Inflammation Northern Railway Central Hospital,
and Infection. 2018;8(1). New Delhi, India
Tab Prednisolone 1mg/kg in tapering 2. Frohman L, Grigorian R, Slamovits
dose T. Evolution of sarcoid granulomas
of the retina. American Journal of
Ocular implants Ophthalmology. 2001;131(5):661-662.
• Triamcinolone acetonide (40%) 3. Belfer M, Stevens R. Sarcoidosis:
• Dexamethasone 0.7mg (intravitreal A Primary Care Review. Am Fam
Physician. 2020;.Am Fam Physician.
1998 Dec 1;58(9):2041-2050.
www.dosonline.org/dos-times DOS Times - Volume 25, Number 6, May-June 2020 55
Monthly Meeting Update
Advances and Newer Trends in
Cataract Surgery
Jatinder Singh Bhalla MS, DNB, MNAMS, Prathama Sarkar MS
Department of Ophthalmology, Deen Dayal Upadhyay Hospital, Hari Nagar, New Delhi, India
Abstract: The journey of cataract surgery began in 800 BC and is still continuing with loads of upgradation, refinement and
precision. In this article we intend to highlight the major achievements that have been achieved during the course of this
evolution of cataract surgery.
The journey of cataract surgery began in three machines which use the latest Figure 1: MICS
800 BC with ‘couching’ which entailed technology ie. Alcon Centurion (Active fit snugly through the wound. The
the use of a sharp-tipped instrument to sentry system), Stellaris Elite and sleeve facilitates infusion around the
push the cloudy lens into the vitreous Whitestar Signature Pro3. needle and prevents thermal injury to
cavity1. Since then, cataract surgery has (a) Alcon Centurion the cornea. A second smaller incision
evolved through leaps and bounds with It uses the active fluidics technology and is made to insert an instrument,
ICCE, ECCE, SICS, Phacoemulsification hence, optimises the anterior chamber the so-called ‘second instrument’
and FLACS as a few of the landmark stability by maintaining the target IOP to manoeuvre the cataract during
milestones. If we take a glance on the during cataract removal. By increasing emulsification.
advancement in phacoemulsification the Phacoemulsification efficiency The micro-incision cataract surgery
through all these times, we will through the Ozil IP and intrepid (MICS) concept involves removing
come across the various advances balanced tip probe, this machine helps the sleeve from the hand-piece of the
in phacoemulsification technology, to maintain a balanced energy. phacoemulsifier and transferring
Femtosecond Laser Assisted Cataract (b) Stellaris Elite the irrigation system to the second
Surgery, Zepto cataract surgery, It uses adaptive fluidics and dual-linear instrument. This allows reducing
Capsulo-Laser, intra-operative use of control. It helps in attenuation of the the incision width to about 1.5mm.
OCT in cataract surgery, intra-operative energy and uses eyetelligence. Aggarwal et al. from Chennai in
aberrometry, heads up cataract surgery (c) Whitestar Signature Pro India have helped to rekindle the
and robot assisted simulated cataract It monitors IOP and vaccum levels. It has interest in this area and they coined
surgery. the facility of on-demand fluidics with the term ‘Phakonit’ to describe their
peristaltic, Venturi or a combination of technique. Microphacoemulsification
Advances in Phacoemulsification pump capabilities. Ellips FX handpiece is yet another term to describe the
technology with Transversal mode is used along same concept, although MICS has
Phacoemulsification was introduced by with this machine.
Charles D Kelman2 in 1967 after being
inspired by his dentist’s ultrasound Micro-incisional cataract surgery
probe.Phacoemulsification technique (MICS)
recently turned 53 years old. During The conventional incisions for
these 53 years, phacoemulsification phacoemulsification are in the region
machines have undergone tremendous of 2.8mm in length4. This allows for
upgradation that have improved the phacoemulsification hand-piece
the safety and efficacy of cataract with a silicone sleeve covering it to
surgery. Today’s phaco machines offer
advanced fluidics, IOP control and
anterior chamber stability. Among the
various upgraded versions, there are
56 DOS Times - Volume 25, Number 6, May-June 2020 www.dosonline.org/dos-times
Monthly Meeting Update
Figure 2: The Centurion Active Sentry System in decrease in the time needed to vent and flow. The suction force is generated
uses the ASM technology significantly over standard Centurion by either a peristaltic or venturi pump
have (0.1 - 0.15 sec). in conventional systems depending on
come to be accepted as the appropriate the machine type. Peristaltic pumps
term for the procedure. Although this Torsional/ Transversal ultrasound generate a vacuum on occlusion, which
technique has been around for a while, Tip-fragment interaction is another builds up steadily until the fragments
the availability of lens implants that area where major strides are are consumed, when a post-occlusion
could be introduced through such small occurring in the development of surge is generated. A venturi pump
incisions has delayed its uptake. The phacoemulsification. Conventional generates a more constant vacuum
benefits of MICS include a reduction in phacoemulsifier tip movement is and is capable of drawing fragments
surgically-induced corneal aberrations linear, like the effect of a jack-hammer, towards the tip. There are advantages
and a potential reduction in post- where the stroke length determines and disadvantages with both systems
surgical infections, however, it is not the power of the phacoemulsifier. and with conventional incision sizes,
without its limitations. Dense cataracts Increased phacoemulsification energy it is a matter of the surgeon’s personal
have been difficult to manage owing to results in greater corneal endothelial preference. With MICS, a high degree
the amount of heat generated. There is a injury8. Torsional movements rather of fine-tuning of the machine’s fluidics
loss of efficiency due to lower vacuum, than the longitudinal movement are capabilities is required. The balance
aspiration and infusion rates. Incision claimed to be beneficial for two reasons: between inflow and outflow has to
leaks and loss of chamber stability First, the linear movement in the balance perfectly throughout surgery
have also been areas of concern. conventional phacoemulsifier tends to maintain chamber stability. A ‘dual
The phacoemulsification machines to repulse the fragment away from pump’ is an innovation that provides
have stepped up to this challenge by the tip. Secondly, there is no cutting both venturi-type vacuum and
enhancing the capability of the fluid during the backward cycle of the stroke. peristaltic flow, controlled by specially
management (infusion, aspiration and Both these drawbacks are overcome by designed software. It monitors vacuum
vacuum capabilities termed ‘fluidics’) the torsional movement. Transversal levels and when a predetermined
and phacoemulsification energy ultrasound is another modification threshold is reached, it backs up the
delivery together with improved wherein the longitudinal movement pump instantaneously (response time
instrumentation to facilitate more of the tip of the phacoemulsifier is only 26 milliseconds) to reduce the
effective MICS6. combined with transverse movement vacuum to a lower, preset level thereby
giving rise to an elliptical motion. reducing the post-occlusion surge.
Hand piece design and
construction Energy waveforms Femtosecond laser assisted
The main developments in the hand- The parameters involved in the energy cataract surgery
piece design and construction have waveform of a phacoemulsifier are
been in the use of a flared tip to decrease pulse width, frequency, energy and duty At 2012 ACRS meeting, a survey
ultrasonic time and energy. Smaller cycle. Continuous, pulsed and bursts revealed 29 different names used for this
frequency (sonic rather than ultrasonic have been the traditional profile choices. procedure. Common acronyms include
range) probes, which are claimed to Advanced power modulations include ReLACS (Refractive Laser assisted
improve efficiency and minimisation hyper-pulse and hyper-burst. While, cataract surgery), FLACS (Femtosecond
of thermal dispersion7. The Centurion traditional pulses or bursts are delivered laser assisted cataract surgery), FALCS
Active Sentry System uses the ASM in square waves, newer advances in (Femtosecond-assisted laser cataract
(Anti Surge Mitigation) technology. software permit gradual ramping up of surgery), ReLACS refractive procedures
The system recognises the surge pulses and bursts (variable rise time) as and T-LACS (Therapeutic laser assisted
event and partially vents the line to well as delivering waveform-modulated cataract surgery. The most popular
decrease the vacuum demand leading packets of energy. The aim of these name is FLACS (Femtosecond laser
to decreased surge amount. It also has advances is to minimise the energy assisted cataract surgery).
a quick valve technology which aids delivered and consequently minimise
endothelial injury and heat damage to The femtosecond laser (FSL) is useful
the wound. in ocular surgeries due to its ultrafast
pulses in the range of 10-15 seconds
Fluidics and its decreased energy requirements
Fluidics is based on the physical for tissue destruction, allowing for
principles of fluid dynamics. In an reduced unintended destruction of
intraocular environment, it concerns surrounding tissues. While FSLs were
the co-ordination of vacuum, aspiration previously FDA-approved for use in
lamellar corneal surgery, the modality
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Monthly Meeting Update
was approved in 2010 for cataract Laser capsulotomy of the Anterior Figure 3: Laser based corneal incision
surgery10. There are currently four Capsules
commercially available laser systems: The anterior capsulotomy is created by Figure 4: FLACS capsulotomy pattern
LenSx (Alcon LenSx Lasers Inc., scanning a cylindrical shell extending
Aliso Viejo, California, USA), LensAR from a position in the lens volume Figure 5: Lens fragmentation pattern in FLACS
(LensAR Inc., Orlando, Florida, USA), through the capsule and into the removal of cortical material is slightly
OptiMedica Catalys (Opti- medica, anterior chamber. An integrated OCT- more challenging than with traditional
Sunnyvale, California, USA), and guided femtosecond laser system phacoemulsification.
Technolas VICTUS (Technolas Perfect enables precise cutting of the anterior Challenges with FLACS
Vision GmBH, Munich, Germany). lens capsule creating continuous When the laser creates the
LensAR recently received 501(k) FDA sharp-edged anterior capsulotomies capsulorhexis, it also cuts a circular
approval for lens fragmentation and of exact size, shape, and position. disk of cortex, which exactly matches
anterior capsulotomy. LenSx is now The capsulorrhexis is performed first the diameter of the capsulorhexis . At
approved for lens fragmentation, followed by lens fragmentation and times, it may be difficult to visualize
anterior capsulotomy, and corneal finally corneal incisison14. A perfectly the edge of the cortex because the edge
incisions. OptiMedica is currently sized and centered capsulotomy is may correspond to the edge of the
seeking FDA approval and is already formed with the femto-second laser. It capsulorhexis. Although this perfect
available outside the United States. is sized between of the anterior capsule safety zone ideally protects the capsule,
5.0 to 5.7 mm depending on the type it may be more difficult to extract the
Mechanism of action of IOL being implanted and the pupil residual cortical material from the bag,
The FSL causes tissue disruption with size. In case the pupil size is smaller, the most challenging area being the
its near-infrared scanning pulse focused the capsultomy can be adjusted intra- subincisional cortex. The ease of cortical
to 3 mm with an accuracy of 1 mm. operatively making sure it is slightly removal improves during the learning
Photodisruption is essentially induced away from the pupil to avoid the laser curve and appears to be an insignificant
by vaporization of target tissues, which from hitting the iris tissue. Femto
occurs through the following steps: second laser capsulotomy pattern can
the focused laser energy increases to a include complete treatment plan (Type
level where a plasma is generated; the I), micro adhesions (Type 2), Incomplete
plasma expands and causes a shock treatment pattern (Type 3) complete
wave, cavitation, and bubble formation; pattern but not continuous (Type 4).
and then the bubble expands and
collapses, leading to separation of the Laser lens fragmentation
tissue11. Because FSLs function nearly Nuclocotomy of the lens is achieved
at an infrared wavelength, they are not using femtosecond laser fragmentation,
absorbed by optically clear tissues. This into pattern as designated by the
makes FSL-assisted surgery amenable software15. FSL systems reduce
to anterior chamber targeting at ultrasound energy necessary for
various depths, as the anterior chamber phacoemulsification of all grades
provides an optically clear tissue space. of cataract. Removal of superficial
The near-infrared wavelength is not cortex is done first. This allows clear
absorbed by the cornea, and the waves visualization of the segmentation and
are known to dissipate approximately softening pattern of the nucleus below.
100 mm from the lens tissue target12. At this time, the standard divide-and-
conquer or stop and chop technique
Surgical steps of FLACS Imaging can be used. Since the grooves created
All the laser platforms have inbuilt by the laser are extremely narrow, the
optical coherent tomography (OCT) second instrument selected should
imaging system to image, map and be very narrow, such as an Akahoshi
identify the parameters involved in the chopper (Katena Products, Inc.), a
surgery. Corneal centration within the Nagahara chopper (Storz Ophthalmics),
applanation cone is achieved for proper a Cionni chopper (Duckworth and
positioning of primary corneal incision Kent), or a Neuhann chopper (Geuder
and arcuate incision13. AG). Once the nuclear material has been
removed, the surgeon may find that the
58 DOS Times - Volume 25, Number 6, May-June 2020 www.dosonline.org/dos-times
Monthly Meeting Update
Figure 6: AC tear in FLACS is now being used in patients having intraoperative and postoperative
small or incompletely dilating pupils complications23. With its greater
issue for experienced users. Bimanual with intraoperative use of Malyugin precision and accuracy, femto-second
techniques can be useful when faced pupil expansion ring. It is also used in in lasers are targeted at making cataract
with subincisional cortex or with cortex patients with phacomorphic glaucoma, surgery similar to a refractive procedure
that is thicker than usual and is flush subluxated lens, complicated cataract, and reduce the complication rate24.
with the underlying capsule. eyes with pseudoexfoliation syndrome
Comparison of FLACS and and pediatric cataract has increased Zepto cataract surgery
conventional Phacoemulsification the inclusion criteria tremendously. Mynosys (Fremont, CA, USA) had
In a study17 conducted by Conrad et al. Suction loss can be encountered with developed a novel capsulotomy
it was seen that endothelial cell loss the procedure but is less common than technology called precision pulse
was significantly less in the patients Femto-lasik. Patient with nystagmus capsulotomy (PPC) and trade named
undergoing FLACS. In another study18 and psychiatric disorder may not be able Zepto. The termZepto was coined
it was concluded that FLACS is a to comply. An incomplete capsulotomy because, based on a metric scale,
major advancement and better than may be encountered anytime, but with Zepto is 1 million times smaller than
conventional method. Intra-operative the improvement of technology it is femto25. PPC uses a highly focussed,
complications were found to be similar less encountered with. Patients with quick, multipulse, electrical energy
in both the groups. However, post- steep cornea may be more vulnerable discharge to produce a perfectly round
operative complications when followed for corneal folds during applanation anterior capsulotomy instantaneously
up for 2 months were higher in FLACS cone. Surgeons should be well versed uniformly along 360°. This can be
group. In the review, it was seen that with all the steps of traditional done during the normal sequence of
FLACS is a good option in patients with phacoemulsification as they may have the cataract surgery and is relatively
a white cataract, pseudo exfoliation or to convert the procedure into it if the priced lower than the femtosecond
floppy iris syndrome19. FLACS has been need arises. technology. Capsulotomy is performed
found to be advantageous in patients using a disposable handpiece with a
of Marfan’s syndrome with subluxated Advantages of FLACS soft collapsible tip and circular nitinol
lens20. FLACS also causes less amount ring acting as a cutting element. The
of CME post-operatively. And aids Femto-second laser assisted cataract PPC Zepto device is introduced in the
in reduction of astigmatism in post- surgery offers excellent results for conventional surgical sequence after the
keratoplasty eyes with high regular or precise corneal incisions, circular and keratome entry and anterior chamber
irregular astigmatism. predictable capsulotomies, safer and filling with viscoelastic and can be
Complications with FLACS easier subsequent phacoemulsification centered on the visual axis to produce
Narrow palpebral aperture, kyphosis, steps. Improved UCVA & BCVA, short a capsulotomy of a predetermined
scoliosis, severe claustrophobia and phaco time, tackling of co-existing diameter.
inability to lie down calm and straight astigmatism and reduced endothelial
are challenges for successful docking. cell loss are advantages. As of now Procedure
Small pupils initially presented as a femtosecond laser assisted cataract The tip consists of a soft, transparent,
challenge to the surgeon, as they limit surgery seems to be a safe, efficient, silicone suction cup approximately 6
the size of capsulorrhexis21. Applanation and highly precise mode of treatment mm in diameter that houses a circular
of the cone and firing of laser can further modality. This technology has added ring element made of the shape memory
reduce the diameter of the pupil. FLACS costs of the surgical procedure and if alloy nitinol. This nitinol ring element
patients are convinced that the results has been refined precisely at the
and post-operative rehabilitation micrometer scale to enable consistent
is better with this technology, they and uniform 360° capsulotomies. The
are ready to pay for it. Regarding superelastic properties of nitinol allow
capsulorhexis, the more predictable the capsulotomy tip to be deformed
and precise capsulotomy offers mechanically into a narrower elongated
us the hope of better centration shape for entry through a clear corneal
of IOL that can ultimately lead to incision of even 2.2 mm. This is achieved
superior visual outcome. Also, a with the help of a push rod that comes
smooth curvilinear capsulorhexis from the disposable handpiece. Once the
is known to prevent intraoperative nitinol ring is pushed into the anterior
complications. For phacofragmentation chamber, the push rod is retracted.
and phacoemulsification, it is seen This allows the ring to re-expand
that the phaco time is lesser in FLACS automatically to its native circular
and expected that it will lead to fewer
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Monthly Meeting Update
Figure 7: Nitinol ring with suction cup the layer of water surrounding the Figure 9: CAPSUL Laser fitted to the microscope
nitinol ring. The resulting cutting
Figure 8: Zepto vs conventional CCC effect essentially is a mechanical Figure 10: iOCT showing status of cornea
shape within the anterior chamber. one, similar to that of a manual tear. Figure 11: iOCT showing pre-existing posterior
A circular capsulotomy is created, Unlike a manual or femtosecond laser capsular defect
duplicating the shape of the circular capsulotomy (FSLC)26, however, the extensive testing in animal and human
nitinol element. The capsulotomy size entire circumference of the Zepto cadaver eyes with Miyake Apple view
is 5 mm in diameter, which may expand capsulotomy is created at the very same video imaging, showing insignificant
up to 5.25 mm after intraocular lens instant because of the use of a circular zonular traction compared to manual
(IOL) placement. conducting capsulotomy element. continuous curvilinear capsulorhexis
Mechanism of action (CCC) while performing PPC in paired
PPC is based on a rapid and precisely Zepto vs conventional CCC human cadaver eyes. These results also
controlled method of tissue cleavage Scanning electron microscopy (SEM) showed insignificant inflammation,
specifically developed for the efficient shows that the Zepto capsulotomy edge endothelial cell loss, or heat detection
cutting of thin collagen membranes has a unique morphology characterized when compared to manual CCC in the
such as the human ALC. This precision by an extremely smooth functional opposite eye. An important concern
pulse method uses the capsulotomy edge. Detailed analysis revealed that has arisen from published reports of
device’s circular shape alloy nitinol Zepto not only creates a perfectly an increased rate of anterior capsule
ring element to convert a very brief round, tag-free opening in the capsule tears following femtosecond laser
train of fast electrical pulses efficiently but also at the same time places a capsulotomy. SEM of FSLC anterior
over 4 ms (approximately 1 joule) microscopic eversion at the edge to capsule buttons demonstrates a rougher
into mechanical cutting energy. This present a small amount of the capsule edge when compared to manual CCC
occurs due to vaporization of the water underside for maximal edge integrity specimens. In addition, SEM analysis
molecules trapped between the ring during surgery27.
edge and the microscopically stretched
anterior capsule. This phase transition Indications
creates an instantaneous mechanical PPC is a technology that is cost-
splitting of the anterior capsule along effective and can be used in routine
the entire ring circumference, resulting cataract surgeries of any grade and in
in a perfectly circular opening of premium IOL surgeries. Being able to
a precise diameter. The extremely center, the capsulotomy on the visual
fast millisecond timeframe of PPC axis would be advantageous when
limits any heat dissipation beyond implanting refractive lens implants
such as extended depth of focus and
multifocal IOLs. PPC can be performed
after insertion of iris expansion devices
for small pupils. The tip is also designed
with an angled lip in the suction cup
to allow insertion of the device under
the iris margin in the event of a smaller
diameter pupil if necessary. It does
neither cause any disruption to the iris
tissue nor change in temperature of
the iris tissue or the anterior chamber.
Due to the mild suction effect of the
Zepto, in cases of intumescent mature
cataract with high intralenticular
pressure, the Zepto not only performs
a capsulotomy but also decreases the
intralenticular pressure. Further, there
is no requirement for capsular staining
to perform a PPC28.
Advantages
This device was developed through
60 DOS Times - Volume 25, Number 6, May-June 2020 www.dosonline.org/dos-times
Monthly Meeting Update
also reveals scattered aberrant laser It creates a rolled over edge (double requirements of post processing.
shots that could be explained by thickness), smooth amorphous collagen The significantly increased imaging
microscopic eye movements occurring rim and a continuous 360º tag free speed associated with new graphics-
during the FSLC step. A studycomparing profile30. It has the advantage of giving processing technologies and new
the capsulotomy edge of PPC and femto consistent capsulotomies in every swept-source OCTs has enabled real-
and manual CCC with the help of surgery, provides laser precision for size time volumetric visualization32.
paired cadaver eyes showed that the and centration, is a small ergonomic
PPC edge was noticeably stronger and microscopic mounted laser device Uses
more resistant to radial tears compared and provides a cost and time effective Proper incision construction in cataract
to both manual CCC and FSLC. This solution. surgery is essential to prevent wound-
can be explained by the microscopic related complications and postoperative
eversion of the capsulotomy edge, The laser wavelength requires a target, hypotony in cases undergoing cataract
providing the integrity and the which is created by staining the anterior surgery. Intraoperative OCT has been
resistance to tearing. PPC Zepto device is capsule with an enhanced solution of used to assess the morphological
significantly cheaper, less per-case cost, trypan blue dye (Capsul Blue, Excel- features of the wound such as length,
can be introduced during surgery in the Lens). After the capsule is stained, the breadth, and the number of planes in real
conventional surgical sequence, can be eye is filled with an optically clear time as well as epithelium disruption,
centered on the visual axis to produce OVD, a specially manufactured sodium amount of wound gape, endothelial
a capsulotomy of a predetermined hyaluronate 2% solution (Capsul Visc, alignment, and Descemet’s detachment.
diameter, can be used in small pupils Excel-Lens). A patient interface is then The adequacy of stromal hydration and
and can be used in mature cataracts placed, and the laser is focused by wound apposition can be ascertained at
with relative ease. the surgeon. The patient assists with the end of surgery, thus decreasing the
centration by looking at a fixation light. incidence of postoperative wound leak.
Limitations When the laser is activated, it takes 1
One of the limitations of Zepto device second to create the capsulotomy, which Intraoperative OCT is a useful tool in
is the need to insert it in the anterior can be sized from 4.5 to 6.0 mm in 0.1- assessing the status of the posterior
chamber. There are concerns about mm increments. The type IV collagen of capsule during cataract surgery in
possible endothelial cell loss in cases the capsule absorbs the laser energy and various clinical scenarios.
with shallow anterior chamber. is converted into amorphous collagen.
Insertion of this device should be The edge of the capsular opening is In cases with posterior polar cataract,
done very carefully in cases of nano- then rolled over and it is much more it may help detect cases with a true
ophthalmos and phacomorphic elastic than a normal capsulotomy edge posterior capsular defect. This may allow
glaucoma with very shallow anterior because of the amorphous collagen. the surgeon to exercise extra caution in
chamber. Preoperative injection of such cases, thus reducing the incidence
intravenous mannitol with or without Anterior capsulotomy with Capsul of complications33. It may also help
pars plana vitreous tap may be helpful Laser was compared against manual ascertain the posterior capsule status in
in these difficult cases to deepen curvilinear continuous capsulorhexis cases with a traumatic cataract. Patients
the anterior chamber. Frequent use in a prospective study and was shown with posterior segment pathology often
of chondroitin sulfate-based OVD to be superior for sizing, circularity, and develop cataract during the course of
(Viscoat, Alcon Fort Worth, USA) to coat centration31. Also, there were 100% free treatment which may be associated
the corneal endothelium to minimize capsulotomy caps, and there was 100% with iatrogenic posterior capsular
endothelial cell lost during insertion 360º capsulotomy coverage of the IOL, defect. Intraoperative OCT-assisted
or removal of the handpiece from the which is important for PCO prevention. phacoemulsification can help identify
anterior chamber. Inability to open the the preexisting posterior capsular
device, suction loss, incomplete CCC, Intra-operative volumetric OCT defect in cases with operated pars plana
and difficulty in folding the device are In current commercial iOCT systems, vitrectomy or a history of multiple
the other complications. real-time OCT visualization is intravitreal injections34. In cases with
currently limited to B-scans of variable silicon oil in situ and hyperoleon,
CAPSUL Laser orientation. Volumetric visualization the density and extent of silicon oil
It is a new portable technology. Unlike provides a unique opportunity for in anterior chamber can be assessed
FLACS, the laser energy is delivered real-time iOCT. Current spectral with the help of iOCT35. In pediatric
in a continuous manner rather than a domain systems are unable to create patients, the presence of fibrovascular
pulsed beam which can create tissue live volumetric imaging due to low stalk in cases of primary hyperplastic
bridges. Capsul Laser creates an elastic scan speeds, computational challenges persistent vitreous and posterior
capsulotomy rim resistant to tearing. with volume rendering and the high capsular defect in posterior polar
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Monthly Meeting Update
Figure 12: The ORA system and distance which produces a fringe in routine cataract surgery has been
pattern as wave-fronts are diffracted reached.
Figure 13: HOLOS through the grates. This fringe pattern
cataract may be ascertained with the is then analyzed to provide information Role in astigmatism correction
help of iOCT36. Intraoperative optical on sphere, cylinder and axis. ORange is Toric Lens
coherence tomography measurements attached to surgical microscope and has Toric IOLs require extreme precision
of the anterior capsule are a better a range from -5 to +20 D39. Both aphakic in axis alignment as one-third of the
predictor of the postoperative IOL and pseudophakic measurements cylinder correction is lost for every 10
position compared with preoperatively can be taken while in the operating degrees of misalignment. Aberrometry
measured factors37. room to guide IOL power selection can be utilized for toric lens placement
Intraoperative aberrometry and lens placement. In 2012, WaveTec in both the aphakic and pseudophakic
Surgeons use many biometric formulas released ORange’s successor, ORA, with state, as an aphakic reading will give
and measurements pre-operatively in improved optics (super luminescent an accurate axis while a pseudophakic
hopes of minimizing refractive error light-emitting diode as opposed to laser reading will confirm alignment. In
after cataract exchange. Intraoperative light), interface and algorithms. In a studylooking at IWA-guided toric
aberrometry is an additional tool 2014, Alcon acquired WaveTec and the IOL placement in post-refractive
that allows surgeons to take both ORA system. They also incorporated surgery eyes, ORA was shown to have
aphakic and pseudophakic refractive AnalyzOR, which compares pre-, intra-, a lower mean prediction error (0.43)
measurements in the operating room to and post-op data and allows surgeons to compared to pre-operative calculations
aid in the determination of intraocular fine-tune their calculations to improve using the IOLMaster (0.77) and the
lens (IOL) power selection and outcomes. ASCRS calculator (0.61). With ORA,
placement38. 80% of eyes were +.75D sphere. Pre-
WaveTec Vision Systems, ORange HOLOS operative measurements showed only
and ORA HOLOS IntraOp by Clarity is the 53% of eyes would have achieved this
ORange intraoperative wavefront newest available product. It utilizes the without ORA43. An additional study
aberrometer by WaveTec Vision technology of a rapidly rotating micro regarding toric IOL placement guided
Systems, Inc. was the first commercially electro-mechanical system (MEMS) by intraoperative aberrometry showed
available intraoperative wave-front mirror and quad detector to measure the an increase in likeliness by a factor of
aberrometer. It utilizes Talbot moiré magnitude of wavefront displacement. 2.4 that mean postoperative residual
interferometry, a system involving It takes up to 90 measurements per refractive astigmatism would be less
two gratings offset at a specific angle second and has a range from -5D to than 0.5D44.
+16 D40. It is based on a proprietary
form of aberrometry referred to as Limbal Relaxing Incisions (LRIs)
sequential scanning wavefront. Holos is Pre-operative planning of LRIs using
capable of high-speed, high-resolution corneal topography can also be
measurement and simultaneous display challenging. Using ORange to guide
of real-time refractive data throughout LRIs, postoperative residual refractive
the operation. astigmatism was shown to be reduced
Like its competitor, it attaches to by a factor of 5.7, although this trend
the operating microscope to give was not statistically significant45.
intraoperative refractive measurements.
Benefits of ORA system
Role in routine cataract surgery There are many benefits associated with
While early studies using ORange use of the ORA System:
showed a post-op spherical error as
low as 0.36+0.30 D, others question a. Prediction Error Gap: Clinical
the reliability and precision data reveals there is an 8 percent
of intraoperative wave-front prediction error and distribution
aberrometry41. Studies have not been gap at 0.50 diopters between the
conclusive about the superiority of outcomes achieved by cataract
intraoperative wavefront aberrometry refractive surgeons using the
(IWA) compared to traditional formulas ORA System, versus traditional
in the uncomplicated eye. As a result no biometry46.
consensus regarding the utility of IWA
b. Toric Cylinder Reduction Success: The
ORA System provides significantly
62 DOS Times - Volume 25, Number 6, May-June 2020 www.dosonline.org/dos-times
Monthly Meeting Update
better cylinder reduction with Toric Figure 14: Light adjustable IOL can be visualized by the fluorescence
intraocular lenses than previous microscope. RIS has been successfully
technologies47. resulting in highly localized refractive performed on both hydrophobic and
c. The ORA/Femto Advantage: The index changes. Within the laser focus hydrophilic IOLs in vivo.
synergy between the ORA System volume (approximately 5–10 mm
and laser-assisted refractive cataract in diameter and length), instead of RIS can hence help in changing the
surgery has been demonstrated to removing or disrupting tissue, we are power of IOL, converting monodical
provide the greatest possible visual altering collagen fibril density50. LIRIC IOL to multifocal IOL and vice versa
outcome for cataract patients. is relatively noninvasive in that we are and changing monodical IOL to topic
using pulse energies that are 1/100th IOL. Thus, RIS is helpful in patients
Factors Contributing Variability to to 1/1,000th those used to create a who have blurring of the intermediate
IWA femtosecond laser flap. During LIRIC, vision (depending on the IOL type),
Factors such as eyelid speculums, the laser alters the refractive index in a the lowered contrast, and even
eyelid pressure and post-operative highly localized fashion-akin to using a halo and glare after implantation
changes all add a degree of variability fine-point pen. LIRIC can be performed of multifocalIOLs or may even be
to intraoperative aberrometry48. on IOLs, corneas, or contact lenses. used to adjust the power of an IOL
Positioning of the speculum can implanted during childhood because
introduce pressure to the globe, Refractive Index Shaping: In Vivo of congenital or juvenile cataract, and
altering the shape of the eye. Proper Optimization of an Implanted done so repeatedly, whenever deemed
positioning of the speculum can help Intraocular Lens (IOL) necessary, for an entire lifetime51.
to minimize this effect. In addition, a The refractive index shaping (RIS)
significant difference has been noted technology in development by Perfect Modular IOLs
in the cylinder of the eye immediately Lens, which can theoretically alter an Modular IOLs include a base unit
post-operatively vs 1 week post- IOL after it has been implanted and implanted in the capsular bag and an
operatively. Contributing factors for has settled in the eye. High repetition exchangeable optic. To improve the
this effect include49 alterations made rate femtosecond laser pulses are refractive accuracy by changing the
by the incision, stromal hydration and directed to a designated area to create optic, one requires a second surgery
changes in intraocular pressure (IOP). a “lens” inside an IOL. RIS changes and a second incision. Modular IOL
To minimize this effect, IOP should the refractive characteristics of the systems allow for adjustment of the
be returned to physiologic range prior polymeric material without cutting the optic throughout a patient’s life. Toric
to measurements. Intraoperative material. The RIS-lens is a gradient lens, optics can be rotated and realigned
wavefront aberrometry is a novel with the related refractive index change and multifocal IOLs can be exchanged
platform that enables real-time generated by the instantaneous energy for monofocals if patients fail to
refractive analysis in the aphakic and of the laser pulse, which is regulated by neuroadapt52.
pseudophakic states while the patient an acousto-optical modulator (AOM)
is on the operating table. It enables at approx. 1 MHz speed51. In a process Light adjustable IOLs RXSight’s
cataract surgeons to make adjustments called “phase wrapping,” a convex lens Light Adjustable Lens (RxLAL)
to IOL power and orientation before is reduced by the femtosecond laser to It is the only FDA approved light
the surgery is completed. In this era of a thin layer of approximately 50 mm in adjustable IOL. The RxLAL is an
increasing high patient expectations, thickness, creating multiple refractive exciting technology that increases
this technology has the potential to zones. The different phase levels are cataract surgeons’ flexibility, but it
significantly improve IOL selection, created by controlling the energy per requires having the patient avoid UV
accuracy, and patient satisfaction rates pulse and focal spot. This whole process
with cataract surgery.
Laser-induced refractive index
change (LIRIC)
LIRIC is a minimally invasive method
to correct the eye’s aberrations with a
laser. This is a paradigm shift in how
we correct the eye’s refractive error.
LIRIC is performed at a wavelength of
405 nm, which is at the blue end of the
visible spectrum. At this wavelength,
LIRIC is a 2-photon absorption process,
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Monthly Meeting Update
Figure 15: SimVis
light exposure and can require repeat Figure 16: Gemini Refractive Capsule after cataract surgery, it became clear
treatment. Moreover, the procedure is early on that a “function follows form”
limited to a specific IOL, and the range can change shape when electric current approach to a new lens design would
is limited. Perfect Lens is working on is applied. The shape of the lens can yield many downstream advantages as
modifying IOLs, and the company be switched quickly to simulate the well.
has reported some positive results. A clear distance vision and blurred close
3-piece foldable silicone monofocal vision of a monofocal lens, as well as Three-dimensional (3D) heads-up
light adjustable IOL is implanted simulating the loss of image quality and display surgical visualization
through a 2.8 mm clear corneal incision contrast in a multifocal lens54. It is an evolving technology
with a proprietary injector. The overall Gemini Refractive Capsule demonstrating comparable efficacy to
diameter of the lens is 13 mm with 6 mm (Omega) the standard operating microscope for
optics, squared posterior optic edges, The Gemini Refractive CapsuleTM macular surgery. The use of 3D heads-
round anterior edges and blue PMMA is designed to neutralize the single up display systems in the COVID era
modified-C haptics. The IOL is available most important variable with regard can help in increasing the distance
in powers from +10 to +30 Dioptres. The to predictable visual results: Effective between surgeon and patient and also
IOL can be modified upto a total of 3 D Lens Position (ELP). Instead of using in improving ergonomics . A wide-field
of cylinder and 2D of sphere53. two-dimensional arms to hold the viewing system paired with a chandelier
lens centrally within the X/Y plane endoilluminator can represent a valid
SimVis of the eye, the Gemini Refractive aid for surgeons who opt for an ab-
It gives a glimpse of the visual CapsuleTM utilizes a revolutionary externo surgical approach. Moreover,
capabilities on the other side of surgery. design to also control the Z plane in a personal protective equipment
Since nowadays one can choose among three-dimensional way55. The design including masks and face shields are
several types of IOLs, hence, one borrows from current lens designs only better tolerated from the surgeon using
definitely wants to make the best and with regard to the advanced optics and 3D heads- up viewing system.
most informed decision. The SimVis biocompatible materials so that the
can simulate how the world will look pathway to approval is minimized. It provides five times extended depth of
through each type of artificial lens so By finally having control of the X, Y field and helps in maintaining the sharp
that the patient can feel confident in his and Z planes within the eye, surgeons focus across the expanded surgical
choice. at last will have three-dimensional space. It also resolves the finer details
When patients need to decide what control of the lens plane, resulting in by enhancing 42% depth resolution.
type of IOL they want inserted, they exponential improvement in outcome The view of the intricate steps is also
must decide whether they want a for their patients while significantly magnified by 48% by this system56.
monofocal lens (which creates sharp reducing the need for costly glasses or
vision for far objects but blurred vision contact lenses to correct eyesight after Robot-assisted simulated cataract
for close objects) or a multifocal lens surgery. While the initial goal of this surgery
(which focuses near and far objects new refractive capsule was simply to Cataract surgeries were performed
on the retina, but with lower image solve the problem of refractive results on a Kitaro cataract wet-lab training
quality and contrast). The SimVis uses
an optoelectronic turntable lens that
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Monthly Meeting Update
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Knorz MC, Nagy ZZ. Femtosecond laser clinical evaluation of an intraocular Intraoperative Spectral Domain Optical
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of American Society of Cataract and JC, Chan VK, Law AK, et al. Initial T., Bachmann B., Steven P., Cursiefen
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Krummenauer F. New technology 27. Chang DF, Mamalis N, Werner
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17. Conrad-Hengerer I, Hengerer FH, coherence tomography measurements.
Joachim SC, Schultz T, Dick HB. 28. Waltz K, Thompson VM, Quesada G. Invest Ophthalmol Vis Sci.
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surgery in intumescent white cataracts. clinical experience in simple and
J Cataract Refract Surg. 2014;40:44–50. challenging cataract surgery cases. J 38. Gayton JL. Another view on the benefits
Cataract Refract Surg. 2017;43:606–14. of intraoperative aberrometry. J Cataract
18. Filkorn T, Kovács I, Takács Á, Horváth Refract Surg. 2020;46(2):328.
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31. Stodulka P, Packard R, Mordaunt D.
20. Dryjski O, Awidi A, Daoud YJ. Clinical investigation of an innovative 41. Kabra N, Gupta SOptiwave Refractive
Femtosecond laser-assisted cataract selective laser device to assess its efficacy Analysis (ORA). DJO 2020;30:78-79.
surgery in patients with zonular and safety for the creation of anterior
weakness. Am J Ophthalmol Case Rep. capsulotomies in cataract patients. Paper 42. Canto AP, Chhadva P, Cabot F, et al.
2019;15:100483. presented at: ESCRS Annual Meeting; Comparison of IOL power calculation
September 22-26, 2018; Vienna, Austria. methods and intraoperative wavefront
21. Conrad-Hengerer I, Hengerer FH, aberrometer in eyes after refractive
Schultz T, Dick HB. Femtosecond laser– 32. Shen L, Carrasco-Zevallos O, Keller surgery. J Refract Surg. 2013;29:484-489.
assisted cataract surgery in eyes with B, et al. Novel microscope-integrated
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2013;39:1314–1320. intrasurgical optical coherence Yoo SH, Donaldson K. Intraoperative
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Espana EM, Krueger RR. Suction a history of refractive surgery. Journal of
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Tackman R et al. Clinical outcomes Assisted Phacoemulsification. Curr. Eye Refractive Surgery meeting. March 25-
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45. Wiley WF, Bafna S. Intra-operative Intratissue refractive index shaping presented at: the 2018 ASCRS meeting;
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Ophthalmol. 2018;96(4):e427-e433. Deen Dayal Upadhyay Hospital, Hari Nagar,
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50. Ding L, Knox WH, Bühren J, et al. long-term after cataract surgery. Paper
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Monthly Meeting Update
Bilateral Simultaneous Loss of
Vision: A Clinical Dilemma
Kanika Jain, N.Z.Farooqui, J.S.Bhalla, Satender Singh, Rakesh Verma, Ashwini Kulkarni
Department of Ophthalmology, Deen Dayal Upadhyay Hospital, Hari Nagar, New Delhi, India
Abstract: Bilateral simultaneous nonarteritic anterior ischaemic optic neuropathy (NA-AION) is extremely rare. A 50 year-old
woman presented with bilateral optic disc oedema. Initial visual acuities were no perception of light in both eyes. The patient
had hypercholesterolemia and mildly elevated Erythrocyte sedimentation rate. C- reactive protein and rest of investigations
including neuroimaging and carotid Doppler were within normal limits. Incomplete macular star formation was seen in left
eye after 3 weeks when the disc edema was resolving. Marked visual improvement occurred in both eyes (4/60 in the right eye,
6/60 in the left eye) after systemic steroid therapy in the 3rd month of follow-up. OCT RNFL confirmed resolved disc edema
with significant peripapillary thinning in all quadrants in both eyes and the disc was small, crowded in both eyes (disc size was
1.125mm in right eye and 1.4mm in left eye). VEP showed increased latency in both eyes.
Keywords: Nonarteritic anterior ischaemic optic neuropathy treatment, simultaneous Nonarteritic anterior ischaemic optic
neuropathy, bilateral NA-AION, Arteritic AION, Neuromyelitis Optica Spectrum Disorder (NMOSD).
Anterior ischaemic optic neuropathy Figure 1 A,B: Fundus photograph of the patient at presentation A) right eye, B) left eye
(AION) causes sudden visual loss showing bilateral disc edema with increased venous dilatation and tortousity, a flame
and visual field defects, which can shaped haemorrhage can be seen at 11o’clock position in left eye.
be associated with various systemic
disorders. Arteritic AION (AAION) (no perception of light bilaterally) who obscuration of vision, no pain on ocular
is caused by giant cell arteritis, and later developed incomplete macular movements, no jaw claudication/
nonarteritic AION (NA-AION) is star unilaterally when the disc edema scalp tenderness/headache, prolonged
the commonly occurring type and was resolving and was treated with medication intake, known systemic
associated with hypertension (HTN), systemic corticosteroids. co-morbidities- DM, HTN, no focal
diabetes mellitus (DM), obstructive sleep neurological deficits/ paraesthesia,
apnea (OSA), hypercholesterolemia Case Report no headache, nausea, diplopia or any
A 50-year-old woman came to the OPD similar family history. At presentation,
and small crowded discs. Bilateral with sudden onset, simultaneous vision visual acuity (VA) was no perception
AION occurs more often in arteritic loss in both eyes which she noticed of light in both eyes. The pupils were
patients and bilateral simultaneous when she woke up in the middle of the 5mm, regular, round and sluggishly
NA-AION is extremely rare1-7. There night for going to the washroom. There reacting bilaterally. Anterior segment
are only a few reports of bilateral was no history of any similar complaints examination was unremarkable in both
simultaneous NAION, which is in the past, any episodes of transient eyes. Fundoscopy revealed swollen,
usually caused by sudden systemic
arterial hypotension- severe blood
loss or overdose of antihypertensive
medications8. Incomplete macular star
formation is also a rare occurrence
in patients with NA-AION especially
diabetics or patients with deranged
serum cholesterol. In this report,
we present a patient with sudden,
bilateral, simultaneous NAION who
presented with profound loss of vision
68 DOS Times - Volume 25, Number 6, May-June 2020 www.dosonline.org/dos-times
Monthly Meeting Update
hyperemic optic discs with full cups Figure 2 A,B: Fundus photograph of the patient after 3 weeks A) right eye, B) Left eye
and venous dilatation, tortousity in showing resolving disc edema with gliotic changes bilaterally. An incomplete macular star
both eyes and peripapillary splinter formation can also be seen in left eye (Figure B).
haemorrhages (more distinctive in the
left eye at 11o’clock position) (Figure Figure 3: OCT-Macula of left eye acquired when the patient had incomplete macular star
1A, B). Intraocular pressure was 14 mm formation showing some hyper-reflective exudation in outer retinal layers and RPE. There
Hg bilaterally. Fat-suppressed, contrast- was no macular edema and neurosensory detachment, the foveal contour was maintained.
enhanced magnetic resonance imaging
of brain, orbit and spinal cord showed Table 1: Subclassification of optic neuropathies on the basis of presence or
the absence of inflammatory changes absence of optic nerve dysfunction
or acute haemorrhage/ infarct. Colour
Doppler ultrasound examination Optic neuropathies readily Optic neuropathies generally not
of both carotid arteries showed no leading to optic nerve leading to optic nerve dysfunction
significant thrombus/stenosis. Blood dysfunction
pressure was 125/84 mm Hg without
any medication. Serum glucose levels Optic neuritis Papilledema
(98 mg/dL), HbAIC-4.8, C-reactive
protein (CRP- negative), complete Ischemic optic neuropathy Pseudo-papilledema
blood counts, liver and kidney function
tests, serum homocysteine, RA- Factor Hereditary optic neuropathy Papillophlebitis
were all in normal limits. Erythrocyte
sedimentation rate (ESR; 30/mm/h) Toxic/ Nutritional optic neuropathy Optic nerve perineuritis
was marginally raised. Serum total
cholesterol, low-density lipoprotein Traumatic optic neuropathy Diabetic papillitis
(LDL) cholesterol, and triglyceride
levels were 247 (normal: 125–200), 161 Compressive/ Infiltrative optic Hypertensive papillitis
(normal: 150), and 209 (normal: 50– neuropathy
150) mg/dL, respectively. Anti-nuclear
antibodies, anti-DNA, cytoplasmic Glaucoma (unless markedely asymmetric)
and perinuclear anti-neutrophil
cytoplasmic antibodies (c-ANCA acuities in both eyes progressively left eye (Figure 2). OCT- Macula left eye
and p-ANCA), and anti-phospholipid increased to counting fingers from 3m done at the same visit showed the foveal
antibodies were negative. Thyroid in both eyes and the fundus evaluation contour was maintained with hyper-
function tests, angiotensin-converting showed resolving disc edema with reflective exudates in the outer layers of
enzyme, rapid plasma reagin, Typhi dot, gliotic changes bilaterally along with retina (no neurosensory detachment or
HIV, HbsAg, HCV, COVID-19 test (RT- incomplete macular star formation in macular edema was present) (Figure 3).
PCR), chest radiography, and thorax
contrast tomography were all in the
normal range or unremarkable.
In view of marginally raised ESR,
negative CRP, no thrombocytosis, no
jaw claudication/ neck pain/ headache/
scalp tenderness/ constitutional
symptoms and non tender/ prominent
temporal artery, the neurosurgeon
ruled out the possibility of giant
cell arteritis and thus AAION. Upon
initial examination, systemic steroid
(methylprednisolone 1 mg/ kg/ day),
methylcobalamine 1500µg / day,
medications to lower serum cholesterol
and triglycerides were started along
with blood pressure monitoring.
At the end of the 3rd week, visual
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Monthly Meeting Update
Figure 4 A-D: Fundus Fluorescein Angiography photographs of the patient showing A) Choroidal phase and early arterial phase showing
delayed optic disc filling (as marked by arrows), B) arterial phase, C) Early A- V phase, D) Late A-V phase which were within normal limits.
Figure 5 A,B: Fundus photograph of the patient at 3 months after presentation showing A) Neuromyelitis Optica Spectrum
right eye, B) left eye with resolved disc edema with gliotic changes. Disorder (NMOSD), Intracranial space
occupying lesion. All the causes were
Figure 6: OCT- RNFL showing resolved disc edema with significant RNFL thinning in all ruled out in view of history, systemic
quadrants in both the eyes. evaluation and neuromaging except
ischemic optic neuropathy. NA-AION
Fundus fluorescein angiography (FFA) eye respectively. Pattern visual evoked cannot be definitively distinguished
showed delayed prelaminar optic disc potentials of the patient showed normal from idiopathic optic neuritis by: age
filling in both eyes (Figure 4). At the end morphologies but delayed latencies of patient, initial presenting visual
of the 3rd month, Best Corrected Visual in both eyes. The systemic steroids are acuity, progression of vision loss, visual
Acuity (BCVA) were 4/60 and 6/60 in being slowly tapered and the patient is field defect, appearance of optic nerve
right and left eye respectively with N8 still under follow up. and presence of modest improvement
near vision in both eyes. She was able to in visual acuity. Normalization of
differentiate red- green colors and fields Discussion visual acuity and visual fields is not
were severely depressed bilaterally. Assessing for optic nerve dysfunction uncommon in optic neuritis, but not in
Meanwhile, optic disc oedema resolved is a critical first step in subclassifying NA-AION.
substantially, and both optic discs were different causes of optic neuropathies
mildly pale (Figure 5). Retinal nerve as is highlighted with their subsequent AION is caused by diminished blood
fibre layer analysis by OCT showed causes in (Table 1). The main differential supply to the optic disc and anterior
pathologic thinning in all quadrants in diagnosis which came to our mind portion of the optic nerve by the
both eyes (Figure 6) and disc size was were- AAION, NA-AION, Optic neuritis, posterior ciliary arteries. AAION occurs
1.125mm and 1.4mm in right and left Hereditary/ Toxic optic neuropathy, in patients with temporal arteritis (giant
cell arteritis). Immediate systemic
steroid therapy should be initiated
in patients with AAION in order to
prevent fellow eye involvement. In
contrast to AAION, NA-AION usually
has diabetes and/or hypertension, and
is particularly at risk if they have a
small, crowded optic nerve head (with
axonal crowding and compression).
Other systemic conditions such
as hyperlipidaemia, nocturnal
hypotension, sleep apnoea, optic nerve
head drusen and migraine have been
reported in association with NA-AION.
Consumption of phosphodiesterase-5
inhibitors and Amiodarone has also
been associated with NA-AION. In
contrast to hypertension, nocturnal
hypotension is one of the frequently
suggested risk factors in NA-AION9-12.
This explains the high rate of vision
70 DOS Times - Volume 25, Number 6, May-June 2020 www.dosonline.org/dos-times
Monthly Meeting Update
loss upon awakening in these patients. AION in elderly patients to facilitate patients.
Hypertension treatment may cause early resolution of disc edema and
nocturnal hypotension, which may thus early visual recovery. Controlling References
cause NA-AION in these patients who systemic risk factors and avoiding
already have vasculopathy. Although, anti-hypertensives at night to prevent 1. Shibayama J, Oku H, Imamura Y, Kajiura
the only positive associations found in nocturnal diastolic arterial hypotension S, Sugasawa J, Ikeda T. Bilateral, nearly
our case were hyperlipidemia and small are the key management strategies in simultaneous anterior ischemic optic
crowded discs bilaterally. these cases. neuropathy complicated by diabetes and
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Arnold and Hepler have shown that Usually, the vision loss is not so severe J Ophthalmol 2005;49:235–238.
delayed prelaminar optic disc filling in cases with NA-ION. Gundogan et al
during the acute phase of NA-AION presented with a case of simultaneous 2. Hayreh SS. Anterior ischemic optic
as was seen in our patient, reflective bilateral NA-ION but the presenting neuropathy. V. Optic disc edema an early
of impaired flow in the direct arterial visual acuity was hand movements sign. Arch ophthalmol 1981;99:1030–
branches of optic disc13. Impaired in the right eye, and light perception 1040.
perfusion pressure in a water shed zone in the left eye. Our case came with
within the distribution of the posterior bilateral profound loss of vision and the 3. Beri M, Klugman MR, Kohler JA, Hayreh
ciliary artery of optic disc predisposes visual acuity was no perception of light SS. Anterior ischemic optic neuropathy.
it to infarction in patients with NA- at presentation which is very rare and VII. Incidence of bilaterality and various
AION14. Arteriosclerosis, embolic no similar case report with such severe influencing factors. Ophthalmology
disease and cerebrovascular occlusive vision loss could be found on literature 1987;94:1020–1028.
disease are not associated with NA- review.
AION. Impaired autoregulation of optic 4. Gundogan FC, Guven S, Yolcu U, Sari
disc perfusion might also play a role esp Alberto-Galvez Rulz et al have S, Sobaci G. Bilateral simultaneous
in bilateral, simultaneous NA-AION14. highlighted the formation of macular Nonarteritic Anterior Ischemic
Bilateral NA-AION cases are extremely star formation in patients with diabetes Optic Neuropathy: Case Report.
rare (accounting to 10-15% of the total and NA-AION. They have observed that Neurophtholmol 2013;37(5):214-9.
cases of NA-AION), except in cases with in bilateral NA-AION cases, strikingly
severe arterial hypotension during macular star formation is found only 5. KanhereM, Ramakrishnan R, Choudhary
cardiopulmonary or extensive surgery in one eye, as in our case also. It is an A. Bilateral Non-Arteritic Anterior
with massive blood loss, haemodialysis, incomplete star formation with lipid Ischemic Optic Neuropathy in a young
etc or overdose of antihypertensives. deposits around macula as observed male. Delhi J Ophthalmol 2019;29:114-6.
Although, no such history predisposing on OCT similar to our case. This
to bilateral NA-AION was present in our phenomenon was more common in 6. Alberto Galvez-Ruiz. Macular star
case. diabetics and hypercholesterolemics formation in diabetic patients with
Shibayama et al. and Gundogan et although, present case is non-diabetic non-arteritic anterior ischemic optic
al have individually reported cases but hypercholesteremia is present. neuropathy (NA-AION). Saudi J
of bilateral and simultaneous NA- They also pointed out that this usually Ophthalmol 2015;71-5.
AION in diabetic patients with small develops when disc swelling begins to
discs and small optic cups. Bilateral resolve (in 2-8 weeks), and is not present 7. C.Giusti. Bilateral non-arteritic anterior
simultaneous NAION is extremely rare in acute period of visual loss as was seen ischemic optic neuropathy (NAAION):
as in our case. The most critical point is in our patient after 3 weeks of initial Case report and review of the literature.
to decide whether it has an arteritic or presentation. They also pointed out that European Review for M edical and
nonarteritic origin. Immediate systemic macular star formation is not associated pharmacological Sciences 2010;14:141-
steroid treatment carries prognostic with visual loss or neurosensory 4.
and vital significance in AAION, it may detachment or macular edema as was
be better to initiate this treatment in proven in our case by OCT-Macula. 8. Basile C, Addabbo G, Montanaro A.
doubtful cases to prevent further visual Anterior ischemic optic neuropathy and
loss and aid in visual recovery if any. This case highlights that patients dialysis: role of hypotension and anemia.
However, there is no known effective presenting with uncommon findings J Nephrol 2001;14:420–423.
therapy for NA-AION. It seems better need to be investigated thoroughly
to initiate systemic steroid therapy keeping in mind typical conditions 9. Hayreh SS, Podhajsky P, Zimmerman MB.
in patients with simultaneous NA- with atypical presentations. Prompt Role of nocturnal arterial hypotension
and correct management of these cases in optic nerve head ischemic disorders.
can help to prognosticate the pathology Ophthalmologica 1999;213:76–96.
and predict the visual outcome in these
10. Hayreh SS, Podhajsky PA, Zimmerman
B. Nonarteritic anterior ischemic optic
neuropathy: time of onset of visual loss.
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11. Hayreh SS, Zimmerman MB, Podhajsky
P, Alward WL. Nocturnal arterial
hypotension and its role in optic nerve
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J Ophthalmol 1994;117:603–624.
12. Landau K, Winterkorn JM, Mailloux LU,
Vetter W, Napolitano B. 24-Hour blood
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Monthly Meeting Update
pressure monitoring in patients with 14. Hayreh SS. Anterior ischaemic Corresponding Author:
anterior ischemic optic neuropathy. optic neuropathy. II. Fundus on
Arch Ophthalmol 1996;114:570–575 ophthalmoscopy and fluorescein Dr. Kanika Jain
angiography. Br J Ophthalmol. Deen Dayal Upadhyay Hospital, Hari Nagar,
13. Arnold AC, Hepler RS. Fluorescein 1974;58(12):964-980. New Delhi, India.
Angiography in Acute Nonarteritic
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30.
72 DOS Times - Volume 25, Number 6, May-June 2020 www.dosonline.org/dos-times
Monthly Meeting Update
Optic Atrophy - Easy to Catch,
Difficult to Diagnose
Mohmad Uzair Zakai MS, Amit Mehtani MS, DNB, J.S. Bhalla MS, DNB, MNAMS, Himani Anchal MS
Department of Ophthalmology, Deen Dayal Upadhyay Hospital, Hari Nagar, New Delhi, India
Abstract: Central nervous system tuberculosis (CNS TB) is the most important and serious manifestation of extrapulmonary
TB. It leads to a number of complications, vision impairment being one of them, associated with significant morbidity. Here, we
are highlighting a case of CNS TB developing primary optic atrophy along with relevant pathophysiology. It is rarely reported
in the literature.
An 18 years old female presented with in L/E was hand movement close to 30-2 showed R/E temporal field loss,
history of gradual progressive painless face, projection of rays were accurate respecting the vertical meridian. Visual
diminution of vision in left eye past 2 in all the quadrants and grade 3 RAPD evoked potential showed reduction in
months. There was no history of any was present, rest anterior segment was amplitude and delayed latency, which
other ocular symptoms. There was unremarkable. Fundus examination was more in the left eye (Figure 2).
no history of headache, vomiting, of R/E revealed 0.5 vertical cup-disc
altered sensorium. She did not have ratio, superior, nasal, inferior NRR were On systemic investigation, we found
hearing loss, facial deviation, nasal healthy with temporal pallor (Figure ESR and CRP were raised, mantoux
regurgitation, weakness of limbs or 1). However L/E revealed chalky white was highly positive (20mm x20mm),
involuntary movements. No history of disc with well distinct disc margins CB- NAAT sputum was negative for
fever, cough, loss of weight. No history and also reduced Kestenbaum index. tuberculosis and RT-PCR for covid 19
of loose stools, vomiting, dysuria. Fundus findings were suggestive of was negative.
bilateral primary Optic atrophy (L/E >
There was history of tuberculous R/E). Colour vision in R/E showed red NCCT chest, Usg abdomen and X-ray
meningitis 3 years back, for which green discrimination loss and also the lumbosacral spine were normal.
patient took ATT for 10 months and the contrast sensitivity was reduced, Colour However on NCCT head axial scan
patient was non compliance with the vision and contrast sensitivity of L/E showed hyperdensity in the suprasellar
treatment of ATT. Previous treatment could not be done, due to marked vision cistern with focal edema in the
records were not available with the loss. basal ganglia, finding suggestive of
patient. tuberculoma (Figure 3) but these
After complete ophthalmological findings could not explained us why
No past history of systemic history and the bilateral optic atrophy has occurred
family history were not relevant. She evaluation, the following differential in our case, then patient was advised for
did not have any addictions and did not diagnosis were considered:- Contrast enhanced (Gadolinium) MRI
consume any toxic substance. Compression of optic tract, Ethambutol BRAIN and t1 weighted images showed
induced optic neuropathy, Toxic/ , enhancing lesions in the suprasellar
On examination, Patient was average nutritional optic neuropathy, cistern involving the optochiasmatic
build, her vital parameters were normal. Hereditary optic neuropathy, region with focal edema in the basal
No Signs of meningeal inflammation ganglia findings were suggested of
were present. Higher mental functions Demyelinating optic neuropathy like optochiasmatic arachnoiditis, these
were normal. Multiple sclerosis and primary optic findings explained us why there were
asymmetrical optic atrophy (L/E>R/E),
Ocular examination revealed best atrophy due to tuberculosis. The patient as we can see in (Figure 4), exudates/
corrected visual acuity (BCVA) in R/E was advised for ocular as well systemic inflammation in optochiasmatic region
was 6/12, not improving with any investigation. Optical Coherence and these are extending toward the left
correction, rest anterior segment was Tomography (OCT) of optic disc head optic nerve. Lumbar puncture was done
with in normal limit, Visual acuity showed peripapillary retinal nerve fibre
layer thinning in both the eyes more
in the left eye. Humphrey’s visual field
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Monthly Meeting Update
and the C.S.F findings were suggestive (Fig.1) (Fig.2)
of Tubercular meningitis.
So we made a final diagnosis of
Optochiasmatic arachnoiditis with B/E
primary optic atrophy (L/E>R/E).
She was started on anti-tuberculous (Fig.3)
drug regimen with isoniazid, rifampin,
pyrazinamide and streptomycin (Fig.4)
(substituted for ethambutol) along
with steroids( dexamethasone). Patient
was follow up after 1 month, the
vision in the both the eyes marginally
improved R/E 6/9 and L/E 4/60. Also, the
neuroimaging to confirm resolution.
Discussion
Tuberculosis is one of the major
global public health problems in
both developing as well as developed
countries. More recently, there has
been resurging trend in the magnitude
of this problem especially in developed Figure 1: Fundus picture of both eye.
countries. Central nervous system (CNS) Figure 2: HVF 30-2 of R/E- showing field loss respecting the vertical meridian.
involvement is one of the most serious Figure 3: NCCT head showing hyperdensity in suprasellar cistern with focal edema in basal
forms of extrapulmonary tuberculosis. ganglia.
It can manifest in a variety of ways such Figure 4: T1W gadolinium coronal and axial MRI images; multiple confluent enhancing
as TBM, TBM with miliary tuberculosis, lesions in the suprasellar cistern involving the optochiasmatic region with focal edema in the
tuberculous encephalopathy, basal ganglia.
vasculopathy and abscess1. Vision
impairment is one of the most
devastating sequelae associated with hydrocephalus with raised intracranial the optic nerve and the optic chiasma.
CNS TB causing significant morbidity. tension, optochiasmatic arachnoiditis, Thick basal exudates compress and
It may result from optochiasmatic chiasmal compression due to dilated occlude the blood supply to the optic
arachnoiditis, compression of optic third ventricle or tuberculomas. In nerve and the optic chiasma, and
nerve by tuberculoma, optic nerve such cases, disc margins are blurred. produce a severe vasculitis, which
granuloma, optic neuritis associated However, sometimes primary optic affects the meningeal vessels on the
with antitubercular therapy atrophy, though uncommon, may be surface of these structures. Ischemia
(ethambutol, sometimes isoniazid), seen in TBM. of the optic nerve and optic chiasma
secondary to hydrocephalus and raised Optochiasmatic arachnoiditis (OCA) due to vasculitis of the vasa nervosum
intracranial tension, bilateral occipital refers to inflammatory changes with results in damage to the optic nerve and
infarcts due to vasculitis2. Fundus exudates in the leptomeninges around subsequently profound vision loss5,6.
examination may reveal papilloedema, the optic chiasm and the optic nerves. Early recognition of this condition
optic atrophy and choroid tubercles, This can lead to a decrease in the visual and continued ATT and corticosteroid
findings sometimes suggestive of acuity, with variable progression to therapy or surgical decompression
neuroretinitis. As aforementioned, the partial or total blindness. The causes of optic pathway may help in
incidence of vision impairment varies of optochiasmatic arachnoiditis are preserving the visual function of the
from 27 to 72%3. Tuberculosis, Sarcoidosis, Rheumatoid patient7,8,9. Other Treatment modalities
pachymeningitis, Epstein - Barr are thalidomide10 and intrathecal
Aaron et al4 reported that young viral infection, Neurocysticercosis, hyaluronidase11. In Steroid-refractory
women having high CSF protein values Subarachnoid hemorrhage. The case TNF-a antagonist (Infliximab)12,13.
are at risk of developing optochiasmatic etiopathogenesis of OCA characterized can be used. A paradoxically response
arachnoiditis. Optic atrophy is one of the by thickening of the arachnoid mater can be developed in optochiasmatic
sequelae of TBM. In most patients, it is of at the base of the brain surrounding arachnoiditis while the patient is
secondary type, occurring as a result of being adequately treated with anti-
74 DOS Times - Volume 25, Number 6, May-June 2020 www.dosonline.org/dos-times
Monthly Meeting Update
TB drugs14. A paradoxical response is Neurol Sci 2010;290:27–32. and optochiasmatic arachnoiditis)
thought to represent a delayed-type complicating tuberculous meningitis.
hypersensitivity reaction to the massive 4. Aaron S, Mathew V, Anupriya A, Acta Neurol Scand 1980;62:368-81.
release of mycobacterial proteins et al. Tuberculous optochiasmatic 12. Jorge JH, Graciela C, Pablo AP, Luis SH. A
into the core of the tuberculoma arachnoiditis. Neurol India 2010;58:732– life-threatening central nervous system-
and subarachnoid space, leading to 5. tuberculosis inflammatory reaction
intense inflammation and expansion nonresponsive to corticosteroids and
of the tuberculoma. The Onset of a 5. Garg RK. Tuberculous meningitis. Acta. successfully controlled by infliximab
paradoxical response can occur as early Neurol. Scand. 122, 75–90 (2010). in a young patient with a variant of
as 2 weeks and as late as 18 months after juvenile idiopathic arthritis. J Clin
starting therapy. 6. Subramanian PC. Bacteria and bacterial Rheumatol 2012; 18: 189-191.
diseases. In: Walsh and Hoyt’s Clinical 13. Wallis RS, van Vuuren C, Potgieter
Conclusion Neuro-ophthalmology. Volume 3 (6th S. Adalimumab treatment of life-
Optic atrophy which itself is a Edition). Miller NR, Fletcher W (Eds). threatening tuberculosis. Clin Infect Dis
misnomer, characterized by function Lippincott Williams and Wilkins, 2009; 48: 1429-1432.
loss of conductive capacity of the optic Baltimore, MD, USA, 2647–2774 (2005). 14. Sinha MK, Garg RK, Anuradha HK,
nerve. A morphological diagnosis of Agarwal A, Parihar A, Mandhani PA.
either primary/secondary optic atrophy 7. Monga PK, Dhaliwal U: Paradoxical Paradoxical vision loss associated
always entails a responsibility on reaction in tubercular meningitis with optochiasmatic tuberculoma in
ophthalmologist to search for etiology. resulting in involvement of optic tuberculous meningitis: a report of 8
radiation. Indian J Ophthalm patients. J. Infect 2010; 60: 458–466.
Hence a step ladder approach required 2009,57:139-41.
in all cases to decipher the etiology Corresponding Author:
of optic atrophy and optimize visual 8. Yeh S, Cunningham MA, Patronas N,
outcomes in such patients. Foroozan R: Optic neuropathy and Dr. Mohmad Uzair Zakai MS
perichiasmal tuberculomas associated Deen Dayal Upadhyay Hospital, Hari Nagar,
Reference with Mycobacterium tuberculosis New Delhi, India.
1. Garg RK. Tuberculosis of the central meningitis in pregnancy Can J
Ophthalmol 2009;44(6):713-5.
nervous system. Postgrad Med J
1999;75:133–40. 9. Sharma K, Pradhan S, Varma A, Rathi B:
2. Malhotra HS, Garg RK, Gupta A, et al. Irreversible blindness due to multiple
An unusual cause of visual impairment tuberculomas in the suprasellar cistern.
in tuberculous meningitis. J Neurol Sci J Neuroophthalmol 2003, 23(3):211-212.
2012;318:174–7.
3. Sinha MK, Garg RK, Anuradha HK, et 10. Schoeman JF, Andronikou S, Stefan DC,
al. Vision impairment in tuberculous Freeman N, van Toom R. Tuberculous
meningitis: predictors and prognosis. J meningitis-related optic neuritis:
Recovery of vision with thalidomide
in 4 consecutive cases. J Child Neurol
2010;25:822-8.
11. Gourie-Devi M, Satish P. Hyaluronidase
as an adjuvant in the treatment of
cranial arachnoiditis (Hydrocephalus
www.dosonline.org/dos-times DOS Times - Volume 25, Number 6, May-June 2020 75
Monthly Meeting Update
Optimizing Outcomes in Uveitic
Cataract
Harish Chandar Gandhi MS, Prathama Sarkar MS, DNB, J.S. Bhalla MS, DNB, MNAMS
Department of Ophthalmology, Deen Dayal Upadhyay Hospital, Hari Nagar, New Delhi, India
Abstract: The underlying vision limiting pathology and the perioperative optimization of uveitis, plays a very important role
in the final visual outcome after uveitic cataract surgery. A meticulous examination in conjunction with adjunct investigations
can help in preoperative surgical planning and in determining the need for combined or staged procedures. In this article we
would like to emphasize upon the importance of proper patient selection, modified surgical techniques and optimization of
peri- and post-operative care in the patients of Uveitic cataract so that they may achieve a good visual outcome.
Cataract is one of the commonest patient of uveitis include3: and posterior uveitis have a poorer
complications seen in chronic or outcome due to high incidence of CME
recurrent uveitis. It is responsible for • Visually significant cataract. (most and co-existing posterior pathology4.
approximately 40% of the visual loss in common indication)
patients of uveitis1. It is reported to be Pre-operative evaluation5,6
one of the major indications for surgery • Cataract hampering the view of A proper evaluation of the uveitic
in the uveitic patients. It compromises posterior segment. entity is very helpful to establish the
of approximately 1.2% of all cataract appropriate surgical strategy and to
surgeries2. • The cases where posterior segment determine the prognosis. It is important
treatment is indicated but view is to undertake relevant history and do a
Cataract development depends on hampered. detailed local and systemic evaluation.
multiple factors including etiology, Wherever required, the appropriate
localization of the inflammatory • Phacoantigenic uveitis. hematological and biochemical
process, time elapsed between the onset The knowledge of the etiology in cases investigations should be done.
and diagnosis of uveitis, the degree of of Uveitic cataract not only helps to Ophthalmological testing includes
inflammation, the clinical course, and prognosticate the disease course but proper recording of visual acuity, slit
the use of corticosteroids (both topically also helps to have a better preoperative lamp examination of cornea to rule out
and systemically). control of inflammation and hence, an presence of any central opacity, haze or
improved response to the treatment. It band shaped keratopathy (Figure 1).
The surgical management of cataract also aids in deciphering the associated
in uveitic patients although critical complications, visual potential or Any keratin precipitates, cells or flare in
is less important than managing the prognosis in the patients and ultimately the anterior chamber should be assessed
patients medically before and after gauging the rate of post-operative to find the signs of active inflammation.
surgery. The post-operative outcome complications. Finally, it helps in Any tell-tale sign of iritiseg. loss
is less predictable in these cases. This giving the patient and/or their relatives of iris pattern, posterior synechae,
is because these uveitic eyes have a an objective report on the status of the peripheral anterior synaechie, pupillary
pre-existing inflammation, hence, eye to be operated in order to have a membranes, seclussio pupil, occlusio-
the blood aqueous barrier (BAB) is realistic expectation of the final visual pupil, abnormal vessels in angle or
already compromised. Cataract surgery result. iris and the size, shape and reactivity
further hampers this BAB. It leads to of pupil should be noted. Associated
greater fibrin formation and enhanced Anterior idiopathic Uveitic cataract glaucoma or hypotony should be
inflammatory sequel. cases have the best prognosis. Due to analysed.
persistent inflammation, difficulty
Managing uveitic cataract in controlling inflammation and Proper fundus examination should be
The indications for cataract surgery in a increased chances of synechiae and conducted to rule out any pathology.
cyclic membrane formation, cases of
JIA have a poor outcome. VKH, Behcet’s
76 DOS Times - Volume 25, Number 6, May-June 2020 www.dosonline.org/dos-times
Monthly Meeting Update
Figure 1: Slit lamp examination of a uveitic cataract. Eye should be quiet for at least 3
months prior to surgery and for 6
Diseases that spare the posterior lesions and accurate documentation months in cases of Behcet’s disease13.
segment generally have a better of disease progression10. Indocyanine There should be no or occasional cells
prognosis than those involving the green angiography (ICGA) helps in in the anterior chamber. Baseline flare,
macula, retina, and/or optic nerve. detection of choroidal inflammation. though is acceptable, may enhance the
It helps in diagnosis of multiple breakdown of BAB. A study has shown
Ancillary diagnostic tests evanescent white dot syndrome, acute that surgery done in quiet eyes have
They are always necessary to detect posterior multifocal placoid pigment resulted in 68% of patients having
pre-existing pathologic changes epitheliopathy, multifocal choroiditis, vision of 20/40 or more14.
that will allow us to render a more serpiginouschoroidopathy, Vogt-
accurate visual prognosis. Linear A-B Koyanagi-Harada disease (VKH), ocular Role of steroids
ultrasound helps to identify vitreous sarcoidosis, tuberculosis, and birdshot Various modes of steroids are present
hemorrhage and opacity, as well as chorioretinopathy11. at our disposal for the control of
posterior segment changes like, retinal inflammation ie. topical, periocular,
detachment, optic nerve swelling, and High risk indicators for post- systemic, intra-vitreal or in form of
sclerochoroidal thickness7. The use of operative hypotony12 implants. The intravitreal steroid
ultrabiomicroscopy (UBM) in uveitis implants give a more targeted delivery,
include uveitis-glaucoma-hyphema These include (1) low IOP <6mm in controlled and consistent release,
syndrome (UGH), sclerouveitis, quiescent eye, (2) seclusiopupillae with immediate achievement of therapeutic
herpetic anterior uveitis, pars planitis, normal IOP, (3) apparent phacodonesis concentration, bypass the blood ocular
pseudophakic uveitis, hypotony, without evident zonulysis, (4) difficult barrier, reduces the systemic toxicity
peripheral toxocariasis, and ciliary to control uveitis causing risk of severe and decreases the need of compliance in
body pathology8. Fundus fluorescein postoperative inflammation or (5) present15.
angiography (FFA) allows the UBM showing ciliary body atrophy, Pre-operative management is also
recognition of many different forms detachment or cyclitic membrane. guided by the type of uveitis. In patients
of posterior segment inflammatory with non-granulomatous idiopathic
changes eg. chorioretinitis and These patients should be well anterior uveitis or Fuch’s uveitis,
optic nerve involvement; identify counselled beforehand to avoid post- topical steroids eg. Prednisolone acetate
macular edema and choroidal operative confusions. 1% is used 3 days prior to surgery. In
neovascularization etc9. Wide field cases of granulomatous, intermediate
scanning laser ophthalmoscopy Perioperative Optimization and or posterior uveitis and panuveitis or
performs ultra-wide-angle FA allowing Postoperative Care in cases with history of cystoid macular
clear identification of peripheral edema, systemic steroids ie prednisolone
The most important step in 0.5-1 mg/kg may be prescribed 3 days
management is pre-operative control of before surgery. In the patients who
inflammation. have intolerance to steroids or oral
steroids are contraindicated, posterior
sub-tenon injection of Triamcinalone
or Intravitreal steroids may be given.
There is also a role of pre-operative,
intra-operative and post-operative
Ozurdex or Intra-vitreal triamcinolone
injections16 in cases of refractory uveitis.
Role of immunomodulators
Recently immunomodulatory drugs
have gained favor. They may be used in
conditions where (1) inflammation is
not controlled by high doses of steroids
even after one month of use, (2) more
than 10 mg of steroid is required daily
or (3) side effects of steroids are present
in the patient. The immunomodulators
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Monthly Meeting Update
have shown to have better outcomes. daily20 or valacyclovir 0.5 g four times Figure 2: Step-wise approach in
They have shown promising results daily preoperatively and for 2–3 weeks management of small pupil.
in cases of pediatric cataracts, patients postoperatively may help to prevent
with JIA or in patients with persistent the recurrence of herpes simplex uveitis Intracameralmydiatrics
post-operative inflammation or after surgery. Various intra-cameral mydiatrics are
with mild cystoid macular edema. used. Adrenaline in a bottle of ringer
Commonly used immunomodulators Uveitic cataract surgery lactate or balanced salt solution (BSS)
are Methotrexate (2.5 to 7.5 mg/ in concentration of 0.5 ml in 1:1000
week orally/ subcutaneously), Small pupil adrenaline in 500mL may be used intra-
Azathioprine (50 mg/day orally) or Managing the small pupil is the key intra- operatively. Intracameral adrenaline
Mycophenolatemofetil (500 to 1,000 operative aspect. Definition of a small in concentration of 1:1000 may also
mg/day orally). Reports have shown to pupil usually differs with each surgeon be considered. Now a days, Omidria
have a 66-85% better surgical outcomes and his experience. It is theoretically (Phenylephrine 1.0% and ketorolac
with these immunomodulatory drugs17. defined as pupil less than 4 mm in 0.3%) in BSS has shown to be equally
diameter21. Two goals of a hassle-free effective23. Mydrane / Phenocaine
Role of biologics cataract surgery include adequate pupil (Entod) (Tropicamide 0.02%,
Various tumor necrosis factor -alpha size and the maintenance of pupillary phenylephrine 0.31%, and lidocaine
antagonists are available now a days. function and good cosmoses. Having 1.0%) has been another effective
Infliximab is a IgG1k monoclonal a small pupil complicates the surgery. combination that can be used24.
antibody which is specific for human Iris may come into the phaco probe or
TNF-a. High rate of remission is seen the irrigation/ aspiration tip causing Procedures for small pupil
in recalcitrant uveitis when given by iris chaffing, more inflammation, iris The management of small pupil can
intravenous route. Uveitis in patients of defects, iris bleeding and iris prolapse be divided into two categories: (1)
JIA have reported to be subsided in 80% from ports. Inadequate pupil size leads Sphincter sparing and (2) Sphincter
of the cases after six weeks of treatment18. to a smaller rhexsis, anterior capsule involving procedures.
Adalimumab is a monoclonal antibody damage from chopper, and phaco tip.
which also inhibits the factor TNF-a. There is difficulty in nucleotomy and Sphincter sparing procedures
It may be used subcutaneously and cortex removal with increased chances Viscomydriasis
administered in every two weeks. of posterior capsular rent. The poor High molecular weight sodium
Other biologicals that may be used reflex affects the IOL placement and hyluronate may be used25. It helps to
are Golimumab, Gevokizumab, alignment too. Post operatively there mechanically move the iris tissue to
Tocilizumab Interferon, Rituximab, may be capsular contracture, phimosis angle and cause bowing of iris more
Alemtuzumab or Daclizumab. or IOL shift in these patients. posteriorly leading to a deeper chamber
and more dilatation. However, repeated
NSAIDS Managing the small pupil injections may be required.
They are administered at least 3 days The strategies of managing a small
prior to surgery and continued for pupil depends upon surgeon’s skill,
6-8 weeks post-surgery. They help in intra-operative situation or the status
maintaining the pupillary mydriasis of iris and the availability of the
as well as preventing CME induced by pupil expanding devices. Various
surgery. procedures may be used in isolation or
in combination. The stepwise approach
Antimicrobial prophylaxis is depicted in (Figure 2).
Care should be taken in eyes with
infectious uveitis that may reactivate Pharmacological dilation
after surgery. Bosch-Driessenet al. Dilatation should be avoided for
found a 36% risk of reactivation of more than 1–2 hours before surgery
toxoplasmicretinochoroiditis after as the dilation effect wears off and
cataract surgery19 and hence suggested subsequent drops work less efficiently.
the use of prophylactic antiparasitic Additionally, surgical sponge or cotton
drugs during and after cataract surgery wool soaked in 10% phenylephrine
in patients at risk of visual loss due to or a mixture of phenylephrine and
lesions near the macula or the optic cycloplegiceyedrops, into the inferior
nerve. In cases of herpes simplex fornix 30 minutes before surgery may
uveitis, oral acyclovir 400 mg twice be used22.
78 DOS Times - Volume 25, Number 6, May-June 2020 www.dosonline.org/dos-times
Monthly Meeting Update
Figure 3: Peripapillarymembranectomy. Figure 4: Membranectomy. Iris hooks
They are made up of polypropylene.
For performing the phacoemulsification Figure 5: Iris hooks. Four-point fixation is used in this
surgery in vacuum setting of less than They are used after putting OVD in the method. In this technique initially
200 mm hg and aqueous flow rate of anterior chamber. The incisions are four paracenteses of 0.6mm are made.
25 cc/minute, dispersive viscoelastic made on the same meridian. Then with Hook is then inserted parallel to the
is preferred; while in higher settings the pull or push technique, the iris is iris. Hook is then tilted posteriorly at
cohesive are recommended26. It is always released. It may be repeated at 90 degrees. pupillary margin to engage the iris. It
better to start with low parameters and This technique is simple and doesn’t is pulled and the bolster is then fixated
later switch to high parameters for need any special instrumentation. (Figure 5). It is very important to put
aspiration. Phacoemulsification should However, the tears caused may lead OVD at placement point to avoid the
be avoided in anterior chamber as US to pupillary instability which can capsular damage. To avoid the tenting
energy shatters the tightly packed long compromise surgery. The tears have of iris, the hook is bent backwards for
chained molecules of the viscoelastic, a tendency to bleed. There may be a 15 sec. This manipulation pulls the
hence, they can get easily aspirated. permanent damage to sphincter leading iris. All the paracentesis is made limbal
Moreover, bottle height should be kept to enlarged atonic pupil. It may also for the hook insertion. Main incision
low to prevent OVDs from being pushed cause photophobia, poor cosmoses or is placed on one side of the square
out from port. It is always advised to pigment dispersion. obtained after inserting the 4 hooks. It
perform the phacoemulsification under Microsphincterotomies29 helps in achieving a dilation of >7 mm.
OVD. 6-8 equally placed, partial thickness However, it is reported that stretching
Synechiolysis 0.5 mm cuts in sphincter with micro- beyond 6mm can cause atonic pupil in
It is recommended to release PAS before scissors or vanna’s under OVD are 1.1% cases30.
removing the posterior synechiae. made. By doing these uncontrolled
OVD may be used to bulldoze the iris tears are avoided and the sphincter 5 hooks may be used to get a
from cornea or anterior lens capsule. retains some function. However, the pentagonal shape. This causes a 17%
Synechiae may be broken using disadvantages include atonic pupils, less pupillary stretch. The diamond
the viscocannula or iris repositor. photophobia, poor cosmoses, pigment configuration hence obtained helps
Care should be taken to prevent the dispersion and damage to endothelium in inserting the phaco needle along
descement’s detachment and damage to while maneuvering (Figure 4). the long axis, making the procedure
anterior capsule. of phacoemulsification simplified. To
Peripupillarymembranectomy remove the hook, the bolster is pulled
With the help of McPhearsons forceps, backhand the hook is pushed to the
the fine edge of the string like fibrotic centre. The iris is disengaged after
membrane at border of pupil is ensuring that the rhexis margin is not
stripped27. The pupil gets released and snagged. The hook is then brought out
hence dilates (Figure 3). in the same direction as of the incision.
Sphincter involving procedure This method may require multiple
Pupil stretch mechanisms paracentesis and cause sphincter
It is used in for small pupils with rigid tears, iris defects, tenting or billowing
iris tissue. of iris, atonic pupil and difficulty in
(a) Spatula, sinskey hook, collar maneuvering other instruments.
buttons/ Kuglen hooks or Bheeler Pupil ring expanders
pupil dilator 2 or 328. They are very popular with the surgeons
nowadays. They have the advantage
of insertion from the same incision.
They cause less stress to iris tissue
and avoid over stretching of the pupil,
preventing the sphincter damage and
hence, keeping the pupil round pupil
and causing a uniform dilatation. Since
there is a minimal iris contact, therefore,
there is less iris chaffing and no tenting
of iris. There is no effect on instrument
movement as well. However, the main
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Monthly Meeting Update
Figure 6: Malugin ring 1.0 and 2.0 Figure 7: B- Hex rings. capture. Hence, these IOLs are also
comparison. deferred. Multifocal IOLs cause glare
tips leading to chaffing. The critical and the haloes are aggravated by
disadvantage is that one cannot titrate factor in the pahcoemulsification is irregular and atonic pupils and the
it. Now a days there are various other fluid velocity. Higher velocity of fluid decentration of IOL. Moreover, there
commercially available pupil expanders passing through the anterior chamber may be poor contrast sensitivity due
too in the market. increases the force exerted on the iris to these multifocal IOLs in addition to
(a) Malugin ring 2.0 by the square of the velocity (Bernoullie the macular or optic nerve pathology
It is made up of 5-0 polypropylene softer principal). Hence, it is required to keep and hazy vitreous. Thus, multifolacal
(larger scrolls), more elastic previously. the flow parameters reduced. Decrease IOLs are also nor preferred. Square edge
It has a paper clip scroll design. It helps the vacuum and AFR. A low vacuum foldable hydrophobic acrylic IOL are the
in eight-point fixation and has a reliable setting of 200-250 mm and AFR of IOLs of choice33. In the bag placement is
clamping mechanism. It has its own 20cc/minute with a bottle height of ensured and prioritization of capsular
injector and is easy in implantation and approximately 70mm (slow motion) is biocompatibility is done.
removal. preferred.
It smoothly goes through a 2.0 mm Concurrent surgeries
incision. In cases of sub-2mm incisions, Phacoemulsification manoeuvres Glaucoma surgery is not combined as
wound assisted technique may be Central positioning and minimal there is an increased risk of bleb failure
used31. It is available in two sizes: 6.25 movements of the handpiece to prevent due to inflammatory exudates. The
and 7mm. (Figure 6). iris damage is of prime importance. vitreoretinal surgery may be combined
(b) Bhattacharjee (B-hex) pupil For doing nucleotomy in small pupils, to deal with any coexisting posterior
expander vertical chop is favoured. Endocapsular segment pathologies like epiretinal
It is available in two varieties. (1) Square lens nucleus fragmentation is much membranes, coexisting retinal
(6.5 mm, 7 mm) and (2) Hexagonal safer in this scenario, as the highest detachment, to clear the vitreous gel to
(6,7 mm). The hexagonal expander is fluidic currents remains inside the reduce the vitreous clouding and also
better for small eyes. The average pupil capsular bag. Chopping of fragments resolve the CME.
size achieved is 5.75 mm with this is done within the pupillary aperture
expander32. A single-plane device with with the phaco tip kept in view so that Post-operative complications
alternating notches and flanges with there are less chances of engaging and Cataract surgery in uveitic eyes is
positioning rings are present (Figure 7). traumatizing the iris. associated with significantly higher
The notches engage the pupil margin rates of both intra- and post-operative
and the alternate flanges are tucked Choice of IOL complications.
under it. It can be inserted through a Plate Haptics are avoided in Uveitic
smaller sub 1 mm incision. cataract patients as the rate of posterior Post-operative inflammation
Phacoemulsification parameters capsular opacification (PCO) formation This is the most dreaded complication.
In poorly dilating pupils with atrophic is more in these patients as compared It may be severe due leading to protein
iris and loss of tone, there is billowing to the normal population. The YAG exudates, fibrinous membrane or
and prolapse of iris reported in 0.3-1% capsulotomy done in these cases may hypopyon formation. Aggressive
cases of complicated cataract. Iris closer cause posterior dislocation of the plate treatment is required in these cases.
to high fluidic currents have a tendency haptics. The anterior chamber or sulcus
of getting aspirated into the phaco/ IA fixated IOLs leads to inflammatory a. Steroids are started at a higher dose
reaction, more chaffing and pupillary and then tapered34. Treatment is
tailored according to the amount
of inflammation. Topical pulsed
steroids eg. prednisoloneaceteate
1% is administered every hour and
later tapered as per the response to
the baseline in one month.
If pre-operatively oral steroids were
given, then the same dose is given for 1
week and then tapered over 4-6 weeks.
If steroids are started post operatively,
then 1mg/kg or least 60 mg is prescribed
for 1 week and then tapered by 10 mg
every week. Intravitreal injections
80 DOS Times - Volume 25, Number 6, May-June 2020 www.dosonline.org/dos-times
Monthly Meeting Update
may be considered if not given Figure 8: CME post uveitic cataract surgery Figure 9: Capsular contraction post-
intraoperatively. Immunomodulators and after management with steroids. surgery.
are contemplated when the above
measures fail or are contra-indicated. with topical NSAIDs and oral steroids. A proper exhaustive ophthalmic
Tailoring of the dosage of steroids is evaluation is required in the uveitic
b. Topical NSAIDS are prescribed required according to the response. patients undergoing cataract surgery.
for 6-8 weeks to prevent cystoid Reportshaveshowncompleteresolution The disease should stay in abeyance
macular edema. of CME in 50% of patients treated with for at least a period of three months,
intravitreal triamcinalone37. Ozurdex and should be treated with adequate
c. Mydriatics – Tropicamide 1% or gives a sustained effect for longer pre-operative prophylactic anti-
homatropine 2% is given for 10- periods, decreased rate of recurrence of inflammatory therapy. A good visual
14 days to prevent formation of inflammation and an improved need outcome is the result of amalgamation
synechie, decrease ciliary spasm for systemic mmunosuppression with of pre-operative, intra-operative and
and evaluate the fundus easily. no intra-operative complications38. post-operative management in these
Intravitreal anti VEGF have shown patients.
d. Antibiotics and lubricants are also comparable results in patients with
administered. CME receiving IVTA but visual acuity Conflicts of interest
improvement has been seen more in the N
Surgical removal of the membrane IVTA group39.
may be done once the inflammation is Financial disclosure
controlled. Vitrectomy of the vitreous Capsular opacification/ None
membranes may be performed later35. contracture
It is found post-operatively in 23%-96% References
Intra-ocular pressure abnormality of uveitic eyes40 (Figure 9). Making 1. Durrani OM, Tehrani NN, Marr JE,
IOP is raised transiently in the early a circular well-centredcapsulorhexis,
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The greatest post-operative fear in cases of severe inflammatory membrane 3. Rojas B, Foster CS. Cataract
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present and increase the frequency 4. Mehta S, Linton MM, Kempen JH.
of topical and systemic steroids. This Conclusion Outcomes of cataract surgery in patients
may be effective in raising the IOP and The patient of uveitic cataract should with uveitis: A systematic review
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Incidence of CME is more in uveitic
cataract. It ranges between 21%-50%36.
Its more prevalent post-operatively
in patients with previous CME,
intermediate or posterior uveitis
(Figure 8). However, the incidence is
significantly low if cataract surgery is
done in quite eyes or the patient has
been treated pre-operatively with oral
steroids. Patients with CME are treated
www.dosonline.org/dos-times DOS Times - Volume 25, Number 6, May-June 2020 81
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DOS Times Quiz
May-June 2020
Answer the following?
Q. Who is the Ophthalmologist considered as the whistleblower of COVID 19?
1. Li Wenliang
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3. Li Wangchu
4. Li Wen
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Dr. Rajendra Prasad Centre for Ophthalmic
Sciences, All India Institute of Medical Sciences,
New Delhi, India.
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84 DOS Times - Volume 25, Number 6, May-June 2020 www.dosonline.org/dos-times
Tearsheet
Types of Lacrimal Stents or
Intubation Systems
Types of lacrimal stents or intubation systems
Monocanalicular Bicanalicular
Monocanalicular stent
Material Parts Dimensions
MonokaTM stent Silicone yy Proximal punctal fixation device External diameter of 0.64 mm with 80 mm
Vertical hollow tube long and 0.8mm wide metal bodkin
yy Metallic bodkin or blue/black The lumen (0.3mm) of collarette
coloured monofilament thread
Mini- Silicone yy Proximal punctal fixation device External diameter of 0.64 mm with 30 mm
MonokaTM yy Vertical hollow tube long
stent The lumen (0.3mm) of collarette
Monoka- Silicone yy Proximal punctal fixation device External diameter of 0.64 mm with 30 mm
Crawford stent yy Vertical hollow tube long
yy Crawford type (olive tip) metallic The lumen (0.3mm) of collarette
bodkin to its working end
MasterkaTM Silicone yy Proximal punctal fixation device External outer diameter of 0.96 mm
stent (pushed yy Vertical hollow tube Three lengths available- 30, 35 and 40 mm
Monoka) yy Thin metallic stylet or guidewire
Disposable Polypropylene Two polypropylene compressible flanges and a stainless-steel tip
Punctum Dilator
and Plug Inserter
Bicanalicular lacrimal intubation stents
Crawford stents Silicone Single stent which is swaged onto 2 malleable steel bodkins (0.4-0.6mm diameter)
at both of its ends.
The Crawford- II intubation device has wider diameter silicone of 0.93mm
Ritleng Stainless steel The probe has a funnel-shaped External diameter of probe is 1-2 mm and
intubation probe Prolene proximal entrance, a flat guide disc the lumen are 0.5-1mm wide.
device monofilament stent for orientation and a narrow slit like Stent 0.2-0.4 mm diameter Monoka stent is
opening attached to prolene
O’Donoghue, Metallic Probe Straight tips like a Bowman’s probe.
Guboir and Bika Silicone Stent Thickness or gauge of silicone stent can vary from 20, 23 (adults) and 27 (pediatric)
(bicanalicular)
stents
Self-retaining Silicone stent segments traverse both canaliculi till the Lengths of 25, 30 and 35 mm with a
bicanalicular lacrimal sac. Each end of this semicircular device has 2 stout disposable sizer
stents angulated wings/flanges
Mechanism of action
Anatomical Functional
yy Mechanically increases diameter of yy Tears flow along the surface of stent by the capillary action and keeps the lumen
lumen patent.
yy Straightens various bends in the yy Riverbed phenomenon
canaliculi
www.dosonline.org/dos-times DOS Times - Volume 25, Number 6, May-June 2020 85
Tearsheet
Material Parts Dimensions
Indications for Usage
yy Punctal and/or canalicular stenosis
yy Traumatic canalicular laceration/tear
yy Congenital nasolacrimal duct obstruction
yy Maintain ostium patency after DCR
yy Situations such as repeat DCR, young age, small/ fibrosed sac, inadvertent damage to sac during surgery, inadequate/small
sac flaps or nasal mucosal flaps, history of acute dacryocystitis and certain systemic conditions
yy Functional epiphora
Post DCR 4-6weeks
yy For punctal stenosis, canalicular stenosis/obstruction, canalicular laceration and 3 months
canalicular trephination
yy Silicone
Complications
yy Stent prolapse
yy Punctal slitting
yy Granuloma formation
yy Secondary Infections
Corresponding Author: Sahil Agrawal MD1, Deepsekhar Das MD1,
Sujeeth Modaboyina MD1,
Dr. Deepsekhar Das MD Saloni Gupta MS2, Prof. M.S. Bajaj MD1
Oculoplasty and Paediatric Ophthalmology 1. Oculoplasty and Paediatric Ophthalmology Services, Dr Rajendra
Services, Dr Rajendra Prasad Centre for Prasad Centre for Ophthalmic Sciences, All India Institute of Medical
Ophthalmic Sciences, All India Institute of Sciences, New Delhi, India
Medical Sciences, New Delhi, India 2. Dept. of Ophthalmology, Northern Railway Central Hospital,
Connaught Place, New Delhi, India.
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