DOS_July_2007

(approximately three months). It also provides a larger posterior 2. Ramirez M, Hernandez-Quintela E, Naranjo-Tackman R. A
diameter, allowing for a greater number of endothelial cells to be comparative confocal microscopy analysis after LASIK with the
transplanted. Surgeons can select a shape for the corneal graft IntraLase femtosecond laser vs Hansatome microkeratome.
depending on the type of disease or opacity present. The J Refract Surg. 2007; 23:305-7.
femtosecond laser also can create a nearly limitless variety of shapes
and angulations to maximize the area of contact between donor 3. Buratto L, Bohm E. The use of the femtosecond laser in penetrating
button and recipient. keratoplasty. Am J Ophthalmol. 2007; 143:737-742.

Our Experience 4. Patel SV, Maguire LJ, McLaren JW, Hodge DO, Bourne WM.
Femtosecond Laser versus Mechanical Microkeratome for LASIK A
We have done 16 Femtosecond Laser procedures and found that Randomized Controlled Study. Ophthalmology. 2007 10;
flaps are more uniform, and stick on well over the stromal bed
after reposition. This is due to a steeper side cut angle (70 degrees 5. Montes-Mico R, Rodriguez-Galietero A, Alio JL, Cervino A. Contrast
with Femtosecond Laser Vs 30 degrees with micro-keratome). sensitivity after LASIK flap creation with a femtosecond laser and a
The average time taken to create the flap is about 25 to 30 seconds. mechanical microkeratome. J Refract Surg. 2007; 23:188-92.
On intraoperative pachymetry, the standard deviation from
intended flap thickness was very low (10-12 microns). 6. Tran DB, Shah V. Higher order aberrations comparison in fellow
eyes following intraLase LASIK with wavelight allegretto and
Conclusions customcornea LADArvision4000 systems. J Refract Surg.
2006; 22:S961-4.
Femtosecond Laser provides more consistent flap thickness with
fewer complications than mechanical microkeratomes and results 7. Tan CS, Au Eong KG, Lee HM. Visual experiences during different
in better visual outcome in most patients. The Femtosecond Laser stages of LASIK: Zyoptix XP microkeratome vs Intralase
femtosecond laser provides better safety and accuracy than femtosecond laser. Am J Ophthalmol. 2007;143:90-96.
microkeratomes in creating corneal flaps for LASIK.
8. Friedlaender MH. LASIK surgery using the IntraLase femtosecond
Not only does the Femtosecond Laser provide comparable, and laser. Int Ophthalmol Clin. 2006; 46:145-53. Review.
possibly, better, results than the microkeratome, but the
Femtosecond Laser is preferred by patients, staff, and physicians 9. Munoz G, Albarran-Diego C, Sakla HF, Perez-Santonja JJ, Alio JL.
over the microkeratome. Femtosecond laser in situ keratomileusis after radial keratotomy.
J Cataract Refract Surg. 2006; 32:1270-5.
References
10. Lim T, Yang S, Kim M, Tchah H. Comparison of the IntraLase
1. Hu MY, McCulley JP, Cavanagh HD, Bowman RW, Verity SM, femtosecond laser and mechanical microkeratome for laser in situ
Mootha VV, Petroll WM. Comparison of the corneal response to keratomileusis. Am J Ophthalmol. 2006;141:833-9.
laser in situ keratomileusis with flap creation using the FS15 and
FS30 femtosecond lasers: clinical and confocal microscopy findings. 11. Stonecipher KG, Dishler JG, Ignacio TS, Binder PS. Transient light
J Cataract Refract Surg. 2007; 33:673-81. sensitivity after femtosecond laser flap creation: clinical findings
and management. J Cataract Refract Surg. 2006;32:91-4.

12. Lifshitz T, Levy J, Klemperer I, Levinger S. Anterior chamber gas
bubbles after corneal flap creation with a femtosecond laser.
J Cataract Refract Surg. 2005; 31:2227-9.

Author
Mahipal S. Sachdev MD

Monthly Clinical Meetings Calendar 2007-2008

Centre for Sight Sir Ganga Ram Hospital
29th July, 2007 (Sunday) 25th November, 2007 (Sunday)

Dr. R.P. Centre for Ophthalmic Sciences Mohan Eye Institute
26th August, 2007 (Sunday) 30th December, 2007 (Sunday)

Dr. Shroff Charity Eye Hospital Venu Eye Institute
30th September, 2007 (Sunday) 20th January, 2008 (Sunday)

New Hospital or Institute Army Hospital (R&R)
28th October, 2007 (Sunday) 24th February, 2008 (Sunday)

Midterm Conference of DOS New Hospital / Institute
17th,18th November, 2007 (Saturday - Sunday) 30th March, 2008 (Sunday)

60 DOS Times - Vol. 13, No.1, July 2007

Sutureless DSAEK Cornea

Rasik B. Vajpayee MS, FRCSEd, FRANZCO

A new innovative modification was done in the technique of head. A 10-0 monofilament suture was looped out at one of the
descemet’s stripping automated endothelial keratoplasty was edges of the donor lenticule. The edge of the graft was held and
undertaken. A “Sutureless DSAEK” surgery was done in a 70 year the suture bite was kept as close to the edge as possible. A “loop”
old male patient with pseudophakic bullous keratopathy. He had was then made on one side of the graft. The diameter of the
a pre-operative visual acuity of 5/60.The following surgery was suture loop was large enough to facilitate pulling by the Sinskey
done. hook through one of the stab incisions which had been made
Surgical Technique previously in the recipient cornea.
Donor lenticule Preparation
The donor lenticule was prepared using the Moria automated Recipient Preparation
lamellar therapeutic keratoplasty (ALTK) system with a 350-µm
A temporal limbal conjunctival peritomy was performed with
Figure 1. Edges of the conjunctiva are cauterized. conjunctival scissors. After cautery of the scleral bed, a 5.0-mm
No suture has been put frown or ant-smile incision was made about 1.5 mm away from
the temporal limbus. A crescent knife was used to fashion the
Figure 2. Sutureless DSAEK (Diffuse) tunnel. Subsequently, the wound was temporarily sutured. Two
limbal stab incisions were made with the MVR blade at about 11
Figure 3. Sutureless DSAEK (Slit) and 6 o’clock. An anterior chamber maintainer was used to maintain
Centre for Eye Research Australia the anterior chamber. A reverse Sinskey hook was used to strip
the Descemet membrane in the central 8 mm of the host cornea.
Department of Ophthalmology Trypan blue dye was used to stain and visualize the descemet’s
University of Melbourne membrane. Subsequently the donor lenticule was folded and
inserted in the anterior chamber of the recipient eye with the help
32, Gisborne Street, East Melbourne of Goosey’s forceps. The donor lenticule was folded in a 60/40 taco
Victoria 3002, Australia configuration such that the suture loop was placed in the posterior
40% part of the folded lenticule. The temporal scleral wound was
hydrated and left sutureless. The donor lenticule tissue was
unfolded by pulling the suture loop out of the 6 o’clock limbal stab,
using a Sinskey hook. The air was injected in the anterior chamber
to facilitate adhesion of the donor lenticule against the recipient’s
stroma. The position of the graft was centered on the recipient
cornea by moving this suture in the desired direction. The loop
was cut with the help of Vannas scissors, and the suture was
removed. Stab incisions were then made with the MVR blade at 3,
6, 9, and 12 o’clock in the recipient’s cornea in the paracentral
region to drain the fluid from the interface between the donor
and recipient. The side ports and the sclera tunnels were hydrated
using BSS. No suture was used to close the side ports or the sclera
tunnel. The edges of the conjunctiva were cauterized on either
side. The air in the anterior chamber was removed after 8 minutes,
and balanced salt solution was used to form the chamber. The
postoperative regimen consisted of ofloxacin 0.3%, 4 drops hourly,
prednisolone acetate 1% , 4 drops hourly, tropicamide 1% HS
drops , preservative-free tear substitutes, 4 drops hourly, and
Muro eye ointment three times a day.

Post-operatively, at two month’s follow up, the patient’s graft
adhered well graft and was clear( Figure 1, 2 3 ). The uncorrected
visual acuity was 6/ 12 with astigmatism of 0.5 D.

Sutureless DSAEK using a frown or anti-smile incision is a beneficial
technique as it induces minimal astigmatism and results in optimal
uncorrected visual acuity.

Acknowledgements

Medical Photographic Imaging Centre, Royal Victorian Eye and
Ear Hospital.

www.dosonline.org 61



Modified Osteo-Odonto-Keratoprosthesis Cornea

Ramendra Bakshi MS,Vinay S. DNB, Bhaskar Srinivasan MS, Geetha K. Iyer FRCS, G. Sitalakshmi FRCS

End stage ocular surface disorders still remain an enigma to proliferating following contact with the dentoalveolar ligament
ophthalmologists. These eyes are not amenable to conventional which in turn reduces the risks of retroprosthetic membrane
lamellar or penetrating keratoplasty. Though stem cell transplant formation as well as extrusion, the two major complications of
has a role to play in unilateral disorders, in bilateral disorders, any Kpro procedure1-3.
stem cell allograft requires long term immunosuppression with
its attendant risks and variable outcomes. In cases of severe dry Indications and Contraindications
eyes associated with surface keratinization, stem cell transplant
has no role to play. The implantation of a keratoprosthesis thus All cases of bilateral blindness due to severe end stage ocular surface
serves as a last resort to restore vision in these eyes. A vast number disease form the major indications of the procedure. (Table 1)
of designs and materials of keratoprostheses with different methods
of insertion have been developed and implanted in patients over The only absolute contraindications to the procedure include
the past two centuries with quite variable long-term results. absent light perception and an edentulous patient. Age below 17
years, retinal detachment or other posterior segment pathologies
The long-term fixation and retention of alloplastic material on that severely interferes with potential visual acuity, mentally
the surface of the eye for visual rehabilitation seems to be largely unstable patients, unavailability for long term follow up and
unsuccessful. Most studies report either a short follow up or a unreasonable visual or cosmetic expectations are relative
comparatively short lived visual recovery in majority of the cases. contraindications for the surgery 2,3.
The technique with by far the best results and proven long term
follow up is the osteo-odonto-keratoprosthesis (OOKP) invented For edentulous patients and those below 17 years the option of
by Strampelli and modified over the years by Prof. G. Falcinelli1. using a dental allograft does exist, but requires long term
immunosuppressives and is associated with high incidence of
MOOKP lamina resorption4.

OOKP developed some 40 years ago by Strampelli uses a biological Preoperative Assessment
skirt in the form of the patient’s own tooth root and alveolar bone
to support a polymethylmethacrylate (PMMA) optical cylinder. A detailed history to determine the primary diagnosis and previous
Over the years, Prof. Falcinelli devised stepwise modifications to surgical interventions is recorded. A brisk perception of light and
the original Strampelli technique, now termed as the modified normal B- scan are essential pre-requisites. An inaccurate
osteo-odonto-keratoprosthesis (MOOKP), which has led to projection of rays (PR) is not a contraindication, as a severely
improved visual results and retention of the device1. disturbed ocular surface may itself lead to inaccurate PR.
Electrodiagnostic tests can be done to aid in the assessment of the
Principles and Rationale visual potential. Intraocular pressure is usually assessed by digital
tonometry as other forms of measurement give erroneous readings
The basic principle of the technique involves the use of a wide on a disturbed ocular surface. Oral assessment includes assessment
single rooted tooth with surrounding alveolar bone to fashion a of oral and dental hygiene and state of buccal mucosa. An
plate as a carrier for a PMMA optical cylinder, which is covered orthopantomography(OPG), X-ray and spiral CT scan of canines
by buccal mucous membrane, the dentine being separated from is carried out for selection of a suitable tooth with the assistance
the alveolar bone by the dentoalveolar ligament. This simulates of an oromaxillofacial surgeon 1,3.
the environment in the mouth wherein the gingival mucosa stops

Table 1. Indications for MOOKP

• Stevens-Johnson syndrome
• Ocular cicatricial pemphigoid
• Epidermolysis bullosa
• Chemical injury
• Thermal injury
• Trachoma
• Multiple failed penetrating keratoplasties
• Aniridia with severe corneal changes
• Corneal failure after vitrectomy with silicone oil filled eyes

Cornea Services Figure 1. Steven -Johnson Syndrome.
Sankara Nethralaya, Pre-op vision- Hand Movements.

Chennai 63

www.dosonline.org

Surgical Technique

The MOOKP procedure involves 2 stages performed over a period
of 6-9 months.

Stage I

Stage I is split further into 3 stages (IA, B & C).

Stage 1A: ICCE +Anterior vitrectomy + Total iridectomy +
penetrating keratoplasty

Stage 1B:Mucous membrane grafting

Stage 1C: Preparation of Osteodentalacrylic Lamina (ODAL)

Stage II Figure 2. After Mucous Membrane Graft.
Implantation of ODAL on the bulbar surface

Stage IA involves preparation of the ocular surface by performing
a superficial keratectomy and fibrovascular pannus removal.
This is accompanied with intracapsular cataract extraction
(ICCE) using cryotherapy with anterior vitrectomy with total
iridectomy. Complete removal of these structures is done to
reduce the possibility of postoperative glaucoma and formation
of retroprosthetic membranes. Whenever required, a tectonic
penetrating keratoplasty is also performed at this stage.
This procedure also aids in the intraoperative examination
of the health of the posterior segment thus aiding in
assessing visual prognosis and decision to proceed with further
stages.

Stage IB, done usually 6 weeks after stage IA and often in Figure 3. Extraction of canine with surrounding alveolar bone.
combination with stage IC involves covering of the ocular surface
with full thickness mucous membrane graft (MMG) harvested
from the buccal mucosa. The extent of MMG should be large
enough to extend from upper to lower fornix and measures around
3-4 cm in diameter. Corneal epithelium is removed and
Bowmanectomy is performed prior to suturing MMG on the
surface covering the muscle inertions. The buccal mucosa serves
to provide adequate blood supply to the bone, protects the anterior
surface of the lamina, and acts as a barrier against microbial
invasion. (Figure 2)

Stage IC involves preparation of the osteodentalacrylic Lamina Figure 4. Tooth with alveolar bone after extraction.
(ODAL).(Figure 3-7) A single rooted tooth, preferably the upper
canine is chosen for preparation of the lamina. The tooth with The Optical Cylinder
the surrounding alveolar bone is extracted. It is then fashioned
into a lamina with bone on one side and dentine on the other. The dioptric power of the PMMA cylinder is about 50-60 dioptres
Extreme care is taken to preserve the alveolar dental ligament. in an aphakic eye and varies with the axial length (Appasamy
The neck is thoroughly cleaned of the gingival tissue, the dental Associates). A slight variation in the curvature of posterior surface
pulp canal is opened and all soft tissue removed. The crown is will lead to change in total dioptric power of the cylinder. Hence
cut off. A central hole is drilled within the area of dentine, into each cylinder is based on the axial length of the eye. The length of
which a customized PMMA optical cylinder is cemented with the anterior part is from 5.75-6.0 mm and posterior part from
acrylic resin. The drilling of the optical cylinder should be centred 2.25- 2.50 mm. This results in a total length of 8-8.25 mm1.
on the dentine, with atleast 1mm of dentine left on either side of
the cylinder. The ODAL is then placed in the subcutaneous pouch
in the orbitozygomatic area for next 3 months to develop
vascularization and to promote the growth of connective
tissue.(Figure 8) A spiral CT scan is performed prior to stage II
to rule out resorption of lamina and to document lamina
measurements3.

64 DOS Times - Vol. 13, No.1, July 2007

Figure 6. Lamina in submuscular pouch for 3 months.

Figure 5. Hole is drilled in the center of the canal at the in the post-operative period. Visual acuity, refraction, digital
widest part of root. tonometry, fundus, optic nerve status and visual fields should be
checked at each follow up. The health of the mucous membrane,
protrusion and stability of the optic cylinder should be looked for.
The need for long term follow up should be emphasized upon.

Stage II Complications

This is performed 3 months after stage IB+IC The procedure is associated with complications (listed in Table
2). Awareness regarding these complications is necessary for early
The ODAL is dissected off from the subcutaneous pouch and recognition and appropriate management4-6.
examined for its integrity prior to proceeding with ocular surgery.
Once the intactness of the lamina is confirmed, the ocular surgery Conclusions
is commenced by reflecting the mucous membrane.
MOOKP provides a stable and superior long term visual
The central cornea is trephined according to the posterior rehabilitation in patients with end stage ocular surface disorders.
diameter of the cylinder. The ODAL is placed with the cylinder Though an extremely demanding and time consuming surgical
centered over the corneal trephination and sutured.(Figure 9-11) procedure, the rewards are extremely satisfying which makes the
The centration is confirmed by indirect ophthalmoscopic effort worthwhile.
findings of a well centered optic disc and macula and is altered
by appropriately placed tension sutures if required. The mucous Very few centers worldwide offer the MOOKP procedure. The
membrane is finally reflected back on the lamina with a central “Prof. G. Falcinelli MOOKP Center” at Sankara Nethralaya,
trephination through which the anterior cylinder protrudes Chennai, is an exclusive center for performing this surgery
out 1-3. (Figure12) dedicated to the visual rehabilitation of end stage ocular surface
disorders, with a team of surgeons trained by Prof G Falcinelli. So
Postoperative Management far, 21 cases of MOOKP have been successfully completed with
visual acuity of > 6/12 in 70% of the cases at a mean 9 month
Perioperatively, systemic and topical antibiotics are administered. follow up.
Systemic steroids and antiglaucoma medication are also prescribed

Figure 7. Excision of soft tissue from the lamina (ODAL) after removal from submuscular pouch. 65

www.dosonline.org

Table 2. Complications Mucous membrane/ODAL Oral

Ocular MMG thining Oroantral fistula
Glaucoma MMG necrosis Damage to parotid duct
Retroprosthetic membrane Expulsion of cylinder Damage to adjacent teeth
Vitritis Extrusion of prosthesis Mandibular fracture
Endophthalmitis
Retinal detachment

Figure 8. Corneal trephination after reflecting Figure 9. Implantation of ODAL.
the mucous membrane graft.

References

1. Hille K, Grabner G, Liu C, et al. Standards for modified
osteoodontokeratoprosthesis (OOKP) surgery according to
Strampelli and Falcinelli: the Rome-Vienna Protocol.Cornea.
2005;24:895-908.

2. Falcinelli G, Falsini B, Taloni M, et al. Modified osteo-odonto-
keratoprosthesis for treatment of corneal blindness:long-term
anatomical and functional outcomes in 181 cases. Arch Ophthalmol.
2005;123:1319-29.

3. Liu C, Paul B, Tandon R, et al. The osteo-odonto-keratoprosthesis
(OOKP).Semin Ophthalmol. 2005;20:113-28. Review.

4. Stoiber J, Forstner R, Csaky D, et al. Evaluation of bone reduction

in osteo-odontokeratoprosthesis (OOKP) by three-dimensional

Figure 10. Final appearance of the eye (Post - op best computed tomography. Cornea. 2003;22:126-30.

corrected vision 6/6 with 1 year follow-up). 5: Stoiber J, Csaky D, Schedle A, et al. Histopathologic findings in

explanted osteo-odontokeratoprosthesis. Cornea. 2002;21:400-4.

Acknowledgements 6: Falcinelli GC, Falsini B, Taloni M, Piccardi M, Falcinelli G. Detection

We are extremely grateful to Prof Giancarlo Falcinelli and Dr of glaucomatous damage in patients with osteo-
Giovanni Falcinelli for their initiation and continued support of odontokeratoprosthesis.Br J Ophthalmol. 1995;79:129-34.

the MOOKP procedure at Sankara Nethralaya.

First Author
Ramendra Bakshi MS

66 DOS Times - Vol. 13, No.1, July 2007



Retinal Pigment Epithelial Tear After Intravitreal Retina
Anti-VEGF Injection

Atul Kumar MD, FAMS, Subijay Sinha MD, Yog R. Sharma MD, Raj V. Azad MD

We are reporting Retinal Pigment Epithelial (RPE) tears
following intravitreal injections of both Lucentis
(ranibizumab) and Avastin (bevacizumab) which are currently
being used extensively for managing exudative AMD.1 -3
RPE tears are known to occur after various treatment modalities
for choroidal neovascular membranes, including thermal laser
photocoagulation, photo-dynamic therapy (PDT) or even
spontaneously.1 Administration of intravi-treal bevacizumab and
ranibizumab had prior informed consent in all patients.

Case 1 Figure 1. Pre Avastin (1.25mg) intravitreal
shows large PED with sub retinal fluid suggesting occult CNV.
A 62 year old man had a 3 week history of metamorphopsia in the
left eye. His best corrected visual acuity (BCVA) was 20/200 in
the left eye. Ophthalmoscopy of the left fundus followed by OCT
revealed subretinal fluid, hemorrhage and a retinal pigment
detachment (PED). (Figure 1) Fluorescein angiography showed
an occult choroidal neovascular membrane. He was administered
1.25mg intravitreal bevacizumab. Four weeks later he returned
because of sudden vision loss. His visual acuity measured 2/200.
Fluorescein Angiography (FA) and OCT revealed a large RPE tear.
(Figure 2a and 2b).

Case 2 Figure 2a. 4 weeks post Avastin reveals ballooning of RPE
with defect (depicted by arrow) suggesting RPE rip.
A 74 year old man complained of blurred vision in his left eye for
several weeks. BCVA was 20/160 in the right eye.

Ophthalmoscopy followed by angiography and OCT confirmed
the diagnosis of occult CNV with associated PED. He was also
administered 1.25mg intravitreal bevacizumab. Four weeks later
his visual acuity deteriorated to 20/400. Ophthalmoscopy showed
a RPE tear.

Case 3

A 58 year old woman presented with BCVA of 20/200 and was Figure 2b. FFA of the same eye confirms parafoveal RPE
diagnosed with occult choroidal neovascular membrane with rip in late phase angiogram.
associated PED. She was injected 0.5 mg ranibizumab. She also
complained of metamorphopsia and her visual acuity dropped to intra PED fluid by the anti-VEGF action of monoclonal antibodies
20/800 in the fourth week.OCT and angiography revealed a RPE can rip the stretched RPE leading to severe visual disturbance as in
tear. our cases.4, 5

Several mechanisms may contribute to the pathogenesis of RPE We would recommend that occult CNV with extremely large PEDs
tears. In choroidal neovascularization, new vessels invade the suggesting taut, thinned out stretched pigment epithelium, could
Bruch’s membrane and lead to a serous RPE detachment. best be treated either by a lower dose of anti VEGF drugs to cause
Tangential shearing forces may then cause a spontaneous RPE tear. a gradual shrinkage of choroidal vessels and slow resorption of
Laser treatment may also cause sudden contraction of fibrovascular fluid, or treated conservatively if no recent disease progression or
tissue, leading to a RPE rip. Alternatively shrinkage of the choroidal
vessels secondary to anti-VEGF drug, and rapid resorption of

Vitreous-Retina Services
Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi-110029

www.dosonline.org 69

drop in vision is reported. However this visually catastrophic 3. Coscas G, Coscas F, Soubrane G. Clinical case of management with

complication should be kept in mind in occult CNV with intravitreal injection of Ranibizumab (Lucentis) on AMD

relatively larger pigment epithelial detachments undergoing anti- predominant occult CNV: 6-month follow-up with FA, ICG-A, and
VEGF therapy. OCT] J Fr Ophtalmol. 2006 Sep; 29(7):731-7.

References 4. Spandau UH, Jonas JB.: Retinal pigment epithelium tear after
intravitreal bevacizumab for exudative age-related macular

1. Goldstein M, Heilweil G, Barak A, Loewenstein A.Retinal pigment degeneration. Am J Ophthalmol. 2006 Dec; 142(6):1068-70.

epithelial tear following photodynamic therapy for choroidal 5. Bakri SJ, Kitzmann AS. Retinal pigment epithelial tear
neovascularization secondary to AMD. Eye. 2005; 19:1315-24.
after intravitreal ranibizumab. Am J Ophthalmol. 2007

2. Yoganathan P, Deramo VA, Lai JC, Tibrewala RK, Fastenberg DM. Mar; 143(3):505-7.

Visual improvement following intravitreal bevacizumab (Avastin)

in exudative age-related macular degeneration. Retina. 2006 Nov-

Dec; 26(9):994-8.

First Author
Atul Kumar MD

70 DOS Times - Vol. 13, No.1, July 2007

Orbitotomy Ophthalmoplasty

Noornika Khuraijam MS, DNB, Neelam Pushkar MD, Mandeep Singh Bajaj MD

Orbital mass lesions are variable in nature and location. Their Extraconal
management can be challenging, and surgical intervention Space
is often needed. Although a significant percentage of these tumors
can be treated by the ophthalmologist alone, often collaboration Subperiosteal
with a neurosurgeon or an otorhinolaryngologist is required, Space
especially for tumors that are located deep within the orbit, are
large, or have an extension into the paranasal /nasal spaces or
intracranial spaces.1

Though orbital surgeries can be difficult and related with various
complications, advances in imaging modalities as well as in surgical
techniques have decreased surgery related morbidity and increased
its success.

Surgical Spaces

Before we attempt to explain about the various orbitotomy Intraconal
approaches and procedures, a brief revision of the surgical spaces Space
within the orbit is required Tenons Space

Principally there are 4 surgical spaces in the orbit (Figure1) Figure 1. Zones of the orbit

• The subperiosteal orbital surgical space- which is the potential Middle Anterior
space between the bone and the periorbita.
Apical
• The extraconal surgical space (peripheral surgical space)-
which lies within the periorbita and the muscle cone

• The intraconal surgical space (central surgical space)- which
lies within the muscle cone

• The episcleral space- which lies between the tenons capsule
and the globe.

Further the orbit can be divided into 3 zones- (Figure 2)

Zone 1- anterior

Zone 2 – middle

Zone 3 – deep or apical

In general anterior lesions are treated via an anterior approach, Figure 2. Surgical spaces of the orbit.
whereas lesions in the middle third usually require a lateral
orbitomy approach. The deeply situated lesions in the apical zone Hemoglobin level should be assessed and blood grouping done
may require a medial orbitotomy or external ethmoidectomy with the coordination of a blood bank, lest transfusion is required
approach or, an intracranial approach. intraoperatively.

Preoperative Evaluation • Informed consent should be obtained ensuring that the patient
understands the risk of surgery which mainly includes
Preoperatively there are certain factors that are important to be diplopia, ptosis, visual loss and recurrence.
kept in mind before proceeding with an orbitotomy.
• Anterior orbitotomy for a very anterior lesion or for the
Firstly the patient should be properly prepared for surgery, purpose of biopsy may be undertaken under local anesthesia.
particularly with regard to the management of hypertension and Most of the orbital surgeries are however to be planned in
the use of anticoagulant and antiplatelet agents. general anesthesia. The anesthetist should understand the
surgical approach and the requirements for head positions,
Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences,
New Delhi-110029

www.dosonline.org 71

Figure 3. -bipolar and cutting cautery. Figure 4. - Postoperative patient with
drain in place.

nasal packing, the use of vasoconstrictive agents, potential excisional biopsy is indicated for the removal of a well-
risk of oculocardiac reflex, the anticipated length of the circumscribed lesion suggestive of a benign process.
surgery and the requirement of postoperative pain medication.
Familiarity with surgical approaches as well as with the required
• It is essential that the patient’s CT/MRI scans are available. instrumentation can only be gained by experience. It is essential
These should be clearly visible on a viewing screen adjacent to observe and assist at a variety of surgical approaches to the orbit
to the OT table. They should be reviewed before the before undertaking this surgery.
orbitotomy is commenced and the correct side confirmed
Surgical approach within the orbit requires a delicate patient
• The appropriate surgical instrumentation should be made approach.2 Lesions can often be palpated with the tip of the little
available. A potential change in the approach depending on finger that can greatly assist orientation. Gentle blunt dissection
the intraoperative findings should be anticipated and the should be undertaken.
necessary instrumentation made available.
Good hemostasis is required for a successful orbital surgery.
• It is also important to complete pathology request forms and Generous use of bipolar cautery (Figure 3) is required. But it is to
discuss with the pathologist prior to surgery. be remembered that tissue to be submitted for histopathological
examination should not be damaged by cautery. Sometimes a drain
Principles of Orbital Surgery (Figure 4) may have to be kept in place after the surgery to prevent
postoperative hematoma formation.
The prerequisites for a successful atraumatic orbital surgery are:
Types of Surgical Approaches
• A thorough knowledge of orbital anatomy and its tumors
There are two types of surgical approaches:
• A complete understanding and correct interpretation of
imaging techniques. • The Transorbital approaches, which are undertaken by the
ophthalmologist alone, and
• Familiarity with the surgical approaches. Familiarity with the
required surgical instrumentation. • The Extraorbital approaches, which are best, performed in
collaboration with a neurosurgeon or an ENT surgeon.
• Proper illumination and magnification of the surgical field. Various incision can be given for orbitotomies (Figure 5).

• Meticulous surgical dissection. Good haemostasis. Transorbital Approaches

A complete evaluation of the patient should be done. Differential There are four primary transorbital approaches: (Figure 5)
diagnosis based on a thorough history, clinical picture, imaging
and lab investigations should enable an appropriate decision. CT • Anterior orbitotomy
scanning is excellent for the original detection of a mass & to
differentiate between dysthyroid orbitopathy from a diffuse orbital • Lateral orbitotomy.
mass, from a resectable well-encapsulated lesion. It also allows the
visualization of the mass in relation to the bony orbit. MRI on the • Medial orbitotomy
other hand allows the surgeon to differentiate the mass from the
optic nerve and to establish the vascularity of the tumor. It is worth • A combination of the above.
mentioning that along with MRI/CT scans, ultrasound imaging
(also cost effective) plays an important role, in the diagnosis of Upper eyelid crease can be done via the transeptal route
the lesion. B scan echography of the orbit can tell us the internal (Figure 6), which provides entry into the peripheral surgical
reflectivity of the tumor helping us to differentiate a solid lesion space. This incision provides good surgical approach and the scar
from a cystic or vascular one. is hidden. The extra periosteal route upper eyelid incision provides
exposure to the superior orbital rim where the periosteum can be
As a general rule, an incisional biopsy will be required for a lesion incised allowing entry into the subperiosteal space. This is mainly
that is suggestive of malignancy or inflammation, whereas an indicated for evacuating a sub periosteal hemmorhage or abscess
(Figure 7)

72 DOS Times - Vol. 13, No.1, July 2007

Figure 5. Orbitotomies. 1 – Lynch, Figure 6. Anterior orbit being Figure 7. CT scan picture showing
2 – Gull wing, 3- upper eyelid crease, approached by transeptal route. subperiosteal hematoma.
4-Subciliary, 5- Berke’s, 6- Stallard Wright.

Transconjunctival incision can be used to access the episcleral, • Now the periorbita is exposed.
central, or peripheral surgical spaces. •
Proper hemostasis in the extraocular structures is to be
Subciliary incision allows dissection beneath the orbicularis muscle • ensured before the periorbita is opened.
to expose the inferior orbital septum and orbital rim, minimizing
visible scarring. This can be done to expose the peripheral surgical • The globe can be retracted medially by traction sutures to
space. ensure a wide area of exposure.

Lateral orbitotomy is usually indicated when a lesion is located Once the periorbita is cut the orbital fat prolapses. This might
within the muscle cone, behind the equator of the globe or in the obscure the view. It is absolutely essential that we dissect the
lacrimal gland fossa.3 orbital fat with blunt dissection and not cut it. With a blunt
dissection the orbital fat is retracted to expose the mass.
In our center lateral orbitomy is usually done using a Stallard- •
Wright incision.(Figure 5) A brief summary of the steps of the • Now the mass is to be freed from the surrounding structures
surgery is- • by blunt dissection.

• An S- shaped incision extending from the eyebrow laterally A proper wide area of the mass is to be exposed to allow a
and curving down along the zygomatic arch is given. It is cryo probe to be placed on the mass for extraction.
essential to provide proper hemostasis while dissecting by use
of bipolar cautery or a Bovies cautery for cutting. Proper Once the cryo is placed, proper formation of the ice ball is to
exposure by means of traction sutures or retractor held by be ensured before making rocking movements with the cryo
the assistant is necessary. probe. With slow rocking motion along with blunt dissection
the mass is freed from its adhesions and it can be removed
• The periosteum and the temporalis muscle are reflected from with ease.

the zygoma. • It is important not to pull on the cryo probe. This might lead
to tearing of the mass and its capsule leading to difficulty in its
• Two osteotomies are made using the Strykar bone saw. The removal.
superior one is superior to the zygomatico temporal suture
and the inferior one is just superior to the inferior orbital rim. • After proper hemostasis the wound is closed in layers.
The zygoma is removed and kept aside for re-fixation after
the procedure.

Figure 8. - A patient requiring transcranial approach. Proptosis caused by a large meningioma arising from 73
the frontal region after eroding the orbital roof as seen in the CT scan.

www.dosonline.org

• The bone may be fixed to the area with microplates and • Good hemostasis

screws. The periosteum, muscle and skin are closed in layers. • Consultation with a neurosurgeon or otorhinolaryngologist

• A vacuum drain may be sutured in place (or both) where appropriate

Medial Orbitotomy via the Lynch approach can be done to reach The most serious complication is decreased or lost vision that can
the medial subperiosteal space or to reach a tumor near the lacrimal be caused by traction, or contusion of the optic nerve.
sac, frontal or ethmoidal sinus. The medial canthal tendon can be
reflected with the periosteum and therefore does not need to be A patient with severe pain postoperatively should be evaluated for
incised. possible orbital hemorrhage.

Combined orbitotomy- The orbitotomies described above may be Other complications include extra ocular muscle damage, ptosis,
used in combination if necessary. Access to the medial orbitial neuroparalytic keratopathy, pupillary changes, vitreous
apex for example can be improved by combining a medial hemorrhage, detached retina, hypoesthesia of the forehead,
orbitotomy with a lateral orbitotomy keratitis sicca, CSF leak, and infection.

Extraorbital Approaches Conclusions

There are two primary extraorbital approaches: To conclude, orbital tumors may be approached by various routes
depending on the location of tumor and goal of surgery. With the
• The trans cranial approach advances in Neuroimaging and USG over the last decade, it has
become more accurate in the evaluation and hence in the
• The inferior orbital approach. appropriate therapy for a patient with orbital disorders. A
multidisciplinary approach is often required involving a team
These approaches are usually done in conjunction with a which consists of an oculoplastic surgeon, neurosurgeon, ENT
neurosurgeon or an otorhinolaryngologist and will not be surgeon, radiologist and pathologist. In all orbitotomy can be a
discussed in detail here. (Figure 8) rewarding surgery provided that meticulous care is taken in
undertaking the right approaches.
Complications

Complications of Orbital Surgeries can be reduced by Reference

• A complete pre-op evaluation 1. Leatherbarrow B : Oculoplastic surgery 1st edition. Chapter 17

• Surgical incision enabling the appropriate approach (away Surgical approaches to the orbit 203 – 224, Martin Dunitz Ltd. UK
from the optic nerve) 2002

• Adequate exposure 2. Rootman J: Orbital surgery A Conceptual Approach. Lippincott-
Raven 1995

• Careful manipulation of tissues 3. Smith Byron: Ophthalmic plastic & reconstructive surgery. Orbital
surgery 853- 869 Mosby. 1998

First Author
Noornika Khuraijam MS, DNB

Missed DOS Times Copy

If your have missed your copy of DOS Times.

Please Contact:
Secretary DOS : Dr. Namrata Sharma

Room No. 474, 4th Floor,
Dr. Rajendra Prasad Centre for Ophthalmic Sciences

All India Institute of Medical Sciences,
Ansari Nagar, New Delhi – 110029

Ph.: 91-11-65705229, Fax: 91-11-26588919,
E-mail: [email protected],
Website: www.dosonline.org

74 DOS Times - Vol. 13, No.1, July 2007

Medica International

Measurement of Stereoacuity Squint

Rohit Saxena MD, Vimla Menon MD

Stereopsis is the perception of depth on the basis of binocular
disparity. Tests of near stereoacuity are commonly available,
eg. TNO, Randot, Frisby. The measurement of distance
stereoacuity provides useful information regarding the
management of strabismus primarily affecting distance fixation
as in cases of Intermittent Divergent strabismus.

Measurement of stereopsis to distant targets is possible using the FD2 stereotest using animal shapes.
synoptophore, the AO Vectographic Project-O-Chart Slide test,
and the Mentor II-SG B-VAT (Baylor Video Acuity Test-Mentor • Negative: comprehension established at 1 metre but incorrect
system 2). The latter two tests require the patient to wear spectacles. responses for two presentations at the largest disparity at
The AO Vectographic Project-O-Chart Slide test uses polarising 6 metres and then also at 3 metres.
lenses on a phoropter, generating disparities from 480-30 seconds
of arc. The Mentor II-SG B-VAT uses liquid crystal goggles and • Responder: comprehension established and stereoacuity
generates disparities from 240-15 seconds of arc. However, most measured to threshold, either at 6 metres or 3 metres.
of the studies using these methods of distance stereopsis
measurement have been performed on patients who are 5 years The FD2 is constructed as a real depth, free space test enabling
and older and as the majority of cases of pediatric strabismus assessment of stereoacuity without dissociating the eyes. This type
present before the age of 5 years, these tests have had limited clinical of construction reflects binocular viewing as it occurs in everyday
application. Moreover, both these tests are no longer easily life but there is the potential to allow positive responses based on
available. perception of monocular cues.

Currently, two new tests for distance stereoacuity have been Distance randot test: This test is designed to evaluate 3 levels of
introduced and are undergoing evaluation. They are the Frisby- disparity (800,200 and 60 arc sec) using vectographic random
Davis Distance (FD2; Frisby Stereotest, Sheffield, UK) and the dot stimuli and are mounted on books to be viewed through
Distance Randot (DR; Stereo Optical Co., Inc., Chicago, USA). polarizing glasses. The test consists of 6 books (2 books for
each level of disparity; each book containing 2 vectographs). For
The Frisby Davis distance stereotest (FD2). This is a child each disparity level, there are 3 vectographs that contain a
friendly, free-space test of real depth. The FD2 test comprises a stereotarget and 1 vectograph is blank. The stereotargets are simple
box containing four back illuminated and differently shaped plastic geometric shapes. The subjects have to view the books at a distance
objects mounted on rods. These are either four animal or four of 3 m. Testing is started with the coarse disparity (800 sec of arc)
geometric shapes set in a transparent frame pointing towards the and proceeded to progressively smaller disparity. To enhance
observer. The shapes are translucent but sufficiently dark to testing in small children, matching cards can be provided. If the
obscure the rods, giving the appearance that the shapes are free subject identifies or matches 2 out of 3 of the stereotargets, the
floating. One shape is set by the examiner to be nearer to the level is passed. Stereoacuity value is the smallest level of disparity
observer at each presentation and the test requirement is to identify passed.
this target. The size of disparity presented is altered by the amount
by which the rod is set to protrude and by the distance of the Comparison of the two tests: Although both the tests are relatively
observer from the targets, generating disparities from 200-4 new, few studies have compared the two tests in controls and cases
seconds of arc. The child is asked to name the animal shapes from of IDS. Studies show that the real world contour based targets of
a distance of 1 metre from the box. One shape is set to protrude the new distance FD2 appear to stimulate fusion in cases of IDS
and the child is asked to identify which animal "jumped out" of and may show a good level of stereopsis despite having poor
the box. The testing is then performed starting with the largest control. In contrast, the Distance randot has an elevated threshold
disparity at 6 metres. If the child cannot respond accurately at 6 and is very sensitive to even minor changes in binocularity. The
metres then the distance is reduced to 3 metres and the procedure reason for this could be due to the lack of monocularly visible
repeated. contours in the latter.

There are three possible outcomes on the test, recorded as follows:

• Non-responder: unable to comprehend the test when presented
with the largest disparity at 1 metre.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences,
New Delhi-110029

www.dosonline.org 77

Near Stereoacuity surrounding portion. Viewed against a featureless background, for
example a sheet of white paper, and with head and test held
The Titmus Test reasonably steady, the only clue to depth perception is binocular
parallax. In this case it is the difference between the two levels,
In the Titmus test, devised by Wirt in 1971, the subject wears a related to the distance from the observer, and the PD, which gives
polarizing spectacle to separate two superimposed polarized the measure of the stereo acuity. The test can be held at any of six
monocular images. The picture for the left eye is polarized at 450 distances, from 30cm to 80cm, the distance being controlled by
and that for the right eye at 1350, and the viewers correspondingly the use of a tape attached to the test and held by the patient against
orientated. The test comprises of three subtests. The first is a large the check. The tape is folded and marked in 10cm divisions,
picture of a fly, in which parts of the monocular pictures are facilitating accurate positioning. The six positions, combined with
separated by some 7.5mm, which, held at a viewing distance of the three thicknesses of plates, provide 18 values of stereo acuity,
30cm from the eyes, and demonstrates only the presence of gross from 880 seconds of arc to 20 seconds.
stereopsis. This is intended as a demonstration of the test to the
patient, and, by its striking nature attracts the attention and interest Random Dot Stereograms
of children.
Random dot stereograms were introduced about 1959, and in 1969
The next subtest consists of a series of nine squares in each of printed on cards to be viewed in a stereoscope with some separating
which are four circles. In each set of four, one circle is made device. They have the advantage of excluding the possibility of
stereoscopic and the subject has to detect which of the four is seen any extraneous clues contributing to the sensation of depth--
to 'stand out'. Each successive set of circles represents an increasing movement parallax, size, perspective, experience, etc. The principle
degree of stereopsis, from 800 seconds of arc to 40 seconds. is the same as in pictorial stereograms except that nothing is
recognizable when viewed monocularly. In a small area of each of
The third of the Titmus subtests is three rows of animal pictures. the dot patterns, the dots are displaced with respect to the
One animal in each row appears to stand out, and the three rows surrounding dots, so that when viewed binocularly the separation
represent stereo acuities of 400 seconds, 200 seconds and 100 between the small areas is different to the separation of the
seconds respectively. remainder of the 'picture'.

The Frisby Test The patterns do not necessarily have to be composed of dots. They
can be lines, letters, figures or shapes, but the essential feature is
The Frisby test is designed to present targets which are actually 'in the random arrangement over the area. Because of the random
depth'. The pictures are random dot patterns. In this test, no arrangement of the characters, no difference is visible when viewed
spectacles or other separating device need be worn by the patient. monocularly, but when seen binocularly the central area appears
The targets are actually 'in depth', being printed on the two sides at a different distance from the observer, and therefore
of transparent plates of different thicknesses. There are three plates, stereoscopically. The amount of displacement of the small area,
1mm, 3mm and 6mm thick respectively. Each plate has four relative to the distance at which it is viewed, and the PD, is the
squares of random dot patterns, one square having the central measure of the stereo acuity.
portion printed on the opposite side of the plate from the

First Author
Rohit Saxena MD

Answer Quiz No. 1

Extra word: OPHTHALMIC

5. PROPTOSIS 8. DACRYOCYSTITIS 9. BEHCETS 7. BIOMETRY 6. GONIOLENS
10. AMAUROSIS
4. SYNOPTOPHORE 3. KERATITIS 2. RETINOPATHY 1. HYPERMETROPIA

78 DOS Times - Vol. 13, No.1, July 2007

Post Operative Malignancy Photo Essay

Gopal S. Pillai MD, DNB, FRCS, Niranjan Pehere DNB, Anuradha Rao MS, DO, Meenakshi Dhar MS

• 65-year-old gentleman with painless diminution of vision in Discussion
left eye since cataract surgery in the left eye.
Since the patient came with a hypopyon immediately following a
• Operated for cataract in right eye 2 years back. cataract surgery, a possibility of postoperative endophthalmitis was
also kept. However absence of other signs of inflammation and
• Left Phaco and IOL 3 weeks back (Figure 1a) the obvious presence of choroidal masses in both eyes spelt the
diagnosis. (Figure 2a, 2b)
• BCVA 6/6 OD and 6/24 OS.
The importance of diagnosing choroidal metastasis in the setting
A provisional diagnosis of secondary malignancy of the choroid lies in drastic change in management options in the case. This also
in both eyes and infiltration of the optic nerve in the left eye and shows the importance of a dilated retinal examination in all cases
pseudohypopyon was made (Figure 1b). A search for primary as
conducted.

Figure 1a. Posterior chamber intraocular Figure 1b. Left eye hypopyon.
lens in right eye.

Figure 2a. Right eye showed choroidal mass in Figure 2b. On fundus examination, there was left optic disc
the superotemporal quadrant. edema and exudative retinal detachment and RPE changes

Amrita Institute of Medical Sciences, around the optic nerve.
Cochin, Kerala
79
www.dosonline.org

Figure 3a. FFA showed disc leakage and multiple areas of Figure 3b. USG B scan was done which showed
staining in the left eye. optic disc edema in the left eye.

Figure 4. CT scan of the abdomen showed polypoidal growth Figure 5. HPE picture showing poorly differentiated
along lesser curvature of stomach extending upto gastroesophageal adenocarcinoma of stomach.

junction and proximal esophagus with enlargement of
multiple preaortic and peripancreatic lymph nodes.

of uveitis. Ultrasound B scan and a fundus fluorescein agniography esophagus and jejunum (Figure 4, Figure 5). Patient succumbed in
were done. (Figure 3a, 3b) 3 months, despite chemotherapy and radiation.

Within few months he developed metastasis to right submandibular Consider masquerade syndrome in older age group even in a
salivary gland and recurrence at the site of anastomosis between postoperative setting.

First Author
Gopal S. Pillai MD, DNB, FRCS

80 DOS Times - Vol. 13, No.1, July 2007

Allied Medical

Contact Lens Solution Related Acanthamoeba Industy News
Keratitis-‘Alert’

Vishal Jhanji MD

A few days ago the United States Food and Drug Administration a film within contact lens cases that blocked disinfectant properties
(FDA) released a Public Health Notification regarding needed to destroy the fungus (Fusarium) causing the eye infections.
Acanthamoeba keratitis. Health care professionals and their patients The same film or coating from the contact lens formula that
who wear soft contact lenses were alerted about a voluntary recall of enhanced wearer comfort may have created an environment in
Complete Moisture Plus Multi Purpose Solution manufactured by which the fungus actually thrived (July 2006 issue of The Lancet
Advanced Medical Optics of Santa Ana, California. The company Infectious Diseases).
took this action as a precaution because of reports of a serious eye
infection, Acanthamoeba keratitis, in users of contact lens solution Overview of 2006 Fungal Eye Infection Outbreak
manufactured by their company. The link between the solution and
the infection was identified as a result of an investigation by the First Outbreak in Asia: In February 2006, clustered outbreaks of
Centers for Disease Control and Prevention (CDC). fungal keratitis eye infections were reported among contact lens
wearers in Singapore and Hong Kong, where investigators
It is estimated that Acanthamoeba keratitis infections occur in identified an association with Bausch & Lomb ReNu with
approximately 2 out of every 1 million contact lens users in the MoistureLoc contact lens cleaning solution. Malaysia also reported
United States each year. However, in a multi-state investigation to outbreaks associated with the contact lens solution. These unusual
evaluate a recent increase in Acanthamoeba keratitis cases, CDC numbers of Asian cases reportedly were first noticed beginning in
determined that the risk of developing Acanthamoeba keratitis was the fall of 2005.
at least seven times greater for those consumers who used
Complete MoisturePlus solution versus those who did not. U.S. Outbreak: In early 2006, increasing numbers of fungal eye
infections primarily among contact lens wearers also began
The consumers who wear soft contact lenses were alerted against showing up in the United States largely in association with the
the use of this solution. They were advised to discard all partially- same contact lens cleaning/disinfectant solution.
used or unopened bottles and replace their lenses and storage
container. The company’s action was remarked as a responsible European Outbreak: In early May, news reports indicated that a
step taken in the interest of public health. few fungal keratitis eye infections were being investigated in Europe
to determine any possible link to use of contact lens solutions.
Consumers were asked to consult their doctors about choosing an
appropriate alternative cleaning and/or disinfecting contact lens Lately, the CDC issued a common notice in public interest
solution and seek immediate treatment if they have symptoms of declaring that all contact lens users should closely adhere to the
eye infection as early diagnosis is important for effective treatment. following measures to help prevent eye infections:
The symptoms of Acanthamoeba keratitis can be very similar to
those of other more common eye infections and may include pain, • Remove contact lenses before any activity involving contact
redness, blurred vision, light sensitivity, foreign body sensation or with water.
excessive watering. Acanthamoeba keratitis may lead to vision loss
and corneal ulceration which may subsequently require a corneal • Wash hands with soap and water and dry them before
transplantation in some patients. handling contact lenses.

In late 2006, the U.S. Food and Drug Administration had issued a • Clean contact lenses according to instructions from an eye
warning letter saying Bausch & Lomb had inappropriately delayed care professional.
reporting fungal eye infections associated with its ReNu with o Use fresh cleaning or disinfecting solution each time
MoistureLoc contact lens solution, which now has been lenses are cleaned and stored.
permanently withdrawn from U.S. and global markets. o Never use saline solution and rewetting drops to disinfect
lenses.
In early 2006, soft contact lens wearers were warned about a
possible link between use of the once popular contact lens cleaning/ • Schedule regular eye exams with your eye care professional
disinfectant solution ReNu with MoistureLoc and development • Wear and replace contact lenses according to the schedule
of a potentially serious fungal keratitis eye. In mid May of that
year, Bausch & Lomb voluntarily withdrew ReNu with prescribed by your eye care professional.
MoistureLoc products worldwide while investigations continued. • Store lenses in a proper storage case.

Accumulated evidence indicated an association between the o Storage cases should be irrigated with sterile contact lens
specific formula in ReNu With MoistureLoc and development of solution (never use tap water) and left open to dry after
each use.

o Replace storage cases at least once every three months.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, Author
All India Institute of Medical Sciences, Vishal Jhanji MD
New Delhi-110029
83
www.dosonline.org

Classifying Patterns of Localized Glaucomatous Visual Abstracts
Field Defects on Automated Perimetry

Ramanjit Sihota MD, FRCS, Gupta V, Tuli D, Sharma A, Sony P, Srinivasan G

Glaucoma Research Facility and Clinical Services,
Dr Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi, India.
AIM

To classify the classic patterns of glaucomatous visual field defects on automated perimetry and to study their proximity to fixation.
STUDY DESIGN

Cross-sectional observational study.
MATERIALS AND METHODS

About 1120 full threshold 30-2 reliable visual fields of glaucoma patients were analyzed by 2 glaucomatologists. Classically described
patterns of visual field defects were identified on the pattern deviation plot and definitions proposed. Interreader agreement between
3 independent (not involved in the classification) readers was determined. Proximity to fixation of the different patterns was assessed.
RESULTS

Interreader agreement with 3 readers was found to be 93% or more between any 2 readers using the present system of classification.
Central fixation was seen to be involved in 45% of the glaucomatous visual field defects studied overall.
CONCLUSIONS

The proposed definitions of topographical glaucomatous field defects based on the pattern deviation probability plot are simple to use
in clinical practice with good interreader agreement.

One Donor Cornea for 3 Recipients: A New Concept for
Corneal Transplantation Surgery

Vajpayee RB, Sharma N, Jhanji V, Titiyal JS, Tandon R.

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

OBJECTIVE

To describe the use of a single donor corneal tissue in 3 patients with corneal pathologic conditions.

METHODS

A donor corneal tissue was divided into 3 parts using a microkeratome and a trephine. The anterior lamellar disc was transplanted into
a patient with macular corneal dystrophy using the automated lamellar therapeutic keratoplasty technique. The posterior lamellar disc
was transplanted into a patient with pseudophakic bullous keratopathy using the Descemet stripping automated endothelial keratoplasty
technique. The peripheral corneoscleral rim was used for limbal stem cell transplantation in a child with limbal stem cell deficiency.

RESULTS

All surgical procedures were performed successfully. At 3 months, the best-corrected visual acuities achieved following automated
lamellar therapeutic keratoplasty, Descemet stripping automated endothelial keratoplasty, and limbal stem cell transplantation were
20/60, 20/40, and 20/200, respectively.

CONCLUSION

The advent of customized component corneal transplantation techniques may allow the use of 1 donor cornea to treat multiple patients.

www.dosonline.org 85

Deep Anterior Lamellar Keratoplasty by Big-Bubble
Technique for Treatment Corneal Stromal Opacities.

Vajpayee RB, Tyagi J, Sharma N, Kumar N, Jhanji V, Titiyal JS

Centre for Eye Research Australia,
University of Melbourne Melbourne, Australia.
[email protected]

PURPOSE

To evaluate the efficacy of using the big-bubble technique of deep anterior lamellar keratoplasty (DALK) for newer indications.

DESIGN

Prospective, noncomparative, interventional case series.

METHODS

Ten eyes of eight patients with pathologies involving the corneal stroma and sparing the Descemet membrane (DM) were included in
this study conducted at a tertiary care hospital. The indications for DALK included corneal clouding attributable to
mucopolysaccharidoses (n = 2), macular corneal dystrophy (n = 5), lattice corneal dystrophy (n = 1), granular corneal dystrophy (n =
1), and stromal scar attributable to infectious keratitis (n = 1). DALK was performed using the big-bubble technique in order to achieve
the complete separation of DM from the corneal stromal tissue in the recipient’s eye. Subsequently, the corneal stromal tissue was
excised completely, and a full-thickness donor corneal lenticule without its DM was secured over the bared DM of the host. The main
outcome measures of the study were the ability to successfully bare DM, the gain in visual acuity, and the presence of any complications.

RESULTS

Using the big-bubble technique, DM was bared, and DALK could be performed successfully in all eyes. No intraoperative or
postoperative complications were observed. All patients achieved a best-corrected visual acuity (BCVA) of 20/40 or better at the end of
six months.

CONCLUSIONS

DALK using the big-bubble technique can be useful in treating corneal stromal dystrophies, corneal clouding attributable to
mucopolysaccharidoses, and stromal scar attributable to infectious keratitis.

Delhi Ophthalmological Society
Monthly Clinical Meeting

Venue : Centre For Sight, B 5/24, Safdarjung Enclave, New Delhi.

Date and Time : 29th July, 2007 Sunday 11 AM to 1 PM

Case Presentations:

• Management of RIOFB with Endophthalmitis : Our way Avnindra Gupta
• ICL upside down Archana Chafle
Clinical Talk:
Mahipal Sachdev
• Intralase Femtosecond laser

Symposium: Cutting Edge Technology

Chairman: Vijay K. Dada Co-Chairman: Hem K. Tewari, Lalit Verma

• Custom Match IOLs Deepender Chauhan
• Collagen Cross Linkage Ashu Agarwal
• Management of intractable glaucoma Harsh Kumar
• Combination therapy for ARMD Dinesh Talwar

Academic program will be followed by fellowship and lunch.

86 DOS Times - Vol. 13, No.1, July 2007

Prof Michael Blumenthal (1935-2007) Remembrance

*Ruchi Goel MS, DNB, FICS **KPS Malik MS, MNAMS, FICS

An innovative genius, dedicated teacher, dynamic researcher with a special sense of humor,
Prof. M Blumenthal succumbed to metastatic melanoma on 28th April’07 at the age of seventy two.

He contributed to the field of Ophthalmology throughout his distinguished career but is fondly
remembered for his ‘mini-nuc’ technique of Small incision cataract surgery (SICS).

Born in a family with both the parents being Ophthalmologists, Dr Blumenthal completed his basic Prof. Michael Blumenthal
medical training in Israel. He went to New York to do a fellowship in glaucoma at the Flower Hospital MD
of New York Medical College. At a young age, he undertook the responsibility as the Chairman of
Ophthalmology department at Soraka Hospital in Beer Sheba, Israel. In 1976, he became the head of
Ophthalmology at Sheba Hospital in Tel Aviv. Later he was appointed head of Ophthalmology Tel Aviv
University and started the Goldschlager Eye Research Institute in Tel-Hashomer Hospital. He initiated
the Israeli society of cataract surgery and was head of this organization for several years. He later went
into private practice and his institute ‘Ein-Tal’ is one of the largest and most respected Eye centers in
Israel.

He was one of the founders of the European Society of Cataract and Refractive Surgeons, then known
as EIIC and served as its president from 1995 to 1997. He was a member of International Intraocular implant club and International
Ocular Microsurgery study group. He was the chief editor of Israel Journal of Ophthalmology. He served on the editorial board of
Ophthalmic Surgery Lasers& Imaging and Ocular Surgery News Europe/Asia-Pacific edition.

In his career, he attended more than 200 Ophthalmology Congresses all over the world. His most significant contribution is development
of the ‘mini-nuc’ technique of SICS using Anterior chamber maintainer (ACM) where cataract could be removed, without
phacoemulsification machine through a relatively small self sealing incision. The small sized versatile tool, ACM is now being used in
numerous intraocular surgeries in lieu of viscoelastic material for the maintenance of anterior chamber like phacoemulsification, deep
lamellar endothelial keratoplasty, scleral fixation, e.t.c.

He performed extensive research in hydrophilic acrylic lens implants and was honoured the Jan Worst Medal lecture by his International
Intra-ocular Implant club colleagues. In addition to his innovations in surgery, he coined the term ‘epinucleus’.

He traveled around the world tirelessly teaching others his surgical skills. He popularized SICS globally and was the patron at the Indo-
Israel Ophthalmic congress at Chennai. Inspite of his busy schedule he never failed to personally respond to e-mail correspondence
by the authors.

In February 2007, when we all eagerly waited to attend his * Guru Nanak Eye Center,
Instruction course at the Annual conference of All India Maulana Azad Medical College, New Delhi
Ophthalmological Society at Hyderabad, he expressed his inability
to come. Little did we know that the person who had bestowed us ** Vardhman Mahavir Medical College,
with so much knowledge was battling with life…….. Safdarjung Hospital, New Delhi

Contributory Author
Ruchi Goel MS

Obituary 87

Dr. K. Ammini Menon “Karuna”, left for heavenly abode due to Renal failure on 19th January 2007, at Kallingal lane,
Thiruvambady, Thrissur. DOS offers deepest condolences to the grieved family members.

www.dosonline.org

Columns DOS Quiz

Anagram Time

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

So get cracking.

1. RACEMYPEPRITHO ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ____
____
2. LATHYPOINTER ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ____

3. SITTERAKAI ___ ___ ___ ___ ___ ___ ___ ___ ___

4. ENPOTHYPOROSO ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ____
____
5. ROOSTPIMPS ___ ___ ___ ___ ___ ___ ___ ___ ___ ____
____
6. GOOSELINNT ___ ___ ___ ___ ___ ___ ___ ___ ___ ____
____
7. TIEMYBORI ___ ___ ___ ___ ___ ___ ___ ___ ___

8. COSHYCRITYSTAID ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

9. SHEEPCBT ___ ___ ___ ___ ___ ___ ___

10. RUHISAMOSA ___ ___ ___ ___ ___ ___ ___ ___ ___ ____

Answers on page number 78 Saurabh Sawhney DO, DNB, Ashima Agarwal DNB, MS
Insight Eye Clinic, New Delhi

DOS Library

DOS Library has shifted from ground floor to 4th floor of Dr. R.P. Centre for Ophthalmic Sciences, All India Institute of
Medical Sciences, New Delhi-110029. The timings are from 9.30 A.M. to 6.00 P.M. on week days and 9.30 A.M. - 2.00 P.M. on
Saturday. The Library will remain closed on Gazetted Holidays. Members are requested to utilise the available facilities i.e.
Computer with Video Editing & Conversion facility VHS to VCD, Journals Viewing, Books and Journals etc.

Vinay Garodia
Library Officer,
Delhi Ophthalmological Society

Annual General Body Meeting

The Annual General Body Meeting of Delhi Ophthalmological Society will be held on Sunday the 26th August 2007
at 09.00 A.M. at Dr. R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi.
All members are requested to attend.

Namrata Sharma
Secretary,

Delhi Ophthalmological Society

88 DOS Times - Vol. 13, No.1, July 2007







Delhi Ophthalmological Society

(LIFE MEMBERSHIP FORM)

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

Clinic/Hospital/Practice _______________________________________________________________________
________________________________________________________________ Phone __________________
Residence _________________________________________________________________________________
________________________________________________________________ Phone __________________
Correspondence ____________________________________________________________________________
________________________________________________________________ Phone __________________
Email ___________________________________________________________ Fax No. _________________
Proposed by
Dr. _____________________________________ Membership No. ________ Signature ___________________
Seconded by
Dr. _____________________________________ Membership No. ________ Signature ___________________
[Must submit a photocopy of the MBBS/MD/DO & State Medical Council / MCI Certificate for our records.]

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

Signature of Applicant
with Date

Three specimen signatures for I.D. Card.

FOR OFFICIAL USE ONLY

Dr._______________________________________________________________has been admitted as Life Member of

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

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

drawn on __________________________________________________________________.

(Secretary DOS)

www.dosonline.org 93

INSTRUCTIONS

1. The Society reserve all rights to accepts or reject the application.
2. No reasons shall be given for any application rejected by the Society.
3. No application for membership will be accepted unless it is complete in all respects and accompanied by a Demand Draft of Rs.

3100/- in favour of “Delhi Ophthalmological Society” payable at New Delhi.
4. Every new member is entitled to received Society’s Bulletin (DOS Times) and Annual proceedings of the Society free.
5. Every new member will initially be admitted provisionally and shall be deemed to have become a full member only after formal

ratification by the General Body and issue of Ratification order by the Society. Only then he or she will be eligible to vote, or apply
for any Fellowship/Award, propose or contest for any election of the Society.
6. Application for the membership along with the Bank Draft for the membership fee should be addressed to Dr. Namrata Sharma,
Secretary, Delhi Ophthalmological Society, R.No. 474, 4th Floor, Dr. R.P. Centre for Ophthalmic Sciences, AIIMS, Ansari Nagar,
New Delhi - 110 029.
7. Licence Size Coloured Photograph is to be pasted on the form in the space provided and two Stamp/ Licence Size Coloured
photographs are required to be sent along with this form for issue of Laminated Photo Identity Card (to be issued only after the
Membership ratification).

REQUIRED

Vitroretinal Surgeon for well Established and Fully Equipped Modern Eye Centre
Contact: Dr. G.K. Bhatnagar

BHATNAGAR EYE CARE CENTRE
Opp Civil Hospital, KARNAL, Haryana - 132001

(M) 09812410022

94 DOS Times - Vol. 13, No.1, July 2007

Delhi Ophthalmological Society Fellowship for Partial
Financial Assistance to Attend Conferences

Applications are invited for DOS Fellowship for partial financial assistance to attend conference(s).

Conferences Points Awarded

International: Two fellowships per year (two fellowships can be 1) Age of the Applicant Points
awarded at a time if committee feels that papers are very good)
a) < 35 years 10
• Maximum of Rs. 25,000/- per fellowship will be sanctioned
b) 36 to 45 years 07
National: Three fellowships per year (only for AIOS)
c) 45 years plus 05
• Maximum of Rs. 5,000/- per fellowship will be sanctioned
2) Type of Presentation
Eligibility
a) Instructor/ Co-instructor of Course 12
• DOS Life Members (Delhi Members only)
b) Free Paper (Oral) / Video 07
• 75 or More DCRS Points
c) Poster 05
• Accepted paper for oral presentation, poster, video or instruction
course. 3) Institutional Affiliation

Time since last DOS Fellowship a) Academic Institution 15
Preference will be given to member who has not attended conference in
last three years. However if no applicant is found suitable the fellowship b) Private Practitioner 20
money will be passed on to next year. Members who has availed DOS
fellowship once will not be eligible for next fellowship for a minimum 4) DCRS Rating in the immediate previous year
period of three years.
a) 75-150 05
Authorship
b) > 150 08
The fellowship will be given only to presenting author. Presenting author
has to obtain certificate from all other co-authors that they are not c) < 75 not eligible for fellowship
attending the said conference or not applying for grant for the same
conference. (Preference will be given to author where other authors are Documents
not attending the same conference). If there is repeatability of same
author group in that case preference will be given to new author or new • Proof for age. Date of Birth Certificate
group of authors. Preference will also be given to presenter who is attending
the conference for the first time. • Original / attested copy of letter of acceptance of paper for oral
presentation / video / poster or instruction course.
Quality of Paper
• Details of announcement of the conference
The applicant has to submit abstract along with full text to the DOS
Fellowship Committee. The committee will review the paper for its • Details of both International & National Conferences attended in
scientific and academic standard. The paper should be certified by the previous three years.
head of the department / institution, that the work has been carried out
in the institution. In case of individual practitioner he or she should • Copy of letter from other national or international agency / agen-
mention the place of study and give undertaking that work is genuine. cies committing to bear partial cost of conference if any.
The fellowship committee while scrutinizing the paper may seek further
clarification from the applicant before satisfying itself about the quality • At least one original document should be provided, that is ticket,
and authenticity of the paper. Only Single best paper has to be submitted boarding pass or registration certificate along with attendance cer-
by the applicant for review (6 copies). Quality of the paper will carry 50% tificate of the conference.
weightage while deciding the final points.
• Fellowship Money will be reimbursed only after submission of all
Poster and Video the required documents and verified by the committee.

The applicant will need to submit poster and video for review. • Undertaking from the applicant stating that above given information’s
are true.
Credit to DOS
• If found guilty the candidate is liable to be barred for future fellow-
The presenter will acknowledge DOS partial financial assistance ships.
in the abstract book / proceedings.
The author will present his or her paper in the immediate next DOS Application should reach Secretary’s office and should be addressed to
conference and it will be published in DJO/DOS Times. President, DOS before 30th August and 31st January for International
Conference and before 30th September for National Conference. The
committee will meet thrice in a year in the month of August, October
and February with in 2 weeks of last date of receipt of applications. The
committee will reply within four week of last date of submission in yes/
no to the applicant. No fellowship will be given retrospectively, that
means prior sanction of executive will be necessary.

Dr. Namrata Sharma
Room No. 474, 4th Floor,
Dr. Rajendra Prasad Centre for Ophthalmic Sciences
All India Institute of Medical Sciences,
Ansari Nagar, New Delhi – 110029
Ph.: 91-11-65705229, Fax: 91-11-26588919
E-mail: [email protected], Website: www.dosonline.org

www.dosonline.org 95

Vision World

Metro System

Forthcoming Events : National

August 2007 23-25 PATNA, BIHAR
25-29 HYDERABAD, ANDRA PRADESH
34th Annual Conference of
Meeting Information International Society for Kerala Society of Ophthalmic Surgeons
Clinical Electrophysiology of Vision Contact Person & Address
Hyderabad Dr. Anup Chirayath
Contact Person & Address: Ahalia Foundation Eye Hospital
Subhadra Jalali Near Kanalpirivu, Walayar, Palakkad, Kerala
Phone: 0-91-0-4-030-612-607 Ph: 04923-235999,
Fax: 0-91-0-4-023-548-271 Tele-Fax: 235900
E-Mail: [email protected] Cell: 9447774439
Email: [email protected]
16-17 NEW DELHI

Workshop on Glaucoma 30 Nov., 1-2 Dec. BAREILLY, U.P.
Contact Person & Address:
Dr. Viney Gupta Annual Conference of
Dr. R.P. Centre for Ophthalmic Sciences, U.P. State Ophthalmological Society
AIIMS, Ansari Nagar, New Delhi - 110 029 Contact Person & Address
Ph.: 011-26588500, Extn. 3003 Dr. Kapil Agarwal
B-39/B, Rajendra Nagar
Fax: 011-26588919, E-mail: [email protected] Bareilly-243122 (U.P.)
Ph: 2442592, 2455353
September 2007
20-22 MUSSORRIE, UTTARANCHAL December 2007
1-2 HYDERABAD, ANDHRA PRADESH
VRSI 2007 XVI Annual Conference of
Vitreoretinal Society of India International Pediatric Ophthalmology Symposium
Contact Person & Address Contact Person & Address:
Dr. Saurabh Luthra Dr. K. Ramesh
Organizing Secretary, VRSI 2007 Pediatric Ophthalmology, Strabismus and
Drishti Eye Centre for Retina and Lasers, Neuro-Ophthalmology
9B Astley Hall, Dehradun-248 001 L.V. Prasad Eye Institute
Ph.: 0135-2655354, 2656364 L.V. Prasad Marg, Banjara Hills
Mobile: 09412059288, Website: www.vrsi2007.com Hyderabad - 500 034 A.P INDIA
E-mail: [email protected] Tel : +91-40-30612 644/ 345,
Fax : +91-40-2354 827
October 2007 Email : [email protected]
27-28 RAM NAGAR, UTTARANCHAL Web : www.lvpei.org

Annual Conference of Uttaranchal State 7-9 KOLKATA, WEST BENGAL
Ophthalmological Society
Contact Person & Address 17th Annual Conference of
Dr. Satanshu Mathur Glaucoma Society of India
Doctors’ Lane, Contact Person & Address
Kashipur (U.S. Nagar)-244713 (Uttaranchal) Dr. Chandrima Paul
Ph: 05947-274539, Cell: 9837120191 B.B. Eye Foundation
Email: [email protected] 2/5, Sarat Bose Road, Sukhsagar
1st & 2nd Floors, Kolkata-700020
November 2007 Ph: 033-24746608,24748816
17-18 NEW DELHI Email: [email protected]

Midterm Conference of 14-16 HYDERABAD, ANDHRA PRADESH
Delhi Ophthalmological Soceity
Contact Person & Address Annual Meeting of
Dr. Namrata Sharma the Oculoplastic Association of India
Room No. 474, 4th Floor, Contact Person & Address:
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, Dr. Milind Naik, Dr. Santosh G Honavar
All India Institute of Medical Sciences, LV Prasad Eye Institute
Ansari Nagar, New Delhi – 110029 LV Prasad Marg, Banjara Hills,
Ph.: 011-65705229, Fax: 26588919 Hyderabad 500034
E-mail: [email protected], Website: http://www.opai.in
Website: www.dosonline.org E-mail: [email protected], [email protected]

98 DOS Times - Vol. 13, No.1, July 2007

Forthcoming Events : International

August, 2007 5-6 LAS VEGAS, NV
2-5 CALIFORNIA
CLAO (Contact Lens Association of
ASCRS Summer Refractive Congress 2007 Ophthalmologists) Annual Meeting 2007
Four Seasons Aviara, North San Diego, California Caesars Palace Hotel, Las Vegas, NV

September, 2007 13-17 VIENNA, AUSTRIA
5–8 TAORMINA, SICILY
20th ECNP Congress
5th International Conference on Tear Film & VIENNA, AUSTRIA
Ocular Surface: Basic Science & Clinical Relevance Tel: +31 20 504 0200 / Fax: +31 20 504 0225
Taormina, Sicily Email: [email protected]
Tele: 39 349 898 3580 or Email: [email protected]

24-27 TAMPA, FLORIDA

7-8 VANCOUVER, PROVINCE American Academy of Optometry Meeting
Tampa Florida
Pediatric Ophthalmology & Adult Strabismus http://www.aaopt.org/meetings
Vancouver, Province: BC
Contact: UBC CPD-KT Registrations and Inquiries November, 2007
Phone: 604-875-5101 / Fax: 604-875-5078 10-13 NEW ORLEANS, UNITED STATES
E-Mail: [email protected]
American Academy of Ophthalmology 2007
8-12 STOCKHOLM, SWEDEN Annual Meeting
New Orleans , Province: LA (United States)
XXV Congress of the ESCRS (European Society of Contact: American Academy of Ophthalmology,
Cataract Refractive Surgeons) P.O. Box 7424 San Francisco, CA 94120-7424
Stockholm International Fairs and Congress Center, Phone: 415-561-8500, Fax: 415-561-8533
SE-125 80 Stockholm, Sweden E-Mail: [email protected]
Temple House, Temple Road, Blackrock, Co.
Dublin, Ireland December, 2007
Tel: +353 1 209 1100 / Fax: +353 1 209 1112 1-5 CALIFORNIA
Email: [email protected]
25th Annual Meeting of the American Society of
14-16 HERAKLION Retina Specialists
Palm Springs area, city of Indian Wells, California.
Mini Fellowship in LASIK and EPI-LASIK Tel: (914) 722-0664, Fax: (914) 722-0465
Heraklion, Country: Greece [email protected]
Contact: University of Crete
Phone: 302-810-394-654 / Fax: 302-810-394-653 March, 2008
E-Mail: [email protected]
28 Mar. - 2 Apr. HUNGARY
17-20 PARIS, FRANCE
7th International Symposium on Ocular
9th IOIS International Symposium Pharmacology and Therapeutics
International Ocular Inflammation Society Budapest, Hungary
Tel:+33 (0) 1 70 08 69 82 / Fax:+33 (0) 1 42 93 29 28 Contact: Robert Nesbitt
Email: [email protected] Phone: 44-229-080-488
Web: www.iois-paris-2007.com Fax: 44-227-322-850
E-Mail: [email protected]
28-30 CHICAGO, UNITED STATES

Ophthalmic Anesthesia Society (OAS) New Secretariat Office Address
21st Annual Meeting
Contact Person & Address Dr. Namrata Sharma, Secretary DOS
Ms Karen MORGAN Room No. 474, 4th Floor,
Chicago , Province: IL (United States) Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
Phone: 1-805-534-0300 / Fax: 1-805-534-9030 All India Institute of Medical Sciences,
E-Mail: [email protected] Ansari Nagar, New Delhi – 110029
Ph.:91-11-65705229, Fax: 91-11-26588919
October, 2007 E-mail: [email protected]
3-6 PORTOROZ, SLOVENIA Website: www.dosonline.org

European Association for Vision and Eye Research
(EVER) congress 2007
Portoroz, Slovenia
Tele: 32-16-233-849 or fax: 32-16-234-097

www.dosonline.org 99

Advertisement Tariff : DOS Times

Display One Issue Advertisement One Issue Advertisement
Advertisements Copies 4,500 Copies 8,500

• Full Page B&W Rs. 8,800 Rs. 11,550
• Half page B&W Rs. 5,500 Rs. 6,050
• Quarter page B&W Rs. 3,300 Rs. 4,400
• 1/8 page B&W Rs. 2,200 Rs. 3,300
• Back Inside Cover Colour Rs. 22,000 Rs. 27,500
• Full Page Colour Rs. 16,500 Rs. 19,800
• 2 Page Centre Spread B&W Rs. 22,000 Rs. 27,500
• 2 Page Centre Spread Colour Rs. 44,000 Rs. 55,000

• Discount on Long Term Booking

Three issues 5 % discount

Five issues 10 % discount

Ten issues 20 % discount

o Two Pages ten issue additional 10% discount
o Three pages ten issues additional 15% discount
o Four pages B&W for ten issues additional 20% discount
o Four pages color ten issues Flat 50% discount

Service Tax will be charged extra @ 12.36%.

Please send your bookings at the earliest accompanied by Demand Draft in the name of
“Delhi Ophthalmological Society” payable at Delhi to Dr. Namrata Sharma, Secretary, DOS.

SPECIFICATION : : 7.5" x 10.25"
Size of Advertisement page
Frequency : Monthly (10 Issues in a year)
Model of Printing
Advertisement Material : Offset

For Color : For Black & White: Positive films
Mailing and Contact (With proper density dots)

Email : Positive films with proofs

: Dr. Namrata Sharma, Secretary, DOS
Room No. 474, 4th Floor,
Dr. R.P. Centre for Ophthalmic Sciences,
AIIMS, Ansari Nagar, New Delhi - 110029.
Ph. 011-65705229, Fax : 011-26588919

: [email protected]

100 DOS Times - Vol. 13, No.1, July 2007









DOS Credit Rating System (DCRS)

DOS has always been in the forefront of efforts to ensure In a bid to strengthen our efforts in this direction DOS had
that its members remain abreast with the latest developments DOS Credit Rating System (DCRS), the details of which are
in Ophthalmology. Among the important objectives given below. Our Primary objective is to promote value-
formulated by the founders of our constitution was the based knowledge and skills in Ophthalmology for our
cultivation and promotion of the Science of Ophthalmology members and give recognition and credit for efforts made
in Delhi. by individual members to achieve standards of academic
excellence in Ophthalmic Practice.
The rapid strides in skills and knowledge have created a need
for an extremely intensive Continuing Medical Education
programme.

DOS CREDIT RATING SYSTEM (DCRS)

DCRS Max.

1) Attending Monthly Clinical Meeting* † (For full attendence) 10 90

2) Making Case Presentation at Monthly Meeting** 10 10

3) Delivering a Clinical Talk at Monthly Meeting** 10 10

4) Free Paper Presentation at Annual Conference (To Presenter)** 10 20

5) Speaker/Instructor** in : Monthly Symposium 10 10

: Mid Term Symposium 15 10

: Annual Conference 15 30

6) Registered Delegate at Mid Term DOS Conference 10 10

7) Registered Delegate at Annual DOS Conference 10 10

8) Full Article publication in Delhi Journal of Ophthalmology/DOS Times 15 45

9) Letter to editor in DOS Times 5 10

10) Letter to editor in DJO 5 10

11) > 3 Bonus points for Monthy Clinical Meeting: 10 bonus points ——

12) > 5 Bonus points for Monthy Clinical Meeting: 30 bonus points ——

13) All Monthly Clinical Meeting: 50 Bonus Points ——

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

If any of the presentations is given an Award – * Based on Signature in DCAC
Additional 20 bonus Credits. ** Subject to Submission of Full Text to Secretary, DOS
Member who have earned 100 Credits, are entitled † Credits will be reduced in case attendance is only for part
a) Certificate of Academic Excellence in Ophthalmic
b) Eligible for DOSTravel fellowship for attending conference. of the meeting.

If any member earns 200 Credits, he/she shall, in addition to DCRS !! Attention !!
above, be awarded Certificate of Distinguished Resource-
Teacher of the Society. * Members are requited to sign on monthly meeting
attendance register and put their membership number.
Institutional assessment for best performance will be based
on the total score of members who attend divided by num- * The DCRS paper will be issued only after the valid
ber of members who attended. Institutional assessment re- signature of the member in the attendance register.
garding decision to retain the institute for the next year will
be based on total score. * Please submit your DCRS papers to the designated DOS
Staff only.
Please note that the Institutions’ grading increases if the at-
tendance at its meeting is higher (i.e. more than the average * The collected DCRS papers will be countersigned by
attendance of the eight monthly meetings). President and Secretary and sealed immediately after the
meeting is over.